Cervical Cancer Screening among Underscreened and Unscreened Brazilian Women: Training Community Health Workers to be Agents of Change

BACKGROUND

Despite the availability of cervical cancer screening programs in Brazil, some women do not participate in these programs owing to structural and/or interpersonal/intrapersonal barriers, resulting in high cervical cancer incidence and mortality. Integrating community health workers (CHWs) into the delivery of cervical cancer screening interventions is potentially a feasible strategy to address these barriers.

OBJECTIVES

This study aimed to implement and evaluate a CHW training to deliver a brief intervention to promote cervical cancer screening among underscreened and unscreened women in Brazil.

METHODS

The curriculum addressed cervical cancer and screening, behavioral intervention strategies, and protection of human subjects in research. Pretest and post-test questionnaires assessed changes in CHW objective and perceived knowledge as well as perceived skills and confidence (N = 15).

RESULTS

There was a significant increase in objective and perceived knowledge about cervical cancer, behavior change strategies, and protection of human subjects in research between pretest and post-test, but not in self-perception about skills and confidence to motivate women to engage in cervical cancer screening.

CONCLUSIONS

Improvements in CHW knowledge about cervical cancer screening and behavior change represents a step forward toward successful interventions, but adaptations are needed to boost their self-confidence and perceived skills with regard to their ability to promote behavior change at the community level.

Lay navigation across the cancer continuum for older cancer survivors: Equally beneficial for Black and White survivors?

OBJECTIVES

The Patient Care Connect Program (PCCP), through lay navigators' distress assessments and assistance, was shown to lower healthcare utilization and costs in older cancer survivors. PCCP benefits and assistance needs for disadvantaged minorities (e.g., Black) vs. Whites are unknown.

MATERIALS AND METHODS

We examined the PCCP impact with retrospective analyses of Medicare claims (2012-2015). Outcomes were quarterly costs and utilization (emergency room (ER), hospitalizations) for navigated and matched survivors. Repeated measures generalized linear models with normal (costs), and Poisson (utilization) distributions assessed differences in trends overall and separately for Blacks and Whites. With distress data for navigated survivors, we assessed high distress (score > 3), ≥1 distress cause (overall, by domain), and ≥ 1 assistance request by minority group.

RESULTS

Beneficiaries were: 772 Black and 5350 White navigated, and 770 Black and 5348 White matched survivors. Impact was: i) costs: -$557.5 Blacks (p < .001), -$813.4 Whites (p < .001); ii) ER: Incidence Rate Ratio (IRR) 0.97 Blacks (NS), 0.93 Whites (p < .001); iii) hospitalizations: IRR 0.97 Blacks (NS), 0.91 Whites (p < .001). There was no significant difference in impact across minority groups. No significant differences were found in high distress (29% Black, 25.1% White), ≥1 distress cause (61.6% Black, 57.8% White), or ≥ 1 assistance request (64.5% Black, 59.1% White). Blacks were more likely to have ≥1 distress cause in the Practical domain.

CONCLUSION

The PCCP may benefit both Black and White older cancer survivors. Programs should consider the proportion of older survivors with high distress, and the specific needs of minorities.

Unmet social support needs among older adults with cancer

BACKGROUND

Adequate social support for older adults is necessary to maintain quality of life and reduce mortality and morbidity. However, little is known regarding the social support needs of older adults with cancer. The objective of the current study was to examine social support needs, specifically the unmet needs, among older adults with cancer.

METHODS

Medicare beneficiaries (those aged ≥65 years) with cancer were identified from the University of Alabama at Birmingham Health System Cancer Community Network. Social support needs were assessed using a modified version of the Medical Outcomes Study Social Support Survey. The authors defined an "unmet need" if participants reported having some/a little/never availability of support and requiring support for that need.

RESULTS

Of the 1460 participants in the current study, the average age was 74 years (standard deviation, 5.8 years). Approximately two-thirds of participants (986 participants; 67.5%) reported having at least 1 social support need, with the highest needs noted in the emotional (49.5%) and physical (47.4%) support subdomains. Of those individuals with a support need, approximately 45% had at least 1 unmet need, with the greatest percentages noted in the medical (39%) and informational (36%) subdomains. Multivariable analyses demonstrated that participants who were nonwhite, were divorced or never married, or had a high symptom burden were at greatest risk of having unmet social support needs across subdomains.

CONCLUSIONS

In this population of older adults with cancer, the authors found high levels of unmet social support needs, particularly in the medical and informational support subdomains. Participants who were nonwhite, were divorced or never married, or had a high symptom burden were found to be at greatest risk of having unmet needs.

Participation in Cervical Screening by Self-collection, Pap, or a Choice of Either in Brazil

Most cervical cancers occur in women who do not participate in cervical-cancer screening. We therefore evaluated adherence to screening for clinic-based Pap testing, self-collected sampling for HPV testing, and choice of the 2 among 483 unscreened/underscreened women in Brazil. Three public Basic Health Units (BHU) were each randomly assigned to three arms: (i) Pap testing at the BHU (N = 160), (ii) "Self&HPV" (self-collection for HPV testing) (N = 161), and (iii) "Choice" between self-collection and HPV testing and Pap test at the local BHU (N = 162). The theory-based (PEN-3 and Health Belief Model) intervention in all three arms was implemented by trained Community Health Workers (CHW) at participants' home. With the first invitation, 60.0% in the Pap arm, 95.1% [154 of 161 (95.7%) who selected Self&HPV and 0 of 1 (0.0%) who selected Pap] in the Choice arm, and 100% in the Self&HPV arm completed screening. By the second invitation to choose a method of screening in the Choice arm, 100% completed screening. After three invitations, 75.0% of women in the Pap arm completed screening. Adherence to screening differed by study arm (P < 0.001). In conclusion, Self&HPV testing is a promising strategy for unscreened/underscreened women who are recalcitrant or unable to undergo clinic-based cervical screening to complement the screening modality used in the general population. In Brazil, where Pap testing is recommended for routine cervical screening, training CHWs in behavior change strategies and offering Self&HPV or Choice could greatly improve screening population coverage by reaching the unscreened/underscreened populations.

Participation and interest in support services among family caregivers of older adults with cancer

OBJECTIVE

The purpose of this study was to describe distressed and underprepared family caregiver's use of and interest in formal support services (eg, professional counseling, education, organizational assistance).

METHOD

Cross-sectional mail survey conducted in communities of 8 cancer centers in Tennessee, Alabama, and Florida (response rate: 42%). Family caregivers of Medicare beneficiaries with pancreatic, lung, brain, ovarian, head and neck, hematologic, and stage IV cancers reported support service use and completed validated measures of depression, anxiety, burden, preparedness, and health.

RESULTS

Caregivers (n = 294) were on average age 65 years and mostly female (73%), White (91%), and care recipients' spouse/partner (60%); patients averaged 75 years were majority male (54%) with lung cancer (39%). Thirty-two percent of caregivers reported accessing services while 28% were "mostly" or "extremely" interested. Thirty-five percent of caregivers with high depressive symptoms (n = 122), 33% with high anxiety symptoms (n = 100), and 25% of those in the lowest quartile of preparedness (n = 77) accessed services. Thirty-eight percent of those with high depressive symptoms, 47% with high anxiety symptoms, and 36% in the lowest quartile of preparedness were "mostly" or "extremely" interested in receiving services. Being interested in support services was significantly associated with being a minority, shorter durations of caregiving, and with higher stress burden.

CONCLUSIONS

A large proportion of family caregivers, including those experiencing depression and anxiety symptoms and who were underprepared, are not using formal support services but have a strong interest in services. Strategies to increase service use may include targeting distressed caregivers early in their caregiving experience.

Factors associated with participating in formal support services among family caregivers of older adults with poor-prognosis cancers

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Background: Family caregivers of persons with cancer are at high risk for distress and may benefit from formal support services. The purpose of this study was to describe cancer family caregiver’s use of and desire for formal support services. Methods: Cross-sectional mail survey conducted in communities of eight cancer centers in Tennessee, Alabama, and Florida. Family caregivers of Medicare beneficiaries with pancreatic, lung, brain, ovarian, head and neck, hematologic, and stage IV cancers reported support service use and completed validated measures of depression, anxiety, burden, preparedness, and health. Results: Caregivers(n = 294) were on average age 65.5 years and mostly female (72.8%), white (91.2%), and care recipients’ spouse/partner (60.2%). Patients averaged 75.3 years and were mostly male (54.4%). Formal support services were used by 32.0% (n = 94) of all caregivers; 4.4% used therapy or counseling, 19.7% received education and training; and 11.2% received assistance from local, state, or national organizations. Twenty-eight percent of all caregivers were “mostly or “extremely” interested in receiving support services; of those, 44% had high depressive symptoms, 52.3% had high anxiety symptoms, and 36.4% in the lowest quartile of preparedness. In multivariate analyses, participation in services was significantly associated with lower objective burden, higher preparedness, not working, and not being the patient’s spouse. Being “mostly” or “extremely” interested in support services was significantly associated with being a minority, shorter durations of caregiving, and with higher stress burden. Conclusions: While distressed and underprepared family caregivers reported strong interest in formal support services, only a small proportion accessed these services. Strategies to increase service use may include targeting those caregivers who are still early in their caregiving experience and who report high stress burden.

