Enhancing cancer screening in primary care: rationale, design, analysis plan, and recruitment results

Tristetraprolin activation by resveratrol inhibits the proliferation and metastasis of colorectal cancer cells

Resveratrol (RSV) is a polyphenolic compound that naturally occurs in grapes, peanuts and berries. Considerable research has been conducted to determine the benefits of RSV against various human cancer types. Tristetraprolin (TTP) is an AU-rich element-binding protein that regulates mRNA stability and has decreased expression in human cancer. The present study investigated the biological effect of RSV on TTP gene regulation in colon cancer cells. RSV inhibited the proliferation and invasion/metastasis of HCT116 and SNU81 colon cancer cells. Furthermore, RSV induced a dose-dependent increase in TTP expression in HCT116 and SNU81 cells. The microarray experiment revealed that RSV significantly increased TTP expression by downregulating E2F transcription factor 1 (E2F1), a downstream target gene of TTP and regulated genes associated with inflammation, cell proliferation, cell death, angiogenesis and metastasis. Although TTP silencing inhibited TTP mRNA expression, the expression was subsequently restored by RSV. Small interfering RNA-induced TTP inhibition attenuated the effects of RSV on cell growth. In addition, RSV induced the mRNA-decaying activity of TTP and inhibited the relative luciferase activity of baculoviral IAP repeat containing 3 (cIAP2), large tumor suppressor kinase 2 (LATS2), E2F1, and lin‑28 homolog A (Lin28) in HCT116 and SNU81 cells. Therefore, RSV enhanced the inhibitory activity of TTP in HCT116 and SNU81 cells by negatively regulating cIAP2, E2F1, LATS2, and Lin28 expression. In conclusion, RSV suppressed the proliferation and invasion/metastasis of colon cancer cells by activating TTP.

Assessing Colorectal Cancer Screening Barriers by Two Methods

Colorectal cancer (CRC) is commonly diagnosed in the USA despite screening tests that have decreased CRC incidence and mortality. Finding the best method to identify patient-level screening barriers is important to improve CRC screening rates. A group-randomized trial was conducted among ten primary-care clinics. Clinics were randomized to a multi-level (clinic, provider, patient) CRC screening intervention or usual care (2007-2013). Subsequent to clinic- and provider-level interventions, a three-step, patient-level intervention was conducted. One step of the patient-level intervention was a CRC screening barriers counseling call conducted by a lay health advisor (LHA). During the call, two methods were used to identify CRC screening barriers. An open-ended question was used first to determine why participants had not completed screening (without probes). Subsequently, the LHA read a list of additional potential screening barriers and asked participants whether each barrier was applicable (with probes). A generalized estimating equation approach was used to compare the two methods. Participants (n = 109) were female (59%), had a mean age of 57.2 years, and were white (67%) or black (31%). Most participants had some college education or a college degree (79%), annual household income $30,000+ (60%), and health insurance (80%). The number of CRC screening barriers increased with probing compared to the open-ended question format (OR 2.10, 95% CI 1.92-2.31; p < 0.01). The ranking of reported CRC screening barriers did not vary by assessment method. However, the methodology used to document CRC screening barriers may influence the content of patient-directed interventions.

Implementation successes and challenges in participating in a pragmatic study to improve colon cancer screening: perspectives of health center leaders

Little is known about the challenges faced by community clinics who must address clinical priorities first when participating in pragmatic studies. We report on implementation challenges faced by the eight community health centers that participated in Strategies and Opportunities to STOP Colon Cancer in Priority Populations (STOP CRC), a large comparative effectiveness cluster-randomized trial to evaluate a direct-mail program to increase the rate of colorectal cancer (CRC) screening. We conducted interviews, at the onset of implementation and 1 year later, with center leaders to identify challenges with implementing and sustaining an electronic medical record (EMR)-driven mailed program to increase CRC screening rates. We used the Consolidated Framework for Implementation Research to thematically analyze the content of meeting discussions and identify anticipated and experienced challenges. Common early concerns were patients' access to colonoscopy, patients' low awareness of CRC screening, time burden on clinic staff to carry out the STOP CRC program, inability to accurately identify eligible patients, and incompatibility of the program's approach with the patient population or organizational culture. Once the program was rolled out, time burden remained a primary concern and new organizational capacity and EMR issues were raised (e.g., EMR staffing resources and turnover in key leadership positions). Cited program successes were improved CRC screening processes and rates, more patients reached, reduced costs, and improved patient awareness, engagement, or satisfaction. These findings may inform any clinic considering mailed fecal testing programs and future pragmatic research efforts in community health centers.

Malaria prevalence metrics in low- and middle-income countries: an assessment of precision in nationally-representative surveys

Background

One pillar to monitoring progress towards the Sustainable Development Goals is the investment in high quality data to strengthen the scientific basis for decision-making. At present, nationally-representative surveys are the main source of data for establishing a scientific evidence base, monitoring, and evaluation of health metrics. However, little is known about the optimal precisions of various population-level health and development indicators that remains unquantified in nationally-representative household surveys. Here, a retrospective analysis of the precision of prevalence from these surveys was conducted.

