Cancer screening in the United States, 2009: a review of current American Cancer Society guidelines and issues in cancer screening

Organization and Evaluation of Performance Indicators of a Breast Cancer Screening Program in Meknes-Tafilalt Region, Morocco

Objective: The benefits of screening and early detection of breast cancer, including reduced morbidity and mortality, have been well-reported in the literature. In 2011, a breast cancer screening program was launched in Meknes-Tafilalt region of Morocco. The aim of this study was to evaluate the early performance indicators of this program. Materials and Methods: This retrospective evaluative study was conducted between April 2012 and December 2014, in Meknes-Tafilalt region of Morocco. Several performance indicators of the breast cancer screening program were calculated: the compliance rate, the positivity rate, the referral rate, the cancer detection rate and the organizational indicators. Results: During 2012-2014, a total of 184,951 women participated in the breast cancer screening program. The compliance rate was 26%, the positive rate was 3.3%, the referral rate was 36.7%, and the cancer detection rate was 1.2 per 1,000 women. The median time between the date of clinical breast examination and the date of biopsy (or cyto-puncture) was 36 days. The median time between the date of positive mammography and the date of biopsy (or cyto-puncture) was 6 days. The median time between the date of clinical breast examination and the date of the first received treatment was 61 days. Conclusions: The program needs better monitoring, as well as implementation of quality assurance tools to improve performance in our country.

A randomized controlled trial of a multicomponent, targeted, low-literacy educational intervention compared with a nontargeted intervention to boost colorectal cancer screening with fecal immunochemical testing in community clinics

BACKGROUND

The objective of the current study was to improve colorectal cancer (CRC) screening uptake with the fecal immunochemical test (FIT). The current study investigated the differential impact of a multicomponent, targeted, low-literacy educational intervention compared with a standard, nontargeted educational intervention.

METHODS

Patients aged 50 to 75 years who were of average CRC risk and not up-to-date with CRC screening were recruited from either a federally qualified health center or a primary care community health clinic. Patients were randomized to the intervention condition (targeted photonovella booklet/DVD plus FIT kit) or comparison condition (standard Centers for Disease Control and Prevention brochure plus FIT kit). The main outcome was screening with FIT within 180 days of delivery of the intervention.

RESULTS

Of the 416 participants, 54% were female; the participants were racially and ethnically diverse (66% white, 10% Hispanic, and 28% African American), predominantly of low income, and insured (the majority had county health insurance). Overall, the FIT completion rate was 81%, with 78.1% of participants in the intervention versus 83.5% of those in the comparison condition completing FIT (P =  .17). In multivariate analysis, having health insurance was found to be the primary factor predicting a lack of FIT screening (adjusted odds ratio, 2.10; 95% confidence interval, 1.04-4.26 [P =  .04]).

CONCLUSIONS

The multicomponent, targeted, low-literacy materials were not found to be significantly different or more effective in increasing FIT uptake compared with the nontargeted materials. Provision of a FIT test plus education may provide a key impetus to improve the completion of CRC screening. The type of educational material (targeted vs nontargeted) may matter less. The findings of the current study provide a unique opportunity for clinics to adopt FIT and to choose the type of patient education materials based on clinic, provider, and patient preferences. Cancer 2017;123:1390-1400. © 2016 American Cancer Society.

Primary Care Physicians' Action Plans for Responding to Results of Screening Tests Based on the Concept of Quaternary Prevention

Since noncommunicable diseases (NCDs) are generally controllable rather than curable, more emphasis is placed on prevention than on treatment. For the early detection of diseases, primary care physicians (PCPs), as well as general practitioners and family physicians, should interpret screening results accurately and provide screenees with appropriate information about prevention and treatment, including potential harms. The concept of quaternary prevention (QP), which was introduced by Jamoulle and Roland in 1995, has been applied to screening results. This article summarizes situations that PCPs encounter during screening tests according to the concept of QP, and suggests measures to face such situations. It is suggested that screening tests be customized to fit individual characteristics instead of being performed based on general guidelines. Since screening tests should not be carried out in some circumstances, further studies based on the concept of prevention levels proposed by Jamoulle and Roland are required for the development of strategies to prevent NCDs, including cancers. Thus, applying the concept of QP helps PCPs gain better insights into screening tests aimed at preventing NCDs and also helps improve the doctor-patient relationship by helping screenees understand medical uncertainties.

Reducing, Maintaining, or Escalating Uncertainty? The Development and Validation of Four Uncertainty Preference Scales Related to Cancer Information Seeking and Avoidance

Uncertainty is a central characteristic of many aspects of cancer prevention, screening, diagnosis, and treatment. Brashers's (2001) uncertainty management theory details the multifaceted nature of uncertainty and describes situations in which uncertainty can both positively and negatively affect health outcomes. The current study extends theory on uncertainty management by developing four scale measures of uncertainty preferences in the context of cancer. Two national surveys were conducted to validate the scales and assess convergent and concurrent validity. Results support the factor structure of each measure and provide general support across multiple validity assessments. These scales can advance research on uncertainty and cancer communication by providing researchers with measures that address multiple aspects of uncertainty management.

Ever and Annual Use of Prostate Cancer Screening in African American Men

Since prostate cancer continues to disproportionately affect African American men in terms of incidence, morbidity, and mortality, prostate-specific antigen (PSA) screening plays an important role in early detection, especially when men engage in informed decision making to accept or decline this test. The authors evaluated utilization of PSA testing among African American men based on factors that are important components of making informed decisions. Utilization of PSA testing was evaluated based on whether men had ever had PSA testing and PSA testing during the past year in a community-based sample of African American men ages 50 to 75 ( n = 132). Overall, 64% of men ( n = 85) reported that they had ever had a PSA test; the mean ( SD) age for first use of PSA testing was 47.7 ( SD = 7.4). The likelihood of ever having a PSA test increased significantly with physician communication (odds ratio [OR] = 14.2; 95% confidence interval [CI] = 4.20, 48.10; p = .0001) and with having an annual household income that was greater than $20,000 (OR = 9.80; 95% CI = 3.15, 30.51; p = .0001). The odds of ever having a PSA test were also decreased with each unit increase in future temporal orientation (OR = 0.66; 95% CI = 0.47, 0.93; p = .02). Of the men who had ever had PSA testing, 57% were screened during the past year. Only health insurance status had a significant independent association with having annual PSA testing (OR = 5.10; 95% CI = 1.67, 15.60; p = .004). Different factors were associated significantly with ever having PSA testing and annual testing among African American men. African American men may not be making an informed decision about prostate cancer screening.

