Aspiring toward equitable benefits from genomic advances to individuals of ancestrally diverse backgrounds

Advancements in genomic technologies have shown remarkable promise for improving health trajectories. The Human Genome Project has catalyzed the integration of genomic tools into clinical practice, such as disease risk assessment, prenatal testing and reproductive genomics, cancer diagnostics and prognostication, and therapeutic decision making. Despite the promise of genomic technologies, their full potential remains untapped without including individuals of diverse ancestries and integrating social determinants of health (SDOHs). The NHGRI launched the 2020 Strategic Vision with ten bold predictions by 2030, including "individuals from ancestrally diverse backgrounds will benefit equitably from advances in human genomics." Meeting this goal requires a holistic approach that brings together genomic advancements with careful consideration to healthcare access as well as SDOHs to ensure that translation of genetics research is inclusive, affordable, and accessible and ultimately narrows rather than widens health disparities. With this prediction in mind, this review delves into the two paramount applications of genetic testing-reproductive genomics and precision oncology. When discussing these applications of genomic advancements, we evaluate current accessibility limitations, highlight challenges in achieving representativeness, and propose paths forward to realize the ultimate goal of their equitable applications.

Role of histone variants H2BC1 and H2AZ.2 in H2AK119ub nucleosome organization and Polycomb gene silencing

Ubiquitination of histone H2A at lysine 119 residue (H2AK119ub) plays critical roles in a wide range of physiological processes, including Polycomb gene silencing 1,2 , replication 3-5 , DNA damage repair 6-10 , X inactivation 11,12 , and heterochromatin organization 13,14 . However, the underlying mechanism and structural basis of H2AK119ub remains largely elusive. In this study, we report that H2AK119ub nucleosomes have a unique composition, containing histone variants H2BC1 and H2AZ.2, and importantly, this composition is required for H2AK119ub and Polycomb gene silencing. Using the UAB domain of RSF1, we purified H2AK119ub nucleosomes to a sufficient amount and purity. Mass spectrometry analyses revealed that H2AK119ub nucleosomes contain the histone variants H2BC1 and H2AZ.2. A cryo-EM study resolved the structure of native H2AK119ub nucleosomes to a 2.6A resolution, confirming H2BC1 in one subgroup of H2AK119ub nucleosomes. Tandem GST-UAB pulldown, Flag-H2AZ.2, and HA-H2BC1 immunoprecipitation revealed that H2AK119ub nucleosomes could be separated into distinct subgroups, suggesting their composition heterogeneity and potential dynamic organization. Knockout or knockdown of H2BC1 or H2AZ.2 reduced cellular H2AK119ub levels, establishing H2BC1 and H2AZ.2 as critical determinants of H2AK119ub. Furthermore, genomic binding profiles of H2BC1 and H2AZ.2 overlapped significantly with H2AK119ub binding, with the most significant overlapping in the gene body and intergenic regions. Finally, assays in developing embryos reveal an interaction of H2AZ.2, H2BC1, and RING1A in vivo . Thus, this study revealed, for the first time, that the H2AK119ub nucleosome has a unique composition, and this composition is required for H2AK119ub and Polycomb gene silencing.

Mi-CARE: Comparing Three Evidence-Based Interventions to Promote Colorectal Cancer Screening among Ethnic Minorities within Three Different Clinical Contexts

Multiple evidence-based interventions (EBIs) have been developed to improve the completion of colorectal cancer (CRC) screening within Federally Qualified Health Centers (FQHCs) and other safety net settings in marginalized communities. Little effort has been made, however, to evaluate their relative effectiveness across different clinical contexts and populations. To this end, we tested the relative effectiveness of three EBIs (mailed birthday cards, lay navigation, and provider-delivered education) among a convenience sample of 1252 patients (aged 50-75 years old, who were due for CRC screening and scheduled for a visit at one of three clinics within a network of Federally Qualified Health Centers (FQHCs) in the United States. To be eligible for the study, patients had to identify as African American (AA) or Latino American (LA). We compared the effects of the three EBIs on CRC screening completion using logistic regression. Overall, 20% of the study population, an increase from a baseline of 13%, completed CRC screening. Clinical demographics appeared to influence the effectiveness of the EBIs. Mailed birthday reminders appeared to be the most effective within the multi-ethnic clinic (p = 0.03), provider-delivered education within the predominantly LA clinic (p = 0.02), and lay navigation within the predominantly AA clinic (p = 0.03). These findings highlight the importance of understanding clinical context when selecting which evidence-based interventions to deploy.

Neighbor-specific gene expression revealed from physically interacting cells during mouse embryonic development

Development of multicellular organisms is orchestrated by persistent cell-cell communication between neighboring partners. Direct interaction between different cell types can induce molecular signals that dictate lineage specification and cell fate decisions. Current single-cell RNA-seq technology cannot adequately analyze cell-cell contact-dependent gene expression, mainly due to the loss of spatial information. To overcome this obstacle and resolve cell-cell contact-specific gene expression during embryogenesis, we performed RNA sequencing of physically interacting cells (PIC-seq) and assessed them alongside similar single-cell transcriptomes derived from developing mouse embryos between embryonic day (E) 7.5 and E9.5. Analysis of the PIC-seq data identified gene expression signatures that were dependent on the presence of specific neighboring cell types. Our computational predictions, validated experimentally, demonstrated that neural progenitor (NP) cells upregulate Lhx5 and Nkx2-1 genes, when exclusively interacting with definitive endoderm (DE) cells. Moreover, there was a reciprocal impact on the transcriptome of DE cells, as they tend to upregulate Rax and Gsc when in contact with NP cells. Using individual cell transcriptome data, we formulated a means of computationally predicting the impact of one cell type on the transcriptome of its neighboring cell types. We have further developed a distinctive spatial-t-distributed stochastic neighboring embedding to display the pseudospatial distribution of cells in a 2-dimensional space. In summary, we describe an innovative approach to study contact-specific gene regulation during embryogenesis.

Gene Screening in High-Throughput Right-Censored Lung Cancer Data

Background

Advances in sequencing technologies have allowed collection of massive genome-wide information that substantially advances lung cancer diagnosis and prognosis. Identifying influential markers for clinical endpoints of interest has been an indispensable and critical component of the statistical analysis pipeline. However, classical variable selection methods are not feasible or reliable for high-throughput genetic data. Our objective is to propose a model-free gene screening procedure for high-throughput right-censored data, and to develop a predictive gene signature for lung squamous cell carcinoma (LUSC) with the proposed procedure.

Methods

A gene screening procedure was developed based on a recently proposed independence measure. The Cancer Genome Atlas (TCGA) data on LUSC was then studied. The screening procedure was conducted to narrow down the set of influential genes to 378 candidates. A penalized Cox model was then fitted to the reduced set, which further identified a 6-gene signature for LUSC prognosis. The 6-gene signature was validated on datasets from the Gene Expression Omnibus.

Results

Both model-fitting and validation results reveal that our method selected influential genes that lead to biologically sensible findings as well as better predictive performance, compared to existing alternatives. According to our multivariable Cox regression analysis, the 6-gene signature was indeed a significant prognostic factor (p-value < 0.001) while controlling for clinical covariates.

Conclusions

Gene screening as a fast dimension reduction technique plays an important role in analyzing high-throughput data. The main contribution of this paper is to introduce a fundamental yet pragmatic model-free gene screening approach that aids statistical analysis of right-censored cancer data, and provide a lateral comparison with other available methods in the context of LUSC.

The All of Us Research Program: Data quality, utility, and diversity

The All of Us Research Program seeks to engage at least one million diverse participants to advance precision medicine and improve human health. We describe here the cloud-based Researcher Workbench that uses a data passport model to democratize access to analytical tools and participant information including survey, physical measurement, and electronic health record (EHR) data. We also present validation study findings for several common complex diseases to demonstrate use of this novel platform in 315,000 participants, 78% of whom are from groups historically underrepresented in biomedical research, including 49% self-reporting non-White races. Replication findings include medication usage pattern differences by race in depression and type 2 diabetes, validation of known cancer associations with smoking, and calculation of cardiovascular risk scores by reported race effects. The cloud-based Researcher Workbench represents an important advance in enabling secure access for a broad range of researchers to this large resource and analytical tools.

