Barriers to the assessment and recommendation of HPV vaccination among healthcare providers in Texas

Background

Healthcare providers (HCPs) recommendations for HPV vaccination plays a critical role in increasing vaccination uptake. This study assesses the prevalence of reported barriers to HPV vaccination assessment and recommendation among HCPs in Texas.

Methods

Study data were obtained from a population-based survey of HCPs currently practicing in Texas. Participants were asked about their HPV vaccination assessment and recommendation practices and the reasons for not assessing or recommending the vaccine. Barriers were stratified by HCP characteristics including age, sex, race/ethnicity, location of practice, provider type, and type of facility.

Results

Among the 826 HCPs included in this study, 47.3 % never, 49.6 % sometimes, and 3.0 % often/always assessed a patient's HPV vaccination status. Similarly, 36.0 % never, 36.2 % sometimes, and 27.9 % often/always recommended HPV vaccination. The most frequently reported barriers to assessment and recommendation of HPV vaccination were time constraints (22.9 %), delegating the task to others (15.0 %), lack of effective tools and information to give patients (12.0 %), and requiring additional training (9.2 %). HCPs who were female, less than 35 years old, non-Hispanic black, and nonphysician HCPs (Physician Assistant, Nurse Practitioner) most frequently reported lacking effective tools and information and a need for additional training.

Conclusion

The assessment and recommendation for HPV vaccination among HCPs in Texas is suboptimal. Barriers reported varied based on the provider's characteristics. Addressing these barriers, such as by providing more effective tools and information and offering additional training to HCPs, could potentially increase HPV vaccination rates in Texas. The findings also suggest that interventions should be tailored to specific demographic groups.

Exome sequencing implicates ancestry-related Mendelian variation at SYNE1 in childhood-onset essential hypertension

Childhood-onset essential hypertension (COEH) is an uncommon form of hypertension that manifests in childhood or adolescence and, in the United States, disproportionately affects children of African ancestry. The etiology of COEH is unknown, but its childhood onset, low prevalence, high heritability, and skewed ancestral demography suggest the potential to identify rare genetic variation segregating in a Mendelian manner among affected individuals and thereby implicate genes important to disease pathogenesis. However, no COEH genes have been reported to date. Here, we identify recessive segregation of rare and putatively damaging missense variation in the spectrin domain of spectrin repeat containing nuclear envelope protein 1 (SYNE1), a cardiovascular candidate gene, in 3 of 16 families with early-onset COEH without an antecedent family history. By leveraging exome sequence data from an additional 48 COEH families, 1,700 in-house trios, and publicly available data sets, we demonstrate that compound heterozygous SYNE1 variation in these COEH individuals occurred more often than expected by chance and that this class of biallelic rare variation was significantly enriched among individuals of African genetic ancestry. Using in vitro shRNA knockdown of SYNE1, we show that reduced SYNE1 expression resulted in a substantial decrease in the elasticity of smooth muscle vascular cells that could be rescued by pharmacological inhibition of the downstream RhoA/Rho-associated protein kinase pathway. These results provide insights into the molecular genetics and underlying pathophysiology of COEH and suggest a role for precision therapeutics in the future.

Smoking Cessation After Initial Treatment Failure With Varenicline or Nicotine Replacement: A Randomized Clinical Trial

Importance

Most people who smoke do not quit on their initial attempt.

Objective

To determine the best subsequent strategy for nonabstinence following initial treatment with varenicline or combined nicotine replacement therapy (CNRT).

Design, Setting, and Participants

Using a double-blind, placebo-controlled, sequential multiple assignment randomized trial, 490 volunteers were randomized to receive 6 weeks of varenicline or CNRT. After 6 weeks, nonabstainers were rerandomized to continue, switch, or increase medication dosage for 6 additional weeks. The study was conducted from June 2015 through October 2019 in a Texas tobacco treatment clinic.

Interventions

The initial treatment was 2 mg/d of varenicline or the combined replacement therapy of a 21-mg patch plus 2-mg lozenge. The rerandomized participants either continued with their initial therapies, switched between varenicline and CNRT, or increased dosages either to 3-mg or more of varenicline or to a 42-mg patch and lozenges. All received weekly brief counseling.

Main Outcomes and Measures

Biochemically verified 7-day point prevalence abstinence at the end of treatment at 12 weeks.

Results

The 490 randomized participants (210 female [43%], 287 non-Hispanic White [58%], mean age, 48.1 years) smoked an average of 20 cigarettes per day. After the first phase, 54 participants in the CNRT group were abstinent and continued their therapy; of the 191 who were not abstinent, 151 were rerandomized, and the 40 who did not return for rerandomization were assigned to continue their initial CNRT condition in phase 2. The end-of-treatment abstinence rate for the 191 phase 1 nonabstainers was 8% (95% credible interval [CrI], 6% to 10%) for the 90 (47%) who continued at the dosage condition, 14% (CrI, 10% to 18%) for the 50 (33%) who increased their dosage, and 14% (95% CrI, 10% to 18%) for the 51 (34%) who switched to varenicline (absolute risk difference [RD], 6%; 95% CrI, 6% to 11%) with more than 99% posterior probability that either strategy conferred benefit over continuing the initial dosage. After the first phase, 88 participants in the varenicline group were abstinent and continued their therapy; of the 157 who were not abstinent, 122 were rerandomized and 35 who did not return for rerandomization were assigned to continue with the varenicline condition. The end-of-treatment abstinence rate for the 157 phase 1 nonabstainers was 20% (95% CrI, 16% to 26%) for the 39 (32%) who increased their varenicline dosage, 0 (95% CrI, 0 to 0) for the 41 (34%) who switched CNRT, and 3% (95% CrI, 1% to 4%) for the 77 (49%) who were assigned to the continued varenicline condition (absolute RD, -3%; 95% CrI, -4% to -1%) with more than 99% posterior probability that continuing varenicline at the initial dosage was worse than switching to a higher dosage. Furthermore, increasing the varenicline dosage had an absolute RD of 18% (95% CrI, 13% to 24%) and a more than 99% posterior probability of conferring benefit. The secondary outcome of continuous abstinence at 6 months indicated that only increased dosages of the CNRT and varenicline provided benefit over continuation of the initial treatment dosages.

Conclusions and Relevance

For individuals who smoked but did not achieve abstinence after treatment with varenicline, increasing the dosage enhanced abstinence vs continuing, whereas for nonabstainers initially treated with CNRT, a dosage increase or switch to varenicline enhanced abstinence and may be viable rescue strategies.

Trial Registration

ClinicalTrials.gov Identifier: NCT02271919.

TGF-β1 and TGF-βR1 variants are associated with clinical outcomes in smoking-related head and neck cancer patients treated with chemoradiation through modulating microRNA-mediated regulation

TGF-β1 and TGF-βR1 play important roles in immune and inflammatory responses. Genetic variants of TGF-β1 rs1800470 and TGF-βR1 rs334348 have emerged as potentially prognostic biomarkers for HPV-related head and neck cancer, while their prognostic effect on survival of smoking-related head and neck cancer remains unknown. This study included 1403 patients with smoking-related head and neck cancer, and all these patients were genotyped for TGF-β1 rs1800470 and TGF-βR1 rs334348. Both univariate and multivariate analyses were performed to evaluate associations between the two functional genetic variants in microRNA binding sites of TGF-β1 and TGF-βR1 and survivals. Patients with TGF-β1 rs1800470 CT or CC genotype had 30-35% risk reductions for OS, DSS, and DFS compared to patients with TT genotype among overall patients, ever smokers, and patients administered chemoradiation. Furthermore, patients with TGF-βR1 rs334348 GA or GG genotype had significant 50-60% risk reductions for OS, DSS, and DFS compared to patients with AA genotype among overall patients and patients administered chemoradiation; among ever smokers, the risk reductions even reached 60-70%. The TCGA dataset was used for validation. These findings suggest that TGF-β1 rs1800470 and TGF-βR1 rs334348 significantly affect survival outcomes in patients with smoking-related head and neck cancer, especially in the subgroups of ever smokers and patients treated with chemoradiation. These genetic variants may serve as prognostic indicators for patients with smoking-related head and neck cancer and could play a role in advancing the field of personalized chemoradiation, thereby improving patient survival and quality of life.

