Engaging Community-Academic Partnerships: A Case Study of the Influence of Social Drivers of Health on Equitable Transitions of Cancer Care in the United States

Enduring community-academic partnerships are essential for expediting the successful dissemination and implementation of promising interventions and programs, particularly for complex public health issues such as cancer prevention and control. The purpose of this case study was to understand the combined voices of a diverse group of stakeholders to outline the essential factors needed to translate research into sustainable cancer care within communities. System dynamics group model building was used to develop system maps of the factors impacting equitable access to cancer care services among three stakeholder groups (Group A: survivors and family members, n = 20; Group B: providers and administrators in community agencies/organizations, n = 40; Group C: administrators from a cancer institute, academic universities, foundations, and healthcare facilities that coordinate care, n = 25) in central Texas, USA. The lead researcher identified factors involved in transitions of care and their linkages with each other. The analysis of this work displays these connections visually. These models represent the ripple effect of factors influencing the transition of care for stakeholders who are invested in cancer care outcomes. All three groups identified medical mistrust, a culturally sensitive and diverse provider workforce, and care coordination as three essential factors (i.e., themes). Group A also identified caregiver navigation. The groups varied in their emphasis on upstream vs. downstream social drivers of health, with Group B emphasizing the former and Group C emphasizing the latter. To achieve cancer care equity, all stakeholder groups agreed on the importance of addressing the impact of social drivers as critical gaps. Eliminating or reducing these impacts allows each stakeholder group to work more efficiently and effectively to improve cancer care for patients.

Social workers are key to addressing social determinants of health in integrated care settings

Social workers play an important role in assessing social determinants of health (SDH) and providing behavioral health services in integrated care settings. Evidence suggests that integrated care interventions improve quality of life and other patient outcomes. However, the ambiguous role of social workers on the interdisciplinary team, the lack of protocol in SDH screening and intervention, and restrictions due to healthcare reimbursement limit social workers' ability to intervene. Future directions include standardizing integrated care models, evaluating integrated care's efficacy to address SDH, incorporating SDH into interprofessional training including role clarification and reimbursing for SDH assessment and intervention.

Sociodemographic Correlates of Low Health Literacy Skills Among Cancer Survivors: National Findings From BRFSS 2016

PURPOSE

This study aimed to explore associations of sociodemographic factors with difficulties in three health literacy (HL) skills and the severity of low HL skills.

DESIGN

Cross-sectional secondary data analysis. Subjects: Data came from 17,834 adults who responded to the HL module with a response rate of 47% in the 2016 Behavioral Risk Factor Surveillance System.

MEASURES

Independent variables included sex, age, race/ethnicity, education, employment and income. Dependent variables are three HL skills: obtaining, understanding oral, and understanding written health information.

ANALYSIS

We conducted weighted Chi-square tests and multinominal logistic regressions.

RESULTS

Cancer survivors younger than 65 (aged 18-39: AOR = 4.46, P < .001; aged 40-64: AOR = 2.29, P < .001), Hispanic (AOR = 2.17, CI = 1.61-2.50, P < .01) had higher odds of difficulty obtaining health information. Female cancer survivors had lower odds of difficulty comprehending oral (AOR = .69, CI = .55-.87, P < .01) and written (AOR = .58, CI = .46-.74, P < .001) information. The relative risk ratio of having difficulties in three HL tasks was higher for those who were younger than 65 (aged 18-39: RRR = 10.18, CI = 2.41-4.3, P < .01; aged 40-64: RRR = 4.01, CI = 2.09-7.69, P < .001), Hispanic (RRR = 3.24, CI = 1.66-11.34, P < .01), unemployed (RRR = 6.1, CI = 2.88-12.76, P < .001), education levels lower than some college (some high school: RRR = 4.34, P < .01; high school: RRR = 2.62, P < .05) and household income under $25,000 (RRR = 6.99, CI = 2.8-17.5, P < .001).

CONCLUSION

Intervention and communication materials need to be tailored for patients with different HL skills considering age, gender, socioeconomic status and cultural backgrounds.

Navigating Financial Barriers to Papanicolaou Tests and Mammograms for Young Adult Women Residing in Rural and Border Areas of Texas

Purpose: Costs of Papanicolaou (Pap) tests and mammograms are a primary barrier for women aged 18-39 seeking screening and diagnostic services. Race/ethnicity and rural/border resident status compound their risks for delayed diagnosis, possibly resulting in higher mortality. Methods: We analyzed cross-sectional data from young adult (YA) women (aged 18-39) from a cancer education and patient navigation (PN) program in rural and border Texas from 2012 to 2016. Descriptive statistics, Chi-square tests, and logistic regressions summarized sociodemographic variables and receipt of PN, Pap tests, and mammograms. Results: The sample consisted of 1181 women aged 31.8 years (standard deviation 5.5) on average. A total of 795 (67.3%) received PN, 494 (41.8%) received a Pap test, and 121 (10.3%) received a mammogram. The YA women attending the program due to cost (odds ratio [OR]: 7.24; confidence interval [CI]: 4.74-11.05) and reporting 1 (OR: 3.84; CI: 2.40-6.14) or 2+ barriers (OR: 6.00; CI: 3.61-9.99) had higher odds of being navigated than those not concerned about cost and not identifying a barrier. The YA women attending due to cost (OR: 2.22, CI: 1.61-3.05) and receiving navigation (OR: 1.92; CI: 1.29-2.84) had higher odds of receiving a Pap test than their counterparts. The majority receiving a mammogram were worried about cost (85.1%); 40.5% had a family history of breast cancer, and a doctor or nurse recommended a mammogram for 15.7%. Conclusion: Detection of cervical and breast cancer in YA women residing in rural and border Texas may be improved with PN to assist with financial barriers to care and service coordination.