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The All of Us Research Program has released data for over 315,000 participants

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Demonstration projects support the utility and validity of the All of Us dataset

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The cloud-based Researcher Workbench provides secure, low-cost compute power

The engagement of participants in the research process and broad availability of data to diverse researchers are essential elements in building precision medicine equitably available for all. The NIH has established the ambitious All of Us Research Program to build one of the most diverse health databases in history with tools to support research to improve human health. Here, we present the initial launch of the Researcher Workbench with data types including surveys, physical measurements, and electronic health record data with validation studies to support researcher use of this novel platform. Broad access for researchers to data like these is a critical step in returning value to participants seeking to support the advancement of precision medicine and improved health for all.

Pilot study of a culturally sensitive intervention to promote genetic counseling for breast cancer risk

BACKGROUND

Despite the benefits of genetic counseling and testing, uptake of cancer genetic services is generally low and Black/African American (Black) women are substantially less likely to receive genetic services than non-Hispanic White women. Our team developed a culturally sensitive, narrative decision aid video to promote uptake of genetic counseling among Black women at risk for a hereditary breast cancer syndrome that can be incorporated in conjunction with population-based cancer risk assessment in a clinical setting. We report here a pilot study to demonstrate changes in intention to access genetic counseling and intervention satisfaction.

METHODS

Black women who were personally unaffected by breast cancer and were recommended for genetic counseling based on family history screening in a mammography center were recruited at the time of the mammogram. A prospective, pre-post survey study design, guided by theoretical constructs, was used to evaluate baseline and immediate post-intervention psychosocial factors, including intention to participate in genetic counseling and intervention satisfaction.

RESULTS

Pilot recruitment goals were met (n = 30). Pre-intervention, 50% of participants indicated that they were extremely likely to make a genetic counseling appointment, compared with 70% post-intervention (p = 0.05). After watching the intervention, 50% of participants indicated that the video changed their mind regarding genetic counseling.

CONCLUSIONS

This study demonstrated cultural satisfaction with a decision aid intervention designed to motivate Black women with hereditary breast cancer risk to attend a genetic counseling appointment. Our study showed that intention may be a specific and key construct to target in interventions designed to support decision-making about genetic services. Study results informed the design of a subsequent large scale, randomized implementation study.

TRIAL REGISTRATION

Trial registration: Clinicaltrials.gov NCT04082117 . Registered September 9, 2019. Retrospectively registered.

Endorsement of COVID-19 related misinformation among cancer survivors

OBJECTIVES

To determine whether cancer survivors currently in treatment are more or less likely to endorse COVID-19 related misinformation compared to their counterparts no longer in treatment and those without a cancer history.

METHODS

We conducted a Qualtrics survey among 897 adults to determine differences in endorsement of COVID-19 misinformation among cancer survivors in active treatment, cancer survivors no longer in treatment, and a control group with no cancer history.

RESULTS

Cancer survivors currently undergoing treatment were more likely to believe misinformation related to COVID-19 than those without a cancer history. Least likely to endorse COVID-19 misinformation were cancer survivor no longer in treatment.

CONCLUSION

These results alert healthcare professionals to overall high levels of endorsement of COVID-19 misinformation among cancer survivors on active treatment. Oncologists and other providers working with patients undergoing treatment for cancer should be particularly mindful of the potential elevated beliefs in misinformation among this group.

PRACTICAL IMPLICATIONS

Since patients undergoing cancer treatment seem to be particularly vulnerable to COVID-19 misinformation, oncologists and other healthcare providers working with this patient population should help address patients' concerns about the pandemic and how it relates to their course of treatment.

Advancing Inclusive Research: Establishing Collaborative Strategies to Improve Diversity in Clinical Trials

Well-characterized disparities in clinical research have disproportionately affected patients of color, particularly in underserved communities. To tackle these barriers, Genentech formed the External Council for Advancing Inclusive Research, a 14-person committee dedicated to developing strategies to increase clinical research participation. To help improve the recruitment and retention of patients of color, this article chronicles our efforts to tangibly address the clinical research barriers at the system, study, and patient levels over the last four years. These efforts are one of the initial steps to fully realize the promise of personalized health care and provide increased patient benefit at less cost to society. Instead of simply acknowledging the problem, here we illuminate the collaborative and multilevel strategies that have been effective in delivering meaningful progress for patients.

Abstract PO-064: Health literacy as a tool to drive equitable action for lung cancer screening in high-risk communities

In the United States, communities at risk of developing lung cancer include rural populations, low socioeconomic status (SES) and the under-insured, immigrants, aged populations, racial and ethnic minority groups, and LGBTQIA communities. Many of these high-risk communities are diagnosed at much later stages than high SES whites. When lung cancer is detected early, survival rates are higher due to the possibility of curative surgery. Lung cancer screening (LCS) using low-density computed tomography (LDCT) has been recommended by the USPSTF since 2013. Guidelines for those who meet the USPSTF LCS criteria were expanded in 2021. A major barrier to accessing screening by vulnerable populations is the lack of health literate LCS education materials that can be used to engage and empower these groups and motivate them to seek screening. Research Question: How do we develop health literate (HL), culturally sensitive, and linguistically appropriate health information about LCS to high-risk communities and make them available through trusted community partners? Methods: A multi-phased approach that included material creation, testing, and dissemination was conceptualized by LUNGevity Foundation in partnership with Health Literacy Media (HLM) and a leading expert in accessible patient education. Using an IRB-approved protocol, the study team identified a representative population of persons (N=40 in 15 states) with online recruitment facilitated by NCI community cancer center outreach leaders in high-risk geographies. The participants gave extensive quantitative and qualitative feedback via virtual focus groups or in-depth interviews to obtain opinions and insights into how easily LUNGevity Foundation's Screening and Early Detection Booklet was understood. Revised materials were created using HL best practices, and re-tested with new community members to ensure acceptability, accessibility, and HL. Then, additional materials with relevant health topics were developed consistent with HL principles for extensive testing with communities. An additional 24 people in 11 states took part in 1 of 4, 1 ½ hour focus groups for final review. New HL lung cancer screening materials were made available to NCI community outreach leaders via LUNGevity Foundation's trusted national community engagement network. Results: The participants raised important insights about eligibility for and accessibility to screening. Based on their insights and recommendations, HLM transformed one large booklet into 4 fact sheets and 6 mini booklets. Final materials were disseminated to vulnerable populations via LUNGevity Foundation's trusted community engagement network. Conclusions: The feasibility of creating patient-centered health literate materials that also incorporate community engagement is established. Using LCS as an example, we were able to successfully create materials that were acceptable to high-risk communities. We recommend offering understandable and accessible information to all communities regardless of their literacy or education levels.

Citation Format: Jeanne M. Regnante, Upal Basu Roy, Catina O'Leary, Linda M. Fleisher, Diane W. Webb, Linda Wenger, Andrea Ferris, Robert Winn. Health literacy as a tool to drive equitable action for lung cancer screening in high-risk communities [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-064.

A Study Protocol for Increasing Access to Smoking Cessation Treatments for Low-Income Minority Smokers

Background: Smoking rates among low-income patients are double those of the general population. Access to health care is an essential social determinant of health. Federally qualified health care centers (FQHC) are government-supported and community-based centers to increase access to health care for non-insured and underinsured patients. However, barriers to implementation impact adherence and sustainability of evidence-based smoking cessation within FQHC settings. To address this implementation barrier, our multi-disciplinary team proposes Mi QUIT CARE (Mile Square QUIT Community-Access-Referral-Expansion) to establish the acceptability, feasibility, and capacity of an FQHC system to deliver an evidence-based and multi-level intervention to increase patient engagement with a state tobacco quitline. Methods: A mixed-method approach, rooted in an implementation science framework of RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance), will be used in this hybrid effectiveness-implementation design. We aim to evaluate the efficacy of a novel delivery system (patient portal) for increasing access to smoking cessation treatment. In preparation for a future randomized clinical trial of Mi QUIT CARE, we will conduct the following developmental research: (1) Examine the burden of tobacco among patient populations served by our partner FQHC, (2) Evaluate among FQHC patients and health care providers, knowledge, attitudes, barriers, and facilitators related to smoking cessation and our intervention components, (3) Evaluate the use of tailored communication strategies and patient navigation to increase patient portal uptake among patients, and (4) To test the acceptability, feasibility, and capacity of the partner FQHC to deliver Mi QUIT CARE. Discussion: This study provides a model for developing and implementing smoking and other health promotion interventions for low-income patients delivered via patient health portals. If successful, the intervention has important implications for addressing a critical social determinant of cancer and other tobacco-related morbidities. Trial Registration: U.S. National Institutes of Health Clinical Trials, NCT04827420, https://clinicaltrials.gov/ct2/show/NCT04827420.

