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Kalathoor S, Ghazi S, Otieno B, Babcook MA, Chen S, Nidhi N, Bae J, Pierre-Charles J, Breathett K, Mazimba S, Johnson A, Brewer L, Mohammed S, Carter RR, Bonsu JM, Ferdousi M, Kola-Kehinde O, McLaughlin E, Brammer J, Ruz P, Khan S, Odei B, Mitchell D, Wei L, Patel P, Paskett ED, Addison D. Representation of women in clinical trials supporting FDA-approval of contemporary cancer therapies. Int J Cancer 2024. [PMID: 39155749 DOI: 10.1002/ijc.35110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 04/24/2024] [Accepted: 05/02/2024] [Indexed: 08/20/2024]
Abstract
Contemporary anticancer therapies frequently have different efficacy and side effects in men and women. Yet, whether women are well-represented in pivotal trials supporting contemporary anticancer drugs is unknown. Leveraging the Drugs@FDA database, clinicaltrials.gov, MEDLINE, and publicly available FDA-drug-reviews, we identified all pivotal (phase II and III) non-sex specific trials supporting FDA-approval of anticancer drugs (1998-2018). Observed-enrollment-rates were compared to expected-population-rates derived from concurrent US-National-Cancer-Institute's Surveillance-Epidemiology-and-End-Results (SEER) reported rates and US-Census databases. Primary outcome was the proportional representation of women across trials, evaluated by a participation-to-prevalence ratio (PPR), according to cancer type. Secondary outcome was the report of any sex-specific analysis of efficacy and/or safety, irrespective of treatment-arm. Overall, there were 148 trials, enrolling 60,216 participants (60.5 ± 4.0 years, 40.7% female, 79.1% biologic, targeted, or immune-based therapies) evaluating 99 drugs. Sex was reported in 146 (98.6%) trials, wherein 40.7% (24,538) were women, compared to 59.3% (35,678) men (p < .01). Altogether, women were under-represented in 66.9% trials compared to the proportional incidence of cancers by respective disease type; weight-average PPR of 0.91 (relative difference: -9.1%, p < .01). Women were most under-represented in gastric (PPR = 0.63), liver (PPR = 0.71), and lung (PPR = .81) cancer trials. Sex-based safety data was reported in 4.0% trials. There was no association between adequate female enrollment and drug efficacy (HR: 0.616 vs. 0.613, p = .96). Over time, there was no difference in the percentage of women recruited into clinical trials. Among pivotal clinical trials supporting contemporary FDA-approved cancer drugs, women were frequently under-represented and sex-specific-efficacy and safety-outcomes were commonly not reported.
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Affiliation(s)
- Sujay Kalathoor
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Sanam Ghazi
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Beryl Otieno
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
- Department of Medicine, Greater Baltimore Medical Center, Baltimore, Maryland, USA
| | - Melissa A Babcook
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
- Division of Oncology, James Cancer Hospital and Solove Research Institute at The Ohio State University, Columbus, Ohio, USA
| | - Sunnia Chen
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Neha Nidhi
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Junu Bae
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Jovan Pierre-Charles
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | | | - Sula Mazimba
- Division of Cardiology, University of Virginia, Charlottesville, Virginia, USA
| | - Amber Johnson
- Division of Cardiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | - Selma Mohammed
- Division of Cardiology, Creighton University, Omaha, Nebraska, USA
| | - Rebecca R Carter
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
- Center for the Advancement of Team Science, Analytics, and Systems Thinking (CATALYST), Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Janice M Bonsu
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Mussammat Ferdousi
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Onaopepo Kola-Kehinde
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Eric McLaughlin
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus, Ohio, USA
| | - Jonathan Brammer
- Division of Hematology, James Cancer Hospital and Solove Research Institute at The Ohio State University, Columbus, Ohio, USA
| | - Patrick Ruz
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Sarah Khan
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Bismarck Odei
- Department of Radiation Oncology, James Cancer Hospital and Solove Research Institute at The Ohio State University, Columbus, Ohio, USA
| | - Darrion Mitchell
- Department of Radiation Oncology, James Cancer Hospital and Solove Research Institute at The Ohio State University, Columbus, Ohio, USA
| | - Lai Wei
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus, Ohio, USA
| | - Prem Patel
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Electra D Paskett
- Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Daniel Addison
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
- Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, Ohio, USA
