Racial/ethnic disparities in knowledge about one's breast cancer characteristics

Sharing Genomic Tumor Sequencing Results With Patients: Experiences of Advanced Practice Oncology Providers

Background

Patients with cancer routinely undergo genomic tumor sequencing, a component of molecular profiling (MP), to better characterize their cancer and identify potential targetable alterations. Targeted treatments potentially confer higher response rates and better efficacy. With increasing complexity, patients may require detailed explanations of MP results. Patient understanding of MP results increases the likelihood that eligible patients receive targeted treatment. Advanced practice providers (APPs), defined as nurse practitioners, physician assistants, and pharmacists, frequently review and discuss MP results with patients. Purpose: The aim of this study is to understand APP experiences discussing MP results with adult cancer patients.

Methods

A qualitative study was conducted through virtual semi-structured interviews with APPs recruited via study invitation shared through the Advanced Practitioner Society for Hematology and Oncology (APSHO). Eligibility criteria included APPs with > 1 year of oncology experience and involvement in discussing MP results. Data were analyzed utilizing a constant comparative analysis and coded in three stages: open, axial, and selective.

Results

Thirteen participants were enrolled from across the United States. Participants discussed learning to understand and explain MP findings primarily through on-the-job experiences. Barriers to patient education were also described. Initially coded participant statements (open codes) produced six themes (axial codes).

Conclusions

With MP now standard practice in oncology, APPs frequently discuss these results with patients. This study highlights that additional and continuing education related to MP is needed in communicating complex results. Patient educational tools, specific to patients' MP findings and tailored to their preferences and literacy levels, are critically needed.

What Do Patients With Cancer Know, or Want to Know, About Genomic Tumor Sequencing and Genetic Testing? A State-of-the-Art Review

Molecular profiling (MP), which involves testing tissue, blood, or other body fluids to identify biomarkers, has become increasingly important in cancer treatment. Genomic tumor sequencing, a specific type of MP, is commonly used to identify specific gene variants or proteins that can be targeted for treatment. Germline testing is also routinely recommended for certain cancers. Low levels of genomic literacy among cancer patients, coupled with increasingly complex test results, challenge clinicians to communicate results and provide appropriate education. In addition, patients may have varying preferences for the level of information they desire and are able to process. This state-of-the-art review explores cancer patients' expectations, attitudes, knowledge, satisfaction, and concerns as they undergo molecular profiling. A search was conducted through four databases to identify studies from 2016 to 2022 to explore cancer patients' knowledge and preferences regarding genomic testing. Nineteen studies met the inclusion criteria. Most studies revealed that people with cancer have low levels of knowledge regarding MP, albeit with significant variability. Patients primarily desired MP to identify new treatment options and increase survival. While patients relied on their providers to interpret test results, they wanted to be informed of all results, mainly if those results might guide treatment decisions or future care planning. Most patients, especially those with low genomic/genetic knowledge, tended to overestimate the personal benefits of MP. Further study is needed to provide tailored education to fulfill patients' information needs.

Lost in Translation: Multilingual Analysis of Online Breast Cancer Information

INTRODUCTION

Patients use the internet to learn more about health conditions. Non-English-speaking patients may face additional challenges. The quality of online breast cancer information, the most common cancer in women, is uncertain. This study aims to examine the quality of online breast cancer information for English and non-English-speaking patients.

METHODS

Three search engines were queried using the terms: "how to do a breast examination," "when do I need a mammogram," and "what are the treatment options for breast cancer" in English, Spanish, and Chinese. For each language, 60 unique websites were included and classified by type and information source. Two language-fluent reviewers evaluated website quality using the Journal of American Medical Association benchmark criteria (0-4) and the DISCERN tool (1-5), with higher scores representing higher quality. Scores were averaged for each language. Health On the Net code presence was noted. Inter-rater reliability between reviewers was assessed.

RESULTS

English and Spanish websites most commonly originated from US sources (92% and 80%, respectively) compared to Chinese websites (33%, P < 0.001). The most common website type was hospital-affiliated for English (43%) and foundation/advocacy for Spanish and Chinese (43% and 45%, respectively). English websites had the highest and Chinese websites the lowest mean the Journal of American Medical Association (2.2 ± 1.4 versus 1.0 ± 0.8, P = 0.002) and DISCERN scores (3.5 ± 0.9 versus 2.3 ± 0.6, P < 0.001). Health On the Net code was present on 16 (8.9%) websites. Inter-rater reliability ranged from moderate to substantial agreement.

CONCLUSIONS

The quality of online information on breast cancer across all three languages is poor. Information quality was poorest for Chinese websites. Improvements to enhance the reliability of breast cancer information across languages are needed.

Developing questions to assess and measure patients' perceived survival benefit from adjuvant endocrine therapy in breast cancer: a mixed methods pilot study

This mixed method study developed multiple question types to understand and measure women's perceived benefit from adjuvant endocrine therapy. We hypothesis that patients do not understand this benefit and sought to develop the questions needed to test this hypothesis and obtain initial patient estimates. From 8/2022 to 3/2023, qualitative interviews focused on assessing and modifying 9 initial varied question types asking about the overall survival (OS) benefit from adjuvant endocrine therapy. Subsequent focus groups modified and selected the optimal questions. Patients' self-assessment of their OS benefit was compared to their individualized PREDICT model results. Fifty-three patients completed the survey; 42% Hispanic, 30% rural, and 47% with income < $39,999 per year. Patients reported adequate health care literacy (61.5%) and average confidence about treatment and medication decisions 49.4 (95% CI 24.4-59.5). From the original 9 questions, 3 modified questions were ultimately found to capture patients' perception of this OS benefit, focusing on graphical and prose styles. Patients estimated an OS benefit of 42% compared to 4.4% calculated from the PREDICT model (p < 0.001). In this group with considerable representation from ethnic minority, rural and low-income patients, qualitative data showed that more than one modality of question type was needed to clearly capture patients' understanding of treatment benefit. Women with breast cancer significantly overestimated their 10-year OS benefit from adjuvant endocrine therapy compared to the PREDICT model.

Breast cancer survivorship experiences among Black women

BACKGROUND

Black women experience significant disparities in breast cancer across the care continuum, including survivorship. Ensuring that Black women obtain high-quality follow-up care is critical but understudied. This study was aimed at understanding the experiences and needs of Black women during breast cancer survivorship.

METHODS

Black patients diagnosed with invasive breast cancer within the past 5 years were invited to participate in a focus group and complete a survey. Focus groups examined the following: (1) the transition from active treatment to survivorship; (2) interactions with health care providers; (3) survivorship experiences, information needs, and preferences; and (4) existing educational materials. Results were thematically coded and analyzed for main themes. Surveys collected information on sociodemographics, health care experiences, quality of life, lifestyle, and education needs.

RESULTS

The study enrolled 53 participants, 43 of whom completed a survey and participated in one of 11 focus groups. The median age was 54 years, 44% had private insurance, 81% were English speaking, and 86% had completed their treatment more than a year before. Participants identified the importance of relationships with health care providers, gaps in survivorship care, experiences with cancer-related symptoms, challenges with mental health, worry about recurrence, body image, cancer financial toxicity, and coping through religion and spirituality. Unmet needs were centered around preparation for long-term symptoms, diet and physical activity, emotional support, and more explanations of information resources. Participants reported preferences for educational videos, personal stories, and culturally relevant content.

CONCLUSIONS

Some Black breast cancer survivors may have specific challenges and preferences. Supportive interventions that address these concerns can be responsive and help to ameliorate disparities.

Developing Questions to Assess and Measure Patients' Perceived Survival Benefit from Adjuvant Endocrine Therapy in Breast Cancer: A Mixed Methods Pilot Study

Purpose

This mixed methods study developed multiple question types to understand and measure women's perceived benefit from adjuvant endocrine therapy. We hypothesis that patients do not understand this benefit and sought to develop the questions needed to test this hypothesis and obtain initial patient estimates.

