Eliminating disparities in cancer screening and follow-up of abnormal results: what will it take?

Digital tools to support informed decision making among screening invitees in a vulnerable position for population-based cancer screening: A scoping review

BACKGROUND

Individuals in a vulnerable position are generally less inclined to participate in population-based cancer screening. Digital tools, such as educational videos, narratives or decision aids, show promise in reaching and informing these invitees by tailoring information needs based on their preferences. This review aims to provide an overview of design features and reported outcomes of digital tools intended to support informed decision making among screening invitees in a vulnerable position.

METHODS

The review was conducted according to the Preferred Reporting Items for Scoping Reviews guidelines. We searched PubMed, Scopus/MEDLINE and Web of Science and included studies when the effectiveness of the digital tool was assessed and focussed on reaching and/or informing screening invitees in a vulnerable position for breast, cervical or colorectal cancer screening. For each included study, the study population, type of digital tool, the development process, reported design features and reported effects were extracted.

FINDINGS

We found 448 articles, and finally 13 were included in this review after reading full text. Study designs included randomised controlled trials (n = 5), pre-post-test design (n = 7) and experimental design (n = 1). Six different types of digital tools were identified: decision aids (n = 6), educational programs (n = 3), narrative video (n = 1), text-messaging intervention (n = 1), animation video (n = 1), and iPad program (n = 1). A population specific design was applied in 12/13 interventions, such as avoiding jargon and using a voice over function. Reported outcomes measures regarding reaching and informing the target population were: knowledge, attitude, screening intention, self-efficacy, susceptibility, feeling informed, values clarity, and screening uptake. All digital tools reported a significant improvement on at least one of the reported outcome measures.

PRINCIPAL CONCLUSIONS

The use of digital tools seems to contribute to reach or inform screening invitees in a vulnerable position for cancer screening. However, insufficient evidence was found regarding the development process of the tools and their effects on outcome measures related to reaching and informing the screening invitees in a vulnerable position. Future research may look in to combining multiple digital tools and animated visual information in combination with spoken text to improve reaching and informing screening invitees in a vulnerable position.

Applying cognitive walkthrough methodology to improve the usability of an equity-focused implementation strategy

BACKGROUND

Our research team partnered with primary care and quality improvement staff in Federally Qualified Community Health Centers (CHCs) to develop Partnered and Equity Data-Driven Implementation (PEDDI) to promote equitable implementation of evidence-based interventions. The current study used a human-centered design methodology to evaluate the usability of PEDDI and generate redesign solutions to address usability issues in the context of a cancer screening intervention.

METHODS

We applied the Cognitive Walkthrough for Implementation Strategies (CWIS), a pragmatic assessment method with steps that include group testing with end users to identify and prioritize usability problems. We conducted three facilitated 60-min CWIS sessions with end users (N = 7) from four CHCs that included scenarios and related tasks for implementing a colorectal cancer (CRC) screening intervention. Participants rated the likelihood of completing each task and identified usability issues and generated ideas for redesign solutions during audio-recorded CWIS sessions. Participants completed a pre-post survey of PEDDI usability. Our research team used consensus coding to synthesize usability problems and redesign solutions from transcribed CWIS sessions.

RESULTS

Usability ratings (scale 0-100: higher scores indicating higher usability) of PEDDI averaged 66.3 (SD = 12.4) prior to the CWIS sessions. Scores averaged 77.8 (SD = 9.1) following the three CWIS sessions improving usability ratings from "marginal acceptability" to "acceptable". Ten usability problems were identified across four PEDDI tasks, comprised of 2-3 types of usability problems per task. CWIS participants suggested redesign solutions that included making data fields for social determinants of health and key background variables for identifying health equity targets mandatory in the electronic health record and using asynchronous communication tools to elicit ideas from staff for adaptations.

