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Ron D, Gunn CM, Havidich JE, Ballacchino MM, Burdick TE, Deiner SG. Preoperative Communication Between Anesthesia, Surgery, and Primary Care Providers for Older Surgical Patients. Jt Comm J Qual Patient Saf 2024; 50:326-337. [PMID: 38360446 DOI: 10.1016/j.jcjq.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 01/10/2024] [Accepted: 01/11/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND Suboptimal communication between clinicians remains a frequent driver of preventable adverse health care-related events, increased costs, and patient and physician dissatisfaction. METHODS Cross-sectional surveys on preoperative interspecialty communication, tailored by stakeholder type, were administered to (1) primary care providers in northern New England, (2) anesthesia providers working in the perioperative clinic of a tertiary rural academic medical center, (3) surgeons from the same center, and (4) older surgical patients who underwent preoperative assessment at the same center. RESULTS In total, 107/249 (43.0%) providers and 103/265 (39.9%) patients completed the survey. Preoperative communication was perceived as logistically challenging (59.8%), particularly across health systems. More than 77% of anesthesia and surgery providers indicated that they communicate frequently or sometimes, but 92.5% of primary care providers indicated that they rarely or never communicate with anesthesia providers. Some of the most common reasons for preoperative communication were discussion of complex patients, perioperative medication management, and optimization of comorbidities. Although 96.1% of older surgical patients reported that preoperative communication between providers is important, only 40.4% felt that their providers communicate very or extremely well. Many patients emphasized the importance of preoperative communication between providers to ensure transfer of critical clinical information. CONCLUSION Surgeons and anesthesiologists infrequently communicate with primary care providers in one rural tertiary center, in contrast to patient expectations and values. These study results will help identify priorities and potentially resolvable barriers to bridging the gap between the inpatient perioperative and outpatient primary care teams. Future studies should focus on strategies to improve communication between hospital and community providers to prevent complications and readmission.
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Harris MTH, Laks J, Hurstak E, Jain JP, Lambert AM, Maschke AD, Bagley SM, Farley J, Coffin PO, McMahan VM, Barrett C, Walley AY, Gunn CM. "If you're strung out and female, they will take advantage of you": A qualitative study exploring drug use and substance use service experiences among women in Boston and San Francisco. J Subst Use Addict Treat 2024; 157:209190. [PMID: 37866442 PMCID: PMC11040599 DOI: 10.1016/j.josat.2023.209190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 05/12/2023] [Accepted: 10/10/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Significant disparities in substance use severity and treatment persist among women who use drugs compared to men. Thus, we explored how identifying as a woman was related to drug use and treatment experiences. METHODS The study recruited participants for a qualitative interview study in Boston and San Francisco from January-November 2020. Self-identified women, age ≥ 18 years, with nonprescribed opioid use in the past 14 days were eligible for inclusion. The study team developed deductive codes based on intersectionality theory and inductive codes generated from transcript review, and identified themes using grounded content analysis. RESULTS The study enrolled thirty-six participants. The median age was 46; 58 % were White, 16 % were Black, 14 % were Hispanic, and 39 % were unstably housed. Other drug use was common with 81 % reporting benzodiazepine, 50 % cocaine, and 31 % meth/amphetamine use respectively. We found that gender (i.e., identifying as a woman) intersected with drug use and sex work practices and exacerbated experiences of marginalization. Violence was ubiquitous in drug use environments. Some women reported experiences of gender-based violence in substance use service settings that perpetuated cycles of trauma and reinforced barriers to care. Substance use services that were women-led, safe, and responsive to women's needs were valued and sought after. CONCLUSION Women reported a cycle of trauma and drug use exacerbated by oppression in substance use services settings. In addition to increasing access to gender-responsive care, our study highlights the need for greater research and examination of practices within substance use service settings that may be contributing to gender-based violence.
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Affiliation(s)
- Miriam T H Harris
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, 801 Massachusetts Ave, Boston, MA 02118, USA.
| | - Jordana Laks
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, 801 Massachusetts Ave, Boston, MA 02118, USA.
| | - Emily Hurstak
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, 801 Massachusetts Ave, Boston, MA 02118, USA.
| | - Jennifer P Jain
- School of Nursing and Department of Community Health Systems at the University of California, San Francisco, CA 94143, USA.
| | - Audrey M Lambert
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, 801 Massachusetts Ave, Boston, MA 02118, USA.
| | - Ariel D Maschke
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, 801 Massachusetts Ave, Boston, MA 02118, USA.
| | - Sarah M Bagley
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, 801 Massachusetts Ave, Boston, MA 02118, USA; Division of General Pediatrics, Department of Pediatrics, Boston University School of Medicine and Boston Medical Center, Boston, MA 02118, USA.
| | - John Farley
- San Francisco Department of Public Health, 101 Grove St, San Francisco, CA 94102, USA; Department of Medicine, University of California, 533 Parnassus Ave, San Francisco, CA 94143, USA.
| | - Phillip O Coffin
- San Francisco Department of Public Health, 101 Grove St, San Francisco, CA 94102, USA; Department of Medicine, University of California, 533 Parnassus Ave, San Francisco, CA 94143, USA.
| | - Vanessa M McMahan
- San Francisco Department of Public Health, 101 Grove St, San Francisco, CA 94102, USA; Department of Medicine, University of California, 533 Parnassus Ave, San Francisco, CA 94143, USA.
| | - Cynthia Barrett
- San Francisco Department of Public Health, 101 Grove St, San Francisco, CA 94102, USA; Department of Medicine, University of California, 533 Parnassus Ave, San Francisco, CA 94143, USA.
| | - Alexander Y Walley
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, 801 Massachusetts Ave, Boston, MA 02118, USA.
| | - Christine M Gunn
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, 801 Massachusetts Ave, Boston, MA 02118, USA; Boston University School of Public Health, Department of Health Law, Policy, and Management, Boston, MA 02118, USA.
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Rocque GB, Patel MI, Wallner LP, Bailey SC, Schear R, Gunn CM, Rivers J, Wilson R, Freeman EC, Buckingham TL, May SG, Kamal AH. Patient-Centered Decision-Making in Metastatic Breast Cancer Care Delivery: A Call to Action. J Natl Compr Canc Netw 2024; 22:e237113. [PMID: 38394778 DOI: 10.6004/jnccn.2023.7113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Affiliation(s)
- Gabrielle B Rocque
- Divisions of Hematology & Oncology and Gerontology, Geriatrics, & Palliative Care, University of Alabama, Birmingham, Alabama
| | - Manali I Patel
- Department of Medicine, Stanford University, Stanford, CA, and Medical Services, VA Palo Alto Health Care System, Palo Alto, California
| | - Lauren P Wallner
- Departments of Internal Medicine and Epidemiology, University of Michigan, Ann Arbor, Michigan
| | - Stacy C Bailey
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | - Christine M Gunn
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine; Dartmouth Cancer Center, Lebanon, New Hampshire
| | - Jamil Rivers
- The Chrysalis Initiative, Philadelphia, Pennsylvania
| | | | | | | | | | - Arif H Kamal
- American Cancer Society, Charlotte, North Carolina
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Blakeslee SB, Gunn CM, Parker PA, Fagerlin A, Battaglia T, Bevers TB, Bandos H, McCaskill-Stevens W, Kennedy JW, Holmberg C. Talking numbers: how women and providers use risk scores during and after risk counseling - a qualitative investigation from the NRG Oncology/NSABP DMP-1 study. BMJ Open 2023; 13:e073138. [PMID: 37984961 PMCID: PMC10660821 DOI: 10.1136/bmjopen-2023-073138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 09/29/2023] [Indexed: 11/22/2023] Open
Abstract
OBJECTIVES Little research exists on how risk scores are used in counselling. We examined (a) how Breast Cancer Risk Assessment Tool (BCRAT) scores are presented during counselling; (b) how women react and (c) discuss them afterwards. DESIGN Consultations were video-recorded and participants were interviewed after the consultation as part of the NRG Oncology/National Surgical Adjuvant Breast and Bowel Project Decision-Making Project 1 (NSABP DMP-1). SETTING Two NSABP DMP-1 breast cancer care centres in the USA: one large comprehensive cancer centre serving a high-risk population and an academic safety-net medical centre in an urban setting. PARTICIPANTS Thirty women evaluated for breast cancer risk and their counselling providers were included. METHODS Participants who were identified as at increased risk of breast cancer were recruited to participate in qualitative study with a video-recorded consultation and subsequent semi-structured interview that included giving feedback and input after viewing their own consultation. Consultation videos were summarised jointly and inductively as a team.tThe interview material was searched deductively for text segments that contained the inductively derived themes related to risk assessment. Subgroup analysis according to demographic variables such as age and Gail score were conducted, investigating reactions to risk scores and contrasting and comparing them with the pertinent video analysis data. From this, four descriptive categories of reactions to risk scores emerged. The descriptive categories were clearly defined after 19 interviews; all 30 interviews fit principally into one of the four descriptive categories. RESULTS Risk scores were individualised and given meaning by providers through: (a) presenting thresholds, (b) making comparisons and (c) emphasising or minimising the calculated risk. The risk score information elicited little reaction from participants during consultations, though some added to, agreed with or qualified the provider's information. During interviews, participants reacted to the numbers in four primary ways: (a) engaging easily with numbers; (b) expressing greater anxiety after discussing the risk score; (c) accepting the risk score and (d) not talking about the risk score. CONCLUSIONS Our study highlights the necessity that patients' experiences must be understood and put into relation to risk assessment information to become a meaningful treatment decision-making tool, for instance by categorising patients' information engagement into types. TRIAL REGISTRATION NUMBER NCT01399359.
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Affiliation(s)
- Sarah B Blakeslee
- Research Group: Prevention, Integrative Medicine and Health Promotion in Pediatrics, Department of Pediatrics, Division of Oncology and Hematology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christine M Gunn
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Cancer Center, Dartmouth College, Hanover and Lebanon, New Hampshire, USA
| | - Patricia A Parker
- Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Angela Fagerlin
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, Utah, USA
| | - Tracy Battaglia
- Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Therese B Bevers
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hanna Bandos
- NRG Oncology SDMC, and the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Worta McCaskill-Stevens
- Community Oncology and Prevention Trials Research Group, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, UK
| | - Jennifer W Kennedy
- Institute of Public Health, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christine Holmberg
- Institute of Public Health, Charité Universitätsmedizin Berlin, Berlin, Germany
- Institute of Social Medicine and Epidemiology, Brandenburg Medical School Theodor Fontane, Brandenburg/Havel, Germany
- Faculty of Health Sciences, Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
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Kressin NR, Wormwood JB, Battaglia TA, Slanetz PJ, Gunn CM. Sociodemographic Variations in Women's Reports of Discussions With Clinicians About Breast Density. JAMA Netw Open 2023; 6:e2344850. [PMID: 38010653 PMCID: PMC10682834 DOI: 10.1001/jamanetworkopen.2023.44850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 10/14/2023] [Indexed: 11/29/2023] Open
Abstract
Importance Breast density notifications advise women to discuss breast density with their clinicians, yet little is known about such discussions. Objectives To examine the content of women's reports of breast density discussions with clinicians and identify variations by women's sociodemographic characteristics (age, income, state legislation status, race and ethnicity, and literacy level). Design, Setting, and Participants This US nationwide, population-based, random-digit dial telephone survey study was conducted from July 1, 2019, to April 30, 2020, among 2306 women aged 40 to 76 years with no history of breast cancer who underwent mammography in the prior 2 years and had heard the term dense breasts or breast density. Results were analyzed from a subsample of 770 women reporting a conversation about breast density with their clinician after their last mammographic screening. Statistical analysis was conducted in April and July 2023. Main Outcomes and Measures Survey questions inquired whether women's clinicians had asked about breast cancer risk or their worries or concerns about breast density, had discussed mammography results or other options for breast cancer screening or their future risk of breast cancer, as well as the extent to which the clinician answered questions about breast density. Results Of the 770 women (358 [47%] aged 50-64 years; 47 Asian [6%], 125 Hispanic [16%], 204 non-Hispanic Black [27%], 317 non-Hispanic White [41%], and 77 other race and ethnicity [10%]) whose results were analyzed, most reported that their clinicians asked questions about breast cancer risk (88% [670 of 766]), discussed mammography results (94% [724 of 768]), and answered patient questions about breast density (81% [614 of 761]); fewer women reported that clinicians had asked about worries or concerns about breast density (69% [524 of 764]), future risk of breast cancer (64% [489 of 764]), or other options for breast cancer screening (61% [459 of 756]). Women's reports of conversations varied significantly by race and ethnicity; non-Hispanic Black women reported being asked questions about breast cancer risk more often than non-Hispanic White women (odds ratio [OR], 2.08 [95% CI, 1.05-4.10]; P = .04). Asian women less often reported being asked about their worries or concerns (OR, 0.42 [95% CI, 0.20-0.86]; P = .02), and Hispanic and Asian women less often reported having their questions about breast density answered completely or mostly (Asian: OR, 0.28 [95% CI, 0.13-0.62]; P = .002; Hispanic: OR, 0.48 [95% CI, 0.27-0.87]; P = .02). Women with low literacy were less likely than women with high literacy to report being asked about worries or concerns about breast density (OR, 0.64 [95% CI, 0.43-0.96]; P = .03), that mammography results were discussed with them (OR, 0.32 [95% CI, 0.16-0.63]; P = .001), or that their questions about breast density were answered completely or mostly (OR, 0.51 [95% CI, 0.32-0.81]; P = .004). Conclusions and Relevance In this survey study, although most women reported that their clinicians counselled them about breast density, the unaddressed worries or concerns and unanswered questions, especially among Hispanic and Asian women and those with low literacy, highlighted areas where discussions could be improved.