Methods

From 8/2022 to 3/2023, qualitative interviews focused on assessing and modifying 9 initial varied question types asking about the overall survival (OS) benefit from adjuvant endocrine therapy. Subsequent focus groups modified and selected the optimal questions. Patients' self-assessment of their OS benefit was compared to their individualized PREDICT model results.

Results

Fifty-three patients completed the survey; 42% Hispanic, 30% rural, and 47% with income <$39,999 per year. Patients reported adequate health care literacy (61.5%) and average confidence about treatment and medication decisions 49.4 (95% CI 24.4-59.5). From the original 9 questions, 3 modified questions were ultimately found to capture patients' perception of this OS benefit, focusing on graphical and prose styles. Patients estimated an OS benefit of 42% compared to 4.4% calculated from the PREDICT model (p < 0.001).

Conclusion

In this group with considerable representation from ethnic minority, rural and low-income patients, qualitative data showed that more than one modality of question type was needed to clearly capture patients' understanding of treatment benefit. Women with breast cancer significantly overestimated their 10-year OS benefit from adjuvant endocrine therapy compared to the PREDICT model.

Breast cancer treatment receipt and the role of financial stress, health literacy, and numeracy among diverse breast cancer survivors

PURPOSE

Disparities in breast cancer treatment for low-income and minority women are well documented. We examined economic hardship, health literacy, and numeracy and whether these factors were associated with differences in receipt of recommended treatment among breast cancer survivors.

METHODS

During 2018-2020, we surveyed adult women diagnosed with stage I-III breast cancer between 2013 and 2017 and received care at three centers in Boston and New York. We inquired about treatment receipt and treatment decision-making. We used Chi-squared and Fisher's exact tests to examine associations between financial strain, health literacy, numeracy (using validated measures), and treatment receipt by race and ethnicity.

RESULTS

The 296 participants studied were 60.1% Non-Hispanic (NH) White, 25.0% NH Black, and 14.9% Hispanic; NH Black and Hispanic women had lower health literacy and numeracy and reported more financial concerns. Overall, 21 (7.1%) women declined at least one component of recommended therapy, without differences by race and ethnicity. Those not initiating recommended treatment(s) reported more worry about paying large medical bills (52.4% vs. 27.1%), worse household finances since diagnosis (42.9% vs. 22.2%), and more uninsurance before diagnosis (9.5% vs. 1.5%); all P < .05. No differences in treatment receipt by health literacy or numeracy were observed.

CONCLUSION

In this diverse population of breast cancer survivors, rates of treatment initiation were high. Worry about paying medical bills and financial strain were frequent, especially among non-White participants. Although we observed associations of financial strain with treatment initiation, because few women declined treatments, understanding the scope of impact is limited. Our results highlight the importance of assessments of resource needs and allocation of support for breast cancer survivors. Novelty of this work includes the granular measures of financial strain and inclusion of health literacy and numeracy.

Effect of receiving a customizable brochure on breast cancer patients' knowledge about their diagnosis and treatment: A randomized clinical trial

BACKGROUND

Patients' lack of knowledge about their own disease may function as a barrier to shared decision-making and well-being. This study aimed to evaluate the impact of written educational materials on breast cancer patients.

METHODS

This multicenter, parallel, unblinded, randomized trial included Latin American women aged ≥18 years with a recent breast cancer diagnosis yet to start systemic therapy. Participants underwent randomization in a 1:1 ratio to receive a customizable or standard educational brochure. The primary objective was accurate identification of molecular subtype. Secondary objectives included identification of clinical stage, treatment options, participation in decision-making, perceived quality of information received, and illness uncertainty. Follow-up occurred at 7-21 and 30-51 days post-randomization.

CLINICALTRIALS

gov identifier: NCT05798312.

RESULTS

One hundred sixty-five breast cancer patients with a median age of 53 years and 61 days from diagnosis were included (customizable: 82; standard: 83). At first available assessment, 52%, 48%, and 30% identified their molecular subtype, disease stage, and guideline-endorsed systemic treatment strategy, respectively. Accurate molecular subtype and stage identification were similar between groups. Per multivariate analysis, customizable brochure recipients were more likely to identify their guideline-recommended treatment modalities (OR: 4.20,p = 0.001). There were no differences between groups in the perceived quality of information received or illness uncertainty. Customizable brochure recipients reported increased participation in decision-making (p = 0.042).

CONCLUSIONS

Over one third of recently diagnosed breast cancer patients are incognizant of their disease characteristics and treatment options. This study demonstrates a need to improve patient education and shows that customizable educational materials increase patients' understanding of recommended systemic therapies according to individual breast cancer characteristics.

Feasibility of delivering survivorship care via lay health educators: A pilot randomized controlled trial among rural cancer survivors

PURPOSE

We tested the feasibility of survivorship care plan (SCP) delivery with/without a lay health educator (LHE) telephone-delivered information session among rural cancer survivors, and their effects on health-related self-efficacy and knowledge of cancer history.

METHODS

Randomized trial of cancer survivors from 3 rural oncology clinics featuring either SCP alone (control) or SCP plus LHE-delivered information session (intervention). Participants completed a questionnaire on health-related self-efficacy and knowledge of cancer-specific medical history. Responses were compared to medical records for accuracy. SCPs were then mailed to participants. Approximately 5 months later, participants completed a follow-up questionnaire. A subset of participants took part in subsequent qualitative interviews about their study experience.

FINDINGS

Of 301 survivors approached, 72 (23.9%) were randomized (mean age 66.4 years; 3.1 years from diagnosis; 62.5% female), and 65 (90.3%) completed the study. Global mental and physical health or self-efficacy scores did not change significantly from baseline to follow-up for either group. In exploratory analyses, self-efficacy increased in participants with inadequate/marginal health literacy in the intervention arm (+0.7, 95% CI = 0.1-1.2; P = .01). Accuracy of knowledge did not improve but was high at baseline (mean 76.0±14.5%). 60.1% and 48.4% of control and intervention participants, respectively, found SCPs definitely/somewhat useful. Qualitative data (n = 20) suggested that SCPs were helpful to patients when primary and oncology care were less integrated.

CONCLUSIONS

An LHE-delivered informational session was feasible but had limited benefit to rural cancer survivors versus delivery of SCP alone but may be of benefit to patients with low health literacy or with less integrated care.

Not Too Little, Not Too Much: Optimizing More Versus Less Locoregional Treatment for Older Patients With Breast Cancer

Although undertreatment of older women with aggressive breast cancers has been a concern for years, there is increasing recognition that some older women are overtreated, receiving therapies unlikely to improve survival or reduce morbidity. De-escalation of surgery may include breast-conserving surgery over mastectomy for appropriate candidates and omitting or reducing extent of axillary surgery. Appropriate patients to de-escalate surgery are those with early-stage breast cancer, favorable tumor characteristics, are clinically node-negative, and who may have other major health issues. De-escalation of radiation includes reducing treatment course length through hypofractionation and ultrahypofractionation regimens, reducing treatment volumes through partial breast irradiation, omission of radiation for select patients, and reducing radiation dose to normal tissues. Shared decision making, which aims to facilitate patients making decisions concordant with their values, can guide health care providers and patients through complicated decisions optimizing breast cancer care.

Feasibility of introducing a smartphone navigation application into the care of breast cancer patients (The FIONA Study)

PURPOSE

Patients with breast cancer (BC) face complex medical information and decisions. The Outcomes4Me mobile app provides evidence-based BC education, symptom management tracking and clinical trial matching. This study sought to evaluate the feasibility of introducing this app into routine BC care.

METHODS

In this pilot study among BC patients undergoing therapy at an academic cancer center, patients were followed for 12 weeks with survey administration and electronic health record (EHR) abstraction at baseline and completion. Feasibility was defined as 40% of patients engaging with the app 3 or more times during the study. Additional endpoints included app usability (system usability scale), patient care experience, symptom evaluation, and clinical trial matching.

RESULTS

The study enrolled 107 patients from 6/01/2020 to 3/31/2021. Utilization of the app was deemed feasible with 60% of patients engaging with the app at least 3 times. SUS score of 70 indicated above average usability. New diagnosis and higher education level was associated with greater app engagement, with usability similar across all age groups. 41% of patients found the app helped track symptoms. Cognitive and sexual symptoms were infrequently reported, but were more frequently captured in the app than in the EHR. After using the app, 33% of patients reported increased interest in clinical trial enrollment.

