Cancer screening adherence: does physician-patient communication matter?

Age as a Moderator of Health Outcomes and Trust in Physicians

Objectives: Patient trust in physicians is associated with patient satisfaction with healthcare, patients engaging in follow-up care, and positive health-related outcomes. The current study investigated whether age moderated the relation between trust in physicians and four health outcome variables, including patient satisfaction, doctor visits, emergency room visits, and hospital admissions. Methods: 398 English-speaking, community-dwelling adults completed measures of physician trust and important health outcome variables via Amazon Mechanical Turk. Results: Age significantly moderated relations between trust in physicians and hospital admissions, and trust in physicians and patient satisfaction, with both positive relations becoming stronger with increasing age. Discussion: The results highlight the need for a lifespan approach to the study of physician trust and related health outcomes. They offer an avenue for increasing physician trust, engagement with the healthcare system prior to the need for hospitalization, and the reduction of healthcare costs.

Attitudes and health behaviors of middle-aged and older adults with elevated tumor markers in China

Objectives

To understand the attitudes and health behaviors of middle-aged and older adults in China after receiving elevated results of tumor markers (TMs) test in the annual health examinations (AHEs) and explore the influencing factors.

Methods

A three-section online questionnaire survey was conducted from March 1 to April 30, 2020 in Hangzhou, China, to people who were aged 45 and older and had at least one elevated result of TMs test. Clinical information was collected from the online survey and medical records. Descriptive statistics were carried out followed by regression analyses.

Results

Of 380 participants, 76.1% were unwilling to quit the TMs test in AHEs, whereas 75.3% would take the doctor's advice and quit unnecessary TMs test; 67.4% felt stressed about their TMs. Among participants with elevated TMs, 76.8% changed lifestyle to keep healthy, 74.2% sought health information, 58.9% requested a TMs retest, and 50.3% did further tests to confirm a diagnosis. Family history of cancer was associated with lifestyle changing; education level, area of residence and health insurance were associated with health information seeking; comorbidity were associated with retests and sequential confirming tests.

Conclusion

The application of the TMs test in AHEs among Chinese people may lead to positive and negative behavioral consequences and psychological distress. Doctors have a significant impact on patients' health behaviors. Accurate indications and adequate communication with patients before and after the TMs test are in great need.

Factors associated with receiving results and attending colposcopy in patients with positive HPV screens in Mexico City

We identified patient and healthcare system factors related to receipt of screening results and attendance to colposcopy among patients with positive screening results in a cervical cancer screening program in Mexico City, Mexico. We analyzed data from 1,351 patients with high-risk human papillomavirus (HPV)-positive results from two screening demonstration studies conducted between 2017 and 2018. Factors associated with receipt of screening results and with adherence to a colposcopy appointment were identified using multivariable logistic regression. Participants had a median age of 40 years (IQR = 32-48), 60% had less than high school education, and 74% had a previous Pap screening in the last 5 years. Fifty-five percent of participants retrieved their screening results at the healthcare facility (HCF) without any reminder. Providing an email address for contact information, attending a HCF with family medicine, and receiving care from experienced nurses were associated with greater adherence to obtaining screening test results. Fifty-seven percent of participants attended their first scheduled colposcopy appointment. Providing a phone number improved adherence to colposcopy, whereas longer travel times between the HCF and the colposcopy clinic was associated with a decrease in colposcopy adherence. Having a Pap test in the last 5 years was positively associated with better compliance with both outcomes. Securing contact information may help to overcome barriers to future follow-up. Additional research is necessary on strategies for obtaining screening test results and scheduling appointments, which may help address barriers to access, such as limited staff availability, distance from the clinic, and travel costs.

Examining Associations between Source of Cancer Information and Mammography Behavior among Black Church-Going Women

Black women have a slightly lower breast cancer incidence rate than White women, but breast cancer mortality is approximately 40% higher among Black women than among White women. Early detection by mammography may improve survival outcomes. Outlets providing information on cancer and cancer screening often present data, including mammography recommendations, that are unreliable, accessible, and/or inconsistent. We examined associations between sources of cancer information and mammography behavior among Black church-going women. A logistic regression model was used to examine associations between self-reported preferred source of cancer information (provider, cancer organization, social network, internet, or other media (e.g., books, magazines)) and self-reported most recent source of cancer information (same categories as preferred sources), respectively, and having received a mammogram within the prior 12 months. Participants were 832 Black women over 40 years old, recruited from three churches in Houston, Texas. Data were collected in 2012. Overall, 55.41% of participants indicated their preferred source of cancer information was a provider, 21.88% the internet, 11.54% other media, 10.22% a cancer organization, and 0.96% their social network. In contrast, 17.88% of participants indicated their most recent source of cancer information was a provider, 63.02% the internet, 12.04% other media, 4.50% a cancer organization, and 2.55% their social network. About 70% of participants indicated receiving a mammogram in the prior 12 months. Results indicated that women who most recently sought information from the internet had lower odds of having a mammogram than those who most recently sought information from a provider (aOR: 0.546, CI_95%: 0.336-0.886, p = 0.014). These results reveal an opportunity to advance health equity by encouraging Black church-going women to obtain cancer information from providers rather than from the internet as a method to enhance mammography use. These results also reveal an opportunity to investigate what modifiable social determinants or other factors prevent Black church-going women from seeking cancer information from their preferred source, which was a provider for the majority of the sample, and designing interventions to better actualize this preference.

Barriers to Screening for Gestational Diabetes Mellitus in New Zealand Following the Introduction of Universal Screening Recommendations

Background:

In 2014 the New Zealand Ministry of Health implemented a universal program of screening for gestational diabetes mellitus (GDM) in pregnancy; however, data suggest that only half of all women are being screening according to the guidelines. This study aimed to explore women's views and experiences of GDM screening and to determine what the main screening barriers are.

Methods:

Eighteen women were recruited from the Waikato region of New Zealand, who were either pregnant (>28 weeks of gestation) or had given birth in the last 6 months. These women participated in a semi-structured interview about their experience of GDM screening and the transcripts were thematically analyzed. Of these women, 14 had been screened for gestational diabetes (three were screened late) and four had not been screened at all.