Understanding the role of access in Hispanic cancer screening disparities

BACKGROUND

Hispanic populations in the United States experience numerous barriers to care access. It is unclear how cancer screening disparities between Hispanic and non-Hispanic White individuals are explained by access to care, including having a usual source of care and health insurance coverage.

METHODS

A secondary analysis of the 2019 National Health Interview Survey was conducted and included respondents who were sex- and age-eligible for cervical (n = 8316), breast (n = 6025), or colorectal cancer screening (n = 11,313). The proportion of ever screened and up to date for each screening type was compared.  Regression models evaluated whether controlling for reporting a usual source of care and type of health insurance (public, private, none) attenuated disparities between Hispanics and non-Hispanic White individuals.

RESULTS

Hispanic individuals were less likely than non-Hispanic White individuals to be up to date with cervical cancer screening (71.6% vs. 74.6%) and colorectal cancer screening (52.9% vs. 70.3%), but up-to-date screening was similar for breast cancer (78.8% vs. 76.3%). Hispanic individuals (vs. non-Hispanic White) were less likely to have a usual source of care (77.9% vs. 86.0%) and more likely to be uninsured (23.6% vs. 7.1%). In regressions, insurance fully attenuated cervical cancer disparities. Controlling for both usual source of care and insurance type explained approximately half of the colorectal cancer screening disparities (adjusted risk difference: -8.3 [-11.2 to -4.8]).

CONCLUSION

Addressing the high rate of uninsurance among Hispanic individuals could mitigate cancer screening disparities. Future research should build on the relative successes of breast cancer screening and investigate additional barriers for colorectal cancer screening.

PLAIN LANGUAGE SUMMARY

This study uses data from a national survey to compare cancer screening use those who identify as Hispanic with those who identify as non-Hispanic White. Those who identify as Hispanic are much less likely to be up to date with colorectal cancer screening than those who identify as non-Hispanic White, slightly less likely to be up to date on cervical cancer screening, and similarly likely to receive breast cancer screening. Improving insurance coverage is important for health equity, as is further exploring what drives higher use of breast cancer screening and lower use of colorectal cancer screening.

Interprofessional collaboration between social workers and community health workers to address health and mental health in the United States: A systematised review

Collaboration between social workers (SW) and community health workers (CHW) plays an essential role in addressing health inequities in the United States (US). However, little is known about the current state of CHW/SW collaboration. The objectives of this review were to identify (a) the nature, goals and setting of CHWs and SW collaboration; (b) the patient outcomes utilised to measure intervention efficacy. The literature search was conducted in December 2020 using six databases. The inclusion criteria were (1) interventions that included CHWs and SWs; (2) US-based; (3) published between 2000-2020; (4) peer-reviewed journal articles; (5) examining health or mental health outcomes. Search results identified 281 articles, and 15 were included in the final analysis. Settings that utilised SW/CHW collaboration included outpatient clinics (n = 10); community organisations (n = 4) or hospital (n = 1). CHW and SW interventions focused on disease prevention (n = 8), chronic care (n = 4) and mental health (n = 3). Health outcomes were the most evaluated (n = 13), and significant improvement of at least one health outcome was reported in those studies. Mental health outcomes (n = 3) were also significantly improved, while social determinants of health (n = 2) were least common and descriptive only. This is the first review of SW and CHW collaboration. Clarity regarding SW and CHW roles and scopes of practice are needed to understand better SW/CHW collaboration and its impacts on community health outcomes and improve the process of collaboration. SW and CHW collaboration may increase clients' access to preventive care, mental health and address health inequities.

Socioeconomic inequalities and Black/White disparities in US cocaine-involved overdose mortality risk

PURPOSE

This study examined whether socioeconomic inequalities account for Black/White disparities in: (a) the prevalence of potential risk factors for overdose among adults using cocaine; and (b) national mortality rates for cocaine-involved overdose.

METHODS

Data from 2162 Non-Hispanic (NH) Black or White adults (26 +) who reported past-year cocaine use in the 2015-2019 National Survey of Drug Use and Health were analyzed to obtain predicted probabilities of potential overdose risk factors by race and sex, using marginal effects via regression analyses, adjusting for age and socioeconomic indicators. Next, National Center for Health Statistics data (for 47,184 NH Black or White adults [26 +] who died of cocaine-involved overdose between 2015 and 2019) were used to calculate cocaine-involved overdose mortality rates by race and sex across age and educational levels.

RESULTS

Several potential overdose vulnerabilities were disproportionately observed among NH Black adults who reported past-year cocaine use: poor/fair overall health; cocaine use disorder; more days of cocaine use yearly; hypertension (for women); and arrests (for men). Adjusting for age and socioeconomic indicators attenuated or eliminated many of these racial differences, although predicted days of cocaine use per year (for men) and cocaine use disorder (for women) remained higher in NH Black than White adults. Cocaine-involved overdose mortality rates were highest in the lowest educational strata of both races; nonetheless, Black/White disparities were observed even at the highest level of education, especially for adults ages 50 + .

