Abstract
Introduction:
Food desert (FD) residence has emerged as a risk factor for poor outcomes in breast, colon and esophageal cancers. The purpose of this retrospective study was to examine FD residence as an associated risk factor in non-small cell lung cancer (NSCLC) patients treated with anatomic lung resection (ALR).
Materials and Methods:
All consecutive ALRs for stage I-III NSCLC from January 2015 to December 2017 at a single institution were reviewed. The primary exposure of interest was FD residence as defined by the United States Department of Agriculture (USDA). The primary outcome was 5-year overall mortality. Secondary outcomes were 30-day complications and 1- and 3-year mortality. Cox proportional hazard analysis was used to model factors associated with each outcome, adjusted for covariates.
Results:
A total of 348 ALRs were included, with 101 (29%) patients residing in a FD. In the unadjusted Cox model, those residing in FD had an associated lower 5-year mortality risk compared to those not residing in a FD (HR=0.56, 95% CI (0.33–0.97); p=0.04). That association was not statistically significant once adjusted for covariates (HR=0.59, 95% CI (0.34–1.04); p=0.07).
Conclusions:
In this study, FD residence was not associated with an increase in the risk of 5-year mortality. Selection bias of patients deemed healthy enough to undergo surgery may have mitigated the negative association of FD residence demonstrated in other cancers. Future work will evaluate all NSCLC patients undergoing treatments at our institution to further evaluate FDs as a risk factor for worse outcomes.
Keywords: food desert, lung cancer, anatomic lung resection, outcomes, survival
Introduction:
Lung cancer remains one of the most common cancers among men and women in the United States, with at least 200,000 new cases reported annually.1 Based on treatment and disease stage, it is estimated that 35–70% of lung cancer patients experience malnutrition.2–4 Malnutrition in lung cancer patients has been associated with poor treatment tolerance, increased hospitalizations, shorter survival, and poor quality of life.2,5 For medically eligible patients, the optimal treatment of early-stage lung cancer is anatomic lung resection with mediastinal lymph node dissection. Since malnutrition can impact a patient’s operative eligibility and overall ability to undergo recommended treatments, ensuring proper nutritional status is an essential part of cancer care.
Food insecurity, defined as “lacking access to enough food for a healthy life”, is a significant risk factor for malnutrition.6, 7 The United States Department of Agriculture (USDA) estimated that in 2021, 10.2% of American households experienced food insecurity.8 Furthermore, food insecurity has been linked to increased risk for multiple chronic conditions, including diabetes and heart disease,7 and is heavily impacted by socioeconomic status. Geographic location can impact an individual’s food security potential, as access to grocery stores and supermarkets that carry healthy food options is not equitably distributed. Food deserts are defined by the USDA as “low-income census tracts with a substantial number or share of residents with low levels of access to retail outlets selling healthy and affordable foods”.9 The USDA provides an online tool, the Food Access Research Atlas, that can be conveniently searched to determine whether someone resides in a food desert. 10 As such, food desert residence has become an easily identifiable surrogate marker for food insecurity.
Food desert residence has been associated with worse outcomes in patients with heart failure and chronic limb ischemia and more recently as a risk factor for poor outcomes and survival in patients with breast, colon and esophageal cancers.11–15 The purpose of this study was to examine food desert residence as an associated risk factor for long-term survival for non-small cell lung cancer (NSCLC) patients treated with anatomic lung resection. Our hypothesis was that patients residing in a food desert would have increased risk for postoperative complications and worse overall 5-year survival.
Material and Methods:
A retrospective cohort study of all consecutive anatomic lung resections was performed at a single, rural quaternary academic medical center. Records were eligible for review if the anatomic resection occurred between January 1, 2015 and December 31, 2017. Cases were excluded if they had metastatic primary lung cancer, metastatic disease to the lung from another primary site, benign disease, or small cell lung cancer. This study was approved by the Institutional Review Board at Dartmouth-Hitchcock Medical Center and was granted a waiver of consent.