Results:

Multiple barriers to screening for GDM were identified, with two overarching themes of “confusion, concerns, and access to information for screening,” and “challenges to accessing and completing the screening test.” Specific barriers included the preference of risk-based assessments for GDM by their leading health professional (usually a registered midwife); negative perceptions of “sugar drink test”; needing time off work and childcare; travel costs for rural women; previous negative screening experiences; and reduced health literacy.

Conclusion:

There appear to be both woman-, midwife-, and system-level barriers to screening for GDM. While screening is ultimately a woman's choice, there does appear to be capacity to increase screening rates by improving awareness of the updated guidelines, and making the test environment more accessible and comfortable.

Patient-Centered Home Cancer Screening Attitudes During COVID-19 Pandemic

The COVID-19 pandemic disrupted health care delivery of cancer screenings. The primary aim of our work was to evaluate the degree to which populations were accepting of home-based screenings for colorectal cancer (CRC) and cervical cancer (ie, primary human papillomavirus [HPV] testing). Three groups of adults having distinct health burdens that may affect acceptance of home-based cancer screening were identified through outpatient electronic medical records: those having survived a COVID-19 hospitalization; those having been positive for a non-COVID-19 respiratory illness; or those having type 2 diabetes. A total of 132 respondents (58% female) completed an online survey with hypothetical cases about their acceptance of home-based CRC or cervical cancer screening. Among women respondents, urine and vaginal screening for primary HPV testing was acceptable to 64% and 59%, respectively. Among both men and women, at-home CRC screening with fecal immunochemical test or Cologuard^® was acceptable to 60% of the respondents. When adjusting for education, women with a positive attitude toward home-based urine and vaginal screening were 49 times and 23 times more likely, respectively, to have a positive attitude toward CRC screening. These findings indicate that home-based cancer screens for CRC and primary HPV testing are acceptable to men and women and may allow for greater compliance with screening in the future.

Prospective assessment of contralateral prophylactic mastectomy decision-making in women with average risk: an application of perceptual mapping

Women with early-stage unilateral breast cancer and no familial or genetic risk factors are increasingly electing contralateral prophylactic mastectomy (CPM), despite the lack of evidence demonstrating improved outcomes. To better understand and extend the literature focused on treatment decision-making, a survey was conducted among women with early-stage breast cancer and no associated risk factors, who were in the process of making a surgical decision. This prospective study sought to expand our understanding of the factors that influence patients' decision to have CPM, with the goal of providing healthcare providers with useful guidance in supporting breast cancer patients who are making treatment decisions. Data were collected for this prospective study through an internet survey. Results were analyzed using perceptual mapping, a technique that provides visual insight into the importance of specific variables to groups of women making different surgical decisions, not available through conventional analyses. Results suggest that women more likely to elect CPM demonstrate greater worry about breast cancer through experiences with others and feel the need to take control of their health through selection of the most aggressive treatment option. The information obtained offers guidance for the development of targeted intervention and counsel that will support patients' ability to make high quality, informed decisions.

Factors Associated with Breast Cancer Screening Adherence among Church-Going African American Women

Relative to White women, African American/Black women are at an increased risk of breast cancer mortality. Early detection of breast cancer through mammography screening can mitigate mortality risks; however, screening rates are not ideal. Consequently, there is a need to better understand factors associated with adherence to breast cancer screening guidelines to inform interventions to increase mammography use, particularly for groups at elevated mortality risk. This study used the Andersen Behavioral Model of Health Services Use to examine factors associated with adherence to National Comprehensive Cancer Network breast cancer screening guidelines amongst 919 African American, church-going women from Houston, Texas. Logistic regression analyses measured associations between breast cancer screening adherence over the preceding 12 months (adherent or non-adherent) and predisposing (i.e., age, education, and partner status), enabling (i.e., health insurance status, annual household income, employment status, patient-provider communication, and social support), and need (i.e., personal diagnosis of cancer, family history of cancer, and risk perception) factors, separately and conjointly. Older age (predisposing: OR = 1.015 (1.007-1.023)), having health insurance and ideal patient-provider communication (enabling: OR = 2.388 (1.597-3.570) and OR = 1.485 (1.080-2.041)), and having a personal diagnosis of cancer (need: OR = 2.244 (1.058-4.758)) were each associated with greater odds of screening adherence. Only having health insurance and ideal patient-provider communication remained significantly associated with screening adherence in a conjoint model; cancer survivorship did not moderate associations between predisposing/enabling factors and screening adherence. Overall, results suggest that interventions which are designed to improve mammography screening rates amongst African American women might focus on broadening health insurance coverage and working to improve patient-provider communication. Implications for multi-level intervention approaches, including the role of churches in their dissemination, are proposed.

Correlates of the perceived quality of patient-provider communication among German adults

BACKGROUND

Since a higher perceived quality of patient-provider communication is known to be associated with improved health outcomes, it is essential to analyze determinants influencing patients' perceived quality of patient-provider communication. Due to the limited knowledge about patient-related influencing factors of quality perception available so far, the objective of this study is to explore and assess determinants of the perceived quality of patient-provider communication with regards to sociodemographic, health-related, healthcare-specific and information-related factors.

METHODS

Linear regression of cross-sectional data from the first wave of Health Information National Trends Survey Germany (n = 2902) was conducted. Independent variables were sociodemographic, health-, healthcare- and information-related factors; the dependent variable was the perceived quality of patient-provider communication.

RESULTS

Results show that age, migration background, the perceived quality of healthcare, health-related self-efficacy and trust in health information from health professionals are significantly associated with the perceived quality of patient-provider communication.

CONCLUSIONS

Sociodemographic, healthcare- and health information-related factors influence the perceived quality of patient-provider communication. In particular, patients having a migration background and patients reporting low self-efficacy showed significant lower levels of their perceived patient-provider communication quality. With the aim to improve quality issues, patients of both target groups should be empowered and supported.