Patterns of radiation delivery in the last 6 months of life

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Background: The purpose of this analysis is to report patterns of radiation delivery at the end of life among older cancer patients. Methods: This was a retrospective cohort study of deceased Medicare patients age ≥65 with Stage IV cancer treated from 2012-2014 at 12 cancer community networks affiliated with an academic center in the Southeast, with available follow-up through 2015. Patients without Medicare coverage through 2015 were excluded. The outcome of interest was receipt of radiation in the last 6 months of life. Bivariate analyses for age group (65-69, 70-79, 80+), gender, Charlson comorbidity index (0, 1, 2+), cancer type (lung, GI, GU, H&N), and center volume (high = > 4000 cases/year) associated with receipt of radiation were performed. Results: 3688 patients met inclusion criteria; 700 (19%) received radiation in the last 6 months of life. In the radiation group (RT) & no radiation group (no-RT), median age at cancer diagnosis was 73 & 75 years, 41% & 45% were female, and 50% & 54% had Charlson comorbidity index of 2+. For the RT and no-RT groups, the cancer distribution was lung (39% & 33%), GI (15% & 26%), GU (7% & 9%), and H&N (6% & 5%); median time from diagnosis to death for RT and no RT was 449 & 400 days. Median time from last fraction of radiation to death was 84 days for the entire cohort; 27% of radiation was delivered in the last 30 days of life. On bivariate analysis, patients treated with radiation were more likely to be younger, Caucasian, have lung cancer, lower Charlson comorbidity score, and be treated at smaller volume centers(all p < 0.05). Conclusions: Among older terminally ill cancer patients who received radiation, > 25% received radiation in the last 30 days of life, which may reflect the challenges of prognostication in this cohort. Older patients were less likely to receive radiation, which may be indicative of barriers associated with receipt of treatment with increasing age.

Optimizing dosing in navigation interventions across the cancer continuum: A planned secondary data analysis from the Patient Care Connect implementation

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Background: Patient navigation programs in cancer care have historically focused on assisting persons to overcome barriers to accessing care. Evidence is emerging to support the impact of navigation interventions across the cancer continuum. However, navigation programs have varied designs, resulting in a lack of clarity about the optimal approach to delivering services to patients, and a lack of evidence linking program design to outcomes. Methods: A planned retrospective analysis of Medicare administrative claims for a population of older beneficiaries diagnosed with cancer: The main exposure was the number of contacts in person or over the phone with PCCP navigators in the 6 month period starting from the quarter in which patients enrolled in the PCCP. Repeated measures generalized linear models with normal distribution were used to evaluate trends in total cost over time based on: number of contacts, quarters post-enrollment (TIME), and the interaction between number of contacts and TIME. Intra-correlation was controlled for repeated measures. Results: 4,337 patients were included in this analysis. 17.9% had one contact, 17.7% had two, 22.2% had 3-4, 24.2% had 5-10, and 18.0% had more than 10 contacts. African Americans had a greater number of participants with more than 10 navigator contacts, as stage 4 cancers, and initial or end-of-life phase of care. Patients who received more than 3 contacts had significantly higher levels of baseline cost. Models to evaluate total cost over time demonstrate an effect of navigator contact on cost that is associated with number of contacts. This trend is statistically significant at 3-4 contacts or more, and remains significant at 10 or more contacts. Conclusions: Increased navigator contact is associated with increased slope of decline in utilization and cost indicates that navigation programs should be adequately resourced to deliver care that enables navigators to have contact with patients a minimum of 3-4 contacts over a six month period.

Where Are the Opportunities for Reducing Health Care Spending Within Alternative Payment Models?

PURPOSE

The Oncology Care Model (OCM) is a highly controversial specialty care model developed by the Centers for Medicare & Medicaid aimed to provide higher-quality care at lower cost. Because oncologists will be increasingly held accountable for spending as well as quality within new value-based health care models like the OCM, they need to understand the drivers of total spending for their patients.

METHODS

This retrospective cohort study included patients ≥ 65 years of age with primary fee-for-service Medicare insurance who received antineoplastic therapy at 12 cancer centers in the Southeast from 2012 to 2014. Medicare administrative claims data were used to identify health care spending during the prechemotherapy period (from cancer diagnosis to antineoplastic therapy initiation) and during the OCM episodes of care triggered by antineoplastic treatment. Total health care spending per episode includes all types of services received by a patient, including nononcology services. Spending was further characterized by type of service.

RESULTS

Average total health care spending in the three OCM episodes of care was $33,838 (n = 3,427), $23,811 (n = 1,207), and $19,241 (n = 678). Antineoplastic drugs accounted for 27%, 32%, and 36% of total health care spending in the first, second, and third episodes. Ten drugs, used by 31% of patients, contributed 61% to drug spending ($18.8 million) in the first episode. Inpatient spending also substantially contributed to total costs, representing 17% to 20% ($30.5 million) of total health care spending.

CONCLUSION

Health care spending was heavily driven by both antineoplastic drugs and hospital use. Oncologists' ability to affect these types of spending will determine their success under alternative payment models.

Plasma Protein Profiles Differ between Women Diagnosed with Cervical Intraepithelial Neoplasia (CIN) 1 and 3

Early detection of precancerous cells in the cervix and their clinical management is the main purpose of cervical cancer prevention and treatment programs. Cytological findings or testing for high risk (HR)-human papillomavirus (HPV) are inadequately sensitive for use in triage of women at high risk for cervical cancer. The current study is an exploratory study to identify candidate surface-enhanced laser desorption/ionization (SELDI) time of flight (TOF) mass spectrometry (MS) protein profiles in plasma that may distinguish cervical intraepithelial neoplasia (CIN 3) from CIN 1 among women infected with HR-HPV. We evaluated the SELDI-TOF-MS plasma protein profiles of HR-HPV positive 32 women with CIN 3 (cases) and 28 women with CIN1 (controls). Case-control status was kept blinded and triplicates of each sample and quality control plasma samples were randomized and after robotic sample preparations were run on WCX2 chips. After alignment of mass/charge (m-z values), an iterative method was used to develop a classifier on a training data set that had 28 cases and 22 controls. The classifier developed was used to classify the subjects in a test data set that has six cases and six controls. The classifier separated the cases from controls in the test set with 100% sensitivity and 100% specificity suggesting the possibility of using plasma SELDI protein profiles to identify women who are likely to have CIN 3 lesions.

Resource Use and Medicare Costs During Lay Navigation for Geriatric Patients With Cancer

Importance

Lay navigators in the Patient Care Connect Program support patients with cancer from diagnosis through survivorship to end of life. They empower patients to engage in their health care and navigate them through the increasingly complex health care system. Navigation programs can improve access to care, enhance coordination of care, and overcome barriers to timely, high-quality health care. However, few data exist regarding the financial implications of implementing a lay navigation program.

Objective

To examine the influence of lay navigation on health care spending and resource use among geriatric patients with cancer within The University of Alabama at Birmingham Health System Cancer Community Network.

Design, Setting, and Participants

This observational study from January 1, 2012, through December 31, 2015, used propensity score-matched regression analysis to compare quarterly changes in the mean total Medicare costs and resource use between navigated patients and nonnavigated, matched comparison patients. The setting was The University of Alabama at Birmingham Health System Cancer Community Network, which includes 2 academic and 10 community cancer centers across Alabama, Georgia, Florida, Mississippi, and Tennessee. Participants were Medicare beneficiaries with cancer who received care at participating institutions from 2012 through 2015.

Exposures

The primary exposure was contact with a patient navigator. Navigated patients were matched to nonnavigated patients on age, race, sex, cancer acuity (high vs low), comorbidity score, and preenrollment characteristics (costs, emergency department visits, hospitalizations, intensive care unit admissions, and chemotherapy in the preenrollment quarter).

Main Outcomes and Measures

Total costs to Medicare, components of cost, and resource use (emergency department visits, hospitalizations, and intensive care unit admissions).

Results

In total, 12 428 patients (mean (SD) age at cancer diagnosis, 75 (7) years; 52.0% female) were propensity score matched, including 6214 patients in the navigated group and 6214 patients in the matched nonnavigated comparison group. Compared with the matched comparison group, the mean total costs declined by $781.29 more per quarter per navigated patient (β = -781.29, SE = 45.77, P < .001), for an estimated $19 million decline per year across the network. Inpatient and outpatient costs had the largest between-group quarterly declines, at $294 and $275, respectively, per patient. Emergency department visits, hospitalizations, and intensive care unit admissions decreased by 6.0%, 7.9%, and 10.6%, respectively, per quarter in navigated patients compared with matched comparison patients (P < .001).

Conclusions and Relevance

Costs to Medicare and health care use from 2012 through 2015 declined significantly for navigated patients compared with matched comparison patients. Lay navigation programs should be expanded as health systems transition to value-based health care.

A Community Health Advisor Program to Reduce Cancer Screening Disparities in the Deep South and Appalachia: The American Cancer Society's CHA Collaborative

INTRODUCTION

Cancer disparities continue to exist in the United States. Community health advisors (CHAs) can play a critical role in addressing cancer disparities. The American Cancer Society (ACS) implemented a 3-year pilot CHA program in the South based on an evidence-based program to increase breast cancer screening.

STUDY DESIGN

Evaluation assessed the extent to which ACS successfully implemented the program. Quantitative data were tracked and reported by ACS staff, and qualitative data were collected through focus groups and interviews with volunteer participants.