Data collection
Demographic data, comorbidities, body mass index (BMI), treatment characteristics, disease stage, operative characteristics, post-operative length of stay, readmissions, 30-day complications, 1-year, 3-year and 5-year mortality were obtained. Postoperative complications were recorded through 30 days after surgery and graded I-V as classified by Clavien-Dindo.16 Complication data follow the Society of Thoracic Surgeons definitions.17 The primary outcome measure was 5-year overall mortality, defined as death from any cause from the time of surgery through the follow-up period. Secondary outcomes included 30-day complications and 1-year and 3-year overall mortality. The primary exposure was residing in a food desert (FD), obtained from the USDA Food Access Research Atlas10 and cross-referenced with patient home zip code to determine FD status (yes versus no) as previously described.14,15 Covariates were selected among available data and based on their potential associations with residing in a food desert and overall mortality.
Statistical Analysis:
Statistical analysis was performed using STATA (v16.6 Statacorp, College Station, TX). Descriptive statistics were used to compare those who resided in a FD and those who did not. Student’s t-test was used for continuous variables and Chi- Square test was used for categorical variable. For the survival analysis, cases that were lost to follow-up at 5-years were treated as censored. Kaplan-Meier analysis was used to assess unadjusted survival outcomes by FD residence. Univariable and multivariable Cox proportional hazard analysis was used to model factors associated with FD residence and 5-year overall mortality. Demographic and clinical measures statistically associated with survival in univariable analysis were used in the multivariable analysis. A p value of <0.05 was considered statistically significant.
Results:
A total of 348 resections were included in the analysis and of those 101 (29%) resided in a FD. Compared to those who did not reside in a FD (Table 1), there were no differences in male sex, age, marital status, insurance status, BMI, smoking history, COPD, coronary artery disease, myocardial infarction, stroke, diabetes, pulmonary function testing, clinical stage or use of induction therapy. Interestingly, those who resided in a food desert had lower rates of significant alcohol use (42.6% v 57.1%, p=0.01) and history of congestive heart failure (0% v 4.9%, p=0.02).
Table 1:
Pre-Operative Characteristics of Patients with Stage I-III Primary Lung Cancer who Underwent Anatomic Lung Resection, Stratified by Food Desert Residence
| All n=348 |
Food Desert1 n=101 |
No Food Desert1 247 |
P-value2 | |
|---|---|---|---|---|
| Male Sex, (%) | 159 (45.7) | 39 (38.6) | 120 (48.6) | 0.1 |
| Caucasian, (%) | 342 (98.3) | 96 (95.1) | 246 (99.6) | 0.009 |
| Age, years,Mean (SD) | 66.7 (9.2) | 66.9 (10.0) | 66.7 (8.9) | 0.84 |
| Marital Status, (%) | ||||
| Married | 205 (58.9) | 48 (47.5) | 157 (63.6) | 0.08 |
| Domestic Partner | 3 (0.9) | 2 (2.0) | 1 (0.4) | |
| Single | 41 (11.8) | 16 (15.8) | 25 (10.1) | |
| Divorced | 56 (16.1) | 20 (19.8) | 36 (14.6) | |
| Separated | 1 (0.3) | 0 | 1 (0.4) | |
| Widowed | 42 (12.1) | 15 (14.9) | 27 (10.9) | |
| Insurance Status, (%) | 0.68 | |||
| Commercial | 92 (26.4) | 27 (26.7) | 65 (26.3) | |
| Medicare | 210 (60.3) | 59 (58.4) | 151 (61.1) | |
| Medicaid | 35 (10.1) | 11 (10.9) | 24 (9.7) | |
| Military | 8 (2.3) | 2 (2.0) | 6 (2.4) | |
| Correctional Facility | 1 (0.3) | 1 (1.0) | 0 | |
| None | 2 (0.6) | 1 (1.0) | 1 (0.4) | |
| Body Mass Index, kg/m2, Mean (SD) | 27.5 (6.1) | 27.2 (6.2) | 27.6 (6.1) | 0.6 |
| Smoking History, (%) | 0.83 | |||