Rectal cancer treatment and outcomes in elderly patients treated with curative intent

The elderly population comprises a significant proportion of patients diagnosed with rectal cancer. However, there is a lack of evidence to guide treatment decisions in this group. Thus, this multicentre study compares the histopathology, treatment patterns and outcomes between the elderly and young populations with non-metastatic rectal cancer. The present study reported on the clinicopathological variables, treatment modalities and survival outcomes in 736 patients diagnosed with non-metastatic rectal cancer between 2006 and 2015. Patients were divided into the following two groups, <70 and ≥70 years of age, which were compared using Chi-square and survival outcome analysis using Kaplan-Meier. Elderly patients made up nearly half of the cohort and were less likely to undergo trimodality therapy or be discussed in a multidisciplinary meeting. Surgery in the elderly patients was associated with increased mortality. Elderly patients had worse cancer-specific survival (75 vs. 85%), which was particularly evident in stage III disease (hazard ratio, 2.1). Elderly patients in this subgroup treated with trimodality therapy had similar survival outcomes to younger patients. Elderly patients with locally advanced rectal cancer comprise a large proportion of the patient cohort. Consideration should be given for trimodality therapy in this group, taking into account biological age, especially in the context of increasing life expectancy and improvement in the management of age-related comorbidities.

Society of Behavioral Medicine (SBM) position statement: support increased knowledge and efforts to address the financial burden associated with cancer treatment

Millions of individuals and their families struggle with both treatment-related and out-of-pocket (OOP) economic repercussions of a cancer diagnosis, an effect increasingly referred to as "financial toxicity." In 2014, the Agency for Healthcare Research and Quality (AHRQ) estimated the total U.S. expenditures for cancer at $87.8 billion dollars with patient OOP costs accounting for $3.9 billion dollars (2014). These figures do not take into account indirect costs, such as those from lost earnings. As a result, financial toxicity can extend well beyond the active treatment phase and have a substantial impact on a household's economic reserve and financial resilience well into the future. Of the 9.5 million U.S. adults aged 50 years and older diagnosed with cancer (2000-2012), 42.2% have depleted their assets at 2 years and 38.2% were financially insolvent in 4 years. Bankruptcy rates are 2.65 times higher among cancer survivors than matched controls. A full 70% of Americans want to have conversations about the costs of care with their health care providers, but only 28% report doing so. Delaying or deferring these conversations can have major financial consequences for patients. According to a polling conducted for the Robert Wood Johnson Foundation (RWJF) by Avalere Health, almost 20% of patients report forgoing care when they have questions about costs. A critical element to achieve this is to have accurate cost information, including health care insurance coverage policies. Specifically, while patients and their families look to their health care providers to help them better navigate the cost implication of their treatment choices, most who are willing to undertake this challenging task need to have accessible and comprehensive (including direct and indirect) cost information to facilitate the discussion.

Implementation of an integrated framework for a breast cancer screening and navigation program for women from underresourced communities

BACKGROUND

Trends in breast cancer mortality in the United States are decreasing, but racial disparities persist. Using an implementation science framework to inform evidence-based breast cancer screening and navigation within federally qualified health centers (FQHCs) with community stakeholders can mitigate barriers to screening.

METHODS

Using an integrated theoretical framework of the Practical, Robust Implementation and Sustainability Model and the Social Ecological Model, the University of Illinois Cancer Center and Mile Square Health Centers (MSHC) FQHC developed a breast cancer screening and navigation program, known as the Mile Square Accessible Mammogram Outreach and Engagement (Mi-MAMO) program, to tackle breast cancer disparities in Chicago among underresourced communities. To increase access to screening, patient navigators conducted community outreach activities. Partnerships were forged with community-based organizations, health care systems, and insurers. Outcomes were monitored with standardized performance measures.

RESULTS

Between January and December 2017, 103 women received a screening mammogram at MSHC. To increase screening rates, Mi-MAMO was started in August 2017. Between January and December 2018, the number of women who received a screening mammogram increased to 567. From August 2017 to December 2018, 779 women received navigation to screening and/or diagnostic services through the Mi-MAMO program. The majority of women were uninsured (63.9%), and 95.5% were racial/ethnic minorities. Twenty-four percent (n = 185) completed diagnostic services, and 10 women received positive breast cancer diagnoses (mean age, 49.7 years); all successfully navigated to treatment. The Mi-MAMO program is ongoing.

CONCLUSIONS

Deploying an integrated framework for patient navigation programs can increase breast cancer screening utilization and awareness among underresourced populations at higher risk for breast cancer.

Keynote Session: Reducing Racial Disparities in Oncology—Recommendations for Implementing Guideline-Adherent Cancer Care

Research shows that racial disparities exist in the delivery of guideline-adherent cancer care, and that non-White patients are less likely to receive guideline-concordant care than White patients, leading to worse health outcomes. However, these disparities are not often addressed. The Elevating Cancer Equity initiative aims to address these disparities through policy-change recommendations developed by a working group and informed by data from patients/caregivers and oncologists. The hope is that the results of these surveys and the resultant recommendations will be a step toward cancer care equity in the United States.

Survival in stage IIB/C compared to stage IIIA rectal cancer: an Australian experience affirming that size does matter

BACKGROUND

Colorectal cancer (CRC) is one of the most commonly diagnosed malignancies globally; however, a survival paradox has been observed unique to this malignancy. The aim of this study was to review survival outcomes of patients diagnosed with stage II and stage III rectal cancer, to determine whether a survival paradox is present in our centre and assess for patient-related factors that can explain the observed paradox or were predictors of prognosis.

METHODS

A retrospective review of data collected from 2006 to 2018 of patients diagnosed with rectal cancer in three separate centres was conducted. Percentages pertaining to patient and tumour characteristics, presentation, management and subsequent recurrence were reported. Preoperative and postoperative factors associated with survival were determined using univariable and multivariable logistic regression analysis.

RESULTS

Stage IIB/C patients had significantly higher carcinoembryonic antigen (CEA) levels compared to stage IIA and stage IIIA patients (P < 0.001). Stage IIB/C patients had significantly larger primary rectal tumour and were more symptomatic (i.e. rectal bleeding, altered bowel habits and obstruction) at the time of diagnosis (P = 0.007). Preoperative CEA was an independent prognostic factor for cancer-specific survival in patients diagnosed with stage IIB/C and stage IIIA disease (P = 0.008) on multivariable analysis. Overall survival was greatest in stage IIIA disease, which was significantly greater than stage IIB/C disease.

CONCLUSION

This study confirms the existence of a survival paradox in patients diagnosed with CRC in an Australian tertiary centre and adds further weight to the revision of the TNM staging to provide more emphasis on the T stage.

Development of a culturally sensitive narrative intervention to promote genetic counseling among African American women at risk for hereditary breast cancer

BACKGROUND

African American women with hereditary breast cancer risk are less likely to undergo genetic counseling and testing compared with non-Hispanic White women. Inequities in the use of precision cancer care are likely to exacerbate racial disparities in cancer outcomes. A culturally sensitive multimedia narrative intervention was developed to motivate African American women at risk for hereditary breast cancer to engage in genetic counseling.

METHODS

Development of the intervention was grounded in the Integrative Model of Behavioral Prediction using a phenomenological, deductive approach and employed multiple qualitative methods for data collection, including 1-on-1 interviews and story circles with members of the target audience to identify salient themes and lived experiences. Focus group testing was then conducted with members of the group of focus, primary care providers, and community stakeholders.

RESULTS

Six themes that mapped to the theoretical model were identified. Lived experiences were abstracted from story circle data to create a narrative storyline. Educational content and motivational messaging derived from the 6 themes were embedded into the script. Focus group testing with stakeholder groups was used to refine the intervention. Testing of the final multimedia narrative with focus groups indicated that the intervention was culturally sensitive and authentic, and the messaging was effective.

CONCLUSIONS

Multiple qualitative data collection methods and a robust theoretical framework of health behavior were key elements for this study to develop a culturally sensitive, narrative intervention that reflects lived experiences and motivates underserved African American women with hereditary breast cancer risk to engage in genetic counseling. This strategy can be applied to mitigate racial inequities in the use of other genomic approaches for personalizing cancer care.

Health disparities and equity in the era of COVID-19

Over the last year, COVID-19 has emerged as a highly transmissible and lethal infection. As we address this global pandemic, its disproportionate impact on Black, Indigenous, and Latinx communities has served to further magnify the health inequities in access and treatment that persist in our communities. These sobering realities should serve as the impetus for reexamination of the root causes of inequities in our health system. An increased commitment to strategic partnerships between academic and nonacademic health systems, industry, local communities, and policy-makers may serve as the foundation. Here, we examine the impact of the recent COVID-19 pandemic on health care inequities and propose a strategic roadmap for integration of clinical and translational research into our understanding of health inequities.