SETTING/PARTICIPANTS

The pilot was implemented in 28 communities in nine states. ACS staff recruited volunteer community network partners (CNPs) as local advisory groups, and volunteer CHAs to conduct outreach, education, and screening navigation.

MEASURES

Outcome measures included number of individuals educated and screened, and number of communities reaching education and screening targets. Process measures included number of volunteers recruited, number of communities reaching recruitment targets, and implementation process, challenges, and successes.

RESULTS

A total of 383 CHAs were recruited and recruitment goals were met in 68%; 31,439 individuals were educated, and 93% of communities reached education goals. In all, 5,056 individuals were screened, but screening goals were attained in only 36% of communities.

CONCLUSION

This pilot demonstrates the ability of ACS to adapt and disseminate an evidence-based program to fit into its volunteer-based outreach model. ACS built community network partnerships, recruited a cadre of volunteers, and trained them to conduct education and screening navigation.

A higher degree of expression of DNA methyl transferase 1 in cervical cancer is associated with poor survival outcome

Background

Even though novel therapies based on aberrant DNA methylation could be of particular importance for the treatment of cervical cancer (CC) because the oncoproteins E6/E7 of high-risk human papillomaviruses, the causative agents for developing CC, have the capacity to bind and upregulate DNA methyltransferases (DNMTs), to our knowledge, no previous studies have evaluated the expression of this enzyme in CC in relation to survival outcomes. The purpose of the study was to evaluate the expression of DNMT1 in CC and its association with survival outcomes.

Methods

The study population consisted of 76 women treated for primary CC and followed up by the University of Alabama at Birmingham (UAB) cancer registry. The expression of DNMT1 was examined using immunohistochemistry, and the degree of expression of DNMT1 was expressed as a percentage of cells positive for DNMT1 and its intensity. Cox proportional hazards model was used to assess the relationship between the degree of expression of DNMT1 and overall survival after adjusting for relevant covariates.

Results

The expression of DNMT1 was significantly higher in CC cells compared to that in the normal cervical epithelium. A higher percentage of cells positive for DNMT1 and a higher intensity score for DNMT1 were significantly associated with poor survival outcome (hazard ratio [HR] =4.3, P=0.03 and HR =4.9, P=0.02, respectively).

Conclusion

Our findings suggested that the degree of expression of DNMT1 could be considered as a target in the epigenetic treatment of CC. Replication of our results in other study populations with CC could create the opportunity of using DNMT inhibitors to treat CC.

Feasibility of a Telehealth Educational Program on Self-Management of Pain and Fatigue in Adult Cancer Patients

CONTEXT

Pain and fatigue are common symptoms among cancer patients and often lead to substantial distress. Innovative self-management programs for pain and fatigue are needed.

OBJECTIVES

The primary objective was to assess the feasibility of a telehealth pain and fatigue self-management program among adult cancer patients. Secondary objectives included assessment of differences in patient characteristics, recruitment, and retention of patients based on two screening strategies: 1) navigator-collected, patient-reported pain or fatigue and 2) in-clinic, physician-identified pain or fatigue.

METHODS

This prospective, nonrandomized, pre-post evaluation assessed feasibility, which was defined as 50% of eligible patients choosing to participate and completing the intervention. Patient demographics and patient-reported outcomes (patient activation, distress, symptoms, and quality of life) were collected at baseline and study completion. Differences in baseline characteristics were compared between cohorts and for patients who did vs. did not graduate from the program.

RESULTS

The program did not meet feasibility requirements because of only 34% of eligible patients choosing to participate. However, 50% of patients starting the program graduated. Differences in baseline characteristics and retention rates were noted by recruitment strategy. At baseline, 27.3% of navigated patients were at the highest activation level compared with 7.1% in the physician-referred, non-navigated patients (P = 0.17); more than 15% of non-completers were at the lowest activation level compared with 9% of completers (P = 0.85).

CONCLUSION

Telehealth self-management program for pain and fatigue may be better accepted among selected segments of cancer patients. Larger scale studies are needed to assess the efficacy of this program in a more selective activated population.

Implementation and Impact of Patient Lay Navigator-Led Advance Care Planning Conversations

CONTEXT

Advance care planning (ACP) improves alignment between patient preferences for life-sustaining treatment and care received at end of life (EOL).

OBJECTIVES

To evaluate implementation of lay navigator-led ACP.

METHODS

A convergent, parallel mixed-methods design was used to evaluate implementation of navigator-led ACP across 12 cancer centers. Data collection included 1) electronic navigation records, 2) navigator surveys (n = 45), 3) claims-based patient outcomes (n = 820), and 4) semistructured navigator interviews (n = 26). Outcomes of interest included 1) the number of ACP conversations completed, 2) navigator self-efficacy, 3) patient resource utilization, hospice use, and chemotherapy at EOL, and 4) navigator-perceived barriers and facilitators to ACP.

RESULTS

From June 1, 2014 to December 31, 2015, 50 navigators completed Respecting Choices® First Steps ACP Facilitator training. Navigators approached 18% of patients (1319/8704); 481 completed; 472 in process; 366 declined. Navigators were more likely to approach African American patients than Caucasian patients (20% vs. 14%, P < 0.001). Significant increases in ACP self-efficacy were observed after training. The mean score for feeling prepared to conduct ACP conversations increased from 5.6/10 to 7.5/10 (P < 0.001). In comparison with patients declining ACP participation (n = 171), decedents in their final 30 days of life who engaged in ACP (n = 437) had fewer hospitalizations (46% vs. 56%, P = 0.02). Key facilitators of successful implementation included physician buy-in, patient readiness, and prior ACP experience; barriers included space limitations, identifying the "right" time to start conversations, and personal discomfort discussing EOL.

CONCLUSION

A navigator-led ACP program was feasible and may be associated with lower rates of resource utilization near EOL.

Disparities in chronic medical conditions in the Mid-South

OBJECTIVE

This study examined differences in socio-demographic characteristics and health behaviors relevant to chronic medical conditions (CMCs) in the Mid-South region (Alabama, Mississippi, Louisiana, Kentucky, Tennessee, and Arkansas), and identified subpopulations with increased burden of chronic disease.

METHODS

Data were obtained from the 2013 Behavioral Risk Factor Surveillance System. The top five most prevalent CMCs in the Mid-South were analyzed: asthma, high blood pressure (HBP), obesity, arthritis, and depression. Adjusted odds ratios (AOR) and confidence intervals (CI) of race-gender combinations were estimated using logistic regression. Differences in associations between socio-demographic characteristics and CMCs according to income were also examined.

RESULTS

The weighted prevalence estimates of the top five CMCs ranged from 66% (asthma) to 20% (depression). Higher income and employment were associated with better outcomes in all five CMCs. Higher educational attainment and physical activity were associated with better HBP, obesity, and arthritis status. Black and white females had higher odds of asthma compared to white males (black AOR = 1.7, CI: 1.1-2.6, white AOR = 1.7, CI: 1.3-2.2). Black males had lower odds of arthritis (AOR = 0.8, CI: 0.6-0.9), while white females had higher odds (AOR = 1.3, CI: 1.2-1.4). Similarly, the odds of depression were lower among black males (AOR = 0.5, CI: 0.4-0.6) and higher among white females (AOR = 2.2, CI: 2.0-2.5). Income-related differences by race were observed for HBP and obesity.

CONCLUSION

Disparities in CMCs are associated with income and disproportionately affect the black population. In the Mid-South, race and gender disparities in the top five chronic conditions are more prominent among higher-income rather than lower-income individuals.

Quantifying episode-based costs of care under the oncology care model: Analysis of Medicare beneficiaries in the UAB cancer community network

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Background: The Oncology Care Model (OCM) is a specialty care model developed by the Centers for Medicare & Medicaid (CMS) Innovation Center aimed at providing higher quality, more highly coordinated cancer care and reducing costs for patients undergoing chemotherapy. The OCM calculates costs of care in a novel way by anchoring costs within episodes of care, defined as six-month intervals triggered by initial anti-cancer treatment, as opposed to diagnosis date. The purpose of this study is to assess costs within the OCM episodes of care. Methods: This was a secondary analysis of Medicare administrative claims data for beneficiaries 65 and older with cancer who received anti-cancer drug treatment (chemotherapy, hormone therapy) between 2012-2015 at an institution in the UAB Cancer Community Network (CCN). Total and service-specific costs (Medicare reimbursement to providers) per patient-episode were summed from inpatient, outpatient, chemotherapy, radiation therapy, testing/pathology, evaluation and management (E/M), home health, skilled nursing facility (SNF), and hospice claims. Prescription drug costs were not included. Mean costs for the first three OCM episodes were calculated and compared to (1) diagnosis-based costs (six-month intervals starting at cancer diagnosis) and (2) service type. Results: Average total cost in the first three OCM episodes of care was $24,922 (n=13,902), $18,534 (n=6,618), and $16,548 (n=4,672). Compared to episode-based cost, average total diagnosis-based cost was higher in the first episode of care ($33,244, n=9,615), and lower in the second and third episodes ($17,143, n=9,110; $12,897, n=8,002). Episode-based outpatient, inpatient, and chemotherapy costs were the highest service-specific costs in all three episodes of care (1st: $8,374, $5,493, $2,445; 2nd: $6,188, $3,913, $3,158; 3rd: $5,909, $3,251, $3,399). Conclusions: Costly chemotherapy and inpatient and outpatient visits indicate an opportunity for targeted improvement resulting in higher value care. Knowledge of current costs of care will aid oncology practices in transition to the OCM and in usage of value-based services for better quality cancer care.