A Randomized Trial to Compare Alternative Educational Interventions to Increase Colorectal Cancer Screening in a Hard-to-Reach Urban Minority Population with Health Insurance

This randomized controlled trial assessed different educational approaches for increasing colorectal cancer screening uptake in a sample of primarily non-US born urban minority individuals, over aged 50, with health insurance, and out of compliance with screening guidelines. In one group, participants were mailed printed educational material (n = 180); in a second, participants' primary care physicians received academic detailing to improve screening referral and follow-up practices (n = 185); in a third, physicians received academic detailing and participants received tailored telephone education (n = 199). Overall, 21.5% of participants (n = 121) received appropriate screening within one year of randomization. There were no statistically significant pairwise differences between groups in screening rate. Among those 60 years of age or older, however, the detailing plus telephone education group had a higher screening rate than the print group (27.3 vs. 7.7%, p = .02). Different kinds of interventions will be required to increase colorectal cancer screening among the increasingly small population segment that remains unscreened. ClinicalTrials.gov Identifier: NCT02392143.

Perspectives of Mobile Versus Fixed Mammography in Santa Clara County, California: A Focus Group Study

Objective: Our aim was to examine underserved women’s perceptions on mobile versus fixed mammography in Santa Clara, California through a focus group study.

Background: Research has shown that medically underserved women have higher breast cancer mortality rates correlated with under-screening and a disproportional rate of late-stage diagnosis. The Community Health Partnership in Santa Clara County, California runs the Community Mammography Access Project (CMAP) that targets nearly 20,000 medically underserved women over the age of 40 in the county through the collaborative effort of an existing safety net of healthcare providers. However, little data exists on the advantages or disadvantages of mobile mammography units from the patient perspective. 

Methods: We assessed underserved women’s perspectives on mammography services in Santa Clara County through two focus groups from women screened at mobile or fixed site programs. Patients were recruited from both CMAP clinics and a county hospital, and focus group data were analyzed using content analysis.

Results: We found that women from both the mobile and fixed sites shared similar motivating factors for getting a mammogram. Both groups recognized that screening was uncomfortable but necessary for good health and had positive feedback about their personal physicians. However, mobile participants, in particular, appreciated the atmosphere of mobile screening, reported shorter wait times, and remarked on the good communication from the clinic staff and empathetic treatment they received. However, mobile participants also expressed concern about the quality of films at mobile sites due to delayed initial reading of the films. 

Conclusions: Mobile mammography offers a unique opportunity for women of underserved populations to access high satisfaction screenings, and it encourages a model similar to CMAP in other underserved areas. However, emphasis should be placed on providing a warm and welcoming environment for patients and ensuring the quality of mammography images. 

The impact of mammographic screening on the surgical management of breast cancer

BACKGROUND AND OBJECTIVES

Mammographic screening has been shown to result in downward stage migration, reflected by smaller tumor sizes and less extensive nodal involvement. National guidelines restrict screening recommendations in women age 40-49. The purpose of this study is to evaluate the specific impact of mammographic screening patterns on the surgical management of breast cancer in women aged 40-49.

METHODS

The study is a population-based retrospective review of the Vermont Breast Cancer Surveillance System of women aged 40-49 with a diagnosis of breast cancer. Tumor stage and related characteristics at the time of diagnosis, as well as the type of surgical intervention performed were recorded for women presenting with screen-detected versus non-screen-detected breast cancer.

RESULTS

Screen-detected breast cancers in women aged 40-49 were associated with a greater incidence of DCIS, smaller invasive tumor size, fewer cases of positive nodes, and higher rates of breast conservation compared to non-screened women presenting with symptomatic disease.

CONCLUSIONS

Mammographic screening is associated with less aggressive surgical treatment of breast cancer including higher rates of breast conservation. The observed changes in surgical management should factor into individual decision-making regarding screening mammography. J. Surg. Oncol. 2016;113:496-500. © 2016 Wiley Periodicals, Inc.

ESMO-ESGO-ESTRO Consensus Conference on Endometrial Cancer: Diagnosis, Treatment and Follow-up

The first joint European Society for Medical Oncology (ESMO), European SocieTy for Radiotherapy & Oncology (ESTRO) and European Society of Gynaecological Oncology (ESGO) consensus conference on endometrial cancer was held on 11-13 December 2014 in Milan, Italy, and comprised a multidisciplinary panel of 40 leading experts in the management of endometrial cancer. Before the conference, the expert panel prepared three clinically-relevant questions about endometrial cancer relating to the following four areas: prevention and screening, surgery, adjuvant treatment and advanced and recurrent disease. All relevant scientific literature, as identified by the experts, was reviewed in advance. During the consensus conference, the panel developed recommendations for each specific question and a consensus was reached. Results of this consensus conference, together with a summary of evidence supporting each recommendation, are detailed in this article. All participants have approved this final article.

Novel rhodanines with anticancer activity: design, synthesis and CoMSIA study

A library of novel rhodanines are reported for their anticancer activity along with the 3D QSAR.

ESMO-ESGO-ESTRO Consensus Conference on Endometrial Cancer: diagnosis, treatment and follow-up

The first joint European Society for Medical Oncology (ESMO), European SocieTy for Radiotherapy & Oncology (ESTRO) and European Society of Gynaecological Oncology (ESGO) consensus conference on endometrial cancer was held on 11-13 December 2014 in Milan, Italy, and comprised a multidisciplinary panel of 40 leading experts in the management of endometrial cancer. Before the conference, the expert panel prepared three clinically relevant questions about endometrial cancer relating to the following four areas: prevention and screening, surgery, adjuvant treatment and advanced and recurrent disease. All relevant scientific literature, as identified by the experts, was reviewed in advance. During the consensus conference, the panel developed recommendations for each specific question and a consensus was reached. Results of this consensus conference, together with a summary of evidence supporting each recommendation, are detailed in this article. All participants have approved this final article.