Society of Behavioral Medicine Update: retain support for the National Colorectal Cancer Roundtable's call to action to reach 80% colorectal cancer screening

Colorectal cancer (CRC) remains the third most commonly diagnosed cancer and the third leading cause of cancer-related death in the USA. CRC can be prevented through regular screening and removal of precancerous polyps. However, roughly one third of eligible adults in the USA are not up to date with recommended CRC screening. To increase timely CRC screening uptake in the USA, in 2014, the National Colorectal Cancer Roundtable (NCCRT) launched 80% by 2018. This multilevel effort involved more than 1,500 pledged organizations targeting patients, providers, health care systems, and policymakers to increase U.S. CRC screening rates to 80% by 2018. Concurrent with this campaign, between 2012 and 2018, CRC screening rates increased nationwide by 3.6% from 65.2% to 68.8%, meaning that about 9.3 million more U.S. adults are being screened. NCCRT attributes these successes to widespread implementation of center- and system-wide evidence-based interventions to increase screening uptake, including direct patient communication, provider reminders via electronic health records, and patient navigation, among others. Moving beyond 2018, NCCRT has rebranded the initiative as the 80% Pledge and has since identified several targeted campaigns, including increased outreach to Hispanics, Latinos, and Asians, whose CRC screening uptake remains less than 50%; encouragement of Medicaid outreach activities around CRC screening in all 50 states; and advocacy for screening right at 50 years of age. Society of Behavioral Medicine continues to support NCCRT and encourages policymakers to do the same by taking legislative action to assure funding for Medicaid outreach, research innovations, and clinical quality improvement that supports the 80% Pledge.

Optimizing the Use of Telemedicine in Oncology Care: Postpandemic Opportunities

Utilization of telehealth as part of the cancer care delivery continuum dramatically escalated in response to the COVID-19 pandemic at major cancer centers across the globe. The rapid shift toward telehealth visits for nontreatment cancer care provided immediate benefit through reducing unnecessary risk of exposure, overcoming transportation barriers faced by both patients and caregivers, and fast-tracking care transformation. As such, delineating the impact of telehealth on access, health equity, quality, and outcomes will be essential for refining the use of digital strategies and telehealth toward optimizing cancer care. Herein, experiences to date with telehealth usage for oncology care are reviewed, and priorities are outlined for postpandemic opportunities to improve the lives of patients with cancer through telemedicine.

Accuracy of pelvic magnetic resonance imaging in local staging for rectal cancer: a single local health district, real world experience

BACKGROUND

Neoadjuvant chemoradiotherapy plays a key role in reducing local recurrence rates for locally advanced rectal cancer. Pelvic magnetic resonance imaging (pMRI) is the gold standard for local clinical staging which allows clinicians to decide the treatment patients receive. A more advanced tumour or the presence of high-risk features on pMRI mean that neoadjuvant therapy will be offered to these patients. Understanding the accuracy of pMRI in local staging for rectal cancer is therefore crucial.

METHODS

A retrospective cohort analysis of the accuracy of pMRI staging in a subgroup of patients who had primary rectal cancer surgery without neoadjuvant therapy was performed. Specificity and sensitivity for T-staging, N-staging and presence of high-risk features (threatened circumferential resection margin and extramural venous invasion) were calculated. Patients who had previous pelvic surgery, previous pelvic radiotherapy and previous surgery for continence were excluded.

RESULTS

A total of 114 patients were included in the analysis. MRI accurately predicts T-stage in 56.6% and N-stage in 55.8%. Prediction of extramural disease was accurate in 51%. A negative circumferential resection margin was accurately predicted in 98.6% of patients. Overall adherence to reporting proforma was 15.8%.

CONCLUSION

Overall, this study provided valuable information about the clinical staging of patients with rectal cancer who are at an early stage within a large regional catchment area in Australia with pMRI. These results allow us to assess the accuracy of our local staging with ramifications to the clinical decisions being made in the context of the more recent trials which questioned the need for neoadjuvant chemo-radiotherapy in all node positive patients.

BIOM-28. IDENTIFICATION OF SOLUBLE AXL AS A POTENTIAL NON-INVASIVE SERUM BIOMARKER FOR GLIOBLASTOMA

AXL, a member of the TAM family of tyrosine kinases, engages cellular pathways that promote a cancer phenotype. In glioblastoma, increasing AXL expression is associated with worse prognosis. The extracellular domain of AXL is cleaved by the sheddases ADAM10 and ADAM17, releasing soluble AXL (sAXL), which is detectable in blood and tumor related fluid collections. In this study we use ELISA to measure serum sAXL levels in 23 patients with newly diagnosed GBM pre- and post- operatively and every 3 months during treatment. Relative AXL expression was assessed in tumor tissue obtained from 13 patients via western blotting. Additionally, we used T1-weighted MRI scans to interpolate pre-operative tumor volume for all patients enrolled in the study. We found that serum sAXL concentrations were elevated in 84 GBM serum samples (35.77 ±1.25 ng/mL) compared to 40 healthy volunteer samples (30.16 ±1.88 ng/mL). When normalized to total serum albumin the difference between GBM and healthy controls was statistically significant (t(df)=5.647(122), p= 0.0132). In the 19 patients with paired samples, the pre- and post- operative sAXL levels were not significantly different. Using the Pearson method, we did not find a significant correlation between tumor volume and sAXL level. However, in patients with sAXL levels above the healthy population average, there was a moderate negative correlation between sAXL and pre-operative tumor volume (r= -0.58; p= 0.23). Interestingly, there was a strong correlation between sAXL level and tumor expression of AXL in patients with high preoperative sAXL levels (r= 0.85; p= 0.03). Though sAXL shed from brain tumors is detectable in the serum of GBM patients, in this small series of patients, it does not correlate with tumor volume. That said, we feel a larger study correlating sAXL level with improved volumetric MRI determination of viable GBM is warranted.

High body mass index is associated with an increased overall survival in rectal cancer

Background

The impact of increased body mass index (BMI) on clinical outcomes in locoregional rectal cancer is unknown.

Methods

This is a retrospective cohort study which included 453 consecutive rectal cancer patients undergoing definitive treatment, with confirmed stage I, II or III rectal adenocarcinoma. The association of BMI at diagnosis with overall survival (OS), cancer specific survival (CSS) and disease-free survival (DFS) was explored, controlling for key covariates using multivariable analyses. BMI as defined by the World Health Organization (WHO) is as follows: BMI <18.5-underweight; 18.5-24.9-normal; 25.0-29.9-pre-obesity; >30-obese.

Results

Overweight and obese patients had significantly better OS than underweight/normal weight patients (5-year OS 80% for overweight, 77% for obese, and 65% for underweight/normal weight patients, P=0.02). High BMI (>25) was significantly associated with improved OS in univariate [0.62 (0.4-0.8) P=0.007] and multivariable [0.65 (0.4-0.9) P=0.023] analyses. When stratified by stage, high BMI was associated with improved OS in stage III patients (P=0.0009), but not stage II (P=0.21) or stage I (0.54). High BMI was also significantly associated with improved CSS in univariate (HR 0.62, P=0.048) and multivariable analyses (HR 0.58, P=0.03).

Conclusions

In our study a BMI greater than 25 is significantly associated with a longer OS and CSS in patients with locoregional rectal cancer. These findings may be due to the reduced metabolic capacity for non-obese patients to deal with rectal cancer treatment as well as the burden of disease, however further research is needed to evaluate this.

Factors influencing recurrence of stage I-III rectal cancer in regional Australia

BACKGROUND

As treatments for rectal cancer improve with developments in surgical techniques, radiotherapy and chemotherapy, the nature of recurrences are evolving. We used a comprehensive database of a large Australian population with stage I-III rectal adenocarcinoma to identify timing and prognostic significance of recurrences, and factors associated with risk of developing recurrent disease.

METHODS

All patients with locoregional rectal cancer treated with curative intent in our health district from 2006 to 2017 were included. Multivariate analysis using Cox regression models were used to identify factors associated with recurrence.

