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Crew KD, Anderson GL, Arnold KB, Stieb AP, Amenta JN, Collins N, Law CW, Pruthi S, Sandoval-Leon A, Bertoni D, Grosse Perdekamp MT, Colonna S, Krisher S, King T, Yee LD, Ballinger TJ, Braun-Inglis C, Mangino D, Wisinski KB, DeYoung CA, Ross M, Floyd J, Kaster A, Vander Walde L, Saphner T, Zarwan C, Lo S, Graham C, Conlin A, Yost K, Agnese D, Jernigan C, Hershman DL, Neuhouser ML, Arun B, Kukafka R. Making Informed Choices On Incorporating Chemoprevention into carE (MiCHOICE, SWOG 1904): Design and methods of a cluster randomized controlled trial. Contemp Clin Trials 2024; 142:107564. [PMID: 38704119 PMCID: PMC11180561 DOI: 10.1016/j.cct.2024.107564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 04/15/2024] [Accepted: 05/01/2024] [Indexed: 05/06/2024]
Abstract
INTRODUCTION Women with atypical hyperplasia (AH) or lobular carcinoma in situ (LCIS) have a significantly increased risk of breast cancer, which can be substantially reduced with antiestrogen therapy for chemoprevention. However, antiestrogen therapy for breast cancer risk reduction remains underutilized. Improving knowledge about breast cancer risk and chemoprevention among high-risk patients and their healthcare providers may enhance informed decision-making about this critical breast cancer risk reduction strategy. METHODS/DESIGN We are conducting a cluster randomized controlled trial to evaluate the effectiveness and implementation of patient and provider decision support tools to improve informed choice about chemoprevention among women with AH or LCIS. We have cluster randomized 26 sites across the U.S. through the SWOG Cancer Research Network. A total of 415 patients and 200 healthcare providers are being recruited. They are assigned to standard educational materials alone or combined with the web-based decision support tools. Patient-reported and clinical outcomes are assessed at baseline, after a follow-up visit at 6 months, and yearly for 5 years. The primary outcome is chemoprevention informed choice after the follow-up visit. Secondary endpoints include other patient-reported outcomes, such as chemoprevention knowledge, decision conflict and regret, and self-reported chemoprevention usage. Barriers and facilitators to implementing decision support into clinic workflow are assessed through patient and provider interviews at baseline and mid-implementation. RESULTS/DISCUSSION With this hybrid effectiveness/implementation study, we seek to evaluate if a multi-level intervention effectively promotes informed decision-making about chemoprevention and provide valuable insights on how the intervention is implemented in U.S. CLINICAL SETTINGS TRIAL REGISTRATION NCT04496739.
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Affiliation(s)
- K D Crew
- Columbia University Irving Medical Center, New York, NY, USA.
| | - G L Anderson
- SWOG Statistics and Data Management Center, Seattle, WA, USA
| | - K B Arnold
- SWOG Statistics and Data Management Center, Seattle, WA, USA
| | - A P Stieb
- Columbia University Irving Medical Center, New York, NY, USA
| | - J N Amenta
- Columbia University Irving Medical Center, New York, NY, USA
| | - N Collins
- Columbia University Irving Medical Center, New York, NY, USA
| | - C W Law
- Columbia University Irving Medical Center, New York, NY, USA
| | - S Pruthi
- Mayo Clinic, Rochester, MN, United States of America
| | - A Sandoval-Leon
- Miami Cancer Institute at Baptist Health South Florida, Miami, FL, USA
| | - D Bertoni
- Good Samaritan Hospital Corvallis, Corvallis, OR , USA
| | | | - S Colonna
- Huntsman Cancer Institute / University of Utah Medical Center, Salt Lake City, UT, USA
| | - S Krisher
- Holy Redeemer Hospital and Medical Center, Meadowbrook, PA, USA
| | - T King
- Dana-Farber Brigham Cancer Center, Brigham and Women's Hospital, Boston, MA, USA
| | - L D Yee
- City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - T J Ballinger
- Indiana University Simon Comprehensive Cancer Center, Indianapolis, IN, USA
| | | | - D Mangino
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - K B Wisinski
- University of Wisconsin Carbone Cancer Center, Madison, WI, USA
| | | | - M Ross
- Virginia Commonwealth University, Richmond, VA, USA
| | - J Floyd
- Cancer Care Specialists of Illinois, Heartland NCORP, Decatur, IL, USA
| | - A Kaster
- Sanford Roger Maris Cancer Center, Fargo, ND, United States of America
| | - L Vander Walde
- Baptist Memorial Health Care, Memphis, TN, United States of America
| | | | - C Zarwan
- Lahey Hospital & Medical Center, Burlington, MA, USA
| | - S Lo
- Loyola University Stritch School of Medicine, Maywood, IL, USA
| | - C Graham
- Emory University Hospital/Winship Cancer Institute, Atlanta, GA, USA
| | - A Conlin
- Providence Cancer Institute, Portland, OR, USA
| | - K Yost
- Cancer Research Consortium of West Michigan NCORP, Kalamazoo, MI, USA
| | - D Agnese
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - C Jernigan
- SWOG Statistics and Data Management Center, Seattle, WA, USA
| | - D L Hershman
- Columbia University Irving Medical Center, New York, NY, USA
| | | | - B Arun
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - R Kukafka
- Columbia University Irving Medical Center, New York, NY, USA
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Austin JD, James E, Perez RL, Mazza GL, Kling JM, Fraker J, Mina L, Banerjee I, Sharpe R, Patel BK. Factors influencing U.S. women's interest and preferences for breast cancer risk communication: a cross-sectional study from a large tertiary care breast imaging center. BMC Womens Health 2024; 24:359. [PMID: 38907193 PMCID: PMC11191185 DOI: 10.1186/s12905-024-03197-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 06/10/2024] [Indexed: 06/23/2024] Open
Abstract
BACKGROUND Breast imaging clinics in the United States (U.S.) are increasingly implementing breast cancer risk assessment (BCRA) to align with evolving guideline recommendations but with limited uptake of risk-reduction care. Effectively communicating risk information to women is central to implementation efforts, but remains understudied in the U.S. This study aims to characterize, and identify factors associated with women's interest in and preferences for breast cancer risk communication. METHODS This is a cross-sectional survey study of U.S. women presenting for a mammogram between January and March of 2021 at a large, tertiary breast imaging clinic. Survey items assessed women's interest in knowing their risk and preferences for risk communication if considered to be at high risk in hypothetical situations. Multivariable logistic regression modeling assessed factors associated with women's interest in knowing their personal risk and preferences for details around exact risk estimates. RESULTS Among 1119 women, 72.7% were interested in knowing their breast cancer risk. If at high risk, 77% preferred to receive their exact risk estimate and preferred verbal (52.9% phone/47% in-person) vs. written (26.5% online/19.5% letter) communications. Adjusted regression analyses found that those with a primary family history of breast cancer were significantly more interested in knowing their risk (OR 1.5, 95% CI 1.0, 2.1, p = 0.04), while those categorized as "more than one race or other" were significantly less interested in knowing their risk (OR 0.4, 95% CI 0.2, 0.9, p = 0.02). Women 60 + years of age were significantly less likely to prefer exact estimates of their risk (OR 0.6, 95% CI 0.5, 0.98, p < 0.01), while women with greater than a high school education were significantly more likely to prefer exact risk estimates (OR 2.5, 95% CI 1.5, 4.2, p < 0.001). CONCLUSION U.S. women in this study expressed strong interest in knowing their risk and preferred to receive exact risk estimates verbally if found to be at high risk. Sociodemographic and family history influenced women's interest and preferences for risk communication. Breast imaging centers implementing risk assessment should consider strategies tailored to women's preferences to increase interest in risk estimates and improve risk communication.
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Affiliation(s)
- Jessica D Austin
- Department of Quantitative Health Sciences, Division of Epidemiology, Mayo Clinic, 13400 E. Shea Blvd, Scottsdale, AZ, 85259, USA.
| | - Emily James
- Mayo Clinic College of Medicine of Medicine and Science, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Rachel L Perez
- Mayo Clinic College of Medicine of Medicine and Science, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Gina L Mazza
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, 13400 E. Shea Blvd, Scottsdale, AZ, 85259, USA
| | - Juliana M Kling
- Women's Health Internal Medicine, Department of Internal Medicine, Mayo Clinic, 13400 E. Shea Blvd, Scottsdale, AZ, 85259, USA
| | - Jessica Fraker
- Women's Health Internal Medicine, Department of Internal Medicine, Mayo Clinic, 13400 E. Shea Blvd, Scottsdale, AZ, 85259, USA
| | - Lida Mina
- Department of Internal Medicine, Division of Medical Oncology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Imon Banerjee
- Department of Diagnostic Radiology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Richard Sharpe
- Department of Diagnostic Radiology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Bhavika K Patel
- Department of Diagnostic Radiology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
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Sacca L, Lobaina D, Burgoa S, Lotharius K, Moothedan E, Gilmore N, Xie J, Mohler R, Scharf G, Knecht M, Kitsantas P. Promoting Artificial Intelligence for Global Breast Cancer Risk Prediction and Screening in Adult Women: A Scoping Review. J Clin Med 2024; 13:2525. [PMID: 38731054 PMCID: PMC11084581 DOI: 10.3390/jcm13092525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 04/01/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
Background: Artificial intelligence (AI) algorithms can be applied in breast cancer risk prediction and prevention by using patient history, scans, imaging information, and analysis of specific genes for cancer classification to reduce overdiagnosis and overtreatment. This scoping review aimed to identify the barriers encountered in applying innovative AI techniques and models in developing breast cancer risk prediction scores and promoting screening behaviors among adult females. Findings may inform and guide future global recommendations for AI application in breast cancer prevention and care for female populations. Methods: The PRISMA-SCR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) was used as a reference checklist throughout this study. The Arksey and O'Malley methodology was used as a framework to guide this review. The framework methodology consisted of five steps: (1) Identify research questions; (2) Search for relevant studies; (3) Selection of studies relevant to the research questions; (4) Chart the data; (5) Collate, summarize, and report the results. Results: In the field of breast cancer risk detection and prevention, the following AI techniques and models have been applied: Machine and Deep Learning Model (ML-DL model) (n = 1), Academic Algorithms (n = 2), Breast Cancer Surveillance Consortium (BCSC), Clinical 5-Year Risk Prediction Model (n = 2), deep-learning computer vision AI algorithms (n = 2), AI-based thermal imaging solution (Thermalytix) (n = 1), RealRisks (n = 2), Breast Cancer Risk NAVIgation (n = 1), MammoRisk (ML-Based Tool) (n = 1), Various MLModels (n = 1), and various machine/deep learning, decision aids, and commercial algorithms (n = 7). In the 11 included studies, a total of 39 barriers to AI applications in breast cancer risk prediction and screening efforts were identified. The most common barriers in the application of innovative AI tools for breast cancer prediction and improved screening rates included lack of external validity and limited generalizability (n = 6), as AI was used in studies with either a small sample size or datasets with missing data. Many studies (n = 5) also encountered selection bias due to exclusion of certain populations based on characteristics such as race/ethnicity, family history, or past medical history. Several recommendations for future research should be considered. AI models need to include a broader spectrum and more complete predictive variables for risk assessment. Investigating long-term outcomes with improved follow-up periods is critical to assess the impacts of AI on clinical decisions beyond just the immediate outcomes. Utilizing AI to improve communication strategies at both a local and organizational level can assist in informed decision-making and compliance, especially in populations with limited literacy levels. Conclusions: The use of AI in patient education and as an adjunctive tool for providers is still early in its incorporation, and future research should explore the implementation of AI-driven resources to enhance understanding and decision-making regarding breast cancer screening, especially in vulnerable populations with limited literacy.
