Randomized Noninferiority Trial of Telephone Delivery of BRCA1/2 Genetic Counseling Compared With In-Person Counseling: 1-Year Follow-Up

PURPOSE

The ongoing integration of cancer genomic testing into routine clinical care has led to increased demand for cancer genetic services. To meet this demand, there is an urgent need to enhance the accessibility and reach of such services, while ensuring comparable care delivery outcomes. This randomized trial compared 1-year outcomes for telephone genetic counseling with in-person counseling among women at risk of hereditary breast and/or ovarian cancer living in geographically diverse areas.

PATIENTS AND METHODS

Using population-based sampling, women at increased risk of hereditary breast and/or ovarian cancer were randomly assigned to in-person (n = 495) or telephone genetic counseling (n = 493). One-sided 97.5% CIs were used to estimate the noninferiority effects of telephone counseling on 1-year psychosocial, decision-making, and quality-of-life outcomes. Differences in test-uptake proportions for determining equivalency of a 10% prespecified margin were evaluated by 95% CIs.

RESULTS

At the 1-year follow-up, telephone counseling was noninferior to in-person counseling for all psychosocial and informed decision-making outcomes: anxiety (difference [d], 0.08; upper bound 97.5% CI, 0.45), cancer-specific distress (d, 0.66; upper bound 97.5% CI, 2.28), perceived personal control (d, -0.01; lower bound 97.5% CI, -0.06), and decisional conflict (d, -0.12; upper bound 97.5% CI, 2.03). Test uptake was lower for telephone counseling (27.9%) than in-person counseling (37.3%), with the difference of 9.4% (95% CI, 2.2% to 16.8%). Uptake was appreciably higher for rural compared with urban dwellers in both counseling arms.

CONCLUSION

Although telephone counseling led to lower testing uptake, our findings suggest that telephone counseling can be effectively used to increase reach and access without long-term adverse psychosocial consequences. Further work is needed to determine long-term adherence to risk management guidelines and effective strategies to boost utilization of primary and secondary preventive strategies.

Factors Associated with Interest in Gene-Panel Testing and Risk Communication Preferences in Women from BRCA1/2 Negative Families

Scientific advances have allowed the development of multiplex gene-panels to assess many genes simultaneously in women who have tested negative for BRCA1/2. We examined correlates of interest in testing for genes that confer modest and moderate breast cancer risk and risk communication preferences for women from BRCA negative families. Female first-degree relatives of breast cancer patients who tested negative for BRCA1/2 mutations (N = 149) completed a survey assessing multiplex genetic testing interest and risk communication preferences. Interest in testing was high (70 %) and even higher if results could guide risk-reducing behavior changes such as taking medications (79 %). Participants preferred to receive genomic risk communications from a variety of sources including: primary care physicians (83 %), genetic counselors (78 %), printed materials (71 %) and the web (60 %). Factors that were independently associated with testing interest were: perceived lifetime risk of developing cancer (odds ratio (OR) = 1.67: 95 % confidence interval (CI) 1.06-2.65) and high cancer worry (OR = 3.12: CI 1.28-7.60). Findings suggest that women from BRCA1/2 negative families are a unique population and may be primed for behavior change. Findings also provide guidance for clinicians who can help develop genomic risk communications, promote informed decision making and customize behavioral interventions.

Health care concerns of rural childhood cancer survivors

BACKGROUND

Geographic isolation may limit health care access due to burdens of time, cost and travel distance. We explored rural childhood cancer survivors' experiences and concerns about accessing affordable, quality care.

METHODS

In-depth, semi-structured telephone interviews were conducted with 17 rural adult survivors recruited from the Utah Cancer Registry. Interviews were recorded, transcribed, and content analyzed with NVivo 9 by two coders (kappa = 0.93).

RESULTS

Two primary themes emerged: (1) concerns about health care quality and (2) geographic and insurance issues. Within these main themes, we identified salient sub-themes: quality of primary care, patient-provider trust, specialty care access, travel burdens, and financial and insurance concerns.

CONCLUSIONS

Rural childhood cancer survivors have concerns about local health care services, but are willing to travel several hours to receive care. Partnerships between local primary care and cancer specialty providers via telemedicine that incorporate survivor care plans could improve risk-based care for rural survivors.

Breast Cancer Risk Perceptions among Relatives of Women with Uninformative Negative BRCA1/2 Test Results: The Moderating Effect of the Amount of Shared Information

The most common result of BRCA1/2 mutation testing when performed in a family without a previously identified mutation is an uninformative negative test result. Women in these families may have an increased risk for breast cancer because of mutations in non-BRCA breast cancer predisposition genes, including moderate- or low-risk genes, or shared environmental factors. Genetic counselors often encourage counselees to share information with family members, however it is unclear how much information counselees share and the impact that shared information may have on accuracy of risk perception in family members. We evaluated 85 sisters and daughters of women who received uninformative negative BRCA1/2 results. We measured accuracy of risk perception using a latent variable model where accuracy was represented as the correlation between perceived risk (indicators = verbal and quantitative measures) and calculated risk (indicators = Claus and BRCAPRO). Participants who reported more information was shared with them by their sister or mother about her genetic counseling session had greater accuracy of risk perception (0.707, p = 0.000) than those who reported little information was shared (0.326, p = 0.003). However, counselees shared very little information; nearly 20 % of family members reported their sister or mother shared nothing with them about her genetic counseling. Family members were generally not aware of the existence of a genetic counseling summary letter. Our findings underscore the need for effective strategies that facilitate counselees to share information about their genetic counseling sessions. Such communication may help their relatives better understand their cancer risks and enhance risk appropriate cancer prevention.

Implementation intention and planning interventions in Health Psychology: Recommendations from the Synergy Expert Group for research and practice

The current article details a position statement and recommendations for future research and practice on planning and implementation intentions in health contexts endorsed by the Synergy Expert Group. The group comprised world-leading researchers in health and social psychology and behavioural medicine who convened to discuss priority issues in planning interventions in health contexts and develop a set of recommendations for future research and practice. The expert group adopted a nominal groups approach and voting system to elicit and structure priority issues in planning interventions and implementation intentions research. Forty-two priority issues identified in initial discussions were further condensed to 18 key issues, including definitions of planning and implementation intentions and 17 priority research areas. Each issue was subjected to voting for consensus among group members and formed the basis of the position statement and recommendations. Specifically, the expert group endorsed statements and recommendations in the following areas: generic definition of planning and specific definition of implementation intentions, recommendations for better testing of mechanisms, guidance on testing the effects of moderators of planning interventions, recommendations on the social aspects of planning interventions, identification of the preconditions that moderate effectiveness of planning interventions and recommendations for research on how people use plans.

Risk of Incident Colorectal Cancer and Death After Colonoscopy: A Population-based Study in Utah

BACKGROUND & AIMS

Colonoscopy is widely recommended for colorectal (CRC) screening in the United States, but evidence of effectiveness is limited. We examined whether exposure to colonoscopy decreases the odds of incident CRC and death from CRC in Utah.

METHODS

We performed a case-control study of Utah residents, 54 to 90 years old, who received a CRC diagnosis from 2000 through 2010 (cases). Age- and sex-matched controls with no history of CRC (controls) were selected for each case. We determined receipt of colonoscopy 6 months to 10 years before the reference date for each case and control through administrative claims data. Colonoscopy exposure was compared by using conditional logistic regression.

RESULTS

We identified 5128 cases and 20,512 controls; 741 cases (14%) and 5715 controls (28%) received a colonoscopy. Exposure to colonoscopy reduced the odds for a diagnosis of CRC; the odds ratios (ORs) were 0.41 for any CRC (95% confidence interval [CI], 0.38-0.44), 0.58 for proximal colon cancer (95% CI, 0.51-0.65), and 0.29 for distal colon or rectal cancer (95% CI, 0.25-0.33). This finding was consistent among sexes, age groups, and cancer stages. Similarly, in a subgroup analysis, colonoscopy was associated with decreased odds of death from CRC (OR, 0.33; 95% CI, 0.28-0.39) in both the proximal colon (OR, 0.43; 95% CI, 0.34-0.55) and distal colon or rectum (OR, 0.23; 95% CI, 0.18-0.30).

CONCLUSIONS

In the population of Utah, colonoscopy is associated with a large reduction in risk of new-onset CRC and death from CRC. This reduction in risk for CRC was greatest for the distal colon and rectum, with a more modest reduction for proximal colon cancer.

Knowledge and Uptake of Genetic Counseling and Colonoscopic Screening Among Individuals at Increased Risk for Lynch Syndrome and their Endoscopists from the Family Health Promotion Project

OBJECTIVES

Individuals whose families meet the Amsterdam II clinical criteria for hereditary non-polyposis colorectal cancer are recommended to be referred for genetic counseling and to have colonoscopic screening every 1-2 years. To assess the uptake and knowledge of guideline-based genetic counseling and colonoscopic screening in unaffected members of families who meet Amsterdam II criteria and their treating endoscopists.

METHODS

Participants in the Family Health Promotion Project who met the Amsterdam II criteria were surveyed regarding their knowledge of risk-appropriate guidelines for genetic counseling and colonoscopy screening. Endoscopy/pathology reports were obtained from patients screened during the study to determine the follow-up recommendations made by their endoscopists. Survey responses were compared using Fisher's Exact and the χ(2) test. Concordance in participant/provider-reported surveillance interval was assessed using the kappa statistic.