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Ver Hoeve ES, Calhoun E, Hernandez M, High E, Armin JS, Ali-Akbarian L, Frithsen M, Andrews W, Hamann HA. Evaluating implementation of a community-focused patient navigation intervention at an NCI-designated cancer center using RE-AIM. BMC Health Serv Res 2024; 24:550. [PMID: 38685006 PMCID: PMC11059763 DOI: 10.1186/s12913-024-10919-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 03/28/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Patient navigation is an evidence-based intervention that reduces cancer health disparities by directly addressing the barriers to care for underserved patients with cancer. Variability in design and integration of patient navigation programs within cancer care settings has limited this intervention's utility. The implementation science evaluation framework, RE-AIM, allows quantitative and qualitative examination of effective implementation of patient navigation programs into cancer care settings. METHODS The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework was used to evaluate implementation of a community-focused patient navigation intervention at an NCI-designated cancer center between June 2018 and October 2021. Using a 3-month longitudinal, non-comparative measurement period, univariate and bivariate analyses were conducted to examine associations between participant-level demographics and primary (i.e., barrier reduction) and secondary (i.e., patient-reported outcomes) effectiveness outcomes. Mixed methods analyses were used to examine adoption and delivery of the intervention into the cancer center setting. Process-level analyses were used to evaluate maintenance of the intervention. RESULTS Participants (n = 311) represented a largely underserved population, as defined by the National Cancer Institute, with the majority identifying as Hispanic/Latino, having a household income of $35,000 or less, and being enrolled in Medicaid. Participants were diagnosed with a variety of cancer types and most had advanced staged cancers. Pre-post-intervention analyses indicated significant reduction from pre-intervention assessments in the average number of reported barriers, F(1, 207) = 117.62, p < .001, as well as significant increases in patient-reported physical health, t(205) = - 6.004, p < .001, mental health, t(205) = - 3.810, p < .001, self-efficacy, t(205) = - 5.321, p < .001, and satisfaction with medical team communication, t(206) = - 2.03, p = .029. Referral patterns and qualitative data supported increased adoption and integration of the intervention into the target setting, and consistent intervention delivery metrics suggested high fidelity to intervention delivery over time. Process-level data outlined a successful transition from a grant-funded community-focused patient navigation intervention to an institution-funded program. CONCLUSIONS This study utilized the implementation science evaluation framework, RE-AIM, to evaluate implementation of a community-focused patient navigation program. Our analyses indicate successful implementation within a cancer care setting and provide a potential guide for other oncology settings who may be interested in implementing community-focused patient navigation programs.
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Affiliation(s)
| | | | | | | | | | | | - Michael Frithsen
- Banner Health, Tucson, AZ, USA
- University of Arizona College of Medicine, Tucson, AZ, USA
| | - Wendy Andrews
- Banner Health, Tucson, AZ, USA
- University of Arizona College of Medicine, Tucson, AZ, USA
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Mossburg S, Kilany M, Jinnett K, Nguyen C, Soles E, Wood-Palmer D, Aly M. A Rapid Review of Interventions to Improve Care for People Who Are Medically Underserved with Multiple Sclerosis, Diabetic Retinopathy, and Lung Cancer. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:529. [PMID: 38791744 PMCID: PMC11121396 DOI: 10.3390/ijerph21050529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 04/11/2024] [Accepted: 04/19/2024] [Indexed: 05/26/2024]
Abstract
In the United States, patients with chronic conditions experience disparities in health outcomes across the care continuum. Among patients with multiple sclerosis, diabetic retinopathy, and lung cancer, there is a lack of evidence summarizing interventions to improve care and decrease these disparities. The aim of this rapid literature review was to identify interventions among patients with these chronic conditions to improve health and reduce disparities in screening, diagnosis, access to treatment and specialists, adherence, and retention in care. Using structured search terms in PubMed and Web of Science, we completed a rapid review of studies published in the prior five years conducted in the United States on our subject of focus. We screened the retrieved articles for inclusion and extracted data using a standard spreadsheet. The data were synthesized across clinical conditions and summarized. Screening was the most common point in the care continuum with documented interventions. Most studies we identified addressed interventions for patients with lung cancer, with half as many studies identified for patients with diabetic retinopathy, and few studies identified for patients with multiple sclerosis. Almost two-thirds of the studies focused on patients who identify as Black, Indigenous, or people of color. Interventions with evidence evaluating implementation in multiple conditions included telemedicine, mobile clinics, and insurance subsidies, or expansion. Despite documented disparities and a focus on health equity, a paucity of evidence exists on interventions that improve health outcomes among patients who are medically underserved with multiple sclerosis, diabetic retinopathy, and lung cancer.