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Affiliation(s)
- Lea Sacca
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, USA; (D.L.); (S.B.); (K.L.); (E.M.); (N.G.); (J.X.); (R.M.); (G.S.); (M.K.); (P.K.)
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Kamil D, Wojcik KM, Smith L, Zhang J, Wilson OWA, Butera G, Jayasekera J. A Scoping Review of Personalized, Interactive, Web-Based Clinical Decision Tools Available for Breast Cancer Prevention and Screening in the United States. MDM Policy Pract 2024; 9:23814683241236511. [PMID: 38500600 PMCID: PMC10946080 DOI: 10.1177/23814683241236511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 02/04/2024] [Indexed: 03/20/2024] Open
Abstract
Introduction. Personalized web-based clinical decision tools for breast cancer prevention and screening could address knowledge gaps, enhance patient autonomy in shared decision-making, and promote equitable care. The purpose of this review was to present evidence on the availability, usability, feasibility, acceptability, quality, and uptake of breast cancer prevention and screening tools to support their integration into clinical care. Methods. We used the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews Checklist to conduct this review. We searched 6 databases to identify literature on the development, validation, usability, feasibility, acceptability testing, and uptake of the tools into practice settings. Quality assessment for each tool was conducted using the International Patient Decision Aid Standard instrument, with quality scores ranging from 0 to 63 (lowest-highest). Results. We identified 10 tools for breast cancer prevention and 9 tools for screening. The tools included individual (e.g., age), clinical (e.g., genomic risk factors), and health behavior (e.g., alcohol use) characteristics. Fourteen tools included race/ethnicity, but no tool incorporated contextual factors (e.g., insurance, access) associated with breast cancer. All tools were internally or externally validated. Six tools had undergone usability testing in samples including White (median, 71%; range, 9%-96%), insured (99%; 97%-100%) women, with college education or higher (60%; 27%-100%). All of the tools were developed and tested in academic settings. Seven (37%) tools showed potential evidence of uptake in clinical practice. The tools had an average quality assessment score of 21 (range, 9-39). Conclusions. There is limited evidence on testing and uptake of breast cancer prevention and screening tools in diverse clinical settings. The development, testing, and integration of tools in academic and nonacademic settings could potentially improve uptake and equitable access to these tools. Highlights There were 19 personalized, interactive, Web-based decision tools for breast cancer prevention and screening.Breast cancer outcomes were personalized based on individual clinical characteristics (e.g., age, medical history), genomic risk factors (e.g., BRCA1/2), race and ethnicity, and health behaviors (e.g., smoking). The tools did not include contextual factors (e.g., insurance status, access to screening facilities) that could potentially contribute to breast cancer outcomes.Validation, usability, acceptability, and feasibility testing were conducted mostly among White and/or insured patients with some college education (or higher) in academic settings. There was limited evidence on testing and uptake of the tools in nonacademic clinical settings.
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Affiliation(s)
- Dalya Kamil
- Health Equity and Decision Sciences Research Laboratory, Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Kaitlyn M. Wojcik
- Health Equity and Decision Sciences Research Laboratory, Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Laney Smith
- Frederick P. Whiddon College of Medicine, Mobile, AL, USA
| | | | - Oliver W. A. Wilson
- Health Equity and Decision Sciences Research Laboratory, Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Gisela Butera
- Office of Research Services, National Institutes of Health Library, Bethesda, MD, USA
| | - Jinani Jayasekera
- Health Equity and Decision Sciences Research Laboratory, Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
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Burgermaster M, Desai PM, Heitkemper EM, Juul F, Mitchell EG, Turchioe M, Albers DJ, Levine ME, Larson D, Mamykina L. Who needs what (features) when? Personalizing engagement with data-driven self-management to improve health equity. J Biomed Inform 2023; 144:104419. [PMID: 37301528 DOI: 10.1016/j.jbi.2023.104419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 06/05/2023] [Accepted: 06/06/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVES To examine the feasibility of promoting engagement with data-driven self-management of health among individuals from minoritized medically underserved communities by tailoring the design of self-management interventions to individuals' type of motivation and regulation in accordance with the Self-Determination Theory. METHODS Fifty-three individuals with type 2 diabetes from an impoverished minority community were randomly assigned to four different versions of an mHealth app for data-driven self-management with the focus on nutrition, Platano; each version was tailored to a specific type of motivation and regulation within the SDT self-determination continuum. These versions included financial rewards (external regulation), feedback from expert registered dietitians (RDF, introjected regulation), self-assessment of attainment of one's nutritional goals (SA, identified regulation), and personalized meal-time nutrition decision support with post-meal blood glucose forecasts (FORC, integrated regulation). We used qualitative interviews to examine interaction between participants' experiences with the app and their motivation type (internal-external). RESULTS As hypothesized, we found a clear interaction between the type of motivation and Platano features that users responded to and benefited from. For example, those with more internal motivation reported more positive experience with SA and FORC than those with more external motivation. However, we also found that Platano features that aimed to specifically address the needs of individuals with external regulation did not create the desired experience. We attribute this to a mismatch in emphasis on informational versus emotional support, particularly evident in RDF. In addition, we found that for participants recruited from an economically disadvantaged community, internal factors, such as motivation and regulation, interacted with external factors, most notably with limited health literacy and limited access to resources. CONCLUSIONS The study suggests feasibility of using SDT to tailor design of mHealth interventions for promoting data-driven self-management to individuals' motivation and regulation. However, further research is needed to better align design solutions with different levels of self-determination continuum, to incorporate stronger emphasis on emotional support for individuals with external regulation, and to address unique needs and challenges of underserved communities, with particular attention to limited health literacy and access to resources.
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Affiliation(s)
- Marissa Burgermaster
- Department of Nutritional Sciences, The University Of Texas At Austin, Department Of Population Health, Dell Medical School, Austin, TX, United States
| | - Pooja M Desai
- Department Of Biomedical Informatics, Columbia University, United States
| | | | - Filippa Juul
- School Of Global Public Health, New York University, United States
| | | | | | | | | | - Dagny Larson
- Department Of Nutritional Sciences, University of Texas In Austin, United States
| | - Lena Mamykina
- Department Of Biomedical Informatics, Columbia University, United States.
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Lacey HP, Lacey SC, Dayal P, Forest C, Blasi D. Context Matters: Emotional Sensitivity to Probabilities and the Bias for Action in Cancer Treatment Decisions. Med Decis Making 2023; 43:417-429. [PMID: 36951184 PMCID: PMC10595072 DOI: 10.1177/0272989x231161341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
BACKGROUND Past studies have shown a commission bias for cancer treatment, a tendency to choose active treatment even when watchful waiting is less risky. This bias suggests motivations for action beyond mortality statistics, but recent evidence suggests that individuals differ in their emotional sensitivity to probabilities (ESP), the tendency to calibrate emotional reactions to probability. The current study aims to examine the role of ESP in the commission bias, specifically whether those higher in ESP are more likely to choose watchful waiting when risk probabilities align with that choice. METHODS Participants (N = 1,055) read a scenario describing a hypothetical cancer diagnosis and chose between surgery and watchful waiting, with random assignment between versions where the mortality rate was either lower for surgery or for watchful waiting. We modeled choice using the Possibility Probability Questionnaire (PPQ), a measure of ESP, and several other individual differences in a logistic regression. RESULTS We observed a commission bias as in past studies with most participants choosing surgery both when surgery was optimal (71%) and when watchful waiting was optimal (58%). An ESP × Condition interaction indicated that the predictive role of ESP depended on condition. Those higher in ESP were more likely to choose surgery when probabilities favored surgery, β = 0.57, P < 0.001, but when probabilities favored watchful waiting, ESP had a near-zero relationship with choice, β = 0.05, P < 0.99. CONCLUSIONS The role of ESP in decision making is context specific. Higher levels of ESP predict choosing action when that action is warranted but do not predict a shift away from surgery when watchful waiting offers better chances of survival. ESP does not overcome the commission bias. HIGHLIGHTS Past studies have identified a "commission bias," a tendency to choose active treatment over watchful waiting, even when mortality rate is lower for waiting.Evaluation of risk probabilities is related to individual differences in emotional sensitivity to probabilities (ESP) and has been shown to predict reactions to and decisions about health risk situations.ESP appears to be selectively factored into decision making. ESP was a robust predictor of choosing surgery when probability information supported surgery but did not predict decisions when probability information supported watchful waiting.Those who are most emotionally attuned to probabilities are just as susceptible to the commission bias as those who are less attuned.