CONCLUSION

Introducing the Outcomes4Me patient navigation app into routine BC care is feasible and may improve the patient experience. These results support further evaluation of this mobile technology platform to improve BC education, symptom management, and decision making.

CLINICAL TRIAL REGISTRY

Clinicaltrials.gov registration #: NCT04262518.

Increasing socioeconomically disadvantaged patients' engagement in breast cancer surgery decision-making through a shared decision-making intervention (A231701CD): protocol for a cluster randomised clinical trial

INTRODUCTION

Socioeconomic disparities for breast cancer surgical care exist. Although the aetiology of the observed socioeconomic disparities is likely multifactorial, patient engagement during the surgical consult is critical. Shared decision-making may reduce health disparities by addressing barriers to patient engagement in decision-making that disproportionately impact socioeconomically disadvantaged patients. In this trial, we test the impact of a decision aid on increasing socioeconomically disadvantaged patients' engagement in breast cancer surgery decision-making.

METHODS AND ANALYSIS

This multisite randomised trial is conducted through 10 surgical clinics within the National Cancer Institute Community Oncology Research Program (NCORP). We plan a stepped-wedge design with clinics randomised to the time of transition from usual care to the decision aid arm. Study participants are female patients, aged ≥18 years, with newly diagnosed stage 0-III breast cancer who are planning breast surgery. Data collection includes a baseline surgeon survey, baseline patient survey, audio-recording of the surgeon-patient consultation, a follow-up patient survey and medical record data review. Interviews and focus groups are conducted with a subset of patients, surgeons and clinic stakeholders. The effectiveness of the decision aid at increasing patient engagement (primary outcome) is evaluated using generalised linear mixed-effects models. The extent to which the effect of the decision aid intervention on patient engagement is mediated through the mitigation of barriers is tested in joint linear structural equation models. Qualitative interviews explore how barriers impact engagement, especially for socioeconomically disadvantaged women.

ETHICS AND DISSEMINATION

This protocol has been approved by the National Cancer Institute Central Institutional Review Board, and Certificate of Confidentiality has been obtained. We plan to disseminate the findings through journal publications and national meetings, including the NCORP network. Our findings will advance the science of medical decision-making with the potential to reduce socioeconomic health disparities.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT03766009).

Breast cancer knowledge and understanding treatment rationales among diverse breast cancer survivors

Purpose

The degree to which breast cancer survivors know about their tumors and understand treatment rationales is not well understood. We sought to identify information gaps within a diverse sample and explore whether knowledge about breast cancer and treatment may impact care.

Methods

We conducted a one-time, interviewer-administered survey of women who were diagnosed with breast cancer during 2013–2017 and received care at one of three centers in Boston, MA, and New York, NY. We examined knowledge of breast cancer and treatment rationales, information preferences, and treatment receipt.

Results

During 2018–2020, we interviewed 313 women (American Association for Public Opinion Research Cooperation Rates 58.4–76.5% across centers) who were 56.9% White, 23.6% Black, 14.1% Hispanic, and 5.4% other. Among the 296 included in analyses, we observed high variability in knowledge of breast cancer and treatment rationales, with a substantial number demonstrating limited knowledge despite feeling highly informed; > 25% actively avoided information. Black and Hispanic (vs. White) women consistently knew less about their cancers. Lack of understanding of treatment rationales for chemotherapy, radiation, and hormonal therapy was common but not consistently different by race and ethnicity. Understanding treatment rationale (but not cancer knowledge) was associated with treatment initiation, but small sample sizes limited in-depth examination.

Conclusions

Our study highlights the need for enhanced informational support for breast cancer survivors, who are challenged with complex information during the decision-making process and beyond. More research is needed to understand how to further educate and empower diverse populations of patients with breast cancer.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10549-022-06752-8.

Community health workers and precision medicine: A randomized controlled trial

BACKGROUND

Precision cancer care has reduced cancer-related mortality. However, minorities remain less likely to receive precision medicine than White populations with cancer due to language and system-level barriers. Precision medicine knowledge increases involvement in treatment decisions and receipt of such treatment. Few interventions exist that seek to improve precision medicine knowledge among low-income and racial and ethnic minorities with cancer.

METHODS

We designed a randomized controlled trial to evaluate the effectiveness of a community health worker (CHW)-delivered intervention on patients' knowledge of precision medicine in partnership with a community oncology clinic in Monterey County, California. Eligibility includes adults with newly diagnosed, progression or recurrence of cancer, low-income, or racial and ethnic minorities, or uninsured, insured by Medicaid or by a local agricultural employer. We will randomize 110 patients with cancer to the intervention or usual cancer care. The intervention group will be assigned to a CHW who will deliver culturally tailored and personalized education on precision medicine and advance care planning, screen for social determinants of health barriers and connect patients to community resources. The primary outcome is precision medicine knowledge measured by a 6-item survey adapted from Davies at baseline, 3-, 6- and 12-months post-enrollment. Exploratory outcomes include patient satisfaction with decision, activation, health care utilization, and receipt of evidence-based precision medicine care.

CONCLUSION

This trial will assess whether the CHW-led intervention can increase knowledge of precision medicine as well as several exploratory outcomes including receipt of evidence-based cancer care among low-income and racial and ethnic minority adults with cancer.

CLINICALTRIALS

gov Registration # NCT04843332.

Outcomes of Abbreviated MRI (Ab-MRI) for Women of any Breast Cancer Risk and Breast Density in a Community Academic Setting

BACKGROUND

Abbreviated magnetic resonance imaging (Ab-MRI) has been evaluated for elevated breast cancer risk or dense breasts but has not been evaluated across all risk profiles.

METHODS

Patients selected underwent Ab-MRI from February 2020 to September 2021. Women were older than aged 30 years, up to date with screening mammography, and paid $299 cash.

RESULTS

A total of 93 patients were identified with a mean age of 52 years; 92.5% were Caucasian, 0% black, and 97.9% were from high socioeconomic status. Mean Gail score was 14.2, and 83.3% had a lifetime risk of breast cancer <20%. Reasons for Ab-MRI: dense breasts (36.6%); family history (24.7%); palpable mass (12.9%). Providers ordering: OBGYN (49.5%); breast surgeon (39.1%); primary care (6.6%). Thirteen biopsies (14%) detected one breast cancer. 31.1% had a change in follow-up screening: 58.6% 6-month MRI, 20.7% 6-month mammogram, and 10.3% 6-month ultrasound. Negative predictive value was 100% (95% confidence interval [CI]: 95-100%, p < 0.0001). Sensitivity was 100% (95% CI: 2.5-100%, p < 0.0001), and specificity was 87% (95% CI: 78.3-93.1%, p < 0.0001) compared with 77.6% and 98.8% for mammography. Only one cancer was detected: cost of $27,807 plus cost of 13 MRI or ultrasound (US)-guided biopsies and additional follow-up imaging. Historically 20% of abnormalities detected on full MRI are malignant; however, 7.7% of ab-MRI abnormalities were malignant CONCLUSIONS: One third of women were recommended a change in follow-up, which predominantly included a 6-month MRI. Ab-MRI may introduce average risk women to unnecessary follow-up and increased biopsies with a lower cancer detection rate. Ab-MRI should be evaluated closely before implementation.

The impact of pain neuroscience education in a Hispanic-American population: A mixed-methods exploratory study

BACKGROUND

Chronic pain and pain catastrophization are growing problems across the United States, within the Hispanic-American population. Pain neuroscience education (PNE) changes pain knowledge and beliefs in many populations, but its impact on reconceptualization in people of Hispanic-American origin is unknown.

PURPOSE

Explore the changes in pain knowledge in Hispanic-American individuals and the process involved in reconceptualization following a PNE lecture.

