Provider-Patient Discussions About Smoking and the Impact of Lung Cancer Screening Guidelines: NHIS 2011-2015

Examining Racial/Ethnic Disparities in Tobacco Dependence Treatment Among Medicaid Beneficiaries Using Fifty State Medicaid Claims, 2009-2014

In the USA, low-income racial/ethnic minority groups experience higher smoking rates and greater smoking-related disease burden than their White counterparts. Despite the adverse effects, racial/ethnic minorities are less likely to access tobacco dependence treatment (TDT). Medicaid is one of the largest payers of TDT in the USA and covers predominantly low-income populations. The extent of TDT use among beneficiaries from distinct racial/ethnic groups is unknown. The objective is to estimate racial/ethnic differences in TDT use among Medicaid fee-for-service beneficiaries. Using a retrospective study design and 50 state (including the District of Columbia) Medicaid claims (2009-2014), we employed multivariable logistic regression models and predictive margin methods to estimate TDT use rates among adults (18-64) enrolled (≥ 11 months) in Medicaid fee-for-service programs (January 2009-December 2014) by race/ethnicity. The population included White (n = 6,536,004), Black (n = 3,352,983), Latinx (n = 2,264,647), Asian (n = 451,448), and Native American/Alaskan Native (n = 206,472) beneficiaries. Dichotomous outcomes reflected service use in the past year. Any TDT use was operationalized as any smoking cessation medication fill, any smoking cessation counseling visit, or any smoking cessation outpatient visit. In secondary analyses, we disaggregated TDT use into three separate outcomes. Results suggested that Black (10.6%; 95% CI = 9.9-11.4%), Latinx (9.5%; 95% CI = 8.9-10.2%), Asian (3.7%; 95% CI = 3.4-4.1%), and Native American/Alaskan Native (13.7%; 95% CI = 12.7-14.7%) beneficiaries had lower TDT use rates compared to White beneficiaries (20.6%). Similar racial/ethnic treatment disparities were identified across all outcomes. By identifying significant racial/ethnic disparities in TDT use between 2009 and 2014, this study provides a benchmark against which to measure recent interventions in state Medicaid programs improving equity in smoking cessation interventions.

Assessment and Counseling Gaps Among Former Smokers Eligible for Lung Cancer Screening in US Adults : A Cross-Sectional Analysis of National Health and Nutrition Examination Surveys (NHANES), 2013-2018

BACKGROUND

Lung cancer screening (LCS) for former and current smokers requires that current smokers are counseled on tobacco treatment. In the USA, over 4 million former smokers are estimated to be eligible for LCS based on self-report for "not smoking now." Tobacco use and exposure can be measured with the biomarker cotinine, a nicotine metabolite reflecting recent exposure.

OBJECTIVE

To examine predictors of tobacco use and exposure among self-reported former smokers eligible for LCS.

DESIGN

Cross-sectional study using the 2013-2018 National Health and Nutrition Examination Survey.

PARTICIPANTS

Former smokers eligible for LCS (n = 472).

MAIN MEASURES

Recent tobacco use was defined as reported tobacco use in the past 5 days or a cotinine level above the race/ethnic cut points for tobacco use. Recent tobacco exposure was measured among former smokers without recent tobacco use and defined as having a cotinine level above 0.05 ng/mL.

KEY RESULTS

One in five former smokers eligible for LCS, totaling 1,416,485 adults, had recent tobacco use (21.4%, 95% confidence interval (CI) 15.8%, 27.0%), with about a third each using cigarettes, e-cigarettes, or other tobacco products. Among former smokers without recent tobacco use, over half (53.0%, 95% CI: 44.6%, 61.4%) had cotinine levels indicating recent tobacco exposure. Certain subgroups had higher percentages for tobacco use or exposure, especially those having quit within the past 3 years or living with a household smoker.

CONCLUSIONS

Former smokers eligible for LCS should be asked about recent tobacco use and exposure and considered for cotinine testing. Nearly 1.5 million "former smokers" eligible for LCS may be current tobacco users who have been missed for counseling. The high percentage of "passive smokers" is at least double that of the general nonsmoking population. Counseling about the harms of tobacco use and exposure and resources is needed.

Physicians' characteristics and practices associated with the provision of cancer screening advice to their patients: the Spanish SUN cohort study

OBJECTIVES

To evaluate the association between cancer screening counselling provided by medical doctors to their patients and each doctor's own anthropometrics, lifestyle, cancer screening practices, and personal and family history of cancer.

DESIGN

Prospective cohort study.

SETTING

Substudy including physicians participating in a Spanish cohort study with open enrolment.

PARTICIPANTS

Among 22 800 participants in the cohort as of May 2018, there were 2371 physicians who had replied to the cohort baseline questionnaire, had an email account and were younger than 65 years (retirement age in Spain). From this subsample, 890 replied to an online questionnaire focused on their clinical practices related to the counselling provided to their patients and to their prescription practices of preventive medications. Their mean age was 51.7 (SD 9.4) years and 48% were women.

OUTCOME MEASURES

Frequency of counselling given to their patients on specific practices of breast, colorectal and prostate cancer screenings.