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Affiliation(s)
- Heather P Lacey
- Department of Psychology, Center for Health and Behavioral Sciences, Bryant University, Smithfield, RI, USA
| | - Steven C Lacey
- Carroll School of Management, Boston University, Chestnut Hill, MA, USA
| | - Prerna Dayal
- Department of Psychology, Center for Health and Behavioral Sciences, Bryant University, Smithfield, RI, USA
| | - Caroline Forest
- Department of Psychology, Center for Health and Behavioral Sciences, Bryant University, Smithfield, RI, USA
| | - Dana Blasi
- Department of Psychology, Center for Health and Behavioral Sciences, Bryant University, Smithfield, RI, USA
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Dron HA, Bucio D, Young JL, Tabor HK, Cho MK. Latinx attitudes, barriers, and experiences with genetic counseling and testing: A systematic review. J Genet Couns 2023; 32:166-181. [PMID: 36301246 PMCID: PMC10091969 DOI: 10.1002/jgc4.1632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 08/09/2022] [Accepted: 08/13/2022] [Indexed: 11/05/2022]
Abstract
As genetics is increasingly used across clinical settings, there is a need to understand the impact and experiences of diverse patients. This review systematically examined research literature on Latinx experiences with genetic counseling and genetic testing (GC/GT) in the United States, synthesizing key themes and knowledge gaps pertaining to both patient experience and hypothetical scenarios. Findings were based on a systematic search, inclusion, and thematic analysis of 81 empirical peer-reviewed articles published from January 1990 to July 2019 pertaining to Latinx populations and GC/GT. Studies most commonly addressed Latinas' perspectives on GC/GT in prenatal settings or for hereditary breast and ovarian cancer (HBOC). Costs, referrals, and communication were significant barriers to accessing genetic services for many Latinx patients, particularly those with low English proficiency (LEP). Studies highlighted difficulties accessing and communicating in healthcare settings, and how medical context and prior experience with healthcare workers and institutions influenced GC/GT decision-making. Providers' implicit biases about Latinx patients negatively impacted their care and impeded communication. Despite low awareness of cancer GT, Latinx patients often reported interest in learning more about GC/GT or unmet needs for GT discussion and provider involvement. This systematic review identified areas where providers can take action to improve Latinx experiences with GC/GT. Clinicians should elicit and respond to patient preferences about shared decision-making. For patients with low numeracy or LEP, providers should consider tailored educational and communication techniques. Most studies focused on HBOC and prenatal testing, and Latinx patients are heterogeneous, leaving many research questions about Latinx experience with GT/GC in other clinical areas.
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Affiliation(s)
- Heather A Dron
- Stanford Center for Biomedical Ethics (SCBE), Stanford University, Stanford, California, USA.,University of Michigan, Ann Arbor, Michigan, USA
| | - Daiana Bucio
- Providence St. Joseph Health, Burbank, California, USA
| | - Jennifer L Young
- Stanford Center for Biomedical Ethics (SCBE), Stanford University, Stanford, California, USA.,Center for Genetic Medicine, Northwestern University, Chicago, Illinois, USA
| | - Holly K Tabor
- Stanford Center for Biomedical Ethics (SCBE), Stanford University, Stanford, California, USA.,Departments of Medicine, and by courtesy, Epidemiology, Stanford University, Stanford, California, USA
| | - Mildred K Cho
- Stanford Center for Biomedical Ethics (SCBE), Stanford University, Stanford, California, USA.,Department of Pediatrics, Stanford University, Stanford, California, USA
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Crew KD, Bhatkhande G, Silverman T, Amenta J, Jones T, McGuinness JE, Mata J, Guzman A, He T, Dimond J, Tsai WY, Kukafka R. Patient and Provider Web-Based Decision Support for Breast Cancer Chemoprevention: A Randomized Controlled Trial. Cancer Prev Res (Phila) 2022; 15:689-700. [PMID: 35679576 PMCID: PMC9532364 DOI: 10.1158/1940-6207.capr-22-0013] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 05/09/2022] [Accepted: 06/06/2022] [Indexed: 11/16/2022]
Abstract
Significant underutilization of breast cancer chemoprevention remains, despite guidelines stating that physicians should recommend chemoprevention with antiestrogen therapy to high-risk women. We randomized women, ages 35 to 75 years, who met high-risk criteria for breast cancer, without a personal history of breast cancer or prior chemoprevention use, to standard educational materials alone or combined with a web-based decision aid. All healthcare providers, including primary care providers and breast specialists, were given access to a web-based decision support tool. The primary endpoint was chemoprevention uptake at 6 months. Secondary outcomes included decision antecedents (perceived breast cancer risk/worry, chemoprevention knowledge, self-efficacy) and decision quality (decision conflict, chemoprevention informed choice) based upon patient surveys administered at baseline, 1 and 6 months after randomization. Among 282 evaluable high-risk women enrolled from November 2016 to March 2020, mean age was 57 years (SD, 9.9) and mean 5-year invasive breast cancer risk was 2.98% (SD, 1.42). There was no significant difference in chemoprevention uptake at 6 months between the intervention and control groups (2.1% vs. 3.5%). Comparing the intervention and control arms at 1 month, there were significant differences among high-risk women in accurate breast cancer risk perceptions (56% vs. 39%, P = 0.017), adequate chemoprevention knowledge (49% vs. 27%, P < 0.001), mean decision conflict (34.0 vs. 47.0, P < 0.001), and informed choice (41% vs. 23%, P = 0.003). These differences were no longer significant at 6 months. Although our decision support tools did not result in a significant increase in chemoprevention uptake, we did observe improvements in decision antecedents and decision quality measures. PREVENTION RELEVANCE In this randomized controlled trial of decision support for 300 high-risk women and 50 healthcare providers, we did not observe a significant increase in chemoprevention uptake, which remained low at under 5%. However, these decision support tools may increase knowledge and informed choice about breast cancer chemoprevention.
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Affiliation(s)
- Katherine D. Crew
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
| | - Gauri Bhatkhande
- Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY
| | - Thomas Silverman
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY
| | - Jacquelyn Amenta
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY
| | - Tarsha Jones
- Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, FL
| | - Julia E. McGuinness
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
| | - Jennie Mata
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
| | - Ashlee Guzman
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
| | - Ting He
- Department of Biomedical Informatics and Data Sciences, Johns Hopkins University, Baltimore, MD
| | | | - Wei-Yann Tsai
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
- Department of Biostatistics, Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY
| | - Rita Kukafka
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY
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9
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Qualitative analysis of shared decision-making for chemoprevention in the primary care setting: provider-related barriers. BMC Med Inform Decis Mak 2022; 22:208. [PMID: 35927732 PMCID: PMC9354269 DOI: 10.1186/s12911-022-01954-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 07/26/2022] [Indexed: 11/10/2022] Open
Abstract
Background Chemoprevention with anti-estrogens, such as tamoxifen, raloxifene or aromatase inhibitors, have been shown to reduce breast cancer risk in randomized controlled trials; however, uptake among women at high-risk for developing breast cancer remains low. The aim of this study is to identify provider-related barriers to shared decision-making (SDM) for chemoprevention in the primary care setting. Methods Primary care providers (PCPs) and high-risk women eligible for chemoprevention were enrolled in a pilot study and a randomized clinical trial of web-based decision support tools to increase chemoprevention uptake. PCPs included internists, family practitioners, and gynecologists, whereas patients were high-risk women, age 35–75 years, who had a 5-year invasive breast cancer risk ≥ 1.67%, according to the Gail model. Seven clinical encounters of high-risk women and their PCPs who were given access to these decision support tools were included in this study. Audio-recordings of the clinical encounters were transcribed verbatim and analyzed using grounded theory methodology. Results Six primary care providers, of which four were males (mean age 36 [SD 6.5]) and two were females (mean age 39, [SD 11.5]) and seven racially/ethnically diverse high-risk female patients participated in this study. Qualitative analysis revealed three themes: (1) Competing demands during clinical encounters; (2) lack of knowledge among providers about chemoprevention; and (3) limited risk communication during clinical encounters. Conclusions Critical barriers to SDM about chemoprevention were identified among PCPs. Providers need education and resources through decision support tools to engage in risk communication and SDM with their high-risk patients, and to gain confidence in prescribing chemoprevention in the primary care setting.
Supplementary Information The online version contains supplementary material available at 10.1186/s12911-022-01954-y.