METHODS

Eight Hispanic-American adults participated in a mixed-methods exploratory study. The Revised Neurophysiology of Pain Questionnaire (R-NPQ) was completed before, immediately after, and eight months after an adapted PNE lecture. A focus group involving four participants discussed the impact of PNE. Transcripts were translated and theme coded, and a concept map was developed by consensus.

RESULTS

R-NPQ scores improved from 25.3% to 43.5% post-lecture, and the number of unsure responses decreased from 41.5% to 18.4%. At eight months, R-NPQ scores remained stable (44.2%) but unsure responses increased (28.9%). Themes that contributed to the process of change included cognitive dissonance, relevance of instruction, idea exchange through peer interaction, reflection, confidence, changed behaviors, and educational utility.

CONCLUSION

While small improvements in knowledge and perception of pain appeared to occur with the PNE, knowledge remained low. Consideration of adult learning principles such as applicability, peer-interaction, the confrontation of beliefs, and reflection throughout PNE may enhance its impact. Future investigation should explore the efficacy of this intervention, when compared or combined with other techniques in the treatment of Hispanic-Americans experiencing persistent pain.

How Do African-American Community Members' Perceptions About Environmental Risks of Breast Cancer Compare with the Current State of the Science?

African-American (AA) women experience higher mortality from breast cancer than any other racial group. Understanding community-held perceptions of environmental contaminants as risk factors for breast cancer can inform the development of tailored prevention and education efforts for improve health outcomes. Six focus groups were conducted with AA participants in two counties in South Carolina, and themes were identified using open and axial coding. Perceived environmental risks for breast cancer most frequently discussed by participants were compared to findings from published systematic reviews. Frequently discussed environmental risk factors by participants were deodorants containing aluminum, plastics, pesticides, and air and water pollution. While perceptions of aluminum and air pollution as risk factors did not align with the state of the science, perceived risk factors of chemicals in plastics and pesticides were found to be in alignment. There is some congruence between perceived environmental risks for breast cancer within the AA community and the current state of the science; however, there is a need to communicate information that reflects current science regarding commonly held misconceptions. Development of evidence-based, clear, and culturally appropriate messaging that reflects the current state of the science is warranted.

Communicating Critical Information to Cancer Survivors: an Assessment of Survivorship Care Plans in Use in Diverse Healthcare Settings

Survivorship care plans (SCPs) serve to communicate critical information needed for cancer survivors' long-term follow-up care. The extent to which SCPs are tailored to meet the specific needs of underserved patient populations is understudied. To fill this gap, this study aimed to assess the content and communication appropriateness of SCPs collected from diverse healthcare settings. We analyzed collected SCPs (n = 16) for concordance with Institute of Medicine (IOM) recommendations for SCP content and for communication appropriateness using the Suitability Assessment of Materials (SAM) instrument. All plans failed to incorporate all IOM criteria, with the majority of plans (n = 11) incorporating less than 60% of recommended content. The average reading grade level of all the plans was 14, and only one plan received a superior rating for cultural appropriateness. There is significant variation in the format and content of SCPs used in diverse hospital settings and most plans are not written at an appropriate reading grade level nor tailored for underserved and/or minority patient populations. Co-designing SCPs with diverse patient populations is crucial to ensure that these documents are meeting the needs and preferences of all cancer survivors.

Patients’ awareness about their own breast cancer characteristics

BACKGROUND

Patients’ knowledge about the characteristics of their own cancer could be an important factor for understanding treatment regimens and adhering to therapies. However, to date nothing is known about the awareness among Chinese breast cancer patients about the characteristics of their own tumors.

AIM

To investigate how much knowledge that Chinese breast cancer patients have about their tumor characteristics and the impact of health and education literacy on the acquisition of such information.

METHODS

The survey was administered to patients who were diagnosed with breast cancer from 2017 to 2019 in three hospitals in China, and who came in for regular follow-up on an outpatient basis. We collected responses from 226 respondents who were asked about their cancer characteristics (stage, grade, and estrogen receptor status and human epidermal growth factor receptor 2 status of the cancer), and evaluated the correctness by comparing with their medical records. Logistic regression was used to assess the probability of knowing and of correctly answering questions. We also analyzed the association between our findings and the level of the patient’s education and their health literacy.

RESULTS

Overall, 20.80% to 57.96% of the patients reported knowing about the characteristics of breast cancer; of these, 10.18% to 46.46% reported these characteristics correctly. Education, age, and health literacy were all significantly associated with awareness rate, and with the level to which this information was accurate.

CONCLUSION

Breast cancer patients in China know little about their disease, and better education aimed at improving their knowledge about cancer characteristics is urgently needed. The low level of awareness could represent a deficiency of communication between surgeons and patients, which may be one of the reasons why medical disputes occur in China.

Recall of genomic testing results among cancer patients

BACKGROUND

Genomic testing of somatic and germline DNA has transformed cancer care. However, low genetic knowledge among patients may compromise care and health outcomes. Given the rise in genomic testing, we sought to understand patients' knowledge of their genetic test results.

MATERIALS AND METHODS

We conducted a survey-based study with 85 patients at a comprehensive cancer center. We compared self-reported recall of 1) having had somatic/germline testing and 2) their specific somatic/germline results to the genomic test results documented in the medical record.

RESULTS

Approximately 30% of patients did not recall having had testing. Of those who recalled having testing, 44% of patients with pathogenic/likely pathogenic germline mutations and 57% of patients with reported somatic alterations did not accurately recall their specific gene or variant-level results.

CONCLUSION

Given significant knowledge gaps in patients' recall of genomic testing, there is a critical need to improve patient-directed education and return-of-results strategies.

Health Literacy in Adult Oncology: An Integrative Review

PROBLEM IDENTIFICATION

Patients with cancer face high expectations for performing health literacy activities necessary for self-management and decision making, but only 12% of adults in the United States are proficient in health literacy. This review explores evidence regarding what is known about functional, interactive, and critical health literacy in adult oncology populations.

LITERATURE SEARCH

The review was conducted by searching extensively in the CINAHL® Plus database.

DATA EVALUATION

Of 614 articles retrieved from the literature search, 22 were included in the final sample. Most were cross-sectional, descriptive, correlational studies.

SYNTHESIS

Health literacy research in the United States focuses primarily on functional health literacy, but studies that include interactive and/or critical health literacy indicate their applicability in adult oncology populations.

IMPLICATIONS FOR RESEARCH

Additional research is needed to clarify the role of health literacy in cancer care to develop effective interventions that facilitate self-management and decision making.

COVID-19 Pandemic: Changes in Care for a Community Academic Breast Center and Patient Perception of Those Changes

Background

Philadelphia and its suburbs were an epicenter for the initial COVID-19 outbreak. Accordingly, alterations were made in breast cancer care at a community hospital.

Methods

The authors developed a prospective database of all the patients with invasive or in situ breast cancer between March 1 and June 15 at their breast center. Any change in a breast cancer plan due to the pandemic was documented, and the patients were grouped into two cohorts according to whether a change was made (CTX) or no change was made (NC) in their care. The patients were asked a series of questions about their care, including those in the Generalized Anxiety Disorder two-item questionnaire (GAD-2), via telephone.

Results

The study enrolled 73 patients: 41 NC patients (56%) and 32 CTX patients (44%). The two cohorts did not differ in terms of age, race, or stage. Changes included delay in therapy (15.1%) and use of neoadjuvant endocrine therapy (NET, 28.8%). The median time to surgery was 24 days (interequartile range [IQR], 16–45 days) for the NC patients and 82 day s (IQR, 52–98 days) for the CTX patients (p ≤ 0.001). The median duration of NET was 78 days. The GAD-2 showed anxiety positivity to be 29.6% for the CTX patients and 32.4% for the NC patients (p = 1.00). More than half (55.6%) of the CTX patients believed COVID-19 affected their treatment outlook compared with 25.7% of the NC patients (p = 0.021).

Conclusions

A prospective database captured changes in breast cancer care at a community academic breast center during the initial phase of the COVID-19 pandemic. 44% of patients experienced a change in breast cancer care due to COVID-19. The same level of anxiety and depression was seen in both change in therapy (CTX) and no change (NC). 55.6% of CTX cohort believed COVID-19 affected their treatment outlook.