The self-care practices of family caregivers of persons with poor prognosis cancer: differences by varying levels of caregiver well-being and preparedness

PURPOSE

Little is known about the impact of family caregiving for adults with poor prognosis cancer on caregivers' own individual self-care practices. We explored differences in caregivers' discrete self-care practices associated with varying levels of caregiver well-being, preparedness, and decision-making self-efficacy.

METHODS

Cross-sectional survey within eight community-based southeastern U.S. cancer centers was conducted. Family caregivers of Medicare beneficiaries ≥65 years with pancreatic, lung, brain, ovarian, head and neck, hematologic, or stage IV cancer completed measures of individual self-care practices (health responsibility, physical activity, nutrition, spiritual growth, interpersonal relations, stress management, and sleep), well-being (anxiety, depression, and health-related quality of life [HRQoL]), preparedness, and decision-making self-efficacy.

RESULTS

Caregivers (n = 294) averaged 66 years, were mostly female (72.8%), white (91.2%), Protestant (76.2%), retired (54.4%), and patients' spouse/partner (60.2%). Approximately, half were rural-dwellers (46.9%) with incomes <$50,000 (53.8%). Most provided support 6-7 days/week (71%) for >1 year (68%). Nearly a quarter (23%) reported high depression and 34% reported borderline or high anxiety. Low engagement in all self-care practices was associated with worse caregiver anxiety, depression, and mental HRQoL (all p values < .05). Caregivers with lower health responsibility, spiritual growth, interpersonal relation, and stress management scores had lower preparedness and decision-making self-efficacy.

CONCLUSIONS

A significant proportion of caregivers simultaneously report low engagement in all forms of self-care practices, high depression and anxiety, and low HRQoL mental health scores. Caregiver well-being, preparedness, and decision-making self-efficacy might be optimized through interventions targeted at enhancing health responsibility, stress management, interpersonal relationships, and spiritual growth self-care practices.

Recent trends in racial and regional disparities in cervical cancer incidence and mortality in United States

BACKGROUND

Although black women experienced greater cervical cancer incidence and mortality rate reduction in recent years, they continue to have higher incidence rates than whites. Great variations also exist among geographic regions of the US, with the South having both the highest incidence and mortality rates compared to other regions. The present study explores the question of whether living in the South is associated with greater racial disparity in cervical cancer incidence and mortality by examining race- and region-specific rates and the trend between 2000 and 2012.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) 18 Program data was used. Cervical cancer incidence and mortality rates, annual percent changes, and disparity ratios were calculated using SEER*Stat software and Joinpoint regression for four groups: US14-Non-Hispanic White (NHW), US14-Non-Hispanic Black (NHB), South-NHW, and South-NHB, where South included 4 registries from Georgia and Louisiana and US14 were 14 US registries except the four South registries.

RESULTS

The average age-adjusted cervical cancer incidence rate was the highest among South-NHBs (11.1) and mortality rate was the highest among US14-NHBs (5.4). In 2012, the degree of racial disparities between South-NHBs and South-NHWs was greater in terms of mortality rates (NHB:NHW = 1.80:1.35) than incidence rates (NHB:NHW = 1.45:1.15). While mortality disparity ratios decreased from 2000-2012 for US14-NHB (APC: -1.9(-2.3,-1.4), mortality disparity ratios for South-NHWs (although lower than NHBs) increased compared to US14-NHW. Incidence rates for NHBs continued to increase with increasing age, whereas rates for NHWs decreased after age 40. Mortality rates for NHBs dramatically increased at age 65 compared to a relatively stable trend for NHWs. The increasing racial disparity with increasing age in terms of cervical cancer incidence rates became more pronounced when corrected for hysterectomy prevalence.

CONCLUSIONS

Black race and South region were associated with higher cervical cancer incidence and mortality. Cervical cancer rates uncorrected for hysterectomy may underestimate regional and racial disparities. Increasing incidence rates for older NHBs compared to NHWs warrant further research to determine whether screening should continue for NHBs over age 65.

Sociodemographic Patterns of Chronic Disease: How the Mid-South Region Compares to the Rest of the Country

INTRODUCTION

States in the Mid-South region are among the least healthy in the nation. This descriptive study examines sociodemographic differences in the distribution of chronic diseases and health-related behaviors in the Mid-South versus the rest of the U.S., identifying subgroups at increased risk of chronic disease.

METHODS

Data were obtained from the 2013 Behavioral Risk Factor Surveillance System; analyses were completed in January 2016. Twelve chronic health conditions were assessed: obesity, diabetes, high blood pressure, coronary heart disease, myocardial infarction, stroke, chronic kidney disease, cancer, arthritis, asthma, chronic obstructive pulmonary disease, and depression. Evaluated health-related behaviors included smoking, physical activity, and fruit and vegetable consumption. Age-standardized percentages were reported using complex survey design parameters to enhance generalizability.

RESULTS

The Mid-South population had increased rates of chronic disease and worse health-related behaviors than the rest of the U.S.

POPULATION

Mid-South blacks had the highest percentages of obesity, diabetes, high blood pressure, and stroke of all subgroups, along with lower physical activity and fruit and vegetable consumption. In both races and regions, individuals with lower income and education had higher rates of chronic disease and unhealthy behaviors than those with higher income and education. However, black men in both regions had higher obesity and cancer rates in the higher education category. In general, education-level disparities were more pronounced in health-related behaviors, whereas income-level disparities were more pronounced in chronic health conditions.

CONCLUSIONS

Future studies should test tailored interventions to address the specific needs of population subgroups in order to improve their health.

Guiding Lay Navigation in Geriatric Patients With Cancer Using a Distress Assessment Tool

BACKGROUND

There is growing interest in psychosocial care and evaluating distress in patients with cancer. As of 2015, the Commission on Cancer requires cancer centers to screen patients for distress, but the optimal approach to implementation remains unclear.

METHODS

We assessed the feasibility and impact of using distress assessments to frame lay navigator interactions with geriatric patients with cancer who were enrolled in navigation between January 1, 2014, and December 31, 2014.

RESULTS

Of the 5,121 patients enrolled in our lay patient navigation program, 4,520 (88%) completed at least one assessment using a standardized distress tool (DT). Navigators used the tool to structure both formal and informal distress assessments. Of all patients, 24% reported distress scores of 4 or greater and 5.5% reported distress scores of 8 or greater. The most common sources of distress at initial assessment were pain, balance/mobility difficulties, and fatigue. Minority patients reported similar sources of distress as the overall program population, with increased relative distress related to logistical issues, such as transportation and financial/insurance questions. Patients were more likely to ask for help with questions about insurance/financial needs (79%), transportation (76%), and knowledge deficits about diet/nutrition (76%) and diagnosis (66%) when these items contributed to distress.

CONCLUSIONS

Lay navigators were able to routinely screen for patient distress at a high degree of penetration using a structured distress assessment.

Choosing Wisely: Opportunities for Improving Value in Cancer Care Delivery?

INTRODUCTION

Patients, providers, and payers are striving to identify where value in cancer care can be increased. As part of the Choosing Wisely (CW) campaign, ASCO and the American Society for Therapeutic Radiology and Oncology have recommended against specific, yet commonly performed, treatments and procedures.

METHODS

We conducted a retrospective analysis of Medicare claims data to examine concordance with CW recommendations across 12 cancer centers in the southeastern United States. Variability for each measure was evaluated on the basis of patient characteristics and site of care. Hierarchical linear modeling was used to examine differences in average costs per patient by concordance status. Potential cost savings were estimated on the basis of a potential 95% adherence rate and average cost difference.

RESULTS

The analysis included 37,686 patients with cancer with Fee-for-Service Medicare insurance. Concordance varied by CW recommendation from 39% to 94%. Patient characteristics were similar for patients receiving concordant and nonconcordant care. Significant variability was noted across centers for all recommendations, with as much as an 89% difference. Nonconcordance was associated with higher costs for every measure. If concordance were to increase to 95% for all measures, we would estimate a $19 million difference in total cost of care per quarter.

CONCLUSION

These results demonstrate ample room for reduction of low-value care and corresponding costs associated with the CW recommendations. Because variability in concordance was driven primarily by site of care, rather than by patient factors, continued education about these low-value services is needed to improve the value of cancer care.