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10
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Kukafka R, Pan S, Silverman T, Zhang T, Chung WK, Terry MB, Fleck E, Younge RG, Trivedi MS, McGuinness JE, He T, Dimond J, Crew KD. Patient and Clinician Decision Support to Increase Genetic Counseling for Hereditary Breast and Ovarian Cancer Syndrome in Primary Care: A Cluster Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2222092. [PMID: 35849397 PMCID: PMC9294997 DOI: 10.1001/jamanetworkopen.2022.22092] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE To promote the identification of women carrying BRCA1/2 variants, the US Preventive Services Task Force recommends that primary care clinicians screen asymptomatic women for an increased risk of carrying a BRCA1/2 variant risk. OBJECTIVE To examine the effects of patient and clinician decision support about BRCA1/2 genetic testing compared with standard education alone. DESIGN, SETTING, AND PARTICIPANTS This clustered randomized clinical trial was conducted at an academic medical center including 67 clinicians (unit of randomization) and 187 patients. Patient eligibility criteria included women aged 21 to 75 years with no history of breast or ovarian cancer, no prior genetic counseling or testing for hereditary breast and ovarian cancer syndrome (HBOC), and meeting family history criteria for BRCA1/2 genetic testing. INTERVENTIONS RealRisks decision aid for patients and the Breast Cancer Risk Navigation Tool decision support for clinicians. Patients scheduled a visit with their clinician within 6 months of enrollment. MAIN OUTCOMES AND MEASURES The primary end point was genetic counseling uptake at 6 months. Secondary outcomes were genetic testing uptake at 6 and 24 months, decision-making measures (perceived breast cancer risk, breast cancer worry, genetic testing knowledge, decision conflict) based upon patient surveys administered at baseline, 1 month, postclinic visit, and 6 months. RESULTS From December 2018 to February 2020, 187 evaluable patients (101 in the intervention group, 86 in the control group) were enrolled (mean [SD] age: 40.7 [13.2] years; 88 Hispanic patients [46.6%]; 15 non-Hispanic Black patients [8.1%]; 72 non-Hispanic White patients [38.9%]; 35 patients [18.9%] with high school education or less) and 164 (87.8%) completed the trial. There was no significant difference in genetic counseling uptake at 6 months between the intervention group (20 patients [19.8%]) and control group (10 patients [11.6%]; difference, 8.2 percentage points; OR, 1.88 [95% CI, 0.82-4.30]; P = .14). Genetic testing uptake within 6 months was also statistically nonsignificant (13 patients [12.9%] in the intervention group vs 7 patients [8.1%] in the control group; P = .31). At 24 months, genetic testing uptake was 31 patients (30.7%) in intervention vs 18 patients (20.9%) in control (P = .14). Comparing decision-making measures between groups at baseline to 6 months, there were significant decreases in perceived breast cancer risk and in breast cancer worry (standard mean differences = -0.48 and -0.40, respectively). CONCLUSIONS AND RELEVANCE This randomized clinical trial did not find a significant increase in genetic counseling uptake among patients who received patient and clinician decision support vs those who received standard education, although more than one-third of the ethnically diverse women enrolled in the intervention underwent genetic counseling. These findings suggest that the main advantage for these high-risk women is the ability to opt for screening and preventive services to decrease their cancer risk. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03470402.
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Affiliation(s)
- Rita Kukafka
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
- Herbert Irving Comprehensive Cancer, Columbia University Irving Medical Center, New York, New York
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University Irving Medical Center, New York, New York
| | - Samuel Pan
- Herbert Irving Comprehensive Cancer, Columbia University Irving Medical Center, New York, New York
| | - Thomas Silverman
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - Tianmai Zhang
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - Wendy K. Chung
- Herbert Irving Comprehensive Cancer, Columbia University Irving Medical Center, New York, New York
- Department of Pediatrics and Medicine, Columbia University Irving Medical Center, New York, New York
| | - Mary Beth Terry
- Herbert Irving Comprehensive Cancer, Columbia University Irving Medical Center, New York, New York
- Department of Epidemiology, Columbia University Irving Medical Center, New York, New York
| | - Elaine Fleck
- Division of Community and Population Health, New York Presbyterian Hospital, New York
| | - Richard G. Younge
- Division of Community and Population Health, New York Presbyterian Hospital, New York
| | - Meghna S. Trivedi
- Herbert Irving Comprehensive Cancer, Columbia University Irving Medical Center, New York, New York
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - Julia E. McGuinness
- Herbert Irving Comprehensive Cancer, Columbia University Irving Medical Center, New York, New York
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - Ting He
- Department of Biomedical Informatics, Johns Hopkins University, Baltimore, Maryland
| | | | - Katherine D. Crew
- Herbert Irving Comprehensive Cancer, Columbia University Irving Medical Center, New York, New York
- Department of Epidemiology, Columbia University Irving Medical Center, New York, New York
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
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11
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Burns A, Donnelly B, Feyi-Waboso J, Shephard E, Calitri R, Tarrant M, Dean SG. How do electronic risk assessment tools affect the communication and understanding of diagnostic uncertainty in the primary care consultation? A systematic review and thematic synthesis. BMJ Open 2022; 12:e060101. [PMID: 35768084 PMCID: PMC9244669 DOI: 10.1136/bmjopen-2021-060101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES To conduct a systematic review and synthesise qualitative research of electronic risk assessment tools (eRATs) in primary care, examining how they affect the communication and understanding of diagnostic risk and uncertainty. eRATs are computer-based algorithms designed to help clinicians avoid missing important diagnoses, pick up possible symptoms early and facilitate shared decision-making. DESIGN Systematic search, using predefined criteria of the published literature and synthesis of the qualitative data, using Thematic Synthesis. Database searches on 27 November 2019 were of MEDLINE, Embase, CINAHL and Web of Science, and a secondary search of the references of included articles. Included studies were those involving electronic risk assessment or decision support, pertaining to diagnosis in primary care, where qualitative data were presented. Non-empirical studies and non-English language studies were excluded. 5971 unique studies were identified of which 441 underwent full-text review. 26 studies were included for data extraction. A further two were found from citation searches. Quality appraisal was via the CASP (Critical Appraisal Skills Program) tool. Data extraction was via line by line coding. A thematic synthesis was performed. SETTING Primary care. RESULTS eRATs included differential diagnosis suggestion tools, tools which produce a future risk of disease development or recurrence or calculate a risk of current undiagnosed disease. Analytical themes were developed to describe separate aspects of the clinical consultation where risk and uncertainty are both central and altered via the use of an eRAT: 'Novel risk', 'Risk refinement', 'Autonomy', 'Communication', 'Fear' and 'Mistrust'. CONCLUSION eRATs may improve the understanding and communication of risk in the primary care consultation. The themes of 'Fear' and 'Mistrust' could represent potential challenges with eRATs. TRIAL REGISTRATION NUMBER CRD219446.
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Affiliation(s)
- Alex Burns
- College of Medicine and Health, University of Exeter, Exeter, Devon, UK
- PenARC, Exeter, Devon, UK
| | | | | | | | - Raff Calitri
- College of Medicine and Health, University of Exeter, Exeter, Devon, UK
| | - Mark Tarrant
- College of Medicine and Health, University of Exeter, Exeter, Devon, UK
- PenARC, Exeter, Devon, UK
| | - Sarah Gerard Dean
- College of Medicine and Health, University of Exeter, Exeter, Devon, UK
- PenARC, Exeter, Devon, UK
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12
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McGuinness JE, Zhang TM, Cooper K, Kelkar A, Dimond J, Lorenzi V, Crew KD, Kukafka R. Extraction of Electronic Health Record Data using Fast Healthcare Interoperability Resources for Automated Breast Cancer Risk Assessment. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2022; 2021:843-852. [PMID: 35308910 PMCID: PMC8861753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Women at high risk for breast cancer may benefit from enhanced screening and risk-reduction strategies. However, limited time during clinical encounters is one barrier to routine breast cancer risk assessment. We evaluated if electronic health record (EHR) data downloaded using Fast Healthcare Interoperability Resources (FHIR) is sufficient for breast cancer risk calculation in our decision support tools, RealRisks and BNAV. We accessed EHR data using FHIR for six patient advocates, and downloaded and parsed XML documents. We searched for relevant clinical variables, and evaluated if data was sufficient to calculate risk using validated models (Gail, Breast Cancer Screening Consortium [BCSC], BRCAPRO). While only one advocate had sufficient EHR data to calculate risk using the BCSC model only, we identified variables including age, race/ethnicity, mammographic density, and prior breast biopsy in most advocates. EHR data from FHIR could be incorporated into automated breast cancer risk calculation in clinical decision support tools.
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Affiliation(s)
- Julia E McGuinness
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
| | - Tianmai M Zhang
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | | | - Arusha Kelkar
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Jill Dimond
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
| | - Virginia Lorenzi
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Katherine D Crew
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Rita Kukafka
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
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13
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Mehta J, MacLaughlin KL, Millstine DM, Faubion SS, Wallace MR, Shah AA, Fields HE, Ruddy BE, Bryan MJ, Patel BK, Buras MR, Golafshar MA, Kling JM. A Comparison of Perceived Lifetime Breast Cancer Risk to Calculated Lifetime Risk Using the Gail Risk Assessment Tool. J Womens Health (Larchmt) 2022; 31:356-361. [PMID: 35041492 DOI: 10.1089/jwh.2019.8231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Understanding the accuracy of a woman's perceived breast cancer risk can enhance shared decision-making about breast cancer screening through provider and patient discussion. We aim to report and compare women's perceived lifetime breast cancer risk to calculated lifetime breast cancer risk. Methods: Women presenting to Mayo Clinic in Arizona and Minnesota in July 2016 completed a survey assessing their perceived breast cancer risk. Lifetime Gail risk scores were calculated from questions pertaining to health history and were then compared with perceived breast cancer risk. Results: A total of 550 predominantly white, married, and well-educated (≥college) women completed surveys. Using lifetime Gail risk scores, 5.6% were classified as high risk (>20% lifetime risk), 7.7% were classified as intermediate risk (15%-20%), and 86.6% were classified as average risk (<15%). Of the 27 women who were classified as high risk, 18 (66.7%) underestimated their risk and of the 37 women who were intermediate risk, 12 (32.4%) underestimated risk. Women more likely to underestimate their risk had a reported history of an abnormal mammogram and at least one or more relative with a history of breast cancer. Surveyed women tended to overestimate risk 4.3 (130/30) times as often as they underestimated risk. Conclusion: In a group of predominantly white, educated, and married cohort of women, there was a large portion of women in the elevated risk groups who underestimated risk. Specific aspects of medical history were associated with underestimation including a history of abnormal mammogram and family history of breast cancer. Overall, in our sample, more women overestimated than underestimated risk.