Racial disparities in low-value surgical care and time to surgery in high-volume hospitals

BACKGROUND

The objective of this study is to examine racial differences in receipt of low-value surgical care and time to surgery (TTS) among women receiving treatment at high-volume hospitals.

METHODS

Stage I-III non-Hispanic Black (NHB) and Non-Hispanic White (NHW) breast cancer patients were identified in the National Cancer Database. Low-value care included (1) sentinel lymph node biopsy (SLNB) among T1N0 patients age ≥70 with hormone receptor-positive cancers, (2) axillary lymph node dissection (ALND) in patients meeting ACOSOG Z0011 criteria, and (3) contralateral prophylactic mastectomy (CPM) with unilateral cancer. TTS was days from biopsy to surgery. Bivariate and logistic regression analyses were used to compare the groups.

RESULTS

Compared to NHWs, NHBs had lower rates of SLNB among women age ≥70 with small hormone-positive cancers (NHB 58.5% vs. NHW 62.2% p < .001) and CPM (NHB 26.3% vs. NHW 36%; p < .001). ALND rates for patients meeting ACOSOG Z0011 criteria were similar between both groups (p = .13). The odds of surgery >60 days were higher among NHBs (odds ratio, 1.77; 95% confidence interval, 1.64-1.91; NHW ref).

CONCLUSIONS

NHBs treated at high-volume hospitals have higher rates of surgical delay but are less likely to undergo low-value surgical procedures compared to NHW women.

Racial disparities in knowledge, attitudes and practices related to COVID-19 in the USA

Background

Recent reports indicate racial disparities in the rates of infection and mortality from the 2019 novel coronavirus (coronavirus disease 2019 [COVID-19]). The aim of this study was to determine whether disparities exist in the levels of knowledge, attitudes and practices (KAPs) related to COVID-19.

Methods

We analyzed data from 1216 adults in the March 2020 Kaiser Family Foundation ‘Coronavirus Poll’, to determine levels of KAPs across different groups. Univariate and multivariate regression analysis was used to identify predictors of KAPs.

Results

In contrast to White respondents, Non-White respondents were more likely to have low knowledge (58% versus 30%; P < 0.001) and low attitude scores (52% versus 27%; P < 0.001), but high practice scores (81% versus 59%; P < 0.001). By multivariate regression, White race (odds ratio [OR] 3.06; 95% confidence interval [CI]: 1.70–5.50), higher level of education (OR 1.80; 95% CI: 1.46–2.23) and higher income (OR 2.06; 95% CI: 1.58–2.70) were associated with high knowledge of COVID-19. Race, sex, education, income, health insurance status and political views were all associated with KAPs.

Conclusions

Racial and socioeconomic disparity exists in the levels of KAPs related to COVID-19. More work is needed to identify educational tools that tailor to specific racial and socioeconomic groups.

Correlates of Adjuvant Therapy Attitudes in African American Breast Cancer Patients

PURPOSE

Black breast cancer patients delay and underutilize adjuvant breast cancer therapies; yet, very few studies have specifically examined Black women's attitudes toward breast cancer therapy. This study observed the influence of self-reported interpersonal processes of care (e.g. self-efficacy) clinical and sociodemographic factors and sociocultural (e.g. religiosity), related to Black breast cancer patients' attitudes toward radiation and systemic therapies (chemotherapy and adjuvant endocrine therapy - "AET").

METHODS

This was a secondary analysis of data from the Narrowing Gaps in Adjuvant Therapy Study (2006-2011). The analysis included 210 Black women who were newly diagnosed with breast cancer. Bivariate and multiple regression analyses were performed between independent variables (e.g., demographics) and three outcome variables (chemotherapy, AET, and radiation therapy) to asses women's perceptions of therapy type. The lasso method was used to select variables correlated with therapy attitudes.

RESULTS

Most women reported negative attitudes toward AET (56%) and radiation (54%); fewer negative attitudes were observed toward chemotherapy (47%). Higher education and greater perceived susceptibility of a recurrence were associated with more positive attitudes toward chemotherapy. Regarding radiation therapy, women with greater patient satisfaction were more likely to have more positive attitudes.

CONCLUSIONS

Our study findings may aid in the development of behavioral interventions targeted to mitigate Black women breast cancer treatment disparities. We found modifiable factors (e.g. communication, satisfaction ratings) that support opportunities for clinicians to better address Black women's needs regarding adjuvant treatment options. The development of tailored interventions for newly diagnosed Black breast cancer patients on patient related factors in health care are warranted for Black women with lower educational levels.

Examining Associations of Racial Residential Segregation With Patient Knowledge of Breast Cancer and Treatment Receipt

BACKGROUND

The effect of racial residential segregation on breast cancer treatment disparities is unclear. We examined whether racial segregation is associated with adjuvant treatment receipt and patient knowledge of disease.

PATIENTS AND METHODS

We surveyed a population-based sample of women in Northern California with stage I to III breast cancer diagnosed in 2010 to 2011 (participation rate = 68.5%, 500 patients). For black, Hispanic, and white women, we measured black and Hispanic segregation using the location quotient (LQ) of racial residential segregation, a proportional measure of the size of a minority group in the census tract compared with the larger metropolitan statistical area. We categorized LQ values for black and Hispanic participants into quartiles, with quartile 1 representing a lower relative level of segregation than quartile 4. We used multivariable logistical regression to assess the odds of receiving guideline-recommended adjuvant therapy and patient knowledge of tumor characteristics according to relative residential segregation.

RESULTS

We observed greater residential segregation for black versus Hispanic patients (P < .05). Overall, there were no treatment differences according to Hispanic or black LQ, except for black LQ quartile 3 (vs. 1) for which we observed higher odds of hormonal therapy. Knowledge of disease did not vary according to black LQ, but patients in the Hispanic LQ quartile 3 (vs. quartile 1) had less tumor knowledge.

CONCLUSION

We did not find clear associations for racial residential segregation and treatment or cancer knowledge in Northern California, an area with low levels of segregation. Additional research should assess the effect of segregation on breast cancer treatment disparities in a variety of geographical locations.

"For lack of knowledge, our people will perish": Using focus group methodology to explore African-American communities' perceptions of breast cancer and the environment

Among women living in the United States, breast cancer is the second leading cause of cancer death. Disproportionate racial disparities in breast cancer exist, with African American (AA) women consistently having the highest rates of breast cancer related mortality despite lower incidence. This study attends to the Institute of Medicine's (IOM) call to action recommending the identification of effective strategies for communicating accurate and reliable breast cancer risk information to diverse audiences. Using focus group methodology, this study explores how AAs perceive and decipher information related to breast cancer and its relationship to their environment. Six focus groups were conducted. The sample (n = 50) was African American, 98% female, with an average age of 50.1 years. The focus group protocol consisted of open-ended questions designed to elicit information about participants' perceptions of their environment and its link to breast cancer. Focus groups were audio recorded and professionally transcribed. Analysis of the focus group transcripts revealed themes pertaining to these categories: (1) general knowledge and beliefs about breast cancer, (2) perceived environmental risks factors for breast cancer, (3) importance of seeking knowledge about breast cancer and the environment, and (4) recommended communication strategies. The emergent themes reflect the knowledge participants possessed about breast cancer and environmental risk factors, in addition to concerns about the importance of possessing accurate information, and how culturally appropriate health communication strategies can be used to disseminate breast cancer knowledge in the community. Findings from this study can be used for culturally appropriate communication about breast cancer and the environment with AA communities.

Knowledge of Genetic Counseling Among Patients With Breast Cancer and Their Relatives at a Nigerian Teaching Hospital

Breast cancer prevalence continues to increase globally, and a significant proportion of the disease has been linked to genetic susceptibility. As we enter the era of precision medicine, genetics knowledge and skills are increasingly essential for achieving optimal cancer prevention and care. However, in Nigeria, patients with breast cancer and their relatives are less knowledgeable about genetic susceptibility to chronic diseases. This pilot study collected qualitative data during in-depth interviews with 21 participants. Of these, 19 participants were patients with breast cancer and two were relatives of patients with breast cancer. Participants were asked questions regarding their knowledge of breast cancer, views on heredity and breast cancer, and views on genetic counseling. Participants' family histories were used as a basis with which to assess their hereditary risk of breast cancer. Participant responses were audio recorded and transcribed manually. The study evaluated patients' and relatives' knowledge of genetic counseling and the use of family history for the assessment of familial risk of breast cancer. This will serve as a guide to the processes of establishing a cancer risk assessment clinic.