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Affiliation(s)
- Nancy R. Kressin
- Section of General Internal Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | | | - Tracy A. Battaglia
- Section of General Internal Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Priscilla J. Slanetz
- Department of Radiology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Christine M. Gunn
- Section of General Internal Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
- Dartmouth Cancer Center, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
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Gunn CM, Gignac G, Hardy B, Zayhowski K, Pankowska M, Loo S, Wang C. Characterizing Referrals for Prostate Cancer Genetic Services in a Safety-Net Hospital. JCO Oncol Pract 2023; 19:852-859. [PMID: 37384869 DOI: 10.1200/op.23.00055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/21/2023] [Accepted: 05/26/2023] [Indexed: 07/01/2023] Open
Abstract
PURPOSE Little is known about the uptake of germline genetic testing for patients with prostate cancer after 2018 guideline changes. This study characterizes genetic service referral patterns and predictors of referrals among patients with prostate cancer. METHODS A retrospective cohort study using electronic health record data was conducted at an urban safety-net hospital. Individuals diagnosed with prostate cancer between January 2011 and March 2020 were eligible. The primary outcome was referral to genetic services after diagnosis. Using multivariable logistic regression, we identified patient characteristics associated with referrals. Interrupted time series analysis using a segmented Poisson regression examined whether guideline changes resulted in higher rates of referral after implementation. RESULTS The cohort included 1,877 patients. Mean age was 65 years; 44% identified as Black, 32% White; and 17% Hispanic or Latino. The predominant insurance type was Medicaid (34%) followed by Medicare or private insurance (25% each). Most were diagnosed with local disease (65%), while 3% had regional and 9% had metastatic disease. Of the 1,877 patients, 163 (9%) had at least one referral to genetics. In multivariable models, higher age was negatively associated with referral (odds ratio [OR], 0.96; 95% CI, 0.94 to 0.98), while having regional (OR, 4.51; 95% CI, 2.44 to 8.34) or metastatic disease (OR, 4.64; 95% CI, 2.98 to 7.24) versus local only disease at diagnosis was significantly associated with referral. The time series analysis demonstrated a 138% rise in referrals 1 year after guideline implementation (relative risk, 3.992; 97.5% CI, 2.20 to 7.24; P < .001). CONCLUSION Referrals to genetic services increased after guideline implementation. The strongest predictor of referral was clinical stage, suggesting opportunities to raise awareness about guideline eligibility for patients with advanced local or regional disease who may benefit from genetic services.
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Affiliation(s)
- Christine M Gunn
- Section of General Internal Medicine, Boston University Chobanian and Avedesian School of Medicine, Boston, MA
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH
- Dartmouth Cancer Center, Lebanon, NH
| | - Gretchen Gignac
- Evans Department of Medicine, Section of Hematology/Oncology, Boston University Chobanian and Avedesian School of Medicine, Boston, MA
- Department of Obstetrics and Gynecology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Brianna Hardy
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH
- Dartmouth Cancer Center, Lebanon, NH
| | - Kimberly Zayhowski
- Department of Obstetrics and Gynecology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Magdalena Pankowska
- Section of General Internal Medicine, Boston University Chobanian and Avedesian School of Medicine, Boston, MA
| | - Stephanie Loo
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA
| | - Catharine Wang
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA
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Gunn CM, Berrian K, Weiss JE, Tosteson AAN, Hasson RM, Di Florio-Alexander R, Peacock JL, Rees JR. A population-based survey of self-reported delays in breast, cervical, colorectal and lung cancer screening. Prev Med 2023; 175:107649. [PMID: 37517458 PMCID: PMC10763992 DOI: 10.1016/j.ypmed.2023.107649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 07/24/2023] [Accepted: 07/27/2023] [Indexed: 08/01/2023]
Abstract
The early COVID-19 pandemic was associated with cessation of screening services, but the prevalence of ongoing delays in cancer screening into the third year of the pandemic are not well-characterized. In February/March 2022, a population-based survey assessed cancer needs in New Hampshire and Vermont. The associations between cancer screening delays (breast, cervical, colorectal or lung cancer) and social determinants of health, health care access, and cancer attitudes and beliefs were tested. Distributions and Rao-Scott chi-square tests were used for hypothesis testing and weighted to represent state populations. Of 1717 participants, 55% resided in rural areas, 96% identified as White race, 50% were women, 36% had high school or less education. Screening delays were reported for breast cancer (28%), cervical cancer (30%), colorectal cancer (24%), and lung cancer (30%). Delays were associated with having higher educational attainment (lung), urban living (colorectal), and having Medicaid insurance (breast, cervical). Low confidence in ability to obtain information about cancer was associated with screening delays across screening types. The most common reason for delay was the perception that the screening test was not urgent (31% breast, 30% cervical, 28% colorectal). Cost was the most common reason for delayed lung cancer screening (36%). COVID-19 was indicated as a delay reason in 15-29% of respondents; 12-20% reported health system capacity during the pandemic as a reason for delay, depending on screening type. Interventions that address sub-populations and reasons for screening delays are needed to mitigate the impact of the COVID-19 pandemic on cancer burden and mortality.
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Affiliation(s)
- Christine M Gunn
- The Dartmouth Cancer Center, Lebanon, NH, United States of America; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, NH, United States of America.
| | - Kedryn Berrian
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, NH, United States of America
| | - Julie E Weiss
- The Dartmouth Cancer Center, Lebanon, NH, United States of America
| | - Anna A N Tosteson
- The Dartmouth Cancer Center, Lebanon, NH, United States of America; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, NH, United States of America
| | - Rian M Hasson
- The Dartmouth Cancer Center, Lebanon, NH, United States of America; Department of Surgery, Geisel School of Medicine, Dartmouth College, Hanover, NH, United States of America
| | - Roberta Di Florio-Alexander
- The Dartmouth Cancer Center, Lebanon, NH, United States of America; Department of Radiology, Geisel School of Medicine, Dartmouth College, Lebanon, NH, United States of America
| | - Janet L Peacock
- Department of Epidemiology, Geisel School of Medicine, Dartmouth College, Hanover, NH, United States of America
| | - Judy R Rees
- The Dartmouth Cancer Center, Lebanon, NH, United States of America; Department of Epidemiology, Geisel School of Medicine, Dartmouth College, Hanover, NH, United States of America
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Skipper TA, Weiss JE, Carlos HA, Gunn CM, Hasson RM, Peacock JL, Schiffelbein JE, Tosteson AN, Lansigan F, Rees JR. A Survey of Cancer Risk Behaviors, Beliefs, and Social Drivers of Health in New Hampshire and Vermont. Cancer Res Commun 2023; 3:1678-1687. [PMID: 37649812 PMCID: PMC10464638 DOI: 10.1158/2767-9764.crc-23-0267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/28/2023] [Accepted: 07/28/2023] [Indexed: 09/01/2023]
Abstract
Compared with urban areas, rural areas have higher cancer mortality and have experienced substantially smaller declines in cancer incidence in recent years. In a New Hampshire (NH) and Vermont (VT) survey, we explored the roles of rurality and educational attainment on cancer risk behaviors, beliefs, and other social drivers of health. In February-March 2022, two survey panels in NH and VT were sent an online questionnaire. Responses were analyzed by rurality and educational attainment. Respondents (N = 1,717, 22%) mostly lived in rural areas (55%); 45% of rural and 25% of urban residents had high school education or less and this difference was statistically significant. After adjustment for rurality, lower educational attainment was associated with smoking, difficulty paying for basic necessities, greater financial difficulty during the COVID-19 pandemic, struggling to pay for gas (P < 0.01), fatalistic attitudes toward cancer prevention, and susceptibility to information overload about cancer prevention. Among the 33% of respondents who delayed getting medical care in the past year, this was more often due to lack of transportation in those with lower educational attainment (21% vs. 3%, P = 0.02 adjusted for rurality) and more often due to concerns about catching COVID-19 among urban than rural residents (52% vs. 21%; P < 0.001 adjusted for education). In conclusion, in NH/VT, smoking, financial hardship, and beliefs about cancer prevention are independently associated with lower educational attainment but not rural residence. These findings have implications for the design of interventions to address cancer risk in rural areas. Significance In NH and VT, the finding that some associations between cancer risk factors and rural residence are more closely tied to educational attainment than rurality suggest that the design of interventions to address cancer risk should take educational attainment into account.
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Affiliation(s)
- Thomas A. Skipper
- Dartmouth Cancer Center, Lebanon, New Hampshire
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | | | | | - Christine M. Gunn
- Dartmouth Cancer Center, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Rian M. Hasson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- Department of Surgery, Section of Thoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Janet L. Peacock
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | | | - Anna N.A. Tosteson
- Dartmouth Cancer Center, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Frederick Lansigan
- Dartmouth Cancer Center, Lebanon, New Hampshire
- Department of Hematology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Judy R. Rees
- Dartmouth Cancer Center, Lebanon, New Hampshire
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
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Rees JR, Weiss JE, Gunn CM, Carlos HA, Dragnev NC, Supattapone EY, Tosteson AN, Kraft SA, Vahdat LT, Peacock JL. Cancer Epidemiology in the Northeastern United States (2013-2017). Cancer Res Commun 2023; 3:1538-1550. [PMID: 37583435 PMCID: PMC10424700 DOI: 10.1158/2767-9764.crc-23-0152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 07/09/2023] [Accepted: 07/11/2023] [Indexed: 08/17/2023]
Abstract
We tested the hypotheses that adult cancer incidence and mortality in the Northeast region and in Northern New England (NNE) were different than the rest of the United States, and described other related cancer metrics and risk factor prevalence. Using national, publicly available cancer registry data, we compared cancer incidence and mortality in the Northeast region with the United States and NNE with the United States overall and by race/ethnicity, using age-standardized cancer incidence and rate ratios (RR). Compared with the United States, age-adjusted cancer incidence in adults of all races combined was higher in the Northeast (RR, 1.07; 95% confidence interval [CI] 1.07-1.08) and in NNE (RR 1.06; CI 1.05-1.07). However compared with the United States, mortality was lower in the Northeast (RR, 0.98; CI 0.98-0.98) but higher in NNE (RR, 1.05; CI 1.03-1.06). Mortality in NNE was higher than the United States for cancers of the brain (RR, 1.16; CI 1.07-1.26), uterus (RR, 1.32; CI 1.14-1.52), esophagus (RR, 1.36; CI 1.26-1.47), lung (RR, 1.12; CI 1.09-1.15), bladder (RR, 1.23; CI 1.14-1.33), and melanoma (RR, 1.13; CI 1.01-1.27). Significantly higher overall cancer incidence was seen in the Northeast than the United States in all race/ethnicity subgroups except Native American/Alaska Natives (RR, 0.68; CI 0.64-0.72). In conclusion, NNE has higher cancer incidence and mortality than the United States, a pattern that contrasts with the Northeast region, which has lower cancer mortality overall than the United States despite higher incidence. Significance These findings highlight the need to identify the causes of higher cancer incidence in the Northeast and the excess cancer mortality in NNE.
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Affiliation(s)
- Judy R. Rees
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- Dartmouth Cancer Center, Lebanon, New Hampshire
| | | | - Christine M. Gunn
- Dartmouth Cancer Center, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | | | | | | | - Anna N.A. Tosteson
- Dartmouth Cancer Center, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Sally A. Kraft
- Dartmouth College, Hanover, New Hampshire
- Dartmouth Health, Lebanon, New Hampshire
| | - Linda T. Vahdat
- Dartmouth Cancer Center, Lebanon, New Hampshire
- Dartmouth Health, Lebanon, New Hampshire
| | - Janet L. Peacock
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
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Kressin NR, Wormwood JB, Battaglia TA, Slanetz PJ, Gunn CM. Women's Reactions to Breast Density Information Vary by Sociodemographic Characteristics. Womens Health Issues 2023:S1049-3867(23)00070-1. [PMID: 37087312 DOI: 10.1016/j.whi.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 02/27/2023] [Accepted: 03/07/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND Breast density information aims to increase awareness of breast density and its risks and to foster more informed future breast screening decisions among women with dense breasts. We explored associations between such information and outcomes including anxiety, confusion, or feeling informed, and whether they varied by race/ethnicity or literacy, or differentially affected future mammography plans. METHODS A national telephone survey of a diverse sample of women previously informed of personal breast density (N = 1,322) assessed reactions to receipt of breast density information and future mammography plans. RESULTS Most women (86%) felt informed after receiving personal breast density information; however, some felt anxious (15%) or confused (11%). Reactions varied significantly by sociodemographics; non-Hispanic Black, Asian, and Hispanic women and women with low literacy were nearly two to three times more likely to report anxiety than non-Hispanic White women (all ps < .05). Asian women and those with low literacy less often felt informed and more often felt confused. Non-Hispanic Black and Asian women were nearly twice as likely to report that knowing their breast density made them more likely to have future mammograms. Women with low literacy were more likely to change mammography plans, with some being more likely and others less likely to plan to have future mammograms. Greater anxiety and confusion were associated with higher likelihood of planning future mammograms; those feeling informed were less likely to plan future mammography. CONCLUSIONS Differential reactions to breast density information are concerning if associated with disparate future screening plans. Future breast density education efforts should ensure that such information is readily accessible and understandable to all women in order to lead to desired effects.
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Affiliation(s)
- Nancy R Kressin
- Section of General Internal Medicine, Department of Medicine, Boston University Chobanian and Avedesian School of Medicine, Boston, Massachusetts.
| | - Jolie B Wormwood
- Department of Psychology, University of New Hampshire, Durham, New Hampshire
| | - Tracy A Battaglia
- Section of General Internal Medicine, Department of Medicine, Boston University Chobanian and Avedesian School of Medicine, Boston, Massachusetts
| | - Priscilla J Slanetz
- Department of Radiology, Boston University Chobanian and Avedesian School of Medicine, Boston, Massachusetts
| | - Christine M Gunn
- Section of General Internal Medicine, Department of Medicine, Boston University Chobanian and Avedesian School of Medicine, Boston, Massachusetts; The Dartmouth Institute for Health Policy and Clinical Practice and Dartmouth Cancer Center, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
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Kressin NR, Slanetz PJ, Gunn CM. Ensuring Clarity and Understandability of the FDA's Breast Density Notifications. JAMA 2023; 329:121-122. [PMID: 36508205 PMCID: PMC10152312 DOI: 10.1001/jama.2022.22753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This Viewpoint discusses the use of breast density notifications to inform women with dense breast tissue of the potential need for supplemental cancer screening, as well as the need to ensure that such notifications are clear and understandable to women of all language backgrounds, literacy levels, educational levels, and socioeconomic backgrounds.