Differences in self-care behaviors by varying levels of caregiving intensity, performance, and well-being among family caregivers of patients with high-mortality cancer

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Background: Family caregivers of high-mortality cancer patients perform vital tasks that deter from their own self-care. We aimed to determine differences in self-care behaviors by varying levels of caregiving intensity, well-being, and performance. Methods: Cross-sectional survey conducted in community settings of 8 cancer centers in AL, FL, and TN. Two-hundred and ninety-four family caregivers of Medicare beneficiaries diagnosed with pancreatic, lung, brain, ovarian, head & neck, hematologic, or stage IV cancer completed measures of self-care behaviors, including health responsibility, physical activity, nutrition, spiritual growth, interpersonal relations, stress management, and sleep; anxiety and depression; health-related quality of life (HRQoL); caregiver competence and preparedness; and decision-making self-efficacy. Results: Caregivers averaged 66 years and were mostly female (72.8%), white (91.2%), Protestant (76.2%), retired (54.4%) and patients’ spouse/partner (60.2%). Approximately half were rural-dwellers (46.9%) and had incomes <$50,000 (53.8%). The majority provided support 6-7 days per week (71%) for > 1 year (68%). Lower self-care behavior scores were associated with longer durations, higher hours, and more days/week of caregiving and with fair or poor patient health. Worse caregiver anxiety, depression, and mental HRQoL scores were significantly associated with lower scores in every self-care subdomain (all ps < .05). Nearly a quarter of respondents reported high depression scores (23%) and 34% reported borderline or high anxiety scores. Caregivers with lower competence, preparedness, and decision-making efficacy had lower spiritual growth, interpersonal relation, and stress management scores. Conclusions: Higher caregiving intensity is associated with worse caregiver self-care. Poorer self-care in all domains is associated with worse caregiver well-being. Interventions to optimize caregiver wellbeing should target all self-care behaviors and to optimize caregiver performance should target spiritual growth, interpersonal relation, and stress management self-care behaviors.

Using Community Feedback to Improve Community Interventions: Results From the Deep South Network for Cancer Control Project

The Deep South Network for Cancer Control (DSNCC), initiated in 2000, is a dual-state, community-based participatory research infrastructure composed of academic and community partners committed to reducing cancer disparities among underserved African Americans in 12 designated counties of the Alabama Black Belt and the Mississippi Delta, 2 historically underserved areas of the country. Local residents trained as Community Health Advisors as Research Partners implemented a 3-tier community action plan (CAP) focused on promoting cancer screening, physical activity, and nutrition. Breast, cervical and colorectal cancer screening, healthy eating habits, and physical activity levels increased among many, but not all, African American women in the 12-county DSNCC coverage area. Seeking to improve our reach to include participants who reported they had never heard of the DSNCC or participated in the CAP, we conducted in-depth conversations with community residents about reasons for selective nonparticipation and ways to improve participation in the DSNCC community health interventions. Three patterns and their associated themes described ways to improve the penetration of CAP strategies and tailor them to effectively reach underserved African Americans in the intervention counties. We conclude with lessons learned for future interventions.

Treatment Summaries and Follow-Up Care Instructions for Cancer Survivors: Improving Survivor Self-Efficacy and Health Care Utilization

To assess the effect of treatment summaries and follow-up care plans on self-efficacy and health care utilization, cancer survivors (≥65 years old) were surveyed. Receiving a verbal explanation of follow-up care instructions was significantly associated with higher self-efficacy scores, which in turn were significantly associated with lower prevalence ratios of emergency room visits and hospitalizations.

Background.

Treatment summaries and follow-up care plan information should be provided to cancer survivors. This study examines the association of receiving summaries and care plans with cancer survivor self-efficacy for chronic illness management, and whether self-efficacy was associated with health care utilization.

Methods.

Four hundred forty-one cancer survivors (≥2 years from diagnosis and had completed treatment) ≥65 years old from 12 cancer centers across 5 states completed telephone surveys. Survivors responded to three questions about receiving a written treatment summary, written follow-up plan, and an explanation of follow-up care plans. Respondents completed the Stanford Chronic Illness Management Self-Efficacy Scale and reported emergency room visits and hospitalizations in the past year. Three multiple linear regression models estimated the association of written treatment summary, written follow-up care plan, and verbal explanation of follow-up plan with total self-efficacy score. Log-binomial models estimated the association of self-efficacy scores with emergency room visits and hospitalizations (yes/no).

Results.

Among survivors, 40% and 35% received a written treatment summary and follow-up care plan, respectively. Seventy-nine percent received an explanation of follow-up care plans. Receiving a verbal explanation of follow-up care instructions was significantly associated with higher self-efficacy scores (β = 0.72, p = .009). Higher self-efficacy scores were significantly associated with lower prevalence ratios of emergency room visits (prevalence ratio, 0.92; 95% confidence interval, 0.88–0.97) and hospitalizations (prevalence ratio, 0.94; 95% confidence interval, 0.89–0.99).

Conclusion.

Explanation of the follow-up care plan, beyond the written component, enhances survivor self-efficacy for managing cancer as a chronic condition—an important mediator for improving health care utilization outcomes.

Implications for Practice:

Older cancer survivors (>65 years) are especially vulnerable to poor outcomes in survivorship because of the complexity of follow-up care and other chronic conditions. Delivering written treatment summaries, written follow-up care plans, and verbal explanations of follow-up care plans all independently increased the self-efficacy for chronic illness management among older survivors. In particular, delivering this information in the verbal format was significantly associated with higher self-efficacy and, subsequently, a lower likelihood of emergency room visits. Understanding the mechanism through which summaries and follow-up care plans may positively influence survivor health is critical to increasing the delivery of the information.

Accuracy of urinary human papillomavirus testing for the presence of cervical human papillomaviruses and higher grades of cervical intraepithelial neoplasia

BACKGROUND

Although urine-based testing for human papillomavirus (HPV) is being explored as a practical approach for cervical cancer screening, whether the results differ by age, race, or indicators of excess body weight or in populations exposed to HPV vaccines has not been documented by previous studies. The purpose of this study was to determine the accuracy of urinary HPV testing for the presence of cervical HPVs and high-grade cervical intraepithelial lesions (grade 2 and 3 cervical intraepithelial neoplasia [CIN]) by the aforementioned population characteristics.

METHODS

The study population consisted of 502 women diagnosed with different grades of CIN. HPV testing was performed with paired urine and cervical cell DNA with the Roche Diagnostics Linear Array test. Agreement coefficient 1 and probabilities were calculated to determine the accuracy of urinary HPV testing for the presence of cervical HPVs and CIN lesions.

RESULTS

Substantial to almost perfect agreement (0.66-0.83) was observed in the detection of any HPV genotype in urine specimens versus cervical specimens, regardless of the population characteristics. Although the positive predictive value for the detection of CIN lesions was relatively low, the negative predictive value for CIN-3 was high (≥90%) among women positive for any of the urinary or cervical high-risk human papillomavirus (HR-HPV) genotypes or HPV genotypes not included in currently available HPV vaccines.

CONCLUSIONS

The results demonstrate that urinary HPV testing provides highly satisfactory results for excluding the possibility of any cervical HPV infections, including HPV types not included in vaccines and CIN lesions associated with any HR-HPV, regardless of a woman's age, race, or excess body weight. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2836-2844. © 2016 American Cancer Society.

Patient Navigation As a Model to Increase Participation of African Americans in Cancer Clinical Trials

PURPOSE

Less than 10% of patients enrolled in clinical trials are minorities. The patient navigation model has been used to improve access to medical care but has not been evaluated as a tool to increase the participation of minorities in clinical trials. The Increasing Minority Participation in Clinical Trials project used patient navigators (PNs) to enhance the recruitment of African Americans for and their retention in therapeutic cancer clinical trials in a National Cancer Institute-designated comprehensive cancer center.

METHODS

Lay individuals were hired and trained to serve as PNs for clinical trials. African American patients potentially eligible for clinical trials were identified through chart review or referrals by clinic nurses, physicians, and social workers. PNs provided two levels of services: education about clinical trials and tailored support for patients who enrolled in clinical trials.

RESULTS

Between 2007 and 2014, 424 African American patients with cancer were referred to the Increasing Minority Participation in Clinical Trials project. Of those eligible for a clinical trial (N = 378), 304 (80.4%) enrolled in a trial and 272 (72%) consented to receive patient navigation support. Of those receiving patient navigation support, 74.5% completed the trial, compared with 37.5% of those not receiving patient navigation support. The difference in retention rates between the two groups was statistically significant (P < .001). Participation of African Americans in therapeutic cancer clinical trials increased from 9% to 16%.

CONCLUSION

Patient navigation for clinical trials successfully retained African Americans in therapeutic trials compared with non-patient navigation trial participation. The model holds promise as a strategy to reduce disparities in cancer clinical trial participation. Future studies should evaluate it with racial/ethnic minorities across cancer centers.

The Patient Care Connect Program: Transforming Health Care Through Lay Navigation

The Patient Care Connect Program (PCCP) is a lay patient navigation program, implemented by the University of Alabama at Birmingham Health System Cancer Community Network. The PCCP's goal is to provide better health and health care, as well as to lower overall expenditures. The program focuses on enhancing the health of patients, with emphasis on patient empowerment and promoting proactive participation in health care. Navigator training emphasizes palliative care principles and includes development of skills to facilitate advance care planning conversations. Lay navigators are integrated into the health care team, with the support of a nurse supervisor, physician medical director, and administrative champion. The intervention focuses on patients with high needs to reach those with the greatest potential for benefit from supportive services. Navigator activities are guided by frequent distress assessments, which help to identify patient concerns across multiple domains, triage patients to appropriate resources, and ultimately overcome barriers to health care. In this article, we describe the PCCP's development, infrastructure, selection and training of lay navigators, and program operations.