RESULTS

Counselling on cancer screening to their patients was provided by 65% of physicians in a scenario of colorectal cancer, 59% for prostate cancer and 58% for breast cancer. More frequent cancer screening counselling was associated with the specialties of family medicine (OR=9.4, 95% CI 5.1 to 17.1) and internal medicine (OR=2.9, 95% CI 1.5 to 5.7) as compared with other specialties. Recommending cancer screening was associated with more frequent counselling on smoking cessation (OR=3.7, 95% CI 2.6 to 5.4), having personally attended colorectal cancer screening (OR=2.2, 95% CI 1.1 to 4.7) and prescribing blood pressure medication more often than their colleagues (OR=2.1, 95% CI 1.2 to 3.7).

CONCLUSIONS

Among medical doctors, cancer screening counselling was provided to their patients more frequently for doctors with family medicine or internal medicine specialties and for physicians who regularly offered counselling on certain lifestyle behaviours, and those having personally attended colorectal cancer screening. Doctors' own personal practices and knowledge of healthy lifestyles may help doctors to more frequently provide counselling on cancer screening to their patients.

Examining the role of healthcare access in racial/ethnic disparities in receipt of provider-patient discussions about smoking: A latent class analysis

Using insurance as a single indicator of healthcare access in examining the association between race/ethnicity and healthcare encounter-based interventions for smoking may not be adequate. In this study, we assessed the role of healthcare access using multifactorial measures in accounting for racial/ethnic disparities in the receipt of provider-patient discussions, defined as either being asked about smoking or advised to quit smoking by providers. We identified adult current smokers from the 2015 National Health Interview Survey. We first conducted a latent class analysis (LCA) to identify the underlying patterns of healthcare access measured by 13 indicators of healthcare access and utilization. We then used a propensity score - based weighting approach to examine racial/ethnic disparities in receiving provider-patient discussions about smoking or quitting in stratified groups by the distinct healthcare access clusters. Out of the 4134 adult current smokers who visited a doctor or a healthcare provider during the past 12 months, 3265 (79.90%) participants were classified as having high healthcare access and 869 (20.10%) participants as having low healthcare access. Compared to non-Hispanic whites, Hispanics had significantly lower odds of being asked about smoking (OR 0.46, 95% CI (0.27-0.77)) and being advised to quit (OR 0.57, 95% CI (0.34-0.97)) in the low access group, but neither association was significant in the high access group. In addition to increasing health insurance coverage, reducing other healthcare access barriers for Hispanics will likely facilitate provider-patient discussion and promote tobacco cessation among Hispanic smokers.

Examining lung cancer screening utilization with public-use data: Opportunities and challenges

Lung cancer screening with low-dose computed tomography is recommended for high-risk smokers who meet specific eligibility criteria. Current guidelines suggest that eligible adults with a heavy smoking history will benefit from annual low dose computed tomography but due to several associated risks (e.g., false-positives, radiation exposure, overdiagnosis) a shared decision-making consultation is required by the Centers for Medicare & Medicaid Services, and endorsed by the United States Preventive Services Task Force. In order to examine potential for tracking LCS uptake, adherence, and patient-provider communication at a national level, we reviewed four regularly publicly available national surveys (National Health Interview Survey [NHIS], Behavioral Risk Factor Surveillance System [BRFSS], National Health and Nutrition Examination Survey [NHANES], and Health Information National Trends Survey [HINTS]) to assess available data; an overview of 37 publications using these sources is also provided. The results show that none of the surveys include items that fully assess current LCS guidelines. Implications for future research-including the potential to examine factors associated with LCS uptake and patient-provider communication-are addressed.

The Influence of Increasing Levels of Provider-Patient Discussion on Quit Behavior: An Instrumental Variable Analysis of a National Survey

Objective: We aimed to examine the influence of increasing levels of discussion (both asked and advised, either asked or advised but not both, and neither asked nor advised) on quit behavior. Methods: We included 4133 adult current smokers from the 2015 National Health Interview Survey. The primary outcomes were quit intent and quit attempt, and the secondary outcomes were methods used for quitting. We used an instrumental variable analysis, as well as propensity score weighted and multivariable logistic regressions. Results: Compared to no discussion, having both or only one discussion, respectively, increased quit intent (OR = 1.65, 95% CI = 1.63–1.66 and OR = 1.02, 95% CI = 0.99–1.05), quit attempt (OR = 1.76, 95% CI = 1.75–1.77 and OR = 1.60, 95% CI = 1.57–1.63). Among those who attempted to quit (n = 1536), having both or only one discussion increased the use of pharmacologic (OR = 1.99, 95% CI = 1.97–2.02 and OR = 1.56, 95% CI = 1.49–1.63) or behavioral (OR = 2.01, 95% CI = 1.94–2.08 and OR = 2.91, 95% CI = 2.74–3.08) quit methods. Conclusions: Increasing levels of provider–patient discussion encourages quit behavior, and should be an integral part of reducing the health and economic burden of smoking. Strategies that promote the adherence and compliance of providers to communicate with patients may help increase the success of smoking cessation.