Focused Education Increases Hepatocellular Cancer Screening in Patients with Cirrhosis Regardless of Functional Health Literacy

BACKGROUND

Health education interventions are successful in modifying lifestyle. Functional health literacy (FHL) can determine patient adherence to clinic visits and procedures and may adversely impact the success of these interventions.

AIMS

We sought to evaluate the hypothesis that a health education intervention would improve compliance with hepatocellular cancer (HCC) screening and that poor FHL would reduce such compliance.

METHODS

We assessed FHL using a short version test of functional health literacy in adults (STOFHLA). Cirrhotic patients free of HCC were prospectively enrolled from clinics and provided an educational intervention consisting of focused physician-led discussion regarding cirrhosis and HCC, along with written material on these topics for the subject to review at home. Patients were subsequently followed for 6 months (prospective time period), and the same cohort's clinic/HCC screening behavior between 6 and 12 months prior to the educational intervention (retrospective time period) was compared.

RESULTS

In total, 104 cirrhotic patients (age 60.01 ± 8.58 years, 80% men, MELD 12.70 ± 5.76) were included. Of these, 89 (85.57%) of patients had educational level 12th grade and higher. There were 76% (n = 79) with adequate, while 24% (n = 25) had inadequate/marginal FHL on S-TOHFLA. The number of HCC-related imaging increased from 59 (56.7%) to 86 (82.6%, p < 0.0001) post-education in the prospective compared to prior time period which was similar regardless of FHL.

CONCLUSIONS

While the educational intervention was successful in improving compliance with HCC screenings, FHL status did not impact the power of this intervention. Hence, the combination of specific verbal information, along with targeted written material, improved compliance with clinic visits and liver imaging for HCC.

[Validation of the Informed Choice instrument for Chilean women facing a mammography decision in primary care]

Objetivo

Adaptar y validar el instrumento Informed Choice (IC) para la decisión de mamografía al contexto chileno.

Diseño

Estudio transversal, analítico, de adaptación y validación psicométrica.

Emplazamiento

Centro de atención primaria del sector sur oriente de Santiago de Chile.

Métodos

1) traducir y contra-traducir IC; 2) realizar un grupo focal para la relevancia cultural/lingüística; 3) examinar la validez del contenido; 4) pilotar el instrumento; 5) aplicar para validación. Para la consistencia interna se usó el alfa de Cronbach, prueba de esfericidad de Bartlett y la medida de Kaiser-Meyer-Olkin para determinar correlaciones entre las variables y análisis factorial.

Resultados

Se construyeron 3 versiones del IC, modificándose según la opinión de usuarios y expertos. La validación se llevó a cabo en una muestra de 70 mujeres. La edad media fue de 54,4 años, el 47,1% de educación secundaria completa y el 92,9% al menos se había realizado alguna vez una mamografía. Se realizó análisis factorial del IC y se eliminó uno de sus ítems. El alfa de Cronbach final fue 0,79.

Conclusión

El uso de instrumentos de medición requiere de su validación previa ya que la versión original puede variar de acuerdo al contexto cultural donde será aplicado y las necesidades locales particulares. El proceso de validación del IC permite contar con un instrumento confiable para medir la decisión de las mujeres que deben realizarse la mamografía en la dimensión conocimiento, actitud e intención hacia el examen.

Health and lifestyle behaviors in colorectal cancer survivors with and without Lynch syndrome

Lynch syndrome (LS), a hereditary cancer syndrome, accounts for approximately 3% of colorectal cancers (CRC). Positive health behaviors and surveillance are preventive strategies, but research on whether recommended behavioral guidelines are followed by individuals with LS is limited. Additional health education and promotion could be beneficial to the improved survivorship of CRC survivors. Explore health and lifestyle behaviors in CRC survivors with and without LS. We conducted a case-control study of CRC survivors with and without LS using a mailed questionnaire. Recruitment was conducted via patient registries at The University of Texas MD Anderson Cancer Center (cases n = 33; controls n = 75) and through social media (cases n = 42). CRC survivors with and without LS in our study had substantially lower smoking prevalence (5.5% and 2.7%) compared to national prevalence (18.0%). However, they had higher levels of alcohol consumption (36.8% and 10.3% for male and female LS survivors, respectively, and 35.8% and 22.0% for male and female sporadic survivors, respectively) compared to national prevalence of 13.88% for males and 6.02% for females. Both groups of CRC survivors participate in negative health behaviors that impact survivorship. More research is needed to examine the relationship between personal engagement in preventive behaviors and patient-provider relationships to improve health behaviors and explore strategies for intervention. Additionally, better health education and lifestyle change recommendations would promote and reinforce positive health outcomes in the CRC population and especially in LS survivors.

The Patient Perspective on Lung Cancer Screening and Health Disparities

Lung cancer screening is just starting to be implemented across the United States. Challenges to screening include access to care, awareness of the option for screening, stigma and implicit bias that are due to stigmatization of smoking, stigma of race, nihilism with lung cancer diagnosis viewed as a "death sentence," shared decision making, and underestimation of lung cancer risk. African Americans (AA) have the highest lung cancer mortality rate in the United States despite similar smoking rates as whites. AAs are diagnosed at a later stage, and there is a greater likelihood they will refuse treatment options when diagnosed. Additionally, fewer AAs were found to meet lung cancer screening eligibility criteria compared with whites because of lower tobacco exposure and younger age at time of diagnosis. Outreach and access for lung cancer screening in the AA community and other subpopulations at risk are critical to avoid further increasing disparities in lung cancer morbidity and mortality as lung cancer screening is implemented across the United States. The path forward requires implementing outreach programs and providing lung cancer screening in underserved communities at high risk for lung cancer; consideration of using National Comprehensive Cancer Network guidelines for screening selection criteria, including risk model screening selection; and developing interventions to address stigma, clinician implicit bias, and nihilism.

Decisional conflict among breast cancer patients considering contralateral prophylactic mastectomy

OBJECTIVES

The study's goals were to characterize decisional conflict and preparedness for making the decision about having CPM among breast cancer patients considering CPM who do not carry cancer-predisposing mutation and to evaluate correlates of decisional conflict and preparedness.