RESULTS

Of the 165 participants, the majority (98%) agreed that genetics and family history are important predictors of CRC, and 63% had heard of genetic testing for CRC, although only 31% reported being advised to undergo genetic counseling by their doctor, and only 7% had undergone genetic testing. Only 26% of participants reported that they thought they should have colonoscopy every 1-2 years and 30% of endoscopists for these participants recommended 1-2-year follow-up colonoscopy. There was a 65% concordance (weighted kappa 0.42, 95% CI 0.24-0.61) between endoscopist recommendations and participant reports regarding screening intervals.

CONCLUSIONS

A minority of individuals meeting Amsterdam II criteria in this series have had genetic testing and reported accurate knowledge of risk-appropriate screening, and only a small percentage of their endoscopists provided them with the appropriate screening recommendations. There was moderate concordance between endoscopist recommendations and participant knowledge suggesting that future educational interventions need to target both health-care providers and their patients.

Economic Evaluation Alongside a Clinical Trial of Telephone Versus In-Person Genetic Counseling for BRCA1/2 Mutations in Geographically Underserved Areas

PURPOSE

BRCA1/2 counseling and mutation testing is recommended for high-risk women, but geographic barriers exist, and no data on the costs and yields of diverse delivery approaches are available.

METHODS

We performed an economic evaluation with a randomized clinical trial comparing telephone versus in-person counseling at 14 locations (nine geographically remote). Costs included fixed overhead, variable staff, and patient time costs; research costs were excluded. Outcomes included average per-person costs for pretest counseling; mutations detected; and overall counseling, testing, and disclosure. Sensitivity analyses were performed to assess the impact of uncertainty.

RESULTS

In-person counseling was more costly per person counseled than was telephone counseling ($270 [range, $180 to $400] v $120 [range, $80 to $200], respectively). Counselors averaged 285 miles round-trip to deliver in-person counseling to the participants (three participants per session). There were no differences by arm in mutation detection rates (approximately 10%); therefore, telephone counseling was less costly per positive mutation detected than was in-person counseling ($37,160 [range, $36,080 to$38,920] v $40,330 [range, $38,010 to $43,870]). In-person counseling would only be less costly than telephone counseling if the most favorable assumptions were applied to in personc ounseling and the least favorable assumptions were applied to telephone counseling.

CONCLUSION

In geographically underserved areas, telephone counseling is less costly than in-person counseling.

Structuring Health in Colorectal Cancer Screening Conversations: An Analysis of Intersecting Activity Systems

This study used structurating activity theory to analyze 21 conversations between genetic counselors and individuals at increased risk for familial colorectal cancer (CRC). The qualitative analysis revealed ways elements of family, primary healthcare, cancer prevention and treatment, and other systems emerged in intervention conversations as shaping CRC screening attitudes and behaviors. Results indicate that family stories, norms, and roles are resources for enacting health practices in families and that the authority of healthcare providers is a resource for making screening decisions. Conclusions include practical implications for using findings in clinical applications as well as future research directions to build on this exploratory study.

Abstract B12: To screen or not to screen: Examining components of the Extended Parallel Process Model in a tailored-risk communication intervention to promote colorectal cancer screening

The Extended Parallel Process Model (EPPM) has been effectively used to promote healthy behaviors, but less is known about the effectiveness of the EPPM in promoting screening adherence in individuals at familial risk for colorectal cancer (CRC). The original EPPM model posits that an additive relationship exists between the constructs perceived severity and susceptibility (“threat”) and between perceived self- and response efficacy (“efficacy”). However, this model may not be as effective in predicting message acceptance in the context of CRC screening as these constructs may independently contribute to the model. For example, with CRC threat, there may be little variance in the perceived severity score as perceptions of cancer severity have been shown to be universally high. Likewise, one may have high levels of response efficacy (“Colonoscopy can save my life”) but low self-efficacy (“Without insurance I can't pay for a colonoscopy”) thus influencing efficacy scores. To determine the effectiveness of the EPPM in promoting CRC screening, we used data from the Family Colorectal Cancer Awareness and Risk Education Project (Family CARE), that tested a remote tailored-risk communication intervention aimed at individuals with familial risk for CRC. Intention-to-screen and medical record-verified colonoscopy (CS) were collected on 218 participants who received the personalized intervention. Using structural equation modeling (SEM), we examined associations of CRC threat and efficacy with greater message acceptance in a full additive model, and in an apriori alternative model in which perceived severity, susceptibility, self-efficacy and response efficacy acted as independent predictors. We considered indicators of good fit to be Root Mean Square Error of Approximation (RMSEA) <.08, Standardized Root Mean Residual (SRMR) <.08, and Comparative Fit Index (CFI) >.90. We compared the two models based on model fit indices, Akaike Information Criterion (AIC) and Bayesian Information Criterion (BIC), with the preferred model having lower AIC and BIC. SEM results indicated poor fit for the full additive EPPM model (RMSEA=0.109; SRMR=0.137; CFI 0.800) while the alternative model showed good fit (RMSEA=0.068; SRMR=0.063; CFI=0.933). Additionally, comparison of the two models indicated that the alternative model was a better fit than the full additive model (RMSEA=0.071; SRMR=0.108; CFI 0.918; AIC=11021; BIC=11332). Further, we found perceptions of susceptibility (B =0.321, p <.001) and self-efficacy (B=0.365, p<0.001) to be significantly associated with intention to screen, while severity (B=0.059, p=0.454) and response efficacy (B=-0.189, p=0.101) showed no significant association. Importantly, intention to screen was significantly associated with medically verified CS behavior (B=0.728, p<0.001).

Relatives of CRC patients are at increased risk for the disease, yet screening rates remain low among these individuals despite the effectiveness of CS in both early detection and cancer prevention. Theory-based communication such as the EPPM that addresses multiple determinates of behavior may help promote CRC screening yet few studies have tested conceptual models with regard to an intervention's effect on psychosocial pathways and actual cancer screening behavior. Our results indicate that focusing on individuals' perceptions of CRC susceptibility and screening self-efficacy may more effectively contribute to CRC screening behavior. Noteworthy, we measured both intentions to screen and actual screening behavior. These findings uniquely contribute to the literature by providing evidence of the underlying theoretical psychosocial pathways of how a personalized health promotion intervention works in motivating CRC screening among individuals at increased familial risk.

Citation Format: Wendy C. Birmingham, Man Hung, Watcharaporn Boonyasiriwat, Scott T. Walters, Antoinette M. Stroup, Marc D. Schwartz, Jeremy D. Franklin, Anita Y. Kinney. To screen or not to screen: Examining components of the Extended Parallel Process Model in a tailored-risk communication intervention to promote colorectal cancer screening. [abstract]. In: Proceedings of the Thirteenth Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2014 Sep 27-Oct 1; New Orleans, LA. Philadelphia (PA): AACR; Can Prev Res 2015;8(10 Suppl): Abstract nr B12.

Health behaviors, quality of life, and psychosocial health among survivors of adolescent and young adult cancers

PURPOSE

Survivors of adolescent and young adult (AYA) cancer may engage in unhealthy lifestyles (e.g., smoking), potentially heightening their risk for long-term health problems. We assessed health behaviors and constructs including quality of life (QOL) and psychosocial well-being among survivors of AYA cancer compared to the general population.

METHODS

We used 2009 Behavioral Risk Factor Surveillance System data to evaluate health behaviors for survivors of AYA cancer compared to AYAs without cancer. Multivariable regressions assessed health behaviors (smoking, binge drinking, physical inactivity, and low fruit/vegetable intake) by sex and age between AYA survivors and controls, and among survivors to determine the effects of demographic, QOL, psychosocial, and cancer factors on behaviors.

RESULTS

A greater proportion of female survivors of AYA cancer smoked than controls (currently aged 20-39: 27 vs. 14.3%, respectively; currently aged 40-64: 29.3 vs. 18.4%, respectively). Generally, survivors and controls were non-adherent to national health behavior guidelines. Uninsured survivors were at greater risk of smoking vs. insured (females, Relative Risk (RR) = 1.64, 95% confidence interval (CI) 1.43-1.90; males, RR = 2.62, 95% CI 1.71-4.02). Poor social/emotional support was associated with smoking (RR = 1.26, 95% CI 1.07-1.48) among female survivors and was associated with low fruit/vegetable intake among male (RR = 1.12, 95% CI 1.01-1.23) and female (RR= 1.12, 95% CI 1.05-1.19) survivors. Female survivors >10 years from diagnosis had higher risk of smoking (RR = 1.26-1.91, all p < 0.01) than survivors 5-10 years from diagnosis.

CONCLUSIONS

Unhealthy lifestyle behaviors are common in survivors of AYA cancer.

IMPLICATIONS FOR CANCER SURVIVORS

AYA survivors require health behavior support.

Effectiveness of the extended parallel process model in promoting colorectal cancer screening

OBJECTIVE

Relatives of colorectal cancer (CRC) patients are at increased risk for the disease, yet screening rates still remain low. Guided by the Extended Parallel Process Model, we examined the impact of a personalized, remote risk communication intervention on behavioral intention and colonoscopy uptake in relatives of CRC patients, assessing the original additive model and an alternative model in which each theoretical construct contributes uniquely.

METHODS

We collected intention-to-screen and medical record-verified colonoscopy information on 218 individuals who received the personalized intervention.

RESULTS

Structural equation modeling showed poor main model fit (root mean square error of approximation (RMSEA) = 0.109; standardized root mean residual (SRMR) = 0.134; comparative fit index (CFI) = 0.797; Akaike information criterion (AIC) = 11,601; Bayesian information criterion (BIC) = 11,884). However, the alternative model (RMSEA = 0.070; SRMR = 0.105; CFI = 0.918; AIC = 11,186; BIC = 11,498) showed good fit. Cancer susceptibility (B = 0.319, p < 0.001) and colonoscopy self-efficacy (B = 0.364, p < 0.001) perceptions predicted intention to screen, which was significantly associated with colonoscopy uptake (B = 0.539, p < 0.001).