Deep sequencing of candidate genes identified 14 variants associated with smoking abstinence in an ethnically diverse sample

Despite the large public health toll of smoking, genetic studies of smoking cessation have been limited with few discoveries of risk or protective loci. We investigated common and rare variant associations with success in quitting smoking using a cohort from 8 randomized controlled trials involving 2231 participants and a total of 10,020 common and 24,147 rare variants. We identified 14 novel markers including 6 mapping to genes previously related to psychiatric and substance use disorders, 4 of which were protective (CYP2B6 (rs1175607105), HTR3B (rs1413172952; rs1204720503), rs80210037 on chr15), and 2 of which were associated with reduced cessation (PARP15 (rs2173763), SCL18A2 (rs363222)). The others mapped to areas associated with cancer including FOXP1 (rs1288980) and ZEB1 (rs7349). Network analysis identified significant canonical pathways for the serotonin receptor signaling pathway, nicotine and bupropion metabolism, and several related to tumor suppression. Two novel markers (rs6749438; rs6718083) on chr2 are flanked by genes associated with regulation of bodyweight. The identification of novel loci in this study can provide new targets of pharmacotherapy and inform efforts to develop personalized treatments based on genetic profiles.

Identification of genetically predicted DNA methylation markers associated with non-small cell lung cancer risk among 34,964 cases and 448,579 controls

BACKGROUND

Although the associations between genetic variations and lung cancer risk have been explored, the epigenetic consequences of DNA methylation in lung cancer development are largely unknown. Here, the genetically predicted DNA methylation markers associated with non-small cell lung cancer (NSCLC) risk by a two-stage case-control design were investigated.

METHODS

The genetic prediction models for methylation levels based on genetic and methylation data of 1595 subjects from the Framingham Heart Study were established. The prediction models were applied to a fixed-effect meta-analysis of screening data sets with 27,120 NSCLC cases and 27,355 controls to identify the methylation markers, which were then replicated in independent data sets with 7844 lung cancer cases and 421,224 controls. Also performed was a multi-omics functional annotation for the identified CpGs by integrating genomics, epigenomics, and transcriptomics and investigation of the potential regulation pathways.

RESULTS

Of the 29,894 CpG sites passing the quality control, 39 CpGs associated with NSCLC risk (Bonferroni-corrected p ≤ 1.67 × 10-6 ) were originally identified. Of these, 16 CpGs remained significant in the validation stage (Bonferroni-corrected p ≤ 1.28 × 10-3 ), including four novel CpGs. Multi-omics functional annotation showed nine of 16 CpGs were potentially functional biomarkers for NSCLC risk. Thirty-five genes within a 1-Mb window of 12 CpGs that might be involved in regulatory pathways of NSCLC risk were identified.

CONCLUSIONS

Sixteen promising DNA methylation markers associated with NSCLC were identified. Changes of the methylation level at these CpGs might influence the development of NSCLC by regulating the expression of genes nearby.

PLAIN LANGUAGE SUMMARY

The epigenetic consequences of DNA methylation in lung cancer development are still largely unknown. This study used summary data of large-scale genome-wide association studies to investigate the associations between genetically predicted levels of methylation biomarkers and non-small cell lung cancer risk at the first time. This study looked at how well larotrectinib worked in adult patients with sarcomas caused by TRK fusion proteins. These findings will provide a unique insight into the epigenetic susceptibility mechanisms of lung cancer.

Approaches to estimate bidirectional causal effects using Mendelian randomization with application to body mass index and fasting glucose

Mendelian randomization (MR) is an epidemiological framework using genetic variants as instrumental variables (IVs) to examine the causal effect of exposures on outcomes. Statistical methods based on unidirectional MR (UMR) are widely used to estimate the causal effects of exposures on outcomes in observational studies. To estimate the bidirectional causal effects between two phenotypes, investigators have naively applied UMR methods separately in each direction. However, bidirectional causal effects between two phenotypes create a feedback loop that biases the estimation when UMR methods are naively applied. To overcome this limitation, we proposed two novel approaches to estimate bidirectional causal effects using MR: BiRatio and BiLIML, which are extensions of the standard ratio, and limited information maximum likelihood (LIML) methods, respectively. We compared the performance of the two proposed methods with the naive application of UMR methods through extensive simulations of several scenarios involving varying numbers of strong and weak IVs. Our simulation results showed that when multiple strong IVs are used, the proposed methods provided accurate bidirectional causal effect estimation in terms of median absolute bias and relative median absolute bias. Furthermore, compared to the BiRatio method, the BiLIML method provided a more accurate estimation of causal effects when weak IVs were used. Therefore, based on our simulations, we concluded that the BiLIML should be used for bidirectional causal effect estimation. We applied the proposed methods to investigate the potential bidirectional relationship between obesity and diabetes using the data from the Multi-Ethnic Study of Atherosclerosis cohort. We used body mass index (BMI) and fasting glucose (FG) as measures of obesity and type 2 diabetes, respectively. Our results from the BiLIML method revealed the bidirectional causal relationship between BMI and FG in across all racial populations. Specifically, in the White/Caucasian population, a 1 kg/m2 increase in BMI increased FG by 0.70 mg/dL (95% confidence interval [CI]: 0.3517-1.0489; p = 8.43×10-5), and 1 mg/dL increase in FG increased BMI by 0.10 kg/m2 (95% CI: 0.0441-0.1640; p = 6.79×10-4). Our study provides novel findings and quantifies the effect sizes of the bidirectional causal relationship between BMI and FG. However, further studies are needed to understand the biological and functional mechanisms underlying the bidirectional pathway.

Cardiovascular events after cancer immunotherapy as oncologic emergencies: Analyses of 610 head and neck cancer patients treated with immune checkpoint inhibitors

BACKGROUND

Cardio-oncology and emergency medicine are closely collaborative, as many cardiac events in cancer patients require evaluation and treatment in the emergency department (ED). Immune checkpoint inhibitors (ICIs) have become a common treatment for patients with head and neck cancer (HNC). However, the immune-related adverse events (irAEs) from ICIs can be clinically significant.

METHODS

We reviewed and analyzed cardiovascular diagnoses among HNC patients who received ICI during the period April 1, 2016-December 31, 2020 in a large tertiary cancer center. Demographics, clinical and cancer-related data were abstracted, and billing databases were queried for cardiovascular disease (CVD)-related diagnosis using International Classification of Disease-version10 (ICD-10) codes. We recorded receipt of care at the ED as one of the outcome variables.

RESULTS

A total of 610 HNC patients with a median follow-up time of 12.3 months (median, interquartile range = 5-30 months) comprised our study cohort. Overall, 25.7% of patients had pre-existing CVD prior to ICI treatment. Of the remaining 453 patients without pre-existing CVD, 31.5% (n = 143) had at least one CVD-related diagnosis after ICI initiation. Tachyarrhythmias (91 new events) was the most frequent CVD-related diagnosis after ICI. The time to diagnosis of myocarditis from initiation of ICI occurred the earliest (median 2.5 months, 1.5-6.8 months), followed by myocardial infarction (3.7, 0.5-9), cardiomyopathy (4.5, 1.6-7.3), and tachyarrhythmias (4.9, 1.2-11.4). Patients with myocarditis and tachyarrhythmias mainly presented to the ED for care.

CONCLUSION

The use of ICI in HNC is still expanding and the spectrum of delayed manifestation of ICI-induced cardiovascular toxicities is yet to be fully defined in HNC survivors.

Lung Cancer in Ever- and Never-Smokers: Findings from Multi-Population GWAS Studies

BACKGROUND

Clinical, molecular, and genetic epidemiology studies displayed remarkable differences between ever- and never-smoking lung cancer.

METHODS

We conducted a stratified multi-population (European, East Asian, and African descent) association study on 44,823 ever-smokers and 20,074 never-smokers to identify novel variants that were missed in the non-stratified analysis. Functional analysis including expression quantitative trait loci (eQTL) colocalization and DNA damage assays, and annotation studies were conducted to evaluate the functional roles of the variants. We further evaluated the impact of smoking quantity on lung cancer risk for the variants associated with ever-smoking lung cancer.