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Affiliation(s)
- Nancy R Kressin
- Section of General Internal Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Priscilla J Slanetz
- Department of Radiology, Boston University Aram V. Chobanian & Edward Avedisian School of Medicine, Boston, Massachusetts
| | - Christine M Gunn
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Cancer Center, Dartmouth Geisel School of Medicine, Hanover, New Hampshire
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Beidler LB, Kressin NR, Wormwood JB, Battaglia TA, Slanetz PJ, Gunn CM. Perceptions of Breast Cancer Risks Among Women Receiving Mammograph Screening. JAMA Netw Open 2023; 6:e2252209. [PMID: 36689223 PMCID: PMC9871800 DOI: 10.1001/jamanetworkopen.2022.52209] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 12/02/2022] [Indexed: 01/24/2023] Open
Abstract
Importance Breast density is an independent risk factor for breast cancer. Despite the proliferation of mandated written notifications about breast density following mammography, there is little understanding of how women perceive the relative breast cancer risk associated with breast density. Objective To assess women's perception of breast density compared with other breast cancer risks and explore their understanding of risk reduction. Design, Setting, and Participants This mixed-methods qualitative study used telephone surveys and semistructured interviews to investigate perceptions about breast cancer risk among a nationally representative, population-based sample of women. Eligible study participants were aged 40 to 76 years, reported having recently undergone mammography, had no history of prior breast cancer, and had heard of breast density. Survey participants who had been informed of their personal breast density were invited for a qualitative interview. Survey administration spanned July 1, 2019, to April 30, 2020, with 2306 women completing the survey. Qualitative interviews were conducted from February 1 to May 30, 2020. Main Outcomes and Measures Respondents compared the breast cancer risk associated with breast density with 5 other risk factors. Participants qualitatively described what they thought contributed to breast cancer risk and ways to reduce risk. Results Of the 2306 women who completed the survey, 1858 (166 [9%] Asian, 503 [27%] Black, 268 [14%] Hispanic, 792 [43%] White, and 128 [7%] other race or ethnicity; 358 [19%] aged 40-49 years, 906 [49%] aged 50-64 years, and 594 [32%] aged ≥65 years) completed the revised risk perception questions and were included in the analysis. Half of respondents thought breast density to be a greater risk than not having children (957 [52%]), having more than 1 alcoholic drink per day (975 [53%]), or having a prior breast biopsy (867 [48%]). Most respondents felt breast density was a lesser risk than having a first-degree relative with breast cancer (1706 [93%]) or being overweight or obese (1188 [65%]). Of the 61 women who were interviewed, 6 (10%) described breast density as contributing to breast cancer risk, and 43 (70%) emphasized family history as a breast cancer risk factor. Of the interviewed women, 17 (28%) stated they did not know whether it was possible to reduce their breast cancer risk. Conclusions and Relevance In this qualitative study of women of breast cancer screening age, family history was perceived as the primary breast cancer risk factor. Most interviewees did not identify breast density as a risk factor and did not feel confident about actions to mitigate breast cancer risk. Comprehensive education about breast cancer risks and prevention strategies is needed.
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Affiliation(s)
- Laura B. Beidler
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Nancy R. Kressin
- Section of General Internal Medicine, Boston University Chobanian and Avedesian School of Medicine, Boston, Massachusetts
| | | | - Tracy A. Battaglia
- Section of General Internal Medicine, Boston University Chobanian and Avedesian School of Medicine, Boston, Massachusetts
| | - Priscilla J. Slanetz
- Department of Radiology, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Christine M. Gunn
- Dartmouth Cancer Center, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
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Gunn CM, Li EX, Gignac GA, Pankowska M, Loo S, Zayhowski K, Wang C. Delivering Genetic Testing for Patients with Prostate Cancer: Moving Beyond Provider Knowledge as a Barrier to Care. Cancer Control 2023; 30:10732748221143884. [PMID: 36946278 PMCID: PMC10037728 DOI: 10.1177/10732748221143884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
INTRODUCTION The 2018 National Comprehensive Cancer Network guidelines for prostate cancer genetic testing expanded access to genetic services. Few studies have examined how this change has affected provider practice outside of large cancer centers. METHODS We conducted a qualitative study of multi-disciplinary health care providers treating patients with prostate cancer at a safety-net hospital. Participants completed an interview that addressed knowledge, practices, and contextual factors related to providing genetic services to patients with prostate cancer. A thematic analysis using both inductive and deductive coding was undertaken. RESULTS Seventeen providers completed interviews. Challenges in identifying eligible patients for genetic testing stemmed from a lack of a) systems that facilitate routine patient identification, and b) readily available family history data for eligibility determination. Providers identified non-medical patient characteristics that influenced their referral process, including health literacy, language, cultural beliefs, patient distress, and cost. Providers who see patients at different times along the cancer care continuum viewed benefits of testing differently. CONCLUSION The use of digital technologies that systematically identify those eligible for genetic testing referrals may mitigate some but not all challenges identified in this study. Further research should determine how individual provider perceptions influence referral practices and patient access to genetics both within and across cancer specialties.
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Affiliation(s)
- Christine M Gunn
- Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical Practice and Dartmouth Cancer Center, Lebanon, NH, USA
- Evans Department of Medicine, Section of General Internal Medicine, 12259Boston University Aram V. Chobanian & Edward Avedisian School of Medicine, Boston, MA, USA
- Department of Health Law, Policy, and Management, 27118Boston University School of Public Health, Boston, MA, USA
| | - Emma X Li
- Evans Department of Medicine, Boston University Aram V. Chobanian & Edward Avedisian School of Medicine, Boston, MA, USA
| | - Gretchen A Gignac
- Evans Department of Medicine, Boston University Aram V. Chobanian & Edward Avedisian School of Medicine, Boston, MA, USA
- Evans Department of Medicine, 1836Section of Hematology and Oncology, Boston University Aram V. Chobanian & Edward Avedisian School of Medicine, Boston, MA, USA
| | - Magdalena Pankowska
- Evans Department of Medicine, Section of General Internal Medicine, 12259Boston University Aram V. Chobanian & Edward Avedisian School of Medicine, Boston, MA, USA
| | - Stephanie Loo
- Department of Health Law, Policy, and Management, 27118Boston University School of Public Health, Boston, MA, USA
| | - Kimberly Zayhowski
- Evans Department of Medicine, 1836Section of Hematology and Oncology, Boston University Aram V. Chobanian & Edward Avedisian School of Medicine, Boston, MA, USA
| | - Catharine Wang
- Department of Community Health Sciences, 27118Boston University School of Public Health, Boston, MA, USA
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Gunn CM, Pankowska M, Harris M, Helsing E, Battaglia TA, Bagley SM. The representation of females in clinical trials for substance use disorder conducted in the United States (2010-19). Addiction 2022; 117:2583-2590. [PMID: 35165969 PMCID: PMC10062729 DOI: 10.1111/add.15842] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 01/26/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIMS Women have historically been under-represented in clinical research, but the extent to which this is true for substance use disorder (SUD) trials is unknown. We aimed to determine the ratio of female:male participation in clinical trials for SUDs and describe the reporting of sex-specific outcomes from 2010 to 2019. DESIGN A retrospective cohort review of clinical trials involving people with SUD. SETTING United States. PARTICIPANTS Clinical trials including people with SUD registered in clinicaltrials.gov and completed between 1 January 2010 and 31 December 2019 were reviewed. Trials were excluded if they had < 30 participants, focused on SUD prevention, were conducted outside the United States and/or did not report data on participant sex or gender. MEASUREMENTS The following were extracted for each trial: primary outcome, number of participants enrolled, analytical sample size, percentage of participants who were female, inclusion of transgender participants, whether sex-based analyses were performed, funding source, type of SUD and type of intervention. Relative representation in trials was examined using the female:male ratio, reported using median ratios and by year of trial completion. The proportion of females participating was adjusted using the underlying disease prevalence among females using National Survey on Drug Use and Health data. FINDINGS A total of 316 trials met inclusion criteria: 274 were mixed-sex, 12 enrolled only males and 30 only females. In 274 mixed-sex trials, 40% of 57 544 participants were female. Only 22 trials (8%) reported any sex-specific analyses; four studies (1.5%) reported inclusion of transgender participants. Females represented 35% of participants in trials targeting illicit drug use disorder, 52% in nicotine use disorder and 29% in alcohol use disorder. Accounting for underlying disease prevalence revealed that women had the lowest relative enrollment in alcohol use disorder trials (median participation to prevalence ratio in 2017: 0.58; 95% confidence interval: 0.13, 0.91). CONCLUSIONS A review of 316 US clinical trials for alcohol, nicotine and illicit substance use disorders completed between 2010 and 2019 showed that females were enrolled at lower rates than males overall. Only 8% of the trials reviewed reported sex-specific analyses and 1.5% reported transgender participants.
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Affiliation(s)
- Christine M Gunn
- Department of Medicine, Section of General Internal Medicine, Women's Health Unit, Boston University School of Medicine, Boston, MA, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Magda Pankowska
- Department of Medicine, Section of General Internal Medicine, Women's Health Unit, Boston University School of Medicine, Boston, MA, USA
| | - Miriam Harris
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Emma Helsing
- Department of Medicine, Section of General Internal Medicine, Women's Health Unit, Boston University School of Medicine, Boston, MA, USA
| | - Tracy A Battaglia
- Department of Medicine, Section of General Internal Medicine, Women's Health Unit, Boston University School of Medicine, Boston, MA, USA
| | - Sarah M Bagley
- Department of Medicine, Section of General Internal Medicine, Department of Pediatrics, Division of General Pediatrics, Boston University School of Medicine, Boston, MA, USA
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Kressin NR, Wormwood JB, Battaglia TA, Slanetz PJ, Gunn CM. A letter is not enough: Women's preferences for and experiences of receiving breast density information. Patient Educ Couns 2022; 105:2450-2456. [PMID: 35534300 PMCID: PMC9250336 DOI: 10.1016/j.pec.2022.03.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/11/2022] [Accepted: 03/15/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Despite evidence of disparate uptake of breast density (BD) information, little is known about diverse women's preferences for and experiences learning about BD. METHODS Telephone survey among 2306 racially/ethnically and literacy diverse women; qualitative interviews with 61 survey respondents. Responses by participant race/ethnicity and literacy were examined using bivariate, then multivariable analyses. Interviews were content-analyzed for themes. RESULTS Most women (80%) preferred learning of personal BD from providers, with higher rates among Non-Hispanic Black (85%) than Non-Hispanic White women (80%); and among Non-Hispanic White than Asian women (72%, all ps<0.05). Women with low literacy less often preferred receiving BD information from providers (76% v. 81%), more often preferring written notification (21% vs. 10%); women with high literacy more often preferred learning through an online portal (9% vs 3%). Most women (93%) received BD information from providers (no between group differences). Qualitative findings detailed women's desires for obtaining BD information from providers, written information, and visual depictions of BD. CONCLUSIONS When educating women about BD, one size does not fit all. PRACTICE IMPLICATIONS Additional educational methods are needed beyond written BD notifications to sufficiently address the varying informational needs and preferences of all USA women.
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Affiliation(s)
- Nancy R Kressin
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA.
| | - Jolie B Wormwood
- Department of Psychology, University of New Hampshire, Durham, NH, USA
| | - Tracy A Battaglia
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Priscilla J Slanetz
- Department of Radiology, Boston University School of Medicine, Boston, MA, USA
| | - Christine M Gunn
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
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Battaglia TA, Gunn CM, Bak SM, Flacks J, Nelson KP, Wang N, Ko NY, Morton SJ. Patient navigation to address sociolegal barriers for patients with cancer: A comparative-effectiveness study. Cancer 2022; 128 Suppl 13:2623-2635. [PMID: 35699610 PMCID: PMC10152516 DOI: 10.1002/cncr.33965] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 08/17/2021] [Accepted: 08/18/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Sociolegal barriers to cancer care are defined as health-related social needs like affordable healthy housing, stable utility service, and food security that may be remedied by public policy, law, regulation, or programming. Legal support has not been studied in cancer care. METHODS The authors conducted a randomized controlled trial of patients who had newly diagnosed cancer at a safety-net medical center in Boston from 2014 through 2017, comparing standard patient navigation versus enhanced navigation partnered with legal advocates to identify and address sociolegal barriers. English-speaking, Spanish-speaking, or Haitian Creole-speaking patients with breast and lung cancer were eligible within 30 days of diagnosis. The primary outcome was timely treatment within 90 days of diagnosis. Secondary outcomes included patient-reported outcomes (distress, cancer-related needs, and satisfaction with navigation) at baseline and at 6 months. RESULTS In total, 201 patients with breast cancer and 19 with lung cancer enrolled (response rate, 78%). The mean patient age was 55 years, 51% of patients were Black and 22% were Hispanic, 20% spoke Spanish and 8% spoke Haitian Creole, 73% had public health insurance, 77% reported 1 or more perceived sociolegal barrier, and the most common were barriers to housing and employment. Ninety-six percent of participants with breast cancer and 73% of those with lung cancer initiated treatment within 90 days. No significant effect of enhanced navigation was observed on the receipt of timely treatment among participants with breast cancer (odds ratio, 0.88; 95% CI, 0.17-4.52) or among those with lung cancer (odds ratio, 4.00; 95% CI, 0.35-45.4). No differences in patient-reported outcomes were observed between treatment groups. CONCLUSIONS Navigation enhanced by access to legal consultation and support had no impact on timely treatment, patient distress, or patient needs. Although most patients reported sociolegal barriers, few required intensive legal services that could not be addressed by navigators. LAY SUMMARY In patients with cancer, the experience of sociolegal barriers to care, such as unstable housing, utility services, or food insecurity, is discussed. Addressing these barriers through legal information and assistance may improve care. This study compares standard patient navigation versus enhanced navigation partnered with legal advocates for patients with breast and lung cancers. Almost all patients in both navigation groups received timely care and also reported the same levels of distress, needs, and satisfaction with navigation. Although 75% of patients in the study had at least 1 sociolegal barrier identified, few required legal advocacy beyond what a navigator who received legal information and coaching could provide.