Disparities in the survivorship experience among Latina survivors of breast cancer

BACKGROUND

The authors investigated disparities in the survivorship experience among Latinas with breast cancer (BC) in comparison with non-Latinas.

METHODS

A cross-sectional bilingual telephone survey was conducted among 212 Latina and non-Latina women within 10 to 24 months after a diagnosis of BC (AJCC TNM staging system stage 0-III) at 2 Los Angeles County public hospitals. Data were collected using the Preparing for Life as a (New) Survivor (PLANS) scale, Perceived Efficacy in Patient-Physician Interactions Questionnaire (PEPPI), Breast Cancer Prevention Trial (BCPT) Symptom Checklist, Satisfaction with Care and Information Scale, Consumer Assessment of Healthcare Providers and Systems (CAHPS) tool, Charlson Comorbidity Index adapted for patient self-report, and the 12-item Short Form Health Survey. Controlling variables included age, stage as determined by the American Joint Committee on Cancer (AJCC) TNM staging system, educational level, and study site in multivariate analyses.

RESULTS

The mean ages of Latinas and non-Latinas were 51.5 years and 56.6 years, respectively. Compared with non-Latinas, Latinas reported less BC survivorship knowledge (27.3 vs 30.7; P<.0001), were more dissatisfied with BC care information (2.3 vs 3.4; P<.0001), reported lower PEPPI scores (38.2 vs 42.2; P = .03), and experienced more BCPT symptoms (6.4 vs 5.0; P = .04). No differences were noted regarding their confidence in survivorship care preparedness (42.7 vs 41; P = .191), satisfaction with BC survivorship care (9.6 vs 8.8; P = .298), or their discussion with physicians (9.6 vs 8.1; P = .07). These ethnic group differences persisted in multivariate analyses, with the exception of PEPPI.

CONCLUSIONS

Latina survivors of BC experienced disparities in BC knowledge and satisfaction with information received, but believed themselves to be prepared for survivorship and were as satisfied with providers, care received, and discussions with physicians as non-Latinas. Cancer 2018;124:2373-80. © 2018 American Cancer Society.

Understanding Breast Cancer Knowledge and Barriers to Treatment Adherence: A Qualitative Study Among Breast Cancer Survivors

Disparities in breast cancer treatment receipt are common and multifactorial. Data are limited on how knowledge about one's breast cancer and understanding treatment rationales may impact treatment completion. In this qualitative analysis, we explored barriers to care with a focus on knowledge. We conducted 18 in-depth interviews with women from diverse socioeconomic backgrounds who were treated at Dana-Farber Cancer Institute (n = 12; Boston, MA) and Columbia University Medical Center (n = 6; New York, NY) and had undergone neo/adjuvant breast cancer treatment within the prior 3 years. Interviews focused on treatments received, adherence, barriers experienced, and questions related to breast cancer knowledge and treatment rationales. We analyzed transcribed interview recordings in N'Vivo using a two-stage coding process that allowed for both preconfigured and emergent themes. Answers for breast cancer knowledge were confirmed using medical records. In our analysis, over one-third of women reported incomplete therapy, including never initiating treatment, stopping treatment prematurely, or missing/delaying treatments due to logistical reasons (childcare, transportation) or patient preferences. Others reported treatment modifications because of provider recommendations. Nearly all women were able to accurately describe the rationale for recommended treatments. Among 17 women for whom medical records were available, women correctly reported 18–71% of their tumor characteristics; incorrect reporting was not consistently associated with treatment incompletion. In conclusion, logistical issues and patient preferences were the main reasons for incomplete therapy in our study. Understanding of treatment rationale was high, but breast cancer knowledge was variable. Further assessment of how knowledge may impact cancer care is warranted.

Validity of self-reported breast cancer characteristics in a nationwide cohort of women with a family history of breast cancer

BACKGROUND

Women may have incomplete understanding of a breast cancer diagnosis, leading to inaccurate reporting in epidemiological studies. However, it is not feasible to obtain consent for medical records from all women participating in a study. Therefore, it is important to determine how well self-reported breast cancer characteristics correspond with what is found in medical records, but few studies have evaluated agreement of self-reported breast cancer characteristics with abstracted medical records.

METHODS

We calculated the positive predictive value (PPV) of self-reports compared to medical records and explored whether participant characteristics may have influenced reporting accuracy. We analyzed data from 2518 reported breast cancer cases from the Sister Study, a large nationwide cohort of women with a family history of breast cancer.

RESULTS

Medical records or pathology reports were obtained for 2066 of 2518 (82%) women who reported incident breast cancer. Breast cancer was confirmed for over 99% (n = 2054) of women with medical records. Confirmation rates were high for invasive, ductal, hormone receptor positive, and HER2 negative breast cancers, with little variation by race/ethnicity or age. Self-reported in situ breast cancer had a lower PPV (64.2%), with medical records showing invasive breast cancer instead, especially for older and Hispanic women. Hormone receptor (ER and PR) negative and HER2 positive self-reports had lower PPVs (83.0%, 71.6%, and 66.1% respectively). Hispanic women and women ages 65 or older at diagnosis were less able to accurately report breast cancer stage, excluding stage I.

CONCLUSIONS

Accuracy of reporting overall breast cancer and common subtypes is high. Despite having a family history of breast cancer and voluntarily enrolling in a study evaluating breast cancer risk factors, participants may have greater difficulty distinguishing between in situ and invasive breast cancer and may less accurately report other less common subtypes. Discrepancies may reflect women's poor understanding of information conveyed by health care providers or lack of consistent terminology used to describe subtypes.

Gaps in the Public's Knowledge About Chronic Pain: Representative Sample of Hispanic Residents From 5 States

Educating the general public about chronic pain and its care is a national health priority. We evaluated knowledge, attitudes, and beliefs (KAB) of a 5-state, population-based sample of Hispanic individuals aged 35 to 75 years without chronic pain, representing more than 8.8 million persons. A Web-based survey assessed KAB using an adapted version of the Survey of Pain Attitudes-Brief and self-reported knowledge about chronic pain (nothing, a little, a lot). In unweighted analyses of participants (N = 349), the mean age was 52.0 (±10.6) years, 54% were women, 53% preferred Spanish, and 39% did not graduate from high school. More participants reported knowing nothing about chronic pain (24%) than a lot (12%). In weighted logistic models with knowing nothing as the reference, knowing a lot was associated with greater KAB for chronic pain-related emotions, functioning, and cure (all P < .01) but poorer KAB about pain medications (P < .001). Associations were similar for those knowing a little. Men and women preferring Spanish had poorer KAB about pain medications than men preferring English (both P < .001). In view of Hispanic individuals' disparities in chronic pain care, these data underscore the need for effective public educational campaigns about chronic pain.

PERSPECTIVE

In this 5-state representative sample of Hispanic individuals without chronic pain, one-quarter reported knowing nothing about chronic pain and had poorer KAB about multiple aspects of this disease. This study reinforces the need to evaluate and address gaps in the general public's knowledge about chronic pain.