RESULTS

Five novel independent loci, GABRA4, intergenic region 12q24.33, LRRC4C, LINC01088, and LCNL1 were identified with the association at two or three populations (P < 5 × 10-8). Further functional analysis provided multiple lines of evidence suggesting the variants affect lung cancer risk through excessive DNA damage (GABRA4) or cis-regulation of gene expression (LCNL1). The risk of variants from 12 independent regions, including the well-known CHRNA5, associated with ever-smoking lung cancer was evaluated for never-smokers, light-smokers (packyear ≤ 20), and moderate-to-heavy-smokers (packyear > 20). Different risk patterns were observed for the variants among the different groups by smoking behavior.

CONCLUSIONS

We identified novel variants associated with lung cancer in only ever- or never-smoking groups that were missed by prior main-effect association studies.

IMPACT

Our study highlights the genetic heterogeneity between ever- and never-smoking lung cancer and provides etiologic insights into the complicated genetic architecture of this deadly cancer.

Acceptability of Personalized Lung Cancer Screening Program Among Primary Care Providers

Current lung cancer screening (LCS) guidelines rely on age and smoking history. Despite its benefit, only 5%-15% of eligible patients receive LCS. Personalized screening strategies select individuals based on their lung cancer risk and may increase LCS's effectiveness. We assess current LCS practices and the acceptability of personalized LCS among primary care providers (PCP) in Texas. We surveyed 32,983 Texas-based PCPs on an existing network (Protocol 2019-1257; PI: Dr. Shete) and 300 attendees of the 2022 Texas Academy of Family Physicians (TAFP) conference. We analyzed the responses by subgroups of interest. Using nonparametric bootstrap, we derived an enriched dataset to develop logistic regression models to understand current LCS practices and acceptability of personalized LCS. Response rates were 0.3% (n = 91) and 15% (n = 60) for the 2019-1257 and TAFP surveys, respectively. Most (84%) respondents regularly assess LCS in their practice. Half of the respondents were interested in adopting personalized LCS. The majority (66%) of respondents expressed concerns regarding time availability with the personalized LCS. Most respondents would use biomarkers as an adjunct to assess eligibility (58%), or to help guide indeterminate clinical findings (63%). There is a need to enhance the engagement of Texas-based PCPs in LCS. Most of the respondents expressed interest in personalized LCS. Time availability was the main concern related to personalized LCS. Findings from this project highlight the need for better education of Texas-based PCPs on the benefits of LCS, and the development of efficient decision tools to ensure successful implementation of personalized LCS.

PREVENTION RELEVANCE

Personalized LCS facilitated by a risk model and/or a biomarker test is proposed as an alternative to existing programs. Acceptability of personalized approach among PCPs is unknown. The goal of this study is to assess the acceptability of personalized LCS among PCPs.

Immune-related adverse event in the emergency department: methodology of the immune-related emergency disposition index (IrEDi)

For many cancer patients, immune checkpoint inhibitors (ICIs) can be life-saving. However, the immune-related adverse events (irAEs) from ICIs can be debilitating and can quickly become severe or even be fatal. Often, irAEs will precipitate visits to the emergency department (ED). Therefore, early recognition and the decision to admit, observe, or discharge these patients from the ED can be key to a cancer patient's morbidity and mortality. ED clinicians typically make their decision for disposition (admit, observe, or discharge) within 2-6 h from their patient's ED presentation. However, irAEs are particularly challenging in the ED because of atypical presentations, the absence of classic symptoms, the delayed availability of diagnostic tests during the ED encounter, and the fast pace in the ED setting. At present, there is no single sufficiently large ED data source with clinical, biological, laboratory, and imaging data that will allow for the development of a tool that will guide early recognition and appropriate ED disposition of patients with potential irAEs. We describe an ongoing federally funded project that aims to develop an immune-related emergency disposition index (IrEDi). The project capitalizes on a multi-site collaboration among 4 members of the Comprehensive Oncologic Emergency Research Network (CONCERN): MD Anderson Cancer Center, Ohio State University, Northwestern University, and University of California San Diego. If the aims are achieved, the IrEDi will be the first risk stratification tool derived from a large racial/ethnically and geographically diverse population of cancer patients. The future goal is to validate irEDi in general EDs to improve emergency care of cancer patients on ICIs.

An Approach to Identifying Spatial Variability in Observed Infectious Disease Spread in a Prospective Time-Space Series with Applications to COVID-19 and Dengue Incidence

Most of the growing prospective analytic methods in space-time disease surveillance and intended functions of disease surveillance systems focus on earlier detection of disease outbreaks, disease clusters, or increased incidence. The spread of the virus such as SARS-CoV-2 has not been spatially and temporally uniform in an outbreak. With the identification of an infectious disease outbreak, recognizing and evaluating anomalies (excess and decline) of disease incidence spread at the time of occurrence during the course of an outbreak is a logical next step. We propose and formulate a hypergeometric probability model that investigates anomalies of infectious disease incidence spread at the time of occurrence in the timeline for many geographically described populations (e.g., hospitals, towns, counties) in an ongoing daily monitoring process. It is structured to determine whether the incidence grows or declines more rapidly in a region on the single current day or the most recent few days compared to the occurrence of the incidence during the previous few days relative to elsewhere in the surveillance period. The new method uses a time-varying baseline risk model, accounting for regularly (e.g., daily) updated information on disease incidence at the time of occurrence, and evaluates the probability of the deviation of particular frequencies to be attributed to sampling fluctuations, accounting for the unequal variances of the rates due to different population bases in geographical units. We attempt to present and illustrate a new model to advance the investigation of anomalies of infectious disease incidence spread by analyzing subsamples of spatiotemporal disease surveillance data from Taiwan on dengue and COVID-19 incidence which are mosquito-borne and contagious infectious diseases, respectively. Efficient R programs for computation are available to implement the two approximate formulae of the hypergeometric probability model for large numbers of events.

HPV vaccination in Africa in the COVID-19 era: a cross-sectional survey of healthcare providers' knowledge, training, and recommendation practices

Introduction

Although the burden of cervical cancer in Africa is highest, HPV vaccination coverage remains alarmingly low in this region. Providers' knowledge and recommendation are key drivers of HPV vaccination uptake. Yet, evidence about providers' knowledge and recommendation practices about the HPV vaccine against a backdrop of emerging vaccine hesitancy fueled by the COVID-19 pandemic is lacking in Africa.

Methods

A cross-sectional study was conducted in 2021-2022 among healthcare providers involved in cervical cancer prevention activities in Africa. They were invited to report prior training, the availability of the HPV vaccine in their practice, whether they recommended the HPV vaccine, and, if not, the reasons for not recommending it. Their knowledge about the HPV vaccine was assessed through self-reporting (perceived knowledge) and with three pre-tested knowledge questions (measured knowledge).

Results

Of the 153 providers from 23 African countries who responded to the survey (mean age: 38.5 years, SD: 10.1), 75 (54.0%) were female and 97 (63.4%) were based In countries with national HPV immunization programs. Overall, 57 (43.8%) reported having received prior training on HPV vaccine education/counseling, and 40 (37.4%) indicated that the HPV vaccine was available at the facility where they work. Most respondents (109, 83.2%) reported recommending the HPV vaccine in their practice. Vaccine unavailability (57.1%), lack of effective communication tools and informational material (28.6%), and need for adequate training (28.6%) were the most commonly reported reasons for not recommending the HPV vaccine. While 63 providers (52.9%) reported that their knowledge about HPV vaccination was adequate for their practice, only 9.9% responded correctly to the 3 knowledge questions.

Conclusion

To increase HPV vaccination coverage and counter misinformation about this vaccine in Africa, adequate training of providers and culturally appropriate educational materials are needed to improve their knowledge of the HPV vaccine and to facilitate effective communication with their patients and the community.

Awareness and interest in cannabis use for cancer management among cancer survivors

BACKGROUND

We examined the awareness, interest, and information sources relating to cannabis use for cancer management (including management of cancer symptoms and treatment-related side effects) and determined factors associated with cancer survivors' awareness and interest in learning about cannabis use for cancer management.

METHODS

This was a cross-sectional study of adult cancer survivors (N = 1886) receiving treatment at a comprehensive cancer center. Weighted prevalence and multivariable logistic regression analyses were conducted.