Correlates of misperception of breast cancer risk among Korean-American Women

In this study, the authors investigate the factors associated with misperception of breast cancer risk, including unrealistic optimism and unrealistic pessimism, among Korean-American women (KAW). Baseline data were collected between March 2010 and October 2011 from 421 KAW aged 40-65 years who participated in a community-based randomized intervention trial designed to promote breast and cervical cancer screening. Multivariate multinomial regression was performed to identify correlates of misperception of breast cancer risk among KAW. A total of 210 KAW (49.9%) had breast cancer risk perception consistent with their objective risk, whereas 50.1% of KAW in the study had some form of misperception of risk. Specifically, 167 participants (39.7%) were unrealistically optimistic about their own breast cancer risk; 44 (10.5%) were unrealistically pessimistic. In multivariate multinomial logistic regression analysis, living with a partner and higher education were significantly associated with higher odds of having unrealistic optimism. High social support is associated with a lower likelihood of having a pessimistic risk perception. Higher worry is associated with a higher likelihood of having unrealistic pessimism. Misperception of breast cancer risk among KAW and related factors must be considered when developing behavioral interventions for this population.

Interleukin-17 promotes angiogenesis by stimulating VEGF production of cancer cells via the STAT3/GIV signaling pathway in non-small-cell lung cancer

The presence of IL-17-positive cells is observed in a variety of inflammatory associated cancers and IL-17 has been found to be involved in angiogenesis. However, it remains unclear how IL-17 might contribute to tumor angiogenesis. In our study, IL-17 enhanced the formation of vessel-like tubes in HUVECs both directly (when HUVECs were incubated with IL-17) and indirectly (when HUVECs were incubated in conditioned cell media (CCM) from IL-17-treated cancer cells). Our results from experiments using siRNA-mediated knockdowns of STAT3 and GIV suggest that the effects of IL-17 were mediated by activating STAT3/GIV signaling in NSCLC cells and subsequently up-regulating its downstream target VEGF. Consistent with these findings, immunostaining experiments on human NSCLC tissues indicated that IL-17 and GIV expression were significantly and positively associated with increased tumor vascularity. The clinical significance of IL-17 was authenticated by our finding that the combination of intratumoral IL-17 + cells and GIV expression served as a better prognosticator for survival than either marker alone. Therefore, our finding highlights a novel aspect of STAT3/GIV pathway in the IL-17 promotes tumor angiogenesis of NSCLC.

Acceptability of Physician Directed Academic Detailing to Increase Colorectal Cancer Screening: an Application of the RESPECT Approach

BACKGROUND

In developing effective interventions to increase colorectal cancer (CRC) screening in at risk populations, a necessary first requirement is feasibility. This paper describes how the RESPECT approach to health education guided the conceptualization and implementation of physician-directed academic detailing (AD) to increase practice-wide CRC screening uptake.

METHODS

Physician-directed AD was one intervention component in a large educational randomized controlled trial to increase CRC screening uptake. Study participants, primarily urban minority, were aged 50 or older, insured for CRC screening with no out-of-pocket expense and out of compliance with current screening recommendations. The trial was conducted in the New York City metropolitan area. Participants identified their primary care physician; 564 individuals were recruited, representing 459 physician practices. Two-thirds of the physician practices were randomized to receive AD. The RESPECT approach, modified for AD, comprises: 1) Rapport, 2) Educate, but don't overwhelm, 3) Start with physicians where they are, 4) Philosophical orientation based on a humanistic approach to education, 5) Engagement of the physician and his/her office staff, 6) Care and show empathy, and 7) Trust. Feasibility was assessed as rate of AD delivery.

RESULTS

The AD was delivered to 283 (92.5%) of the 306 practices assigned to receive it; 222/283 (78.4%) delivered to the doctor.

CONCLUSION

The AD was feasible and acceptable to implement across a range of clinical settings. The RESPECT approach offers a framework for tailoring educational efforts, allowing flexibility, as opposed to strict adherence to a highly structured script or a universal approach.

Between-ward disparities in colorectal cancer incidence and screening in Washington DC

This study aims to investigate the incidence and determinants of colorectal cancer (CRC) and its screening in District of Columbia (DC), and identify modifiable risk factors. Data (2000–2009) from the DC Cancer Registry, Behavioral Risk Factor Surveillance System (BRFSS-DC) and Surveillance Epidemiology and End Results (SEER) were used to estimate CRC incidence in eight DC Wards. Risk factors and CRC screening were analyzed using uni-, bi-, and multivariable statistical methods with survey procedures in SAS (version 9.2) including binary, unconditional multivariable logistic regression analysis. Factors measured included stage of diagnosis, age, gender, race/ethnicity, smoking, alcohol, exercise, body weight, health insurance, education, employment, and income. Over the study time, CRC screening increased from 48.4% to 68.6%. Mean age at diagnosis was 67 years. CRC incidence is high in DC. Furthermore, CRC incidence rates in DC below 50 years age were higher than the SEER18 average. Disparities exist between CRC incidence and screening among DC Wards. Identified risk factors for CRC are smoking, obesity, and low physical activity; screening was less prevalent among the uninsured and low socio-economic group. Local variations in CRC occurrence exist and may vary from average national experiences. Identification of local regions which vary from national trends in disease occurrence is important for comprehensive understanding of the disease in the community.

Recent developments regarding the use of thieno[2,3-d]pyrimidin-4-one derivatives in medicinal chemistry, with a focus on their synthesis and anticancer properties

It is generally understood that the antitumor properties of synthetic heterocyclic compounds are among the most powerful properties that can be made use in medicinal chemistry. More specifically, their substantial cytotoxic effects against different types of human tumor cells, in addition to their roles as enzymes or receptors for various kinase inhibitors, make them critically important. In recent years, thieno[2,3-d]pyrimidin-4-one derivatives (TPs), which are analogs of quinazoline alkaloids, have frequently attracted the interest of medicinal chemistry researchers due to their promising anticancer properties. The present study is a review of the latest advances (i.e., since 2006) in TP derivative-related research, with a focus on how such derivatives are synthesized and on their anticancer activities.