CONCLUSION

Age and socioeconomic characteristics may account for some, yet not all, of Black/White disparities in vulnerability to cocaine-involved overdose.

Dépistage du personnel de santé exposé au SARS-CoV-2 dans un hôpital universitaire

Introduction

Dans le cadre de la pandémie mondiale au SARS-CoV-2, les personnels de santé (PS) sont professionnellement exposés à ce virus. Dans ce contexte, cette étude présente les données de surveillance de 5704 travailleurs exposés au SARS-CoV-2 d’un centre hospitalier du 17 mars au 20 avril 2020.

Matériels et méthodes

Les PS symptomatiques, les cas contacts et ceux présentant une forte anxiété ont été testés. Le diagnostic de COVID-19 a été réalisé par RT-PCR après prélèvement nasopharyngé.

Résultats

Au cours de cette période, 30,4 % (1735/5704) des PS ont bénéficié de 3057 écouvillons nasaux. Parmi ceux-ci, 8,0 % (138/1735) étaient infectés par le SRAS-CoV-2. Parmi les PS positifs au SARS-CoV-2, 21,7 % étaient asymptomatiques. Dans les unités COVID et les unités non COVID, le nombre de personnes infectées par le SARS-CoV-2 était respectivement de 5,8 % (13/223) et 8,2 % (125/1512) (p = 0,2). Parmi les PS travaillant hors des unités COVID, 6,4 % (12/188) des agents des unités pédiatriques et 8,1 % (126/1547) des agents des unités adultes ou des laboratoires étaient positifs au SARS-CoV-2 (p = 0,4). Parmi les PS des unités adultes, 6,4 % (8/125) provenaient de la médecine interne, 5,6 % (7/125) de la neurologie, 5,6 % (7/125) de la pharmacie et 5,6 % (7/125) du service médical d’urgence. Parmi les personnes atteintes du SARS-CoV2, les infirmières, les internes/médecins et les aides-soignants étaient les catégories professionnelles les plus touchées avec respectivement 30,0 % (40/138), 21,0 % (29/138) et 10,9 % (15/138). Parmi les médecins, la majorité étaient des internes (70,0 % ; 20/29). Les travailleurs de plus de 50 ans étaient moins susceptibles d’être positifs au SARS-CoV-2 (3,8 % ; 14/373) que les autres travailleurs plus jeunes (9,1 % ; 124/1362) (p < 0,001). Aucun cas grave de COVID-19 n’a été signalé dans notre population au cours de cette période.

Conclusion

Parmi les PS positifs détectés, 21,7 % (25/115) étaient asymptomatiques. Ces données soulignent l’importance du dépistage systématique des cas contacts même asymptomatiques et de l’utilisation d’équipements de protection individuelle (EPI) pour éviter la transmission. Le pourcentage des cas positifs diminuait à mesure que l’âge augmentait, en particulier après l’âge de 45 ans. Les personnels de plus de 45 ans, étant plus expérimentées et se sentant plus à risque, ont pu être mieux protégées ou affectées à des services moins à risque ou confinés à domicile. Les PS travaillant dans des unités COVID-19 n’étaient pas plus souvent infectés que ceux travaillant dans des unités non COVID-19, probablement parce qu’ils étaient plus conscients des dangers et des risques associés au SARS-CoV-2, qu’ils disposaient de plus d’équipements de protection individuelle, qu’ils les portaient de manière plus stricte et qu’ils étaient mieux informés et formés.

Effectiveness of contingent screening for placenta accreta spectrum disorders based on persistent low-lying placenta and previous uterine surgery

OBJECTIVES

Maternal mortality related to placenta accreta spectrum (PAS) disorders remains substantial when diagnosed unexpectedly at delivery. The aim of this study was to evaluate the effectiveness of a routine contingent ultrasound screening program for PAS.

METHODS

This was a retrospective study of data obtained between 2009 and 2019, involving two groups: a screening cohort of unselected women attending for routine mid-trimester ultrasound assessment and a diagnostic cohort consisting of women referred to the PAS diagnostic service with a suspected diagnosis of PAS. In the screening cohort, women with a low-lying placenta at the mid-trimester assessment were followed up in the third trimester, and those with a persistent low-lying placenta (i.e. placenta previa) and previous uterine surgery were referred to the PAS diagnostic service. Ultrasound assessment by the PAS diagnostic service consisted of two-dimensional grayscale and color Doppler ultrasonography, and women with a diagnosis of PAS were usually managed with conservative myometrial resection. The final diagnosis of PAS was based on a combination of intraoperative clinical findings and histopathological examination of the surgical specimen.

RESULTS

In total, 57 179 women underwent routine mid-trimester fetal anatomy assessment, of whom 220 (0.4%) had a third-trimester diagnosis of placenta previa. Seventy-five of these women were referred to the PAS diagnostic service because of a history of uterine surgery, and 21 of 22 cases of PAS were diagnosed correctly (sensitivity, 95.45% (95% CI, 77.16-99.88%) and specificity, 100% (95% CI, 99.07-100%)). Univariate analysis demonstrated that parity ≥ 2 (odds ratio (OR), 35.50 (95% CI, 6.90-649.00)), two or more previous Cesarean sections (OR, 94.20 (95% CI, 22.00-656.00)) and placenta previa (OR, 20.50 (95% CI, 4.22-369.00)) were the strongest risk factors for PAS. In the diagnostic cohort, there were 173 referrals, with one false-positive and three false-negative diagnoses, resulting in a sensitivity of 96.63% (95% CI, 90.46-99.30%) and a specificity of 98.81% (95% CI, 93.54-99.97%).