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Affiliation(s)
- Tracy A Battaglia
- Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts
| | - Christine M Gunn
- Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts.,Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Sharon M Bak
- Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts
| | - JoHanna Flacks
- Medical-Legal Partnership, Boston (MLPB), Boston, Massachusetts
| | - Kerrie P Nelson
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Na Wang
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | - Naomi Y Ko
- Department of Medicine, Hematology, and Medical Oncology, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts
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Kressin NR, Wormwood JB, Battaglia TA, Maschke AD, Slanetz PJ, Pankowska M, Gunn CM. Women's Understandings and Misunderstandings of Breast Density and Related Concepts: A Mixed Methods Study. J Womens Health (Larchmt) 2022; 31:983-990. [DOI: 10.1089/jwh.2021.0343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Nancy R. Kressin
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jolie B. Wormwood
- Department of Psychology, University of New Hampshire, Durham, New Hampshire, USA
| | - Tracy A. Battaglia
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Ariel D. Maschke
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Priscilla J. Slanetz
- Department of Radiology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Magdalena Pankowska
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Christine M. Gunn
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts, USA
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA
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Gunn CM, Gignac G, Pankowska M, Zayhowski K, Wang C. Abstract PO-050: Characterizing access to genetics referrals for prostate cancer in a safety net hospital. Cancer Epidemiol Biomarkers Prev 2022. [DOI: 10.1158/1538-7755.disp21-po-050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
Genetic testing, as a key component of precision medicine, may reduce prostate cancer treatment-related disparities, but only if widely disseminated outside of tertiary cancer care settings. This study sought to characterize predictors of germline genetic testing referrals and use among patients diagnosed with prostate cancer at a safety-net hospital using electronic medical record data. Men who had a confirmed diagnosis of prostate cancer between January 1, 2011 and March 10, 2020 were identified via the tumor registry. Using a centralized clinical data warehouse, we collected data on age, race, ethnicity, primary language, marital status, clinical stage, and insurance. The primary outcome was receipt of a referral to genetic counseling. We hypothesized that men who were foreign-born, non-English speaking, identified as Black race or Hispanic ethnicity, and were older would be less likely to be referred for genetic testing. A secondary outcome was the completion of genetic testing. Descriptive statistics (means, standard deviations, frequencies) described the cohort. In multivariable analyses, logistic regression estimated odds ratios (OR) and 95% confidence intervals (95% CI) for factors hypothesized to influence referral to genetic testing: age, race (Black, White, Asian, Other), ethnicity (Hispanic vs. non-Hispanic), language (English vs. non-English), country of origin (US vs. Other), insurance (Medicare, Medicaid, Private, Other), and clinical cancer stage (Local, Regional, Metastatic). Overall, 1,877 patients were diagnosed with prostate cancer in the study period. The mean age was 65 years (SD=9). 44% identified as Black race, 32% White. Ethnic composition was 17% Hispanic, 80% Non-Hispanic. Almost half (49%) were married, 46% were foreign born, and 34% had Medicaid insurance at diagnosis. Two-thirds (67%) spoke English, and 33% were non-English speakers. The majority (65%) had local-only disease at diagnosis, 3% had regional disease, 9% metastatic, and 22% had missing clinical stage data. For the primary outcome, 163 (9%) of all patients received at least one genetics referral. In multivariate models, we found that those who were older (OR=0.95, 95% CI: 0.93, 0.98) and identified as White race (OR=0.60, 95% CI: 0.38, 0.96) had lower odds of receiving a referral. Those with regional or metastatic disease at diagnosis were significantly more likely to receive referral, as expected (OR= 4.45 and 4.78, respectively). No other demographics significantly predicted referral. Of the 163 men referred to genetics, 136 (83%) had at least one genetics encounter and 19 (14%) had genetic testing. In sum, few patients received referrals for genetic counseling and testing from 2010-2021, with 80% occurring post-guideline changes in 2018. When referrals were made, our sample had high rates of genetics encounters, although lower rates of testing completion. Low rates of referral and testing indicate opportunities to improve both identification of eligible patients and resolve barriers to completing genetic testing post-encounter.
Citation Format: Christine M. Gunn, Gretchen Gignac, Magdalena Pankowska, Kimberly Zayhowski, Catharine Wang. Characterizing access to genetics referrals for prostate cancer in a safety net hospital [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-050.
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Kim SE, Bachorik AE, Bertrand KA, Gunn CM. Differences in Breast Cancer Screening Practices by Diabetes Status and Race/Ethnicity in the United States. J Womens Health (Larchmt) 2021; 31:848-855. [PMID: 34935471 DOI: 10.1089/jwh.2021.0396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: Socioeconomic and health-related factors, including comorbid illness, may affect mammography screening rates and subsequently contribute to breast cancer outcomes. We explored the association between diabetes and mammography screening, and whether this association varied between racial, ethnic, and geographic groups. Methods: Cross-sectional data from the 2012, 2014, 2016, and 2018 Behavioral Risk Factor Surveillance System were used to fit logistic regression models assessing the association between diabetes and up-to-date mammography screening in 497,600 women, aged 50-74 years. Participants were considered exposed if they responded "yes" to "(Ever told) you have diabetes?" and up to date on screening if they responded "yes" to having a mammogram within the past 2 years. Models were adjusted for age, health status, socioeconomic, and access variables. Results: The majority of participants were White (79.6%), non-Hispanic (88.9%), and up to date on screening (78.8%). Overall, 16.8% reported having diabetes. In fully adjusted models, White women with diabetes were 12% more likely to be up to date on screening (odds ratio [OR]: 1.12, 95% confidence interval [CI]: 1.06-1.19) than those without diabetes. Black/African American women and those of Hispanic ethnicity with diabetes were more likely to report being up to date with mammography (ORBlack: 1.28, 95% CI: 1.12-1.45; ORHispanic: 1.19, 95% CI: 1.13-1.24) than those without. Patterns were similar across geographic regions. Conclusions: Women of ages 50-74 years with diabetes were more likely to be up to date on screening than women without diabetes. Chronic disease management may represent an opportunity to address cancer screening.
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Affiliation(s)
- Sydney E Kim
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Alexandra E Bachorik
- Section of General Internal Medicine, Women's Health Unit, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | | | - Christine M Gunn
- Section of General Internal Medicine, Women's Health Unit, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA.,Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts, USA
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Gunn CM, Maschke A, Paasche-Orlow MK, Housten AJ, Kressin NR, Schonberg MA, Battaglia TA. Using Mixed Methods With Multiple Stakeholders to Inform Development of a Breast Cancer Screening Decision Aid for Women With Limited Health Literacy. MDM Policy Pract 2021; 6:23814683211033249. [PMID: 34350361 PMCID: PMC8295953 DOI: 10.1177/23814683211033249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 06/25/2021] [Indexed: 12/12/2022] Open
Abstract
Background. When stakeholders offer divergent input, it can be unclear how to prioritize information for decision aids (DAs) on mammography screening. Objectives. This analysis triangulates perspectives (breast cancer screening experts, primary care providers [PCPs], and patients with limited health literacy [LHL]) to understand areas of divergent and convergent input across stakeholder groups in developing a breast cancer screening DA for younger women with LHL. Design. A modified online Delphi panel of 8 experts rated 57 statements for inclusion in a breast cancer screening DA over three rounds. Individual interviews with 25 patients with LHL and 20 PCPs from a large safety net hospital explored informational needs about mammography decision making. Codes from the qualitative interviews and open-ended responses from the Delphi process were mapped across stakeholders to ascertain areas where stakeholder preferences converged or diverged. Results. Four themes regarding informational needs were identified regarding 1) the benefits and harms of screening, 2) different screening modalities, 3) the experience of mammography, and 4) communication about breast cancer risk. Patients viewed pain as the primary harm, while PCPs and experts emphasized the harm of false positives. Patients, but not PCPs or experts, felt that information about the process of getting a mammogram was important. PCPs believed that mammography was the only evidence-based screening modality, while patients believed breast self-exam was also important for screening. All stakeholders described incorporating personal risk information as important. Limitations. As participants came from one hospital, perceptions may reflect local practices. The Delphi sample size was small. Conclusions. Patients, experts, and PCPs had divergent views on the most important information needed for screening decisions. More evidence is needed to guide integration of multiple stakeholder perspectives into the content of DAs.
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Affiliation(s)
- Christine M Gunn
- Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, Massachusetts
| | - Ariel Maschke
- Department of Medicine, Section of General Internal Medicine, Women's Health Unit, School of Medicine, Boston University, Boston, Massachusetts
| | - Michael K Paasche-Orlow
- Department of Medicine, Section of General Internal Medicine, School of Medicine, Boston University, Boston, Massachusetts
| | - Ashley J Housten
- Department of Surgery, Division of Public Health Sciences, School of Medicine, Washington University, St. Louis, Missouri
| | - Nancy R Kressin
- Department of Medicine, Section of General Internal Medicine, School of Medicine, Boston University, Boston, Massachusetts
| | - Mara A Schonberg
- Harvard Medical School, Beth Israel Deaconess Medical Center, Brookline, Massachusetts
| | - Tracy A Battaglia
- Department of Medicine, Section of General Internal Medicine, Women's Health Unit, School of Medicine, Boston University, Boston, Massachusetts
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Gunn CM, Maschke A, Harris M, Schoenberger SF, Sampath S, Walley AY, Bagley SM. Age-based preferences for risk communication in the fentanyl era: 'A lot of people keep seeing other people die and that's not enough for them'. Addiction 2021; 116:1495-1504. [PMID: 33119196 PMCID: PMC8081736 DOI: 10.1111/add.15305] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 04/01/2020] [Accepted: 10/16/2020] [Indexed: 02/03/2023]
Abstract
AIMS To explore how people who use fentanyl and health-care providers engaged in and responded to overdose risk communication interactions, and how these engagements and responses might vary by age. DESIGN A single-site qualitative in-depth interview study. SETTING Boston, MA, United States. PARTICIPANTS The sample included 21 people (10 women, 11 men) who were either 18-25 or 35+, English-speaking, and reported illicit fentanyl use in the last year and 10 health-care providers who worked directly with people who use fentanyl (PWUF) in clinical and community settings. MEASUREMENTS Open-ended, flexible interview questions guided by a risk communication framework were used in all interviews. Codes used for thematic analysis included deductive codes related to the risk communication framework and inductive, emergent codes from interview content. FINDINGS We identified potential age-based differences in perceptions of fentanyl overdose, including that younger participants appeared to display more perceptions of an immunity to fentanyl's lethality, while older people seemed to express a stronger aversion to fentanyl due to its heightened risk of fatal overdose, shorter effects and potential for long-term health consequences. Providers perceived greater challenges relaying risk information to young PWUF and believed them to be less open to risk communication. Compassionate harm reduction communication was preferred by all participants and perceived to be delivered most effectively by community health workers and peers. PWUF and providers identified structural barriers that limited compassionate harm reduction, including misalignment of available treatment with preferred options and clinical structures that impeded the delivery of risk communication messages. CONCLUSIONS Among people who engage in illicit fentanyl use, fentanyl-related risk communication experiences and preferences may vary by age, but some foundational elements including compassionate, trust-building approaches seem to be preferred across the age spectrum. Structural barriers in the clinical setting such as provider-prescribing power and infrequent encounters may impede the providers' ability to provide compassionate harm reduction communication.
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Affiliation(s)
- Christine M Gunn
- Department of Medicine, Section of General Internal Medicine, Women's Health Unit, Boston University School of Medicine, Boston, MA, USA
| | - Ariel Maschke
- Department of Medicine, Section of General Internal Medicine, Women's Health Unit, Boston University School of Medicine, Boston, MA, USA
| | - Miriam Harris
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Samantha F Schoenberger
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | | | - Alexander Y Walley
- Boston Medical Center, Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Grayken Center for Addiction, Boston University School of Medicine, Boston, MA, USA
| | - Sarah M Bagley
- Department of Medicine, Section of General Internal Medicine, Department of Pediatrics, Division of General Pediatrics, Boston University School of Medicine, Boston, MA, USA
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22
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Harris MTH, Bagley SM, Maschke A, Schoenberger SF, Sampath S, Walley AY, Gunn CM. Competing risks of women and men who use fentanyl: "The number one thing I worry about would be my safety and number two would be overdose". J Subst Abuse Treat 2021; 125:108313. [PMID: 34016300 PMCID: PMC8140193 DOI: 10.1016/j.jsat.2021.108313] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/16/2020] [Accepted: 01/22/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Standard public health approaches to risk communication do not address the gendered dynamics of drug use. The aim of this study was to explore perceptions of fentanyl-related risks among women and men to inform future risk communication approaches. METHODS We conducted a qualitative study, purposively sampling English-speaking women and men, aged 18-25 or 35+ years, with past 12-month illicitly manufactured fentanyl use. In-depth individual interviews explored experiences of women and men related to overdose and fentanyl use. We conducted a grounded content analysis examining specific codes related to overdose and other health or social risks attributed to drug use. Using a constant comparison technique, we explored commonalities and differences in themes between women and men. RESULTS The study enrolled twenty-one participants, 10 women and 11 men. All participants had personal overdose experiences. Both women and men described overdosing as a "chronic" condition and expressed de-sensitization to the risk of overdose. Women and men described other risks around health, safety, and state services that often superseded their fear of overdose. Women feared physical and sexual violence and prioritized caring for children and maintaining relations with child protective services, while men feared violence arising from obtaining and using street drugs and incarceration. Only women reported that fear of violence prevented their utilization of harm reduction services. CONCLUSIONS Experiences with overdose and risk communication among people who use fentanyl-containing opioids varied by gender. The development of gender-responsive programs that address targeted concerns may be an avenue to enhance engagement with harm reduction and treatment services and create safe spaces for women not currently accessing available services.
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Affiliation(s)
- Miriam T H Harris
- Boston University School of Medicine/Boston Medical Center, Department of Medicine, Section of General Internal Medicine, 801 Massachusetts Ave, Second Floor, Boston, MA 02118, United States of America; Clinical Addiction Research and Education Unit, Grayken Center for Addiction, 801 Massachusetts Ave, Second Floor, Boston, MA 02118, United States of America.
| | - Sarah M Bagley
- Boston University School of Medicine/Boston Medical Center, Department of Medicine, Section of General Internal Medicine, 801 Massachusetts Ave, Second Floor, Boston, MA 02118, United States of America; Clinical Addiction Research and Education Unit, Grayken Center for Addiction, 801 Massachusetts Ave, Second Floor, Boston, MA 02118, United States of America; Boston University School of Medicine, Department of Pediatrics, Division of General Academic Pediatrics, 801 Massachusetts Ave, Second Floor, Boston, MA 02118, United States of America.
| | - Ariel Maschke
- Boston University School of Medicine, Department of Medicine, Section of General Internal Medicine, Women's Health Unit, 801 Massachusetts Ave, First Floor, Boston, MA 02118, United States of America.
| | - Samantha F Schoenberger
- Boston University School of Medicine/Boston Medical Center, Department of Medicine, Section of General Internal Medicine, 801 Massachusetts Ave, Second Floor, Boston, MA 02118, United States of America.
| | - Spoorthi Sampath
- Boston University School of Medicine, Department of Medicine, Section of General Internal Medicine, Women's Health Unit, 801 Massachusetts Ave, First Floor, Boston, MA 02118, United States of America.
| | - Alexander Y Walley
- Boston University School of Medicine/Boston Medical Center, Department of Medicine, Section of General Internal Medicine, 801 Massachusetts Ave, Second Floor, Boston, MA 02118, United States of America; Clinical Addiction Research and Education Unit, Grayken Center for Addiction, 801 Massachusetts Ave, Second Floor, Boston, MA 02118, United States of America.
| | - Christine M Gunn
- Boston University School of Medicine, Department of Medicine, Section of General Internal Medicine, Women's Health Unit, 801 Massachusetts Ave, First Floor, Boston, MA 02118, United States of America; Boston University School of Public Health, Department of Health Law, Policy, and Management, 715 Albany Street, Boston, MA 02118, United States of America.