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Affiliation(s)
- Sarah Mossburg
- American Institutes for Research, Arlington, VA 22202, USA
| | - Mona Kilany
- American Institutes for Research, Arlington, VA 22202, USA
| | - Kimberly Jinnett
- Department of Social and Behavioral Sciences, UCSF Institute for Health and Aging, San Francisco, CA 94158, USA
| | | | - Elena Soles
- American Institutes for Research, Arlington, VA 22202, USA
| | | | - Marwa Aly
- Department of Applied Health Sciences, School of Public Health, Indiana University Bloomington, Bloomington, IN 47405, USA
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Rawl SM, Baltic R, Monahan PO, Stump TE, Hyer M, Ennis AC, Walunis J, Renick K, Hinshaw K, Paskett ED, Champion VL, Katz ML. Receipt, uptake, and satisfaction with tailored DVD and patient navigation interventions to promote cancer screening among rural women. Transl Behav Med 2023; 13:879-890. [PMID: 37708322 PMCID: PMC10724168 DOI: 10.1093/tbm/ibad054] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023] Open
Abstract
Process evaluation is essential to understanding and interpreting the results of randomized trials testing the effects of behavioral interventions. A process evaluation was conducted as part of a comparative effectiveness trial testing a mailed, tailored interactive digital video disc (DVD) with and without telephone-based patient navigation (PN) to promote breast, cervical and colorectal cancer screening among rural women who were not up-to-date (UTD) for at least one screening test. Data on receipt, uptake, and satisfaction with the interventions were collected via telephone interviews from 542 participants who received the tailored interactive DVD (n = 266) or the DVD plus telephone-based PN (n = 276). All participants reported receiving the DVD and 93.0% viewed it. The most viewed sections of the DVD were about colorectal, followed by breast, then cervical cancer screening. Most participants agreed the DVD was easy to understand, helpful, provided trustworthy information, and gave information needed to make a decision about screening. Most women in the DVD+PN group, 98.2% (n = 268), reported talking with the navigator. The most frequently discussed cancer screenings were colorectal (86.8%) and breast (71.3%); 57.5% discussed cervical cancer screening. The average combined length of PN encounters was 22.2 minutes with 21.7 additional minutes spent on coordinating activities. Barriers were similar across screening tests with the common ones related to the provider/health care system, lack of knowledge, forgetfulness/too much bother, and personal issues. This evaluation provided information about the implementation and delivery of behavioral interventions as well as challenges encountered that may impact trial results.
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Affiliation(s)
- Susan M Rawl
- Simon Comprehensive Cancer Center, School of Nursing, Indiana University, Indianapolis, IN, USA
| | - Ryan Baltic
- Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Patrick O Monahan
- Department of Biostatistics and Health Data Science, School of Medicine, Indiana University, Simon Comprehensive Cancer Center, Indianapolis, IN, USA
| | - Timothy E Stump
- Department of Biostatistics and Health Data Science, School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Madison Hyer
- Center for Biostatistics, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Alysha C Ennis
- College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Jean Walunis
- Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | | | - Karen Hinshaw
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Electra D Paskett
- College of Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Victoria L Champion
- School of Nursing, Indiana University, Simon Comprehensive Cancer Center, Indianapolis, IN, USA
| | - Mira L Katz
- College of Public Health, Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
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Griesemer I, Gottfredson NC, Thatcher K, Rini C, Birken SA, Kothari A, John R, Guerrab F, Clodfelter T, Lightfoot AF. Intervening in the Cancer Care System: An Analysis of Equity-Focused Nurse Navigation and Patient-Reported Outcomes. Health Promot Pract 2023:15248399231213042. [PMID: 38050901 DOI: 10.1177/15248399231213042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
BACKGROUND Nurse navigation can improve quality of cancer care and reduce racial disparities in care outcomes. Addressing persistent structurally-rooted disparities requires research on strategies that support patients by prompting structural changes to systems of care. We applied a novel conceptualization of social support to an analysis of racial equity-focused navigation and patient-reported outcomes. METHOD We applied an antiracism lens to create a theory-informed definition of system-facing social support: intervening in a care system on a patient's behalf. Participants were adults with early-stage breast or lung cancer, who racially identified as Black or White, and received specialized nurse navigation (n = 155). We coded navigators' clinical notes (n = 3,251) to identify instances of system-facing support. We then estimated models to examine system-facing support in relation to race, perceived racism in health care settings, and mental health. RESULTS Twelve percent of navigators' clinical notes documented system-facing support. Black participants received more system-facing support than White participants, on average (b = 0.78, 95% confidence interval [CI]: [0.25, 1.31]). The interaction of race*system-facing support was significant in a model predicting perceived racism in health care settings at the end of the study controlling for baseline scores (b = 0.05, 95% CI [0.01, 0.09]). Trends in simple slopes indicated that among Black participants, more system-facing support was associated with slightly more perceived racism; no association among White participants. DISCUSSION The term system-facing support highlights navigators' role in advocating for patients within the care system. More research is needed to validate the construct system-facing support and examine its utility in interventions to advance health care equity.