CONCLUSIONS

A contingent screening strategy for PAS is both feasible and effective in a routine healthcare setting. When linked to a PAS diagnostic and surgical management service, adoption of such a screening strategy has the potential to reduce the maternal morbidity and mortality associated with this condition. However, larger prospective studies are necessary before implementing this screening strategy into routine clinical practice. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Assessment of combined risk to pesticide residues through dietary exposure

Plant protection products (PPPs) are preparations intended to protect plants and their products including one or more active substances. The use of PPPs may cause direct or indirect risks. Residues that can remain in or on food might pose a danger to human health through consumption and acute or/and chronic exposure. Authorisation of active substances and PPPs are decided at European and national level, respectively. Risk assessment of dietary exposure to residues of PPPs is regulated by a very extensive legal framework, ensuring consumer safety. The review and evaluation of the residue section of active substance monographs and the dossiers for PPP authorisations within the French Agency for Food, Environmental and Occupational Health & Safety (ANSES) helped gain hands‐on experience on food risk assessment, as previewed in the framework of the European Food Risk Assessment Fellowship Programme (EU‐FORA). The programme also focused on the cumulative effects of acute exposure to pesticides in food on the human nervous system using probabilistic methodology and it was in continuation of the work carried out by ANSES and the regulated products department residue unit. Using the European Database for processing factors for pesticides in food was one of the main challenges in order to approach a more realistic scenario of exposure. The probabilistic methodology followed was used in accordance with the European Food Safety Authority harmonised guidance.

Clinical performance of a specific granulocyte colony stimulating factor ELISA to determine its concentration in follicular fluid as a predictor of implantation success during in vitro fertilization

This study aimed to demonstrate the clinical performance of an ultra-sensitive follicular fluid (FF) granulocyte colony stimulating factor (G-CSF) immunoassay to confirm previous work, indicating a correlation between FF G-CSF concentration and live birth potential of the corresponding embryo after in vitro fertilization. This study was a noninterventional, prospective, diagnostic clinical multicentric study conducted between August 2012 and January 2014 with 396 single embryo transfers (SETs) from 278 subjects. During oocyte retrieval, FF was individually collected. Embryo morphology and implantation success were evaluated. The implantation success rate in the high G-CSF group (32.3%) was higher than the overall rate (27.5%). Similarly, for embryos with optimal morphology, implantation success rates were highest among those in the high G-CSF concentration category (34.5%) compared with low (19.6%) and intermediate (29.8%) G-CSF concentration categories. Significant differences in mean G-CSF concentrations were observed between the study sites. To minimize bias, analyses were repeated using data from the center with the largest number of SETs. In alignment with the overall analysis, this center demonstrated a 43% greater probability of implantation for optimal embryos with high G-CSF compared to the general implantation rate among optimal embryos and a 327% increase compared with the implantation rate of optimal embryos with low G-CSF.

Community-Academic Partnerships: Approaches to Engagement

Current public health problems such as cancer have an expansive set of lifestyle and social circumstances that affect the cause and course of the disease. In response, over the past 7 years, the National Cancer Institute (NCI) has recognized the important role that cancer centers play in their community and has gradually increased the requirements and stringency of these sections in the Cancer Center Support Grant guidelines to include a plan for community outreach and engagement. Developing sustainable community-academic partnerships is an essential factor for the successful dissemination and implementation of promising interventions and programs aimed at decreasing barriers and improving cancer outcomes. Understanding how best to facilitate linkages and collaboration can expedite translation of research knowledge into practice and allow more evidence-based improvements to be implemented into practice as well as influence research agendas. This article will examine several examples of successful community-academic partnerships focused on cancer prevention and control and explore lessons learned.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Abstract A51: Racial disparities in breast cancer outcomes: The role of socioeconomic influences on treatment decision making

Background African-American women have a 42% higher mortality rate from breast cancer than White women. While there are many factors contributing to this disparity, the timely initiation of treatment is growing area of interest. Certain treatments are associated with increased survival for women with a breast cancer diagnosis, yet evidence suggests that African American women use these treatments less frequently compared to White women with similar tumor characteristics. An under-explored area of attention for scientific studies is how to identify and engage in care women who do not follow up with treatment following a suspicious finding. To date these women have not been included in research focused on understanding treatment decisions and patient engagement in care decisions. Often these are among the most marginalized women of our society who have some of the highest rates of mortality from many different health related outcomes. This study helps to fill this gap by identifying and engaging these women in research. Methods This study explored in-depth the lived experience of eight African American women, living in a socially and economically isolated environment in a large metropolitan area. In all cases the initiation of treatment was delayed for more than six-months, with a delay in the initiation of treatment of more than a year in three of the eight examples and more than two years in one of the eight examples. In accordance with phenomenological qualitative methodology, the interviews were open-ended, allowing for rich, in-depth data to emerge relatively unbiased by the assumptions and expectations of the researcher. The research questions for this study were: (1) What are the lived experiences of African American women who had not followed up with care for a diagnosis of breast cancer for 6-months or more following a suspicious finding? (2) How does she apply meaning to the process of deciding whether or not to initiate treatment? and (3) Under what socioeconomic circumstances does the phenomenon (a delay in treatment initiation) persist? Results Key findings suggest that engaging patients in health care decision making necessitates a better understanding of the processes involved in treating breast cancer, the impact that the side-effects may have on her quality of life, and access to patient support services to counter these side-effects. Also, the findings from this study highlight that most of the communication about treatment initiation occurred at the primary care level, prior to initiating contact with oncology services. Primary care proved to be the most important provider-patient relationship for these women. It is where they go with initial concerns about their breasts and where they return for more information about treatments and patient support for side-effects. Furthermore, the context within how they experienced the phenomenon is structured by underlying conceptualizations of chronic traumatic events coupled with community resource deserts. Finally, all of the women reported keeping their illness to themselves and described social and cultural barriers to utilizing available support systems to assist with unmet needs. All of these situations taken together allowed the delay in the initiation of treatment for breast cancer to persist. Implications These results indicate that future interventions focused on engaging women in care decisions and decreasing socioeconomic barriers to the initiation of the treatment for breast cancer should take place between primary care providers, oncologists, and their patients and focus on de-mystifying the process of treatment. Incorporating this information, as a type of barrier-focused community-based intervention, or improved case management services to assist cancer patients in the primary care setting, would impact cancer mortality outcomes.