| Current | 101 (29.0) | 31 (30.7) | 70 (28.3) | |
| Former | 212 (60.9) | 59 (58.4) | 153 (61.9) | |
| Never | 35 (10.1) | 11 (10.9) | 24 (9.7) | |
| Pack- Years, Mean (SD) | 45.8 (29.4) | 41.3 (30.3) | 47.6 (28.9) | 0.09 |
| Alcohol Use | 0.01 | |||
| Yes | 184 (52.9) | 43 (42.6) | 141 (57.1) | |
| No | 164 (47.1) | 58 (57.4) | 106 (42.9) | |
| Comorbidities, (%) | ||||
| Chronic obstructive pulmonary disease | 104 (29.9) | 28 (27.7) | 76 (30.8) | 0.57 |
| Coronary artery disease | 60 (17.2) | 17 (16.8) | 43 (17.4) | 0.9 |
| Congestive heart failure | 12 (3.5) | 0 | 12 (4.9) | 0.02 |
| Myocardial infarction | 20 (5.8) | 5 (5.0) | 15 (6.1) | 0.68 |
| Diabetes | 64 (18.4) | 17 (16.8) | 47 (19.0) | 0.63 |
| Cerebral vascular accident | 14 (4.0) | 6 (5.9) | 8 (3.2) | 0.43 |
| Pulmonary Function, Mean (SD) | ||||
| FEV1, Liters | 2.1 (0.7) | 2.0 (0.6) | 2.1 (0.7) | 0.22 |
| FEV1% | 78.9 (19.2) | 80.7 (19.5) | 78.2 (19.0) | 0.27 |
| DLCO, mL/min/mmHg | 78.9 (18.2) | 78.8 (19.1) | 79.0 (17.9) | 0.96 |
| Clinical Stage, (%) | 0.17 | |||
| I | 275 (79.0) | 86 (85.2) | 189 (76.5) | |
| II | 43 (12.4) | 10 (9.9) | 33 (13.4) | |
| III | 30 (8.6) | 5 (5.0) | 25 (10.1) | |
| Induction Therapy, (%) | 43 (12.4) | 10 (9.9) | 33 (13.4) | 0.37 |
As defined by the United States Department of Agriculture
P-values from Student’s t-test and Chi-Square test, as applicable
There were no differences by FD status related to operative time, surgical approach, tumor histology, tumor size, or total number or stations of lymph nodes sampled (Table 2). Interestingly, patients living in a food desert were more likely to have pathologic early-stage disease, and thus less likely to need adjuvant therapy.
Table 2:
Operative Characteristics of Patients with Stage I-III Primary Lung Cancer who Underwent Anatomic Lung Resection, Stratified by Food Desert Residence
| All n=348 |
Food Desert1 n=101 |
No Food Desert1 247 |
P-value2 | |
|---|---|---|---|---|
| Operative Time, minutes, Mean (SD) | 217.6 (86.9) | 206.9 (82.8) | 221.9 (88.3) | 0.14 |
| Surgical Approach, (%) | ||||
| Robot | 199 (57.2) | 64 (63.4) | 135 (54.7) | 0.49 |
| VATS | 89 (25.6) | 22 (21.8) | 67 (27.1) | |
| Open | 37 (10.6) | 10 (9.9) | 27 (10.9) | |
| Conversion to Open | 23 (6.6) | 5 (5.0) | 18 (7.3) | |
| Tumor Histology | 0.77 | |||
| Adenocarcinoma | 227 (65.2) | 66 (63.4) | 161 (65.2) | |
| Squamous | 77 (22.1) | 20 (19.8) | 57 (23.1) | |
| Atypical Carcinoid | 4 (1.2) | 2 (2.0) | 2 (0.8) | |
| Typical Carcinoid | 20 (5.8) | 5 (5.0) | 15 (6.1) | |
| Other Cancer | 13 (3.7) | 5 (5.0) | 8 (3.2) | |
| Other | 7 (2.0) | 3 (3.0) | 4 (1.6) | |
| Tumor Size, Mean (SD) | 2.7 (1.8) | 2.6 (1.5) | 2.8 (1.9) | 0.28 |
| Total LN Sampled, Mean (SD) | 13.6 (7.4) | 12.8 (6.3) | 13.9 (7.8) | 0.24 |
| Total LN Station Sampled, Mean (SD) | 4.4 (2.5) | 4.8 (4.1) | 4.2 (1.2) | 0.07 |
| Pathologic Stage, (%) | 0.02 | |||
| 1 | 239 (68.7) | 80 (79.2) | 159 (64.4) | |
| 2 | 60 (17.2) | 14 (13.9) | 46 (18.6) | |
| 3 | 49 (14.1) | 7 (6.9) | 42 (17.0) |
As defined by the United States Department of Agriculture
P-values from Student’s t-test and Chi-Square test, as applicable
VATS: Video-Assisted Thoracic Surgery
There were no differences between groups in length of stay, grade III/IV complications, discharge location, chest tube duration or being discharged with a chest tube, 30-day readmission, or 30-day mortality. (Table 3) We found no significant difference in 1-year or 3-year mortality. Interestingly, patients residing in a food desert had lower rates of 5-year mortality (20.3% vs 32.2%, p=0.05). Kaplan-Meier analysis demonstrated greater 5-year overall survival for those who resided in a FD as compared to those who did not (Figure 1).