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Gunn CM, Maschke A, Paasche-Orlow MK, Kressin NR, Schonberg MA, Battaglia TA. Engaging Women with Limited Health Literacy in Mammography Decision-Making: Perspectives of Patients and Primary Care Providers. J Gen Intern Med 2021; 36:938-945. [PMID: 32935318 PMCID: PMC8042081 DOI: 10.1007/s11606-020-06213-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 09/03/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Limited health literacy is a driver of cancer disparities and associated with less participation in medical decisions. Mammography screening decisions are an exemplar of where health literacy may impact decision-making and outcomes. OBJECTIVE To describe informational needs and shared decision-making (SDM) experiences among women ages 40-54 who have limited health literacy and primary care providers (PCPs). DESIGN Qualitative, in-depth interviews explored experiences with mammography counseling and SDM. PARTICIPANTS Women ages 40-54 with limited health literacy and no history of breast cancer or mammogram in the prior 9 months were approached before a primary care visit at a Boston academic, safety-net hospital. PCPs practicing at this site were eligible for PCP interviews. APPROACH Interviews were audio-recorded and transcribed verbatim. A set of deductive codes for each stakeholder group was developed based on literature and the interview guide. Inductive codes were generated during codebook development. Codes were compared within and across patient and PCP interviews to create themes relevant to mammography decision-making. KEY RESULTS The average age of 25 interviewed patients was 46.5; 18 identified as black, 3 as Hispanic, 2 as non-Hispanic white, and 2 had no recorded race or ethnicity. Of 20 PCPs, 15 were female; 12 had practiced for >5 years. Patients described a lack of technical (appropriate tests and what they do) and process (what happens during a mammogram visit) knowledge, viewing these as necessary for decision-making. PCPs were reluctant to engage patients with limited health literacy in SDM due to time constraints and feared that increased information might confuse patients or deter them from having mammograms. Both groups felt pre-visit education would facilitate mammography-related SDM during clinical visits. CONCLUSION Both patients and PCPs perceived a need for tools to relay technical and process knowledge about mammography prior to clinical encounters to address the scope of information that patients with limited health literacy desired.
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Affiliation(s)
- Christine M Gunn
- Department of Medicine, Section of General Internal Medicine, Women's Health Unit, Boston University School of Medicine, Boston, MA, USA.
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA.
| | - Ariel Maschke
- Department of Medicine, Section of General Internal Medicine, Women's Health Unit, Boston University School of Medicine, Boston, MA, USA
| | - Michael K Paasche-Orlow
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Nancy R Kressin
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Mara A Schonberg
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Tracy A Battaglia
- Department of Medicine, Section of General Internal Medicine, Women's Health Unit, Boston University School of Medicine, Boston, MA, USA
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Abstract
Approximately one-third of adults in the United States (U.S.) have limited health literacy. Those with limited health literacy often have difficultly navigating the health care environment, including navigating care across the cancer continuum (e.g., prevention, screening, diagnosis, treatment). Evidence-based interventions to assist adults with limited health literacy improve health outcomes; however, little is known about health literacy interventions in the context of cancer and their impact on cancer-specific health outcomes. The purpose of this review was to identify and characterize the literature on health literacy interventions across the cancer care continuum. Specifically, our aim was to review the strength of evidence, outcomes assessed, and intervention modalities within the existing literature reporting health literacy interventions in cancer. Our search yielded 1036 records (prevention/screening n = 174; diagnosis/treatment n = 862). Following deduplication and review for inclusion criteria, we analyzed 87 records of intervention studies reporting health literacy outcomes, including 45 pilot studies (prevention/screening n = 24; diagnosis/treatment n = 21) and 42 randomized controlled trials or quasi-experimental trials (prevention/screening n = 31; diagnosis/treatment n = 11). This literature included 36 unique interventions (prevention/screening n = 28; diagnosis/treatment n = 8), mostly in the formative stages of intervention development, with few assessments of evidence-based interventions. These gaps in the literature necessitate further research in the development and implementation of evidence-based health literacy interventions to improve cancer outcomes.
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Affiliation(s)
- A J Housten
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, 660 S. Euclid Ave. Campus Box 8100, St. Louis, MO, 63110, USA.
| | - C M Gunn
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - M K Paasche-Orlow
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - K M Basen-Engquist
- Department of Behavioral Science, Division of Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Kressin NR, Battaglia TA, Wormwood JB, Slanetz PJ, Gunn CM. Dense Breast Notification Laws' Association With Outcomes in the US Population: A Cross-Sectional Study. J Am Coll Radiol 2020; 18:685-695. [PMID: 33358722 DOI: 10.1016/j.jacr.2020.11.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 11/28/2020] [Accepted: 11/30/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Understanding whether states' breast density notifications are associated with desired effects, or disparities, can inform federal policy. We examined self-reported receipt of personal breast density information, breast density discussions with providers, knowledge about density's masking effect, and association with increased breast cancer risk by state legislation status and women's sociodemographic characteristics. METHODS Cross-sectional observational population-based telephone survey of women aged >40 years who underwent mammography within prior 2 years, had no history of breast cancer, and had heard the term "breast density." RESULTS Among 2,306 women, 57% received personal breast density information. Multivariate regression models adjusted for covariates indicated that women in notification states were 1.5 times more likely to receive density information, and older Black and Asian women of lower income and lower health literacy were less likely. Overall, only 39% of women discussed density with providers; women in notification states were 1.75 times as likely. Older and Asian women were less likely to have spoken with providers; women with high literacy or prior biopsy were more likely. State legislation status was not associated with differences in density knowledge, but Hispanic women and women of lower income or low health literacy had less knowledge regarding density's masking effects; older women were more knowledgeable. Hispanic women and women of lower income or low health literacy were more likely, and middle-aged women less likely, to recognize increased breast cancer risk. DISCUSSION Some positive effects were observed, but sociodemographic disparities suggest tailoring of future breast density communications for specific populations of women to ensure equitable understanding.
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Affiliation(s)
- Nancy R Kressin
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts.
| | - Tracy A Battaglia
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts; Associate Director of the Belkin Breast Health Center, Boston Medical Center, and Director, Women's Health Group, Boston Medical Center
| | - Jolie B Wormwood
- Department of Psychology, University of New Hampshire, Durham, New Hampshire
| | - Priscilla J Slanetz
- Vice Chair of Academic Affairs and Associate Program Director of the Diagnostic Radiology Residency, Department of Radiology, Boston University Medical Center; President-Elect of the Massachusetts Radiological Society and Chair of the ACR Appropriateness Criteria Committee Breast Imaging Panel; Department of Radiology, Boston University School of Medicine, Boston, Massachusetts
| | - Christine M Gunn
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
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Harris M, McDonald EG, Marrone E, El-Messidi A, Girard T, Gosselin S, Gunn CM, Shapiro GD, Longo C, Dayan N. Postpartum Analgesia in New Mothers (PAIN) Study: A Survey of Canadian Obstetricians' Post-Delivery Opioid-Prescribing Practices. J Obstet Gynaecol Can 2020; 43:957-966.e9. [PMID: 33321248 DOI: 10.1016/j.jogc.2020.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE We aimed to describe opioid prescribing practices after obstetric delivery and to evaluate how these practices compare with national opioid prescribing guidelines. METHODS A closed survey was developed, evaluated for validity and reliability, and distributed by email to obstetrician members of the Society of Obstetricians and Gynaecologists of Canada (SOGC) in December 2018. Descriptive statistics were used to summarize respondent demographics, pharmaceutical pain management strategies, and opioid prescribing practices. Logistic regression was used to measure associations between respondent characteristics and high-risk opioid prescribing practices (e.g., prescribing >50 mg morphine equivalent dose per day, prescribing >5 days, not screening for substance/opioid use disorder before prescribing). RESULTS Our survey had high content validity (content validity index 0.89; 95% CI 0.78-1.00) and adequate reliability (Kappa 0.70; 95% CI 0.63-0.84 and intraclass correlation coefficient 0.70; 95% CI 0.67-0.81). Of the 1019 SOGC members reached, 243 initiated the survey (response rate, 24%). Among respondents, 235 (92%) completed the survey. Among opioid prescribers, 47% reported at least 1 high-risk opioid prescribing practice, the most frequent being a lack of substance/opioid use disorder screening. In the adjusted logistic regression model, being in practice more than 20 years (adjusted odds ratio [aOR] 0.53; 95% CI 0.29-0.93) and practising in a non-central area of Canada (aOR 0.49; 95% CI 0.28-0.84) reduced the odds of high-risk prescribing. CONCLUSION Further research on barriers to screening are needed to support and enhance safer opioid prescribing practices among Canadian obstetricians.
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Affiliation(s)
- Miriam Harris
- Grayken Center for Addiction, Boston Medical Center, Boston University School of Medicine, Boston, MA; Department of Medicine, McGill University Health Centre, Montréal, QC.
| | - Emily G McDonald
- Department of Medicine, McGill University Health Centre, Montréal, QC; Research Institute, McGill University Health Centre, Montréal, QC
| | - Erica Marrone
- Department of Family Medicine, McGill University, Montréal, QC; Faculté de pharmacie, Université de Laval, Québec, QC
| | - Amira El-Messidi
- Department of Obstetrics and Gynecology, McGill University Health Centre, Montréal, QC
| | - Tanya Girard
- Department of Medicine, McGill University Health Centre, Montréal, QC
| | - Sophie Gosselin
- Department of Emergency Medicine, Faculty of Medicine, McGill University, Montréal, QC; Department of Emergency Medicine, Hôpital Charles-Lemoyne, Longueuil, QC
| | - Christine M Gunn
- Women's Health Unit, Evans Department of Medicine, Boston University School of Medicine, Boston, MA
| | | | - Cristina Longo
- Department of Family Medicine, McGill University, Montréal, QC
| | - Natalie Dayan
- Department of Medicine, McGill University Health Centre, Montréal, QC; Research Institute, McGill University Health Centre, Montréal, QC; Department of Obstetrics and Gynecology, McGill University Health Centre, Montréal, QC
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Maschke A, Paasche-Orlow MK, Kressin NR, Schonberg MA, Battaglia TA, Gunn CM. Discussions of Potential Mammography Benefits and Harms among Patients with Limited Health Literacy and Providers: "Oh, There are Harms?". J Health Commun 2020; 25:951-961. [PMID: 33455518 PMCID: PMC8062298 DOI: 10.1080/10810730.2020.1845256] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Starting breast cancer screening at age 40 versus 50 may increase potential harms frequency with a small mortality benefit. Younger women's screening decisions, therefore, may be complex. Shared decision-making (SDM) is recommended for women under 50 and may support women under 55 for whom guidelines vary. How women with limited health literacy (LHL) approach breast cancer screening decision-making is less understood, and most SDM tools are not designed with their input. This phenomenological study sought to characterize mammography counseling experiences among women with LHL and primary care providers (PCPs). Women ages 40-54 with LHL who had no history of breast cancer or mammogram within 9 months were approached before a primary care visit at a safety-net hospital. PCPs at this site were invited to participate. Qualitative interviews explored mammography counseling experiences. Patients also reviewed sample information materials. A constant comparison technique generated four themes salient to 25 patients and 20 PCPs: addressing family history versus comprehensive risk assessment; potential mammography harms discussions; information delivery preferences; and integrating pre-visit information tools. Findings suggest that current counseling techniques may not be responsive to patient-identified needs. Opportunities exist to improve how mammography information is shared and increase accessibility across the health literacy spectrum.
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Affiliation(s)
- Ariel Maschke
- Women's Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, MA, USA
| | - Michael K Paasche-Orlow
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Nancy R Kressin
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Mara A Schonberg
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Tracy A Battaglia
- Women's Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, MA, USA
| | - Christine M Gunn
- Women's Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, MA, USA
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
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28
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Kressin NR, Wormwood J, Battaglia TA, Slanetz PJ, Gunn CM. Abstract PO-079: Mixed success and persistent disparities in outcomes related to breast density legislation: A national survey. Cancer Epidemiol Biomarkers Prev 2020. [DOI: 10.1158/1538-7755.disp20-po-079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
Little is known about whether women residing in states with mandated dense breast notification (DBN) have improved awareness, knowledge, or discussion with their doctors, or whether there are disparities by sociodemographic characteristics. We conducted a cross-sectional, national telephone survey to assess the primary outcomes intended by DBN legislation: informing women about personal breast density, increasing awareness of its making effect and association with increased cancer risk, and prompting discussions with providers. Specific efforts were made to include women from all race/ethnic groups, education strata, and literacy levels.
Women aged >40 reporting a mammogram in <2 years, with no prior breast cancer diagnosis and having heard of the term ‘breast density’ were eligible. We conducted chi-square analyses for each outcome, comparing each by state DBN legislation status, age, income, race/ethnicity, health literacy, and two clinical breast cancer risk factors (family history, prior breast biopsy). Paired comparisons within each sociodemographic factor were tested using Z-tests (α=0.05). Multivariable, binary logistic regressions predicted each outcome using all variables above entered simultaneously as predictors. Secondary analyses tested whether sociodemographic differences in outcomes were moderated by state DBN status via interaction terms. The sample included 2,306 women; 1,782 residing in DBN states and 524 in non-DBN states. Half of the participants were white (50.3%), 23.1% non-Hispanic black, 14% Hispanic, 8.2% Asian, and 4.4% ‘other’. Women in DBN states were 1.55 (95% CI = 1.20, 1.99) times more likely to have received personal breast density information compared to women in non-DBN states after controlling for sociodemographic and risk factors. Those with lower incomes, Asian women, and those with lower health literacy were less likely to report receiving personal breast density information.
Overall, 39% had a discussion with their provider about breast density, with women in DBN states being 1.82 times more likely to have done so (95% CI= 1.40, 2.37).
There were no differences between women in DBN vs. non-DBN states related to knowledge of masking bias (OR=.99, 0.71, 1.39) or understanding that breast density is a cancer risk factor (OR=0.93, 0.71, 1.22). Hispanic and lower income women had less knowledge about these topics. Interaction models failed to reveal moderating effects of state DBN status, indicating that DBN legislation does not appear to be mitigating or worsening the observed sociodemographic differences. Findings suggest that mandated DBNs have had partial success informing women about their breast density. However, we saw few indications that DBNs increased knowledge and observed less knowledge among women with low income, racial/ethnic minority status and lower literacy. This ‘one size fits all’ policy approach to relaying breast density information appears to be inadequate in reducing disparities in breast density awareness and knowledge.
Citation Format: Nancy R. Kressin, Jolie Wormwood, Tracy A. Battaglia, Priscilla J. Slanetz, Christine M. Gunn. Mixed success and persistent disparities in outcomes related to breast density legislation: A national survey [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-079.