METHODS

93 women considering CPM completed a survey of decisional conflict and preparedness for the CPM decision, knowledge, perceived risk, self-efficacy, reasons for CPM, input from others and discussion with the doctor about CPM, and cancer worry.

RESULTS

Between 8% and 27% of women endorsed elevated decisional conflict. Most women were satisfied with preparatory information that they were provided. Knowledge was low. Top reasons for choosing CPM were the desire for peace of mind, lowering the chance of another breast cancer, and improving survival.

CONCLUSIONS

Decisional conflict is elevated in a subset of patients considering CPM. A more well-informed decision may be fostered by a comprehensive discussion about CPM with the patient's clinician, fostering self-efficacy in managing cancer worry, and helping patients understand their motivations for CPM.

PRACTICE IMPLICATIONS

Clinicians working with breast cancer patients considering CPM should discuss the CPM decision, foster self-efficacy in managing cancer worry, and help patients understand their motivations for the surgery.

A review of sex-related differences in colorectal cancer incidence, screening uptake, routes to diagnosis, cancer stage and survival in the UK

Background

Colorectal cancer (CRC) is an illness strongly influenced by sex and gender, with mortality rates in males significantly higher than females. There is still a dearth of understanding on where sex differences exist along the pathway from presentation to survival. The aim of this review is to identify where actions are needed to improve outcomes for both sexes, and to narrow the gap for CRC.

Methods

A cross-sectional review of national data was undertaken to identify sex differences in incidence, screening uptake, route to diagnosis, cancer stage at diagnosis and survival, and their influence in the sex differences in mortality.

Results

Overall incidence is higher in men, with an earlier age distribution, however, important sex differences exist in anatomical site. There were relatively small differences in screening uptake, route to diagnosis, cancer staging at diagnosis and survival. Screening uptake is higher in women under 69 years. Women are more likely to present as emergency cases, with more men diagnosed through screening and two-week-wait. No sex differences are seen in diagnosis for more advanced disease. Overall, age-standardised 5-year survival is similar between the sexes.

Conclusions

As there are minimal sex differences in the data from routes to diagnosis to survival, the higher mortality of colorectal cancer in men appears to be a result of exogenous and/or endogenous factors pre-diagnosis that lead to higher incidence rates. There are however, sex and gender differences that suggest more targeted interventions may facilitate prevention and earlier diagnosis in both men and women.

Shared Decision-Making and Women's Adherence to Breast and Cervical Cancer Screenings

We examined the effect of shared decision-making (SDM) on women’s adherence to breast and cervical cancer screenings and estimated the prevalence and adherence rate of screenings. The study used a descriptive cross-sectional design using the 2017 Health Information National Trends Survey (HINTS) data collected by the National Cancer Institute. Adherence was defined based on the guidelines from the American Cancer Society and the composite measure of shared decision-making was constructed using three items in the data. Multivariable logistic regression was performed to examine the association between the SDM and adherence, controlling for cancer beliefs and socio-demographic variables. The analysis included 742 responses. Weighted to represent the U.S. population, 68.1% adhered to both breast and cervical cancer screening guidelines. The composite measure of SDM was reliable (α = 0.85), and a higher SDM score was associated with women’s screening adherence (b = 0.17; p = 0.009). There were still women who did not receive cancer screenings as recommended. The results suggest that the use of the SDM approach for healthcare professionals’ communication with patients can improve screening adherence.

Adherence to Radiology Recommendations in a Clinical CT Lung Screening Program

BACKGROUND

Assess patient adherence to radiologist recommendations in a clinical CT lung cancer screening program.

METHODS

Patients undergoing CT lung cancer screening between January 12, 2012, and June 12, 2013, were included in this institutional review board-approved retrospective review. Patients referred from outside our institution were excluded. All patients met National Comprehensive Cancer Network Guidelines Lung Cancer Screening high-risk criteria. Full-time program navigators used a CT lung screening program management system to schedule patient appointments, generate patient result notification letters detailing the radiologist follow-up recommendation, and track patient and referring physician notification of missed appointments at 30, 60, and 90 days. To be considered adherent, patients could be no more than 90 days past due for their next recommended examination as of September 12, 2014. Patients who died, were diagnosed with cancer, or otherwise became ineligible for screening were considered adherent. Adherence rates were assessed across multiple variables.

RESULTS

During the study interval, 1,162 high-risk patients were screened, and 261 of 1,162 (22.5%) outside referrals were excluded. Of the remaining 901 patients, 503 (55.8%) were male, 414 (45.9%) were active smokers, 377 (41.8%) were aged 65 to 73, and >95% were white. Of the 901 patients, 772 (85.7%) were adherent. Most common reasons for nonadherence were patient refusal of follow-up exam (66.7%), inability to successfully contact the patient (20.9%), and inability to obtain the follow-up order from the referring provider (7.8%); 23 of 901 (2.6%) were discharged for other reasons.

CONCLUSIONS

High rates of adherence to radiologist recommendations are achievable for in-network patients enrolled in a clinical CT lung screening program.

Perceptions of Cervical Cancer Screening, Screening Behavior, and Post-Migration Living Difficulties Among Bhutanese-Nepali Refugee Women in the United States

Bhutanese-Nepali refugees are one of the largest refugee groups to be resettled in the U.S. in the past decade. Cervical cancer is a leading cause of cancer disparity in this population, yet screening rates are suboptimal. Nepali-speaking interviewers administered a community health needs questionnaire to a convenience sample of Bhutanese-Nepali refugees in a Midwestern city between July to October of 2015. Descriptive statistics were used to describe socio-demographic characteristics, Pap smear beliefs, post-migration living difficulties, and screening status. Differences in Pap test uptake between groups were tested using t test and Chi square statistics. Of the 97 female participants, 44.3% reported ever having had a Pap smear. Screening rates were lowest among women who did not know English at all. Most women had positive perceptions of Pap smears (80%) and 44.4% had received a Pap test recommendation from their healthcare provider, family, or friends. Pap testing was significantly higher among those who had positive perceptions (58.3 vs. 11.1% for women of negative perception, p = 0.01) and those who had received a recommendation (87.5 vs. 18.6% for women who had no recommendations, p < 0.001). Significant predictors of having a Pap smear were having a healthcare provider/family/friends recommendation (OR 65.3, 95% CI 11.4-373.3) and greater number of post-migration living difficulties (OR 1.18, 95% CI 1.02-1.37). The results of this study have important implications for the development of cervical cancer prevention programs targeting Bhutanese-Nepali refugees. Providing cancer prevention interventions early in the resettlement process could impact Pap test uptake in this population.