Knowledge of breast cancer and breast self-examination practice among Iranian women in Hamedan, Iran

BACKGROUND

In Iran, breast cancer is the most prevalent cancer in women and a major public health problem.

METHODS

A cross sectional study was carried out to determine knowledge on breast cancer and breast self- examination (BSE) practices of 384 females living in the city of Hamadan, Iran. A purposive sampling method was adopted and data were collected via face-to-face interviews based on a validated questionnaire developed for this study.

RESULTS

Among respondents 268 (69.8%) were married and 144 (37.5%) of the respondents reported having a family history of breast cancer. One hundred respondents (26.0%) claimed they practiced BSE. Level of breast cancer knowledge was significantly associated with BSE practice (p=0.000). There was no association with demographic details (p<0.05).

CONCLUSION

The findings showed that Iranian women's knowledge regarding breast cancer and the practice of BSE is inadequate. Targeted education should be implemented to improve early detection of breast cancer.

An innovative strategy to reach the underserved for colorectal cancer screening

Hispanics are an underserved population in terms of colorectal cancer (CRC). CRC is the second leading cause of cancer incidence among Hispanic men and women, and Hispanics have lower screening rates than non-Hispanic whites. The overall purpose of this project was to provide CRC information, education, and fecal occult blood test (FOBT) kits to Hispanics in a rural three-county region of Washington State. We held a series of 47 community health fair events that incorporated the use of a giant inflatable, walk-through colon model with physical depictions of healthy tissue, polyps, and CRC. We used a pre/post-design to look for changes in familiarity with CRC before and after walking through the colon among adults aged 18 and older (n = 947). McNemar's test analysis indicated significant differences in the distribution of the percentage of correct participant responses to CRC-related questions from pre- to post-test after an educational tour of the colon. Results from logistic regression analysis identified multiple participant characteristics associated with self-reported likelihood of being screened for CRC in 3 months following post-test. We distributed 300 free FOBT kits to be analyzed at no charge to the end user and to attendees aged 50 and older who toured the inflatable colon; 226 FOBT kits (75.3%) were returned for analysis. The use of the inflatable colon was an innovative way to attract people to learn about CRC and CRC screening modalities. Furthermore, the response to our distribution of FOBT kits indicates that if given the opportunity for education and access to services, this underserved population will comply with CRC screening.

Effect of acculturation and access to care on colorectal cancer screening in low-income Latinos

Latinos have lower colorectal cancer screening (CRCS) and survival rates compared to other race/ethnic groups. This cross-sectional study examines relationships between acculturation, access to and utilization of healthcare services, and CRCS in low-income Latinos. Bilingual data collectors conducted structured interviews with 544 Latino men and women (>50 years) residing in the Texas-Mexico border area. Using a hierarchical logistic regression model, we examined the relationship between lifetime history of any CRCS test and indicators of acculturation, healthcare utilization and access to care, adjusting for socio-demographic characteristics. Survey results revealed a 34% prevalence of CRCS. Participants reporting a provider recommendation for screening, regular check-ups, higher acculturation level, and health insurance had significantly increased odds of CRCS. Findings indicate CRCS intervention research in Latinos should focus on (1) increasing physicians' recommendations for screening, (2) promoting regular check-ups, (3) and increasing CRC prevention efforts on less acculturated and uninsured groups.

Cost-effectiveness of breast cancer screening policies using simulation

In this paper, we study breast cancer screening policies using computer simulation. We developed a multi-state Markov model for breast cancer progression, considering both the screening and treatment stages of breast cancer. The parameters of our model were estimated through data from the Canadian National Breast Cancer Screening Study as well as data in the relevant literature. Using computer simulation, we evaluated various screening policies to study the impact of mammography screening for age-based subpopulations in Canada. We also performed sensitivity analysis to examine the impact of certain parameters on number of deaths and total costs. The analysis comparing screening policies reveals that a policy in which women belonging to the 40-49 age group are not screened, whereas those belonging to the 50-59 and 60-69 age groups are screened once every 5 years, outperforms others with respect to cost per life saved. Our analysis also indicates that increasing the screening frequencies for the 50-59 and 60-69 age groups decrease mortality, and that the average number of deaths generally decreases with an increase in screening frequency. We found that screening annually for all age groups is associated with the highest costs per life saved. Our analysis thus reveals that cost per life saved increases with an increase in screening frequency.

Improving family history collection

Family history is important for assessing risk of cancer. This study aimed to improve cancer family history communication and collection by training and motivating lay individuals to construct pedigrees. The authors' ultimate goal is to improve identification of familial cancer. Participants (n = 200) completed preintervention, postintervention, and 1-week follow-up surveys to assess pedigree construction. The intervention reviewed basic construction and interpretation of a pedigree for familial cancer. As a result of intervention, individuals reported more positive attitudes about collecting family history, were more likely to intend to speak to family and physicians about cancer risk, better understood a sample pedigree, and constructed more detailed pedigrees of their family history. At follow-up, 25% of the sample had spoken with their families about cancer risk. For those individuals who had not spoken with family, higher postintervention pedigree knowledge was associated with greater intentions to speak with family in the future. The intervention improved the communication and collection of pedigrees and communication about cancer risk, which could be used to improve the identification of individuals with familial cancers and awareness of family cancer risk.

Evaluation of hemoglobin A1c levels in endometrial cancer patients: a retrospective study in Turkey

BACKGROUND

Hemoglobin A1c(HgA1c) is a marker of poor gylcemic control and elevation HgA1c is associated with increased risk of many cancers. We aimed to determine the HgA1c levels in endometrial cancer cases and any relationship with stage and grade of disease.

MATERIALS AND METHODS

A retrospective data review was performed between June 2011 and October 2012 at a tertiary referral center in Turkey. The study included 35 surgically staged endometrial cancer patients and 40 healthy controls. Preoperative HgA1c levels drawn within 3 months before surgery were compared. Also the relationships between HgA1c levels and stage, grade and hystologic type of cancer cases were evaluated.