RESULTS

A total of 483 patients were included. Recurrence occurred in 117 (24.2%) of 483 patients, being locoregional in 15 (3.1%) patients, distant in 85 patients (17.6%) and both locoregional and distant in 17 (3.5%) patients. Compared to those with locoregional recurrence, those with both locoregional and distant recurrence had worse cancer-specific survival. On univariate analysis, factors associated with recurrence included stage, grade, radiotherapy, chemotherapy, surgery type and distal tumour location. Factors which remained significant on multivariate analysis included higher grade and stage.

CONCLUSION

In the era of multimodality therapy for rectal cancer, recurrences are predominantly distant. Traditional predictors including higher stage, grade and distal tumour location remain independently associated with recurrence, despite current treatment paradigms.

Abstract A128: Building sustainable partnerships between cancer centers and safety net community hospitals to increase access to and quality of cancer care

Background: Cervical cancer outcomes are influenced by race, socioeconomic status and region. African American women have the highest mortality rate from cervical cancer and Hispanic and American Indian/Alaska Native women have the highest cervical cancer incidence rates among racial/ethnic groups. Disparities in cervical cancer can be greatly improved by increasing access to and awareness of Pap screening and HPV vaccination among vulnerable populations. Safety net and community hospitals offer broader opportunities to reach at-risk individuals, however these hospitals face many challenges that mirror those of the patients they serve, including: decreased access to innovative research and treatment, decreased access to the full range of specialty care, and funding challenges. Public-Public partnerships between academic medical centers, cancer centers and private service organizations that extend to safety net and community hospitals can increase cervical cancer screening rates among individuals at greatest risk. Methods: The Loretto Hospital and Norwegian American Hospital serve communities that suffer the highest cervical cancer mortality rates in Chicago. Funded by the Bristol Myers Squibb Foundation, the University of Illinois Cancer Center partnered with these two community hospitals located on the west sides of Chicago to increase cervical cancer screening rates through clinical and community patient navigation. Evidence based methods such as small media interventions, client reminders, and one-on-one education will also be used to increase screening awareness and education. The evidence-based, implementation science program is guided by the RE-AIM framework. Reach, adoption and sustainability will be maximized through the integration of community hubs that comprise faith-, community-, school-based organizations and policy makers. Results: The project is a three year project. Now in its pre-implementation phase, the program is currently piloting data instrumentation and implementation processes. Preliminary results will be presented at the meeting. The Partnership development phase has been achieved and Full implementation will begin August 2019. Conclusion: It is expected that building partnerships between large academic medical centers, cancer centers and community hospitals will increase the capacity of community hospitals to offer quality screening and specialized care to community members and increase access to cervical cancer screening and education among at-risk populations ultimately decreasing cervical cancer disparities among underserved populations in the University of Illinois Cancer Center catchment.

Citation Format: Vida Henderson, Jessica Madrigal, Jeanette Gonzalez, Erica Martinez, Katherine Tossas-Milligan, Patricia Doykos, Karriem Watson, Robert Winn. Building sustainable partnerships between cancer centers and safety net community hospitals to increase access to and quality of cancer care [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr A128.

Abstract C110: Implementation of an integrated framework for a breast cancer screening and navigation program for under-resourced women

Background As detection and treatment for breast cancer in the United States have improved, racial and ethnic disparities persist. Utilizing an implementation science framework to inform an evidence-based breast cancer screening and navigation program within Federally Qualified Health Centers (FQHCs) with community stakeholders can mitigate multiple barriers to breast cancer screening. Methods Utilizing an integrated theoretical framework of the Practical, Robust Implementation and Sustainability Model (PRISM) and the social ecological model (SEM), the University of Illinois Cancer Center, University of Illinois Hospital & Health Sciences System (UI Health) including Mile Square Health Centers (MSHC) FQHC, and the Chicago Department of Public Health (CDPH) developed a breast cancer screening and navigation program to tackle breast cancer disparities in Chicago among under-resourced women, known as the Mi-MAMO program. To increase access to screening services, patient navigators conducted community outreach and engagement activities. Program partnerships were forged with community-based organizations, healthcare systems and insurers. Program outcomes were monitored using standardized performance measures. Results Between January-December 2017, 103 women received a screening mammogram at MSHC. To increase screening rates, the Mi-MAMO program was started in August 2017. Between January-December 2018, the number of women who received a screening mammogram at MSHC increased to 1051. From August 2017 (start of program) to December 2018, 779 women received navigation to screening and/or diagnostic services through the Mi-MAMO program. The majority of women were uninsured (63.9%) and 95.5% were racial/ethnic minorities. Twenty-four percent (n=185) of women completed diagnostic services and ten women received positive breast cancer diagnoses (mean age 49.7 years). All diagnosed women were successfully navigated to treatment. The Mi-MAMO program is on-going. Conclusion Deploying an integrated framework that merges an implementation science and multi-level behavioral health framework for patient navigation programs has the potential to increase breast cancer screening utilization and awareness among under-resourced populations who may be at higher risk for breast cancer.

Citation Format: Vida A Henderson, Katherine Tossas-Milligan, Erica Martinez, Barbara Williams, Paola Torres, Nasima Mannan, Lauren Green, Beti Thompson, Robert Winn, Karriem S Watson. Implementation of an integrated framework for a breast cancer screening and navigation program for under-resourced women [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C110.

Abstract A058: Examining preferential mode of obtaining health information in African American women with elevated risk for breast cancer

Background: Breast cancer is the second leading cause of cancer death in the U.S. and is substantially higher in African American (AA) women. Early detection is crucial in decreasing breast cancer mortality and racial disparities. Research shows that low-income minority women are less likely to get breast cancer screening. Previous studies demonstrate that use of technology increases cancer screening rates. However, there are limited studies on the preferred mode of consuming health information for AA women, particularly those with increased risk of developing cancer.

Objectives: The objective of this study is to examine preferences in receiving and accessing health information among AA women with a family history of breast and/or ovarian cancer.

Methods: We conducted a mixed-methods study to address our research objective. For quantitative data, African American women (aged 26-67) were recruited from a Federally Qualified Health Center in the Southside of Chicago who were identified with elevated breast cancer risk via a risk assessment tool. Women were asked to complete a survey that assessed their preferred method of receiving health information. Data were analyzed using SPSS software. To supplement the quantitative data, qualitative data were collected during two focus groups conducted with AA women aged 25-69 with a family history of breast cancer. Bivariate analyses were performed to determine women's preferences in receiving and accessing health information, and if these preferences differed by age (&lt;40 and ≥40).

Results: The analytical sample consisted of 85 AA women with increased breast cancer risk. Sixty-nine women completed the surveys and 16 women attended focus group sessions. The majority of the study participants found reading materials (100%), listening to recordings (73%), and watching videos (96%) or animation (62%) were useful modes of receiving health information. There were no differences in these preferences by age groups. All women aged ≥40 years preferred receiving information explained by a person (p-value = 0.032). Most of the women had a cell phone with texting capabilities (90%). Seventy-eight percent of cell phone owners used their cell phone to access health information on the Internet, and 64% of these women were aged &lt;40 years (p-value = 0.004). Other vital avenues of accessing health information that emerged from the focus groups included social media and health fairs.

Conclusion: Understanding African American women's preferences for receiving and accessing health information can inform development of interventions designed to improve adherence to cancer screening recommendations. Additional research is needed to better understand the impact that accessing health information through various media has on cancer screening rates.

Citation Format: Tera Ivy, Ifeanyi Chukwudozie, Vida Henderson, Silvia Tejeda, Ganga Vijayasiri, Catherine Balthazar, Robert Winn, Kent Hoskins. Examining preferential mode of obtaining health information in African American women with elevated risk for breast cancer [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr A058.

Participatory Genomic Testing Can Effectively Disseminate Cardiovascular Pharmacogenomics Concepts within Federally Qualified Health Centers: A Feasibility Study

Objective

We assessed feasibility of an educational program designed to enhance stakeholder knowledge and perceptions of pharmacogenomics at a federally qualified health center (FQHC).

Design

FQHCs have a rich history of providing care to the underserved, but often are not represented by studies evaluating cutting-edge concepts. We used a novel educational platform to provide participatory genomic testing and classroom education. We assessed participant knowledge and perceptions using questionnaires between May and July 2018.

Setting

We partnered with a FQHC affiliated with an academic medical center in Chicago.

Participants

Using convenience sampling, we recruited 20 providers and 10 community members for a feasibility study. Providers included physicians, physician extenders, community health workers, and patient health navigators. Community members were patients, supporters, and/or FQHC advisory board members.

Intervention

Participants had the option to undergo personal genomic testing. Online educational modules included basic genetics, cardiovascular pharmacogenomics, and personalized medicine. Education concluded in a 2-hour live course with case-based discussions.