CONCLUSIONS

Usability ratings indicated PEDDI was in the acceptable range following CWIS sessions. Staff identified usability problems and redesign solutions that provide direction for future improvements in PEDDI. In addition, this study highlights opportunities to use the CWIS methodology to address inequities in the implementation of cancer screening and other clinical innovations in resource-constrained healthcare settings.

Making Sense of Gynecologic Cancer: A Relational Dialectics Approach

This study used the relational dialectics theory (RDT) as a theoretical lens to examine how the interplay of competing discourses shaped meaning making about gynecologic cancer. A reflexive thematic analysis of the narratives of 12 survivors of cervical cancer, ovarian cancer, and uterine cancer in Arkansas showed two discursive struggles at play, including continuity of care versus change, and voicing versus repressing of feelings. The findings showed that long history of care with physicians contributed to how participants privileged the discourse of continuity of care when faced with a decision to travel for care or receive care locally. We also found that cultural discourses about concealing women's cancer-afflicted bodies, lack of supportive spaces for women to discuss side effects of cancer treatments, and appropriate communication behavior between patients and physicians shaped the interplay of the discursive struggle of voicing versus repressing. The findings extend the RDT by showing that geographic location, disease characteristics, history of care between patients and physicians, and prevailing cultural discourses can contribute to the interplay of discursive struggles in the gynecologic cancer context. Further, the findings suggest to healthcare professionals to address harmful discourses about gynecologic cancer to help create support avenues for survivors.

Effect of a same day appointment initiative on racial disparities in access for radiation oncology

PURPOSE

We present our single-institution experience with the development of a same day access scheduling initiative for an outpatient radiation oncology unit, focusing on its potential influence on ameliorating racial disparities.

METHODS AND MATERIALS

From March 2021 to August 2022, a pilot initiative was conducted such that all new patients referred to a tertiary care-based radiation oncology department were offered the ability to be seen as a same day consultation. The timespan of this analysis was categorized into 2 distinct successive periods over 36 months-a 18-month pre-initiative period (September 2019 to February 2021) and another subsequent one (March 2021 to August 2022). Descriptive statistics were used to study the impact of this initiative on access-related benchmarks.

RESULTS

A total of 2897 patients were referred. Among the 2107 patients scheduled, three hundred and sixteen (15 %) opted for same day appointments. Black, Latino, and Asian patients were significantly more likely to use the same day access initiative versus Caucasian patients (p = 0.01). The same day access initiative increased the proportion of patients seen within 5 days from referral from 8 % to 34 % for Blacks, 12-57 % for Latinos, and 18-67 % for Asians, compared to 39-55 % for Caucasians (p < 0.001). The no-show rate was reduced from 20 % to 7 % and 14-5 %, for Black and Latino patients, respectively (p < 0.001).

CONCLUSIONS

The implementation of a same day access initiative narrowed disparities with respect to access-related benchmarks.

Clinical epidemiology and outcomes of patients with gastric intestinal metaplasia in the Los Angeles County System

BACKGROUND

Gastric intestinal metaplasia (GIM) is a precursor to gastric adenocarcinoma (GAC). In the United States, there is no consensus on the utility of surveillance for GIM, and minority populations most affected by GAC are understudied. Our aims were to define clinical and endoscopic features, surveillance practices, and outcomes in patients with GIM in a multicenter safety-net system.

METHODS

We identified patients with biopsy-proven GIM between 2016-2020 at the three medical centers comprising Los Angeles County Department of Health Services. Demographics, findings at index esophagogastroduodenoscopy (EGD) first showing GIM, recommended interval for repeat EGD, and findings at repeat EGD were abstracted. Descriptive statistics were performed to characterize our cohort. T-tests and chi-squared (χ²) tests were used to compare patients with and without multifocal GIM.

RESULTS

There were 342 patients with newly-diagnosed biopsy-proven GIM, 18 (5.2%) of whom had GAC at index EGD. Hispanic patients comprised 71.8% of patients. For most patients (59%), repeat EGD was not recommended. If recommended, 2-3 years was the most common interval. During a median time to repeat EGD of 13 months and cumulative follow-up of 119 patient-years, 29.5% of patients underwent at least one repeat EGD, of whom 14% had multifocal GIM not previously detected. Progression to dysplasia or GAC was not detected in any patients.