RESULTS

Among cancer survivors, 88% were aware and 60% were interested in learning about cannabis use for cancer management. Common sources of information to learn about cannabis use for cancer management were cancer doctors/nurses (82%), other patients with cancer (27%), websites/blogs (26%), marijuana stores (20%), and family/friends (18%). The odds of being aware of cannabis use for cancer management was lower among male compared to female survivors (adjusted odds ratio [AOR]: 0.61; 95% confidence interval [CI]: 0.41-0.90), non-Hispanic Blacks compared to non-Hispanic Whites (AOR: 0.36; 95% CI: 0.21-0.62), and survivors who do not support the legalization of cannabis for medical use compared to those who do (AOR: 0.10; 95% CI: 0.04-0.23). On the other hand, the odds of being interested in cannabis use for cancer management was higher among non-Hispanic Blacks compared to non-Hispanic Whites (AOR: 1.65; 95% CI: 1.04-2.62), and among cancer survivors actively undergoing cancer treatment compared to patients on non-active treatment (AOR: 2.25; 95% CI: 1.74-2.91).

CONCLUSION

Awareness of cannabis use for cancer management is high within the cancer survivor population. Results indicated health care providers are leading information source and should receive continued medical education on cannabis-specific guidelines. Similarly, tailored educational interventions are needed to guide survivors on the benefits and risks of cannabis use for cancer management.

Prevalence, reasons for use, perceived benefits, and awareness of health risks of cannabis use among cancer survivors - implications for policy and interventions

BACKGROUND

There is increasing discourse on the use of cannabis as a palliative for cancer/cancer-treatment-related symptoms. We described the prevalent reasons for use, perceived benefits, and awareness of health risks from cannabis use for cancer management among cancer survivors.

METHODS

Cross-sectional survey of adult (≥ 18 years) cancer survivors from 41 US states receiving treatment at a comprehensive cancer center.

RESULTS

Of 1,886 cancer survivors included, 17.4% were current users, 30.5% were former users, and 52.2% were never users of cannabis. Among survivors who currently or formerly used cannabis after their cancer diagnosis (n = 510), the reasons for cannabis use in cancer management were; sleep disturbance (60%), pain (51%), stress (44%), nausea (34%), and mood disorder/depression (32%). Also, about a fifth (91/510) of survivors used cannabis to treat their cancer. Across the different symptoms assessed, over half of the survivors who reported a reason for using cannabis currently or after their cancer diagnosis perceived that cannabis was helpful to a great extent in improving their symptoms. However, of the 167 survivors who reported awareness of potential health risks from cannabis use, the awareness of adverse health risks associated with cannabis use was low: suicidal thoughts (5%), intense nausea and vomiting (6%), depression (11%), anxiety (14%), breathing problems (31%), and interaction with cancer drugs (35%).

CONCLUSION

Prevalence of cannabis use among survivors was notable, with most reporting a great degree of symptomatic improvement for the specified reason for use. However, only a few were aware of the health risks of cannabis use during cancer management.

IMPLICATIONS FOR CANCER SURVIVORS

With more cancer survivors using cannabis as a palliative in managing their cancer-related symptoms, future guidelines and policies on cannabis use in cancer management should incorporate cannabis-based interventions to minimize the inadvertent harm from cannabis use during cancer treatment among survivors.

Cannabis Use among Cancer Survivors: Use Pattern, Product Type, and Timing of Use

Despite growing interest in the use of cannabis for the treatment of cancer-related symptoms, there are limited studies that have assessed the use pattern, type, and mode of delivery of cannabis products used by cancer survivors. This study describes the current state of the use pattern, product type, and mode of delivery of cannabis used by cancer survivors. This was a cross-sectional study of cancer survivors from 41 U.S. states who received treatment at the largest NCI-designated comprehensive cancer center. The weighted prevalence of the use patterns, product types, and modes of delivery of cannabis used by cancer survivors was estimated. A total of 1886 cancer survivors were included in the study, with 915 (48% [95% CI: 45-51]) reporting ever using cannabis. Of survivors who had ever used cannabis, 36% (95% CI: 33-40) were current users. Among survivors who reported cannabis use after diagnosis, 40% used cannabis during and after cancer treatment, 35% used cannabis during treatment, and 25% used cannabis after completing their cancer treatment. Additionally, 48% of survivors reported an increase in cannabis use since cancer diagnosis. The commonest types of cannabis products used by cancer survivors were dry leaf cannabis (71%), cannabidiol (CBD) oil (46%), and cannabis candy (40%). Moreover, cancer survivors frequently used baked goods (32%), creams and gels (21%), and tinctures (18%). Furthermore, among ever users, the predominant mode of use was cannabis inhalation/smoking (69%) compared to eating/drinking (59%). More so, the common mode of inhalation/smoking of cannabis products were rolled cannabis cigarettes (79%), pipes (36%), water pipes (34%), vaporizers or vapes (14%), and e-cigarette devices (14%). A substantial number of cancer survivors use cannabis during cancer treatment, with increased use following cancer diagnosis. The forms and modes of delivery of cannabis varied among survivors, with most survivors inhaling or smoking cannabis. There is a need to educate healthcare providers (HCPs) and survivors on current evidence of cannabis use and strengthen cannabis regulatory frameworks to optimize benefits and minimize adverse events from cannabis use during cancer treatment.

Systematic Review of Genetic Polymorphisms Associated with Acute Pain Induced by Radiotherapy for Head and Neck Cancers

Background/objective

Pain is the most common acute symptom following radiation therapy (RT) for head and neck cancer (HNC). The multifactorial origin of RT-induced pain makes it highly challenging to manage. Multiple studies were conducted to identify genetic variants associated with cancer pain, however few of them focused on RT-induced acute pain. In this review, we summarize the potential mechanisms of acute pain after RT in HNC and identify genetic variants associated with RT-induced acute pain and relevant acute toxicities.

Methods

A comprehensive search of Ovid Medline, EMBASE and Web of Science databases using terms including "Variants", "Polymorphisms", "Radiotherapy", "Acute pain", "Acute toxicity" published up to February 28, 2022, was performed by two reviewers. Review articles and citations were reviewed manually. The identified SNPs associated with RT-induced acute pain and toxicities were reported, and the molecular functions of the associated genes were described based on genetic annotation using The Human Gene Database; GeneCards.

Results

A total of 386 articles were identified electronically and 8 more articles were included after manual search. 21 articles were finally included. 32 variants in 27 genes, of which 25% in inflammatory/immune response, 20% had function in DNA damage response and repair, 20% in cell death or cell cycle, were associated with RT-inflammatory pain and acute oral mucositis or dermatitis. 4 variants in 4 genes were associated with neuropathy and neuropathic pain. 5 variants in 4 genes were associated with RT-induced mixed types of post-RT-throat/neck pain.

Conclusion

Different types of pain develop after RT in HNC, including inflammatory pain; neuropathic pain; nociceptive pain; and mixed oral pain. Genetic variants involved in DNA damage response and repair, cell death, inflammation and neuropathic pathways may affect pain presentation post-RT. These variants could be used for personalized pain management in HNC patients receiving RT.

Analysis of Dispensing and Utilization Patterns of Medical Cannabis Products in State Licensed Cannabis Dispensaries

Background: To understand real-world dispensing and utilization patterns of medical cannabis (MC) and its financial impact on patients, we analyzed the database of a cannabis company licensed in New York state. Objectives: To evaluate the tetrahydrocannabinol (THC)/cannabidiol (CBD) dose ratios, association of various medical conditions to THC/CBD dose, and the cost of products in registered patients receiving MC from four licensed state dispensaries. Design: Retrospective analysis conducted on anonymized data between January 1, 2016 and December 31, 2020 listing 422,201 dispensed products from 32,845 individuals aged 18 years and older. Setting/Subjects: Adult patients with medical certification for cannabis use in New York, USA. Measurements: The database included patient's age, gender, qualifying medical condition, type and dose of product, medication directions, and amount of product dispensed. Results: Findings showed a median age of 53 years with 52% of patients female. Males were found to use more products than females (1.06:1). Pain (85%) was the most common medical condition and inhalation (57%) the most common route except when used for cancer-directed treatment and neurological conditions. Individuals received a median of six prescriptions costing a median of $50/product. Average THC:CBD ratios were 28:0.5 mg/day and 12:0.25 mg/dose. Neurological conditions demonstrated the highest average cost [mean (95% confidence interval {CI}): $73 ($71-$75)] and average CBD/dose per product [mean (95% CI): 5.89 (5.38-6.40)]. Individuals with a history of substance use disorder utilizing MC as an alternative substance displayed the highest average THC/dose [mean (95% CI): 14.25 (13.36-15.14)]. Conclusion: MC was utilized for various medical conditions with variability in THC:CBD ratio seen depending on the condition. Cost variation was also observed based on the individual's medical condition.