Main Outcome Measures

Our main outcome was testing pilot feasibility. Baseline knowledge and perceptions were compared with post-intervention assessments using descriptive statistics, t tests (or Wilcoxon rank-sum) for continuous variables and chi-squared (or Fisher's exact) for categorical variables.

Results

We found that attitudes toward the intervention were positive and remained so after intervention. Our intervention was both feasible and acceptable. Genomics knowledge increased for nearly all participants.

Conclusions

We have determined that a pharmacogenomics educational program tailored for an underrepresented community is feasible and acceptable. Outcomes will advise methodology for larger implementation studies.

Insurance status and racial disparities in detection of early-stage breast cancer

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Background: Racial/ethnic minority women are diagnosed with later stage breast cancer. This study identifies the extent insurance can affect stage differences among a large, diverse population of breast cancer patients in the U.S. Methods: Retrospective, population-based study of women aged 40-64 years diagnosed with stages I-III breast cancer in the Surveillance, Epidemiology and End Results Program between 2010 and 2014. The primary outcome was risk of diagnosis with locally-advanced (stage III) versus early stage breast cancer (stages I-II). Causal mediation analyses were conducted to determine effects of race/ethnicity and proportion of observed differences mediated by health insurance status on earlier stage. Results: A total of 124,415 women (104,468 insured and 19,947 uninsured /Medicaid) were included. Among women with health insurance, a lower proportion was diagnosed with locally-advanced breast cancer compared to uninsured/Medicaid-covered women (11% versus 21%). In multivariable models, non-Hispanic Black (OR = 1.50, 95% CI 1.43-1.58), American Indian/Alaskan Native (OR = 1.38, 95% CI 1.11-1.72) and Hispanic (OR = 1.35, 95% CI 1.28-1.42) women had higher odds of being diagnosed with locally-advanced disease compared to non-Hispanic White women. When adjusting for health insurance and other socioeconomic factors, associations between race/ethnicity and risk of locally-advanced breast cancer were attenuated (non-Hispanic Black: OR = 1.30, 95% CI 1.23-1.37; American Indian/Alaskan Native: OR = 1.15, 95% CI 0.91-1.45; Hispanic: OR = 1.16, 95% CI 1.09-1.22). Approximately half (48% to 50%) of racial differences in risk of locally advanced disease were mediated by health insurance. Conclusions: We find that half of the observed racial/ethnic disparities in upstaging at diagnosis are mediated by health insurance coverage.

SBM recommends policy support to reduce smoking disparities for sexual and gender minorities

The Society of Behavioral Medicine supports the inclusion of gender and sexual minorities in all local, state, and national tobacco prevention and control activities. These activities include surveillance of tobacco use and cessation activities, targeted outreach and awareness campaigns, increasing access to culturally appropriate tobacco use dependence treatments, and restricting disproportionate marketing to lesbian, gay, bisexual, and transgender communities by the tobacco industry, especially for mentholated tobacco products.

Rectal cancer treatment and outcomes in elderly patients treated with curative intent

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Background: There is limited information on outcomes in elderly patients with rectal cancer as they are often excluded from clinical trials. This study aimed to assess treatment patterns and outcomes in these patients. Methods: We utilised data from electronic records to identify patients aged ≥ 70 years with a histological diagnosis of rectal cancer from 2006-2015, treated in the South Western Sydney and Illawarra Shoalhaven Local Health Districts, Australia. Treatment modalities, recurrence and survival data were analysed. Results: We identified 942 patients with rectal cancer, with median follow-up of 3.4 years. 393 patients (42%) were aged ≥ 70 years. Median age of this cohort was 77 years (range 70–96 years). Elderly patients were more likely to present with locoregional disease (stage I-III, 83% vs. 75%) and more likely to receive palliative treatment only (21% vs. 16%, p = 0.0005). Of 704 patients who received treatment with curative intent, 300 (43%) were ≥ 70 years. Although clinicopathological features were similar between elderly and young patients, patients ≥ 70 years were more likely to be treated with surgery alone (56% vs. 28%, p < 0.0001), less likely to receive neoadjuvant (25% vs. 44%, p < 0.0001) or adjuvant treatments (29% vs. 55%, p < 0.0001), or be discussed in a multidisciplinary meeting (51% vs. 61%, p = 0.001). Compared to younger patients, elderly patients had a significantly poorer overall survival (HR 2.9, 95% CI 2.2 – 3.7, p < 0.0001). There were no significant differences in cancer specific survival (HR 1.4, 95% CI 0.98 – 2.0, p = 0.06) or relapse free survival (HR 0.92, 95% CI 0.7 – 1.2, p = 0.60). Conclusions: Although more elderly patients were treated with palliative intent compared to younger patients, the majority of elderly rectal cancer patients were still treated with curative intent. Most had surgery alone. Uptake of neoadjuvant and adjuvant therapy, as well as multidisciplinary involvement, was lower. Elderly patients had similar cancer-specific outcomes compared to younger patients, supporting curative intent treatment in these patients. Further analyses are underway to identify subgroups in the elderly population who benefit from trimodality therapy, and potential differences in their disease biology.

Acute cholecystitis and gallbladder perforation leading to massive haemoperitoneum in a patient taking rivaroxaban

We present the case of an 80-year old man taking rivaroxaban for atrial fibrillation who sustained massive intra-abdominal bleeding in the setting of acute cholecystitis. CT scan on admission revealed evidence of active bleeding into the gallbladder lumen and gallbladder perforation. Immediate resuscitation was commenced with intravenous fluids, antibiotics and blood products. Despite attempts to correct coagulopathy, the patient's haemodynamic status deteriorated and an emergency laparotomy was performed, with open cholecystectomy, washout and haemostasis. The patient had a largely uneventful recovery and was discharged on day 11 of admission. Patients with coagulopathies, whether pharmacological or due to underlying disease processes, are at very high risk of severe haemorrhagic complications and subsequent morbidity. As such, prompt recognition and operative management of haemorrhagic perforated cholecystitis is of crucial importance.

Abstract 3308: Urine epigenetic biomarkers for NSCLC diagnosis

Purpose:

The National Lung Cancer Screening Trial showed mortality reduction on patients with NSCLC by the use of Low-dose CT screening. The study exhibits an unreasonably high false positive rate of 96.6%, which can to lead to significant morbidity and mortality from unnecessary tests. This study aim to determine if methylated promoter regions of a panel of genes that are correlated with Non-Small Cell Lung Cancer can be detected in urine from patients with lung cancer versus those without.

Materials and Methods:

We conducted a prospective case-control study recruiting subjects from the Lung Cancer Spore Trial. Urine and pre-operative CT scans were obtained from all patients. We processed the urine using the Methylation on Beads assay to isolate and bisulfite treat circulating DNA and then employed Quantitative Methylation Specific Real-Time PCR to detect promoter methylation status of the genes: CDO1, TAC1, HOXA7, HOXA9, SOX17 and ZFP42. Sensitivity, specificity, PPV and NPV values were calculated for each gene methylation status.

Results:

34 patients were studied, including 23 patients with NSCLC and 11 patients with benign non-cancerous lesions. The sensitivity, specificity, PPV and NPV values for lung cancer detection in urine are shown in Table 1. Sensitivities ranged 43-96%, Specificities 64-91%, PPV 71-100% and NPV 40-67%. Promoter methylation of the gene panel CDO1, TAC1, HOXA7, HOXA9, SOX17 and ZPF42 has a 78% sensitivity, 91% specificity, 95% PPV and 67% NPV for lung cancer detection.

Conclusion:

Our study suggests that urine can provide a highly sensitive and specific non-invasive route for lung cancer detection. These results are very promising and could potentially reduce unnecessary morbidity and mortality in people undergoing screening for NSCLC by use of a non-invasive method that could be more accessible on primary care centers. However, further studies and validation with larger sample sizes and different populations are necessary before its application to clinical practice.

Patients with positive gene methylation from urine samples and its accuracy for NSCLC detection.Cancer (n=23)Cancer (n=23)Control (n=11)Control (n=11)nSensitivitynSpecificityPPVNPVCDO114611919353TAC11565010010058SOX1716704648050HOXA711483737940HOXA910431919143ZPF4222969187167Panel of genes18781919567

Citation Format: Lane Lerner, Lily Zheng, Anastasia Kottorou, Chen Chen, Tomoaki Ito, Kristen Rodgers, Beverly Lee, Robert Winn, Enrico Benedetti, Tza- Huei Wang, Malcolm V. Brock, James G. Herman, Alicia Hulbert. Urine epigenetic biomarkers for NSCLC diagnosis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 3308.