Breast Cancer Screening for Patients of Rural Accountable Care Organization Clinics: A Multi-Level Analysis of Barriers and Facilitators

Not all women 50-74 years received biennial mammography and the situation is worse in rural areas. Accountable care organizations (ACO) emphasize coordinated care, use of electronic health system, and preventive quality measures and these practices may improve their patients' breast cancer screening rate. Using medical record data of 8,347 women patients aged 50-74 years from eight rural ACO clinics in Nebraska, this study examined patient-, provider-, and county-level barriers and facilitators for breast cancer screening. A generalized estimating equations model was used to account for the correlation among patients from the same provider and county. The multi-level logistic regression results suggest that uninsured non-Hispanic Black patients were less likely to meet the biennial mammography screening guideline. Patients whose preferred language being English, having a preventive visit in the past 12 months, having one or more chronic conditions were more likely to meet the biennial mammography screening guideline. Patients with a primary care provider (PCP) that was male, without a medical doctor degree were less likely to screen biennially. Patients with a PCP that reviewed performance report quarterly, or manually checked patients' mammography screening status during visits were more likely to screen biennially. Interestingly, patients whose PCP reported being reminded by a care coordination team were less likely to screen biennially. Patients living in counties with more PCPs were also more likely to screen biennially. The study findings suggest that efforts targeting individual and practice-level barriers could be most effective in improving mammography screening for these rural ACO patients.

Professor Umberto Veronesi: a physician, a researcher, a brilliant man

Many of those who work in oncology or deal with cancer patients know of Prof. Umberto Veronesi and none of them could deny the importance of his battle against cancer. He devoted his life to improving cancer treatment and quality of life for patients. He was a physician, and a politician, but above all he was a researcher. He embodied the true spirit of research, i.e., to believe in something and investigate every aspect of it until all the questions about it have been satisfactorily answered. He never gave up when faced with challenges, and he never stopped being curious. He believed in science, because he wanted to believe in the future. He mixed scientific knowledge with human warmth and was the pioneer of many breast cancer innovations. From the beginning of Prof. Veronesi's career, his mission was clear: 'My first decision was to focus on the fight against cancer. When I started at the National Cancer Institute in Milan, I felt a profound sense of rebellion against the surrender of doctors and patients to a disease that caused intense suffering. In particular, I could not stand the havoc of a woman's body after a mastectomy: in order to remove just a small breast cancer, not only the breast was taken away from the body, but also the axillary lymph nodes and the chest muscles. Consequently, I decided to fight mainly against breast cancer. It was a tough war: the dogma of mastectomy was so deeply-rooted that everybody thought I was crazy when I suggested conservative breast surgery.'.

A patient in the clinic; a person in the world. Why shared decision making needs to center on the person rather than the medical encounter

Interest in shared decision making (SDM) has increased and become widely promoted. However, from both practical and measurement perspectives, SDM's origin as an outgrowth of patient autonomy has resulted in narrowly conceptualizing and operationalizing decision making. The narrow focus on individual patient autonomy fails in four main ways: 1) excluding several facets of the roles, actions, and influences of decision partners in decision making; 2) focusing solely on the medical encounter; 3) ignoring the informational environment to which patients have access; and 4) treating each encounter as independent of all others. In addition to creating a research agenda that could answer important outstanding questions about how decisions are made and the consequences thereof, reconceiving SDM as centered on the person rather than the medical encounter has the potential to transform how illness is experienced by patients and families and how clinicians find meaning in their work.

Patient-reported barriers are associated with lower hepatocellular carcinoma surveillance rates in patients with cirrhosis

Over 20% of patients with cirrhosis are nonadherent with hepatocellular carcinoma (HCC) surveillance recommendations; however, few studies have evaluated the impact of patient-level factors on surveillance receipt. We characterized the association between HCC surveillance receipt and patient knowledge, attitudes, and perceived barriers in a racially diverse and socioeconomically disadvantaged cohort of patients with cirrhosis. Patients with cirrhosis followed at a large urban hospital were invited to complete a survey about HCC surveillance between August 2014 and December 2015. Multivariable logistic regression was performed to identify factors associated with HCC surveillance receipt during the 12-month period preceding and 6-month period after survey administration. We achieved a response rate of 71.8% (n = 541 of 753). Patients demonstrated high levels of HCC-related knowledge (summary score, 77.7%); however, 48.6% believed that eating a healthy diet precluded the need for HCC surveillance, and 34.0% believed that HCC surveillance was not necessary if they had a normal physical exam and/or lacked clinical symptoms. Patients expressed worry about developing and dying from HCC, but nearly half (49.9%) of patients reported barriers to receiving HCC surveillance, including difficulty with the scheduling process (30.5%), costs of surveillance testing (25.3%), and transportation difficulties (17.3%). HCC surveillance receipt was significantly higher in patients who knew cirrhosis is a risk factor for developing HCC (odds ratio [OR], 3.09; 95% confidence interval [CI], 1.25-7.62) and significantly lower in those reporting barriers to surveillance (OR, 0.42; 95% CI, 0.25-0.70).

CONCLUSION

Patients with cirrhosis are knowledgeable and interested in HCC surveillance; however, patient-reported barriers are associated with lower surveillance rates in clinical practice and represent potential intervention targets to improve HCC surveillance effectiveness. (Hepatology 2017;65:875-884).