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Affiliation(s)
- Nancy R. Kressin
- 1Boston University School of Medicine, Department of Medicine, Boston, MA,
| | | | - Tracy A. Battaglia
- 1Boston University School of Medicine, Department of Medicine, Boston, MA,
| | | | - Christine M. Gunn
- 1Boston University School of Medicine, Department of Medicine, Boston, MA,
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Gunn CM, Battaglia TA, Paasche-Orlow MK, Schonberg M, Maschke A, Kressin NR. Abstract PO-017: Using a Delphi panel to establish content for a breast cancer screening decision aid inclusive of women with limited health literacy. Cancer Epidemiol Biomarkers Prev 2020. [DOI: 10.1158/1538-7755.disp20-po-017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
Breast cancer screening decision aids that help women understand their risk for cancer and available screening options can improve the quality of decision-making for women in their 40s, but existing decision aids do not address the needs of women with limited health literacy. We conducted a Delphi panel among breast cancer screening and decision science experts to determine content for a breast cancer screening decision aid for women ages 40-54 who have limited health literacy. Experts were those with an advanced degree (MD, PhD), at least 3 years of experience, and content expertise in breast cancer screening, health literacy, or decision aid design. Experts were invited via email to participate in an online Delphi panel, which aimed to establish consensus on decision aid content, guided by the International Patient Decision Aid Standards. Experts rated the importance of each item on a scale from 1 (not important) to 9 (very important), as well as how strong they felt the evidence was to support each. Open-ended responses explaining ratings were gathered, and in Round 1 experts were asked to nominate new items for inclusion. Following RAND methods, the 30th - 70th percentile range, central point, and asymmetry index were calculated for each item. From these values, a disagreement index was determined, and if the value was >1, indicating disagreement, the item was moved to the next round. Otherwise, consensus was established, and the item was omitted from future rounds. Between rounds, experts received a summary of their rating for each item relative to others, along with a summary of the open-ended explanations. The process was repeated for Rounds 2 and 3. 15 experts were invited, 9 agreed and 8 completed Round 1. All eight participants were female, with an average age of 53. Seven were white and 2 Asian. Five held medical doctorate degrees, 3 had PhDs. Seven experts completed all 3 rounds. Round 1 included 55 items, 30 of which obtained consensus (disagreement index < 1). 29 items were reviewed in Round 2 (25 from Round 1, plus 4 newly nominated items), 15 of which obtained consensus, leaving a final round of 14 items. In Round 3, 1 item achieved consensus, 4 items converged around uncertainty, and 9 did not reach consensus. Experts disagreed or were uncertain on the importance of including breast cancer risk factors and whether a description of the multiple screening modalities available should be included. Explanations for these items described balancing an ethical imperative to provide information and avoid paternalism while limiting information extraneous to the decision. While guidelines suggest that the age of initiating mammography and modalities used should involve an assessment of risk of developing breast cancer, experts did not agree about the inclusion of risk factor or modality information in a breast cancer screening decision aid for women with limited health literacy. Balancing detail with simplicity remains a challenge in determining content for decision support tools that seek to include a range of literacy levels.
Citation Format: Christine M. Gunn, Tracy A. Battaglia, Michael K. Paasche-Orlow, Mara Schonberg, Ariel Maschke, Nancy R. Kressin. Using a Delphi panel to establish content for a breast cancer screening decision aid inclusive of women with limited health literacy [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-017.
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Borno HT, Odisho AY, Gunn CM, Pankowska M, Rider JR. Disparities in precision medicine-Examining germline genetic counseling and testing patterns among men with prostate cancer. Urol Oncol 2020; 39:233.e9-233.e14. [PMID: 33158741 DOI: 10.1016/j.urolonc.2020.10.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 10/15/2020] [Accepted: 10/17/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION This study sought to examine whether germline genetic counseling and testing were employed differentially among men with prostate cancer by race and/or ethnicity and other social factors. METHODS In this retrospective analysis, all patients with prostate cancer listed as a visit diagnosis during the study period (April 2011 to August 2020) were identified from electronic health records. Patient characteristics were collected along with genetic counselor visits and germline genetic testing results in electronic health records. Multivariable analyses were performed with the primary outcome defined as the receipt of a genetic counseling visit and receipt of genetic testing. RESULTS A total of 14,610 patients with a prostate cancer diagnosis code were identified. The majority of patients were White (72%), aged >=65 years (62.7%), English-speaking (95%), married (71.4%), and publicly insured (58.7%). A total of 667 patients completed an appointment with a genetic counselor. A total of 439 patients received germline genetic test result, of whom 403 (91.8%) had also completed an appointment with a genetic counselor. Patients that were 65 years or older (adjusted odds ratio 0.53, 95%CI 0.44-0.65) and non-English proficient (adjusted odds ratio 0.71, 95%CI 0.42-1.21) were less likely to receive genetic counseling. Receiving genetic counseling was the strongest independent predictor of receipt of genetic testing. CONCLUSIONS The results of the current study highlight that the role of social factors in contributing to disparities in genetic counseling and testing among men with prostate cancer. These results underscore the importance of developing novel strategies to tackle contributors of observed disparities including language, age, and insurance status.
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Affiliation(s)
- Hala T Borno
- Department of Medicine, Division of Hematology/Oncology, University of California, San Francisco, CA.
| | - Anobel Y Odisho
- Department of Urology, University of California, San Francisco, CA; Center for Digital Health Innovation, University of California, San Francisco, CA
| | - Christine M Gunn
- Department of Medicine, Boston University School of Medicine, Section of General Internal Medicine, Boston, MA; Department of Health Law, Boston University School of Public Health, Policy, and Management, Boston, MA
| | - Magdalena Pankowska
- Department of Medicine, Boston University School of Medicine, Section of General Internal Medicine, Boston, MA
| | - Jennifer R Rider
- Department of Epidemiology, Boston University School of Public Health, Boston, MA
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Kressin NR, Wormwood JB, Battaglia TA, Gunn CM. Differences in Breast Density Awareness, Knowledge, and Plans Based on State Legislation Status and Sociodemographic Characteristics. J Gen Intern Med 2020; 35:1923-1925. [PMID: 31845108 PMCID: PMC7280429 DOI: 10.1007/s11606-019-05578-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 09/26/2019] [Accepted: 11/22/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Nancy R Kressin
- Veterans Affairs Boston Healthcare System, Boston, MA, USA. .,Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA.
| | - Jolie B Wormwood
- Department of Psychology, University of New Hampshire, Durham, NH, USA
| | - Tracy A Battaglia
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Christine M Gunn
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
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Affiliation(s)
- Hala T Borno
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco
| | - Jennifer R Rider
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
| | - Christine M Gunn
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts
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Gunn CM, Paasche-Orlow MK, Bak S, Wang N, Pamphile J, Nelson K, Morton S, Battaglia TA. Health Literacy, Language, and Cancer-Related Needs in the First 6 Months After a Breast Cancer Diagnosis. JCO Oncol Pract 2020; 16:e741-e750. [PMID: 32216715 DOI: 10.1200/jop.19.00526] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Low health literacy (HL) and language negatively affect cancer screening and prevention behaviors; less is known about how they affect the patient's experience during cancer treatment. This study explores associations among HL, spoken language, and dimensions of cancer-related needs within 6 months of receiving a breast cancer diagnosis. METHODS Women speaking English, Spanish, or Haitian Creole, enrolled in a patient navigation study at diagnosis, completed a survey in their primary spoken language at baseline and 6 months to characterize their cancer-related needs. HL was measured using the Brief Health Literacy Screening Tool. Outcomes included the Cancer Needs Distress Inventory (CaNDI; n = 38 items) and the Communication and Attitudinal Self-Efficacy scale (CASE-Cancer) for cancer (n = 12 items). Linear regressions measured the impact of HL and language on total CaNDI and CASE-Cancer scale for cancer scores and subscales, adjusted for demographics. RESULTS At baseline, 262 women participated and 228 (87%) followed up at 6 months. Of these, 38% had adequate HL, 33% had marginal HL, and 29% had inadequate HL. Women with inadequate or marginal HL had higher median baseline CaNDI scores (P = .02) and lower self-efficacy scores (P = .008), relative to those with adequate HL. Haitian-Creole speakers had significantly lower CANDI scores at baseline (P = .03). Adjusting for demographics, differences in CaNDI scores at baseline remained significant for those with lower HL and Haitian-Creole speakers. At 6 months, differences in self-efficacy persisted for Haitian-Creole speakers. CONCLUSION Findings suggest that interventions oriented to mitigating HL and language barriers might reduce distress at the time of diagnosis and improve self-efficacy over the course of treatment.
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Affiliation(s)
- Christine M Gunn
- Evans Department of Medicine, Section of General Internal Medicine, Women's Health Unit, Boston University School of Medicine, Boston, MA.,Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA
| | - Michael K Paasche-Orlow
- Evans Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA
| | - Sharon Bak
- Evans Department of Medicine, Section of General Internal Medicine, Women's Health Unit, Boston University School of Medicine, Boston, MA
| | - Na Wang
- Biostatistics and Epidemiology Data Analytic Center, Boston University, Boston, MA
| | - Jennifer Pamphile
- Evans Department of Medicine, Section of General Internal Medicine, Women's Health Unit, Boston University School of Medicine, Boston, MA
| | - Kerrie Nelson
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | | | - Tracy A Battaglia
- Evans Department of Medicine, Section of General Internal Medicine, Women's Health Unit, Boston University School of Medicine, Boston, MA
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Gunn CM, Bokhour B, Parker VA, Parker PA, Blakeslee S, Bandos H, Holmberg C. Exploring Explanatory Models of Risk in Breast Cancer Risk Counseling Discussions: NSABP/NRG Oncology Decision-Making Project 1. Cancer Nurs 2020; 42:3-11. [PMID: 28661894 PMCID: PMC5745305 DOI: 10.1097/ncc.0000000000000517] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Explanatory models represent patient understanding of etiology, pathophysiology, illness, symptoms, and treatments, but little attention has been paid to how they are used by patients "at risk" for future disease. OBJECTIVE The aims of this study were to elucidate what constitutes an explanatory model of risk and to describe explanatory models of risk related to developing breast cancer. METHODS Thirty qualitative interviews with women identified as at an increased risk for breast cancer were conducted. Interviews were coded to identify domains of explanatory models of risk using a priori codes derived from the explanatory model of illness framework. Within each domain, a grounded thematic analysis described participants' explanatory models related to breast cancer risk. RESULTS The domains of treatment and etiology remained similar in a risk context compared with illness, whereas course of illness, symptoms, and pathophysiology differed. We identified a new, integrative concept relative to other domains within explanatory models of risk: social comparisons, which was dominant in risk perhaps due to the lack of physical experiences associated with being "at risk." CONCLUSIONS Developing inclusive understandings of risk and its treatment is key to developing a framework for the care of high-risk patients that is both evidence based and sensitive to patient preferences. IMPLICATIONS FOR PRACTICE The concept of "social comparisons" can assist healthcare providers in understanding women's decision making under conditions of risk. Ensuring that healthcare providers understand patient perceptions of risk is important because it relates to patient decision making, particularly due to an increasing focus on risk assessment in cancer.
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Affiliation(s)
- Christine M Gunn
- Author Affiliations: Women's Health Unit, Section of General Internal Medicine, Boston University School of Medicine (Dr Gunn); Department of Health Law, Policy and Management, Boston University School of Public Health (Drs Gunn, Bokhour, and V.A. Parker), Massachusetts; Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York (Dr P.A. Parker); NRG Oncology, and The University of Pittsburgh, Pittsburgh, Pennsylvania (Dr Bandos); and Institute of Public Health, Charité-Universitätsmedizin, Berlin, Germany (Dr Holmberg and Ms Blakeslee)
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Gunn CM, Paasche-Orlow MK. The FDA-Approved Essure Device Counseling Order Fails to Promote Patient Empowerment. Health Lit Res Pract 2019; 3:e70-e73. [PMID: 31289791 PMCID: PMC6607766 DOI: 10.3928/24748307-20190306-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 09/05/2018] [Indexed: 11/24/2022] Open
Affiliation(s)
- Christine M. Gunn
- Address correspondence to Christine M. Gunn, PhD, Boston University School of Medicine, 801 Massachusetts Avenue, First Floor, Women's Health Unit, Boston, MA 02118;
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Gunn CM, Bokhour BG, Parker VA, Battaglia TA, Parker PA, Fagerlin A, McCaskill-Stevens W, Bandos H, Blakeslee SB, Holmberg C. Understanding Decision Making about Breast Cancer Prevention in Action: The Intersection of Perceived Risk, Perceived Control, and Social Context: NRG Oncology/NSABP DMP-1. Med Decis Making 2019; 39:217-227. [PMID: 30803311 DOI: 10.1177/0272989x19827258] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Literature on decision making about breast cancer prevention focuses on individual perceptions and attitudes that predict chemoprevention use, rather than the process by which women decide whether to take risk-reducing medications. This secondary analysis aimed to understand how women's perceptions of breast cancer risk and locus of control influence their decision making. METHODS Women were accrued as part of the NRG Oncology/National Surgical Adjuvant Breast and Bowel Project Decision-Making Project 1, a study aimed at understanding contributors to chemoprevention uptake. Thirty women participated in qualitative in-depth interviews after being counseled about chemoprevention. Deductive codes grouped women based on dimensions of risk perception and locus of control. We used a constant comparative method to make connections among inductive themes focused on decision making, deductive codes for perceived risk and perceived locus of control, and the influence of explanatory models within and across participants. RESULTS Participants were predominantly non-Hispanic white (63%), with an average age of 50.9 years. Decision making varied across groups: the high-perceived risk/high-perceived control group used "social evidence" to model the behaviors of others. High-perceived risk/low-perceived control women made decisions based on beliefs about treatment, rooted in the experiences of social contacts. The low-perceived risk/low-perceived control group interpreted signs of risk as part of the normal continuum of bodily changes in comparison to others. Low-perceived risk/high-perceived control women focused on maintaining a current healthy trajectory. CONCLUSION "Social evidence" plays an important role in the decision-making process that is distinct from emotional aspects. Attending to patients' perceptions of risk and control in conjunction with social context is key to caring for patients at high risk in a way that is evidence based and sensitive to patient preferences.