Abstract B33: Motivating African American women with hereditary breast cancer risk to participate in genetic counseling

Background: The emerging precision health paradigm for breast cancer control will base screening and prevention on individual level of risk. An important element of this approach is cancer genetic risk assessment and genetic counseling for women with familial breast cancer risk. Despite a referral from their primary care physician (PCP), prior work from our group demonstrated poor uptake of genetic counseling among African American (AA) women with a family history of breast/ovarian cancer who meet national guidelines for genetic counseling. This is consistent with other reports of poor utilization of BRCA testing among AA women. We found a strong desire among both PCPs and AA women for culturally sensitive educational material tailored to AA women at risk for hereditary breast cancer to help them understand the purpose of genetic counseling. In response to that finding, we are developing an educational animation delivered on a mobile device platform that is designed to motivate AA women to attend genetic counseling. Content for the animation will be informed by constructs from a theoretical model of health behavior and by themes identified in semistructured interviews with women who were recommended for genetic counseling by their PCP in our formative work.

Methods: We conducted key informant interviews with healthy AA women without a personal history of cancer who all met criteria established by the National Comprehensive Cancer Network for genetic counseling based on a family history of breast/ovarian cancer. Potential participants were identified from a cohort of women who participated in an earlier study of cancer genetic risk assessment performed as part of routine care in a Federally Qualified Health Center in Chicago, IL. All potential participants were referred for genetic counseling by their PCP and provided consent for re-contact for future research. Recruitment letters were mailed to all eligible women, followed 2 weeks later by phone contact. The study group includes both women who did and who did not attend the counseling session. The semistructured interview guide was based on constructs from the Integrative Model of Behavioral Prediction (IMBP). Standard qualitative data analysis techniques were used, including an iterative process to develop a codebook and use of 2 coders to analyze each interview transcript. An inductive methodology using a modified version of constant comparative analysis was the key methodologic strategy for analyzing the qualitative interviews data.

Results: A total of 60 AA women who were age 25-69 at the time of the prior study were eligible to participate in the interviews. Eleven of these women (18%) attended a genetic counseling session. The mean age of eligible participants was 45 years; 25% reported either a high school diploma or a GED as their highest level of attained education, and 73% completed some education beyond high school; 55% reported receiving their health insurance from Medicaid; and the majority (70%) reported annual household income of less than $30,000. Of 60 eligible women, 16 (27%) were not available for a recruitment phone call (13 had an invalid address or phone number, 2 declined a recruitment phone call, and 1 moved out of the area). Twenty interviews will be completed by the end of June, 2017, and themes from IMBP constructs that emerge as key motivators of attendance at a genetic counseling session will be reported.

Conclusion: The findings from this study will provide data to inform interventions that will be necessary to ensure that underserved AA women with familial breast cancer risk receive genetic counseling. In the absence of effective interventions to increase utilization of cancer genetic services, the emergence of precision health care is likely to exacerbate cancer disparities in underserved AA communities.

Citation Format: DeLawnia Comer-HaGans, Zo Ramamonjiarivelo, Shirley Spencer, Beverly Chukwudozie, Vida Henderson, Karriem Watson, Catherine Balthazar, Rupert Evans, Robert Winn, Angela Odoms-Young, Kent Hoskins. Motivating African American women with hereditary breast cancer risk to participate in genetic counseling [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr B33.

Abstract A02: Investigating the association between social disorganization, health-related quality of life (HRQL), and prostate cancer diagnoses in African American Men

This proposed population-based study initiated by the Early Stage Investigator from a collaborative National Cancer Institute (NCI) P20 grant between Governors State University and the University of Illinois at Chicago attempts to identify the influence of social disorganization on health-related quality of life (HRQL) in African American men living in south suburban Cook County in Illinois with prostate cancer diagnosis using the International Classification of Functioning, Disability and Health (ICF) to measure and map disability by zip code using the Geographic Information System (GIS). Although the diagnosis is 65% higher for African American men in the U.S, the relationship between prostate cancer diagnosis, health-related quality of life (HRQL), and social disorganization has not been fully examined.

Pertinent experimental procedures proposed to examine this relationship include using U.S census data to obtain geographical characteristics of socially disorganized communities within south suburban Cook County in Illinois, assessing cases of prostate cancer diagnosis for African American men living in the parameters of the research, examining HRQL for these cases using ICF classifications, spatially mapping these prostate cases to determine SD, and completing a regression analysis based on HRQL and SD scores.

Currently, prostate cancer is the number one cancer among all men in Illinois with 42,773 identified cases between 2002 and 2006 for all races (IDPH, Illinois Cancer Registry, 2008). Additionally, African American men living in Cook County have the highest rate for all racial groups at 227.1 per 100,000 between 2002 and 2006 (IDPH, Illinois Cancer Registry, 2008). More importantly, African American men tend to have fewer prostate-specific antigen (PSA) tests, increasing the risk for latent diagnosis and lower survival rates. These proposed data hypothesized that social disorganization might increase risk for prostate cancer rates and lower HRQL based on socioeconomic and environmental influences identified in the ICF.

The proposed research attempts to identify preventable risk factors that would assist in the development of preventative care for men at risk for prostate cancer, and increasing the HRQL of African American men with a current diagnosis of prostate cancer.

Citation Format: Carolyn D. Rodgers, Shannon Zenk, Karriem S. Watson, Robert Winn, Rupert Evans, Sr., Catherine Balthazar, Ifeanyi Beverly Chukwudozie. Investigating the association between social disorganization, health-related quality of life (HRQL), and prostate cancer diagnoses in African American Men [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr A02.

Abstract PR12: Considering unintended effects of a colorectal cancer navigation program in a Federally Qualified Health Center in Chicago on mammography uptake

Introduction: Health care facilities often have competing public health priorities they must address, including different types of cancer. The burden of addressing these conditions is particularly great in Federally Qualified Health Centers, wherein marginalized populations suffer simultaneously from late-stage detection for various cancers. Patient navigation is an approach that has been documented to be effective across many of these cancers, including breast and colorectal (CRC). What is less known is if and how navigation for one site may influence patients' behaviors with regard to other cancer sites. Such information may be helpful for evaluating the benefits of different programs, and deciding which optimize patients' health maximally.

Methods: During January 2015 through December 2015, a patient navigation intervention was implemented for cancer screening in three of the health clinics: Main site, Englewood, and Back of the Yards site (BOTY). Starting in January 2016, a 1,453-patient chart review was completed using electronic health records. The criteria for the review are as follows: 1) age 50-5 years old and 2) scheduled for a provider visit at one of the three participating sites during the 12-month study period. Neighborhood characteristics were added to the dataset by combining it with the American Community Survey at the zip code level. The sample size for this analysis was n = 863. The independent variable was CRC navigation, with the following categories: none (REFERENT), mailed reminders, provider education, lay patient navigator (LPN), and combined interventions (including 2+ of the intervention types). The outcome variable was mammogram status with the following categories: adherent (receipt of screening within 2 years), nonadherent with a lifetime history of mammography, and nonadherent without a lifetime history of mammography. The analysis conducted was a polychotomous logistic regression model. The association was adjusted by age, race/ethnicity, percent poverty, and percent non-Latino White.

Results: The patient population had a mean age of 60.3. There was an average of 31.3% poverty in each zip code. 60% of the population were non-Latino Black. Latino represented 29% of the study population. Non-Latino White and other category consisted of 11% of the sample. The distribution of the insurance in the study population was as follows: private insurance made up 23% percent of the sample, public insurance represented 69% of the sample, and self-pay made up 8% of the population. Mammography status was associated with neighborhood poverty, %NLW residents, clinic site, and insurance status (all P &lt;.05). In terms of our main question, women receiving LPN (OR = 0.25, 95%CI: 0.08, 0.77) and women receiving mailed reminders (2.16, 95%CI: 1.02, 4.58) were associated with odds of being nonadherent with a lifetime history of mammography.

Conclusion: The results show certain colorectal interventions were associated with mammogram status. The navigation arm showed a protective effect against past-due mammograms if the patient was navigated by LPN. However, it was a risk factor for past-due mammogram for those in the mailed reminders arm. These results implicate that lay patient navigators may improve overall cancer-screening completion rates. This could be due to lay patient navigators' focus on overall patient health, and therefore emphasize the importance of all cancer screenings, whereas mailed reminders solely focus on colorectal cancer and thus do not affect other cancer-screening completion rates.