Beliefs in Chemotherapy and Knowledge of Cancer and Treatment Among African American Women With Newly Diagnosed Breast Cancer

PURPOSE/OBJECTIVES

To examine beliefs regarding the necessity of chemotherapy and knowledge of breast cancer and its treatment in African American women with newly diagnosed breast cancer, and to explore factors associated with women's beliefs and knowledge.
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DESIGN

Descriptive, cross-sectional study.
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SETTING

Six urban cancer centers in Western Pennsylvania and Eastern Ohio.
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SAMPLE

101 African American women with newly diagnosed breast cancer. 
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METHODS

Secondary analysis using baseline data collected from participants in a randomized, controlled trial at their first medical oncology visit before the first cycle of chemotherapy.
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MAIN RESEARCH VARIABLES

Belief in chemotherapy, knowledge of cancer and recommended treatment, self-efficacy, healthcare system distrust, interpersonal processes of care, symptom distress, and quality of life.
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FINDINGS

African American women endorsed the necessity of chemotherapy. Most women did not know their tumor size, hormone receptors, specific therapy, or why chemotherapy was recommended to them. Women who perceived better interpersonal communication with physicians, less self-efficacy, or were less involved in their own treatment decision making held stronger beliefs about the necessity of chemotherapy. Women without financial difficulty or having stronger social functioning had more knowledge of their cancer and recommended chemotherapy. 
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CONCLUSIONS

African American women with newly diagnosed breast cancer generally agreed with the necessity of chemotherapy. Knowledge of breast cancer, treatment, and risk reduction through adjuvant therapy was limited.
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IMPLICATIONS FOR NURSING

Oncology nurses could help advocate for tailored educational programs to support informed decision making regarding chemotherapy acceptance for African American women.

Exploration of communication gaps among women with metastatic breast cancer, caregivers and oncologists

Aim: The Make Your Dialogue Count survey aimed to explore communication gaps between patients/caregivers and oncologists, and the needs of patients/caregivers at diagnosis and most recent treatment change. Methods: Three distinct sets of parallel questions were asked of 359 women with metastatic breast cancer, 234 caregivers and 252 oncologists. Survey respondents were not necessarily associated with each other. Results: Patients/caregivers considered themselves knowledgeable, yet many lacked basic disease information affecting treatment decisions. Patients/caregivers reported that oncologists do not discuss important topics at diagnosis. Patients failed to discuss side effects, but wanted their oncologist’s help to manage side effects. Conclusion: This survey provides additional insight on interactional dynamics to bridge gaps in understanding that affect quality of care.

Racial Difference in Symptom Onset to Door Time in ST Elevation Myocardial Infarction

BACKGROUND

There are poorer outcomes following ST elevation myocardial infarction in blacks compared to white patients despite comparable door-to-reperfusion time. We hypothesized that delays to hospital presentation may be contributory.

METHODS AND RESULTS

We conducted a retrospective analysis of the 1144 patients admitted for STEMI in our institution from 2008 to 2013. The door-to-balloon time (D2BT) and symptom-onset-to-door time (SODT) were compared by race. Bivariate analysis was done comparing the median D2BT and SODT. Stratified analyses were done to evaluate the effect of race on D2BT and SODT, accounting for insurance status, age, sex and comorbidities. The mean age was 59±13 years; 56% of this population was black and 41% was white. Males accounted for 66% of this population. The median D2BT was 60 minutes (interquartile range [IQR] 42-82), and median SODT was 120 minutes (IQR 60-720). There was no significant difference in D2BT by race (P=0.86). Black patients presented to the emergency room (ER) later than whites (SODT=180 [IQR 60-1400] vs 120 [IQR 60-560] minutes, P<0.01) and were more likely to be uninsured (P<0.01). After controlling for comorbidities, insurance, and socioeconomic status, blacks were 60% more likely to present late after a STEMI (OR 1.6, P<0.01). A subset analysis excluding transferred patients showed similar results.

CONCLUSIONS

Black patients present later to the ER after STEMI with no difference in D2BT compared to whites. This difference in time to presentation may be one of the factors accounting for poor outcomes in this population.

Dimensions of Deaf/Hard-of-Hearing and Hearing Adolescents' Health Literacy and Health Knowledge

Deaf and hard-of-hearing (D/HH) adults have lower health literacy compared to hearing adults, but it is unclear whether this disparity also occurs in adolescence. We used the Health Literacy Skills Instrument-Short Form (HLSI-SF), Short Form of the Test of Functional Health Literacy in Adults (S-TOFHLA), Comprehensive Heart Disease Knowledge Questionnaire (CHDKQ), and newly constructed interactive and critical health literacy survey items to quantify D/HH and hearing adolescents' health literacy. We adapted and translated survey materials into sign language and spoken English to reduce testing bias due to variable English language skills. Participants were 187 D/HH and 94 hearing college-bound high school students. When we adjusted for age, gender, race/ethnicity, school grade, and socioeconomic status, D/HH adolescents demonstrated weaker general and functional health literacy and cardiovascular health knowledge than hearing adolescents on the HLSI, S-TOFHLA, and CHDKQ (all ps < .0001). Standard health literacy or knowledge scores were associated with several interactive and critical health literacy skills (all ps < .05). D/HH adolescents who reported greater hearing-culture identity, having hearing aids, experiencing better hearing with assistive devices, having good quality of communication with parents, and attending hearing schools at least half of the time had higher functional health literacy (all ps < .025). Those who reported English as their best language and attending hearing schools at least half of the time had higher cardiovascular health knowledge scores (all ps < .03). Results suggest that interventions to improve D/HH adolescents' health literacy should target their health-related conversations with their families; access to printed health information; and access to health information from other people, especially health care providers and educators.

Survivorship care and support following treatment for breast cancer: a multi-ethnic comparative qualitative study of women's experiences

BACKGROUND

As the number of breast cancer survivors continues to rise, Western populations become more ethnically and socially diverse and healthcare resources become ever-more stretched, follow-up that focuses on monitoring for recurrence is no longer viable. New models of survivorship care need to ensure they support self-management and are culturally appropriate across diverse populations. This study explored experiences and expectations of a multi-ethnic sample of women with breast cancer regarding post-treatment care, in order to understand potential barriers to receiving care and inform new models of survivorship care.

METHODS

A phenomenological qualitative research design was employed. In-depth interviews were conducted with women from diverse socio-demographic backgrounds in England, who completed treatment for breast cancer in the 12 months prior to the study. Data were analysed using Framework Analysis.

RESULTS

Sixty-six women participated and reported expectations and needs were unmet at follow-up. Whilst there were more commonalities in experiences, discernible differences, particularly by ethnicity and age, were identified relating to three key themes: emotional responses on transition to follow-up; challenges communicating with healthcare professionals at follow-up; and challenges finding and accessing information and support services to address unmet needs.

CONCLUSIONS

There are cultural differences in the way healthcare professionals and women communicate, not necessarily differences in their post-treatment needs. We do not know if new models of care meet survivors' needs, or if they are appropriate for everyone. Further testing and potential cultural and linguistic adaptation of models of care is necessary to ensure their appropriateness and acceptability to survivors from different backgrounds. New ways of providing survivorship care mean survivors will need to be better prepared for the post-treatment period and the role they will have to play in managing their symptoms and care.

Comparison of the Initial Loco-Regional Treatment Received for Early-Stage Breast Cancer between Elderly Women in Appalachia and a United States - Based Population: Good and Bad News

BACKGROUND

Breast conserving surgery (BCS) followed by radiation therapy (RT) (BCS+RT) is as effective for long-term survival of invasive early-stage breast cancer (ESBC) as mastectomy, and is the local treatment option selected by the majority of women with ESBC. Women of older age and vulnerable socio-demographic characteristics are at greater risk for receiving substandard (BCS only) and non-preferred treatments (mastectomy), such as populations of women from the Appalachian region of United States.

METHODS

Using a retrospective cohort study design, we identified 26,106 patients from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked dataset and 811 patients from the West Virginia Cancer Registry (WVCR)-Medicare dataset age ≥ 66 diagnosed from 2003 to 2006 with stage I-II breast cancer. Multivariable logistic regression models estimated type of initial treatment received between WVCR-Medicare and SEER-Medicare patients, and the association with type of treatment.

RESULTS

Overall, women in WV were 0.82 (95% CI 0.68-0.99) and 0.70 (95% CI 0.58-0.84) times less likely to have mastectomy or BCS only vs. BCS+RT, than those in SEER regions. Women in WV of increasing age, greater comorbidity, stage II disease, and non-white race were more likely to have mastectomy or BCS only vs. BCS+RT, whereas, those residing in areas of higher income, higher education, and metro status were less likely, than similarly characterized women from SEER regions.