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Affiliation(s)
- Ida Griesemer
- Center for Healthcare Organization & Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
- Greensboro Health Disparities Collaborative, Greensboro, NC, USA
| | | | - Kari Thatcher
- Greensboro Health Disparities Collaborative, Greensboro, NC, USA
| | | | - Sarah A Birken
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Aneri Kothari
- The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Fatima Guerrab
- Greensboro Health Disparities Collaborative, Greensboro, NC, USA
- People's Action Institute, Washington, DC, USA
| | | | - Alexandra F Lightfoot
- Greensboro Health Disparities Collaborative, Greensboro, NC, USA
- The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Center for Health Promotion and Disease Prevention, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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White A, Sabatino SA, White MC, Vinson C, Chambers DA, Richardson LC. Twenty years of collaborative research to enhance community practice for cancer prevention and control. Cancer Causes Control 2023; 34:1-5. [PMID: 37191768 PMCID: PMC10185931 DOI: 10.1007/s10552-023-01700-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 04/10/2023] [Indexed: 05/17/2023]
Abstract
The Cancer Prevention and Control Research Network (CPCRN) was established in 2002 to conduct applied research and undertake related activities to translate evidence into practice, with a special focus on the unmet needs of populations at higher risk of getting cancer and dying from it. A network of academic, public health and community partners, CPCRN is a thematic research network of the Prevention Research Centers Program at the Centers for Disease Control and Prevention (CDC). The National Cancer Institute's Division of Cancer Control and Population Sciences (DCCPS) has been a consistent collaborator. The CPCRN has fostered research on geographically dispersed populations through cross-institution partnerships across the network. Since its inception, the CPCRN has applied rigorous scientific methods to fill knowledge gaps in the application and implementation of evidence-based interventions, and it has developed a generation of leading investigators in the dissemination and implementation of effective public health practices. This article reflects on how CPCRN addressed national priorities, contributed to CDC's programs, emphasized health equity and impacted science over the past twenty years and potential future directions.
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Affiliation(s)
- Arica White
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA USA
| | - Susan A. Sabatino
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA USA
| | - Mary C. White
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA USA
| | - Cynthia Vinson
- Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Bethesda, MD USA
| | - David A. Chambers
- Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Bethesda, MD USA
| | - Lisa C. Richardson
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA USA
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O'Leary MC, Reuland DS, Randolph C, Ferrari RM, Brenner AT, Wheeler SB, Farr DE, Newcomer MK, Crockett SD. Reach and effectiveness of a centralized navigation program for patients with positive fecal immunochemical tests requiring follow-up colonoscopy. Prev Med Rep 2023; 34:102211. [PMID: 37214164 PMCID: PMC10196769 DOI: 10.1016/j.pmedr.2023.102211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/14/2023] [Accepted: 04/13/2023] [Indexed: 05/24/2023] Open
Abstract
Completion rates for follow-up colonoscopies after an abnormal fecal immunochemical test (FIT) are suboptimal in federally qualified health center (FQHC) settings. We implemented a screening intervention that included mailed FIT outreach to North Carolina FQHC patients from June 2020 to September 2021 and centralized patient navigation to support patients with abnormal FITs in completing follow-up colonoscopy. We evaluated the reach and effectiveness of navigation using electronic medical record data and navigator call logs detailing interactions with patients. Reach assessments included the proportion of patients successfully contacted by phone and who agreed to participate in navigation, intensity of navigation provided (including types of barriers to colonoscopy identified and total navigation time), and differences in these measures by socio-demographic characteristics. Effectiveness outcomes included colonoscopy completion, timeliness of follow-up colonoscopy (i.e., within 9 months), and bowel prep adequacy. Among 514 patients who completed a mailed FIT, 38 patients had an abnormal result and were eligible for navigation. Of these, 26 (68%) accepted navigation, 7 (18%) declined, and 5 (13%) could not be contacted. Among navigated patients, 81% had informational needs, 38% had emotional barriers, 35% had financial barriers, 12% had transportation barriers, and 42% had multiple barriers to colonoscopy. Median navigation time was 48.5 min (range: 24-277 min). Colonoscopy completion differed across groups - 92% of those accepting navigation completed colonoscopy within 9 months, versus 43% for those declining navigation. We found that centralized navigation was widely accepted in FQHC patients with abnormal FIT, and was an effective strategy, resulting in high colonoscopy completion rates.