A comparison between Lynch syndrome and sporadic colorectal cancer survivors' satisfaction with their healthcare providers

This study evaluated provider satisfaction in a sample of colorectal cancer (CRC) survivors with and without Lynch syndrome (LS). Participants were case–case‐matched CRC survivors with (n = 75) or without (n = 75) LS (mean age of 55; range: 27–93). Participants completed a mailed questionnaire assessing demographics, clinical characteristics, healthcare utilization, psychosocial variables, and provider satisfaction. LS CRC survivors reported lower provider satisfaction scores on three subscales of the Primary Care Assessment Survey: communication (78.14 vs. 83.96; P < 0.05), interpersonal treatment (78.58 vs. 85.30; P < 0.05), and knowledge of the patient (60.34 vs. 69.86; P < 0.01). Among LS CRC survivors, predictors for mean communication and trust subscale scores were location of treatment and socioeconomic status. Higher mean depression scores also were associated with trust, while social support predicted higher satisfaction with communication. Sporadic CRC survivor satisfaction is driven largely by age (communication, interpersonal treatment) and patient anxiety (communication), while seeing a provider more often was associated with increased satisfaction with knowledge of the patient. LS CRC survivors reported lower levels of provider satisfaction than sporadic CRC survivors. LS survivors who received care at The University of Texas MD Anderson Cancer Center, a comprehensive cancer center (CCC), reported higher satisfaction than those receiving care at other institutions. Depressive symptoms and socioeconomic status may impact provider satisfaction ratings. Exploration of other potential predictors of provider satisfaction should be examined in this population. Additionally, further research is needed to examine the potential impact of provider satisfaction on adherence to medical recommendations in LS CRC survivors, particularly those being treated outside of CCCs.

Prospective Study of Surgical Decision-making Processes for Contralateral Prophylactic Mastectomy in Women With Breast Cancer

OBJECTIVE

We prospectively examined the psychosocial predictors and the decision-making process regarding contralateral prophylactic mastectomy (CPM) among women with sporadic breast cancer.

BACKGROUND

Increasing numbers of women with breast cancer are seeking CPM. Data are limited about the surgical decision-making process and the psychosocial factors that influence interest in CPM.

METHODS

Women with early-stage unilateral breast cancer (n = 117) were recruited before their first surgical visit at MD Anderson and completed questionnaires assessing knowledge of and interest in CPM and associated psychosocial factors. After the appointment, women and their surgeons completed questions about the extent that various surgical options (including CPM) were discussed; also, the women rated their perceived likelihood of having CPM and the surgeons rated the appropriateness of CPM.

RESULTS

Before their first visit, 50% of women were moderately to extremely interested in CPM and 12 (10%) of women had CPM at the time of their primary breast cancer surgery. Less knowledge about breast cancer (P = 0.02) and greater cancer worry (P = 0.03) predicted interest in CPM. Greater cancer worry predicted who had CPM (P = 0.02). Interest in CPM before surgical visit and the likelihood of having CPM after the visit differed (P ≤ 0.001). Surgeons' rating of the appropriateness of CPM and the patient's reported likelihood of having CPM were not significantly different (P = 0.49).

CONCLUSIONS

Interest in CPM is common among women with sporadic breast cancer. The informational and emotional aspects of CPM may affect the decision to have CPM and should be addressed when discussing surgical options.

The role of communication in breast cancer screening: a qualitative study with Australian experts

BACKGROUND

One well-accepted strategy for optimising outcomes in mammographic breast cancer screening is to improve communication with women about screening. It is not always clear, however, what it is that communication should be expected to achieve, and why or how this is so. We investigated Australian experts' opinions on breast screening communication. Our research questions were: 1 What are the views of Australian experts about communicating with consumers on breast screening? 2 How do experts reason about this topic?

METHODS

We used a qualitative methodology, interviewing 33 breast screening experts across Australia with recognisable influence in the Australian mammographic breast cancer screening setting. We used purposive and theoretical sampling to identify experts from different professional roles (including clinicians, program managers, policy makers, advocates and researchers) with a range of opinions about communication in breast screening.

RESULTS

Experts discussed the topic of communication with consumers by focusing on two main questions: how strongly to guide consumers' breast cancer screening choices, and what to communicate about overdiagnosis. Each expert adopted one of three approaches to consumer communication depending on their views about these topics. We labelled these approaches: Be screened; Be screened and here's why; Screening is available please consider whether it's right for you. There was a similar level of support for all three approaches. Experts' reasoning was grounded in how they conceived of and prioritised their underlying values including: delivering benefits, avoiding harms, delivering more benefits than harms, respecting autonomy and transparency.

CONCLUSIONS

There is disagreement between experts regarding communication with breast screening consumers. Our study provides some insights into this persisting lack of consensus, highlighting the different meanings that experts give to values, and different ways that values are prioritised. We suggest that explicit discussion about ethical values might help to focus thinking, clarify concepts and promote consensus in policy around communication with consumers. More specifically, we suggest that decision-makers who are considering policy on screening communication should begin with identifying and agreeing on the specific values to be prioritised and use this to guide them in establishing what the communication aims will be and which communication strategy will achieve those aims.

Physician use of persuasion and colorectal cancer screening

The impact of patient-physician communication on subsequent patient behavior has rarely been evaluated in the context of colorectal cancer (CRC) screening discussions. We describe physicians' use of persuasive techniques when recommending CRC screening and evaluate its association with patients' subsequent adherence to screening. Audio recordings of N = 414 periodic health examinations were joined with screening use data from electronic medical records and pre-/post-visit patient surveys. The association between persuasion and screening was assessed using generalized estimating equations. According to observer ratings, primary care physicians frequently use persuasive techniques (63 %) when recommending CRC screening, most commonly argument or refutation. However, physician persuasion was not associated with subsequent screening adherence. Physician use of persuasion may be a common vehicle for information provision during CRC screening discussions; however, our results do not support the sole reliance on persuasive techniques if the goal is to improve adherence to recommended screening.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

Four-year cluster randomized controlled trial.