RESULTS

The mean HgA1c levels were statistically significantly higher at 6.19 ± 1.44 in endometrial cancer cases than the 5.61 ± 0.58 in controls (p=0.027). With endometrial cancer cases, the mean HgA1c level was found to be 6.62 ± 1.40 for stage I and 6.88 ± 1.15 for stages II-IV (p=0.07). The figures were 6.74 ± 1.65 for endometrioid and 6.63 ± 1.41 for non-endometrioid type tumors (p=0.56). Mean HgA1c levels of 6.72 ± 1.14 for grade 1 and 6.62 ± 1.42 for grade 2-3 were observed (p=0.57).

CONCLUSIONS

HgA1c levels in endometrial cancer patients were statistically higher than healthy controls. However, HgA1c did not show any significant correlation with stage, grade and histologic type in endometrial cancer cases.

Colorectal cancer screening among Latinos in three communities on the Texas-Mexico border

OBJECTIVE

To assess colorectal cancer screening (CRCS) prevalence and psychosocial correlates of CRCS among Latinos in South Texas.

METHOD

Using multivariable analyses, we examined the association of perceived susceptibility, self-efficacy, pros and cons, subjective norms, knowledge and fatalism on CRCS among 544 Latinos (50 years and older).

RESULTS

In this socioeconomically disadvantaged population, 40% had never heard of any CRCS test, only 34% reported ever completing any type of CRCS, and only 25% were adherent to CRCS guidelines. Insurance status, gender, perceived cons, CRCS self-efficacy, and CRCS norms were significantly associated with CRCS.

CONCLUSION

CRCS interventions in this population should focus on improving access, increasing self-efficacy and perceived norms, and decreasing negative perceptions of CRCS.

Serum YKL-40 in risk assessment for colorectal cancer: a prospective study of 4,496 subjects at risk of colorectal cancer

The aim of the present study was to test the hypothesis that high serum YKL-40 associates with colorectal cancer in subjects at risk of colorectal cancer. We measured serum YKL-40 in a prospective study of 4,496 Danish subjects [2,064 men, 2,432 women, median age 61 years (range, 18-97)] referred to endoscopy due to symptoms or other risk factors for colorectal cancer. Blood samples were collected just before large bowel endoscopy. Serum YKL-40 was determined by ELISA. Serum YKL-40 was higher (P < 0.0001, unadjusted for confounding covariates) in subjects diagnosed with colon cancer (median 126 μg/L, 25%-75%: 80-206 μg/L) and rectal cancer (104, 72-204 μg/L) compared with subjects with adenoma (84, 53-154 μg/L), other nonmalignant findings (79, 49-138 μg/L), and no findings (62, 41-109 μg/L). Serum YKL-40 independently predicted colorectal cancer [OR, 1.53; 95% confidence interval (CI), 1.40-1.67; AUC = 0.68, P < 0.0001]. Restricting the analysis to subjects with no comorbidity increased the OR for serum YKL-40 to predict colorectal cancer (OR, 1.82; 1.58-2.08; AUC = 0.73, P < 0.0001). Combining serum YKL-40 and CEA demonstrated that both were significant [(YKL-40, OR, 1.27; 95% CI, 1.16-1.40); (CEA, OR, 1.92; 1.75-2.10; AUC = 0.75, P < 0.0001; OR for a 2-fold difference in marker level)]. Multivariable analysis (YKL-40, CEA, age, gender, body mass index, and center) showed that serum YKL-40 was a predictor for colorectal cancer in individuals without comorbidity (OR, 1.25; 95% CI, 1.05-1.40; P = 0.012), whereas this was not the case for those with comorbidity (OR, 0.98; 95% CI, 0.84-1.14; P = 0.80). In conclusion, high serum YKL-40 in subjects suspected of colorectal cancer and without comorbidity associates with colorectal cancer. Determination of serum YKL-40 may be useful in combination with other biomarkers in risk assessment for colorectal cancer. Cancer Epidemiol Biomarkers Prev; 24(3); 621-6. ©2015 AACR.

Word on the Street: Engaging Local Leaders in a Dialogue About Prostate Cancer Among African Americans

African American men face the highest rates of prostate cancer, yet with no consensus for screening and treatment, making informed health care decisions is difficult. This study aimed to identify approaches to empowering African American men as proactive participants in prostate cancer decision making using an established community-campus partnership employing elements of community-based participatory research methods. Community stakeholders with an interest in, and knowledge about, health care in two local African American communities were recruited and completed key informant interviews (N = 39). Grounded theory coding identified common themes related to prostate cancer knowledge, beliefs, attitudes, and responses to them. Common barriers such as gender roles, fear, and fatalism were identified as barriers to work-up and treatment, and both communities' inadequate and inaccurate prostate cancer information described as the key problem. To build on community strengths, participants said the change must come from inside these communities, not be imposed from the outside. To accomplish this, they suggested reaching men through women, connecting men to doctors they can trust, making men's cancer education part of broader health education initiatives designed as fun and inexpensive family entertainment events, and having churches bring community members in to speak on their experiences with cancer. This study demonstrated the success of community engagement to identify not only barriers but also local strengths and facilitators to prostate cancer care in two suburban/rural African American communities. Building collaboratively on community strengths may improve prostate cancer care specifically and health care in general.

System Strategies for Colorectal Cancer Screening at Federally Qualified Health Centers

Objectives. We assessed the protocols and system processes for colorectal cancer (CRC) screening at federally qualified health centers (FQHCs) in 4 midwestern states. Methods. We identified 49 FQHCs in 4 states. In January 2013, we mailed their medical directors a 49-item questionnaire about policies on CRC screening, use of electronic medical records, types of CRC screening recommended, clinic tracking systems, referrals for colonoscopy, and barriers to providing CRC. Results. Forty-four questionnaires (90%) were returned. Thirty-three of the respondents (75%) estimated the proportion of their patients up-to-date with CRC screening, with a mean of 35%. One major barrier to screening was inability to provide colonoscopy for patients with a positive fecal occult blood test (59%). The correlation of system strategies and estimated percentage of patients up-to-date with CRC screening was 0.43 (P = .01). Conclusions. CRC system strategies were associated with higher CRC screening rates. Implementing system strategies for CRC screening takes time and effort and is important to maintain, to help prevent, or to cure many cases of CRC, the second leading cause of cancer in the United States.