Political Ideology and Trust in Government Health Agencies for Cancer Information

This cross-sectional study assesses the association between political ideology and trust in government health agencies for cancer information.

Automated contouring and statistical process control for plan quality in a breast clinical trial

Background and purpose

Automatic review of breast plan quality for clinical trials is time-consuming and has some unique challenges due to the lack of target contours for some planning techniques. We propose using an auto-contouring model and statistical process control to independently assess planning consistency in retrospective data from a breast radiotherapy clinical trial.

Materials and methods

A deep learning auto-contouring model was created and tested quantitatively and qualitatively on 104 post-lumpectomy patients' computed tomography images (nnUNet; train/test: 80/20). The auto-contouring model was then applied to 127 patients enrolled in a clinical trial. Statistical process control was used to assess the consistency of the mean dose to auto-contours between plans and treatment modalities by setting control limits within three standard deviations of the data's mean. Two physicians reviewed plans outside the limits for possible planning inconsistencies.

Results

Mean Dice similarity coefficients comparing manual and auto-contours was above 0.7 for breast clinical target volume, supraclavicular and internal mammary nodes. Two radiation oncologists scored 95% of contours as clinically acceptable. The mean dose in the clinical trial plans was more variable for lymph node auto-contours than for breast, with a narrower distribution for volumetric modulated arc therapy than for 3D conformal treatment, requiring distinct control limits. Five plans (5%) were flagged and reviewed by physicians: one required editing, two had clinically acceptable variations in planning, and two had poor auto-contouring.

Conclusions

An automated contouring model in a statistical process control framework was appropriate for assessing planning consistency in a breast radiotherapy clinical trial.

Barriers to human papillomavirus vaccine uptake: role of state religiosity and healthcare professionals' participation in a state vaccine program

BACKGROUND

Despite the known benefits of preventing human papillomavirus (HPV)-related cancers, HPV vaccine coverage is low in the United States. Grounded in Social Ecological theory, we assessed the macro-level (state) and meso-level (organization) factors associated with HPV vaccine initiation and up-to-date.

METHODS

Data from 2020 National Immunization Survey-Teen were used to study a sample of 20 163 US adolescents (aged 13-17 years). The data were collected from each teen's parents or guardians and health-care professionals. Weighted prevalence estimates were calculated, and multivariable regression analyses were conducted.

RESULTS

The prevalence of HPV vaccine initiation was 75.1% and of remaining up-to-date was 58.6%. At the macro level, teens living in states with high and moderate religiosity had lower odds of HPV vaccine initiation (high religiosity adjusted odds ratio [AOR] = 0.63, 95% confidence interval [CI] = 0.50 to 0.78; moderate religiosity AOR = 0.68, 95% CI = 0.55 to 0.85) and up-to-date (high religiosity AOR = 0.69, 95% CI = 0.56 to 0.85; moderate religiosity AOR = 0.74, 95% CI = 0.61 to 0.91) than states with low religiosity. At the meso level, when none of their healthcare professionals ordered vaccine from the state, teens had lower odds of initiation (AOR = 0.68, 95% CI = 0.53 to 0.87) and up-to-date (AOR = 0.76, 95% CI = 0.60 to 0.95) than teens whose healthcare professionals ordered vaccine from the state. In addition, race and ethnicity, age, mother's education level, household income, well-child examination status, and doctor's recommendation were significantly associated with HPV vaccine uptake.

CONCLUSION

A multiprong approach is needed to address religious and systemic barriers to HPV vaccination and expand healthcare professionals' access and enrollment in state vaccine initiatives, such as the Vaccine for Children program.

Functional Genetic Variants in TGFβ1 and TGFβR1 in miRNA-Binding Sites Predict Outcomes in Patients with HPV-positive Oropharyngeal Squamous Cell Carcinoma

PURPOSE

TGFβ1 and TGFβ receptor 1 (TGFβR1) participate in regulation of the host's immune system and inflammatory responses and may serve as prognostic biomarkers for human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC).

EXPERIMENTAL DESIGN

This study included 1,013 patients with incident OPSCC, of whom 489 had tumor HPV16 status determined. All patients were genotyped for two functional polymorphisms: TGFβ1 rs1800470 and TGFβR1 rs334348. Univariate and multivariate Cox regression models were performed to evaluate associations between the polymorphisms and overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS).

RESULTS

Patients with TGFβ1 rs1800470 CT or CC genotype had 70%-80% reduced risks of OS, DSS, and DFS compared with patients with TT genotype, and patients with TGFβR1 rs334348 GA or GG genotype had 30%-40% reduced risk of OS, DSS, and DFS compared with patients with AA genotype. Furthermore, among patients with HPV-positive (HPV+) OPSCC, the same patterns were observed but the risk reductions were greater: up to 80%-90% for TGFβ1 rs1800470 CT or CC genotype and 70%-85% for TGFβR1 rs334348 GA or GG genotype. The risk reductions were still greater (up to 17 to 25 times reduced) for patients with both TGFβ1 rs1800470 CT or CC genotype and TGFβR1 rs334348 GA or GG genotype compared with patients with both TGFβ1 rs1800470 TT genotype and TGFβR1 rs334348 AA genotype among patients with HPV+ OPSCC.

CONCLUSIONS

Our findings indicate that TGFβ1 rs1800470 and TGFβR1 rs334348 may individually or jointly modify risks of death and recurrence in patients with OPSCC, particularly those with HPV+ OPSCC undergoing definitive radiotherapy, and may serve as prognostic biomarkers, which could lead to better personalized treatment and improved prognosis.

Individual, systemic and state factors associated with provider recommendation of HPV vaccination: Findings from NIS-Teen, 2020

The most important determinant of HPV vaccination uptake is healthcare provider recommendation, yet not all eligible patients receive HPV vaccination recommendations. We used data from the 2020 National Immunization Survey-Teen to determine individual, systemic, and state factors associated with provider recommendation of HPV vaccination. A total of 18,534 teens were included, with 81.4% receiving provider recommendations for HPV vaccination. HPV vaccination recommendation was higher among females compared to males (AOR: 1.57; 95% CI: 1.27-1.93), teens who received a well-child exam at 11 or 12 years compared to those who did not (AOR: 2.10; 95% CI: 1.61-2.74), and teens whose mothers had college, some college or at least a high school education compared to those with less than high school education. In addition to individual factors, provider recommendation of HPV vaccination was higher in hospitals (AOR: 1.51; 95% CI: 1.00-2.29) and STD/school/teen clinics (AOR: 2.47; 95% CI: 1.05-5.78) compared to public facilities. However, the odds of provider recommendation were lower when none of the teen's providers ordered vaccines from the state compared to when all teen providers ordered vaccines from the state (AOR: 0.69; 95% CI: 0.52-0.93). Moreover, the state's mean prevalence of provider recommendations of HPV vaccination was 7.2% lower (Coefficient: -0.072; 95% CI: -0.107 - -0.036) in states with high religious ideology compared to those with low religious ideology. Interventions to increase provider recommendation of HPV vaccination should take a multiprong and comprehensive approach that addresses religious and systemic barriers to HPV vaccination recommendation.

