All ETDs from UAB

Advisory Committee Chair

Russell L Griffin

Advisory Committee Members

Tomi Akinyemiju

Alfred Bartolucci

Henry Wang

John Waterbor

Document Type


Date of Award


Degree Name by School

Doctor of Philosophy (PhD) School of Public Health


Cancer is the second leading cause of morbidity and death in the United States corresponding to more than 1.7 million incident cases and responsible for more than 550,000 deaths annually. In addition, hospitalized cancer patients are nearly 10 times more likely to develop sepsis when compared to participants with no cancer history. As treatments and therapies for cancer continue to improve, the average 5-year survival is approaching 70% overall among the US population; however, to date there is very limited research that has examined the association between patients with a history of cancer and future risk of sepsis among a longitudinal cohort of community-dwelling adults. Therefore, the objectives of this dissertation were to use data from years 2003 through 2012 of the large national REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort to: 1) determine the risk of sepsis after cancer survivorship compared with participants with no cancer history and 2) whether these differences were modified by race, 3) examine the mediating effects of indicators of frailty, and 4) examine the mediating effects of community characteristics. In our first study, there were a total of 1393 first sepsis events, and sepsis risk was higher for cancer survivors than for participants with no cancer history participants (adjusted HR: 2.60, 95% CI: 2.30 – 2.95). However, risk of sepsis after cancer was similar for both Blacks (adjusted HR: 2.87, 95% CI: 2.27 – 3.62), and Whites (adjusted HR: 2.51, 95% CI: 2.17 – 2.91) (p value for race and cancer interaction = 0.63). These results suggest that regardless of race or personal-level characteristics, cancer survivorship of any cancer type is very important risk factor for sepsis, and tremendous care should be provided to cancer survivors once hospitalized with suspected infection. The second study of the current dissertation observed that while cancer survivors had more than a two-fold increased of sepsis, the mediation effects of frailty on the log-hazard scale were very small: weakness (0.57%), exhaustion (0.31%), low physical activity (0.20%), frailty (0.75%), and total number of frailty indicators (0.69%). In our third study, community-level mediation effects were very weak with income (% mediated = 0.07%) and prevalence of adult smoking (% mediated = 0.21%) being the only significant mediators. In conclusion, these results suggest that cancer survivors are at a very high risk of sepsis and that more cautious care be taken with cancer survivors once admitted for any infection.

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