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Affiliation(s)
- Meghan C. O'Leary
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Daniel S. Reuland
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Medicine, Division of General Medicine and Clinical Epidemiology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Connor Randolph
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Renée M. Ferrari
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Alison T. Brenner
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Medicine, Division of General Medicine and Clinical Epidemiology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Stephanie B. Wheeler
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Deeonna E. Farr
- College of Health and Human Performance, East Carolina University, Greenville, NC, USA
| | | | - Seth D. Crockett
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, OR, USA
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Green HM, Carmona-Barrera V, Diaz L, Yeh C, Williams B, Davis K, Kominiarek MA, Feinglass J, Grobman WA, Zera C, Yee LM. Implementation of postpartum navigation for low-income individuals at an urban academic medical center. PLoS One 2023; 18:e0282048. [PMID: 36821597 PMCID: PMC9949671 DOI: 10.1371/journal.pone.0282048] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 02/07/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Patient navigation, a patient-centered intervention to promote comprehensive health care, is an emerging innovation in obstetrics to optimize postpartum care. We aimed to evaluate the implementation of a novel postpartum patient navigation program at an urban academic medical center. METHODS This mixed-methods study analyzed the implementation of a postpartum patient navigation program within an ongoing randomized control trial. This study analyzed three navigators' logs of interactions with 50 patients, care team members, and community organizations throughout patients' first year postpartum. We categorized and quantified interactions by topic addressed, care team member interacted with, and communication mode used. We also conducted semi-structured interviews with each navigator every three months (5 interviews per navigator), emphasizing navigation experiences, relationships with patients and care teams, integration in the care team, and healthcare system gaps. Interview data were analyzed using the constant comparative method to identify themes using the constructs of the Consolidated Framework for Implementation Research (CFIR). RESULTS Analysis of navigator logs revealed a high patient need level, especially in the first 3 months postpartum. CFIR-guided analysis of intervention characteristics revealed positive perceptions of navigation's utility due to its adaptability. Navigation's complexity, however, posed an early obstacle to implementation that diminished over time. Outer setting analysis indicated navigators addressed patient needs through interactions with multiple systems. Despite clinicians' initial unfamiliarity with navigation, inner setting analysis suggested ongoing communication and electronic medical record use facilitated integration into the care team. Regarding individual and process characteristics, findings emphasized how navigator self-efficacy and confidence increased with experience (individual) and was facilitated by comprehensive training and reflection (process). Overall, barriers to implementation included unfamiliarity, varied patient engagement, and innovation complexity. Facilitators included high patient need, communication with outside organizations, medical record usage, navigator characteristics (self-efficacy, communication skills, and personal growth), a comprehensive training period, consistent reflection, high relative advantage, and high adaptability to patient need. CONCLUSION Patient navigation is a promising innovation to improve postpartum care coordination and support care team efforts. The successful implementation of navigation in this study indicates that, if shown to improve patient outcomes, obstetric navigation could be a component of patient-centered postpartum care.
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Affiliation(s)
- Hannah M. Green
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
- * E-mail:
| | - Viridiana Carmona-Barrera
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Laura Diaz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Chen Yeh
- Biostatistics Collaboration Center, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Brittney Williams
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Ka’Derricka Davis
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Michelle A. Kominiarek
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Joe Feinglass
- Division of General Internal Medicine and Geriatrics, Department of Medicine and Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - William A. Grobman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH, United States of America
| | - Chloe Zera
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
| | - Lynn M. Yee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
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Austin G, Kowalkowski H, Guo Y, Miller-Wilson LA, DaCosta Byfield S, Verma P, Housman L, Berke E. Patterns of initial colorectal cancer screenings after turning 50 years old and follow-up rates of colonoscopy after positive stool-based testing among the average-risk population. Curr Med Res Opin 2023; 39:47-61. [PMID: 36017620 DOI: 10.1080/03007995.2022.2116172] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Effective colorectal cancer (CRC) screening requires proper adherence beginning at the recommended screening age. For those with positive results on stool-based tests (SBTs), a follow-up colonoscopy is warranted. The objectives of this study were to 1) examine initial screening rates after turning 50 years old; and 2) assess rates of follow-up colonoscopy after a positive SBT. METHODS This retrospective study used de-identified administrative claims data from 01/01/2006 to 06/30/2020 for commercially insured and Medicare Advantage enrollees. For objective 1, the index year was the year enrollees turned 50. Rates of CRC screening during and after the index year were captured. For objective 2, the index date was the claim date of a fecal immunochemical test (FIT) or multitarget stool DNA test (mt-sDNA) where linked lab data indicated a positive test result. Rates and time to follow-up colonoscopy after a positive SBT were assessed. RESULTS Approximately 53% of enrollees initiated CRC screening within five years after turning 50 (50+ cohort N = 718,562). Among enrollees with an available lab result indicating a positive SBT (N = 7329; 2110 FIT and 5219 mt-sDNA), overall follow-up colonoscopy within 6 months of the positive result was less than optimal (65%) and varied by modality; 72% vs 46% (p < .001) among enrollees with a positive mt-sDNA test compared to FIT test, respectively. CONCLUSION There is potential for improving CRC screening among the eligible average-risk population, both to start screening once they reach the screening-eligible age, and to complete the CRC screening paradigm after a positive stool-based screen.