Table 3:
Post-Operative Characteristics of Patients with Stage I-III Primary Lung Cancer who Underwent Anatomic Lung Resection, Stratified by Food Desert Residence
| All n=348 |
Food Desert1 n=101 |
No Food Desert1 247 |
P-value2 | |
|---|---|---|---|---|
| Length of Stay, Mean (SD) | 4.7 (4.0) | 4.3 (4.3) | 4.9 (3.9) | 0.27 |
| Grade 3/4 Complications3, (%) | 51 (14.7) | 10 (9.9) | 41 (16.6) | 0.11 |
| Discharge Location, (%) | 0.34 | |||
| Home | 325 (95.6) | 95 (96.0) | 230 (95.4) | |
| Extended Care- Rehab | 12 (3.5) | 3 (3.0) | 9 (3.7) | |
| Nursing Home | 2 (0.6) | 0 | 2 (0.8) | |
| Discharged with chest tube, (%) | 59 (17.0) | 17 (16.8) | 42 (17.0) | 0.97 |
| Chest tube days, Mean (SD) | 5.7 (7.4) | 5.4 (7.3) | 5.8 (7.4) | 0.65 |
| Readmission within 30days, (%) | 40 (11.5) | 11 (10.9) | 29 (11.7) | 0.82 |
| Postop Therapy, (%) | 0.008 | |||
| Surveillance | 272 (78.2) | 91 (90.1) | 181 (73.3) | |
| Systemic Therapy | 46 (13.2) | 6 (5.9) | 40 (16.2) | |
| Radiation Therapy | 17 (4.9) | 2 (2.0) | 15 (6.1) | |
| Systemic + Radiation Therapy | 13 (3.7) | 2 (2.0) | 11 (4.5) | |
| 30 Day Mortality | 2 (0.6) | 0 | 2 (0.8) | 1 |
| 1 Year Mortality | 14 (4.3) | 2 (2.2) | 12 (5.1) | 0.23 |
| 3 Year Mortality | 47 (15.4) | 8 (9.8) | 39 (17.4) | 0.1 |
| 5 Year Mortality | 85 (29.0) | 16 (20.3) | 69 (32.2) | 0.05 |
As defined by the United States Department of Agriculture
P-values from Student’s t-test and Chi-Square test, as applicable
Within 30 days of the index procedure
Figure 1:
Survival probability of patients with surgically treated stage I-III non-small cell lung cancer, stratified by food desert status
Univariable Cox proportional hazard analysis indicated that residing in a FD was associated with a significantly reduced 5-year mortality risk compared to those who did not reside in a FD (Table 4: HR=0.56, 95% CI (0.33–0.97); p=0.04). After adjustment for history of congestive heart failure, age, post-operative therapy, pathologic stage and alcohol use, multivariable survival analysis showed that FD residence had a trend toward associated reduced 5-year mortality risk compared to those who did not, however, this finding was not significant (HR=0.59, 95% CI (0.34–1.04); p=0.07). Subset analysis of stage I patients demonstrated FD residence was not significantly associated with a difference in 5-year mortality (HR=0.84, 95% CI (0.43–1.68); p=0.64).