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Affiliation(s)
- Christine M Gunn
- Section of General Internal Medicine, Women's Health Unit, Boston University School of Medicine, Boston, MA, USA.,Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, USA
| | - Barbara G Bokhour
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, USA.,Center for Healthcare Organization and Implementation Research, Department of Veterans Affairs, Bedford, MA, USA
| | - Victoria A Parker
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, USA.,University of New Hampshire, Durham, NH, USA
| | - Tracy A Battaglia
- Section of General Internal Medicine, Women's Health Unit, Boston University School of Medicine, Boston, MA, USA
| | - Patricia A Parker
- Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Angela Fagerlin
- University of Michigan, Ann Arbor, MI, USA.,Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA.,Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS 2.0) Center for Innovation, Salt Lake City, UT, USA
| | - Worta McCaskill-Stevens
- NRG Oncology, Pittsburgh, PA, USA.,Community Oncology and Prevention Trials Research Group, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Hanna Bandos
- NRG Oncology, Pittsburgh, PA, USA.,University of Pittsburgh, Pittsburgh, PA, USA
| | - Sarah B Blakeslee
- Institute of Public Health, Charité-Universitätsmedizin, Brandenburg, Berlin, Germany
| | - Christine Holmberg
- NRG Oncology, Pittsburgh, PA, USA.,Institute of Public Health, Charité-Universitätsmedizin, Brandenburg, Berlin, Germany.,Institute of Social Medicine and Epidemiology, Brandenburg Medical School Theodor Fontane, Brandenburg, Havel, Germany
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Gunn CM, Fitzpatrick A, Waugh S, Carrera M, Kressin NR, Paasche-Orlow MK, Battaglia TA. A Qualitative Study of Spanish-Speakers' Experience with Dense Breast Notifications in a Massachusetts Safety-Net Hospital. J Gen Intern Med 2019; 34:198-205. [PMID: 30350031 PMCID: PMC6374252 DOI: 10.1007/s11606-018-4709-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 09/04/2018] [Accepted: 10/01/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND Legislation requiring mammography facilities to notify women if they have dense breast tissue found on mammography has been enacted in 34 US states. The impact of dense breast notifications (DBNs) on women with limited English proficiency (LEP) is unknown. OBJECTIVE This study sought to understand Spanish-speaking women's experience receiving DBNs in a Massachusetts safety-net hospital. DESIGN Eligible women completed one audio-recorded, semi-structured interview via telephone with a native Spanish-speaking research assistant trained in qualitative methods. Interviews were professionally transcribed verbatim and translated. The translation was verified by a third reviewer to ensure fidelity with audio recordings. PARTICIPANTS Nineteen Spanish-speaking women ages 40-74 who received mammography with a normal result and recalled receiving a DBN. APPROACH Using the verified English transcripts, we conducted a content analysis to identify women's perceptions and actions related to receiving the notification. A structured codebook was developed. Transcripts were independently coded and assessed for agreement with a modification of Cohen's kappa. Content codes were grouped to build themes related to women's perceptions and actions after receiving a DBN. KEY RESULTS Nineteen Spanish-speaking women completed interviews. Nine reported not receiving the notification in their native language. Four key themes emerged: (1) The novelty of breast density contributed to notification-induced confusion; (2) women misinterpreted key messages in the notification; (3) varied actions were taken to seek further information; and (4) women held unrealized expectations and preferences for follow-up. CONCLUSIONS Not having previous knowledge of breast density and receiving notifications in English contributed to confusion about its meaning and inaccurate interpretations of key messages by Spanish speakers. Tools that promote understanding should be leveraged in seeking equity in risk-based breast cancer screening for women with dense breasts.
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Affiliation(s)
- Christine M Gunn
- Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, School of Medicine, Boston University, 801 Massachusetts Avenue, First Floor, Women's Health, Boston, MA, 02118, USA. .,Department of Health Law, Policy, and Management, School of Public Health, Boston University, Boston, MA, USA.
| | - Amy Fitzpatrick
- Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, School of Medicine, Boston University, 801 Massachusetts Avenue, First Floor, Women's Health, Boston, MA, 02118, USA
| | - Sarah Waugh
- Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, School of Medicine, Boston University, 801 Massachusetts Avenue, First Floor, Women's Health, Boston, MA, 02118, USA
| | - Michelle Carrera
- Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, School of Medicine, Boston University, 801 Massachusetts Avenue, First Floor, Women's Health, Boston, MA, 02118, USA
| | - Nancy R Kressin
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA.,Section of General Internal Medicine, Evans Department of Medicine, School of Medicine, Boston University, Boston, MA, USA
| | - Michael K Paasche-Orlow
- Section of General Internal Medicine, Evans Department of Medicine, School of Medicine, Boston University, Boston, MA, USA
| | - Tracy A Battaglia
- Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, School of Medicine, Boston University, 801 Massachusetts Avenue, First Floor, Women's Health, Boston, MA, 02118, USA
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Gunn CM, Battaglia TA, Paasche-Orlow MK, West AK, Kressin NR. Women's perceptions of dense breast notifications in a Massachusetts safety net hospital: "So what is that supposed to mean?". Patient Educ Couns 2018; 101:1123-1129. [PMID: 29426765 DOI: 10.1016/j.pec.2018.01.017] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 01/19/2018] [Accepted: 01/24/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Currently, 30 US states mandate that radiologists notify women when dense breast tissue is found on mammography. Little is understood about how notifications are perceived by recipients. This qualitative study sought to understand how dense breast notifications (DBNs) impact women's perceptions and their participation in follow-up care. METHODS We assessed rates of DBN recall and conducted semi-structured telephone interviews with 30 English-speaking women ages 40 to 74 after receiving a DBN from a Massachusetts hospital. Content coding characterized women's recall of the notification content, perceptions of breast density, and planned or actual participation in follow-up care. RESULTS Most women (81%) recalled receiving a DBN, but few could recall specific content. Women described struggling to understand the meaning of breast density and created their own explanatory models of dense breasts that differed from medical explanations. Many women planned to or did talk with their doctors about breast density as a result of receiving the notification. CONCLUSIONS Women receiving DBNs have limited knowledge and many misperceptions about the implications of having dense breasts. PRACTICE IMPLICATIONS Educational support is needed to promote informed decision- making about breast cancer screening that incorporates personal risk in the setting of dense breast legislation.
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Affiliation(s)
- Christine M Gunn
- Women's Health Unit, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA; Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA, USA.
| | - Tracy A Battaglia
- Women's Health Unit, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Michael K Paasche-Orlow
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA; Boston Medical Center, Boston, MA, USA
| | - Amanda K West
- Women's Health Unit, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Nancy R Kressin
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA; VA Boston Healthcare System, Jamaica Plain, MA, USA
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Gunn CM, Bokhour B, Battaglia TA, Silliman RA, Hanchate A. False-positive mammography and its association with health service use. Am J Manag Care 2018; 24:131-138. [PMID: 29553275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES A false-positive mammogram can result in anxiety, distress, and increased perceptions of breast cancer risk, potentially changing how women utilize healthcare. This study examined whether having an abnormal mammogram, considered a proxy for elevated risk perception, was associated with greater future health service use (outpatient visits and referrals). STUDY DESIGN A retrospective cohort study using electronic health record data, spanning 2008 to 2012, from Boston Medical Center, a safety-net hospital. METHODS We grouped 3920 women aged 40 to 75 years receiving primary care and who had a mammogram between 2010 and 2011 into 3 categories: false-positive mammogram at index date; previous false positive, but normal index mammogram; and no history of false-positive mammograms. We contrasted the longitudinal changes in outpatient visits and provider referrals, before versus after the index mammogram, between women with false-positive mammogram and those without using Poisson regression models with a difference-in-differences specification. Clinical, visit, and demographic data were obtained from the institutional clinical data warehouse. RESULTS Adjusting for baseline differences in sociodemographic characteristics across risk groups and for secular changes between pre- and postindex periods, a current false-positive mammogram was associated with an 18% increase in overall outpatient visits (incidence rate ratio [IRR], 1.18; 95% CI, 1.07-1.51), but no corresponding increase in provider referrals (IRR, 1.15; 95% CI, 0.99‑1.34), relative to never having a false positive. A previous false-positive mammogram had no associated change in outpatient utilization (IRR, 0.99; 95% CI, 0.91-1.07). CONCLUSIONS Providers should discuss the implications of mammography findings at the time of screening to help mitigate potential detrimental effects and promote appropriate engagement in health services.
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Affiliation(s)
- Christine M Gunn
- Women's Health Unit, Boston Medical Center, 801 Massachusetts Ave, 1st Fl, Boston, MA 02118.
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Gunn CM, Kressin NR, Cooper K, Marturano C, Freund KM, Battaglia TA. Primary Care Provider Experience with Breast Density Legislation in Massachusetts. J Womens Health (Larchmt) 2018; 27:615-622. [PMID: 29338539 DOI: 10.1089/jwh.2017.6539] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Dense breasts on mammography independently increases breast cancer risk and decreases mammography sensitivity. Thirty-two states have adopted notification laws to raise awareness among women with dense breasts about supplemental screening. Little is known about these policies' impact on clinical practice among primary care providers (PCPs). MATERIALS AND METHODS This study explores PCP attitudes, knowledge, and the impact of the Massachusetts dense breast notification legislation on clinical practice after its enactment in 2015. An anonymous, online survey at two urban safety-net hospitals was administered in 2015-2016. Practicing MDs and nurse practitioners in primary care were invited to participate. RESULTS All 145 PCPs in general internal medicine at the two sites were e-mailed a survey link and 80 (55%) were completed. While 64 of 80 PCPs surveyed (80%) had some familiarity with the legislation, none identified the 8 required components of notifications contained in the Massachusetts legislation. Forty-nine percent (39/80) did not feel prepared to respond to patient questions about dense breasts. Forty-one percent (33/80) correctly identified that no current guidelines recommend the use of supplemental screening tests solely based on breast density and 85% (68/80) indicated interest in further training. Female and less experienced providers were more likely to be in favor of the legislation (49% vs. 11% by gender; 76% <5 years vs. 9%> 20 years). Women practitioners (55%) who were more likely than men (17%, p = 0.01) to agree with the policy changed their discussions of mammography results with patients. CONCLUSIONS PCPs feel underprepared to counsel women about breast density identified on mammography and its implications.
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Affiliation(s)
- Christine M Gunn
- 1 Women's Health Unit, Evans Department of Medicine, Section of General Internal Medicine, Boston Medical Center , Boston, Massachusetts.,2 Department of Health Law, Policy, and Management, Boston University School of Public Health , Boston, Massachusetts
| | - Nancy R Kressin
- 1 Women's Health Unit, Evans Department of Medicine, Section of General Internal Medicine, Boston Medical Center , Boston, Massachusetts.,3 Boston University School of Medicine , Evans Department of Medicine, Section of General Internal Medicine Boston, MA
| | - Kristina Cooper
- 1 Women's Health Unit, Evans Department of Medicine, Section of General Internal Medicine, Boston Medical Center , Boston, Massachusetts
| | - Cinthya Marturano
- 4 Division of Internal Medicine and Primary Care, Tufts Medical Center , Boston, Massachusetts
| | - Karen M Freund
- 4 Division of Internal Medicine and Primary Care, Tufts Medical Center , Boston, Massachusetts.,5 Institute for Clinical Research and Health Policy Studies , Tufts Medical Center, Boston, Massachusetts
| | - Tracy A Battaglia
- 1 Women's Health Unit, Evans Department of Medicine, Section of General Internal Medicine, Boston Medical Center , Boston, Massachusetts.,3 Boston University School of Medicine , Evans Department of Medicine, Section of General Internal Medicine Boston, MA
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Blakeslee SB, McCaskill-Stevens W, Parker PA, Gunn CM, Bandos H, Bevers TB, Battaglia TA, Fagerlin A, Müller-Nordhorn J, Holmberg C. Deciding on breast cancer risk reduction: The role of counseling in individual decision-making - A qualitative study. Patient Educ Couns 2017; 100:2346-2354. [PMID: 28734560 PMCID: PMC5683919 DOI: 10.1016/j.pec.2017.06.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 06/13/2017] [Accepted: 06/25/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES The presentation of risks and benefits in clinical practice is common particularly in situations in which treatment recommendations involve trade-offs. The treatment of breast cancer risk with selective estrogen receptor modulators (SERMs) is such a decision. We investigated the influence of health care provider (HCP) counseling on women's decision-making. METHODS Thirty breast cancer risk counseling sessions were recorded from April 2012-August 2013 at a comprehensive cancer center and at a safety-net, community hospital in the US. Participating women and HCPs were interviewed. A cross-case synthesis was used for analysis. RESULTS Of 30 participants 21 received a SERM-recommendation, 11 decided to take SERMs. Counseling impacted decision-making, but did not determine it. Three categories emerged: 1.) ability to change the decision anytime, 2.) perceptions on medications, and 3.) proximity of cancer. CONCLUSION Decision-making under conditions of a risk diagnosis such as increased breast cancer risk is a continuous process in which risk information is transformed into practical and experiential considerations. PRACTICE IMPLICATIONS Individuals' health care decision-making is only marginally dependent on the interactions in the clinic. Accepting patients' experiences and beliefs in their own right and letting them guide the discussion may be important for a satisfying decision-making process.
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Affiliation(s)
- Sarah B Blakeslee
- Charité -Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Public Health.
| | - Worta McCaskill-Stevens
- National Cancer Institute, Division of Cancer Prevention, 9609 Medical Center Drive, Bethesda, MD 20892, United States.
| | - Patricia A Parker
- The University of Texas MD Anderson Cancer Center, 1155 Pressler Street, P.O. Box 301439, Unit Number: 1322, Houston, TX 77230-1439, United States.
| | - Christine M Gunn
- Evans Department of Medicine, Boston Medical Center and Boston University School of Medicine, 801 Massachusetts Ave, Boston, MA 02118, United States
| | - Hanna Bandos
- NRG Oncology, Pittsburgh, United States; The University of Pittsburgh, 201 North Craig St., Suite 350, Pittsburgh, PA 15213, United States.
| | - Therese B Bevers
- The University of Texas MD Anderson Cancer Center, 1155 Pressler Street, P.O. Box 301439, Unit Number: 1322, Houston, TX 77230-1439, United States.
| | - Tracy A Battaglia
- Evans Department of Medicine, Boston Medical Center and Boston University School of Medicine, 801 Massachusetts Ave, Boston, MA 02118, United States.
| | - Angela Fagerlin
- Salt Lake City VA Center for Informatics Decision Enhancement and Surveillance (IDEAS); Department of Population Health Sciences, University of Utah.
| | - Jacqueline Müller-Nordhorn
- Charité -Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Public Health.
| | - Christine Holmberg
- Charité -Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Public Health.
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Casas RS, Ramachandran A, Gunn CM, Weinberg JM, Shaffer K. Explaining Breast Density Recommendations: An Introductory Workshop for Breast Health Providers. MedEdPORTAL 2017; 13:10654. [PMID: 30800855 PMCID: PMC6338146 DOI: 10.15766/mep_2374-8265.10654] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 11/01/2017] [Indexed: 05/22/2023]
Abstract
Introduction High breast density is an independent risk factor for breast cancer and can decrease the sensitivity of mammography. However, evidence surrounding recommendations for patient risk stratification and supplemental screening is evolving, and providers receive limited training on breast density counseling. Methods We implemented an introductory, interactive workshop about breast density including current evidence behind supplemental screening and risk stratification. Designed for providers who counsel women on breast health, this workshop was evaluated with internal medicine providers, primary care residents, and radiology residents. We surveyed participants about knowledge and attitudes at baseline, postintervention (residents and providers), and 3-month follow-up (providers only). We compared baseline and postintervention scores and postintervention and 3-month follow-up scores using paired t tests and McNemar's tests. Results Internal medicine providers had significant gains in knowledge when comparing baseline to postintervention surveys (6.5-8.5 on a 10-point scale, p < .0001), with knowledge gains maintained when comparing postintervention to 3-month follow-up surveys (p = .06). Primary care and radiology residents also had significant gains in knowledge when comparing baseline to postintervention surveys (p < .004 for both). All learner groups reported increases in their confidence regarding counseling women about breast density and referring for supplemental screening. Discussion Through this breast density session, we showed trends for increased knowledge and change in attitudes for multiple learner groups. Because we aim to prepare providers with the best currently available recommendations, these materials will require frequent updating as breast density evidence and national consensus evolve.