Barriers and determinants of consistent offering of HPV vaccination by healthcare facilities

Expanding access to HPV vaccination is critical to increasing HPV vaccine uptake. We assessed the determinants and barriers to consistent offering of HPV vaccine among healthcare facilities. This was a cross-sectional survey of healthcare providers (HCPs) in Texas. Prevalence of the reasons healthcare practices do not consistently offer HPV vaccination was estimated. Multivariable regression analyses were conducted. Of 1169 HCPs included in the study, 47.5% (95% CI: 44.6-50.3%) reported their practices do not provide HPV vaccination or do not offer it consistently. Compared to physicians, nurses had 77% lower odds (Adjusted Odds Ratio (AOR): 0.23, 95% CI: 0.16-0.32, p-value: < .001), and physician assistants had 89% lower odds (AOR: 0.11, 95% CI: 0.07-0.16, p-value: < .001) of their healthcare practices consistently offering HPV vaccination. Compared to university/teaching hospitals, the odds of healthcare practices consistently offering HPV vaccination were 44% lower (AOR: 0.56, 95% CI: 0.35-0.91, p-value: 0.019) in solo practices but 266% higher (AOR: 3.66, 95% CI: 2.04-6.58, p-value: < .001) in FQHC/public facilities. The common reasons healthcare practices do not consistently offer HPV vaccination were; HPV vaccination is not within the scope of the practice (48.1%), referrals to other clinics (27.7%), and limited personnel (11.4%). Non-physicians were more likely to report that HPV vaccination was not in their scope and to refer patients than physicians. Moreover, solo practices were more likely to report challenges with acquisition and storage of the vaccine and referral of patients as reasons for not consistently offering HPV vaccination than university/teaching hospitals, FQHC/public facilities, or group practices. System-level interventions including training of non-physicians and expansion of practice enrollment in programs that support HPV vaccine acquisition and storage are needed.

GWAS-identified telomere length associated genetic variants predict risk of recurrence of HPV-positive oropharyngeal cancer after definitive radiotherapy

BACKGROUND

Lymphocyte telomere length (LTL)-related genetic variants may modulate LTL and affect recurrence of squamous cell carcinoma of the oropharynx (SCCOP).

METHODS

A total of 1013 patients with incident SCCOP were recruited and genotyped for 16 genome-wide association study (GWAS)-identified TL-related polymorphisms. Of these patients, 489 had tumour HPV16 status determination. Univariate and multivariate analyses were performed to evaluate associations.

FINDINGS

Of the 16 TL-related polymorphisms, four were significantly associated with LTL: rs1920116, rs3027234, rs6772228, and rs11125529, and the patients with putatively favourable genotypes had approximately 1.5-3 times the likelihood of shorter LTL compared with patients with the corresponding risk genotypes. Moreover, patients with one to four favourable genotypes of the four combined polymorphisms had approximately 3-11 times the likelihood of shorter LTL compared with patients with no favourable genotype. The four LTL-related polymorphisms were significantly associated with approximately 40% reduced risk (for favourable genotypes) or doubled risk (for risk genotypes) of recurrence, and similar but more pronounced associations were observed in patients with tumour HPV16-positive SCCOP. Similarly, patients with one to four risk genotypes had significantly approximately 2.5-4 times increased recurrence risk compared with patients with no risk genotype, and similar but more pronounced associations were observed in patients with tumour HPV16-positive SCCOP.

INTERPRETATION

Four LTL-related polymorphisms individually or jointly modify LTL and risk of recurrence of SCCOP, particularly HPV-positive SCCOP. These LTL-related polymorphisms could have potential to further stratify patients with HPV-positive SCCOP for individualized treatment and better survival.

FUNDING

Not applicable.

The influence of political ideology on awareness of HPV and HPV vaccine among adults in the United States

This study aimed to investigate the association between political ideology and awareness of HPV and HPV vaccine among US adults. Study data were derived from Health Information National Trends Survey 5 Cycle 4, a 2020 cross-sectional survey of US adults. Multivariable logistic regressions were conducted to examine the association between political ideology with HPV and HPV vaccine awareness. A total of 3418 adults participated in the study, with the majority being non-Hispanic White individuals and women. The results showed that 66.1% and 62.3% of the participants were aware of HPV and HPV vaccine, respectively. A total of 36.9%, 29.7% and 33.4% of the population reported moderate, liberal and conservative political ideologies respectively. Awareness levels were highest among liberals, with 77.1% and 72.7% reporting awareness of HPV and HPV vaccine respectively. Multivariable logistic regression analysis revealed that liberal participants were more likely to be aware of HPV (aOR, 1.94; 95% CI, 1.25-3.00), and HPV vaccines (aOR, 1.94; 95% CI, 1.37-2.74) compared to moderates. Also, liberals had higher odds of HPV (aOR, 2.41; 95% CI, 1.65-3.51), and HPV vaccine awareness (aOR, 1.91; 95% CI, 1.29-2.83) compared to conservatives. However, there was no significant difference in awareness between moderates and conservatives. Study findings point to an association between individuals' political ideology and HPV awareness. Further research is needed to understand the intricacies on how political ideology impacts HPV awareness. Overall, results highlight the need to incorporate individuals' political ideologies in interventions geared toward increasing the awareness and uptake of HPV vaccination.

Reasons patients cite to their health-care professional for not initiating or completing human papillomavirus vaccination

BACKGROUND

Vaccination against human papillomavirus (HPV) is critical to the prevention of HPV-associated cancers. This study aimed to describe the reasons patients cited for not initiating or completing the HPV vaccination series, as reported by health-care professionals.

METHODS

Study data were obtained from a University of Texas MD Anderson Cancer Center population-based cross-sectional survey of health-care professionals practicing in Texas. Prevalence estimates of reasons cited for not initiating or completing HPV vaccination were estimated by patient population (parents of children and adult patients).

RESULTS

The study included 973 primary care clinicians, of whom 45.53% were physicians and 54.47% were midlevel care professionals. For parents who did not initiate HPV vaccination for their child, the most commonly cited reasons were the belief that the vaccine was not needed (52.54%, 95% CI = 48.90% to 56.15%), that the child was not sexually active (52.54%, 95% CI = 48.90% to 56.15%), and safety concerns/side effects (47.05%, 95% CI = 43.44% to 50.69%). Among age-eligible adults who did not initiate HPV vaccination, lack of knowledge and awareness was the most commonly cited reason (30.52%, 95% CI = 27.71% to 33.50%). For noncompletion of the HPV vaccine series, parents most commonly cited competing priorities (41.29%, 95% CI = 37.76% to 44.91%), followed by adverse reactions after the first dose (16.05%, 95% CI = 13.56% to 18.90%). Similarly, for noncompletion of the HPV vaccine series among adults, competing priorities was the most cited reason (31.04%, 95% CI = 28.20% to 34.02%).

CONCLUSION

These findings highlight the importance of addressing misconceptions and improving education about HPV vaccination to increase vaccination uptake rates and prevent HPV-related cancers.

Creating and Activating an Implementation Community to Drive HPV Vaccine Uptake in Texas: The Role of an NCI-Designated Cancer Center

The University of Texas MD Anderson Cancer Center, a comprehensive cancer center designated by the National Cancer Institute (NCI), defines its service population area as the State of Texas (29.1 M), the second most populous state in the country and the state with the greatest number of uninsured residents in the United States. Consistent with a novel and formal commitment to prevention as part of its core mission, alongside clear opportunities in Texas to drive vaccine uptake, MD Anderson assembled a transdisciplinary team to develop an institutional Framework to increase adolescent HPV vaccination and reduce HPV-related cancer burden. The Framework was developed and activated through a four-phase approach aligned with the NCI Cancer Center Support Grant Community Outreach and Engagement component. MD Anderson identified collaborators through data-driven outreach and constructed a portfolio of collaborative multi-sector initiatives through review processes designed to assess readiness, impact and sustainability. The result is an implementation community of 78 institutions collaboratively implementing 12 initiatives within a shared measurement framework impacting 18 counties. This paper describes a structured and rigorous process to set up the implementation of a multi-year investment in evidence-based strategies to increase HPV vaccination that solves challenges preventing implementation of recommended strategies and to encourage similar initiative replication.

Practices and Views of US Oncologists and Genetic Counselors Regarding Patient Recontact After Variant Reclassification: Results of a Nationwide Survey

PURPOSE

Over a 5-year or 10-year period, between 6% and 15% of germline cancer genetic variants undergo reclassification. Up-to-date interpretation can clarify a variant's clinical significance and guide patient management. As the frequency of reclassifications increase, the issue of whether, how, when, and which providers should recontact patients with information about reclassification becomes important. However, the field lacks research evidence and definitive guidance from professional organizations about how providers should recontact patients. We compared the perspectives of US oncologists and cancer genetic counselors (GCs) to describe their practices and views regarding recontact.