Older adults' preferences for colorectal cancer-screening test attributes and test choice

BACKGROUND

Understanding which attributes of colorectal cancer (CRC) screening tests drive older adults' test preferences and choices may help improve decision making surrounding CRC screening in older adults.

MATERIALS AND METHODS

To explore older adults' preferences for CRC-screening test attributes and screening tests, we conducted a survey with a discrete choice experiment (DCE), a directly selected preferred attribute question, and an unlabeled screening test-choice question in 116 cognitively intact adults aged 70-90 years, without a history of CRC or inflammatory bowel disease. Each participant answered ten discrete choice questions presenting two hypothetical tests comprised of four attributes: testing procedure, mortality reduction, test frequency, and complications. DCE responses were used to estimate each participant's most important attribute and to simulate their preferred test among three existing CRC-screening tests. For each individual, we compared the DCE-derived attributes to directly selected attributes, and the DCE-derived preferred test to a directly selected unlabeled test.

RESULTS

Older adults do not overwhelmingly value any one CRC-screening test attribute or prefer one type of CRC-screening test over other tests. However, small absolute DCE-derived preferences for the testing procedure attribute and for sigmoidoscopy-equivalent screening tests were revealed. Neither general health, functional, nor cognitive health status were associated with either an individual's most important attribute or most preferred test choice. The DCE-derived most important attribute was associated with each participant's directly selected unlabeled test choice.

CONCLUSION

Older adults' preferences for CRC-screening tests are not easily predicted. Medical providers should actively explore older adults' preferences for CRC screening, so that they can order a screening test that is concordant with their patients' values. Effective interventions are needed to support complex decision making surrounding CRC screening in older adults.

MyPreventiveCare: implementation and dissemination of an interactive preventive health record in three practice-based research networks serving disadvantaged patients--a randomized cluster trial

BACKGROUND

Evidence-based preventive services for early detection of cancer and other health conditions offer profound health benefits, yet Americans receive only half of indicated services. Policy initiatives promote the adoption of information technologies to engage patients in care. We developed a theory-driven interactive preventive health record (IPHR) to engage patients in health promotion. The model defines five levels of functionality: (1) collecting patient information, (2) integrating with electronic health records (EHRs), (3) translating information into lay language, (4) providing individualized, guideline-based clinical recommendations, and (5) facilitating patient action. It is hypothesized that personal health records (PHRs) with these higher levels of functionality will inform and activate patients in ways that simpler PHRs cannot. However, realizing this vision requires both technological advances and effective implementation based upon clinician and practice engagement.

METHODS/DESIGN

We are starting a two-phase, mixed-method trial to evaluate whether the IPHR is scalable across a large number of practices and how its uptake differs for minority and disadvantaged patients. In phase 1, 40 practices from three practice-based research networks will be randomized to add IPHR functionality to their PHR versus continue to use their existing PHR. Throughout the study, we will engage intervention practices to locally tailor IPHR content and learn how to integrate new functions into their practice workflow. In phase 2, the IPHR to all nonintervention practices to observe whether the IPHR can be implemented more broadly (Scalability). Phase 1 will feature an implementation assessment in intervention practices, based on the RE-AIM model, to measure Reach (creation of IPHR accounts by patients), Adoption (practice decision to use the IPHR), Implementation (consistency, fidelity, barriers, and facilitators of use), and Maintenance (sustained use). The incremental effect of the IPHR on receipt of cancer screening tests and shared decision-making compared to traditional PHRs will assess Effectiveness. In phase 2, we will assess similar outcomes as phase 1 except for effectiveness.

DISCUSSION

This study will yield information about the effectiveness of new health information technologies designed to actively engage patients in their care as well as information about how to effectively implement and disseminate PHRs by engaging clinicians.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02138448.

A snapshot of patients' perceptions of oncology providers' cultural competence

In this paper, we describe an anonymous cross-sectional survey with a sample of 100 racially diverse adult oncology patients using a newly developed patient-reported measure of providers' cultural competence, the Physicians' Cultural Competence for Patient Satisfaction Scale (PCCPS) [1, 2], which was developed using a US midwestern sample of primary care patients. Our primary aims were to examine the reliability of the PCCPS in a more racially diverse urban oncology clinical setting and to identify salient domains of oncology provider cultural competence based on patient-reported satisfaction with direct clinical encounters. Results suggest that patient-reported satisfaction was significantly associated with one of the four domains measured by the PCCPS, physician's patient-centered cultural competence (r = 0.40, p = 0.01), and female patients were more satisfied (t (91) = 5.23, p = 0.02). The PCCPS demonstrated good reliability in an urban diverse cancer patient population. Results help to inform the development of clinical tools that can improve oncology providers' cultural competency.

Symptomatic breast cancer diagnosis and multimodal management in women aged 40 to 50 years; consequences of current mammographic screening programs

INTRODUCTION

Consensus exists that screening mammography is appropriate for women aged 50 to 69 years. However, the effectiveness of such screening for women aged 40 to 50 years is still questioned. The aim of our study was to analyze breast cancer management in the 40- to 50-year age group. We also wished to determine the proportion of patients with a significant family history and whether this was associated with more advanced disease.

PATIENTS AND METHODS

All female patients with primary breast cancer diagnosed between 40 and 50 years of age were included over a 4-year period. The database of the National Breast Cancer Research Institute was interrogated, and a chart and radiology review carried out to obtain relevant details of clinical presentation, family history, radiological findings, and treatments undertaken.

RESULTS

Three hundred thirty-four patients were diagnosed in this cohort during the study period. Twenty-two percent of those diagnosed had a family history of breast cancer with 1.8% having a genetically confirmed predisposition to breast cancer. A significant proportion of patients presented with advanced disease, with 50% of patients having nodal involvement and 3% who presented with distant metastases. The overall rate of mastectomy was 47%, with minimal variation between the surgeons who performed the surgeries. More than half of the patients in our analysis underwent axillary clearance (51%).