Methods

Using malaria indicators, data were assembled in nine sub-Saharan African countries with at least two nationally-representative surveys. A Bayesian statistical model was used to estimate between- and within-cluster variability for fever and malaria prevalence, and insecticide-treated bed nets (ITNs) use in children under the age of 5 years. The intra-class correlation coefficient was estimated along with the optimal sample size for each indicator with associated uncertainty.

Findings

Results suggest that the estimated sample sizes for the current nationally-representative surveys increases with declining malaria prevalence. Comparison between the actual sample size and the modelled estimate showed a requirement to increase the sample size for parasite prevalence by up to 77.7% (95% Bayesian credible intervals 74.7–79.4) for the 2015 Kenya MIS (estimated sample size of children 0–4 years 7218 [7099–7288]), and 54.1% [50.1–56.5] for the 2014–2015 Rwanda DHS (12,220 [11,950–12,410]).

Conclusion

This study highlights the importance of defining indicator-relevant sample sizes to achieve the required precision in the current national surveys. While expanding the current surveys would need additional investment, the study highlights the need for improved approaches to cost effective sampling.

Electronic supplementary material

The online version of this article (10.1186/s12936-017-2127-y) contains supplementary material, which is available to authorized users.

Recruiting community health centers into pragmatic research: Findings from STOP CRC

BACKGROUND

Challenges of recruiting participants into pragmatic trials, particularly at the level of the health system, remain largely unexplored. As part of Strategies and Opportunities to STOP Colon Cancer in Priority Populations (STOP CRC), we recruited eight separate community health centers (consisting of 26 individual safety net clinics) into a large comparative effectiveness pragmatic study to evaluate methods of raising the rates of colorectal cancer screening.

METHODS

In partnership with STOP CRC's advisory board, we defined criteria to identify eligible health centers and applied these criteria to a list of health centers in Washington, Oregon, and California affiliated with Oregon Community Health Information Network, a 16-state practice-based research network of federally sponsored health centers. Project staff contacted centers that met eligibility criteria and arranged in-person meetings of key study investigators with health center leadership teams. We used the Consolidated Framework for Implementation Research to thematically analyze the content of discussions during these meetings to identify major facilitators of and barriers to health center participation.

RESULTS

From an initial list of 41 health centers, 11 met the initial inclusion criteria. Of these, leaders at three centers declined and at eight centers (26 clinic sites) agreed to participate (73%). Participating and nonparticipating health centers were similar with respect to clinic size, percent Hispanic patients, and percent uninsured patients. Participating health centers had higher proportions of Medicaid patients and higher baseline colorectal cancer screening rates. Common facilitators of participation were perception by center leadership that the project was an opportunity to increase colorectal cancer screening rates and to use electronic health record tools for population management. Barriers to participation were concerns of center leaders about ability to provide fecal testing to and assure follow-up of uninsured patients, limited clinic capacity to prepare mailings required by the study protocol, discomfort with randomization, and concerns about delaying program implementation at some clinics due to the research requirements.

CONCLUSION

Our findings address an important research gap and may inform future efforts to recruit community health centers into pragmatic research.

Testing Interventions to Motivate and Educate (TIME): A multi-level intervention to improve colorectal cancer screening

Objective

To test the effectiveness of a colorectal cancer (CRC) screening intervention directed at three levels (clinic, provider, patient) in a primary care setting.

Method

We conducted a group randomized trial (Clinical Trials registration no. NCT01568151) among 10 primary care clinics in Columbus, Ohio that were randomized to a study condition (intervention or usual care). We determined the effect of a multi-level, stepped behavioral intervention on receipt of a CRC screening test among average-risk patients from these clinics over the study period.

Results

Patients (n = 527) who were outside of CRC screening recommendations were recruited. Overall, 35.4% of participants in the intervention clinics had received CRC screening by the end of the study compared to 35.1% of participants who were in the usual care clinics. Time to CRC screening was also similar across arms (HR = 0.97, 95% CI = 0.65–1.45).

Conclusion

The multi-level intervention was not effective in increasing CRC screening among participants who needed a test, perhaps due to low participation of patients in the stepped intervention. Future studies utilizing evidence-based strategies to encourage CRC screening are needed.

•

This study tested the effectiveness of a multi-level CRC screening intervention.

•

There was no difference in receipt of CRC screening between study arms.

•

Innovative strategies need to be developed to improve CRC screening rates.

Mother-Daughter Dyad Recruitment and Cancer Intervention Challenges in an African American Sample

Developing an effective youth-based health messaging intervention for African American women, who remain disparately impacted by cancer, presents unique challenges. This paper reports on the challenges with recruiting familial dyads from predominantly low-income, African American neighborhoods, as well as the challenges associated with designing and implementing an upward-directed cancer screening intervention. We developed and pilot tested an educational workshop that provided adolescents with cancer screening information to share with their mother or female relative. Data from follow-up interviews and focus groups, as well as observation records regarding implementation obstacles highlight important lessons learned. The use of familial dyads as well as issues of access posed challenges for recruitment and follow-up. Workshop-related challenges stemmed from the approach, content and length. Finally, personal and environmental factors presented barriers to adolescent message delivery and adult follow-through. By identifying these challenges, we hope to influence and enable the future development of effective adolescent-initiated health messaging interventions.