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Affiliation(s)
- Jaya Mehta
- Department of General Internal Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | | | - Denise M Millstine
- Division of Women's Health Internal Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - Stephanie S Faubion
- Mayo Clinic, Jacksonville, Florida, USA.,Division of General Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Mark R Wallace
- Department of Community Internal Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - Amit A Shah
- Department of Community Internal Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - Heather E Fields
- Department of Community Internal Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - Barbara E Ruddy
- Department of Community Internal Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - Michael J Bryan
- Department of Family Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - Bhavika K Patel
- Department of Radiology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Matthew R Buras
- Division of Biostatistics and Bioinformatics, Department of Health Sciences Research, Scottsdale, Arizona, USA
| | - Michael A Golafshar
- Division of Biostatistics and Bioinformatics, Department of Health Sciences Research, Scottsdale, Arizona, USA
| | - Juliana M Kling
- Division of Women's Health Internal Medicine, Mayo Clinic, Scottsdale, Arizona, USA.,Mayo Clinic, Jacksonville, Florida, USA
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14
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Kalke K, Studd H, Scherr CL. The communication of uncertainty in health: A scoping review. PATIENT EDUCATION AND COUNSELING 2021; 104:1945-1961. [PMID: 33593644 DOI: 10.1016/j.pec.2021.01.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/22/2020] [Accepted: 01/28/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To conduct a scoping review of existing studies that examine communication strategies that address uncertainty in health and categorize them using the taxonomy of uncertainty. METHODS Relevant articles retrieved from ten databases were categorized according to the dimensions of the taxonomy of uncertainty, and study characteristics were extracted from each article. RESULTS All articles (n = 63) explored uncertainty in the context of probabilistic risk and related to scientific issues (n = 63; 100%). The majority focused on complexity (n = 24; 38.1%) and uncertainty experienced by patients (n = 52; 82.5%). Most utilized quantitative methods (n = 46; 73.0%), hypothetical scenarios (n = 49; 77.8%), and focused on cancer (n = 20; 31.7%). Theory guided messages and study design in fewer than half (n = 27; 42.9%). CONCLUSIONS Heterogeneity in terminology used to refer to different types of uncertainties preclude a unified research agenda on uncertainty communication. Research predominately focuses on probability as the source of uncertainty, uncertainties related to scientific issues, and uncertainty experienced by patients. PRACTICE IMPLICATIONS Additional efforts are needed to understand providers' experience of uncertainty, and to identify strategies to address ambiguity. Future studies should use consistent terminology to allow for coherence and advancement of uncertainty communication scholarship. Continued efforts to refine the existing taxonomy should be undertaken.
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Affiliation(s)
- Kerstin Kalke
- Department of Communication Studies, Northwestern University, Chicago, IL, USA.
| | - Hannah Studd
- Department of Communication Studies, Northwestern University, Chicago, IL, USA
| | - Courtney L Scherr
- Department of Communication Studies, Northwestern University, Chicago, IL, USA
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15
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Keane H, Huilgol YS, Shieh Y, Tice JA, Belkora J, Sepucha K, Shibley WP, Wang T, Che M, Goodman D, Ozanne E, Fiscalini AS, Esserman LJ. Development and pilot of an online, personalized risk assessment tool for a breast cancer precision medicine trial. NPJ Breast Cancer 2021; 7:78. [PMID: 34140528 PMCID: PMC8211836 DOI: 10.1038/s41523-021-00288-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 05/27/2021] [Indexed: 12/24/2022] Open
Abstract
Breast cancer risk reduction has been validated by large-scale clinical trials, but uptake remains low. A risk communication tool could provide personalized risk-reduction information for high-risk women. A low-literacy-friendly, visual, and personalized tool was designed as part of the Women Informed to Screen Depending On Measures of risk (WISDOM) study. The tool integrates genetic, polygenic, and lifestyle factors, and quantifies the risk-reduction from undertaking medication and lifestyle interventions. The development and design process utilized feedback from clinicians, decision-making scientists, software engineers, and patient advocates. We piloted the tool with 17 study participants, collecting quantitative and qualitative feedback. Overall, participants felt they better understood their personalized breast cancer risk, were motivated to reduce their risk, and considered lifestyle interventions. The tool will be used to evaluate whether risk-based screening leads to more informed decisions and higher uptake of risk-reduction interventions among those most likely to benefit.
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Affiliation(s)
- Holly Keane
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
- Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Yash S Huilgol
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Joint Medical Program, School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - Yiwey Shieh
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Jeffrey A Tice
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Jeff Belkora
- Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA
| | - Karen Sepucha
- Health Decision Sciences Center, Massachusetts General Hospital, Boston, MA, USA
| | - W Patrick Shibley
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Tianyi Wang
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Mandy Che
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Deborah Goodman
- Department of Epidemiology, University of California, Irvine, Irvine, CA, USA
| | - Elissa Ozanne
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | | | - Laura J Esserman
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA.
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16
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Sabgul AA, Qattan AMN, Hashmi R, Al-Hanawi MK. Husbands' Knowledge of Breast Cancer and Their Wives' Attitudes and Practices Related to Breast Cancer Screening in Saudi Arabia: Cross-sectional Online Survey. J Med Internet Res 2021; 23:e25404. [PMID: 33629959 PMCID: PMC7952233 DOI: 10.2196/25404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 12/29/2020] [Accepted: 01/31/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Despite Saudi Arabia's free and well-established cancer care program, breast cancer incidence and mortality are rising. Husbands' knowledge, and wives' attitudes and practices related to breast cancer screening are not well understood in Saudi Arabia. OBJECTIVE The aim of this study was to investigate husbands' knowledge, and wives' attitudes and practices related to breast cancer screening in Saudi Arabia. METHODS This cross-sectional study collected data from 403 husbands in the holy city of Makkah through an online self-reported questionnaire over a period of 2 months, from May 6 to July 7, 2020. Tabulation, bivariate, and multiple regression analyses were the major tools used for data analysis. Multivariate logistic regressions were used to examine the association between husbands' knowledge and wives' behavior regarding breast cancer screening methods. RESULTS Husbands' knowledge score (a 1-point increase) was significantly associated with the wives' utilization of mammograms (adjusted odds ratio [AOR] 1.089, 95% CI 1.024-1.159) and breast self-examination (AOR 1.177, 95% CI 1.105-1.255). Husbands' knowledge also influenced the wives' attitudes toward learning about breast self-examination (AOR 1.138, 95% CI 1.084-1.195). There was no significant association between husbands' knowledge and wives' utilization of clinical breast examination. However, richer husbands showed a socioeconomic gradient concerning their wives' utilization of clinical breast examinations (AOR 2.603, 95% CI 1.269-5.341). CONCLUSIONS Overall, husbands' knowledge of breast cancer influences wives' attitudes and practices related to breast cancer screening methods in Saudi Arabia. Thus, interventions delivered to husbands might increase breast cancer awareness and survival.
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Affiliation(s)
- Afnan Abdulnasir Sabgul
- Academic Affairs and Training Department, King Abdulaziz Hospital, Makkah, Saudi Arabia.,Department of Health Services and Hospital Administration, Faculty of Economics and Administration, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ameerah M N Qattan
- Department of Health Services and Hospital Administration, Faculty of Economics and Administration, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Rubayyat Hashmi
- Centre for Health Research, University of Southern Queensland, Springfield, Australia.,School of Business, Faculty of Business, Education, Law and Arts, University of Southern Queensland, Toowoomba, Australia
| | - Mohammed Khaled Al-Hanawi
- Department of Health Services and Hospital Administration, Faculty of Economics and Administration, King Abdulaziz University, Jeddah, Saudi Arabia
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17
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Mackey A, Petrucka P. Technology as the key to women's empowerment: a scoping review. BMC WOMENS HEALTH 2021; 21:78. [PMID: 33622306 PMCID: PMC7903800 DOI: 10.1186/s12905-021-01225-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 02/16/2021] [Indexed: 01/17/2023]
Abstract
Background Information and communications technologies (ICTs) have empowered people to communicate and network at a global scale. However, there is lack of in-depth understanding of the use of ICTs for women's empowerment. This study examines how the concept empowerment is defined, utilized and measured in research studies, the existing evidence on the use of ICTs for women’s empowerment and the gaps in knowledge at the global level. Methods The authors’ conducted a scoping review using the Arksey and O’Malley methodology. The search identified papers from ten databases, including Scopus, Embase, ABI Inform, Soc Index, Sociological Abstracts, Gender Studies, Springer Link, PsychInfo, Science Direct, and Academic Search Complete over the period of 2012–2018. Search criteria included articles that focused on women’s empowerment and utilized technologies as interventions. Out of a total of 4481 articles that were initially identified, 51 were included. Results Technology played a variety of roles in supporting the development of women’s capacities and resources. Results revealed the use of ICT interventions in the overarching areas of outreach (e.g., health promotion), education (e.g., health literacy opportunities), lifestyle (e.g., peer coaching and planning), prevention (e.g., screening opportunities), health challenges (e.g., intimate partner violence apps), and perceptions of barriers (i.e., uptake, utilization and ubiquity to ICTs for women). Despite the positive use of technology to support women in their daily lives, there was a lack of consensus regarding the definition and use of the term empowerment. The concept of empowerment was also inconsistently and poorly measured in individual studies making it difficult to determine if it was achieved. Conclusion This scoping review provides a comprehensive review of current and emerging efforts to use ICTs to empower women. The findings suggest a need for collaborative efforts between researchers, program implementers and policy makers as well as the various communities of women to address the persistent gender disparities with respect to ICTs.
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Affiliation(s)
- April Mackey
- University of Saskatchewan, 100-4400 4th Ave, Regina, SK, S4T 0H8, Canada.
| | - Pammla Petrucka
- University of Saskatchewan, 100-4400 4th Ave, Regina, SK, S4T 0H8, Canada
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18
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Gómez-Ramírez O, Thomson K, Salway T, Haag D, Falasinnu T, Grennan T, Grace D, Gilbert M. "Mini Dial-A-Nurses" and "Good Brands": What Are the Desirable Features of Online HIV/STI Risk Calculators? AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2020; 32:528-542. [PMID: 33779209 DOI: 10.1521/aeap.2020.32.6.528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
A wide variety of risk calculators estimate individuals' risk for HIV/sexually transmitted infections (STI) online. These tools can help target HIV/STI screening and optimize clinical decision-making. Yet, little evidence exists on suitable features for these tools to be acceptable to end-users. We investigated the desirable characteristics of risk calculators among STI clinic clients and testing service providers. Participants interacted with online HIV/STI risk calculators featuring varied target audiences, completion lengths, and message outputs. Thematic analysis of focus groups identified six qualities that would make risk calculators more appealing for online client use: providing personalized risk assessments based on users' specific sexual behaviors and HIV/STI-related concerns; incorporating nuanced risk assessment and tailored educational information; supplying quantifiable risk estimates; using non-stigmatizing and inclusive framing; including explanations and next steps; and developing effective and appropriate branding. Incorporating these features in the design of online HIV/STI risk calculators may improve their acceptability among end-users.