CONCLUSION

Our results indicate that a large proportion of patients in the 40- to 50-year age group presented with advanced disease and required aggressive surgical and adjuvant treatment. The presence of a family history did not identify a subgroup with more advanced disease at presentation.

Virtual gastrointestinal colonoscopy in combination with large bowel endoscopy: Clinical application

Although colorectal cancer (CRC) has no longer been the leading cancer killer worldwide for years with the exponential development in computed tomography (CT) or magnetic resonance imaging, and positron emission tomography/CT as well as virtual colonoscopy for early detection, the CRC related mortality is still high. The objective of CRC screening is to reduce the burden of CRC and thereby the morbidity and mortality rates of the disease. It is believed that this goal can be achieved by regularly screening the average-risk population, enabling the detection of cancer at early, curable stages, and polyps before they become cancerous. Large-scale screening with multimodality imaging approaches plays an important role in reaching that goal to detect polyps, Crohn’s disease, ulcerative colitis and CRC in early stage. This article reviews kinds of presentative imaging procedures for various screening options and updates detecting, staging and re-staging of CRC patients for determining the optimal therapeutic method and forecasting the risk of CRC recurrence and the overall prognosis. The combination use of virtual colonoscopy and conventional endoscopy, advantages and limitations of these modalities are also discussed.

Genetic mechanisms in interval colon cancers

BACKGROUND AND AIM

The factors underlying the development of interval colon cancers are not well defined and are likely heterogeneous. We sought to determine whether there are distinct molecular properties associated with interval colon cancers.

METHODS

Colon cancers diagnosed within 5 years of a complete and well-prepped colonoscopic examination were identified over a 7-year period at a single institution. The clinical and pathological features of the tumors were defined. Analysis of DNA mismatch repair (MMR) and genotyping of a panel of oncogenes associated with colon cancer were performed.

RESULTS

Forty-two interval colon cancers were diagnosed at an average age of 70 years. 69 % of tumors were located in the right colon. 41 % of tumors exhibited DNA microsatellite instability (MSI). Loss of staining of DNA MMR proteins by immunohistochemistry (IHC) was confirmed in 82 % of the MSI-positive tumors. Among tumors with abnormal MSI and IHC, 54 % exhibited somatic methylation of the MLH1 promoter, but the remaining 43 % exhibited molecular features indicative of underlying Lynch syndrome (LS). The frequency of somatic mutations in the KRAS, BRAF, NRAS, and PIK3CA oncogenes was similar between interval cancer cases and controls.

CONCLUSIONS

Interval colon cancers are not distinguished by the activation of the KRAS, NRAS, BRAF, or PIK3CA oncogenic pathways. However, MSI pathway defects are present in a significant proportion of interval colon cancers. Underlying LS may explain nearly half of these MSI-positive cases, and the remaining cases appear to represent sporadic serrated pathway tumors.

Non-communicable diseases in South Asia: contemporary perspectives

INTRODUCTION

Non-communicable diseases (NCDs) such as metabolic, cardiovascular, cancers, injuries and mental health disorders are increasingly contributing to the disease burden in South Asia, in light of demographic and epidemiologic transitions in the region. Home to one-quarter of the world's population, the region is also an important priority area for meeting global health targets. In this review, we describe the current burden of and trends in four common NCDs (cardiovascular disease, diabetes, cancer and chronic obstructive pulmonary disease) in South Asia.

SOURCES OF DATA

The 2010 Global Burden of Disease Study supplemented with the peer-reviewed literature and reports by international agencies and national governments.

AREAS OF AGREEMENT

The burden of NCDs in South Asia is rising at a rate that exceeds global increases in these conditions. Shifts in leading risk factors-particularly dietary habits, tobacco use and high blood pressure-are thought to underlie the mounting burden of death and disability due to NCDs. Improvements in life expectancy, increasing socioeconomic development and urbanization in South Asia are expected to lead to further escalation of NCDs.

AREAS OF CONTROVERSY

Although NCD burdens are currently largest among affluent groups in South Asia, many adverse risk factors are concentrated among the poor, portending a future increase in disease burden among lower income individuals.

GROWING POINTS

There continues to be a notable lack of national surveillance data to document the distribution and trends in NCDs in the region. Similarly, economic studies and policy initiatives addressing NCD burdens are still in their infancy.

AREAS TIMELY FOR DEVELOPING RESEARCH

Opportunities for innovative structural and behavioral interventions that promote maintenance of healthy lifestyles-such as moderate caloric intake, adequate physical activity and avoidance of tobacco-in the context of socioeconomic development are abundant. Testing of health care infrastructure and systems that best provide low-cost and effective detection and treatment of NCDs is a priority for policy researchers.

Dietary inflammatory index and risk of colorectal cancer in the Iowa Women's Health Study

BACKGROUND

Colorectal cancer, the third most common cancer in the United States, has a natural history that usually encompasses several decades. Dietary components have been implicated in the etiology of colorectal cancer, perhaps through their effect on inflammation.

METHODS

We examined the ability of the dietary inflammatory index (DII) to predict colorectal cancer in the Iowa Women's Health Study. The DII was computed based on dietary intake assessed by a 121-item food frequency questionnaire in this cohort of 34,703 women, ages 55 to 69 years, free of any self-reported prior malignancy at enrollment in 1986. Incident colorectal cancer cases were identified through linkage with the State Health Registry of Iowa (a Surveillance, Epidemiology, and End Results program member). Cox proportional hazards regression was used to estimate HRs. Through the end of 2010, 1,636 incident colorectal cancers were identified, including 1,329 colon and 325 rectal cancers.