CONCLUSIONS

Our findings provide support of the utility of Extended Parallel Process Model for designing effective interventions to motivate CRC screening in persons at increased risk when individual elements of the model are considered. Copyright © 2015 John Wiley & Sons, Ltd.

Efficacy of a Telehealth Intervention on Colonoscopy Uptake When Cost Is a Barrier: The Family CARE Cluster Randomized Controlled Trial

BACKGROUND

We tested the efficacy of a remote tailored intervention Tele-Cancer Risk Assessment and Evaluation (TeleCARE) compared with a mailed educational brochure for improving colonoscopy uptake among at-risk relatives of colorectal cancer patients and examined subgroup differences based on participant reported cost barriers.

METHODS

Family members of colorectal cancer patients who were not up-to-date with colonoscopy were randomly assigned as family units to TeleCARE (N = 232) or an educational brochure (N = 249). At the 9-month follow-up, a cost resource letter listing resources for free or reduced-cost colonoscopy was mailed to participants who had reported cost barriers and remained nonadherent. Rates of medically verified colonoscopy at the 15-month follow-up were compared on the basis of group assignment and within group stratification by cost barriers.

RESULTS

In intent-to-treat analysis, 42.7% of participants in TeleCARE and 24.1% of participants in the educational brochure group had a medically verified colonoscopy [OR, 2.37; 95% confidence interval (CI) 1.59-3.52]. Cost was identified as a barrier in both groups (TeleCARE = 62.5%; educational brochure = 57.0%). When cost was not a barrier, the TeleCARE group was almost four times as likely as the comparison to have a colonoscopy (OR, 3.66; 95% CI, 1.85-7.24). The intervention was efficacious among those who reported cost barriers; the TeleCARE group was nearly twice as likely to have a colonoscopy (OR, 1.99; 95% CI, 1.12-3.52).

CONCLUSIONS

TeleCARE increased colonoscopy regardless of cost barriers.

IMPACT

Remote interventions may bolster screening colonoscopy regardless of cost barriers and be more efficacious when cost barriers are absent.

An Exploratory Study of the Effects of Mind–Body Interventions Targeting Sleep on Salivary Oxytocin Levels in Cancer Survivors

Cancer survivors experience high levels of distress, associated with a host of negative psychological states, including anxiety, depression, and fear of recurrence, which often lead to sleep problems and reduction in quality of life (QOL) and well-being. As a neuropeptide hormone associated with affiliation, calmness, and well-being, oxytocin may be a useful biological measure of changes in health outcomes in cancer survivors. In this exploratory study, which comprised a subset of participants from a larger study, we evaluated ( a) the feasibility and reliability of salivary oxytocin (sOT) levels in cancer survivors and ( b) the effects of 2 sleep-focused mind–body interventions, mind–body bridging (MBB) and mindfulness meditation (MM), compared with a sleep hygiene education (SHE) control, on changes in sOT levels in 30 cancer survivors with self-reported sleep disturbance. Interventions were conducted in 3 sessions, once per week for 3 weeks. Saliva samples were collected at baseline, postintervention (~1 week after the last session), and at the 2-month follow-up. In this cancer survivor group, we found that intra-individual sOT levels were fairly stable across the 3 time points, of about 3 months’ duration, and mean baseline sOT levels did not differ between females and males and were not correlated with age. Correlations between baseline sOT and self-report measures were weak; however, several of these relationships were in the predicted direction, in which sOT levels were negatively associated with sleep problems and depression and positively associated with cancer-related QOL and well-being. Regarding intervention effects on sOT, baseline-subtracted sOT levels were significantly larger at postintervention in the MBB group as compared with those in SHE. In this sample of cancer survivors assessed for sOT, at postintervention, greater reductions in sleep problems were noted for MBB and MM compared with that of SHE, and increases in mindfulness and self-compassion were observed in the MBB group compared with those in SHE. The findings in this exploratory study suggest that sOT may be a reliable biological measure over time that may provide insight into the effects of mind–body interventions on health outcomes in cancer survivors.

Intention to undergo colonoscopy screening among relatives of colorectal cancer cases: a theory-based model

BACKGROUND

It is recommended that persons having familial risk of colorectal cancer begin regular colonoscopy screening at an earlier age than those in the general population. However, many individuals at increased risk do not adhere to these screening recommendations.

PURPOSE

The goal of this study was to examine cognitive, affective, social, and behavioral motivators of colonoscopy intention among individuals at increased risk of familial colorectal cancer.

METHODS

Relatives of colorectal cancer cases (N = 481) eligible for colonoscopy screening completed a survey assessing constructs from several theoretical frameworks including fear appeal theories.

RESULTS

Structural equation modeling indicated that perceived colorectal cancer risk, past colonoscopy, fear of colorectal cancer, support from family and friends, and health-care provider recommendation were determinants of colonoscopy intention.

CONCLUSIONS

Future interventions to promote colonoscopy in this increased risk population should target the factors we identified as motivators. (ClinicalTrials.gov number NCT01274143).

Expanding access to BRCA1/2 genetic counseling with telephone delivery: a cluster randomized trial

BACKGROUND

The growing demand for cancer genetic services underscores the need to consider approaches that enhance access and efficiency of genetic counseling. Telephone delivery of cancer genetic services may improve access to these services for individuals experiencing geographic (rural areas) and structural (travel time, transportation, childcare) barriers to access.

METHODS

This cluster-randomized clinical trial used population-based sampling of women at risk for BRCA1/2 mutations to compare telephone and in-person counseling for: 1) equivalency of testing uptake and 2) noninferiority of changes in psychosocial measures. Women 25 to 74 years of age with personal or family histories of breast or ovarian cancer and who were able to travel to one of 14 outreach clinics were invited to participate. Randomization was by family. Assessments were conducted at baseline one week after pretest and post-test counseling and at six months. Of the 988 women randomly assigned, 901 completed a follow-up assessment. Cluster bootstrap methods were used to estimate the 95% confidence interval (CI) for the difference between test uptake proportions, using a 10% equivalency margin. Differences in psychosocial outcomes for determining noninferiority were estimated using linear models together with one-sided 97.5% bootstrap CIs.

RESULTS

Uptake of BRCA1/2 testing was lower following telephone (21.8%) than in-person counseling (31.8%, difference = 10.2%, 95% CI = 3.9% to 16.3%; after imputation of missing data: difference = 9.2%, 95% CI = -0.1% to 24.6%). Telephone counseling fulfilled the criteria for noninferiority to in-person counseling for all measures.

CONCLUSIONS

BRCA1/2 telephone counseling, although leading to lower testing uptake, appears to be safe and as effective as in-person counseling with regard to minimizing adverse psychological reactions, promoting informed decision making, and delivering patient-centered communication for both rural and urban women.

Geography and the burden of care in pediatric cancers

BACKGROUND

Childhood cancers typically require rigorous treatment at specialized centers in urban areas, which can create substantial challenges for families residing in remote communities. We evaluated the impact of residence and travel time on the burden of care for families of childhood cancer patients.

PROCEDURE

We conducted a cross-sectional, self-administered survey of 354 caregivers of pediatric cancer patients at a children's hospital serving a seven state area. Measures included the impact of cancer treatment on relocation, employment, schooling, and finances. We evaluated these domains by rural/urban residence and travel time (>1 hour and >2 hours) to the hospital in multivariable regression models.

RESULTS

Of the 29% of caregivers who reported moving residences as their child was diagnosed, 33% reported that the move was due to their child's cancer. Rural and remote (e.g., >1 hour travel time) caregivers missed more days of work during the first month after diagnosis than did urban and local caregivers, however, these differences did not persist over the first 6 months of therapy. One-third of caregivers reported quitting or changing jobs as a direct result of their child being diagnosed with cancer. Rural respondents had greater out-of-pocket travel expenses and reported a significantly greater perceived financial burden. Rural patients missed more school days and were at an increased risk of having to repeat a grade.

CONCLUSIONS

Childhood cancer has an appreciable impact on the lives of patients and caregivers. The burden is greater for those living far from a treatment center.

Blood pressure, salivary cortisol, and inflammatory cytokine outcomes in senior female cancer survivors enrolled in a tai chi chih randomized controlled trial

PURPOSE

Older cancer survivors are a vulnerable population due to an increased risk for chronic diseases (e.g., cardiovascular disease) compounded with treatment late-effects and declines in physical functioning. Therefore, interventions that reduce chronic disease risk factors (i.e., blood pressure, chronic inflammation, and cortisol) are important in this population. Tai chi chih (TCC) is a mind-body exercise associated with reductions in chronic disease risk factors, but has not been examined with older cancer survivors. In a feasibility randomized controlled trial of TCC, we examined secondary outcomes of blood pressure, salivary cortisol, and inflammatory cytokines (interleukin (IL)-6, IL-12, tumor necrosis factor-α, IL-10, IL-4) due to their implications in chronic diseases.

METHODS

Sixty-three senior female cancer survivors (M age = 67 years, SD = 7.15) with physical functioning limitations (SF-12 physical functioning ≤80 or role-physical ≤72) were randomized to 12-weeks (60-min, three times a week) of TCC or Health Education control (HEC) classes. Resting blood pressure, 1-day salivary cortisol samples, and fasting plasma samples for cytokine multiplex assays were collected at baseline and 1-week post-intervention.

RESULTS

Controlling for baseline values, the TCC group had significantly lower systolic blood pressure (SBP, p = 0.002) and cortisol area-under-curve (AUC, p = 0.02) at post-intervention than the HEC group. There was no intervention effect on inflammatory cytokines (p's > 0.05).