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Affiliation(s)
- Oralia Gómez-Ramírez
- British Columbia Centre for Disease Control, Vancouver, Canada
- University of British Columbia, Vancouver, Canada
| | - Kim Thomson
- British Columbia Centre for Disease Control, Vancouver, Canada
- University of British Columbia, Vancouver, Canada
| | - Travis Salway
- British Columbia Centre for Disease Control, Vancouver, Canada
- University of British Columbia, Vancouver, Canada
| | - Devon Haag
- British Columbia Centre for Disease Control, Vancouver, Canada
| | | | - Troy Grennan
- British Columbia Centre for Disease Control, Vancouver, Canada
- University of British Columbia, Vancouver, Canada
| | | | - Mark Gilbert
- University of British Columbia, Vancouver, Canada
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19
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Chavez-Yenter D, Chou WYS, Kaphingst KA. State of recent literature on communication about cancer genetic testing among Latinx populations. J Genet Couns 2020; 30:911-918. [PMID: 33142015 DOI: 10.1002/jgc4.1351] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 09/29/2020] [Accepted: 10/01/2020] [Indexed: 12/30/2022]
Abstract
Cancer-related genetic testing (hereafter CGT) has transformed cancer prevention, treatment, and care. Researchers debate whether diffusion and use of genetic testing will reduce or widen cancer health disparities through effects on improving or worsening cancer-related mortality, morbidity, and outcomes that disproportionately affect racial and ethnic minority populations. Cancer disparities by race and ethnicity have been associated with social determinants of health and healthcare access and experience. However, little research has explored how communication about CGT may contribute to these disparities. As such, the goal of this study was to characterize the literature published between 2010 and 2017 on communication about CGT among Latinx populations through a secondary analysis of papers identified in a larger scoping review. We found thirteen (2.5%) of 513 papers in the parent scoping review had over 50% Latinx representation; only nine of these (69%) had fully Latinx comprised study cohorts. The majority of the 13 identified studies (n = 9) were conducted to assess knowledge and attitudes regarding CGT. Most studies included services or materials in both Spanish and English. Few studies assessed language preference or acculturation or compared outcomes across sub-ethnicities. We identified opportunities for researchers to explore differences in outcomes by language preference and acculturation, and between sub-ethnicities in future studies. Leveraging a greater understanding of the heterogeneity within the Latinx population will allow genetics researchers and providers to improve utilization of CGT and therein health outcomes to advance health equity.
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Affiliation(s)
- Daniel Chavez-Yenter
- Department of Communication, University of Utah, Salt Lake City, UT, USA.,Huntsman Cancer Institute, Salt Lake City, UT, USA
| | - Wen-Ying Sylvia Chou
- Health Communication and Informatics Research Branch, National Cancer Institute, Rockville, MD, USA
| | - Kimberly A Kaphingst
- Department of Communication, University of Utah, Salt Lake City, UT, USA.,Huntsman Cancer Institute, Salt Lake City, UT, USA
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20
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Thorneloe RJ, Hall LH, Walter FM, Side L, Lloyd KE, Smith SG. Knowledge of Potential Harms and Benefits of Tamoxifen among Women Considering Breast Cancer Preventive Therapy. Cancer Prev Res (Phila) 2020; 13:411-422. [PMID: 31988145 PMCID: PMC7611305 DOI: 10.1158/1940-6207.capr-19-0424] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 12/19/2019] [Accepted: 01/21/2020] [Indexed: 12/28/2022]
Abstract
Tamoxifen reduces breast cancer incidence in women at increased risk, but may cause side effects. We examined women's knowledge of tamoxifen's potential harms and benefits, and the extent to which knowledge reflects subjective judgments of awareness and decision quality. After a hospital appointment, 408 (55.7%) women at increased risk of breast cancer completed a survey assessing objective knowledge about the potential benefit (risk reduction) and harms (endometrial cancer, thromboembolic events, and menopausal side effects) of tamoxifen, and subjective tamoxifen knowledge and decisional quality. Two hundred fifty-eight (63.2%) completed a 3-month follow-up survey. Sixteen percent (15.7%) of participants recognized the potential benefit and three major harms of using tamoxifen. These women were more likely to have degree-level education [vs. below degree level; OR, 2.24; 95% confidence interval (CI), 1.11-4.55] and good numeracy (vs. poor numeracy; OR, 5.91; 95% CI, 1.33-26.19). Tamoxifen uptake was higher in women who recognized all harms and benefits (vs. not recognizing; OR, 2.47; 95% CI, 0.94-6.54). Sixty-six percent (65.8%) of tamoxifen users were unaware of its potential benefit and harms. Most (87.1%) women reported feeling informed about tamoxifen, and subjective decisional quality was high [Mean (SD), 17.03 (1.87), out of 18]. Knowledge regarding the potential harms and benefit of tamoxifen is low in women considering prevention therapy, and they may need additional support to make informed decisions about tamoxifen preventive therapy.
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Affiliation(s)
| | - Louise Hazel Hall
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Fiona Mary Walter
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Lucy Side
- Wessex Clinical Genetics Service, University Hospitals Southampton, Southampton, United Kingdom
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21
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Crew KD, Silverman TB, Vanegas A, Trivedi MS, Dimond J, Mata J, Sin M, Jones T, Terry MB, Tsai WY, Kukafka R. Study protocol: Randomized controlled trial of web-based decision support tools for high-risk women and healthcare providers to increase breast cancer chemoprevention. Contemp Clin Trials Commun 2019; 16:100433. [PMID: 31497674 PMCID: PMC6722284 DOI: 10.1016/j.conctc.2019.100433] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 08/11/2019] [Accepted: 08/19/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Chemoprevention using selective estrogen receptor modulators and aromatase inhibitors has been shown to reduce invasive breast cancer incidence in high-risk women. Despite this evidence, few high-risk women who are eligible for chemoprevention utilize it as a risk-reducing strategy. Reasons for low uptake include inadequate knowledge about chemoprevention among patients and healthcare providers, concerns about side effects, time constraints during the clinical encounter, and competing comorbidities. METHODS/DESIGN We describe the study design of a randomized controlled trial examining the effect of two web-based decision support tools on chemoprevention decision antecedents and quality, referral for specialized counseling, and chemoprevention uptake among women at an increased risk for breast cancer. The trial is being conducted at a large, urban medical center. A total of 300 patients and 50 healthcare providers will be recruited and randomized to standard educational materials alone or in combination with the decision support tools. Patient reported outcomes will be assessed at baseline, one and six months after randomization, and after their clinic visit with their healthcare provider. DISCUSSION We are conducting this trial to provide evidence on how best to support personalized breast cancer risk assessment and informed and shared decision-making for chemoprevention. We propose to integrate the decision support tools into clinical workflow, which can potentially expand quality decision-making and chemoprevention uptake. TRIAL REGISTRATION NCT03069742.
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Affiliation(s)
- Katherine D. Crew
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
| | - Thomas B. Silverman
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Alejandro Vanegas
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Meghna S. Trivedi
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
| | - Jill Dimond
- Sassafras Tech Collective, Ann Arbor, MI, USA
| | - Jennie Mata
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
| | - Margaret Sin
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Tarsha Jones
- Christine E Lynn College of Nursing, Florida Atlantic University, Boca Raton, FL, USA
| | - Mary Beth Terry
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Wei-Yann Tsai
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Rita Kukafka
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA
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22
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Kerr A, Broer T, Ross E, Cunningham Burley S. Polygenic risk-stratified screening for cancer: Responsibilization in public health genomics. SOCIAL STUDIES OF SCIENCE 2019; 49:605-626. [PMID: 31230567 PMCID: PMC6688132 DOI: 10.1177/0306312719858404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
In this article, we examine professional discourse around the development of polygenic risk-stratified screening (PRSS) for cancer. Analyzing a range of contemporary professional literatures from Europe, North America and Australia, we explore how the drive to screen for molecular markers of cancer risk makes professionals, screening recipients and publics responsible, in different ways, for acquiring, curating and analyzing molecular data. Investigating how these responsibilities are invoked in discussions of new data practices, technologies, organizational arrangements, engagement, education and protocols for participation, we argue that agendas for PRSS for cancer are both expanding and stratifying responsibilities. Data collection is to be achieved by intensified responsibilities for including, reassuring and recruiting populations, as well as by opening and enriching the datasets on which models and preventative screening arrangements are based. Enhanced responsibilities for screening recipients and publics are also invoked, not just in relation to personal health but for population health more generally, via research participation and consenting to data re-use in the public interest. Professionals, screening recipients and publics are also to become responsible for moderating expectations of screening according to genomic designations. Together these discourses go beyond individual risk management to extend and diversify the responsibilities of practitioners, screening recipients and publics as public health genomics develops.