Note: This abstract was not presented at the conference.

Citation Format: Lailea Noel. Racial disparities in breast cancer outcomes: The role of socioeconomic influences on treatment decision making. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr A51.

Improving breast cancer services for African-American women living in St. Louis

A mixed methods, community-based research study was conducted to understand how provider-level factors contribute to the African-American and white disparity in breast cancer mortality in a lower socioeconomic status area of North St. Louis. This study used mixed methods including: (1) secondary analysis of Missouri Cancer Registry data on all 885 African-American women diagnosed with breast cancer from 2000 to 2008 while living in the geographic area of focus; (2) qualitative interviews with a subset of these women; (3) analysis of data from electronic medical records of the women interviewed; and (4) focus group interviews with community residents, patient navigators, and other health care professionals. 565 women diagnosed with breast cancer from 2000 to 2008 in the geographic area were alive at the time of secondary data analysis; we interviewed (n = 96; 17 %) of these women. Provider-level obstacles to completion of prescribed treatment included fragmented navigation (separate navigators at Federally Qualified Health Centers, surgical oncology, and medical oncology, and no navigation services in surgical oncology). Perhaps related to the latter, women described radiation as optional, often in the same words as they described breast reconstruction. Discontinuous and fragmented patient navigation leads to failure to associate radiation therapy with vital treatment recommendations. Better integrated navigation that continues throughout treatment will increase treatment completion with the potential to improve outcomes in African Americans and decrease the disparity in mortality.

Breast cancer treatment among African American women in north St. Louis, Missouri

Similar to disparities seen at the national and state levels, African American women in St. Louis, Missouri have higher breast cancer mortality rates than their Caucasian counterparts. We examined breast cancer treatment (regimens and timing) in a sample of African American breast cancer patients diagnosed between 2000 and 2008 while residing in a North St. Louis cluster (eight zip codes) of late stage at diagnosis. Data were obtained from medical record extractions of women participating in a mixed-method study of breast cancer treatment experiences. The median time between diagnosis and initiation of treatment was 27 days; 12.2% of the women had treatment delay over 60 days. These findings suggest that treatment delay and regimens are unlikely contributors to excess mortality rates for African American women diagnosed in early stages. Conflicting research findings on treatment delay may result from the inconsistent definitions of treatment delay and variations among study populations. Breast cancer treatment delay may reduce breast cancer survival; additional research is needed to better understand the points at which delays are most likely to occur and develop policies, programs, and interventions to address disparities in treatment delay. There may also be differences in treatment-related survivorship quality of life; approximately 54% of the women in this sample treated with mastectomies received breast reconstruction surgery. Despite the high reconstruction rates, most women did not receive definitive completion. African American women have higher reconstruction complication rates than Caucasian women; these data provide additional evidence to suggest a disparity in breast reconstruction outcomes by race.

Abstract A86: Identifying system-level barriers to breast cancer treatment which lead to health disparities for vulnerable communities: A qualitative approach

Purpose of Study: This study is a part of a larger community-based participatory research (CBPR) project to decrease African-American and white breast cancer mortality disparities in Saint Louis, Missouri. Specifically, we explore the course of breast cancer treatment for a group of primarily low-income African American women living in North St. Louis at the time of diagnosis to identify factors that may contribute to discontinuation of breast cancer treatment.

Methods: For this study, funded by Susan G Komen for the Cure, two sources of data (semi-structured interviews and medical record extraction) were explored to fully capture reasons for completion or discontinuation of prescribed treatment. We analyze data for 85 women for whom both sources of data were available and were treated at a large teaching hospital. Inclusionary criteria were at least 18 years of age and diagnosed with breast cancer while living in eight zip codes of North St. Louis, the latter chosen because they have been identified as part of a cluster of late stage diagnosis. Women were recruited via letters from the Missouri Cancer Registry and flyers prepared and distributed by community partner organizations. The approach had two components: (1) individual in-home interviews were conducted based on narrative theory to collect treatment history in the women's own voices; and (2) review of electronic medical records of the women to determine what supports were offered, and what treatment prescribed, to them. Patient narratives were coded using NVivo 10.0 and themes derived using grounded theory.