Table 4:
Univariable and Multivariable Analysis for Predictors of 5-Year Overall Survival in Patients with Stage I-III Primary Lung Cancer who Underwent Anatomic Lung Resection
| Univariable for 5-year Survival | Multivariable1 for 5-year Survival | ||||||
|---|---|---|---|---|---|---|---|
| Haz. Ratio | p value | 95% CI | Haz. Ratio | p value | 95% CI | ||
| Food Desert2 | 0.56 | 0.04 | 0.33–0.97 | Food Desert2 | 0.59 | 0.07 | 0.34–1.04 |
| Congestive Heart Failure | 7.07 | <0.001 | 3.5–14.24 | Congestive Heart Failure | 4.3 | <0.001 | 2.00–9.37 |
| Age | 1.03 | 0.02 | 1.01–1.06 | Age | 1.03 | 0.03 | 1.00–1.06 |
| Post Operative Therapy | Post Operative Therapy | ||||||
| Surveillance | ref | ref | ref | Surveillance | ref | ref | ref |
| Systemic Therapy | 1.21 | 0.55 | 0.65–2.25 | Systemic Therapy | 0.33 | 0.003 | 0.16–0.69 |
| Systemic + Radiation | 1.93 | 0.2 | 0.70–5.31 | Systemic + Radiation | 0.73 | 0.6 | 0.23–2.31 |
| Radiation Therapy | 2.33 | 0.03 | 1.11–4.86 | Radiation Therapy | 0.77 | 0.55 | 0.32–1.84 |
| Pathologic Stage | Pathologic Stage | ||||||
| 1 | ref | ref | ref | 1 | ref | ref | ref |
| 2 | 3.09 | <0.001 | 1.86–5.12 | 2 | 3.61 | <0.001 | 2.01–6.49 |
| 3 | 3.29 | <0.001 | 1.94–5.59 | 3 | 4.2 | <0.001 | 2.09–8.46 |
| Alcohol Use | 0.9 | 0.62 | 0.59–1.38 | Alcohol Use | 0.92 | 0.72 | 0.59–1.43 |
Adjusted for food desert residence, history of congestive heart failure, age, post-operative therapy, pathologic stage and alcohol use
As defined by the United States Department of Agriculture
Discussion:
In this study, stage I-III lung cancer patients who underwent an anatomic lung resection who resided in a FD had an association with reduced 5-year mortality and no increased risk of perioperative complications as compared to those who did not reside in a FD. The findings of the current study are contradictory to other recent evidence that FD residence is a risk factor for some cancer patients.11–15 Of note, our study only included patients who underwent an anatomic lung resection, and as such, all patients were deemed fit and healthy enough to undergo surgery. In addition, there was a significantly higher proportion of patients with stage I lung cancer in the FD group and this likely affected our 5-year mortality findings. It is possible that those who were truly food insecure and malnourished as a result of living in a FD were unable to undergo surgery and therefore not included in our analysis. These findings underscore that risk stratification for thoracic surgery is multi-faceted and complex.18 In addition, while FD residence is a surrogate marker for food insecurity and malnutrition risk, work should continue to improve identification of those who are truly food insecure and malnourished.
While FD residence was not associated with decreased survival or worse perioperative outcomes in this present study, it is still important to consider for lung cancer patients. As overall survival continues to improve, especially for early-stage lung cancer, cancer survivorship and quality of life are significant considerations. Food insecurity is prevalent among cancer survivors and prevalence has only increased following the COVID-19 pandemic.19–21 To further exacerbate risk for food insecurity, cancer survivors are most at risk due to increased financial strain from medical bills from treatment.22 In a qualitative study of cancer survivors and caregivers regarding food insecurity, McDougall and colleagues found that a primary barrier to eating healthy was the expense.23 Participants noted not only the importance of nutritional education, particularly at the start of cancer treatment, but also continued education and access to resources throughout the course of treatment and survivorship. Additionally, participants discussed the need for food security screening, but stressed the need for this screening to not increase or perpetuate stigmatization.23 While we did not find an association between FD residence and negative outcomes in resectable lung cancer, the identification and screening of patients for food security remains important. FD residence is only one of multiple potential factors that contributes to food insecurity. Because FD residence can be easily identified using the USDA’s free online atlas,10 clinic staff can efficiently screen patients prior to their arrival, which can help reduce the anxiety and/or stigma of self-reporting and normalize potential interventions to help them. Furthermore, the need for screening for food insecurity should continue through cancer survivorship as changes in residence, income, or access to nutritional resources could occur that impact survival outcomes.
While our study investigated an established risk factor for food insecurity, future research will address interventions that improve outcomes in these patients. A recently published randomized trial provided interventions for food insecurity with the goal of improving cancer outcomes.24 Gany et al. found that those who were provided a monthly debit card for food and access to a food pantry had the highest cancer treatment completion at 6-months (94.6%).24 While the inclusion criteria for this study was limited to urban patients undergoing chemotherapy and/or radiation, this work is encouraging, and we plan to evaluate the feasibility of this type of program in rural patients undergoing cancer surgery and its impact on perioperative and long-term outcomes. In addition, we plan to evaluate all lung cancer patients treated at our institution to further elucidate the association of food desert residence with lung cancer outcomes.