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Affiliation(s)
- Rachel S. Casas
- Assistant Professor, Department of Medicine, Pennsylvania State University College of Medicine
| | - Ambili Ramachandran
- Assistant Professor, Department of Medicine, University of Texas Health San Antonio
| | - Christine M. Gunn
- Assistant Professor, Department of Public Health, Boston University
- Assistant Professor, Evans Department of Medicine, Boston University School of Medicine
| | - Janice M. Weinberg
- Professor, Department of Biostatistics, Boston University School of Public Health
| | - Kitt Shaffer
- Professor, Department of Radiology, Boston University School of Medicine
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Gunn CM, Parker VA, Bak SM, Ko N, Nelson KP, Battaglia TA. Social Network Structures of Breast Cancer Patients and the Contributing Role of Patient Navigators. Oncologist 2017; 22:918-924. [PMID: 28559408 DOI: 10.1634/theoncologist.2016-0440] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 03/13/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Minority women in the U.S. continue to experience inferior breast cancer outcomes compared with white women, in part due to delays in care delivery. Emerging cancer care delivery models like patient navigation focus on social barriers, but evidence demonstrating how these models increase social capital is lacking. This pilot study describes the social networks of newly diagnosed breast cancer patients and explores the contributing role of patient navigators. MATERIALS AND METHODS Twenty-five women completed a one hour interview about their social networks related to cancer care support. Network metrics identified important structural attributes and influential individuals. Bivariate associations between network metrics, type of network, and whether the network included a navigator were measured. Secondary analyses explored associations between network structures and clinical outcomes. RESULTS We identified three types of networks: kin-based, role and/or affect-based, or heterogeneous. Network metrics did not vary significantly by network type. There was a low prevalence of navigators included in the support networks (25%). Network density scores were significantly higher in those networks without a navigator. Network metrics were not predictive of clinical outcomes in multivariate models. CONCLUSION Patient navigators were not frequently included in support networks, but provided distinctive types of support. If navigators can identify patients with poorly integrated (less dense) social networks, or who have unmet tangible support needs, the intensity of navigation services could be tailored. Services and systems that address gaps and variations in patient social networks should be explored for their potential to reduce cancer health disparities. IMPLICATIONS FOR PRACTICE This study used a new method to identify the breadth and strength of social support following a diagnosis of breast cancer, especially examining the role of patient navigators in providing support. While navigators were only included in one quarter of patient support networks, they did provide essential supports to some individuals. Health care providers and systems need to better understand the contributions of social supports both within and outside of health care to design and tailor interventions that seek to reduce health care disparities and improve cancer outcomes.
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Affiliation(s)
- Christine M Gunn
- Evans Department of Medicine, Women's Health Unit, Boston University School of Medicine, Boston, Massachusetts, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Victoria A Parker
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Sharon M Bak
- Women's Health Unit Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Naomi Ko
- Department of Hematology and Oncology, Boston Medical Center, Boston, Massachusetts, USA
| | - Kerrie P Nelson
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Tracy A Battaglia
- Department of Hematology and Oncology, Boston Medical Center, Boston, Massachusetts, USA
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Affiliation(s)
- Nancy R Kressin
- Veterans Affairs Boston Healthcare System, Boston University School of Medicine, Boston, Massachusetts
| | - Christine M Gunn
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Tracy A Battaglia
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
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Gunn CM, Bokhour B, Battaglia TA, Blakeslee S, Holmberg C. Abstract B68: Explanatory models of risk: The role of social context in breast cancer risk perception and decision making. Cancer Epidemiol Biomarkers Prev 2015. [DOI: 10.1158/1538-7755.disp14-b68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
Background: The current practice of counseling high-risk breast cancer patients using probabilistic risk estimates has not proven to be effective in engaging women, with less than 1% of eligible women participating in medical interventions to reduce breast cancer risk. Further, studies show that racial and ethnic minority women are under-represented in breast cancer prevention clinical trials (Cyrus-David, 2006), and they are less likely than whites to be aware of, discuss, or take chemoprevention agents (Kaplan et al., 2006). This study seeks to describe how a diverse group of women use explanatory models of risk to describe perceptions of breast cancer risk and make decisions about risk-reducing behaviors.
Methods: 30 in-depth, qualitative interviews were collected at two US academic hospitals as part of a National Surgical Adjuvant Breast and Bowel Project mixed-methods study to oversample for racial and ethnic minorities. Women identified to have an elevated risk of developing breast cancer were interviewed following risk counseling with a medical provider. A thematic analysis informed by grounded theory methods was conducted. The explanatory model framework (Kleinman, 1978) guided formation of codes around explanatory model topic areas (etiology, symptoms, pathophysiology, course of illness, and treatment). These explanatory model codes were supplemented with inductive codes developed through open coding related to beliefs about cancer, risk, health, and social context.
Results: Two key themes were identified as closely linked to women's explanatory models of risk: ‘risk perception’ and ‘control over risk’. These perceptions of risk and control were used to identify patterns in how women chose to manage their risk for breast cancer. Whether women had high or low perceptions of risk and control affected the ways in which they used explanatory models to describe their decisions. For example, women with perceptions of high risk and high control all discussed their social network as influential in modeling how they could reduce their own risk. These women adopted a variety of behaviors to gain control over risk, ranging from diet and exercise changes to the use of chemoprevention agents. Conversely, women with perceptions of high risk and low control based decisions much more closely on their general explanatory models of health, falling back on established philosophies in their decision-making. Women who opted for chemoprevention agents in this group discussed their philosophy of decision making as dependent on physician recommendations.
How women interpreted ‘symptoms’ of risk was also essential to women's descriptions of their participation in risk-reduction behaviors. Those women who perceived their risk to be high interpreted symptoms such as ADH, ALH, or LCIS as a disease that required medical intervention. On the other hand, women with perceptions of low risk interpreted these symptoms as in the normal course of bodily changes, contrasting with information provided by physicians suggesting an increased risk for breast cancer.
Discussion: There are important differences in how women use explanatory models of risk that contribute to the adoption of medical interventions. Risk counseling must address patient explanatory models, which influence both perceptions of risk and control over risk. These perceptions subsequently influence the ways in which women describe their decisions about participating in risk-reducing behaviors. New approaches are needed to address patient beliefs and perceptions about risk and prevention for breast cancer. Failing to acknowledge the experiences of patients threatens to marginalize minority groups from preventive care.
Citation Format: Christine M. Gunn, Barbara Bokhour, Tracy A. Battaglia, Sarah Blakeslee, Christine Holmberg. Explanatory models of risk: The role of social context in breast cancer risk perception and decision making. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr B68.
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Battaglia TA, Gunn CM, McCoy ME, Mu HH, Baranoski AS, Chiao EY, Kachnic LA, Stier EA. Beliefs About Anal Cancer among HIV-Infected Women: Barriers and Motivators to Participation in Research. Womens Health Issues 2015; 25:720-6. [PMID: 26253825 DOI: 10.1016/j.whi.2015.06.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 04/15/2015] [Accepted: 06/26/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Infection with the human immunodeficiency virus (HIV) remains associated with a greater risk of anal cancer, despite widespread use of combination antiretroviral therapy. Evidence concerning the acceptability of anal cancer screening gives little attention to women. Because HIV-infected women have a high prevalence of depression and history of sexual trauma, understanding acceptability among this group is critical. PURPOSE We sought to assess barriers and motivators to participation in anal cancer screening research among a racial/ethnically diverse HIV-infected female population. METHODS We conducted a survey based on the Health Belief Model to identify characteristics of women willing to participate in anal cancer screening research (n = 200). Bivariate analyses examined associations between willingness to participate and sociodemographics, clinical characteristics, and health beliefs. Logistic regression modeled willingness to participate in research. MAIN FINDINGS Of the women who participated, 37% screened positive for depression, 43% reported a high trauma history, and 36% screened positive for posttraumatic stress disorder. Overall, 65% reported willingness to participate in research. Those likely to participate were older, reported intravenous drug use as their HIV risk factor, and had a history of prior high-resolution anoscopy (HRA) compared with those unwilling to participate. The most commonly reported barrier to anal Pap testing was fear of pain. In adjusted analyses, a lack of fear of pain and prior experience with HRA significantly predicted willingness to participate. CONCLUSIONS Findings suggest that, to increase participation in anal Pap and HRA-related research for HIV-infected women, a single approach may not be adequate. Rather, we must harness patients' previous experiences and address psychosocial and financial concerns to overcome barriers to participation.
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Affiliation(s)
- Tracy A Battaglia
- Women's Health Unit, Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Christine M Gunn
- Women's Health Unit, Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts.
| | - Molly E McCoy
- Women's Health Unit, Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Helen H Mu
- Department of Obstetrics and Gynecology, Boston University Medical Center, Boston, Massachusetts
| | - Amy S Baranoski
- Division of Infectious Diseases and HIV Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Elizabeth Y Chiao
- Department of Medicine, Baylor College of Medicine, Houston Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Lisa A Kachnic
- Department of Radiation Oncology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Elizabeth A Stier
- Department of Obstetrics and Gynecology, Boston University Medical Center, Boston, Massachusetts
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Gunn CM, Soley-Bori M, Battaglia TA, Cabral H, Kazis L. Shared Decision Making and the Use of Screening Mammography in Women Younger Than 50 Years of Age. J Health Commun 2015; 20:1060-1066. [PMID: 26091367 DOI: 10.1080/10810730.2015.1018628] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Current breast cancer screening guidelines promote the use of shared decision making for women younger than 50 years of age, yet their effect on mammography utilization is largely unknown. This study aimed to examine the effect of two elements of shared decision making on the use of mammogram screening: patient-perceived choice and patient-provider communication. Data were obtained from HINTS 4, a nationally representative survey of the U.S. population, administered from 2011 to 2013. Choice was measured with the question "Has a doctor ever told you that you could choose whether or not to have a mammogram?" Communication was measured using a 7-item scale (range: 7-28; higher scores denote better communication). Binary logistic regression models assessed the effect of patient choice and communication on ever having a mammogram using weighted sample data. The sample included 1,085 women younger than 50 years of age: 31% of women perceived having a choice to undergo mammography. The mean patient-provider communication score was 22.8. Those who thought they were given a choice regarding mammography were more likely to have a mammogram relative to those who did not think a choice was given by the provider. Patient-provider communication had no significant association with mammography utilization. Patient perceived choice, but not patient-provider communication, is positively associated with mammography utilization in women younger than 50 years of age.
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Affiliation(s)
- Christine M Gunn
- a Department of Health Policy and Management , Boston University School of Public Health , Boston , Massachusetts , USA
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Ko N, Bak S, Nelson K, Han A, Bergling E, Castano M, Noel V, Wang N, Gunn CM, Festa K, Flacks J, Morton S, Battaglia TA. A patient-centered approach to a cancer care delivery innovation for low income patients: Medical-legal partnership with patient navigation. J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.15_suppl.e17603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Sharon Bak
- Women's Health Unit, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA
| | - Kerrie Nelson
- Boston University School of Public Health, Boston, MA
| | - Ann Han
- Boston Medical Center Women's Health Research Unit, Boston, MA
| | - Emily Bergling
- Boston Medical Center Women's Health Research Unit, Boston, MA
| | - Maria Castano
- Boston Medical Center Women's Health Research Unit, Boston, MA
| | - Vanesa Noel
- Boston Medical Center Women's Health Research Unit, Boston, MA
| | - Na Wang
- Boston University School of Public Health, Boston, MA
| | - Christine M Gunn
- NRG Oncology/NSABP, and the Boston University Medical Center, Boston, MA
| | - Kate Festa
- Boston Medical Center Women's Health Research Unit, Boston, MA
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Blakeslee SB, Parker PA, Gunn CM, Bandos H, Bevers TB, Battaglia TA, Fagerlin A, McCaskill-Stevens WJ, Holmberg C. Decision-making in breast cancer risk reduction: Results from a nested qualitative study from NRG Oncology/NSABP protocol DMP-1. J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.15_suppl.e17569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Sarah B Blakeslee
- Berlin School of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Christine M Gunn
- NRG Oncology/NSABP, and the Boston University Medical Center, Boston, MA
| | - Hanna Bandos
- NRG Oncology, and the University of Pittsburgh, Graduate School of Public Health, Department of Biostatistics, Pittsburgh, PA
| | | | | | - Angela Fagerlin
- University of Michigan and Ann Arbor VA Healthcare System, Ann Arbor, MI
| | | | - Christine Holmberg
- Charité Universitätsmedizin Berlin, Berlin School of Public Health, Berlin, Germany
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Carr PL, Gunn CM, Kaplan SA, Raj A, Freund KM. Inadequate progress for women in academic medicine: findings from the National Faculty Study. J Womens Health (Larchmt) 2015; 24:190-9. [PMID: 25658907 DOI: 10.1089/jwh.2014.4848] [Citation(s) in RCA: 220] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Women have entered academic medicine in significant numbers for 4 decades and now comprise 20% of full-time faculty. Despite this, women have not reached senior positions in parity with men. We sought to explore the gender climate in academic medicine as perceived by representatives to the Association of American Medical Colleges (AAMC) Group on Women in Medicine and Science (GWIMS) and Group on Diversity and Inclusion (GDI). METHODS We conducted a qualitative analysis of semistructured telephone interviews with GWIMS and GDI representatives and other senior leaders at 24 randomly selected medical schools of the 1995 National Faculty Study. All were in the continental United States, balanced for public/private status and AAMC geographic region. Interviews were audiotaped, transcribed, and organized into content areas before an inductive thematic analysis was conducted. Themes that were expressed by multiple informants were studied for patterns of association. RESULTS Five themes were identified: (1) a perceived wide spectrum in gender climate; (2) lack of parity in rank and leadership by gender; (3) lack of retention of women in academic medicine (the "leaky pipeline"); (4) lack of gender equity in compensation; and (5) a disproportionate burden of family responsibilities and work-life balance on women's career progression. CONCLUSIONS Key informants described improvements in the climate of academic medicine for women as modest. Medical schools were noted to vary by department in the gender experience of women, often with no institutional oversight. Our findings speak to the need for systematic review by medical schools and by accrediting organizations to achieve gender equity in academic medicine.
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Affiliation(s)
- Phyllis L Carr
- 1 Department of Medicine, Massachusetts General Hospital , Harvard Medical School, Boston, Massachusetts
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