Results: Two themes were most prevalent among the narratives from the women interviewed that suggest reasons why African-American women in the study may not have complete treatment prescribed. First, women did not connect radiation therapy with survival in the same way that they did surgery and chemotherapy. Rather, they described it in terms that made it seem optional, like breast reconstruction. Second, while women seemed to have been supported in terms of obstacles to treatment near the time of surgery, they reported no such services after receiving chemotherapy. Chart review revealed that patient navigation tapers off after surgery, with only one navigator employed by medical oncology and none in radiation oncology.

Conclusions and Implications: Women describing radiation therapy as an optional treatment reflects a misunderstanding of the importance of radiation therapy in breast cancer survival. Relatedly, having navigators associated with each service (surgical, medical, and radiation oncology) who communicate regularly with one another may help to ensure that women complete prescribed treatment, thus decreasing the African American and white breast cancer mortality disparity in St. Louis. Further study is suggested to determine if these findings persist in other locations.

Citation Format: Lailea Noel, Melody Goodman, Shahnjayla K. Connors, Dwayne Butler, Ron McMullen, Cheryl Oliver, Isaac McCullough, Sarah Gehlert. Identifying system-level barriers to breast cancer treatment which lead to health disparities for vulnerable communities: A qualitative approach. [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 A86. doi:10.1158/1538-7755.DISP13-A86

Abstract C49: Treatment delay among African American women in St. Louis, Missouri

Introduction: Breast cancer mortality rates in the metropolitan St. Louis area are higher than those of Missouri as a whole or the United States. Similar to national trends, African American women in St. Louis have higher mortality rates than their Caucasian counterparts. Differences in the receipt of timely breast cancer treatment have been posited to be a factor that contributes to the disparity in breast cancer mortality between African American and Caucasian women. A cluster of late-stage breast cancer diagnoses has been identified in women living in North St. Louis, a predominantly African American area of St. Louis. Previous studies have shown that significant breast cancer diagnosis delays were occurring in woman referred from the St. Louis Safety Net System. The current study was carried out to examine treatment delay in a cohort of African American women diagnosed with breast cancer in North St. Louis between 2000 and 2008.

Methods: Data were obtained from medical record extractions for 85 women who participated in a study funded by Susan G. Komen for the Cure that also included qualitative semi-structured interviews to determine breast cancer treatment histories. Medical records were examined for information about the type, timing, and sequence of breast cancer treatment. All of the women were treated within a local urban academic medical system. Treatment delay was calculated from the date of biopsy to the initiation of treatment and chi square tests were used to examine bivariate associations between demographic or clinical factors and treatment delay.

Results: The median treatment delay was 26.5 days; 12.2% of the women had treatment delay over 60 days. This percentage is below the National Breast and Cervical Early Detection Program benchmark which states that no more than 20% of women should have a treatment delay of over 60 days. There were no statistically significant associations between demographic or clinical factors and treatment delay.

Discussion: North St. Louis has the most concerning health and community indicators in the St. Louis area. In spite of the fact that this cohort of women resided in North St. Louis at diagnosis, there was no evidence of breast cancer treatment delay. These findings suggest that it is possible to treat racial and ethnic minority women with breast cancer without treatment delay, regardless of demographic factors. Delay in breast cancer treatment affects patient survival and is a vital area of breast cancer treatment research. More multidisciplinary approaches are needed to fully understand the many factors that contribute to breast cancer treatment delay so that interventions can be developed to improve outcomes in all breast cancer patients, particularly for African American women who suffer higher mortality rates despite lower incidence rates.

Citation Format: Shahnjayla K. Connors, Melody Goodman, Neeraja Chavakula, Lailea Noel, Sarah Gehlert. Treatment delay among African American women in St. Louis, Missouri. [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 C49. doi:10.1158/1538-7755.DISP13-C49

Emergency and surgery services of primary hospitals in the United Republic of Tanzania

OBJECTIVE

The primary objective was to evaluate the capacity of first-referral health facilities in Tanzania to perform basic surgical procedures. The intent was to assist in planning strategies for universal access to life-saving and disability-preventing surgical services.

DESIGN

Cross-sectional survey.

SETTING

First-referral health facilities in the United Republic of Tanzania.

PARTICIPANTS

48 health facilities.

MEASURES

The WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was employed to capture a health facility's capacity to perform basic surgical (including obstetrics and trauma) and anaesthesia interventions by investigating four categories of data: infrastructure, human resources, interventions available and equipment. The tool queried the availability of eight types of care providers, 35 surgical interventions and 67 items of equipment.

RESULTS

The 48 facilities surveyed served 18.6 million residents (46% of the population). Supplies for basic airway management were inconsistently available. Only 42% had consistent access to oxygen, and only six functioning pulse oximeters were located in all facilities surveyed. 37.5% of facilities reported both consistent running water and electricity. While very basic interventions (suturing, wound debridement, incision and drainage) were provided in nearly all facilities, more advanced life-saving procedures including chest tube thoracostomy (30/48), open fracture management (29/48) and caesarean section delivery (32/48) were not consistently available.

CONCLUSIONS

Based on the results in this WHO country survey, significant gaps exist in the capacity for emergency and essential surgical services in Tanzania including deficits in human resources, essential equipment and infrastructure. The information in this survey will provide a foundation for evidence-based decisions in country-level policy regarding the allocation of resources and provision of emergency and essential surgical services.

Multivariate analysis of determinants of bacterial contamination of whole-blood donations

BACKGROUND AND OBJECTIVES

Introduction of bacteria into blood components at the collection stage seems to be a frequent occurrence. We therefore assessed determinants of bacterial contamination of whole-blood donations to gain insight into contamination mechanisms and direct prevention.