CONCLUSION

In a predominantly minority population with biopsy-proven GIM, there was a 5% incidence of GAC on index EGD. Though progression to neither dysplasia nor GAC was detected, there was significant variability in endoscopic sampling and surveillance practices.

Disparities in outcomes among patients diagnosed with cancer in proximity to an emergency department visit

A suspected diagnosis of cancer in the emergency department (ED) may be associated with poor outcomes, related to health disparities, however data are limited. This is a retrospective observational cohort of the Indiana State Department of Health Cancer Registry, and the Indiana Network for Patient Care. First time cancer diagnoses appearing in the registry between January 2013 and December 2017 were included. Cases identified as patients who had an ED visit in the 6 months before their cancer diagnosis; controls had no preceding ED visits. The primary outcome was mortality, comparing ED-associated mortality to non-ED-associated. 134,761 first-time cancer patients were identified, including 15,432 (11.5%) cases. The mean age was same at 65, more of the cases were Black than the controls (12.4% vs 7.4%, P < .0001) and more were low income (36.4%. vs 29.3%). The top 3 ED-associated cancer diagnoses were lung (18.4%), breast (8.9%), and colorectal cancers (8.9%), whereas the controls were breast (17%), lung (14.9%), and prostate cancers (10.1%). Cases observed an over three-fold higher mortality, with cumulative death rate of 32.9% for cases vs 9.0% for controls (P < .0001). Regression analysis predicting mortality, controlling for many confounders produced an odds ratio of 4.12 (95% CI 3.72-4.56 for cases). This study found that an ED visit within 6 months prior to the first time of ICD-coded cancer is associated with Black race, low income and an overall three-fold increased adjusted risk of death. The mortality rates for ED-associated cancers are uniformly worse for all cancer types. These data suggest that additional work is needed to reduce disparities among ED-associated cancer diagnoses.

Current and future colorectal cancer screening strategies

Despite strong evidence of effectiveness, colorectal cancer (CRC) screening remains underused. Currently, there are several options for CRC screening, each with its own performance characteristics and considerations for practice. This Review aims to cover current CRC screening guidelines and highlight future blood-based and imaging-based options for screening. In current practice, the leading non-invasive option is the faecal immunochemical test (FIT) based on its high specificity, good sensitivity, low cost and ease of use in mailed outreach programmes. There are currently five blood-based CRC screening tests in varying stages of evaluation, including one that is currently sold in the USA as a laboratory-developed test. There are ongoing studies on the diagnostic accuracy and longitudinal performance of blood tests and they have the potential to disrupt the CRC screening landscape. Imaging-based options, including the colon capsule, MR colonography and the CT capsule, are also being tested in active studies. As the world attempts to recover from the COVID-19 pandemic and adapts to the start of CRC screening among people at average risk starting at age 45 years, non-invasive options will become increasingly important.

Barriers to completing colonoscopy after a positive fecal occult blood test

Background

Colorectal cancer leads to significant morbidity and mortality. Early detection and treatment are essential. Screening using fecal occult blood tests has increased significantly, but adherence to colonoscopy follow-up is suboptimal, increasing CRC mortality risk.

The aim of this study was to identify barriers to colonoscopy following a positive FOBT at the level of the patient, physician, organization and policymakers.

Methods

This mixed methods study was conducted at two health care organizations in Israel. The study included retrospective analyses of 45,281 50–74 year-old members with positive fecal immunochemical tests from 2010 to 2014, and a survey of 772 patients with a positive test during 2015, with and without follow-up. The qualitative part of the study included focus groups with primary physicians and gastroenterologists and in-depth interviews with opinion leaders in healthcare.