CONCLUSIONS

This TCC feasibility trial was associated with significant reductions in SBP and cortisol AUC in senior female cancer survivors. Larger, definitive trials are needed to confirm these findings.

IMPLICATIONS FOR CANCER SURVIVORS

Senior survivors' have an increased risk for chronic diseases; however, TCC interventions may help reduce associated risk factors.

Risk of hospitalization for survivors of childhood and adolescent cancer

BACKGROUND

Childhood cancer survivors may be at increased risk of hospitalization because of cancer-related late effects.

METHODS

Using data from population-based research resources in Utah, we identified childhood and adolescent cancer survivors who were diagnosed from 1973 to 2005 (N = 2,571). We selected a comparison cohort based on birth year and sex (N = 7,713). Hospitalizations from 1996 to 2010, excluding pregnancy and delivery, were determined from discharge records. Multivariable regressions were used to evaluate hospitalization admissions, length of stay, and diagnosis for survivors starting five years from diagnosis versus the comparison cohort.

RESULTS

When follow-up began in 1996, there were N = 1,499 survivors and N = 7,219 comparisons who were alive and eligible for follow-up. Average follow-up for survivors was 13.5 years (SD = 8.5) and for the comparison 14.0 years (SD = 8.7; P = 0.05). Survivors were hospitalized, on average, 1.62 (SD = 3.37) times contrasted to 0.79 (SD = 1.73) for the comparison cohort. In multivariable analyses, the hazard ratio (HR) of any hospitalization since 1996 was higher for survivors than the comparison cohort [HR, 1.52, 95% confidence interval (CI), 1.31-1.66]. Survivors experienced a higher hospital admission rate [rate ratio (RR) = 1.67; 95% CI, 1.58-1.77] than the comparison cohort. The number of hospitalizations was highest for neuroblastoma (RR = 2.21; 95% CI, 1.84-2.66) and bone tumors (RR = 2.55; 95% CI, 2.14-3.02) in reference to the comparison cohort. Survivors were hospitalized because of blood disorders more often (HR, 14.2; 95% CI, 6.3-32.0).

CONCLUSIONS

The risk of hospitalization and lengths of stay are elevated among childhood cancer survivors.

IMPACT

Research to identify strategies to prevent and manage survivors' health problems in outpatient settings is needed.

Sociodemographic Disparities in Quality of Life for Survivors of Adolescent and Young Adult Cancers in the Behavioral Risk Factor Surveillance System

Purpose: Survivors of cancer diagnosed during adolescence and young adulthood (AYA; aged 15-39) may experience quality of life (QOL) limitations; however, little is known about QOL for AYA survivors who are now middle-aged or among racial/ethnic minority survivors. We evaluated QOL outcomes for AYA cancer survivors relative to a non-cancer comparison group by gender, race/ethnicity, and current age. Methods: Using the 2009 Behavioral Risk Factor Surveillance System (BRFSS) data, we identified 8375 individuals diagnosed with cancer while aged 15-39 years old and 334,759 controls. Participants were currently ≥20 years of age. QOL was measured using four items from the Center for Disease Control's Healthy Days Measure (general health, number of days of poor physical and mental health, and activity limitation days). Multivariable regressions compared these measures for survivors and controls by gender, race/ethnicity, and age, and among survivors to determine cancer-related factors associated with poor QOL. Results: Survivors were more likely to report fair/poor general health than controls (relative risk=1.92; 95% confidence interval: 1.77-2.10; p<0.001). QOL limitations existed by gender and race/ethnicity for survivors. Approximately 30% of survivors currently in their 40s, 50s, and early 60s were in poor health, compared to less than 20% of same-aged controls (both p<0.001). Of survivors with two or more cancers, 41.0% reported poor health, compared to 26.2% with one cancer (p<0.001). Conclusion: AYA cancer survivors have worse QOL compared to the general population and these limitations persist across gender, race/ethnicity, and age. Targeted interventions are essential for improving AYA cancer survivors' health status.

Association between individual and geographic factors and nonadherence to mammography screening guidelines

BACKGROUND

This study investigates factors that are associated with nonadherence to mammography screening guidelines in Utah, a state where mammography screening rates have remained consistently lower than national averages.

METHODS

We examined data on reported mammography use among women aged 40-74 years from the 2008 and 2010 Utah Behavioral Risk Factor Surveillance System (n=5,197, weighted n=417,064). Logistic regression models were used to estimate the effects of individual-level and geographic (travel time to nearest mammography facility, geographic accessibility, and rural/urban residence) factors on the odds of a woman not reporting receiving a mammogram in the last 2 years.

RESULTS

In 2008 and 2010, a disproportionate number of women aged 40-49 (43.1%, 95% confidence interval [CI] 39.9%-46.3%) reported not receiving a mammogram within the last 2 years compared to women 50-74 (26.8%, 95% CI 24.9%-28.7%). None of the geographic factors were significant predictors of screening adherence. Based on covariate adjusted models, statistically significant (p<0.05) factors associated with increased odds of not receiving mammogram within the last 2 years included not having a regular physician, no health insurance, being aged 40-49, income less than $25,000, and the presence of three or more children in the home.

CONCLUSION

Mammography screening efforts in Utah should focus on improving access to insurance or a regular source of health care. Future research should also consider how best to address extreme time demands and competing priorities that present potential barriers for women with large families, resulting in lower screening levels among these women.

Preferences for blood-based colon cancer screening differ by race/ethnicity

OBJECTIVES

To examine attitudes of a diverse community-based sample toward SEPT9, a simple, cost-effective colorectal cancer (CRC) blood test.

METHODS

One-hundred participants eligible for CRC screening (Mage =58.3; 44% unscreened; 38% white, 31% Hispanic, 31% black) completed cross-sectional surveys of their screening preferences following group discussions of colonoscopy, sigmoidoscopy, FOBT, and SEPT9.

RESULTS

Overall, 91% ranked SEPT9 first or second. Controlling for sociodemographic factors, unscreened Whites strongly preferred SEPT9, listing multiple advantages, whereas unscreened Blacks preferred colonoscopy. Only 19% of the sample listed negative aspects.

CONCLUSION

Blood-based screening for CRC was widely favored. Future research on medical decision-making should examine the basis for racial/ethnic differences in biomarker screening preferences.

Long-term risk of medical conditions associated with breast cancer treatment

Early and late effects of cancer treatment are of increasing concern with growing survivor populations, but relevant data are sparse. We sought to determine the prevalence and hazard ratio of such effects in breast cancer cases. Women with invasive breast cancer and women with no cancer history recruited for a cancer research cohort completed a mailed questionnaire at a median of 10 years post-diagnosis or matched reference year (for the women without cancer). Reported medical conditions including lymphedema, osteopenia, osteoporosis, and heart disease (congestive heart failure, myocardial infarction, coronary heart disease) were assessed in relation to breast cancer therapy and time since diagnosis using Cox regression. The proportion of women currently receiving treatment for these conditions was calculated. Study participants included 2,535 women with breast cancer and 2,428 women without cancer (response rates 66.0 % and 50.4 %, respectively) Women with breast cancer had an increased risk of lymphedema (Hazard ratio (HR) 8.6; 95 % confidence interval (CI) 6.3-11.6), osteopenia (HR 2.1; 95 % CI 1.8-2.4), and osteoporosis (HR 1.5; 95 % CI 1.2-1.9) but not heart disease, compared to women without cancer Hazard ratios varied by treatment and time since diagnosis. Overall, 49.3 % of breast cancer cases reported at least one medical condition, and at 10 or more years post-diagnosis, 37.7 % were currently receiving condition-related treatment. Responses from survivors a decade following cancer diagnosis demonstrate substantial treatment-related morbidity, and emphasize the need for continued medical surveillance and follow-up care into the second decade post-diagnosis.

Quality of Life and Comorbidities Impact Education and Employment for Survivors of Adolescent and Young Adult Cancers

Survivors of adolescent and young adult (AYA) cancers have a high risk of chronic conditions such as cardiovascular disease and asthma. These conditions may affect their ability to attend school or to work. We examined the impact of quality of life (QOL) and comorbidities on educational attainment and employment status for survivors of AYA cancers relative to a non-cancer comparison group. Methods: Using data from the 2009 Behavioral Risk Factor Surveillance System (BRFSS), we identified 7,471 individuals who were diagnosed with cancer between ages 15 and 39 and were ≥5 years from diagnosis and 326,821 controls without a history of cancer. Participants were ≥25 years of age. QOL was measured by a general health measure (excellent/very good/good/fair/poor). Comorbidities included self-reported cardiovascular disease, hypertension, asthma, and diabetes. Multivariable regressions using BRFSS survey weights were adjusted for sex, race/ethnicity and age, and compared the effects of QOL and comorbidities on educational attainment (college graduate or more vs. less education) and being employed or unable to work (compared to out of work or not in labor force) among the survivor and control groups. Results: Compared to controls, survivors in fair-poor health were less likely to be college graduates or more (survivors 18.5% vs. controls 37.9%, p &lt; 0.01) and less likely to be employed (survivors 31.7% vs. controls 61.6%, p &lt; 0.001), whereas survivors in good-excellent health did not differ from controls for either outcome. In addition, survivors in fair-poor health self-reported being unable to work more often than controls (31.4% vs. 5.4%, respectively; p &lt; 0.001). For comorbidities, inability to work ranged from 14.9% of survivors with hypertension to 27.9% of survivors with cardiovascular conditions compared to 5.4% of controls (all p &lt; 0.001), while survivors with no comorbidities did not differ from controls. Conclusions: AYA cancer survivors with ongoing health problems may face educational or work-related limitations. Early detection and management of health problems could help AYA cancer survivors control health problems before their ability to attend school or employment is disrupted.