MATERIALS AND METHODS

A cross-sectional study was carried out on donors accepted for whole-blood donation in four French blood banks. Each blood bank used its own two-stage procedure for phlebotomy site preparation. Contamination was identified by culturing two 15-ml samples (collected aseptically at the outset of donation) in a BacT/Alert 240 system. Determinants were assessed by logistic regression analysis.

RESULTS

Bacterial contamination, mainly by skin flora, occurred in 76 (2.2%) out of 3385 donations. Significant determinants were as follows: the blood bank (odds ratio [OR] range = 3.0-5.6, P < 0.001); lack of repetition of scrub (OR = 2.7, P = 0.032); and donor age > 35 years (OR = 1.8, P = 0.036).

CONCLUSION

Systematic scrub repetition should be implemented to reduce bacterial contamination by skin flora at the collection stage. Further research is required to clarify the role of different antiseptic agents and of donor age.

Efficacy of a new collection procedure for preventing bacterial contamination of whole-blood donations

BACKGROUND

Transfusion-related bacterial contamination is a serious problem. The introduction of bacteria into donations at the collection stage seems frequent, despite well-conducted phlebotomy site preparation. Additional preventive measures are required.

STUDY DESIGN AND METHODS

The aim of this study was to assess the potential efficacy of excluding the first 15 mL of blood to reduce the bacterial contamination of donations. A special device allowed the aseptic collection of two samples at the beginning of donation: S1 (first 15 mL) and S2 (next 15 mL). Bacteriologic cultures of S1 and S2 were performed by using an automated system. The procedure's efficacy was measured by the proportion of positive donations in S1 that were then negative in S2.

RESULTS

S1 and/or S2 were positive in 76 (2.2%) of 3385 donations. In about three-fourths of the culture-positive donations, contamination was detected in the first 15-mL sample only. Gram-positive cocci accounted for 81 percent of species, gram-positive bacilli for 14 percent, and gram-negative bacilli for 5 percent. The new procedure would have prevented the introduction of bacteria in 55 donations, reducing to 0.6 percent the risk of contamination from the first 15 mL collected.

CONCLUSION

Although the final effect on blood component bacterial contamination rates cannot be derived from the study, excluding the first 15 mL of blood may reduce the rate of bacterial contamination in donations.

A comparative evaluation of the sensitivity of five anti-hepatitis C virus immunoblot assays

BACKGROUND AND OBJECTIVES

In order to compare sensitivity, five anti-hepatitis C virus (HCV) immunoblot assays were tested (Deciscan plus, Inno-Lia III, Matrix, Murex Western blot and RIBA-3).

MATERIALS AND METHODS

The test panel (50 samples for each assay) included 6 anti-HCV-negative samples and 44 samples from 36 HCV-infected subjects.

RESULTS

There were minor differences in core reactivity among the assays. The smallest number of NS3-reactive results occurred with the Murex and Matrix assays, and the smallest number of NS4 reactives with RIBA-3 and Matrix. Among the 20 discrepant results for NS5 there was one clear false-negative with Inno-Lia. Only 28 of the 50 samples of the panel gave the same results in all the assays: 5 negatives and 23 positives. One of the 6 negative samples were indeterminate in 3 assays. Eighteen of the 21 other divergent results were interpreted as either indeterminate or positive, a common reactivity being exhibited by all 5 assays. The most important discrepancies occurred on 3 HCV-RNA-positive samples which came up negative in some assays: 2 samples with isolated NS3 reactivity were negative by Matrix and Murex Western blot, 1 of them being also negative by Inno-Lia III; another sample was negative by RIBA-3 and Matrix due to weak signals (< 1) on core and NS3 proteins, which did not exceed 1+ with the other assays.

CONCLUSIONS

With more uniform criteria for interpretation, the results would have been less divergent. Some assays should improve their sensitivity to the NS3 protein.

How the bacterial plant pathogen Xanthomonas campestris pv. vesicatoria conquers the host

Abstract Xanthomonas campestris pv. vesicatoria (Xcv) is the causal agent of bacterial spot disease on pepper and tomato. Pathogenicity on susceptible plants and the induction of the hypersensitive reaction (HR) on resistant plants requires a number of genes, designated hrp, most of which are clustered in a 23-kb chromosomal region. Nine hrp genes encode components of a type III protein secretion apparatus that is conserved in Gram-negative plant and animal pathogenic bacteria. We have recently demonstrated that Xcv secretes proteins into the culture medium in a hrp-dependent manner. Substrates of the Hrp secretion machinery are pathogenicity factors and avirulence proteins, e.g. AvrBs3. The AvrBs3 protein governs recognition, i.e. HR induction, when bacteria infect pepper plants carrying the corresponding resistance gene Bs3. Intriguingly, the AvrBs3 protein contains eukaryotic signatures such as nuclear localization signals (NLS), and has been shown to act inside the plant cell. We postulate that AvrBs3 is transferred into the plant cell via the Hrp type III pathway and that recognition of AvrBs3 takes place in the plant cell nucleus.