Results

Patient lack of comprehension regarding the test was the strongest predictor of non-adherence to follow-up. Older age, Arab ethnicity, and lower socio economic status significantly reduced adherence. We found no correlation with gender, marital status, patient activation, waiting time for appointments or distance from gastroenterology clinics. Primary care physicians underestimate non-adherence rates. They feel responsible for patient follow-up, but express lack of time and skills that will allow them to ensure adherence among their patients. Gastroenterologists do not consider fecal occult blood an effective tool for CRC detection, and believe that all patients should undergo colonoscopy. Opinion leaders in the healthcare field do not prioritize the issue of follow-up after a positive screening test for colorectal cancer, although they understand the importance.

Conclusions

We identified important barriers that need to be addressed to improve the effectiveness of the screening program. Targeted interventions for populations at risk for non-adherence, specifically for those with low literacy levels, and better explanation of the need for follow-up as a routine need to be set in place. Lack of agreement between screening recommendations and gastroenterologist opinion, and lack of awareness among healthcare authority figures negatively impact the screening program need to be addressed at the organizational and national level.

Trial registration

This study was approved by the IRB in both participating organizations (Meuhedet Health Care Institutional Review Board #02–2–5-15, Maccabi Healthcare Institutional Review Board BBI-0025-16). Participant consent was waived by both IRB’s.

Addressing Disparities in Lung Cancer Screening Eligibility and Healthcare Access. An Official American Thoracic Society Statement

Background: There are well-documented disparities in lung cancer outcomes across populations. Lung cancer screening (LCS) has the potential to reduce lung cancer mortality, but for this benefit to be realized by all high-risk groups, there must be careful attention to ensuring equitable access to this lifesaving preventive health measure.Objectives: To outline current knowledge on disparities in eligibility criteria for, access to, and implementation of LCS, and to develop an official American Thoracic Society statement to propose strategies to optimize current screening guidelines and resource allocation for equitable LCS implementation and dissemination.Methods: A multidisciplinary panel with expertise in LCS, implementation science, primary care, pulmonology, health behavior, smoking cessation, epidemiology, and disparities research was convened. Participants reviewed available literature on historical disparities in cancer screening and emerging evidence of disparities in LCS.Results: Existing LCS guidelines do not consider racial, ethnic, socioeconomic, and sex-based differences in smoking behaviors or lung cancer risk. Multiple barriers, including access to screening and cost, further contribute to the inequities in implementation and dissemination of LCS.Conclusions: This statement identifies the impact of LCS eligibility criteria on vulnerable populations who are at increased risk of lung cancer but do not meet eligibility criteria for screening, as well as multiple barriers that contribute to disparities in LCS implementation. Strategies to improve the selection and dissemination of LCS in vulnerable groups are described.

Evaluating Potential Racial Inequities in Low-dose Computed Tomography Screening for Lung Cancer

BACKGROUND

Lung cancer is the leading cause of cancer death in the US, and significant racial disparities exist in lung cancer outcomes. For example, Black men experience higher lung cancer incidence and mortality rates than their White counterparts. New screening recommendations for low-dose computed tomography (LDCT) promote earlier detection of lung cancer in at-risk populations and can potentially help mitigate racial disparities in lung cancer mortality if administered equitably. Yet, little is known about the extent of racial differences in uptake of LDCT.

OBJECTIVE

To evaluate potential racial disparities in LDCT screening in a large community-based cancer center in central North Carolina.

METHODS

We conducted a retrospective study of the initial patients undergoing LDCT in a community-based cancer center (n = 262). We used the Pearson chi-squared test to assess potential racial disparities in LDCT screening.

RESULTS

Study results suggest that Black patients may be less likely than White patients to receive LDCT screening when eligible (χ2 = 51.41, p < 0.0001).

CONCLUSION

Collaboration among healthcare providers, researchers, and decision makers is needed to promote LDCT equity.