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Affiliation(s)
| | | | | | | | | | - Prat Verma
- Exact Sciences Corporation, Madison, WI, USA
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10
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Chaiyachati KH, Krause D, Sugalski J, Graboyes EM, Shulman LN. A Survey of the National Comprehensive Cancer Network on Approaches Toward Addressing Patients' Transportation Insecurity. J Natl Compr Canc Netw 2023; 21:21-26. [PMID: 36634609 PMCID: PMC9888481 DOI: 10.6004/jnccn.2022.7073] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 09/08/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Addressing patients' social determinants of health is a national priority for cancer treatment centers. Transportation insecurity is one major challenge for patients undergoing active cancer treatment, and missing treatments can result in worse cancer treatment outcomes, including worse morbidity and mortality. How cancer treatment centers are addressing transportation insecurity is understudied. METHODS In January and February 2022, the NCCN Best Practices Committee conducted a survey of NCCN's 31 Member Institutions (currently 32 member institutions as of April 2022) to assess how centers were addressing patient transportation insecurity: how they screen for transportation insecurity, coordinate transportation, and fund transportation initiatives, and their plans to address transportation insecurity in the future. RESULTS A total of 25 of 31 (81%) NCCN Member Institutions responded to the survey, of which 24 (96%) reported supporting the transportation needs of their patients through screening, coordinating, and/or funding transportation. Patients' transportation needs were most often identified by social workers (96%), clinicians (83%), or patients self-declaring their needs (79%). Few centers (33%) used routine screening approaches (eg, universal screening of social risk factors) to systematically identify transportation needs, and 54% used the support of technology platforms or a vendor to coordinate transportation. Transportation was predominantly funded via some combination of philanthropy (88%), grants (63%), internal dollars (63%), and reimbursement from insurance companies (58%). Over the next 12 months, many centers were either going to continue their current transportation programs in their current state (60%) or expand existing programs (32%). CONCLUSIONS Many NCCN Member Institutions are addressing the transportation needs of their patients. Current efforts are heterogeneous. Few centers have systematic, routine screening approaches, and funding relies on philanthropy more so than institutional dollars or reimbursement from insurers. Opportunities exist to establish more structured, scalable, and sustainable programs for patients' transportation needs.
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Affiliation(s)
| | - Diana Krause
- National Comprehensive Cancer Network, Plymouth Meeting, Pennsylvania
| | - Jessica Sugalski
- National Comprehensive Cancer Network, Plymouth Meeting, Pennsylvania
| | | | - Lawrence N. Shulman
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Penn Center for Cancer Care Innovation, University of Pennsylvania, Philadelphia, Pennsylvania
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
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11
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Graboyes EM, Chaiyachati KH, Sisto Gall J, Johnson W, Krishnan JA, McManus SS, Thompson L, Shulman LN, Yabroff KR. Addressing Transportation Insecurity Among Patients With Cancer. J Natl Cancer Inst 2022; 114:1593-1600. [PMID: 36130286 PMCID: PMC9745432 DOI: 10.1093/jnci/djac134] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/18/2022] [Accepted: 05/04/2022] [Indexed: 01/11/2023] Open
Abstract
Health-care-related transportation insecurity is common in the United States. Patients with cancer are especially vulnerable because cancer care is episodic in nature, occurs over a prolonged period, is marked by frequent clinical encounters, requires intense treatments, and results in substantial financial hardship. As a result of transportation insecurity, patients with cancer may forego, miss, delay, alter, and/or prematurely terminate necessary care. Limited data suggest that these alterations in care have the potential to increase the rates of cancer recurrence and mortality and exacerbate disparities in cancer incidence, severity, and outcomes. Transportation insecurity also negatively impacts at the informal caregiver, provider, health system, and societal levels. Recognizing that transportation is a critical determinant of outcomes for patients with cancer, there are ongoing efforts to develop evidence-based protocols to identify at-risk patients and address transportation insecurity at federal policy, health system, not-for-profit, and industry levels. In 2021, the National Cancer Policy Forum of the National Academies of Science, Engineering, and Medicine sponsored a series of webinars addressing key social determinants of health including food, housing, and transportation among patients with cancer. This commentary summarizes the formal presentations and discussions related to transportation insecurity and will 1) discuss the heterogeneous nature of transportation insecurity among patients with cancer; 2) characterize its prevalence along the cancer continuum; 3) examine its multilevel consequences; 4) discuss measurement and screening tools; 5) highlight ongoing efforts to address transportation insecurity; 6) suggest policy levers; and 7) outline a research agenda to address critical knowledge gaps.