Telehealth personalized cancer risk communication to motivate colonoscopy in relatives of patients with colorectal cancer: the family CARE Randomized controlled trial

PURPOSE

The rate of adherence to regular colonoscopy screening in individuals at increased familial risk of colorectal cancer (CRC) is suboptimal, especially among rural and other geographically underserved populations. Remote interventions may overcome geographic and system-level barriers. We compared the efficacy of a telehealth-based personalized risk assessment and communication intervention with a mailed educational brochure for improving colonoscopy screening among at-risk relatives of patients with CRC.

METHODS

Eligible individuals age 30 to 74 years who were not up-to-date with risk-appropriate screening and were not candidates for genetic testing were recruited after contacting patients with CRC or their next of kin in five states. Enrollees were randomly assigned as family units to either an active, personalized intervention that incorporated evidence-based risk communication and behavior change techniques, or a mailed educational brochure. The primary outcome was medically verified colonoscopy within 9 months of the intervention.

RESULTS

Of the 481 eligible and randomly assigned at-risk relatives, 79.8% completed the outcome assessments within 9 months; 35.4% of those in the personalized intervention group and 15.7% of those in the comparison group obtained a colonoscopy. In an intent-to-treat analysis, the telehealth group was almost three times as likely to get screened as the low-intensity comparison group (odds ratio, 2.83; 95% CI, 1.87 to 4.28; P < .001). Persons residing in rural areas and those with lower incomes benefitted at the same level as did urban residents.

CONCLUSION

Remote personalized interventions that consider family history and incorporate evidence-based risk communication and behavior change strategies may promote risk-appropriate screening in close relatives of patients with CRC.

A randomized trial to increase colonoscopy screening in members of high-risk families in the colorectal cancer family registry and cancer genetics network

BACKGROUND

Individuals with a strong family history of colorectal cancer have significant risk for colorectal cancer, although adherence to colonoscopy screening in these groups remains low. This study assessed whether a tailored telephone counseling intervention can increase adherence to colonoscopy in members of high-risk families in a randomized, controlled trial.

METHODS

Eligible participants were recruited from two national cancer registries if they had a first-degree relative with colorectal cancer under age 60 or multiple affected family members, which included families that met the Amsterdam criteria for hereditary non-polyposis colon cancer (HNPCC), and if they were due for colonoscopy within 24 months. Participants were randomized to receive a tailored telephone intervention grounded in behavioral theory or a mailed packet with general information about screening. Colonoscopy status was assessed through follow-up surveys and endoscopy reports. Cox proportional hazards models were used to assess intervention effect.

RESULTS

Of the 632 participants (ages 25-80), 60% were female, the majority were White, non-Hispanic, educated, and had health insurance. Colonoscopy adherence increased 11 percentage points in the tailored telephone intervention group, compared with no significant change in the mailed group. The telephone intervention was associated with a 32% increase in screening adherence compared with the mailed intervention (HR, 1.32; P = 0.01).

CONCLUSIONS

A tailored telephone intervention can effectively increase colonoscopy adherence in high-risk persons. This intervention has the potential for broad dissemination to healthcare organizations or other high-risk populations.

IMPACT

Increasing adherence to colonoscopy among persons with increased colorectal cancer risk could effectively reduce incidence and mortality from this disease.

Randomized noninferiority trial of telephone versus in-person genetic counseling for hereditary breast and ovarian cancer

PURPOSE

Although guidelines recommend in-person counseling before BRCA1/BRCA2 gene testing, genetic counseling is increasingly offered by telephone. As genomic testing becomes more common, evaluating alternative delivery approaches becomes increasingly salient. We tested whether telephone delivery of BRCA1/2 genetic counseling was noninferior to in-person delivery.

PATIENTS AND METHODS

Participants (women age 21 to 85 years who did not have newly diagnosed or metastatic cancer and lived within a study site catchment area) were randomly assigned to usual care (UC; n = 334) or telephone counseling (TC; n = 335). UC participants received in-person pre- and post-test counseling; TC participants completed all counseling by telephone. Primary outcomes were knowledge, satisfaction, decision conflict, distress, and quality of life; secondary outcomes were equivalence of BRCA1/2 test uptake and costs of delivering TC versus UC.

RESULTS

TC was noninferior to UC on all primary outcomes. At 2 weeks after pretest counseling, knowledge (d = 0.03; lower bound of 97.5% CI, -0.61), perceived stress (d = -0.12; upper bound of 97.5% CI, 0.21), and satisfaction (d = -0.16; lower bound of 97.5% CI, -0.70) had group differences and confidence intervals that did not cross their 1-point noninferiority limits. Decision conflict (d = 1.1; upper bound of 97.5% CI, 3.3) and cancer distress (d = -1.6; upper bound of 97.5% CI, 0.27) did not cross their 4-point noninferiority limit. Results were comparable at 3 months. TC was not equivalent to UC on BRCA1/2 test uptake (UC, 90.1%; TC, 84.2%). TC yielded cost savings of $114 per patient.

CONCLUSION

Genetic counseling can be effectively and efficiently delivered via telephone to increase access and decrease costs.

Interest and informational preferences regarding genomic testing for modest increases in colorectal cancer risk

BACKGROUND/AIMS

This study explored the interest in genomic testing for modest changes in colorectal cancer risk and preferences for receiving genomic risk communications among individuals with intermediate disease risk due to a family history of colorectal cancer.

METHODS

Surveys were conducted on 272 men and women at intermediate risk for colorectal cancer enrolled in a randomized trial comparing a remote personalized risk communication intervention (TeleCARE) aimed at promoting colonoscopy to a generic print control condition. Guided by Leventhal's Common Sense Model of Self-Regulation, we examined demographic and psychosocial factors possibly associated with interest in SNP testing. Descriptive statistics and logistic regression models were used to identify factors associated with interest in SNP testing and preferences for receiving genomic risk communications.

RESULTS

Three-fourths of participants expressed interest in SNP testing for colorectal cancer risk. Testing interest did not markedly change across behavior modifier scenarios. Participants preferred to receive genomic risk communications from a variety of sources: printed materials (69.5%), oncologists (54.8%), primary-care physicians (58.4%), and the web (58.1%). Overall, persons who were unmarried (p = 0.029), younger (p = 0.003) and with greater cancer-related fear (p = 0.019) were more likely to express interest in predictive genomic testing for colorectal cancer risk. In a stratified analysis, cancer-related fear was associated with the interest in predictive genomic testing in the intervention group (p = 0.017), but not the control group.

CONCLUSIONS

Individuals with intermediate familial risk for colorectal cancer are highly interested in genomic testing for modest increases in disease risk, specifically unmarried persons, younger age groups and those with greater cancer fear.

A population-based study of childhood cancer survivors' body mass index

Background. Population-based studies are needed to estimate the prevalence of underweight or overweight/obese childhood cancer survivors. Procedure. Adult survivors (diagnosed ≤20 years) were identified from the linked Utah Cancer Registry and Utah Population Database. We included survivors currently aged ≥20 years and ≥5 years from diagnosis (N = 1060), and a comparison cohort selected on birth year and sex (N = 5410). BMI was calculated from driver license data available from 2000 to 2010. Multivariable generalized linear regression models were used to calculate prevalence relative risks (RR) and 95% confidence intervals (95% CI) of BMI outcomes for survivors and the comparison cohort. Results. Average time since diagnosis was 18.5 years (SD = 7.8), and mean age at BMI for both groups was 30.5 (survivors SD = 7.7, comparison SD = 8.0). Considering all diagnoses, survivors were not at higher risk for being underweight or overweight/obese than the comparison. Male central nervous system tumor survivors were overweight (RR = 1.12, 95% CI 1.01-1.23) more often than the comparison. Female survivors, who were diagnosed at age 10 and under, had a 10% higher risk of being obese than survivors diagnosed at ages 16-20 (P < 0.05). Conclusion. While certain groups of childhood cancer survivors are at risk for being overweight/obese, in general they do not differ from population estimates.

Preoperative dynamic contrast-enhanced MRI correlates with molecular markers of hypoxia and vascularity in specific areas of intratumoral microenvironment and is predictive of patient outcome

BACKGROUND

Measures of tumor vascularity and hypoxia have been correlated with glioma grade and outcome. Dynamic contrast-enhanced (DCE) MRI can noninvasively map tumor blood flow, vascularity, and permeability. In this prospective observational cohort pilot study, preoperative imaging was correlated with molecular markers of hypoxia, vascularity, proliferation, and progression-free and overall patient survival.

METHODS

Pharmacokinetic modeling methods were used to generate maps of tumor blood flow, extraction fraction, permeability-surface area product, transfer constant, washout rate, interstitial volume, blood volume, capillary transit time, and capillary heterogeneity from preoperative DCE-MRI data in human glioma patients. Tissue was obtained from areas of peritumoral edema, active tumor, hypoxic penumbra, and necrotic core and evaluated for vascularity, proliferation, and expression of hypoxia-regulated molecules. DCE-MRI parameter values were correlated with hypoxia-regulated protein expression at tissue sample sites.

RESULTS

Patient survival correlated with DCE parameters in 2 cases: capillary heterogeneity in active tumor and interstitial volume in areas of peritumoral edema. Statistically significant correlations were observed between several DCE parameters and tissue markers. In addition, MIB-1 index was predictive of overall survival (P = .044) and correlated with vascular endothelial growth factor expression in hypoxic penumbra (r = 0.7933, P = .0071) and peritumoral edema (r = 0.4546). Increased microvessel density correlated with worse patient outcome (P = .026).