Citation Format: Yazmin San Miguel, Karriem S. Watson, Keia Hobbs, Robert Winn, Yamile Molina. Considering unintended effects of a colorectal cancer navigation program in a Federally Qualified Health Center in Chicago on mammography uptake [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr PR12.

Lung cancer early detection and health disparities: the intersection of epigenetics and ethnicity

Lung cancer is the most prominent cause of cancer-related mortality. Significant disparities in incidence and outcome characterize the disease's manifestations among ethnically and racially diverse populations. Complete surgical resection is the most effective curative treatment. However, success relies on early tumor detection. The National Lung Cancer Screening trial showed that lung cancer related mortality can be reduced by the use of low-dose CT (LDCT) screening. However, this test is plagued by a high false positive rate of 97% and the device itself is limited to designated cancer centers due to its expense and size. This restriction makes it difficult for underserved groups to access LDCT screening, the current standard of care. Highly sensitive and specific epigenetic DNA methylation-based biomarkers have the potential to work independently or in conjunction with LDCT screening to identify early-stage tumors. These tests could reduce unnecessary invasive confirmatory diagnostic tests and their associated morbidity and mortality. These tests also have the opportunity to bring lung cancer screening to the community thereby reducing unequal accessibility. However, epigenetic alterations are closely linked to the interplay between hereditary and environmental factors such as diet, lifestyle, ethnic ancestry, toxin exposure, residential segregation, and disparate community support structures. Despite this, the overwhelming number of early detection DNA methylation biomarker studies to date have either failed to control for ethnicity or have employed heavily Caucasian-biased patient cohorts. This review seeks to summarize the literature related to the early detection of lung cancer through molecular biomarkers among different ethnicities. Ethnical specific epigenetic biomarkers have the potential to be the first step towards an accessible, available personalized medicine approach to cancer through liquid biopsy.

Abstract B64: Impact of neighborhood effects on a multi-approach Colorectal Cancer screening navigation program in an urban federally qualified health center

Purpose.

Mortality and morbidity disparities exist in Colorectal Cancer (CRC). CRC screening rates differs among race/ethnicity, which contribute to these existing disparities. In response, multiple interventions have been developed and assed to address these gaps. Little is known about how efficacy varies across patient populations. In response, multiple interventions have been developed and assessed, including patient navigation. Little is known about how efficacy varies across socioenvironmental contexts.

Objective.

The study sought to examine the interactive effects of patient navigation and provider navigation with contextual factors (facility and residential neighborhood characteristics) on CRC screening uptake among a Chicago-based sample population.

Methods.

Two evidence-based CRC screening interventions were implemented at University of Illinois Mile Square Health Center (MSHC) clinics. The study eligible population was those: 1) Ages 50-75; 2) Had an appointment in 2014 or 2015; and 3) Not up-to-date on CRC screening. The controls were matched by clinic, race/ethnicity, and sex. An individual-level database for the retrospective evaluation of comparative effectiveness of patient navigation-based versus provider-based navigation was created. This database included all patients ages 50-75 who completed at least one patient visit in MSHC in 2015. The database includes patients navigated by the patient navigator, and patients navigated by the provider. The following information was collected from electronic medical record (EMR) data: 1) age; 2) race/ethnicity; 3) insurance status; 4) date mailed birthday reminder was sent; 5) type of one-on-one navigation (CHW, provider, or both); 6) date navigation was administered; 7) patient full address, including zip code; 8) date FOBt given to patient during 2015; 9) date FOBt returned; 10) date colonoscopy scheduled; 11) date colonoscopy completed;12) FOBt result; 13) Screening colonoscopy result; 14) Diagnostic colonoscopy date; 15) Diagnostic colonoscopy date; 16) Cancer Diagnosis date; 17) provider name; and 18) clinic site. The neighborhood characteristics of interest were median household income, poverty, percent black, percent white, and percent of Latino residents based on American Community Survey 2007-2011 data.

Results.

A preliminary analysis was conducted on the database, n= 340. There were significant differences in clinic using Chi-Square statistic (X= 10.7, p = .005). When looking at individual clinics, for the Englewood and Main clinic, patients responded better to provider navigation (20% and 21%) compared to patient navigation (8% and 15%), respectively. Whereas, the Back of the Yards clinic had patients respond better to provider navigation versus patient navigation, 56% versus 14%. Adjusted for clinic, gender, and race/ethnicity, patient navigation was most strongly associated with CRC completion (OR = 5.5, 95% CI:3.1-9.8, p = &lt;.0001). Provider navigation was associated with CRC completion (OR = 1.81, p = .04).

The next steps in the study analysis will be to complete the data abstraction with matched-controls and conduct multivariable spatial logistic and Cox regression models to compare the different types of navigation on a) date patient received FOBt and b) days to FOBt returned since date of navigation c) days to completed colonoscopy since date of navigation. Second, multiple effect modification analyses will be conducted to examine interactive effects by 1) race/ethnicity; 2) clinic site; and 3) neighborhood factors (concentrated disadvantage and racial/ethnic composition).

Conclusions.

In this sample, patient navigation as an intervention was most strongly associated with CRC completion, relative to those who received the standard CRC screening recommendations (controls). CRC screening can lead to increases early detection and improved outcomes. Navigation programs that are tailored to address specific populations can increase uptake and compliance and have far reaching implications in FQHC populations who carry some of the largest burden of cancer morbidity and mortality.

Citation Format: Yazmin San Miguel, Yamile Molina, L. San Miguel, Scott Grumeretz, K. Matthews, Robert Winn, Karriem Watson. Impact of neighborhood effects on a multi-approach Colorectal Cancer screening navigation program in an urban federally qualified health center. [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 B64.

Abstract C89: Lung cancer screening in high risk populations: Developing community based screening and navigation program

Purpose: The National Lung Cancer Screening Trial (NLST) resulted in a 20% reduction in lung cancer (LC) deaths and 6.7% reduction in all-cause mortality. The NLST also resulted in lung cancer screening guidelines from the USPSTF. The population of the NLST was 91% white with less than 5% African Americans (AA) in the trial. AA are known to carry greatest burden of incidence/mortality due to LC. There is little data on populations such as the UI Health population who are predominantly AA with varied smoking behaviors.

Objective: We examined lung cancer screening trends and demographics in AA populations to describe screening outcomes in diverse population compared to the population in the NLST

Methods: The community based LC screening and navigation program of the UI Cancer Center and UI Health navigates patients from a FQHC in Chicago and patients from UI Health to tobacco cessation and LC screening. The screening program navigates high risk patient to screening and examines structural and social barriers that impact screening uptake and examines outcomes in high risk minority population compared to NLST cohort. Eligible screening populations from the FQHC affiliated with UI Health and the outpatient care population were screening and structural and social determinants such as a) age, b) race, c) insurance status, d) educational level, e) smoking status and f) gender were compared to that of the NLST population. The prevalence of LC and abnormal findings were compared in our diverse cohort compared to the NLST population along with an examination of impact of social determinants on LC screening outcomes.

Results: Results from the UI Health Community Based Lung Cancer Screening program demonstrated that the UI Health population which includes patients from the FQHC (Mile Square Health Center) affiliated with UI Health have higher rates of positive screens with 4 of the first 125 patients diagnosed with lung cancer. The comparison of UI Health LC screening population demonstrated the UI Health population has three times higher rate of LC screening finding at baseline screens compared to NLST population. The findings also demonstrate that UI Health population carried larger burden of current smokers and had increased determinants of health associated with poor health outcomes. The results further demonstrated that a community based lung cancer screening program built with a tobacco cessation program can increase LC screening compliance in a high risk population.

Discussion: The outcomes from our research demonstrate that a community based lung cancer screening and navigation program within an FQHC setting can increase lung cancer screening within a high risk population. The findings also suggest that the results from the NLST trial may not be generalizable to high risk racially and ethnically diverse populations. Community based screening and navigation programs may benefit from addressing social determinants such as SES, race and ethnicity, smoking status and insurance status that may impact cancer screening outcomes. The findings also suggest that additional data needs to be collected on lung cancer outcomes in racially and ethnically diverse populations to ensure current screening guidelines are able to ensure early detection and improved survival in racially and ethnically diverse populations not previously included in the pivotal screening trial.

Citation Format: Mary Pasquinelli, Karriem Watson, Scott Grumeretz, Lawrence E. Feldman, Kevin Kovitz, Arkadiusz Z. Dudek, Martha Menchaca, Matthew Koshy, Robert Winn. Lung cancer screening in high risk populations: Developing community based screening and navigation program. [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 C89.