There were several limitations in this study. First, it was a retrospective review at a single institution of a relatively homogenous patient population. As such, the results may not be generalizable to a more heterogenous or urban population. Second, this study was limited to those who were deemed healthy enough to undergo surgical resection for their NSCLC. This selection bias potentially skews the results and could explain why FD residence showed reduced 5-year mortality in this cohort. Lastly, because of its retrospective nature, we were unable to obtain data regarding education, household income, detailed food diaries, or nutritional laboratory values which would have provided further evaluations that could help explain our results. Despite these limitations, these findings add important data to the limited literature related to the association of food deserts with cancer treatment outcomes.
Conclusion:
While food deserts have been associated with negative outcomes in other cancers, in this study, FD status was not associated with a worse 5-year mortality risk or perioperative outcomes in patients with stage I-III NSCLC undergoing anatomic lung resection. Future work will evaluate all NSCLC patients undergoing treatments at our institution to evaluate food deserts residence as a risk factor for worse outcomes in these patients and the feasibility of nutrition-based interventions in a rural patient population.
Acknowledgements:
JD Phillips is supported through The Dartmouth-Hitchcock Cancer Research Fellows Program supported by the NCI Cancer Center Support Grant 5P30CA023108 to the Dartmouth Cancer Center as well as The Dartmouth Clinical and Translational Science Institute, under award number UL1TR001086 from the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health (NIH).
Footnotes
Disclosure: JD Phillips receives research grant funding from KSQ Therapeutics, Inc., which is not related to this work. DJ Finley serves on advisory committees for Merck and Medtronic, which is not related to this work.
References:
- 1.U.S. Cancer Statistics Working Group. U.S. Cancer Statistics Data Visualizations Tool, based on 2022 submission data (1999–2020): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; https://www.cdc.gov/cancer/dataviz, released in June 2023 [Google Scholar]
- 2.Polański J, Chabowski M, Świątoniowska-Lonc N, Dudek K, Jankowska-Polańska B, Zabierowski J, Mazur G. Relationship between Nutritional Status and Clinical Outcome in Patients Treated for Lung Cancer. Nutrients. 2021. Sep 23;13(10):3332. doi: 10.3390/nu13103332. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Hébuterne X, Lemarié E, Michallet M, de Montreuil CB, Schneider SM, Goldwasser F. Prevalence of malnutrition and current use of nutrition support in patients with cancer. JPEN J Parenter Enteral Nutr. 2014. Feb;38(2):196–204. doi: 10.1177/0148607113502674. [DOI] [PubMed] [Google Scholar]
- 4.Kiss NK, Krishnasamy M, Isenring EA. The effect of nutrition intervention in lung cancer patients undergoing chemotherapy and/or radiotherapy: a systematic review. Nutr Cancer. 2014;66(1):47–56. doi: 10.1080/01635581.2014.847966. Epub 2013 Dec 9. [DOI] [PubMed] [Google Scholar]
- 5.Kiss N, Curtis A. Current Insights in Nutrition Assessment and Intervention for Malnutrition or Muscle Loss in People with Lung Cancer: A Narrative Review. Adv Nutr. 2022. Dec 22;13(6):2420–2432. doi: 10.1093/advances/nmac070. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Gkiouras K, Cheristanidis S, Papailia TD, Grammatikopoulou MG, Karamitsios N, Goulis DG, Papamitsou T. Malnutrition and Food Insecurity Might Pose a Double Burden for Older Adults. Nutrients. 2020. Aug 11;12(8):2407. doi: 10.3390/nu12082407. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Food Accessibility, Insecurity and Health Outcomes. National Institute on Minority Health and Health Disparities. https://www.nimhd.nih.gov/resources/understanding-health-disparities/food-accessibility-insecurity-and-health-outcomes.html. Updated April 26,2023. Accessed February 2024.
- 8.Key Statistics and Graphics. U.S. Department of Agriculture Economic Research Service. https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-u-s/key-statistics-graphics/. Updated October 25, 2023. Accessed February 2024.