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Affiliation(s)
- Anne Kerr
- School of Sociology and Social Policy, University of Leeds, Leeds, UK
| | - Tineke Broer
- Tilburg Institute for Law, Technology, and Society (TILT), Tilburg University, Tilburg, The Netherlands
| | | | - Sarah Cunningham Burley
- Usher Institute of Population Health Sciences and Informatics, Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
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23
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Tarver WL, Haggstrom DA. The Use of Cancer-Specific Patient-Centered Technologies Among Underserved Populations in the United States: Systematic Review. J Med Internet Res 2019; 21:e10256. [PMID: 31012855 PMCID: PMC6658273 DOI: 10.2196/10256] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 08/31/2018] [Accepted: 09/14/2018] [Indexed: 12/11/2022] Open
Abstract
Background In the United States, more than 1.6 million new cases of cancer are estimated to be diagnosed each year. However, the burden of cancer among the US population is not shared equally, with racial and ethnic minorities and lower-income populations having a higher cancer burden compared with their counterparts. For example, African Americans have the highest mortality rates and shortest survival rates for most cancers compared with other racial or ethnic groups in the United States. A wide range of technologies (eg, internet-based [electronic health, eHealth] technologies, mobile [mobile health, mHealth] apps, and telemedicine) available to patients are designed to improve their access to care and empower them to participate actively in their care, providing a means to reduce health care disparities; however, little is known of their use among underserved populations. Objective The aim of this study was to systematically review the current evidence on the use of cancer-specific patient-centered technologies among various underserved populations. Methods Computer-based search was conducted in the following academic databases: (1) PubMed (cancer subset), (2) MEDLINE, (3) PsycINFO, and (4) CINAHL. We included studies that were peer-reviewed, published in the English language, and conducted in the United States. Each study was individually assessed for relevance, with any disagreements being reconciled by consensus. We used a 3-step inclusion process in which we examined study titles, abstracts, and full-text papers for assessment of inclusion criteria. We systematically extracted information from each paper meeting our inclusion criteria. Results This review includes 71 papers that use patient-centered technologies that primarily targeted African Americans (n=31), rural populations (n=14), and Hispanics (n=12). A majority of studies used eHealth technologies (n=41) finding them to be leading sources of cancer-related health information and significantly improving outcomes such as screening among nonadherent individuals and increasing knowledge about cancer and cancer screening. Studies on mHealth found that participants reported overall favorable responses to receiving health information via short message service (SMS) text message; however, challenges were experienced with respect to lack of knowledge of how to text among some participants. More complex mobile technologies (eg, a tablet-based risk assessment tool) were also found favorable to use and acceptable among underserved populations; however, they also resulted in more significant barriers, for example, participants expressed concerns regarding security and unfamiliarity with the technology and preferred further instruction and assistance in its use. Conclusions There is a growing body of literature exploring patient-centered technology and its influence on care of underserved populations. In this review, we find that these technologies seem to be effective, especially when tailored, in improving patient and care-related outcomes. Despite the potential of patient-centered technologies and the receptivity of underserved populations, challenges still exist with respect to their effective use and usability.
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Affiliation(s)
- Will L Tarver
- VA Health Services Research and Development, Center for Health Information & Communication, Richard L Roudebush VA Medical Center, Indianapolis, IN, United States.,Department of Health Policy & Management, Fairbanks School of Public Health, Indiana University, Indianapolis, IN, United States
| | - David A Haggstrom
- VA Health Services Research and Development, Center for Health Information & Communication, Richard L Roudebush VA Medical Center, Indianapolis, IN, United States.,Division of General Internal Medicine and Geriatrics, School of Medicine, Indiana University, Indianapolis, IN, United States.,Center for Health Services Research, Regenstrief Institute, Indianapolis, IN, United States
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24
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Ozanne EM, Howe R, Mallinson D, Esserman L, Van't Veer LJ, Kaplan CP. Evaluation of National Comprehensive Cancer Network guideline-based Tool for Risk Assessment for breast and ovarian Cancer (N-TRAC): A patient-reported survey for genetic high-risk assessment for breast and ovarian cancers in women. J Genet Couns 2019; 28:507-515. [PMID: 30663827 DOI: 10.1002/jgc4.1051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 09/07/2018] [Accepted: 09/15/2018] [Indexed: 11/09/2022]
Abstract
Identification of mutations that increase lifetime risk of breast and ovarian cancer is critical to improving women's health. Because these mutations are relatively rare in the general population, there is a need for efficient methods to identify appropriate women to undergo genetic testing. The objective of this study was to assess the feasibility, accuracy, and performance of the NCCN guideline-based Tool for Risk Assessment for breast and ovarian Cancer (N-TRAC)-a patient-facing assessment for those affected and unaffected by cancer. This study enrolled a prospective cohort of 100 affected and 100 unaffected women that used N-TRAC in a clinical setting. Recommendations for referral to genetic counseling based on N-TRAC and other standard risk assessment methods were compared.Seventy-seven of the 100 affected women and 35 of the 100 unaffected women were identified as high risk by N-TRAC. The average completion time was approximately 2 min for both groups. N-TRAC accuracy for family history was exceptional in both groups (kappa > 0.96). N-TRAC and other risk assessment methods do not always identify the same high risk population. N-TRAC is an accurate and feasible tool that can assist in identifying women at increased risk for hereditary breast and ovarian cancer and may lead to more informed decision-making.
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Affiliation(s)
- Elissa M Ozanne
- Division of Health System Innovation and Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah
| | - Rebecca Howe
- Frank H. Netter School of Medicine, Quinnipiac University, North Haven, Connecticut
| | - David Mallinson
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Laura Esserman
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, California.,Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California.,Departments of Surgery and Radiology, University of California, San Francisco, San Francisco, California.,Carol Franc Buck Breast Cancer Center, University of California, San Francisco, San Francisco, California
| | - Laura J Van't Veer
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, California
| | - Celia P Kaplan
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, California.,Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California.,Center for Aging in Diverse Communities, Department of Medicine, University of California San Francisco, San Francisco, California
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25
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Pilot study of decision support tools on breast cancer chemoprevention for high-risk women and healthcare providers in the primary care setting. BMC Med Inform Decis Mak 2018; 18:134. [PMID: 30558581 PMCID: PMC6296071 DOI: 10.1186/s12911-018-0716-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 12/03/2018] [Indexed: 02/08/2023] Open
Abstract
Background Breast cancer chemoprevention can reduce breast cancer incidence in high-risk women; however, chemoprevention is underutilized in the primary care setting. We conducted a pilot study of decision support tools among high-risk women and their primary care providers (PCPs). Methods The intervention included a decision aid (DA) for high-risk women, RealRisks, and a provider-centered tool, Breast Cancer Risk Navigation (BNAV). Patients completed validated surveys at baseline, after RealRisks and after their PCP clinical encounter or at 6-months. Referral for high-risk consultation and chemoprevention uptake were assessed via the electronic health record. The primary endpoint was accuracy of breast cancer risk perception at 6-months. Results Among 40 evaluable high-risk women, median age was 64.5 years and median 5-year breast cancer risk was 2.19%. After exposure to RealRisks, patients demonstrated an improvement in accurate breast cancer risk perceptions (p = 0.02), an increase in chemoprevention knowledge (p < 0.01), and 24% expressed interest in taking chemoprevention. Three women had a high-risk referral, and no one initiated chemoprevention. Decisional conflict significantly increased from after exposure to RealRisks to after their clinical encounter or at 6-months (p < 0.01). Accurate breast cancer risk perceptions improved and was sustained at 6-months or after clinical encounters. We discuss the side effect profile of chemoprevention and the care pathway when RealRisks was introduced to understand why patients experienced increased decision conflict. Conclusion Future interventions should carefully link the use of a DA more proximally to the clinical encounter, investigate timed measurements of decision conflict and improve risk communication, shared decision making, and chemoprevention education for PCPs. Additional work remains to better understand the impact of decision aids targeting both patients and providers. Trial registration ClinicalTrials.gov Identifier: NCT02954900 November 4, 2016 Retrospectively registered.
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26
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Silverman TB, Kuperman GJ, Vanegas A, Sin M, Dimond J, Crew KD, Kukafka R. An Applied Framework in Support of Shared Decision Making about BRCA Genetic Testing. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2018; 2018:961-969. [PMID: 30815139 PMCID: PMC6371283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The United States Preventive Services Taskforce recommends that primary care providers screen patients for an increased risk of carrying a BRCA1 or BRCA2 mutation and refer those who meet family history criteria to genetic counseling. Such screening requires detailed and accurate family history data, which often goes uncollected during a primary care visit due to time constraints, competing priorities, and lack of awareness on behalf of both patients and providers. In order to address these barriers and promote appropriate genetic counseling referral, we developed a user-centered framework that collects and communicates relevant data in order to prepare patients and their primary care providers for an informed discussion on genetic counseling referral. This paper describes this framework and the underlining data schema that makes it possible.
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Affiliation(s)
| | - Gilad J Kuperman
- Department of Biomedical Informatics, Columbia University, New York, NY
- Information Systems, NewYork-Presbyterian, New York, NY
| | - Alejandro Vanegas
- Department of Biomedical Informatics, Columbia University, New York, NY
| | - Margaret Sin
- Department of Biomedical Informatics, Columbia University, New York, NY
| | | | - Katherine D Crew
- Department of Medicine, Columbia University, New York, NY
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY
| | - Rita Kukafka
- Department of Biomedical Informatics, Columbia University, New York, NY
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY
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27
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Huh J, Koola J, Contreras A, Castillo AK, Ruiz M, Tedone KG, Yakuta M, Schiaffino MK. Consumer Health Informatics Adoption among Underserved Populations: Thinking beyond the Digital Divide. Yearb Med Inform 2018; 27:146-155. [PMID: 30157518 PMCID: PMC6115231 DOI: 10.1055/s-0038-1641217] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objectives:
Underserved populations can benefit from consumer health informatics (CHI) that promotes self-management at a lower cost. However, prior literature suggested that the digital divide and low motivation constituted barriers to CHI adoption. Despite increased Internet use, underserved populations continue to show slow CHI uptake. The aim of the paper is to revisit barriers and facilitators that may impact CHI adoption among underserved populations.
Methods:
We surveyed the past five years of literature. We searched PubMed for articles published between 2012 and 2017 that describe empirical evaluations involving CHI use by underserved populations. We abstracted and summarized data about facilitators and barriers impacting CHI adoption.
Results:
From 645 search results, after abstract and full-text screening, 13 publications met the inclusion criteria of identifying barriers to and facilitators of underserved populations' CHI adoption. Contrary to earlier literature, the studies suggested that the motivation to improve health literacy and adopt technology was high among studied populations. Beyond the digital divide, barriers included: low health and computer literacy, challenges in accepting the presented information, poor usability, and unclear content. Factors associated with increased use were: user needs for information, user-access mediated by a proxy person, and early user engagement in system design.