Patient Satisfaction with Navigator Interpersonal Relationship (PSN-I): item-level psychometrics using IRT analysis

BACKGROUND

Patient navigation (PN) is a promising intervention to eliminate cancer health inequities. Patient navigators play a critical role in the navigation process. Patients' satisfaction with navigators is important in determining the effectiveness of PN programs. We applied item response theory (IRT) analysis to establish item-level psychometric properties for the Patient Satisfaction with Interpersonal Relationship with Navigators (PSN-I).

METHODS

We conducted a confirmatory factor analysis (CFA) to establish unidimensionality of the 9-item PSN-I in 751 cancer patients (68% female) between 18 and 86 years old. We fitted unidimensional IRT models-unconstrained graded response model (GRM) and Rasch model-to PSN-I data, and compared model fit using likelihood ratio (LR) test and information criteria. We obtained item parameter estimates (IPEs), item category/operating characteristic curves, and item/test information curves for the better fitting model.

RESULTS

CFA with diagonally weighted least squares confirmed that the one-factor model fit the data (RMSEA = 0.047, 95% CI = 0.033-0.060, and CFI ≈ 1). Responses to PSN-I items clustered into the 4th and 5th categories. We aggregated the first three response categories to provide stable parameter estimates for both IRT models. The GRM fit the data significantly better than the Rasch model (LR = 80.659, df = 8, p < 0.001). Akaike's information coefficient (6384.978 vs. 6320.319) and Bayesian information coefficient (6471.851 vs. 6443.771) were lower for the GRM. IPEs showed substantial variation in items' discriminating power (1.80-3.35) for GRM.

CONCLUSIONS

This IRT analysis confirms the latent structure of the PSN-I and supports its use as a valid and reliable measure of latent satisfaction with PN.

Repeated Automated Mobile Text Messaging Reminders for Follow-Up of Positive Fecal Occult Blood Tests: Randomized Controlled Trial

Background

Fecal occult blood tests (FOBTs) are recommended by the US Preventive Services Task Force as a screening method for colorectal cancer (CRC), but they are only effective if positive results are followed by colonoscopy. Surprisingly, a large proportion of patients with a positive result do not follow this recommendation.

Objective

The objective of this study was to examine the effectiveness of text messaging (short message service, SMS) in increasing adherence to colonoscopy follow-up after a positive FOBT result.

Methods

This randomized controlled trial was conducted with patients who had positive CRC screening results. Randomization was stratified by residential district and socioeconomic status (SES). Subjects in the control group (n=238) received routine care that included an alert to the physician regarding the positive FOBT result. The intervention group (n=232) received routine care and 3 text messaging SMS reminders to visit their primary care physician. Adherence to colonoscopy was measured 120 days from the positive result. All patient information, including test results and colonoscopy completion, were obtained from their electronic medical records. Physicians of study patients completed an attitude survey regarding FOBT as a screening test for CRC. Intervention and control group variables (dependent and independent) were compared using chi-square test. Logistic regression was used to calculate odds ratios (ORs) and 95% CIs for performing colonoscopy within 120 days for the intervention group compared with the control group while adjusting for potential confounders including age, gender, SES, district, ethnicity, and physicians’ attitude.

Results

Overall, 163 of the 232 patients in the intervention group and 112 of the 238 patients in the control group underwent colonoscopy within 120 days of the positive FOBT results (70.3% vs 47.1%; OR 2.17, 95% CI 1.49-3.17; P<.001); this association remained significant after adjusting for potential confounders (P=.001).

Conclusions

A text message (SMS) reminder is an effective, simple, and inexpensive method for improving adherence among patients with positive colorectal screening results. This type of intervention could also be evaluated for other types of screening tests.

Trial Registration

ClinicalTrials.gov NCT03642652; https://clinicaltrials.gov/ct2/show/NCT03642652 (Archived by WebCite at http://www.webcitation.org/74TlICijl)

CRC Screening Results: Patient Comprehension and Follow-up

BACKGROUND:

Fecal occult blood tests are recommended for colorectal cancer screening, but are only effective if colonoscopy follows positive results. Patients with positive results often do not complete follow-up. This study examined the association between patient comprehension and adherence to colonoscopy after positive FIT (Fecal Immunochemical Test).