PARTICIPANTS

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

INTERVENTIONS

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

MAIN MEASURES

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

KEY RESULTS

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

CONCLUSION

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

Factors influencing participation in colorectal screening

Participation of the target population in coloretal screening is generally low. In addition to demographic and socio-economic factors, the health care system and- in particular – family doctors play an important role. Further, the rate of participation is influenced by psychological, cognitive and behavioural factors, too. The paper analyses factors related to colorectal screening behaviour and potential interventions designed to screening uptake. Orv. Hetil., 2014, 155(27), 1051–1056.

Patient-physician colorectal cancer screening discussion content and patients' use of colorectal cancer screening

OBJECTIVE

The US Preventive Services Task Force recommends using the 5As (i.e., Assess, Advise, Agree, Assist and Arrange) when discussing preventive services. We evaluate the association of the 5As discussion during primary care office visits with patients' subsequent colorectal cancer (CRC) screening use.

METHODS

Audio-recordings of n=443 periodic health exams among insured patients aged 50-80 years and due for CRC screening were joined with pre-visit patient surveys and screening use data from an electronic medical record. Association of the 5As with CRC screening was assessed using generalized estimating equations.

RESULTS

93% of patients received a recommendation for screening (Advise) and 53% were screened in the following year. The likelihood of screening increased as the number of 5A steps increased: compared to patients whose visit contained no 5A step, those whose visit contained 1-2 steps (OR=2.96 [95% CI 1.16, 7.53]) and 3 or more steps (4.98 [95% CI 1.84, 13.44]) were significantly more likely to use screening.

CONCLUSIONS

Physician CRC screening recommendations that include recommended 5A steps are associated with increased patient adherence.

PRACTICE IMPLICATIONS

A CRC screening recommendation (Advise) that also describes patient eligibility (Assess) and provides help to obtain screening (Assist) may lead to improved adherence to CRC screening.

From qualitative data to GP training on CRC screening

Colorectal cancer (CRC) is the third most common cancer worldwide. In France, although mass screening has been performed using the guaiac fecal occult blood test since 2008, the participation rate remains too low. Previous studies have explored the perspectives of doctors and patients as well as the performance of general practitioners (GPs) by recording and analyzing consultations in which patients came and asked for fecal occult blood test. Results indicated that improvement was needed in patient-centered communication. This research aims to develop educational material and training programs for GPs in order to enhance their communication with patients on CRC screening, based on data from two qualitative studies. Triangulation of all qualitative data was performed and discussed with communication experts in order to develop educational material and training programs based on the patient-centered clinical method. Two different scenarios were developed to improve communication with patients: one for a compliant patient and another for a noncompliant patient. Two videos were made featuring a doctor and a simulated patient. A two-sequence training program was built, including role-playing and presentation of the video followed by a discussion. The qualitative data helped us to produce a useful, relevant training program for GPs on CRC screening.

Patient-oncologist alliance, psychosocial well-being, and treatment adherence among young adults with advanced cancer

PURPOSE

Patients who develop a strong alliance with their health care providers have been shown to have higher levels of psychosocial well-being and rates of treatment adherence. Young adults with cancer have lower levels of psychosocial well-being and treatment adherence relative to patients with cancer in other age groups. This study sought to evaluate the relationships between the patient-oncologist alliance, psychosocial well-being, and treatment adherence in young adults with advanced cancer.

PATIENTS AND METHODS

Ninety-five young adults (age 20 to 40 years) with advanced cancer were administered measures of alliance, psychosocial well-being, willingness to adhere to treatment, and treatment adherence. Relationships between alliance and psychosocial well-being were examined bivariately. Multiple linear regression models examined the relationship between alliance and adherence, controlling for confounding influences (eg, psychosocial well-being).

RESULTS

Alliance was significantly (P ≤ .01) and positively associated with greater perceived social support and less severe illness-related grief. After controlling for significant confounding influences (ie, metastases, appraised support, and grief), alliance remained significantly (P ≤ .01) associated with greater willingness to adhere to treatment and greater adherence to oral medication.

CONCLUSION

By developing a strong alliance, oncologists may enhance psychosocial well-being and increase treatment adherence in young adult patients with advanced cancer.

Patient-clinician information engagement improves adherence to colorectal cancer surveillance after curative treatment: results from a longitudinal study

Introduction. Follow-up surveillance after curative treatment for colorectal cancer (CRC) patients is recommended to detect early cancer recurrences and improve survival outcomes. However, a substantial proportion of CRC patients do not undergo cancer surveillance. Several demographic and disease-related factors have been associated with cancer surveillance adherence. Thus far, patient-centered communication has not been studied as a determinant for undergoing cancer surveillance. The purpose of this study is to determine whether patient-clinician information engagement (PCIE) influences patients' self-reported adherence to recommended CRC surveillance procedures. Methods. The study was a longitudinal survey among Pennsylvanian patients diagnosed with CRC in 2005. CRC patients who were eligible for surveillance and participated in both the baseline and 1-year follow-up surveys were included in this analysis (n = 305). The main outcome measure was self-reported adherence to physical examination, carcinoembryonic antigen testing, and colonoscopy according to recommended guidelines. Results. Controlling for potential confounders, higher PCIE at baseline predicted a higher odds for CRC patients reporting adherence to recommended surveillance 1 year later by 2.8 times. Other significant predictors of adhering to recommended surveillance were a higher education level and having received systemic therapy. Discussion. In this longitudinal study among CRC patients who received curative treatment, greater patient engagement with clinicians about cancer-related information was found to improve patients' subsequent adherence to recommended surveillance. This finding provides support for encouraging greater patient-physician communication among CRC patients.

Perception of care and experience of examination in women at risk of breast cancer undergoing intensive surveillance by standard imaging with or without MRI

OBJECTIVE

Intensive surveillance in women at breast cancer risk is currently investigated in a French prospective, non-randomized, multicenter study, in which standard imaging--mammography±ultrasound ('Mx') and standard imaging combined with magnetic resonance imaging ('MRI') are compared with regard to perception of care and examination experience.