Choosing Wisely: Opportunities for improving value of cancer care in the Deep South

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Background: Under the Choosing Wisely (CW) Campaign, the American Society of Clinical Oncology (ASCO) and the American Society of Therapeutic Radiology and Oncology (ASTRO) recommend against non-evidence-based costly medications, tests, and procedures. CW recommendation adherence in the Deep South is largely unknown, and opportunities to reduce overuse and costs may exist. Methods: Analysis of administrative claims and tumor registry data from 12 cancer centers of the University of Alabama Health System Cancer Community Network, for Medicare beneficiaries ≥65 years old with cancer. Main outcome: percent of beneficiaries adhering to 9 CW recommendations. Results: 2012-2015 (Q1) adherence varied across CW recommendations and cancer centers, and increased over time for CW 2 and 7, decreased for 3, 5, and 6, and did not change for others. Conclusions: Opportunities to improve quality and value of cancer care exist in the Deep South. Research should understand how to minimize use of non-evidence based medications, tests, and procedures. [Table: see text]

Abstract P6-11-02: Hospitalizations and costs during Implementation of a lay navigation program for older patients with breast cancer in the deep south

Background: Patient-centered strategies are needed to enhance the value of cancer care particularly at the end of life. Lay navigators (LN) can be trained to provide an extra layer of support for cancer patients from diagnosis through survivorship or end of life. We hypothesized that integrating LNs into the care team would reduce healthcare utilization and cost for patients with cancer, including those with breast cancer.

Methods: A prospective, observational study of Medicare claims data was conducted of beneficiaries ≥ 65 years old diagnosed with cancer after 2008 who received care within the UAB Health System Cancer Community Network (12 cancer centers of varying size located in AL, MS, TN, GA, and FL). The first breast cancer (BC) patient was enrolled in navigation in April 2013, and ∼18% of BC patients were navigated by the end of 2014. For this analysis, we report on the subset of patients with BC. The outcomes of interest were calculated per quarter from 2012-2014: (1) the proportion of patients with at least 1 hospitalization, (2) the proportion of the 492 deceased BC patients with a hospitalization in the last 30 and 14 days of life and (3) the Total costs for Medicare, excluding prescription drug costs. We used general linear models to evaluate changes in both health care utilization and cost over time, adjusting for age, sex, cancer stage, phase of care, and navigation group. Differential effects for navigated and non-navigated groups were tested with a group*time interaction. Healthcare utilization estimates are presented as Incidence Rate Ratios (IRR), and costs for Medicare as parameter estimates (β) in terms of dollar amounts.

Results: 4835 BC patients received care from 2012-2014: 622 received navigation services. 14.2 % of navigated BC patients were stage III/IV, compared to 9.33% of non-navigated patients. The proportion of hospitalizations trended downward from 7.9% in quarter 1 (Q1) 2012 to 5.7% in Q4 of 2014 (IRR 0.965, p =0.14), with similar decreases for navigated and non-navigated patients (IRR= 1.00, p &gt; 0.05). Hospitalization in the last 30 days and last 14 days of life were 49.7% and 29.3%, respectively, with no between groups difference. Costs per beneficiary per quarter decreased overall from $4,161 in Q1 2012 to $3,010 in Q4 2014 (p &lt;0.0001). In adjusted analysis, the navigated patients had an average $577 greater decline per quarter than the non-navigated patients (βNavigated=-$636; βnon-Navigated=-$59; p&lt;0.0001).

Conclusions: Medicare costs declined during implementation of a lay navigation program, with greater reductions for navigated patients than non-navigated BC patients. Overall hospitalizations also declined, yet rates remain high for breast cancer patients at the end of life. Integration of LNs should be considered by health systems aiming to transition to value-based healthcare delivery.

The project described was supported by Grant Number 1C1CMS331023 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this abstract are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

Citation Format: Rocque GB, Kvale EA, Jackson BE, Kenzik K, Lisovicz N, Demark-Wahnefried W, Meneses KM, Taylor RA, Acemgil A, Chambless C, Li Y, Martin M, Fouad M, Pisu M, Partridge EE. Hospitalizations and costs during Implementation of a lay navigation program for older patients with breast cancer in the deep south. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-11-02.

Molecular Mechanism Linking BRCA1 Dysfunction to High Grade Serous Epithelial Ovarian Cancers with Peritoneal Permeability and Ascites

Ovarian cancer constitutes the second most common gynecological cancer with a five-year survival rate of 40%. Among the various histotypes associated with hereditary ovarian cancer, high-grade serous epithelial ovarian carcinoma (HGSEOC) is the most predominant and women with inherited mutations in BRCA1 have a lifetime risk of 40-60%. HGSEOC is a challenge for clinical oncologists, due to late presentation of patient, diagnosis and high rate of relapse. Ovarian tumors have a wide range of clinical presentations including development of ascites as a result of deregulated endothelial function thereby causing increased vascular permeability of peritoneal vessels. The molecular mechanisms remain elusive. Studies have shown that fallopian tube cancers develop in women with BRCA1 gene mutations more often than previously suspected. Recent studies suggest that many primary peritoneal cancers and some high-grade serous epithelial ovarian carcinomas actually start in the fallopian tubes. In this article we have addressed the molecular pathway of a recently identified potential biomarker Ubc9 whose deregulated expression due to BRCA1 dysfunction can result in HGSEOC with peritoneal permeability and formation of ascites. We also discuss the role of downstream targets Caveolin-1 and Vascular Endothelial Growth Factor (VEGF) in the pathogenesis of ascites in ovarian carcinomas. Finally we hypothesize a signaling axis between Ubc9 over expression, loss of Caveolin-1 and induction of VEGF in BRCA1 mutant HGSEOC cells. We suggest that Ubc9-mediated stimulation of VEGF as a novel mechanism underlying ovarian cancer aggressiveness and ascites formation. Agents that target Ubc9 and VEGF signaling may represent a novel therapeutic strategy to impede peritoneal growth and spread of HGSEOC.

Shifting Community-Based Participatory Infrastructure from Education/Outreach to Research: Challenges and Solutions

BACKGROUND

For 10 years, the Deep South Network for Cancer Control (DSNCC) focused on training and deploying community health advisors (CHAs) to promote cancer screening and healthy lifestyle through education/outreach activities. In 2009, the request for application (RFA) for renewal of the DSNCC required a controlled research intervention. Converting from education/outreach to research proved more problematic than expected.

OBJECTIVES

The objective of this article was to describe the challenges and solutions during this conversion and to describe the importance of education/outreach to community infrastructure.

METHODS

This is a qualitative assessment of the challenges and solutions encountered in conducting a controlled weight loss trial in a community setting in which education/outreach had been the priority.

LESSON LEARNED

The DSNCC provides a model for overcoming the unique challenges of converting a longstanding education/outreach program into a controlled research program.

CONCLUSION

Although multiple challenges were encountered in conducting a community-based participatory research (CBPR) controlled trial, solutions were developed and the trial continues as proposed.

Trends in health care utilization, cost, and aggressive care at end of life among older cancer patients in the Deep South

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Background: Healthcare utilization and costs escalate near diagnosis and in the final months of life. There is a national trend toward aggressive care at end of life (EOL). We examined patterns in utilization and cost across the trajectory of care and during the last two weeks of life during implementation of a lay navigation intervention. Methods: Claims data were obtained for Medicare beneficiaries ≥ 65 years old with cancer in the UAB Health System Cancer Community Network (UAB CCN). For 10 quarters from January 2012 -June 2014, we examined healthcare utilization for the population at large, navigated patients, and decedents. All analyses included ER visits, hospitalizations, and ICU admissions and use of chemotherapy in the last 2 weeks of life, and hospice utilization (admission or less than 3 days of hospice) in the quarter of death for decedents. Descriptive analyses and linear regression were used to test trends over time; general linear models evaluated changes in health care utilization and cost. Results: Across the population reduction of 13.4% to 11% for hospitalization (18% decrease, p < 0.01), 8.0% to 7.1% for ER visits (12% decrease, p < 0.01), 2.9% to 2.5% for ICU admissions (14% decrease, p = 0.04) and an increase of 3.9% to 4.3% for hospice (9.2% increase p = 0.37) were found. Among 5,861 decedents, in the last 2 weeks of life, there were decreases in ICU admissions (14.6% decrease, p = 0.11), from 39.2% to 32.0%, ER visits (18.4% decrease, p = 0.03), and chemotherapy, from 4.7% to 3.5% (25.5% decrease, p = 0.11).Over the 10 quarters, hospice enrollment increased from 70.7% to 77.4% (9.48% increase; p = 0.06), and the proportion of patients on hospice for less than 3 days changed from 7.8% to 7.5% (3.85% decrease, p = 0.30). Costs decreased about $158 per quarter per beneficiary. A significant pre-post decrease of $952 per beneficiary (p < 0.01) led to an estimated reduction in Medicare costs of $18,406,920 for the 19,335 beneficiaries in the UAB CCN for the five quarters post-implementation. Conclusions: We observed decreased healthcare utilization and cost and trends toward decreased aggressive care at EOL in the UAB CCN. Further work is needed to determine the impact of navigation on utilization trends.