- 9.Characteristics and Influential Factors of Food Deserts. United States Department of Agriculture. https://www.ers.usda.gov/webdocs/publications/45014/30940_err140.pdf. August 2012
- 10.Food Access Research Atlas. U.S. Department of Agriculture Economic Research Service. https://www.ers.usda.gov/data/fooddesert/. Updated September 27,2023. Accessed February 2024.
- 11.Morris AA, McAllister P, Grant A, et al. Relation of Living in a “Food Desert” to Recurrent Hospitalizations in Patients with Heart Failure. The American Journal of Cardiology. 2019;123(2):291–296. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Smith EJT, Ramirez JL Wu B et al. Living in a Food Desert is Associated with 30-day Readmission after Revascularization for Chronic Limb-Threatening Ischemia. Annals of Vascular Surery. 2021;70:36–42. [DOI] [PubMed] [Google Scholar]
- 13.Fong AJ, Lafaro K, Ituarte PHG, Fong Y. Association of Living in Urban Food Deserts with Mortality from Breast and Colorectal Cancer. Annals of Surgical Oncology. 2020:28;1311–1319. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Phillips JD, Fay KA, Wakeam E, et al. Food Deserts Increased Readmission after Esophagectomy for Cancer: A Multi-Institutional Study. The Annals of Thoracic Surgery. 2023:116(2);246–253. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Fay KA, Maeder MA, Emond JA et al. Residing in a food desert is associated with an increased risk of readmission following esophagectomy for cancer. J Thorac Dis. 2022;14(6):1854–1868. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–213. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.The Society of Thoracic Surgeons. STS National Database. Accessed January 1, 2023. https://www.sts.org/registries/sts-national-database
- 18.Hanley C, Donahoe L, Slinger P. “Fit for Surgery? What’s New in Preoperative Assessment of the High-Risk Patient Undergoing Pulmonary Resection”. J Cardiothorac Vasc Anesth. 2021. Dec;35(12):3760–3773. doi: 10.1053/j.jvca.2020.11.025. Epub 2020 Nov 17. [DOI] [PubMed] [Google Scholar]
- 19.Trego ML, Baba ZM, DiSantis KI, Longacre ML. Food insecurity among adult cancer survivors in the United States. J Cancer Surviv. 2019. Aug;13(4):641–652. doi: 10.1007/s11764-019-00783-9. Epub 2019 Jul 11. [DOI] [PubMed] [Google Scholar]
- 20.Robien K, Clausen M, Sullo E, Ford YR, Griffith KA, Le D, Wickersham KE, Wallington SF. Prevalence of Food Insecurity Among Cancer Survivors in the United States: A Scoping Review. J Acad Nutr Diet. 2023. Feb;123(2):330–346. doi: 10.1016/j.jand.2022.07.004. Epub 2022 Jul 12. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Camacho-Rivera M, Islam JY, Rodriguez DR, Vidot DC, Bailey Z. Food Insecurity Disparities and Mental Health Impacts Among Cancer Survivors During the COVID-19 Pandemic. Health Equity. 2022. Sep 21;6(1):729–737. doi: 10.1089/heq.2021.0120. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Parks CA, Carpenter LR, Sullivan KR, Clausen W, Gargano T, Wiedt TL, Doyle C, Kashima K, Yaroch AL. A Scoping Review of Food Insecurity and Related Factors among Cancer Survivors. Nutrients. 2022. Jun 29;14(13):2723. doi: 10.3390/nu14132723. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.McDougall JA, Jaffe SA, Guest DD, Sussman AL. The Balance Between Food and Medical Care: Experiences of Food Insecurity Among Cancer Survivors and Informal Caregivers. J Hunger Environ Nutr. 2022;17(3):380–396. doi: 10.1080/19320248.2021.1892295. Epub 2021 Feb 25. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Gany F, Melnic I, Wu M, Li Y, Finik J, Ramirez J, Blinder V, Kemeny M, Guevara E, Hwang C, Leng J. Food to Overcome Outcomes Disparities: A Randomized Controlled Trial of Food Insecurity Interventions to Improve Cancer Outcomes. J Clin Oncol. 2022. Nov 1;40(31):3603–3612. doi: 10.1200/JCO.21.02400. Epub 2022 Jun 16. [DOI] [PMC free article] [PubMed] [Google Scholar]