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Affiliation(s)
- Evan M Graboyes
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Krisda H Chaiyachati
- Department of Medicine, Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - Jerry A Krishnan
- Population Health Sciences Program, University of Illinois Chicago, Chicago, IL, USA
| | - Sapna S McManus
- Chief Diversity Office, Genentech Inc, San Francisco, CA, USA
| | | | - Lawrence N Shulman
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - K Robin Yabroff
- Surveillance and Health Equity Science, American Cancer Society, Kennesaw, GA, USA
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Maxwell AE, DeGroff A, Hohl SD, Sharma KP, Sun J, Escoffery C, Hannon PA. Evaluating Uptake of Evidence-Based Interventions in 355 Clinics Partnering With the Colorectal Cancer Control Program, 2015-2018. Prev Chronic Dis 2022; 19:E26. [PMID: 35588522 PMCID: PMC9165474 DOI: 10.5888/pcd19.210258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
PURPOSE AND OBJECTIVES Colorectal cancer screening rates remain suboptimal in the US. The Colorectal Cancer Control Program (CRCCP) of the Centers for Disease Control and Prevention (CDC) seeks to increase screening in health system clinics through implementation of evidence-based interventions (EBIs) and supporting activities (SAs). This program provided an opportunity to assess the uptake of EBIs and SAs in 355 clinics that participated from 2015 to 2018. INTERVENTION APPROACH The 30 funded awardees of CRCCP partnered with clinics to implement at least 2 of 4 EBIs that CDC prioritized (patient reminders, provider reminders, reducing structural barriers, provider assessment and feedback) and 4 optional strategies that CDC identified as SAs (small media, professional development and provider education, patient navigation, and community health workers). EVALUATION METHODS Clinics completed 3 annual surveys to report uptake, implementation, and integration and perceived sustainability of the priority EBIs and SAs. RESULTS In our sample of 355 clinics, uptake of 4 EBIs and 2 SAs significantly increased over time. By year 3, 82% of clinics implemented patient reminder systems, 88% implemented provider reminder systems, 82% implemented provider assessment and feedback, 76% implemented activities to reduce structural barriers, 51% implemented provider education, and 84% used small media. Most clinics that implemented these strategies (>90%) considered them fully integrated into the health system or clinic operations and sustainable by year 3. Fewer clinics used patient navigation (30%) and community health workers (19%), with no increase over the years of the study. IMPLICATIONS FOR PUBLIC HEALTH Clinics participating in the CRCCP reported high uptake and perceived sustainability of EBIs that can be integrated into electronic medical record systems but limited uptake of patient navigation and community health workers, which are uniquely suited to reduce cancer disparities. Future research should determine how to promote uptake and assess cost-effectiveness of CRCCP interventions.
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Affiliation(s)
- Annette E Maxwell
- University of California Los Angeles, Los Angeles, California
- Department of Health Policy and Management, University of California, Los Angeles, 650 Charles Young Dr South, A2-125 CHS, Box 956900, Los Angeles, CA 90095-6900. E-mail:
| | - Amy DeGroff
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | - Juzhong Sun
- Centers for Disease Control and Prevention, Atlanta, Georgia
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Pratte MA, Ogazi C, Vozzolo C, Wright D, Griffin A. Evaluating the Impact of Wellness Days on Enrollment of Underserved Women in the Connecticut Early Detection and Prevention Program. Health Promot Pract 2022; 23:375-377. [PMID: 33969727 DOI: 10.1177/15248399211013814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Women in underserved communities are disproportionately affected by chronic diseases such as cardiovascular disease and cancer. The Connecticut Early Detection and Prevention Program (CEDPP) has taken a streamlined approach to improve access to comprehensive preventive health services for minority women and those with incomes below the federal poverty threshold. The CEDPP has implemented Wellness Days to improve outreach in the community and offer opportunities for health assessments, screenings, and education around chronic disease prevention and management. CEDPP contractors coordinated 47 Wellness Days in 2019, reaching 2,509 women and successfully enrolling 107 (4.3%) in the CEDPP. While the majority of Wellness Day events offered health education to participants, only 10.6% offered mammograms and 6.4% offered Papanicolaou (Pap) tests onsite. Through ongoing evaluation efforts, the CEDPP and its contractors have identified opportunities to enhance the success of Wellness Days to connect women with essential preventive services. By expanding its reach, the CEDPP will have a more widespread impact on women's health across Connecticut.