CONCLUSIONS

Findings from this study suggest that the magnitude of disparities in breast cancer treatment between groups of women with more and less resources are even greater in the Appalachian region, than they are among US populations. Improving access to oncology treatment services, as well as, the implementation of patient navigation programs are needed to improve patterns of initial treatment for ESBC among at-risk populations.

Association of Breast Cancer Knowledge With Receipt of Guideline-Recommended Breast Cancer Treatment

PURPOSE

Knowledge about one's breast cancer characteristics is poor, but whether this knowledge affects treatment is uncertain. Among women with breast cancer, we examined whether tumor knowledge was associated with adjuvant treatment receipt.

METHODS

We surveyed a population-based sample of women in Northern California with stage 0 to III breast cancer diagnosed during 2010 to 2011 (participation rate, 68.5%). Interviews were conducted between 4 months and 3 years after diagnosis. Among 414 respondents with stage I to III disease, we examined receipt of guideline-recommended chemotherapy, radiation, and hormonal therapy by reporting correct information about one's tumor, including stage, estrogen receptor, human epidermal growth factor receptor 2 (HER2), and grade (using registry data for confirmation). We performed multivariate logistic regression to assess the probability of receiving each treatment in relevant patient groups, adjusting for patient and tumor characteristics, and examined the impact of reporting correct tumor information on treatment receipt.

RESULTS

Among relevant treatment-eligible groups, 81% received chemotherapy, 91% received radiation, and 83% received hormonal therapy. In adjusted analyses, having correct (v incorrect) information for stage and HER2 were associated with chemotherapy receipt (odds ratio [OR], 4.45; 95% CI, 1.50 to 12.50 for stage; OR, 2.70; 95% CI, 1.02 to 7.18 for HER2). Correctly reporting estrogen receptor status was associated with hormonal therapy receipt (OR, 3.91; 95% CI, 1.73 to 8.86), and correctly reporting stage was associated with radiation receipt (OR, 2.76; 95% CI, 1.03 to 7.40).

CONCLUSION

Knowledge about one's tumor characteristics was strongly associated with receipt of recommended therapies. Interventions to improve patients' knowledge and understanding of their cancers should be tested as a strategy for improving receipt of care.

Higher Stage of Disease Is Associated With Bilateral Mastectomy Among Patients With Breast Cancer: A Population-Based Survey

BACKGROUND

The reasons for increasing rates of bilateral mastectomy for unilateral breast cancer are incompletely understood, and associations of disease stage with bilateral surgery have been inconsistent. We examined associations of clinical and sociodemographic factors, including stage, with surgery type and reconstruction receipt among women with breast cancer.

PATIENTS AND METHODS

We surveyed a diverse population-based sample of women from Northern California cancer registries with stage 0 to III breast cancer diagnosed during 2010-2011 (participation rate, 68.5%). Using multinomial logistic regression, we examined factors associated with bilateral and unilateral mastectomy (vs. breast-conserving surgery), adjusting for tumor and sociodemographic characteristics. In a second model, we examined factors associated with reconstruction for mastectomy-treated patients.

RESULTS

Among 487 participants, 58% had breast-conserving surgery, 32% had unilateral mastectomy, and 10% underwent bilateral mastectomy. In adjusted analyses, women with stage III (vs. stage 0) cancers had higher odds of bilateral mastectomy (odds ratio [OR], 8.28; 95% confidence interval, 2.32-29.50); women with stage II and III (vs. stage 0) disease had higher odds of unilateral mastectomy. Higher (vs. lower) income was also associated with bilateral mastectomy, while age ≥ 60 years (vs. < 50 years) was associated with lower odds of bilateral surgery. Among mastectomy-treated patients (n = 206), bilateral mastectomy, unmarried status, and higher education and income were all associated with reconstruction (P < .05).

CONCLUSION

In this population-based cohort, women with the greatest risk of distant recurrence were most likely to undergo bilateral mastectomy despite a lack of clear medical benefit, raising concern for overtreatment. Our findings highlight the need for interventions to assure women are making informed surgical decisions.

The Relationship between Health Literacy and Health Disparities: A Systematic Review

OBJECTIVES

Health literacy is commonly associated with many of the antecedents of health disparities. Yet the precise nature of the relationship between health literacy and disparities remains unclear. A systematic review was conducted to better understand in how far the relationship between health literacy and health disparities has been systematically studied and which potential relationships and pathways have been identified.

METHODS

Five databases, including PubMed/MEDLINE and CINAHL, were searched for peer-reviewed studies. Publications were included in the review when they (1) included a valid measure of health literacy, (2) explicitly conceived a health disparity as related to a social disparity, such as race/ethnicity or education and (3) when results were presented by comparing two or more groups afflicted by a social disparity investigating the effect of health literacy on health outcomes. Two reviewers evaluated each study for inclusion and abstracted relevant information. Findings were ordered according to the disparities identified and the role of health literacy in explaining them.

RESULTS

36 studies were included in the final synthesis. Most of the studies investigated racial/ethnic disparities, followed by some few studies that systematically investigated educational disparities. Some evidence was found on the mediating function of health literacy on self-rated health status across racial/ethnic and educational disparities, as well as on the potential effect of health literacy and numeracy on reducing racial/ethnic disparities in medication adherence and understanding of medication intake.

CONCLUSION

Overall the evidence on the relationship between health literacy and disparities is still mixed and fairly limited. Studies largely varied with regard to health(-related) outcomes under investigation and the health literacy assessments used. Further, many studies lacked a specific description of the nature of the disparity that was explored and a clear account of possible pathways tested.

Racial/Ethnic Differences in Patients' Selection of Surgeons and Hospitals for Breast Cancer Surgery

IMPORTANCE

Racial differences in breast cancer treatment may result in part from differences in the surgeons and hospitals from whom patients receive their care. However, little is known about differences in patients' selection of surgeons and hospitals.

OBJECTIVE

To examine racial/ethnic differences in how women selected their surgeons and hospitals for breast cancer surgery.

DESIGN, SETTING, AND PARTICIPANTS

We surveyed 500 women (222 non-Hispanic white, 142 non-Hispanic black, 89 English-speaking Hispanic, and 47 Spanish-speaking Hispanic) from northern California cancer registries with stage 0 to III breast cancer diagnosed during 2010 through 2011. We used multivariable logistic regression to assess the reasons for surgeon and hospital selection by race/ethnicity, adjusting for other patient characteristics. We also assessed the association between reasons for physician selection and patients' ratings of their surgeon and hospital.

MAIN OUTCOMES AND MEASURES

Reasons for surgeon and hospital selection and ratings of surgeon and hospital.

RESULTS

The 500 participants represented a response rate of 47.8% and a participation rate of 69%. The most frequently reported reason for surgeon selection was referral by another physician (78%); the most frequently reported reason for hospital selection was because it was a part of a patient's health plan (58%). After adjustment, 79% to 87% of black and Spanish-speaking Hispanic women reported selecting their surgeon based on a physician's referral vs 76% of white women (P = .007). Black and Hispanic patients were less likely than white patients to report selecting their surgeon based on reputation (adjusted rates, 18% and 22% of black and Hispanic women, respectively, vs 32% of white women; P = .02). Black and Hispanic women were also less likely than white women to select their hospital based on reputation (adjusted rates, 7% and 15% vs 23%, respectively; P = .003). Women who selected their surgeon based on reputation more often rated the care from their surgeon as excellent (adjusted odds ratio, 2.21; 95% CI, 1.24-3.93); those reporting their surgeon was one of the only surgeons available through the health plan less often reported excellent quality of surgical care (adjusted odds ratio, 0.56; 95% CI, 0.34-0.91).

CONCLUSIONS AND RELEVANCE

Compared with white patients with breast cancer, minority patients were less actively involved in physician and hospital selection, relying more on physician referral and health plans rather than on reputation. Interventions to promote involvement in surgeon and hospital selection may have potential for addressing disparities related to lower-quality care from surgeons and hospitals.