CONCLUSIONS

Our findings suggest that DCE-MRI may facilitate noninvasive preoperative predictions of areas of tumor with increased hypoxia and proliferation. Both imaging and hypoxia biomarkers are predictive of patient outcome. This has the potential to allow unprecedented prognostic decisions and to guide therapies to specific tumor areas.

Levels of fatigue and distress in senior prostate cancer survivors enrolled in a 12-week randomized controlled trial of Qigong

PURPOSE

Fatigue is a commonly reported symptom by prostate cancer survivors and is associated with significant distress and declines in quality of life. Qigong is a mind-body activity that consists of both physical activity and meditative aspects. This 12-week randomized controlled trial examined the feasibility and efficacy of a Qigong intervention for improving older prostate cancer survivors' levels of fatigue and distress.

METHODS

Forty older (median age = 72, range = 58-93), fatigued (cut-off value of ≥ 1 on the CTCAEv4.0, >20 on a fatigue grading scale), and sedentary (<150 min of moderate exercise/week) prostate cancer survivors were randomized to 12 weeks of Qigong or stretching classes. Primary outcomes were feasibility (i.e., retention and class attendance rates) and fatigue [Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-Fatigue)], and secondary outcome was distress [Brief Symptom Inventory-18 (BSI-18)].

RESULTS

Study retention rates did not significantly differ between study groups (Qigong = 80 %, stretching = 65 %, p = 0.48). The Qigong group had significantly higher class attendance than the stretching group (p = 0.04). The Qigong group had significantly greater improvements in the FACIT-Fatigue (p = 0.02) and distress (i.e., BSI-18 Somatization, Anxiety, & Global Severity Index, p's < 0.05), than the Stretching group.

CONCLUSIONS

This 12-week Qigong intervention was feasible and potentially efficacious in improving senior prostate cancer survivors' levels of fatigue and distress levels. Future, larger definitive randomized controlled trials are needed to confirm these benefits in older prostate cancer survivors and in racially and ethnically diverse populations.

IMPLICATIONS FOR CANCER SURVIVORS

Qigong may be an effective nonpharmacological intervention for the management of senior prostate cancer survivors' fatigue and distress.

Childhood cancer survivors' familiarity with and opinions of the Patient Protection and Affordable Care Act

PURPOSE

The Patient Protection and Affordable Care Act (ACA) offers avenues to increase insurance options and access to care; however, it is unknown whether populations with pre-existing conditions, such as cancer survivors, will benefit from the expanded coverage options. We explored childhood cancer survivors' familiarity with and opinion of the ACA to understand how survivors' insurance coverage may be affected.

MATERIALS AND METHODS

From April to July 2012 we conducted in-depth, semistructured telephone interviews with 53 adult survivors recruited from the Utah Cancer SEER Registry. Participants were randomly selected from sex, age, and rural/urban strata and were younger than 21 years at time of diagnosis. Interviews were recorded, transcribed, and analyzed with NVivo 9 by two coders (kappa=0.94). We report on the 49 participants who had heard of the ACA.

RESULTS

Most survivors were unaware of ACA provisions beyond the insurance mandate. Few knew about coverage for children up to age 26 or pre-existing insurance options. Although one third believed the ACA could potentially benefit them via expanded insurance coverage, many were concerned that the ACA would lead to rising health care costs and decreasing quality of care. Survivors had concerns specific to their cancer history, including fears of future health care rationing if they developed subsequent health problems.

CONCLUSION

Childhood cancer survivors have a low level of familiarity with the ACA and are unaware of how it may affect them given their cancer history. These survivors require targeted education to increase knowledge about the ACA.

Patient and provider attitudes toward genomic testing for prostate cancer susceptibility: a mixed method study

BACKGROUND

The strong association between family history and prostate cancer (PCa) suggests a significant genetic contribution, yet specific highly penetrant PCa susceptibility genes have not been identified. Certain single-nucleotide-polymorphisms have been found to correlate with PCa risk; however uncertainty remains regarding their clinical utility and how to best incorporate this information into clinical decision-making. Genetic testing is available directly to consumers and both patients and healthcare providers are becoming more aware of this technology. Purchasing online allows patients to bypass their healthcare provider yet patients may have difficulty interpreting test results and providers may be called upon to interpret results. Determining optimal ways to educate both patients and providers, and strategies for appropriately incorporating this information into clinical decision-making are needed.

METHODS

A mixed-method study was conducted in Utah between October 2011 and December 2011. Eleven focus group discussions were held and surveys were administered to 23 first-degree relatives of PCa patients living in Utah and 24 primary-care physicians and urologists practicing in Utah to present specific information about these assessments and determine knowledge and attitudes regarding health implications of using these assessments.

RESULTS

Data was independently coded by two researchers (relative Kappa = .88; provider Kappa = .77) and analyzed using a grounded theory approach. Results indicated differences in attitudes and behavioral intentions between patient and provider. Despite the test's limitations relatives indicated interest in genetic testing (52%) while most providers indicated they would not recommend the test for their patients (79%). Relatives expected providers to interpret genetic test results and use results to provide personalized healthcare recommendations while the majority of providers did not think the information would be useful in patient care (92%) and indicated low-levels of genetic self-efficacy.

CONCLUSIONS

Although similarities exist, discordance between provider and patient attitudes may influence the effective translation of novel genomic tests into clinical practice suggesting both patient and provider perceptions and expectations be considered in development of clinical decision-support tools.

Rural vs urban residence affects risk-appropriate colorectal cancer screening

BACKGROUND & AIMS

Little is known about the effects of geographic factors, such as rural vs urban residence and travel time to colonoscopy providers, on risk-appropriate use of colorectal cancer (CRC) screening in the general population. We evaluated the effects of geographic factors on adherence to CRC screening and differences in screening use among familial risk groups.

METHODS

We analyzed data from the 2010 Utah Behavior Risk Factor Surveillance System, which included state-added questions on familial CRC. By using multiple logistic regression models, we assessed the effects of rural vs urban residence, travel time to the nearest colonoscopy provider, and spatial accessibility of providers on adherence to risk-appropriate screening guidelines. Study participants (n = 4260) were respondents aged 50 to 75 years.

RESULTS

Sixty-six percent of the sample adhered to risk-appropriate CRC screening guidelines, with significant differences between urban and rural residents (68% vs 57%, respectively; P < .001) across all familial risk groups. Rural residents were less likely than urban dwellers to be up-to-date with screening guidelines (multivariate odds ratio, 0.65; 95% confidence interval, 0.53-0.79). In the unadjusted analysis, rural vs urban residence (P < .001), travel time to the nearest colonoscopy provider (P = .003), and spatial accessibility of providers (P = .012) were associated significantly with adherence to screening guidelines. However, rural vs urban residence (P < .001) was the only geographic variable independently associated with screening adherence in the adjusted analyses.

CONCLUSIONS

There are marked disparities in use of risk-appropriate CRC screening between rural and urban residents in Utah. Differences in travel time to the nearest colonoscopy provider and spatial accessibility of providers did not account for the geographic variations observed in screening adherence.

Examining the challenges of family recruitment to behavioral intervention trials: factors associated with participation and enrollment in a multi-state colonoscopy intervention trial

BACKGROUND

Colonoscopy is one of the most effective methods of cancer prevention and detection, particularly for individuals with familial risk. Recruitment of family members to behavioral intervention trials remains uniquely challenging, owing to the intensive process required to identify and contact them. Recruiting at-risk family members involves contacting the original cancer cases and asking them to provide information about their at-risk relatives, who must then be contacted for study enrollment. Though this recruitment strategy is common in family trials, few studies have compared influences of patient and relative participation to nonparticipation. Furthermore, although use of cancer registries to identify initial cases has increased, to our knowledge no study has examined the relationship between registries and family recruitment outcomes.

METHODS

This study assessed predictors of case participation and relative enrollment in a recruitment process that utilized state cancer registries. Participation characteristics were analyzed with separate multivariable logistic regressions in three stages: (1) cancer registry-contacted colorectal cancer (CRC) cases who agreed to study contact; (2) study-contacted CRC cases who provided at-risk relative information; and (3) at-risk relatives contacted for intervention participation.

RESULTS

Cancer registry source was predictive of participation for both CRC cases and relatives, though relative associations (odds ratios) varied across registries. Cases were less likely to participate if they were Hispanic or nonwhite, and were more likely to participate if they were female or younger than 50 at cancer diagnosis. At-risk relatives were more likely to participate if they were from Utah, if another family member was also participating in the study, or if they had previously had a colonoscopy. The number of eligible cases who had to be contacted to enroll one eligible relative varied widely by registry, from 7 to 81.

CONCLUSIONS

Family recruitment utilizing cancer registry-identified cancer cases is feasible, but highly dependent on both the strategies and protocols of those who are recruiting and on participant characteristics such as sex, race, or geography. Devising comprehensive recruitment protocols that specifically target those less likely to enroll may help future research meet recruitment goals.

TRIAL REGISTRATION

Family Colorectal Cancer Awareness and Risk Education Project NCT01274143.

Feasibility and acceptability of a Tai Chi Chih randomized controlled trial in senior female cancer survivors

OBJECTIVE

The purpose of this randomized controlled trial (RCT) was to examine the feasibility and acceptability of a Tai Chi Chih (TCC) intervention in senior female cancer survivors with physical functioning limitations, and its effects on health-related quality of life (QOL).

DESIGN

This was a two-armed, parallel group, RCT with 12-weeks of Tai Chi Chih or Health Education Control.

METHODS

Sixty-three senior (M age = 67 years, SD = 7.15) female cancer survivors (83% breast cancer, stages I-III) with physical functioning limitations (SF-12 Health Survey role-physical & physical functioning subscales) were randomized to 12-weeks of TCC or Health Education control (HEC). Primary outcomes were feasibility and acceptability. Secondary outcomes included health-related QOL (SF-36 Health Survey), and participants' qualitative feedback on the intervention.