MATERIALS AND METHODS

We developed a survey using themes identified from semistructured interviews with oncologists and GCs and administered it in a national sample of oncologists and GCs between July and September 2022.

RESULTS

In total, 634 respondents completed the survey including 349 oncologists and 285 GCs. On frequency of recontacting patients with reclassified results, 40% of GCs reported recontacting often compared with 12.5% of oncologists. Neither group reported recording patient preference for recontact on electronic medical record (EMR). Both groups agreed that all reclassified variants, even those that do not affect clinical management, should be returned to patients. They also reported that recontact via EMR messages, mailed letters, and phone calls from GC assistants were more suitable for downgrades. By contrast, face-to-face meetings and phone calls were preferred for upgrades. Remarkably, oncologists were more likely to endorse face-to-face return of results and were more likely to endorse return through a nongenetics provider compared to GCs.

CONCLUSION

These data on current recontact practices and opinions provide a foundation for developing guidelines with explicit recommendations on patient recontact that can help maximize clinical effect while considering provider preferences for recontact within resource-constrained genomic practice settings.

Abstract 716: Trends in Medicare reimbursements within the first year of cervical cancer diagnosis, 2007-2015

Introduction: Although cost trends for commercially insured cervical cancer patients have been reported previously, trends in Medicare reimbursements for patients with cervical cancer have not been reported in the literature.

Methods: Using the Surveillance, Epidemiology and End Results (SEER)-Medicare linked database, we estimated mean monthly Medicare reimbursements (total and stratified by service types) in the first year after cervical cancer diagnosis. Adjusted mean monthly Medicare reimbursements were estimated using two-part regression model with first part as a logistic regression and second part as a generalized linear model (GLM) with log link and gamma distribution. Age at diagnosis, race/ethnicity, marital status, census poverty indicator, urban/rural status, year of diagnosis, NCI comorbidity index (calculated using 6 months pre-diagnosis claims), cancer stage and survival status in the first year after diagnosis were used as covariates in our analyses. Trend analysis was conducted using the Joinpoint Trend Analysis software, where the summary measure Average Annual Percentage Change (AAPC) indicated increasing or decreasing trend over a fixed time period. The service-specific Medicare reimbursements were obtained for: (i) inpatient/skilled nursing facility (SNF), (ii) physician/supplier, (iii) outpatient, and, (iv) durable medical equipment (DME) related services. Cervical cancer was identified using International Classification of Diseases for Oncology, Third Edition (ICD-O-3) codes C53.0-53.9. Patients who were diagnosed with cervical cancer as a primary or first of two or more primary cancers between 2007-2015, had continuous Part A and B Medicare coverage from 6 months prior to diagnosis till December 2016 or death (whichever was earlier) but had no HMO coverage, were included in the study.

Results: Total 2731 cervical cancer patients were included in our study, of whom 19.15% (n=523) were younger than 65 years. Patients were majority white (61.81%, n=1688) and most of the patients (53.46%, n=1460) lived in metro areas with population greater than 1 million. 28.41% (n=776) of the patients died within a year of cancer diagnosis. Mean monthly total Medicare reimbursements increased from $7724 to $9371 between 2007 and 2015. Importantly, increasing trend in total Medicare reimbursements was primarily due to statistically significant increasing trend in reimbursements for outpatient services starting 2012 (AAPC=8.1, P-value &lt;0.01). Inpatient/SNF services consistently incurred the highest amounts, whereas DME services consistently incurred the lowest amounts of Medicare reimbursements.

Conclusion: Our study found recent increasing trend in outpatient services-related Medicare reimbursements for cervical cancer. Our findings highlight the need for cost related policy interventions targeting services that are major cost drivers in cervical cancer.

Citation Format: Mohammad A. Karim, Lakshmi S. Kodali, Sanjay Shete. Trends in Medicare reimbursements within the first year of cervical cancer diagnosis, 2007-2015 [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 716.

Abstract P6-02-04: Use of breast surveillance between women with pathogenic variants and variants of uncertain significance in breast cancer susceptibility genes

Background: Surveillance is a fundamental tool in the early detection and secondary prevention of many cancers. For women at increased genetic risk of breast cancer, mammography and breast magnetic resonance imaging (MRI) serve as the standard screening modalities. Use of surveillance mammography and MRI has been understudied among women with variant of uncertain significance (VUS) compared to pathogenic and likely pathogenic variants (P/LP). To address this gap, we examined the use of breast cancer surveillance and breast surgery in women who underwent multiple gene sequencing in a multicenter cohort of patients. We also expanded the surveillance literature by assessing correlates of breast MRI and mammography among women with VUS and investigating how rates of imaging changed over time after genetic testing. Methods: Using data from two cancer settings, we calculated use of risk reducing mastectomy (RRM) and surveillance for all women at genetically elevated risk of breast cancer, regardless of their personal history of breast cancer, with VUS or P/LP variants in a breast cancer susceptibility gene of high penetrance (BRCA1, BRCA2, PALB2, PTEN, TP53) and moderate penetrance (ATM, CDH1, CHEK2, NBN, NF1, STK11). The primary outcome was longitudinal use of surveillance mammography and breast MRI for women during the 13-month span after genetic testing, and each subsequent 13-month period up to 6 years afterwards. Results: Of 889 women, those with and without personal history of breast cancer were similar with regards to race/ethnicity, marital status, and high- or average-risk status. However, women with a personal history of breast cancer were on average older (54.1 vs 48.2 years), had longer follow-up time since genetic testing (3.4 vs 3.0 years), and were more likely to have VUS (62.5% vs 37.7%) compared to those without personal history of breast cancer. VUS carriers were less likely to undergo RRM compared to those with P/LP (HR=0.17, p=&lt; 0.001) and high-risk women were more likely to undergo RRM than average-risk women (HR=3.91, p=0.005). Longitudinally, surveillance use among unaffected women decreased from 49.8% in the first year to 31.2% in the sixth year after genetic testing. In comparison, a greater proportion of women with a personal history of breast cancer underwent surveillance, which increased from 59.3% in the first year to 63.6% in the sixth year after genetic testing. Mammography rates did not differ between women with P/LP and VUS within the first 13 months after genetic testing and up to 4 years afterwards. Over the first four years after genetic testing, women with VUS were less likely to undergo annual MRIs compared to P/LP. This observation was true for women without a personal history of breast cancer (OR=0.34, p=0.003; OR=0.37, p=0.03; OR=0.19, p=0.004 for years 1, 2, and 3 respectively) as well as for women with a personal history of breast cancer (OR=0.31, p&lt;=0.001; OR=0.33, p=0.002; OR=0.37, p=0.012; OR=0.3, p=0.14 for years 1, 2, 3, and 4 respectively). Conclusion: In this study of surveillance mammography and breast MRI use among women at elevated risk of breast cancer, we found that women with P/LP variants in breast cancer susceptibility genes are more likely to undergo annual breast MRI compared to those with VUS, whereas there was no difference between the groups in their use of annual surveillance mammography. This study is one of the first to examine maintenance of breast surveillance in a sample of women at elevated risk of breast cancer with non-negative genetic test results in BRCA1/2 as well as non-BRCA1/2 genes, while adjusting for personal and family history of cancer. In addition, we found that VUS, whether in high or moderate penetrance breast cancer susceptibility genes, was associated with lower use of annual breast MRI compared to P/LP variants, and equivalent use of annual mammography. These results add important evidence to dispel the myth of VUS-associated mismanagement of care.

Citation Format: Sukh Makhnoon, Minxing Chen, Brooke Levin, Megan Ensinger, Kristin Mattie, Generosa Grana, Sanjay Shete, Banu K. Arun, Susan K. Peterson. Use of breast surveillance between women with pathogenic variants and variants of uncertain significance in breast cancer susceptibility genes [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-02-04.

Integration of Remote Symptom and Biometric Monitoring Into the Care of Adult Patients With Cancer Receiving Chemotherapy-A Decentralized Feasibility Pilot Study

PURPOSE

Although electronic patient-reported outcomes (ePROs) are efficacious in symptom management, much is unknown about the utility of vital signs surveillance. We examined the feasibility of a remote patient monitoring platform that integrates ePROs and biometrics into the ambulatory management of symptom burden.