Conclusions:
While the digital divide remains a barrier, newer studies show that high motivation for CHI use exists. However, simply gaining access to technology is not sufficient to improve adoption unless CHI technology is tailored to address user needs. Future interventions should consider building larger empirical evidence on identifying CHI barriers and facilitators.
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Affiliation(s)
- Jina Huh
- Michigan State University, MI, USA
| | - Jejo Koola
- University of California San Diego, CA, USA
| | - Alejandro Contreras
- Institute for Behavioral and Community Health, San Diego State University, CA, USA
| | - Alanah Kp Castillo
- Institute for Behavioral and Community Health, San Diego State University, CA, USA
| | - Melissa Ruiz
- Institute for Behavioral and Community Health, San Diego State University, CA, USA
| | - Keely G Tedone
- Institute for Behavioral and Community Health, San Diego State University, CA, USA
| | - Melissa Yakuta
- Institute for Behavioral and Community Health, San Diego State University, CA, USA
| | - Melody K Schiaffino
- Institute for Behavioral and Community Health, San Diego State University, CA, USA
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28
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Silverman TB, Vanegas A, Marte A, Mata J, Sin M, Ramirez JCR, Tsai WY, Crew KD, Kukafka R. Study protocol: a cluster randomized controlled trial of web-based decision support tools for increasing BRCA1/2 genetic counseling referral in primary care. BMC Health Serv Res 2018; 18:633. [PMID: 30103738 PMCID: PMC6090728 DOI: 10.1186/s12913-018-3442-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 08/01/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND BRCA1 and BRCA2 mutations confer a substantial breast risk of developing breast cancer to those who carry them. For this reason, the United States Preventative Services Task Force (USPSTF) has recommended that all women be screened in the primary care setting for a family history indicative of a mutation, and women with strong family histories of breast or ovarian cancer be referred to genetic counseling. However, few high-risk women are being routinely screened and fewer are referred to genetic counseling. To address this need we have developed two decision support tools that are integrated into clinical care. METHOD This study is a cluster randomized controlled trial of high-risk patients and their health care providers. Patient-provider dyads will be randomized to receive either standard education that is supplemented with the patient-facing decision aid, RealRisks, and the provider-facing Breast Cancer Risk Navigation Toolbox (BNAV) or standard education alone. We will assess these tools' effectiveness in promoting genetic counseling uptake and informed and shared decision making about genetic testing. DISCUSSION If found to be effective, these tools can help integrate genomic risk assessment into primary care and, ultimately, help expand access to risk-appropriate breast cancer prevention options to a broader population of high-risk women. TRIAL REGISTRATION This trial is retrospectively registered with ClinicalTrials.gov Identifier: NCT03470402 : 20 March 2018.
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Affiliation(s)
- Thomas B Silverman
- Department of Biomedical Informatics, Columbia University, New York, NY, USA
| | - Alejandro Vanegas
- Department of Biomedical Informatics, Columbia University, New York, NY, USA
| | - Awilda Marte
- Department of Medicine, Columbia University, New York, NY, USA
| | - Jennie Mata
- Department of Medicine, Columbia University, New York, NY, USA
| | - Margaret Sin
- Department of Biomedical Informatics, Columbia University, New York, NY, USA
| | | | - Wei-Yann Tsai
- Department of Biostatistics, Columbia University, New York, NY, USA
| | - Katherine D Crew
- Department of Medicine, Columbia University, New York, NY, USA.,Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY, USA
| | - Rita Kukafka
- Department of Biomedical Informatics, Columbia University, New York, NY, USA. .,Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY, USA.
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29
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Hesse-Biber S, Flynn B, Farrelly K. The Pink Underside: The Commercialization of Medical Risk Assessment and Decision-Making Tools for Hereditary Breast Cancer Risk. QUALITATIVE HEALTH RESEARCH 2018; 28:1523-1538. [PMID: 29642776 DOI: 10.1177/1049732318767395] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The growth of the Internet since the millennium has opened up a myriad of opportunities for education, particularly in medicine. Although those looking for health care information used to have to turn to a face-to-face doctor's visit, an immense library of medical advice is now available at their fingertips. The BRCA genetic predispositions (mutations of the BRCA1 and BRCA2 breast cancer genes) which expose men and women to greater risk of breast, ovarian, and other cancers can be researched extensively online. Several nonprofit organizations now offer online risk assessment and decision-making tools meant to supplement conversation with medical professionals, which in actuality are quickly replacing it. We argue here through a critical qualitative template analysis of several such tools that the discursive frameworks utilized are prone to fearmongering, commercialization, and questionable validity. Left unchecked, these assessment tools could do more harm than good in driving young women especially to take unnecessary extreme surgical action.
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Affiliation(s)
| | - Bailey Flynn
- 1 Boston College, Chestnut Hill, Massachusetts, USA
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30
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Brewster AM, Thomas P, Brown P, Coyne R, Yan Y, Checka C, Middleton L, Do KA, Bevers T. A System-Level Approach to Improve the Uptake of Antiestrogen Preventive Therapy among Women with Atypical Hyperplasia and Lobular Cancer In Situ. Cancer Prev Res (Phila) 2018; 11:295-302. [DOI: 10.1158/1940-6207.capr-17-0314] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 12/20/2017] [Accepted: 02/21/2018] [Indexed: 11/16/2022]
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31
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Padamsee TJ, Wills CE, Yee LD, Paskett ED. Decision making for breast cancer prevention among women at elevated risk. Breast Cancer Res 2017; 19:34. [PMID: 28340626 PMCID: PMC5366153 DOI: 10.1186/s13058-017-0826-5] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Several medical management approaches have been shown to be effective in preventing breast cancer and detecting it early among women at elevated risk: 1) prophylactic mastectomy; 2) prophylactic oophorectomy; 3) chemoprevention; and 4) enhanced screening routines. To varying extents, however, these approaches are substantially underused relative to clinical practice recommendations. This article reviews the existing research on the uptake of these prevention approaches, the characteristics of women who are likely to use various methods, and the decision-making processes that underlie the differing choices of women. It also highlights important areas for future research, detailing the types of studies that are particularly needed in four key areas: documenting women's perspectives on their own perceptions of risk and prevention decisions; explicit comparisons of available prevention pathways and their likely health effects; the psychological, interpersonal, and social processes of prevention decision making; and the dynamics of subgroup variation. Ultimately, this research could support the development of interventions that more fully empower women to make informed and values-consistent decisions, and to move towards favorable health outcomes.
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Affiliation(s)
- Tasleem J. Padamsee
- Division of Health Services Management & Policy, College of Public Health, The Ohio State University, 280F Cunz Hall, 1841 Neil Avenue, Columbus, OH 43220 USA
| | - Celia E. Wills
- College of Nursing, The Ohio State University, Columbus, OH USA
| | - Lisa D. Yee
- College of Medicine, The Ohio State University, Columbus, OH USA
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Coe AM, Ueng W, Vargas JM, David R, Vanegas A, Infante K, Trivedi M, Yi H, Dimond J, Crew KD, Kukafka R. Usability Testing of a Web-Based Decision Aid for Breast Cancer Risk Assessment Among Multi-Ethnic Women. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2017; 2016:411-420. [PMID: 28269836 PMCID: PMC5333260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Chemoprevention with antiestrogens could decrease the incidence of invasive breast cancer but uptake has been low among high-risk women in the United States. We have designed a web-based patient-facing decision aid, called RealRisks, to inform high-risk women about the risks and benefits of chemoprevention and facilitate shared decision-making with their primary care provider. We conducted two rounds of usability testing to determine how subjects engaged with and understood the information in RealRisks. A total of 7 English-speaking and 4 Spanish-speaking subjects completed testing. Using surveys, think-aloud protocols, and subject recordings, we identified several themes relating to the usability of RealRisks, specifically in the content, ease of use, and navigability of the application. By conducting studies in two languages with a diverse multi-ethnic population, we were able to implement interface changes to make RealRisks accessible to users with varying health literacy and acculturation.
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Hum S, Wu M, Pruthi S, Heisey R. Physician and Patient Barriers to Breast Cancer Preventive Therapy. CURRENT BREAST CANCER REPORTS 2016; 8:158-164. [PMID: 27617055 PMCID: PMC4995234 DOI: 10.1007/s12609-016-0216-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The uptake of selective estrogen receptor modulators (SERMs) and aromatase inhibitors (AIs) for the primary prevention of breast cancer is low, despite their proven efficacy in several randomized clinical trials. This review summarizes the latest data on physicians' and women's barriers to breast cancer preventive therapy. Physicians' challenges include: identifying suitable candidates for preventive therapy, inadequate training and confidence in risk assessment and counselling, insufficient knowledge of risk-reducing medications, and lack of time. High-risk women fear medication side effects, and they often weigh experiences of others more heavily than statistical probabilities to guide their decision-making. Despite decision aid interventions to help women make an informed decision, acceptance of preventive therapy will remain low until: risk/benefit profiles are more favorable, physicians are better educated and skilled in having these discussions, and suitable biomarkers to monitor drug efficacy and better clinical risk prediction models to assess true individual risk are available.
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Affiliation(s)
- Susan Hum
- Department of Family & Community Medicine, Women’s College Hospital, 76 Grenville St, Toronto, ON M5S 1B2 Canada
| | - Melinda Wu
- Department of Family & Community Medicine, University of Toronto, Women’s College Hospital, Princess Margaret Hospital, 76 Grenville St, Toronto, ON M5S 1B2 Canada
| | - Sandhya Pruthi
- Department of Medicine, Division of General Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905 USA
| | - Ruth Heisey
- Department of Family & Community Medicine, University of Toronto, Women’s College Hospital, Princess Margaret Hospital, 76 Grenville St, Toronto, ON M5S 1B2 Canada
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