The French haemovigilance system

Haemovigilance is a national system of surveillance and alarm, from blood collection to the follow-up of the recipients, gathering and analysing all untoward effects of blood transfusion in order to correct their cause and prevent recurrence. In France haemovigilance was created by law and notification of transfusion incidents is a legal obligation. The haemovigilance network associates local correspondents in each hospital and blood centre with regional co-ordinators and is centralised by the Agence Française du Sang. After 4 years the incident reporting rate is 2.3 per 1,000 allogeneic blood components transfused, justifying for example increased efforts in the prevention of bacteria-associated transfusion reactions, haemolytic transfusion reactions or vascular overload. However, haemovigilance still has to be strenghtened by improved information management or further progress in standardisation from one region to the other. The most important factor of success is collaboration between blood centres and hospitals. Haemovigilance clearly is the ultimate quality indicator of a transfusion service.

The French haemovigilance system

Haemovigilance was part of the reform of the French transfusion system. The haemovigilance network is now operational with approximately 4600 transfusion incidents reported annually. Immediate incidents observed within 8 days after transfusion account for 85% of the reports. A cause cannot be identified in 41% of these, usually concerning minor clinical incidents with transient fever and/or shivers. An allergic reaction is described in 31% of transfusion reactions. Immunological conflicts account for 18% and bacteria associated transfusion reactions for 6%. The importance of bacteria associated transfusion reactions, the first identified cause of death associated with transfusion is one of the findings of haemovigilance. Improvement in the haemovigilance systems aims at obtaining better descriptions of transfusion incidents, standardisation of severity and imputability assessment and definitions of denominators such as the actual number of recipients. Delayed incidents will ultimately provide a true vision of post transfusion immunisation and infection The improvement of haemovigilance now considered as part of transfusion medicine practice is a continuous process.

Nurse educator performance standards

In this article, the authors highlight the process by which one staff education department developed performance standards. These standards facilitate orientation of new educators, assist with the planning of developmental goals, and guide the evaluation process. This process can serve as a prototype for nurse educators faced with the challenge of developing performance standards.

Radiocesium body burdens in immigrants to Israel from areas of the Ukraine, Belarus and Russia near Chernobyl

Of the 500,000 immigrants from the former Soviet Union who came to Israel during 1990-1993, about 100,000 are estimated to have come from radiocontaminated areas near Chernobyl. These people were subject to chronic uptake of environmental radiocesium over protracted periods. During October-November 1991, a joint Israeli-Canadian investigation measured radiocesium body burdens in immigrants to Israel from the Ukraine, Belarus, and the southern Russian republic in order to provide factual information on radiocesium levels to concerned immigrants and to relate the body burdens to the geographic area of residence before coming to Israel. Assessments were made of 137Cs body burdens in 1,228 volunteer men, women, and children. These measurements were accompanied by medical assessments based on clinical histories and examinations. Radiocesium levels were strongly dependent on the duration of residence in Israel, with the highest levels being found in the most recent immigrants. The maximum level, extrapolated back to the time of leaving the former Soviet Union, was estimated to be about 0.83 kBq (10.3 Bq kg-1). Of the most recent immigrants from the Kiev region (< 101 days in Israel), only 15% had back extrapolated body burdens > 50 Bq, whereas 53% of those coming from Gomel and other towns in the contaminated zones (> 3.7 x 10(10) Bq km-2 of radiocesium) had detectable levels > 50 Bq. People coming from the latter region had significantly higher body burdens as compared to those from the former, in accordance with the higher degree of ground radiocesium contamination reported for the latter region. Women and children showed considerably lower total radiocesium content in comparison to men. All radiocesium body burdens at the time of measurement were too low to be of health concern.

Alveolar soft-part sarcoma of the orbit

Alveolar soft-part sarcoma is a malignant soft tissue neoplasm that involves mainly the deep soft tissues of the extremities, particularly the thighs and the buttock. Involvement of the orbit is uncommon. We describe a young child with such a tumor and illustrate the characteristic features.

Transmission of HIV by transfusion of HIV-screened blood: the value of a national register. The 'Recipients' Study Group of the French Society of Blood Transfusion

A National Register of transfusion-transmitted infections was opened by the French Society of Blood Transfusion on 1 October, 1986. Out of 54 initially reported cases of HIV-infection, allegedly transmitted by blood components, further investigation could be completed in 33 cases. The transfusional origin of contamination was considered as established or probable in 28/33 cases, either because a potentially infectious unit was identified among those transfused to the recipient (23/28), or because the recipient was known to be seronegative before transfusion (5/28), or both (10/28). In 5/33 cases transfusion was considered as presumably responsible for contamination because no other risk factor was found in the recipient. Among the 33 documented cases of HIV-transmission by screened blood, 29 (88%) occurred between 1985 and 1987, and four (12%) during 1988. Out of 19 implicated donors later found seropositive, 16 belonged to a high-risk group for HIV-infection. The majority of HIV-infections occurred as a consequence of blood donation in the window period between contamination and the appearance of detectable antibodies in the donor's serum (11/19). In three instances, however, human and operational errors led to the release of seropositive units. We conclude that the main value of this Register is to provide a potential trend-indicator of transfusion-related infectious risks, to allow objective documentation of reported cases and to contribute to the improvement of blood transfusion practice.

Characterization of a human Y chromosome Pvu II repeated sequence

The human Y chromosome carries numerous copies of a tandemly repeated Pvu II sequence, 2.4 kb long. These sequences are specific to humans, and are present in a much smaller amount in the DNA of females. They are localized on the long arm of the Y chromosome. We have compared this sequence with the Hae III 2.1 kb Y-specific repeated sequence, already described.