METHODS:

Five hundred twenty-two patients completed a telephone questionnaire regarding the FIT and its implications 120 days after a positive result. Patients were asked whether they had the test, received the results, and required follow-up. These questions were used to identify the degree to which patients understood medical information. A participant who answered "no" to any question was defined as having "low comprehension" regarding the FIT, and participants who answered "yes" to all 3 questions, as having "high comprehension".

RESULTS:

Comprehension and colonoscopy adherence were significantly associated. Adherence to colonoscopy was significantly higher among participants with high comprehension, after adjusting for gender, age, education, ethnicity, and socio-economic status.

CONCLUSIONS:

This study demonstrates a link between health comprehension and patient follow-up after positive FIT and contributes to understanding the implications of health comprehension in terms of health promotion. We recommend patients undergoing screening tests receive clear explanations regarding need for follow-up of positive results thus reducing health disparities associated with health comprehension.

Cancer care coordination: opportunities for healthcare delivery research

In this commentary, we discuss opportunities to explore issues related to care coordination at three points on the cancer care continuum: (1) screening, particularly coordinating follow-up for abnormal findings, (2) active treatment, particularly challenges for patients with multiple chronic conditions, and (3) survivorship, particularly issues related to facilitating shared care between oncology and primary care. For each point on the continuum, we briefly summarize some of the important coordination issues and discuss potential avenues for future research in the context of existing evidence.

Characteristics of Effective Colorectal Cancer Screening Navigation Programs in Federally Qualified Health Centers: A Systematic Review

In the U.S., colorectal cancer (CRC) incidence and mortality have declined due to screening and improvements in early detection; however, racial/ethnic disparities in screening and mortality persist. Patient navigation has been shown to be effective in increasing CRC screening prevalence. This systematic review answered three questions about navigation in federally qualified community health centers (FQHCs): 1) Which navigation activities increased CRC screening prevalence? 2) What were the challenges to implementing these programs in FQHCs? 3) Which clinic protocols supported screening completion? Findings suggest that navigation services must be tailored to the specific screening test provided. Federally qualified community health centers report difficulty maintaining a current electronic medical records system and sustaining funding; they should establish excellent patient tracking systems (for follow-up and annual rescreening) and establish multiple protocols to facilitate screening completion. With the movement toward patient-centered care models, patient navigation will be integral to FQHCs and their clients.

Refining the Patient Navigation Role in a Colorectal Cancer Screening Program: Results From an Intervention Study

BACKGROUND

Oncology patient navigators help individuals overcome barriers to increase access to cancer screening, diagnosis, and timely treatment. This study, part of a randomized intervention trial investigating the efficacy of patient navigation in increasing colonoscopy completion, examined navigators' activities to ameliorate barriers to colonoscopy screening in a medically disadvantaged population.

METHODS

This study was conducted from 2012 through 2014 at Boston Medical Center. We analyzed navigator service delivery and survey data collected on 420 participants who were navigated for colonoscopy screening after randomization to this intervention. Key variables under investigation included barriers to colonoscopy, activities navigators undertook to reduce barriers, time navigators spent on each activity and per contact, and patient satisfaction with navigation services. Descriptive analysis assessed how navigators spent their time and examined what aspects of patient navigation were most valued by patients.

RESULTS

Navigators spent the most time assessing patient barriers/needs; facilitating appointment scheduling; reminding patients of appointments; educating patients about colorectal cancer, the importance of screening, and the colonoscopy preparation and procedures; and arranging transportation. Navigators spent an average of 44 minutes per patient. Patients valued the navigators, especially for providing emotional/peer support and explaining screening procedures and bowel preparation clearly.