RESULTS

Multivariable analysis, adjusting for body mass index, smoking status, pack-years of smoking, hormone replacement therapy, education, diabetes, and total energy intake, revealed positive associations between higher DII and colorectal cancer risk [HR for DIIcontinuous: 1.07 per unit increase in DII (corresponding to 0.5 SD unit increase); 95% confidence interval (CI), 1.01-1.13; HR for DIIquintiles: Q5 vs. Q1 = 1.20; 95% CI, 1.01-1.43]. HRs for DII were similar for colon cancer and rectal cancer, though not statistically significant for rectal cancer.

CONCLUSIONS

These results indicate that a proinflammatory diet, as indicated by higher DII scores, was associated with higher risk of developing colorectal cancer.

IMPACT

Proinflammatory diets are associated with increased risk of colorectal cancer.

Comparative effectiveness of audit-feedback versus additional physician communication training to improve cancer screening for patients with limited health literacy

BACKGROUND

We designed a continuing medical education (CME) program to teach primary care physicians (PCP) how to engage in cancer risk communication and shared decision making with patients who have limited health literacy (HL).

OBJECTIVE

We evaluated whether training PCPs, in addition to audit-feedback, improves their communication behaviors and increases cancer screening among patients with limited HL to a greater extent than only providing clinical performance feedback.

DESIGN

Four-year cluster randomized controlled trial.

PARTICIPANTS

Eighteen PCPs and 168 patients with limited HL who were overdue for colorectal/breast/cervical cancer screening.

INTERVENTIONS

Communication intervention PCPs received skills training that included standardized patient (SP) feedback on counseling behaviors. All PCPs underwent chart audits of patients' screening status semiannually up to 24 months and received two annual performance feedback reports.

MAIN MEASURES

PCPs experienced three unannounced SP encounters during which SPs rated PCP communication behaviors. We examined between-group differences in changes in SP ratings and patient knowledge of cancer screening guidelines over 12 months; and changes in patient cancer screening rates over 24 months.

KEY RESULTS

There were no group differences in SP ratings of physician communication at baseline. At follow-up, communication intervention PCPs were rated higher in general communication about cancer risks and shared decision making related to colorectal cancer screening compared to PCPs who only received performance feedback. Screening rates increased among patients of PCPs in both groups; however, there were no between-group differences in screening rates except for mammography. The communication intervention did not improve patient cancer screening knowledge.

CONCLUSION

Compared to audit and feedback alone, including PCP communication training increases PCP patient-centered counseling behaviors, but not cancer screening among patients with limited HL. Larger studies must be conducted to determine whether lack of changes in cancer screening were due to clinic/patient sample size versus ineffectiveness of communication training to change outcomes.

Development of a melanoma risk prediction model incorporating MC1R genotype and indoor tanning exposure: impact of mole phenotype on model performance

Background

Identifying individuals at increased risk for melanoma could potentially improve public health through targeted surveillance and early detection. Studies have separately demonstrated significant associations between melanoma risk, melanocortin receptor (MC1R) polymorphisms, and indoor ultraviolet light (UV) exposure. Existing melanoma risk prediction models do not include these factors; therefore, we investigated their potential to improve the performance of a risk model.

Methods

Using 875 melanoma cases and 765 controls from the population-based Minnesota Skin Health Study we compared the predictive ability of a clinical melanoma risk model (Model A) to an enhanced model (Model F) using receiver operating characteristic (ROC) curves. Model A used self-reported conventional risk factors including mole phenotype categorized as “none”, “few”, “some” or “many” moles. Model F added MC1R genotype and measures of indoor and outdoor UV exposure to Model A. We also assessed the predictive ability of these models in subgroups stratified by mole phenotype (e.g. nevus-resistant (“none” and “few” moles) and nevus-prone (“some” and “many” moles)).

Results

Model A (the reference model) yielded an area under the ROC curve (AUC) of 0.72 (95% CI = 0.69, 0.74). Model F was improved with an AUC = 0.74 (95% CI = 0.71–0.76, p<0.01). We also observed substantial variations in the AUCs of Models A & F when examined in the nevus-prone and nevus-resistant subgroups.

Conclusions

These results demonstrate that adding genotypic information and environmental exposure data can increase the predictive ability of a clinical melanoma risk model, especially among nevus-prone individuals.

The future of genomic testing in primary care: the changing face of personalized medicine

Primary care is recognized worldwide as a key component for improving health outcomes in the population. At the same time, healthcare systems are rapidly changing with increasing expectations from technological advances. Genomics is a major driver in changing how medicine is being practiced; however, the importance for primary care has been under-appreciated. Strategically implementing genomics in a way that accounts for the unique characteristics of the primary care context is essential. In this perspective, we present important areas that we believe are critical in consideration of both the future of genomic medicine and primary healthcare delivery.

Test characteristics of faecal immunochemical tests (FIT) compared with optical colonoscopy

BACKGROUND

Faecal occult blood tests are often the initial test in population-based screening. We aimed to: 1) compare the results of single sample faecal immunochemical tests (FITs) with colonoscopy, and 2) calculate the sensitivity for proximal vs. distal adenomatous polyps or cancer.

METHODS

Individuals scheduled for a colonoscopy were invited to complete a FIT prior to their colonoscopy preparation. FIT results were classified as positive, negative, or invalid. Colonoscopy reports were reviewed and abstracted. Because of product issues, four different FIT manufacturers were used. The test characteristics for each FIT manufacturer were calculated for advanced adenomatous polyps or cancer according to broad reason for colonoscopy (screening or surveillance/diagnostic).

RESULTS

Of those invited, 1,026 individuals (43.9%) completed their colonoscopy and had a valid FIT result. The overall sensitivity of the FITs (95% confidence intervals) was 0.18 (0.10 to 0.28) and specificity was 0.90 (0.87 to 0.91) for advanced adenomas or cancer. The sensitivity for distal lesions was 0.23 (0.11 to 0.38) and for proximal lesions was 0.09 (0.02 to 0.25). The odds ratio of an individual with a distal advanced adenoma or cancer testing positive was 2.68 (1.20 to 5.99). The two individuals with colorectal cancer tested negative, as did one individual with high-grade dysplasia.

CONCLUSIONS

The sensitivity of a single-sample FIT for advanced adenomas or cancer was low. Individuals with distal adenomas had a higher odds of testing positive than those with proximal lesions or no lesions.