RESULTS

Retention (TCC = 91%; HEC = 81%) and class attendance (TCC = 79%; HEC = 83%) rates, and satisfaction levels for both study arms were high, but did not significantly differ from one another. At one-week post-intervention, none of the SF-36 scores differed between the TCC and HEC groups. Within-group analyses revealed significant improvements in the mental component summary score in TCC (p = 0.01), but not in HEC. Qualitative analyses indicated that the TCC group felt they received mental and physical benefits, whereas HEC group reported on social support benefits and information received.

CONCLUSION

The TCC intervention was found to be a feasible and acceptable modality for senior female cancer survivors. Future, larger definitive trials are needed to clarify TCC dosage effects on QOL in this vulnerable population.

Abstract A39: Health care barriers for rural and urban adult survivors of child and adolescent cancer

Introduction: By 30 years after diagnosis, 73% of child and adolescent cancer survivors develop at least one chronic health condition. However, there is little information on the health care needs of rural adults treated for child and adolescent cancer and whether they lack access to care to identify and manage chronic health problems. We explored health care barriers of rural and urban adult survivors of childhood and adolescent cancer.

Methods: We performed semi-structured interviews with 36 adult survivors (currently ages 19-56; mean=41.3 years) identified by Utah Cancer SEER Registry. Eligible survivors were diagnosed before age 21 from 1973-2005. We randomly selected participants from gender, age (18-29, 30-45, and 46-60), and rural/urban strata (rural defined as living in a county with less than 75% of population in an urban area [population ≥2,500]). Interviews were performed from April-June 2012. We asked survivors questions about their health insurance coverage, current use of health care, and barriers to accessing care, and whether they discussed their cancer history with their current provider. Interviews were recorded, transcribed, and analyzed for themes using NVivo 9. Themes were compared by urban and rural status.

Results: Half of participants were male and 90% (N=34) were white. The average age at diagnosis was 12.6 years (SD=6.7). The most common cancers were gonad/germ cell (N=8; 22%), leukemia (N=7; 19%), and lymphoma (N=6, 17%). A total of 15 survivors were rural and 21 urban. The majority of both urban and rural survivors were insured.

Common themes among both rural and urban survivors included: general satisfaction about the services covered by their health insurers, concern about increasing insurance costs, and a history of being denied insurance in the past due to their cancer. Most survivors had a primary health care provider; however, urban survivors described seeing specialty providers more often than rural survivors. About half of survivors discussed their cancer diagnosis and treatment with their current primary care provider. Barriers to discussing their cancer history with providers included a belief that their cancer was in the past so there was no need to discuss it with providers, an impression that their providers did not think their cancer history was worth discussing, and a belief that health problems would have already emerged because their cancer diagnosis and treatment occurred years ago.

Health care barriers described only by rural survivors included: difficulty finding quality health care for specific health problems, limitations in finding providers that were familiar with cancer survivors, and having to drive long distances to see providers. Interestingly, most rural survivors were willing to travel long distances to get the care they needed.

Conclusions: Survivors were generally satisfied with their health insurance, but were concerned about future coverage. Despite access to primary care providers, many survivors are unaware of their health risks and do not discuss their cancer history with their providers. Rural survivors lack access to providers who are knowledgeable about cancer and specialty care to screen for specific health conditions. Both rural and urban child and adolescent cancer survivors and their health care providers require education about the risk of late effects from childhood cancer.

Citation Format: Anne C. Kirchhoff, Echo L. Warner, Elyse R. Park, Roberto E. Montenegro, Jennifer Wright, Antoinette M. Stroup, Mark Fluchel, Anita Y. Kinney. Health care barriers for rural and urban adult survivors of child and adolescent cancer. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr A39.

A randomized trial comparing the effect of two phone-based interventions on colorectal cancer screening adherence

BACKGROUND

Early-stage diagnosis of colorectal cancer is associated with high survival rates; screening prevalence, however, remains suboptimal.

PURPOSE

This study seeks to test the hypothesis that participants receiving telephone-based tailored education or motivational interviewing had higher colorectal cancer screening completion rates compared to usual care.

METHODS

Primary care patients not adherent with colorectal cancer screening and with no personal or family history of cancer (n = 515) were assigned by block randomization to control (n = 169), tailored education (n = 168), or motivational interview (n = 178). The response rate was 70%; attrition was 24%.

RESULTS

Highest screening occurred in the tailored education group (23.8%, p < .02); participants had 2.2 times the odds of completing a post-intervention colorectal cancer screening than did the control group (AOR = 2.2, CI = 1.2-4.0). Motivational interviewing was not associated with significant increase in post-intervention screening.

CONCLUSIONS

Tailored education showed promise as a feasible strategy to increase colorectal cancer screening.

Clinically relevant changes in family history of cancer over time

CONTEXT

Knowledge of family cancer history is important for assessing cancer risk and guiding screening recommendations.

OBJECTIVE

To quantify how often throughout adulthood clinically significant changes occur in cancer family history that would result in recommendations for earlier or intense screening.

DESIGN AND SETTING

Descriptive study examining baseline and follow-up family history data from participants in the Cancer Genetics Network (CGN), a US national population-based cancer registry, between 1999 and 2009.

PARTICIPANTS

Adults with a personal history, family history, or both of cancer enrolled in the CGN through population-based cancer registries. Retrospective colorectal, breast, and prostate cancer screening-specific analyses included 9861, 2547, and 1817 participants, respectively; prospective analyses included 1533, 617, and 163 participants, respectively. Median follow-up was 8 years (range, 0-11 years). Screening-specific analyses excluded participants with the cancer of interest.

MAIN OUTCOME MEASURES

Percentage of individuals with clinically significant family histories and rate of change over 2 periods: (1) retrospectively, from birth until CGN enrollment and (2) prospectively, from enrollment to last follow-up.

RESULTS

Retrospective analysis revealed that the percentages of participants who met criteria for high-risk screening based on family history at ages 30 and 50 years, respectively, were as follows: for colorectal cancer, 2.1% (95% confidence interval [CI], 1.8%-2.4%) and 7.1% (95% CI, 6.5%-7.6%); for breast cancer, 7.2% (95% CI, 6.1%-8.4%) and 11.4% (95% CI, 10.0%-12.8%); and for prostate cancer, 0.9% (95% CI, 0.5%-1.4%) and 2.0% (95% CI, 1.4%-2.7%). In prospective analysis, the numbers of participants who newly met criteria for high-risk screening based on family history per 100 persons followed up for 20 years were 2 (95% CI, 0-7) for colorectal cancer, 6 (95% CI, 2-13) for breast cancer, and 8 (95% CI, 3-16) for prostate cancer. The rate of change in cancer family history was similar for colorectal and breast cancer between the 2 analyses.

CONCLUSION

Clinically relevant family history of colorectal, breast, and prostate cancer that would result in recommendations for earlier or intense cancer screening increases between ages 30 and 50 years, although the absolute rate is low for prostate cancer.

Motivation-based intervention to promote colonoscopy screening: an integration of a fear management model and motivational interviewing

Colorectal cancer (CRC) screening rates have been low despite effectiveness of screening in reducing CRC mortality. This article outlines the theoretical background and development of an innovative, telephone-based risk communication designed to promote screening among individuals at increased risk for familial CRC. This ongoing intervention integrates the Extended Parallel Process Model of fear management and the motivational interviewing counselling style. Tailoring and implementation intentions are incorporated. The primary outcome is self-reported colonoscopy within nine months following intervention. If proven effective, the remote intervention could be broadly disseminated to individuals at increased familial CRC risk, especially those in geographically underserved areas.

Psychosocial risk profiles among black male Veterans Administration patients non-adherent with colorectal cancer screening

OBJECTIVE

This study identifies unique psychosocial characteristics among African American men that put the men at risk for non-adherence to colorectal cancer (CRC) screening (colonoscopy, sigmoidoscopy, and fecal occult blood tests (FOBT)). Subgroups sharing similar psychosocial characteristics may be targeted with specific intervention strategies aimed at increasing participation in screening, which could lead to increased early detection and decreased morbidity and mortality.

METHODS

The male African American veterans in our sample (n = 260) had a mean age of 57.3 (SD = 7.3) years. Our study employs latent class analysis, a quantitative-based, audience segmentation method to identify homogeneous subgroups of African American men with similar psychosocial characteristics related to CRC screening, potentially in need of different health information and intervention strategies. Latent class regression was used to examine the relationships among latent class structure and demographic characteristics.

RESULTS

There were four psychosocial risk classes across the three screening tests. A significant subset of men had psychosocial characteristics indicative of willingness to be screened for each test (colonscopy = 21.8%, sigmoidoscopy = 31.5%, and FOBT = 10.8%), although they were currently non-adherent. Men who received a past screening test, had greater than a high school education, or were married were more likely to be represented in a latent class indicative of being prepared for getting colonoscopy or sigmoidoscopy. Sociodemographic variables were unrelated to FOBT latent class structure.

CONCLUSIONS

Segmenting our sample of male African American veterans based on psychosocial risk characteristics can inform the development of more precisely targeted interventions for African American men who are non-adherent for CRC screening.