CONCLUSIONS

Our findings help clarify the role of the navigator in colonoscopy screening within a medically disadvantaged community. These findings may help further refine the navigator role in cancer screening and treatment programs as facilities strive to effectively and efficiently integrate navigation into their services.

Do Lung Cancer Eligibility Criteria Align with Risk among Blacks and Hispanics?

BACKGROUND

Black patients have higher lung cancer risk despite lower pack years of smoking. We assessed lung cancer risk by race, ethnicity, and sex among a nationally representative population eligible for lung cancer screening based on Medicare criteria.

METHODS

We used data from the National Health and Nutrition Examination Survey, 2007-2012 to assess lung cancer risk by sex, race and ethnicity among persons satisfying Medicare age and pack-year smoking eligibility criteria for lung cancer screening. We assessed Medicare eligibility based on age (55-77 years) and pack-years (≥ 30). We assessed 6-year lung cancer risk using a risk prediction model from Prostate, Lung, Colorectal and Ovarian Cancer Screening trial that was modified in 2012 (PLCOm2012). We compared the proportions of eligible persons by sex, race and ethnicity using Medicare criteria with a risk cut-point that was adjusted to achieve comparable total number of persons eligible for screening.

RESULTS

Among the 29.7 million persons aged 55-77 years who ever smoked, we found that 7.3 million (24.5%) were eligible for lung cancer screening under Medicare criteria. Among those eligible, Blacks had statistically significant higher (4.4%) and Hispanics lower lung cancer risk (1.2%) than non-Hispanic Whites (3.2%). At a cut-point of 2.12% risk for lung screening eligibility, the percentage of Blacks and Hispanics showed statistically significant changes. Blacks eligible rose by 48% and Hispanics eligible declined by 63%. Black men and Hispanic women were affected the most. There was little change in eligibility among Whites.

CONCLUSION

Medicare eligibility criteria for lung cancer screening do not align with estimated risk for lung cancer among Blacks and Hispanics. Data are urgently needed to determine whether use of risk-based eligibility screening improves lung cancer outcomes among minority patients.

Public health national approach to reducing breast and cervical cancer disparities

Breast and cervical cancer have had disparate impact on the lives of women. The burden of breast and cervical cancer is more prominent among some racial and ethnic minority women. Providing comprehensive care to all medically underserved women is a critical element in continuing the battle to reduce cancer burden and eliminate disparities. The National Breast and Cervical Cancer Early Detection Program is the only nationally organized cancer screening program for underserved women in the United States. Its public health goal is to ensure access to high-quality screening, follow-up, and treatment services for diverse and vulnerable populations that, in turn, may reduce disparities.

Follow-up to abnormal cancer screening tests: considering the multilevel context of care

The call for multilevel interventions to improve the quality of follow-up to abnormal cancer screening has been out for a decade, but published work emphasizes individual approaches, and conceptualizations differ regarding the definition of levels. To investigate the scope and methods being undertaken in this focused area of follow-up to abnormal tests (breast, colon, cervical), we reviewed recent literature and grants (2007-2012) funded by the National Cancer Institute. A structured search yielded 16 grants with varying definitions of "follow-up" (e.g., completion of recommended tests, time to diagnosis); most included minority racial/ethnic group participants. Ten grants concentrated on measurement/intervention development and 13 piloted or tested interventions (categories not mutually exclusive). All studies considered patient-level factors and effects. Although some directed interventions at provider levels, few measured group characteristics and effects of interventions on the providers or levels other than the patient. Multilevel interventions are being proposed, but clarity about endpoints, definition of levels, and measures is needed. The differences in the conceptualization of levels and factors that affect practice need empirical exploration, and we need to measure their salient characteristics to advance our understanding of how context affects cancer care delivery in a changing practice and policy environment.