METHODS

1561 women were invited to complete the STAI-State Anxiety Inventory and breast cancer risk perception items at baseline (T0), and MGQ (MammoGraphy Questionnaire) and MRI discomfort items within 2 days after examinations (T1).

RESULTS

Baseline compliance was high (>91%). Women from the 'MRI' group were significantly younger and displayed higher education level and risk perception. MRI discomfort related to the duration, immobility, prone position or noise was experienced by more than 20% of women. In multivariate analyses, 'MRI' was associated with more favorable examination psychological experience (p≤.001), especially in women younger than 50; baseline STAI-State anxiety was associated with lower MGQ scores (p≤.001) and higher MRI discomfort (p≤.001).

CONCLUSION

In spite of the discomfort experienced with MRI, perception of care and experience with this surveillance procedure was more positive than with standard imaging.

PRACTICE IMPLICATIONS

Information and support may assuage some of the adverse effects of an uncomfortable examination technique.

A literature review of quality in lower gastrointestinal endoscopy from the patient perspective

BACKGROUND

Given the limited state of health care resources, increased demand for colorectal cancer (CRC) screening raises concerns about the quality of endoscopy services. Little is known about quality in colonoscopy and endoscopy from the patient perspective.

OBJECTIVE

To systematically review the literature on quality that is relevant to patients who require colonoscopy or endoscopy services.

METHODS

A systematic PubMed search was performed on articles that were published between January 2000 and February 2011. Keywords included "colonoscopy" or "sigmoidoscopy" or "endoscopy" AND "quality"; "colonoscopy" or "sigmoidoscopy" or "endoscopy" AND "patient satisfaction" or "willingness to return". The included articles were qualitative and quantitative English language studies regarding aspects of colonoscopy and⁄or endoscopy services that were evaluated by patients in which data were collected within one year of the colonoscopy⁄endoscopy procedure.

RESULTS

In total, 28 quantitative studies were identified, of which eight (28.6%) met the inclusion criteria (four cross-sectional, three prospective cohort and one single-blinded controlled study). Aspects of quality included comfort, management of pain and anxiety, endoscopy unit staff manner, skills and specialty, procedure and results discussion with the doctor, physical environment, wait times for the appointment and procedure, and discharge. Qualitative studies eliciting the patient perspective on what constituted quality in colonoscopy⁄endoscopy were not found.

CONCLUSIONS

Factors related to comfort, staff, communication and the service environment were evaluated from the patient perspective using closed-ended questions that were designed by clinicians and researchers. Future research using qualitative methodology to elicit the patient perspective on quality in colonoscopy and⁄or endoscopy services is needed.

Cancer screening barriers for community-based older Hispanics and Caucasians

Despite advances in screening and early detection, ethnic minority populations, ages 65 and older, are less likely than Caucasians to participate in cancer screening services. Empirical research indicates that older ethnic minorities have cultural values that influence their behaviors. Addressing culturally relevant communication to better understand those values may increase participation in cancer screening. The study reported is a secondary analysis of qualitative data gathered from focus groups. Utilizing an interdisciplinary analytical lens, we compared older Hispanic and Caucasian's cultural values and their screening behaviors. Suggested psychosocial interventions are discussed to assist providers in their ongoing efforts to promote cancer screening.

Current knowledge on contralateral prophylactic mastectomy among women with sporadic breast cancer

The use of contralateral prophylactic mastectomy (CPM) in the U.S. among patients with unilateral invasive breast cancer increased by 150% from 1993 to 2003. Although CPM has been shown to reduce the risk for developing contralateral breast cancer, there is conflicting evidence on whether or not it reduces breast cancer mortality or overall death. The increase in the CPM rate is especially concerning among women with early-stage sporadic breast cancer who have a minimal annual risk for developing contralateral breast cancer, and for many of these women the risk for distant metastatic disease outweighs the risk for contralateral breast cancer. The lack of information about the clinical value of CPM in women with sporadic breast cancer is an important public health problem. This review evaluates current data on the clinical indications for CPM and long-term patient satisfaction and psychosocial outcomes. Gaps in knowledge about the clinical value of CPM, including patient- and physician-related psychosocial factors that influence the decision-making process of CPM among women with sporadic breast cancer, are highlighted.

Older patients' enthusiasm to use electronic mail to communicate with their physicians: cross-sectional survey

Background

Recent evidence indicates increased access to and use of Internet and non-healthcare-related email by older patients. Because email adoption could potentially reduce some of the disparities faced by this age group, there is a need to understand factors determining older patients’ enthusiasm to use email to communicate with their physicians. Electronic mail (email) represents a means of communication that, coupled with face-to-face communication, could enhance quality of care for older patients.

Objective

Test a model to determine factors associated with older patients’ enthusiasm to use email to communicate with their physicians.

Methods

We conducted a secondary data analysis of survey data collected in 2003 for two large, longitudinal, randomized controlled trials. Logistic-regression models were used to model the dichotomous outcome of patient enthusiasm for using email to communicate with their physicians. Explanatory variables included demographic characteristics, health status, use of email with people other than their physician, characteristics of the physician-patient relationship, and physician enthusiasm to use email with patients.

Results

Participants included a pooled sample of 4059 patients over 65 years of age and their respective physicians (n = 181) from community-based practices in Southern California. Although only 52 (1.3%) patient respondents reported that they communicated with their physician by email, about half (49.3%) expressed enthusiasm about the possibility of using it. Odds of being enthusiastic decreased with increased age (by 0.97 for each year over 66) but were significantly higher in African Americans (OR = 2.1, CI = 1.42 - 3.06), Hispanics (OR = 1.6, CI = 1.26 - 2.14) and men (OR = 1.3, CI = 1.1 - 1.5).

A perception of better communication skills of their physician, lower quality of interaction with physician in traditional face-to-face encounters, and physician enthusiasm to use email with patients were significantly associated with an enthusiasm to use email. Patients who did not use email at all were less enthusiastic compared to those who used email for other reasons. Half of the physician respondents were not enthusiastic about communicating with patients using email.

Conclusions

Despite perceived barriers such as limited access to the Internet, older patients seem to want to use email to communicate with their physicians.