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Affiliation(s)
- Morgan A Pratte
- State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Chioma Ogazi
- Connecticut Department of Public Health, Hartford, CT, USA
| | | | - Donette Wright
- Connecticut Department of Public Health, Hartford, CT, USA
| | - Amy Griffin
- The Consultation Center, New Haven, CT, USA
- Yale University, New Haven, CT, USA
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14
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Lenze NR, Bensen JT, Farnan L, Sheth S, Zevallos JP, Yarbrough WG, Zanation AM. Evaluation of Patient-Reported Delays and Affordability-Related Barriers to Care in Head and Neck Cancer. OTO Open 2021; 5:2473974X211065358. [PMID: 34926976 PMCID: PMC8671675 DOI: 10.1177/2473974x211065358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 11/15/2021] [Indexed: 11/17/2022] Open
Abstract
Objective To examine the prevalence and predictors of patient-reported barriers to care among survivors of head and neck squamous cell carcinoma and the association with health-related quality of life (HRQOL) outcomes. Study Design Retrospective cohort study. Setting Outpatient oncology clinic at an academic tertiary care center. Methods Data were obtained from the UNC Health Registry/Cancer Survivorship Cohort. Barriers to care included self-reported delays in care and inability to obtain needed care due to cost. HRQOL was measured with validated questionnaires: general (PROMIS) and cancer specific (FACT-GP). Results The sample included 202 patients with head and neck squamous cell carcinoma with a mean age of 59.6 years (SD, 10.0). Eighty-two percent were male and 87% were White. Sixty-two patients (31%) reported at least 1 barrier to care. Significant predictors of a barrier to care in unadjusted analysis included age ≤60 years ( P = .007), female sex ( P = .020), being unmarried ( P = .016), being uninsured ( P = .047), and Medicaid insurance ( P = .022). Patients reporting barriers to care had significantly worse physical and mental HRQOL on the PROMIS questionnaires ( P < .001 and P = .002, respectively) and lower cancer-specific HRQOL on the FACT-GP questionnaire ( P < .001), which persisted across physical, social, emotional, and functional domains. There was no difference in 5-year OS (75.3% vs 84.1%, P = .177) or 5-year CSS (81.6% vs 85.4%, P = .542) in patients with and without barriers to care. Conclusion Delay- and affordability-related barriers are common among survivors of head and neck cancer and appear to be associated with significantly worse HRQOL outcomes. Certain sociodemographic groups appear to be more at risk of patient-reported barriers to care.
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Affiliation(s)
- Nicholas R. Lenze
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
- Department of Otolaryngology–Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Jeannette T. Bensen
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Laura Farnan
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Siddharth Sheth
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jose P. Zevallos
- Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Wendell G. Yarbrough
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
- Department of Pathology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Adam M. Zanation
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
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Meadows RJ, Padamsee TJ. Financial constraints on genetic counseling and further risk-management decisions among U.S. women at elevated breast cancer risk. J Genet Couns 2021; 30:1452-1467. [PMID: 33749063 DOI: 10.1002/jgc4.1413] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 02/15/2021] [Accepted: 02/20/2021] [Indexed: 12/30/2022]
Abstract
Clinical guidelines recommend that women at high risk of breast cancer should consider various risk-management options, which remain widely underutilized. We conducted semi-structured, qualitative interviews with 50 high-risk women to understand how financial constraints affect use of genetic counseling, genetic testing, and further risk-management decisions. Inductive analyses revealed three categories of health-related financial constraint: (a) lack of insurance, (b) underinsurance, and (c) other financial constraints (e.g., medical debt, raising children, managing comorbidities). Various breast cancer risk-management actions were limited by these financial constraints, including genetic counseling, genetic testing, enhanced screening, and prophylactic surgeries. Women's narratives also identified complex relationships between financial constraint and perceptions of healthcare providers and insurance companies, particularly as related to bias, price transparency, and potential genetic discrimination. Results from this study have implications for further research and expansion of genetic counseling services delivery to more economically and racially diverse women.
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Affiliation(s)
- Rachel J Meadows
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH, USA.,Center for Outcomes Research, JPS Health Network, Fort Worth, TX, USA
| | - Tasleem J Padamsee
- Division of Health Services Management and Policy, College of Public Health and Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
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