Understanding causes of distress in women with gynecologic cancer

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Background: Lay patient navigators can screen patients using a distress tool (DT) to identify and address multiple patient concerns. Patient-reported distress can be used to characterize the needs of patients with ovarian, endometrial, and cervical cancer through all phases of care from initial diagnosis through active treatment and into survivorship. Methods: The Patient Care Connect Program (PCCP) includes 12 cancer centers throughout Alabama, Mississippi, Georgia, Florida, and Tennessee and navigates Medicare beneficiaries with cancer. Within the PCCP, navigators documented distress levels, causes of distress, and requests for intervention. Distress screening results were used to describe needs of patients with gynecologic malignancies and to assess effective resolution of distress. Results: Initial DT results were collected on 360 patients with gynecologic cancers: 206 (57%) ovarian, 111 (31%) endometrial, and 43 (12%) cervical cancers. Fifty-six (16%) were African American. Twenty-four percent of patients reported a distress score ≥ 4 and 4% reported scores ≥8. Physical symptoms most frequently caused distress (44%) particularly fatigue, pain, and neuropathy. Practical problems (11%), informational needs (16%) and emotional issues (19%) were also common. Patients were most likely to request assistance with transportation (63%), financial/insurance issues (77%), and nutritional concerns (75%). Lay navigators were able to address these concerns in 92% of patients. Conclusions: Gynecologic cancer patients report diverse sources of distress extending beyond symptom management. By administering DTs, patient navigators may effectively facilitate resolution of patient identified distress. The project described was supported by Grant Number 1C1CMS331023 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this abstract are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

Abstract IA35: Sustainabity of patient navigation programs: Lessons learned from a Medicare innovation project

In 2012, the University of Alabama at Birmingham (UAB) received $15 million dollar Center for Medicare and Medicaid (CMS) Innovation grant to establish a lay (non-clinical) navigation program within the UAB Health System Cancer Community Network, called the Patient Care Connect Program. This network is comprised of 12 sites, including both academic and community medical centers of varying sizes and practice structures. The navigators provide an extra layer of support to Medicare patients who are ≥65 with cancer, from the time of diagnosis through survivorship or end of lie. We currently have enrolled &gt;6000 patients. The goal of this program is to empower patients to be active participants in their healthcare and to increase the value of the care delivered within the network. We define value as high quality care with high patient satisfaction, delivered at a lower cost. Cost savings can be attained through proactive management of patient concerns and improving communications between patients and the healthcare delivery system, which has the potential to reduce the number of unnecessary ER visits, hospitalizations, and ICU days while increasing hospice use.

Since the program inception, we have been focused on integrating navigation as a sustainable component of the healthcare system. We have identified three key elements to establishing a sustainable navigation program: 1) early stakeholder engagement, 2) robust communication, and 3) data collection for self-monitoring and demonstration of outcomes. We recognize that it is critical to truly incorporate the navigators into the healthcare team, which requires buy-in from administrators, physicians, nurses, and other members of the healthcare team. Lay navigation programs, as the Patient Care Connect Program, must also integrate with existing nurse navigation programs, social workers, chaplains, and other staff to ensure that patients are supported maximally and services are not duplicated. This focus on the team helps to meet the needs of the healthcare system and to demonstrate the navigator's value such that other team members become advocates of system-based approaches to fund navigators. The second component is a robust communication infrastructure, which is important both at the site level and between sites within a network. We conduct peer-to-peer communications between a UAB lead and the site lead. For example, the UAB medical director communicates directly with the site medical director monthly and the UAB administrator has monthly meetings with the administrators from all sites. This personal, frequent communication allows not only for the UAB team to communicate updates and results to the sites, but also allows for bidirectional information about challenges and success encountered with implementation and maintenance of the program. We also have regular site visits to bring larger groups of physicians, nurses, navigators, and administrators together to discuss the program and review results. These site visits allow for greater participation and the ability to create a learning health system that adjusts to programmatic feedback. We also conduct an annual meeting, which includes members from all sites, so that there is an opportunity for everyone to share experiences and best practices. The final and perhaps most essential component of developing a sustainable program is the ability to collect data on program impact. We have a navigation software system that allows for standardized data collection across all 12 cancer centers. Navigators use this system to record patient information, navigators contacts and interventions, and patient-reported outcomes. Through this grant, we also have a partnership with CMS, who provide claims data for monitoring the impact on resource utilization and cost. In addition, sites are developing infrastructure to use their financial records and tumor registries to collect this data on a real-time basis. Inclusion of these key aspects aids in demonstrating value, which frames conversations with future partners about sustainability.

Our approach to sustainability is to work with multiple stakeholders in parallel. We are engaged in discussion with CMS about potential for future funding when our grant ends. Several options exist for funding including both fee-for-service or bundled payments. CMS is also considering an Innovative Oncology Payment Model, which would include shared savings expectations. Navigation services and the ability to use data for quality improvement are considered integral components of this model. We are currently discussing the possibility of expanding the patient population beyond Medicare patients with several insurance companies. We have also begun to engage large employers who are interested in our network as a preferred provider due to the presence of the navigation program and rapid-learning environment that promotes quality. Patients and caregivers can also play a role in program sustainability, both through philanthropy and community engagement. They can choose to receive health care in a system that includes navigators and they can talk with friends, family and their legislators to serve as advocates of navigation services.

The ability to develop data collection infrastructure also positions a network well to obtain additional grant funding to answer specific, patient-centered questions. This data also can be used to demonstrate value, making navigator programs increasingly attractive to the health system itself. Early engagement with the administrators also ensures that the navigation is in line with the strategic vision of the hospital. Given the current, undeniable shift toward value-based care, navigation programs can become a key approach to improve both improve quality and lower cost, supported by the health system that has incentive to fund these programs. These diverse approaches can be used within any health system with the goal of sustaining navigation services.

Citation Format: Gabrielle B. Rocque, Edward E. Partridge. Sustainabity of patient navigation programs: Lessons learned from a Medicare innovation project. [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 IA35.

Abstract 2736: Analysis of ROS concentration in serous ovarian carcinoma

Serous ovarian cancer is the most malignant form of cancer affecting the female reproductive tract. Early detection is associated with 90% five year survival however, current screening tools are not sensitive enough to detect ovarian cancer at early stages. Thus, there remains a critical need for advanced diagnositic tools for early detection and improved prognosis. An accumulation of ROS compounds coupled with increased oxidative stress over time can be deleterious and has been implicated in many human diseases including serous ovarian cancer. Evalution of the ROS concentration in different stages of serous ovarian cancer could be helpful in understanding of the different signaling pathways that may be involved in the transformations of ovarian tumor tissue phenotype. In this study the production of ROS compounds were evaluated in the mitochondria as a caustic of oxidative stress that involve in the transformations of serous ovarian carcinoma. Through the use of a fluorogenic probe, dichlorodihydrofluorescin (DCFH-DiOxyQ) that reacts with the free radicals in a sample, cumulative level of ROS concentrations among stages of serous ovarian carcinoma were detected. Results revealed an increase of 25% ROS fluorescence in the malignant stages compared to normal/surrounding tissues samples. Additionally there was a notably higher ROS concentration in the malignant stages compared to the borderline tissue samples. Results from this study indicate an exponential increase in the levels of ROS from the benign to malignant stages of the disease, suggesting that cumulative ROS levels from early to late of stages may be involved in the progressive stages of the serous ovarian disease type.

Citation Format: Shakeria L. Cohen, Sharifeh Mehbari, Edward E. Partridge, Felix Aikhionbare. Analysis of ROS concentration in serous ovarian carcinoma. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 2736. doi:10.1158/1538-7445.AM2015-2736

A study of the relationship between food group recommendations and perceived stress: findings from black women in the Deep South

Black women in the Deep South experience excess morbidity/mortality from obesity-related diseases, which may be partially attributable to poor diet. One reason for poor dietary intake may be high stress, which has been associated with unhealthy diets in other groups. Limited data are available regarding dietary patterns of black women in the Deep South and to our knowledge no studies have been published exploring relationships between stress and dietary patterns among this group. This cross-sectional study explored the relationship between stress and adherence to food group recommendations among black women in the Deep South. Participants (n = 355) provided demographic, anthropometric, stress (PSS-10), and dietary (NCI ASA-24 hour recall) data. Participants were obese (BMI = 36.5 kg/m(2)) and reported moderate stress (PSS-10 score = 16) and minimal adherence to Dietary Guidelines for Americans food group recommendations (1/3 did not meet recommendations for any food group). Participants reporting higher stress had higher BMIs than those reporting lower stress. There was no observed relationship between stress and dietary intake in this sample. Based on these study findings, which are limited by potential misreporting of dietary intake and limited variability in stress measure outcomes, there is insufficient evidence to support a relationship between stress and dietary intake.

Abstract C61: Genetic alterations in the TP53 genomic region of African American and Caucasian colorectal cancers

Purpose: In the US, colorectal cancer (CRC) is the second leading cause of cancer-related deaths and the third most common cancer in both men and women. CRC affects African Americans (AAs) disproportionately, relative to non-Hispanic Caucasians (CAs). Data from our prior studies indicate that the p53 codon 72 polymorphism is disproportionately higher in AAs compared to CAs [Clin Cancer Res; 15(14); 2406–-2416. 2009]. It is also evident that genetic human diversity is due not only to single nucleotide polymorphisms (SNPs), but also to structural variants or retrotransposons. Retrotransposons induce mutations, near or within genes by several mechanisms: insertions, deletions, duplications, copy number variants, inversions, or translocations, all of which expand human diversity and possibly alter cancer susceptibility. Thus, our objectives are to establish genomic profiles of the p53 tumor suppressor (TP53) region of CRCs of AA and CA patients to identify race/ethnic-specific alterations that are associated with ancestry, and to develop a DNA sequencing protocol to delineate AA and CA patient profiles using this complex genomic region (∼19 Kb).