Parental attitudes, beliefs, and perceptions about genetic testing for FAP and colorectal cancer surveillance in minors

Familial adenomatous polyposis (FAP) is the second most common hereditary colorectal cancer syndrome and confers a nearly 100% lifetime risk of developing colorectal cancer. Understanding factors that facilitate and inhibit genetic testing and cancer surveillance in children who are members of families affected by FAP will better equip clinicians to clarify misunderstandings and facilitate appropriate care. The aims of this study were to examine parental attitudes and beliefs regarding endoscopic surveillance and genetic testing in minors at risk for developing FAP. This cross-sectional study includes analyses of qualitative and quantitative interview data collected from parents of children with or at risk for FAP. This report includes data from 28 parents with a total of 51 biological children between 10-17 years of age. The parents had a clinical and/or genetic diagnosis of FAP. Most commonly reported facilitators included provider recommendation (surveillance) and personalized medical management (genetic testing). Most commonly reported barriers included lack of provider recommendation (surveillance) and cost (genetic testing).

Religiosity, spirituality, and psychological distress in African-Americans at risk for having a hereditary cancer predisposing gene mutation

Elevated psychological distress has been observed among people at increased risk for familial cancer. Researchers consider religiosity and spirituality (RS) to be positive coping mechanisms associated with reduced psychological distress. Relatively little is known about the impact of RS on genomic health issues. The objectives of our study were: (1) describe the prevalence of RS and depressive symptoms and (2) explore how RS relates to psychological distress in a cohort of individuals with a > or =25% prior probability of a genetic predisposition to cancer. Participants (n = 99) were drawn from an African-American, Louisiana-based kindred with a mutation at the BRCA1 locus. This analysis reports findings from a survey assessing RS and the use of three types of religious coping styles: collaborative, self-directing, and deferring. Clinically significant depressive symptoms were relatively high (27%); with females (33%) more likely than males (17%) to report symptoms (P < 0.01). The majority of participants reported being highly religious. The most commonly employed religious problem solving style used by participants was collaborative (X=22.9; SD=5.8) versus self-directing (X=12.8; SD = 5.1) and deferring (X=19.9; SD = 6.3). We did not observe significant associations between RS indicators and psychological distress, nor did we observe appreciable differences related to gender or risk perception. Although RS beliefs and practices are important for many African-Americans, we did not find evidence that indicators of self-reported RS are associated with psychological distress prior to genetic counseling and testing.

Clinician use and acceptance of population-based data about respiratory pathogens: implications for enhancing population-based clinical practice

Front line health care providers (HCPs) play a central role in endemic (pertussis), epidemic (influenza) and pandemic (avian influenza) infectious disease outbreaks. Effective preparedness for this role requires access to and awareness of population-based data (PBD). We investigated the degree to which this is currently achieved among HCPs in Utah by surveying a sample about access, awareness and attitudes concerning PBD in clinical practice. We found variability in the number and nature (national vs. local, pushed vs. pulled) of PBD sources accessed by HCPs, with a subset using multiple sources and using them frequently. We found that HCPs believe PBD improves their clinical performance and that they cannot rely on their own practice to remain informed. These findings suggest that an integrated system, which interprets PBD from multiple sources and optimizes the delivery of PBD may facilitate preparedness of HCPs through the application of PBD in routine clinical practice.

Hypoxia-regulated protein expression, patient characteristics, and preoperative imaging as predictors of survival in adults with glioblastoma multiforme

BACKGROUND

Regions of hypoxia within glioblastoma multiforme (GBM) are common and may influence a tumor's aggressiveness, response to treatment, and the patient's overall survival. In this study, the authors examined 4 markers of hypoxia (hypoxia-inducible factor 1 [HIF-1alpha], glucose transporter 1 [GLUT-1], vascular endothelial growth factor [VEGF], and carbonic anhydrase 9 [CA IX]), cellular proliferation and microvascular density (MVD) indices, extent of surgical resection, and preoperative imaging characteristics and compared them with the overall survival rates of adults with GBM.

METHODS

In this retrospective cohort study, patients who had lower grade astrocytomas were compared with patients who had GBM to verify that the methods used could establish differences between tumor grades. By using preoperative imaging, the amount of necrosis was established versus the overall tumor area. The authors also compared preoperative images with postoperative images to define the amount of tumor resected; and they compared molecular markers, proliferation, MVD, and imaging studies with survival among patients who had GBM.

RESULTS

The hypoxia-regulated molecules (HRMs) and indices for MVD and cellular proliferation were associated significantly with tumor grade. Survival was improved when >or=95% of the tumor was resected. Although the total tumor area was associated with overall survival, no differences were observed when the amount of necrosis or a tumor necrosis index (area of necrosis/area of tumor) was compared with survival. The findings indicated that GLUT-1 and VEGF were correlated with survival after controlling for age.

CONCLUSIONS

Tumor grade was differentiated with HRMs, MVD, and proliferation, but only GLUT-1 predicted survival in this group of patients with GBM. The results suggested that GLUT-1 may be an important independent prognostic indicator.

Interactive, culturally sensitive education on colorectal cancer screening

BACKGROUND

Increasing colorectal cancer screening (CRCS) can have a substantial positive impact on morbidity and mortality.

OBJECTIVES

The purpose of this report is to describe the development and feasibility testing of a computer-based, theory-guided educational program designed to increase CRCS.

RESEARCH DESIGN

This mixed-methods study used focus groups and subsequent randomized controlled trial design.

SUBJECTS

Participants (N = 199) were randomized to an intervention or control group; 75% were African American; mean age was 57.36 (SD = 6.8); 71% were male.

MEASURES

Previously validated measures on knowledge, beliefs, and screening test adherence were used to establish pre- and post-intervention perceptions. Feasibility was measured by response and completion rates, and participants' perceptions of the program.

RESULTS

Before feasibility testing, the program was presented to 2 focus groups. Changes were made to the program based on discussion, leading to a visually appealing, easy to understand and navigate, self-paced program. In the RCT pilot test that followed, of the participants in the intervention group, 80% said the education helped them decide to get CRCS; 49% agreed it helped them overcome barriers; 91% agreed it was useful, 68% thought it raised new concerns about cancer, but only 30% said it made them worry about CRC; 95% agreed their doctor's office should continue giving such education, and 99% said they would inform family about the program.

CONCLUSIONS

The response rate of 83% demonstrated feasibility of conducting colorectal cancer education in the primary care setting; overall the program was well received; participants averaged 23 minutes to complete it. Participants sought no help from attending data collectors and navigated the revised touch screen program with ease. Computer-based education is feasible in primary care clinics.

Application of Natural Language Processing to VA Electronic Health Records to Identify Phenotypic Characteristics for Clinical and Research Purposes

Informatics tools to extract and analyze clinical information on patients have lagged behind data-mining developments in bioinformatics. While the analyses of an individual's partial or complete genotype is nearly a reality, the phenotypic characteristics that accompany the genotype are not well known and largely inaccessible in free-text patient health records. As the adoption of electronic medical records increases, there exists an urgent need to extract pertinent phenotypic information and make that available to clinicians and researchers. This usually requires the data to be in a structured format that is both searchable and amenable to computation. Using inflammatory bowel disease as an example, this study demonstrates the utility of a natural language processing system (MedLEE) in mining clinical notes in the paperless VA Health Care System. This adaptation of MedLEE is useful for identifying patients with specific clinical conditions, those at risk for or those with symptoms suggestive of those conditions.

Genetic counseling communication with an African American BRCA1 kindred

We studied communication in genetic counseling sessions conducted with an African American, Breast Cancer 1, Early Onset (BRCA1) kindred in the USA. The Roter Interaction Analysis System (RIAS) was used to code and compare two sessions of 46 participants (26 females and 20 males) before and after they underwent genetic testing. Three certified genetic counselors and one medical geneticist conducted the sessions. When compared to pre-test communication, most of the providers' post-test communication was devoted to the provision of biomedical information (including screening recommendations) with fewer questions and psychosocial statements. Clients contributed a similar proportion to the total session dialogue in pre- and post-test sessions (40%). A larger proportion of their post-test session was devoted to indicating receptiveness to provider information than in the pre-test session. We found when providers were informing clients that they were BRCA1 mutation carriers, they provided more biomedical and psychosocial information and asked more psychosocial questions than when talking with non-carriers. This study provides the first description of genetic counseling communication for pre- and post-test BRCA1 sessions with African American individuals.

Colorectal cancer surveillance behaviors among members of typical and attenuated FAP families

OBJECTIVES

Although enhanced colorectal surveillance is recommended for members of familial adenomatous polyposis (FAP) families, little is known about individual-level adherence behavior. This study examined factors associated with recent use of colorectal cancer (CRC) surveillance among FAP patients and their at-risk relatives.

METHODS

This cross-sectional study conducted a computer-assisted telephone survey among 150 members of 71 extended families with classic (FAP) or attenuated adenomatous polyposis (AFAP). Participants were enrolled in a university-based hereditary CRC registry or were first-degree relatives of enrollees. Both qualitative and quantitative data were collected and analyzed.

RESULTS

Surveillance behavior varied by disease status. Fifty-four percent of 71 participants with a personal history of FAP and 42% of 79 at-risk relatives reported recent use of CRC surveillance recommendations. In multiple logistic regression analysis, lack of patient recall of provider recommendation for an endoscopic examination of the colon (OR 4.8, 95% CI 1.8-13.1), lack of health insurance or no reimbursement for CRC surveillance (OR 3.6, 95% CI 1.2-10.5), and/or the belief that their relative risk of CRC is not increased (OR 3.1, 95% CI 1.2-7.1) were independently associated with not having had a recent colonoscopy or sigmoidoscopy.

CONCLUSIONS

Despite the known benefits of CRC surveillance, a substantial proportion of FAP family members did not have a recent colonoscopy or endoscopy. Interventions targeted at both clinicians and patients are needed to improve surveillance behavior. These data are also important in designing decision support tools to assist clinicians in identifying and managing high-risk patients.