Provision of Smoking Cessation Resources in the Context of In-Person Shared Decision-Making for Lung Cancer Screening

BACKGROUND

Lung cancer screening (LCS) is effective at reducing mortality for high-risk smokers. Mortality benefits go beyond early cancer detection, because shared decision-making (SDM) may present a "teachable moment" to reinforce cessation and provide resources.

RESEARCH QUESTION

How well is smoking cessation performed during LCS SDM encounters, and what patient and provider characteristics are associated with smoking cessation assistance?

STUDY DESIGN AND METHODS

This is a retrospective cohort study of current smokers participating in initial LCS SDM through a multisite program in Seattle, Washington, between 2015-2018. The LCS tracking database and electronic health record were reviewed for demographics, comorbidity data, and clinical encounter information. The primary outcome was provision of a smoking cessation resource, defined as referral to cessation resources, recommendation for nicotine replacement, or prescription for cessation medication. Participant and provider factor associations with the outcome were evaluated using χ² testing and multivariable logistic regression.

RESULTS

Most of the 423 study participants were men (70%), with a median age of 61 (IQR, 58-66) years and median of 50 (41-72) pack-years of smoking. Only 26% of encounters had documentation consistent with SDM. Thirty-nine percent of participants received at least one smoking cessation resource, and only 5% received both counseling referrals and medication. In a multivariable model, the provision of any smoking cessation resource was half as likely in participants with higher levels of comorbidity (Charlson Index >2; OR, 0.53; 95% CI, 0.31-0.81), and half as likely if the ordering provider was not the patient's PCP or their specialist (OR, 0.55; 95% CI, 0.32-0.96).

INTERPRETATION

Overall provision of smoking cessation resources was moderate during SDM encounters for LCS, and lower in patients with more comorbidities and when not performed by the patient's PCP or specialist. Interventions are needed to improve smoking cessation counseling and resource utilization at the time of LCS encounters.

Machine learning to identify and understand key factors for provider-patient discussions about smoking

We sought to identify key determinants of the likelihood of provider-patient discussions about smoking and to understand the effects of these determinants. We used data on 3666 self-reported current smokers who talked to a health professional within a year of the time the survey was conducted using the 2017 National Health Interview Survey. We included wide-ranging information on 43 potential covariates across four domains, demographic and socio-economic status, behavior, health status and healthcare utilization. We exploited a principled nonparametric permutation based approach using Bayesian machine learning to identify and rank important determinants of discussions about smoking between health providers and patients. In the order of importance, frequency of doctor office visits, intensity of cigarette use, length of smoking history, chronic obstructive pulmonary disease, emphysema, marital status were major determinants of disparities in provider-patient discussions about smoking. There was a distinct interaction between intensity of cigarette use and length of smoking history. Our analysis may provide some insights into strategies for promoting discussions on smoking and facilitating smoking cessation. Health care resource usage, smoking intensity and duration and smoking-related conditions were key drivers. The "usual suspects", age, gender, race and ethnicity were less important, and gender, in particular, had little effect.

Role of SOX Protein Groups F and H in Lung Cancer Progression

Simple Summary

The expression of SOX proteins has been demonstrated in many tissues at various stages of embryogenesis, where they play the role of transcription factors. The SOX18 protein (along with SOX7 and SOX17) belongs to the SOXF group and is mainly involved in the development of the cardiovascular system, where its expression was found in the endothelium. SOX18 expression was also demonstrated in neoplastic lines of gastric, pancreatic and colon adenocarcinomas. The prognostic role of SOX30 expression has only been studied in lung adenocarcinomas, where a low expression of this factor in the stromal tumor was associated with a worse prognosis for patients. Because of the complexity of non-small-cell lung cancer (NSCLC) development, the role of the SOX proteins in this malignancy is still not fully understood. Many recently published papers show that SOX family protein members play a crucial role in the progression of NSCLC.

Abstract

The SOX family proteins are proved to play a crucial role in the development of the lymphatic ducts and the cardiovascular system. Moreover, an increased expression level of the SOX18 protein has been found in many malignances, such as melanoma, stomach, pancreatic breast and lung cancers. Another SOX family protein, the SOX30 transcription factor, is responsible for the development of male germ cells. Additionally, recent studies have shown its proapoptotic character in non-small cell lung cancer cells. Our preliminary studies showed a disparity in the amount of mRNA of the SOX18 gene relative to the amount of protein. This is why our attention has been focused on microRNA (miRNA) molecules, which could regulate the SOX18 gene transcript level. Recent data point to the fact that, in practically all types of cancer, hundreds of genes exhibit an abnormal methylation, covering around 5–10% of the thousands of CpG islands present in the promoter sequences, which in normal cells should not be methylated from the moment the embryo finishes its development. It has been demonstrated that in non-small-cell lung cancer (NSCLC) cases there is a large heterogeneity of the methylation process. The role of the SOX18 and SOX30 expression in non-small-cell lung cancers (NSCLCs) is not yet fully understood. However, if we take into account previous reports, these proteins may be important factors in the development and progression of these malignancies.