Methods: Genomic DNA was extracted from 4 frozen tissue samples (2 CRCs and their corresponding normal pairs) and 4 (2 CRCs/normal pairs) formalin-fixed, paraffin-embedded (FFPE) tissues. For the DNA of two CRC patients (one tumor/normal pair each of AA and CA patients), the complete TP53 gene (∼19 Kb, including exons and introns) was amplified by PCR in two halves, followed by Illumina next-generation sequencing and comparison to the human genome 19 reference sequence. For each patient, paired normal (benign/control) and tumor tissue DNAs were compared.

Results: TheTP53 gene was amplified from DNA extracted from all 4 frozen CRC tissues, but not from the 4 FFPE tissues. Sequence comparisons of normal versus tumor DNA revealed 80 single nucleotide polymorphisms (SNPs). Most (96%, n=77) located within introns. Of these, 34 were shared by AA and CA patients. In contrast, 8 SNPs were detected only in a CA patient, and 13 others were present only in an AA patient. Two SNPs found in our AA patient were absent in our CA patient and in the publicly available HapMap database of CAs, suggesting that these SNPs reflect African ancestry. Also, 22 SNPs were exclusively present in the CA tumor, whereas only 3 SNPs were unique to the AA tumor. These findings deserve further investigation.

Conclusions: We developed PCR protocols that should allow us to conduct a comprehensive mutational profiling of coding and non-coding regions of the TP53 genomic region in DNA isolated from frozen tissues. Comparison of genetic alteration profiles of TP53 in AAs and CAs will aid in determining the race/ethnicity of CRC patients. These studies were supported by a Charles Barkley Foundation grant though the UAB MHRC and a pre-pilot project of the UAB/TU/MSM Partnership grant, U54-CA 118948.

Citation Format: Jesus F. Salazar-Gonzalez, Maria G. Salazar, Balananda Dhurjati Kumar Putcha, Edward E. Partridge, Mona N. Fouad, Manne Upender. Genetic alterations in the TP53 genomic region of African American and Caucasian colorectal cancers. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr C61. doi:10.1158/1538-7755.DISP13-C61

Guiding lay navigation using the distress thermometer

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Background: The Commission on Cancer will require distress evaluation in 2015, given growing emphasis on psychosocial care. We report on a novel use of the distress thermometers (DTs) to frame navigator-patient interactions. Methods: Thirty-eight lay (non-clinical) navigators were trained to utilize a comprehensive distress thermometer to evaluate patients in the Patient Care Connect program (PCCP). The PCCP is a 12-center network throughout AL, MS, GA, FL and TN that serves Medicare patients ≥ 65 with cancer. During patient interactions, navigators assess causes of distress and requests for intervention (barrier). Scores ≥ 4/10 trigger intervention. Navigators report symptom-related barriers to providers for proactive management and address non-clinical barriers by empowering patients to connect to available resources. Results: Of the first 3,000 patients with DTs, pain (n=367), fatigue (n=304), and mobility issues (n=217) were the most common sources of distress. Although pain was common, only 32% requested intervention. Intervention was most often requested for distress related to knowledge deficits about treatment (75%), transportation (69%), and insurance/financial (67%). Patients requested intervention in 32.8% of assessments. Over 90% of all barriers were resolved. Conclusions: The PCCP uses the DT as an integral navigation screening across multiple health systems of varying size and structure. This approach provides continuity and structure to extend the workforce using lay navigators. Use of the DT allows for identification of quality of life, informational, and logistical barriers to care. Monitoring patients using navigator administered DTs is a promising tool for future application across multiple health systems. Additionally, data collected by the DT can be used to identify themes in distress for further research and to design comprehensive interventional programs. The project described was supported by Grant Number 1C1CMS331023 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this abstract are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

Abstract C77: Tristetraprolin suppression is associated with advanced stage colorectal cancer

Background: Interleukin (IL)-8, vascular endothelial growth factor (VEGF), and IL-6 contribute to the colorectal cancer (CRC) progression by inhibiting apoptosis and by promoting angiogenesis and tumor proliferation. We have found that the tristetraprolin (TTP) gene attenuates these processes [J Neurooncol. 2013; 113(2):195-205]. TTP expression is lost or reduced in many cancers, including CRCs, and loss of TTP is thought to contribute to tumorigenesis. We hypothesized that low TTP levels favor expression of growth factors and correlate with CRC progression. In addition, we suggest that TTP modulates CRC growth through negative regulation on cell survival and/or anti-apoptotic factors in the NF-kB pathway. We tested this hypothesis by analyzing mRNA expression of TTP and its targets in primary CRCs of African American (AA) and Caucasian American (CA) patients.

Methods: We analyzed frozen primary tissues from 45 CRC patients (AA=26 and CA=19), each with corresponding normal (benign/control) tissue. cDNAs were reverse-transcribed from total RNA; mRNA levels of TTP and its target genes (IL-8, VEGF, IL-6) were quantified by the qPCR sybr-green method. Expression levels were normalized to GAPDH. To assess TTP effects on the NF-kB pathway, colon cancer cells (CCL235, HCT116, SW480, and LoVo) were stimulated with TNF-α for 0-24 hr, and total RNA was analyzed for TTP, IL-8, IL-6, VEGF, and cIAP2 expression by qRT-PCR. Levels of HuR mRNA in cells were also assessed. Extracts from the cells were immunoblotted with anti-TTP and antiHuR antibodies.

Results: We observed down-regulated expression of TTP mRNA in primary CRCs (31 of 45), and decreased TTP levels correlated with advanced tumor stage. Low levels of TTP were found in 21 of 26 AAs and 12 of 19 CAs. In both racial groups, there was an inverse correlation between TTP and IL-8 expression in relation to tumor stage. Studies with cultured colon cancer cells demonstrated that TTP mRNA levels inversely correlated with levels of IL-8, IL-6, VEGF, and cIAP2 mRNAs, suggesting interactions of TTP with cell survival factors. Western blot analyses confirmed TTP expression levels in these cells.

Conclusions: For both racial groups, TTP expression was lower in tumor tissues relative to normal tissues; the difference was more pronouced in CRCs of AAs. Further, lower TTP levels correlated with advanced tumor stage; and TTP negatively regulated the expression of IL-8, VEGF, and cIAP2 in cultured cells. These studies were supported by a pre-pilot project of the UAB/TU/MSM Partnership grant of NIH/NCI, U54-CA 118948.

Citation Format: Esther A. Suswam, Balanada Dhurjarti Kumar Putcha, Kiera D. Walker, LaJessica Johnson, Jasmine Howard, Edward E. Partridge, Mona N. Fouad, Sejong Bae, Upender Manne. Tristetraprolin suppression is associated with advanced stage colorectal cancer. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr C77. doi:10.1158/1538-7755.DISP13-C77

Abstract C05: Analysis of oxidative modified proteins in serous subtype of ovarian carcinoma

Serous subtype of ovarian cancer accounts for approximately 60% to 80% of ovarian cancer cases and is by far the most aggressive histology. Fewer than 25% of the serous ovarian cancer cases are detected at an early stage (stages I and II), a statistic which reflects grimly on the low survival rates, especially among African-American women. Elevated levels of reactive oxygen species (ROS) are one of many of known and suspected risk factors associated with ovarian cancer. Oxidative stress, which results from an imbalance between ROS and antioxidant capacities, can cause a wide range of direct or indirect DNA damage. There are extensive DNA repair systems that can correct DNA damage caused by ROS before cell replication and mutation fixation. Given that serous cancer subtype is considered to have originated from the fallopian epithelium mucosa that was exposed to immense physiological changes, driven by cyclically altering hormone levels as a result of ovulation. The influence of ovulation is a cause of increased oxidative stress. In this study, we applied spectrophotometric DNPH assay, two dimension gel electrophoresis (2-D SDS-PAGE), and Oxidized protein western blot analysis to identify and evaluate the level of oxidative modified protein, using derivatisation of protein carbonyl group with 2,4-dinitrophenylhyrdozine(DNPH) assay in the obtained 155 snap-freeze primary serous epithelial ovarian tissues including, normal, normal surrounding, cystoadenoma, borderline and carcinoma with age range of 65±12, (55% Caucasian 45% Africa American). Our results showed that the index of carbonyl protein /total protein increased by onset and progression of the serous ovarian malignancy. The elevation of oxidized protein among African American was 40 % higher than Caucasian in advanced stages of disease. SDS-PAGE profiles and western blot analysis of oxidized proteins showed a distinct protein pattern among cancerous and non-cancerous tissues. Our study suggests that level of oxidative stress, may involve the selective modification of some enzymes and structural proteins and play a role in etiological differences that may exist between stages of benign and invasive epithelial ovarian tumors.

This study was funded in part as a result of the grants from NIH-CHDRD CA150317 and NCI CA150039.

Citation Format: Sharifeh Mehrabi, Shakeria Cohen, Edward E. Partridge, Felix O. Aikhionbare. Analysis of oxidative modified proteins in serous subtype of ovarian carcinoma. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr C05. doi:10.1158/1538-7755.DISP13-C05

Cervical cancer screening

These NCCN Guidelines Insights focus on recent recommendations for cervical cancer screening and management of abnormal screening tests. When the NCCN Panel convened to update the NCCN Guidelines for Cervical Cancer Screening, they decided to adopt and endorse guidelines from other organizations to avoid duplication of effort. Therefore, in July 2013, after review and validation of consensus guidelines from the American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology, the NCCN Guidelines for Cervical Cancer Screening were discontinued.