The colorectal cancer screening process in community settings: a conceptual model for the population-based research optimizing screening through personalized regimens consortium

Reducing colorectal cancer mortality by promoting screening has been a national goal for two decades. The NCI's Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium is the first federal initiative to foster coordinated, transdisciplinary research evaluating the entire cancer screening process in community settings. PROSPR is creating a central data repository to facilitate research evaluating the breast, cervical, and colorectal cancer screening process across different patient populations, provider types, and delivery systems. Data are being collected and organized at the multiple levels in which individuals are nested (e.g., healthcare systems, facilities, providers, and patients). Here, we describe a conceptual model of the colorectal cancer screening process guiding data collection and highlight critical research questions that will be addressed through pooled data. We also describe the three research centers focused on colorectal cancer screening with respect to study populations, practice settings, and screening policies. PROSPR comprehensively elucidates the complex screening process through observational study, and has potential to improve care delivery beyond the healthcare systems studied. Findings will inform intervention designs and policies to optimize colorectal cancer screening delivery and advance the Institute of Medicine's goals of effective, efficient, coordinated, timely, and safe health care with respect to evidence-based cancer screening.

Randomized, controlled trial of a multimodal intervention to improve cancer screening rates in a safety-net primary care practice

BACKGROUND

Cancer screening rates are suboptimal for low-income patients.

OBJECTIVE

To assess an intervention to increase cancer screening among patients in a safety-net primary care practice.

DESIGN

Patients at an inner-city family practice who were overdue for cancer screening were randomized to intervention or usual care. Screening rates at 1 year were compared using the chi-square test, and multivariable analysis was performed to adjust for patient factors.

SUBJECTS

All average-risk patients at an inner-city family practice overdue for mammography or colorectal cancer (CRC) screening. Patients' ages were 40 to 74 years (mean 53.9, SD 8.7) including 40.8 % African Americans, 4.2 % Latinos, 23.2 % with Medicaid and 10.9 % without any form of insurance.

INTERVENTION

The 6-month intervention to promote cancer screening included letters, automated phone calls, prompts and a mailed Fecal Immunochemical Testing (FIT) Kit.

MAIN MEASURES

Rates of cancer screening at 1 year.

KEY RESULTS

Three hundred sixty-six patients overdue for screening were randomly assigned to intervention (n = 185) or usual care (n = 181). Primary analysis revealed significantly higher rates of cancer screening in intervention subjects: 29.7 % vs. 16.7 % for mammography (p = 0.034) and 37.7 % vs. 16.7 % for CRC screening (p = 0.0002). In the intervention group, 20 % of mammography screenings and 9.3 % of CRC screenings occurred at the early assessment, while the remainder occurred after repeated interventions. Within the CRC intervention group 44 % of screened patients used the mailed FIT kit. On multivariable analysis the CRC screening rates remained significantly higher in the intervention group, while the breast cancer screening rates were not statistically different.

CONCLUSIONS

A multimodal intervention significantly increased CRC screening rates among patients in a safety-net primary care practice. These results suggest that relatively inexpensive letters and automated calls can be combined for a larger effect. Results also suggest that mailed screening kits may be a promising way to increase average-risk CRC screening.

Breast cancer mortality in Appalachia: reversing patterns of disparity over time

Breast cancer death rates in the U.S. have decreased in recent decades, however areas such as Appalachia with fewer cancer care resources may not have experienced comparable mortality declines. This study examines trends in breast cancer mortality rate disparities in Appalachian states and the continental U.S. using data from SEER mortality files 1969-2007 and the Area Resource File. Overall breast cancer mortality rates decreased significantly, with a smaller decline in Appalachian counties (17.5%) compared with non-Appalachian counties in Appalachian states (30.5%), and compared with non-Appalachia U.S. counties (28.3%). After accounting for poverty, rural/urban status, education, health care resources, and proportion White in the population, residence in Appalachian counties except for those in the Northern subregion was significantly associated with smaller reduction in breast cancer mortality rates. Lower levels of education, physician density, and percent White in the population were also associated with smaller reductions in breast cancer mortality.