METHODS

Using a decentralized workflow, patients with gastrointestinal or thoracic cancer were approached for a 1-month study. Patients reported symptom burden via ePROs and biometrics (blood pressure, oxygen saturation, pulse, weight, and temperature) using bluetooth-enabled devices daily. Alerts on the basis of prespecified thresholds were managed via nurse-led triage. Adherence was defined as the completion of > 70% of daily symptom and biometric reporting requirements. Pilot acceptability, appropriateness, and feasibility were measured using validated instruments. Net promoter score, system usability scale, and emergency department (ED) admission rates were collected.

RESULTS

Over 8 months, 36 patients were enrolled and 25 (60% gastrointestinal) completed the study. Participants had a mean age of 58.0 years, mean Eastern Cooperative Oncology Group score of 0.88, were 52% female, and predominantly had stage IV or recurrent disease (72%). Program adherence was 73% and associated with high acceptability (4.63), feasibility (4.56), and appropriateness (4.46). System usability scale and net promoter score scores were 88 and 55, respectively. Seventy percent of alerts were generated by biometrics, 28% for symptoms, and 2% were patient-initiated communication. Finally, the ED visitation rate over the pilot period was 8%.

CONCLUSION

Our remote patient monitoring pilot program was highly acceptable, feasible, and appropriate. It had high rates of patient adherence and satisfaction and was associated with low ED visitation rates.

Association between employer-based health promotion programs and adherence to breast cancer screening in Texas

Breast cancer is the most common cancer diagnosed among women in Texas. Although adherence to recommended screening mammogram guidelines enables early detection and reduces breast cancer risks, screening mammogram adherence is low in Texas. With the rising percentage of women in the workforce, employer-based health promotion programs could be an effective measure in increasing mammogram adherence, thereby reducing breast cancer risk in Texas. Although employer-based health programs are common in the state, little is known about their effectiveness in increasing screening mammogram adherence among age-eligible employed females. The study survey was administered using Qualtrics and the study participants were representative of the Texas population. The study population included 318 females from Texas who were 50-74 years old. Among those who had access to employer-based health promotion programs, 65.4 % were adherent and 34.6 % were non-adherent to the guidelines. Population-weighted survey logistic regression analysis showed no significant association between access to employer-based health promotion programs and mammogram adherence for employed women (AOR: 0.85 [0.15-4.79], p-value = 0.86). However, access to healthcare coverage (AOR: 7.58 [2.89-19.88], p-value < 0.001), those who disagree with the fatalistic belief that everything causes cancer (AOR: 2.99 [1.45-6.19], p-value < 0.001), and those who perceive cancer screening important (AOR: 12.36 [2.26-67.47], p < 0.05) were found as significant determinants of mammogram adherence among females in Texas. The study concluded that access to employer-based health promotion programs alone was insufficient to improve breast cancer screening. The employers and the insurance companies, with support from the government, should develop a comprehensive program that addresses all structural and psychosocial barriers to employee breast cancer screening adherence.

Immunogenetic Determinants of Susceptibility to Head and Neck Cancer in the Million Veteran Program Cohort

Increasing rates of human papillomavirus (HPV)-driven oropharyngeal cancer (OPC) have largely offset declines in tobacco-associated head and neck squamous cell carcinoma (HNSCC) at non-OPC sites. Host immunity is an important modulator of HPV infection, persistence, and clearance, and also of immune evasion in both virally- and nonvirally-driven cancers. However, the association between collective known cancer-related immune gene variants and HNSCC susceptibility has not been fully characterized. Here, we conducted a genetic association study in the multiethnic Veterans Affairs Million Veteran Program cohort, evaluating 16,050 variants in 1,576 immune genes in 4,012 HNSCC cases (OPC = 1,823; non-OPC = 2,189) and 16,048 matched controls. Significant polymorphisms were further examined in a non-Hispanic white (NHW) validation cohort (OPC = 1,206; non-OPC = 955; controls = 4,507). For overall HNSCC susceptibility in NHWs, we discovered and validated a novel 9q31.1 SMC2 association and replicated the known 6p21.32 HLA-DQ-DR association. Six loci/genes for overall HNSCC susceptibility were selectively enriched in African-Americans (6p21.32 HLA-G, 9q21.33 GAS1, 11q12.2 CD6, 11q23.2 NCAM1/CD56, 17p13.1 CD68, 18q22.2 SOCS6); all 6 genes function in antigen-presenting regulation and T-cell activation. Two additional loci (10q26 DMBT1, 15q22.2 TPM1) were uncovered for non-OPC susceptibility, and three loci (11q24 CRTAM, 16q21 CDH5, 18q12.1 CDH2) were identified for HPV-positive OPC susceptibility. This study underscores the role of immune gene variants in modulating susceptibility for both HPV-driven and non-HPV-driven HNSCC. Additional large studies, particularly in racially diverse populations, are needed to further validate the associations and to help elucidate other potential immune factors and mechanisms that may underlie HNSCC risk.

SIGNIFICANCE

Several inherited variations in immune system genes are significantly associated with susceptibility to head and neck cancer, which could help improve personalized cancer risk estimates.

Impact of U.S. Preventive Services Task Force lung cancer screening update on drivers of disparities in screening eligibility

BACKGROUND

In 2021, the U.S. Preventive Services Task Force (USPSTF) updated its recommendation to expand lung cancer screening (LCS) eligibility and mitigate disparities. Although this increased the number of non-White individuals who are eligible for LCS, the update's impact on drivers of disparities is less clear. This analysis focuses on racial disparities among Black individuals because members of this group disproportionately share late-stage lung cancer diagnoses, despite typically having a lower intensity smoking history compared to non-Hispanic White individuals.

METHODS

We used data from the National Health Interview Survey to examine the impact of the 2021 eligibility criteria on racial disparities by factors such as education, poverty, employment history, and insurance status. We also examined preventive care use and reasons for delaying medical care.

RESULTS

When comparing Black individuals and non-Hispanic White individuals, our analyses show significant differences in who would be eligible for LCS: Those who do not have a high school diploma (28.7% vs. 17.0%, p = 0.002), are in poverty (26.2% vs. 14.9%, p < 0.001), and have not worked in the past 12 months (66.5% vs. 53.9%, p = 0.009). Further, our analyses also show that more Black individuals delayed medical care due to not having transportation (11.1% vs. 3.6%, p < 0.001) compared to non-Hispanic White individuals.

CONCLUSIONS

Our results suggest that despite increasing the number of Black individuals who are eligible for LCS, the 2021 USPSTF recommendation highlights ongoing socioeconomic disparities that need to be addressed to ensure equitable access.

A multicenter study of clinical impact of variant of uncertain significance reclassification in breast, ovarian and colorectal cancer susceptibility genes

BACKGROUND

Clinical interpretation of genetic test results is complicated by variants of uncertain significance (VUS) that have an unknown impact on health but can be clarified through reclassification. There is little empirical evidence regarding VUS reclassification in oncology care settings, including the prevalence and outcomes of reclassification, and racial/ethnic differences.

METHODS

This was a retrospective analysis of persons with and without a personal history of cancer carrying VUS (with or without an accompanying pathogenic or likely pathogenic [P/LP] variant) in breast, ovarian, and colorectal cancer predisposition genes seen at four cancer care settings (in Texas, Florida, Ohio, and New Jersey) between 2013 and 2019.

RESULTS

In 2715 individuals included in the study, 3261 VUS and 313 P/LP variants were reported; 8.1% of all individuals with VUS experienced reclassifications and rates varied significantly among cancer care settings from 4.81% to 20.19% (overall p < 0.001). Compared to their prevalence in the overall sample, reclassification rates for Black individuals were higher (13.6% vs. 19.0%), whereas the rates for Asian individuals were lower (6.3% vs. 3.5%) and rates for White and Hispanic individuals were proportional. Two-year prevalence of VUS reclassification remained steady between 2014 and 2019. Overall, 11.3% of all reclassified VUS resulted in clinically actionable findings and 4.6% subsequently changed individuals' clinical managements.

CONCLUSIONS

The findings from this large multisite study suggest that VUS reclassification alters clinical management, has implications for precision cancer prevention, and highlights the need for implementing practices and solutions for efficiently returning reinterpreted genetic test results.

Healthcare Provider's Perceived Self-Efficacy in HPV Vaccination Hesitancy Counseling and HPV Vaccination Acceptance

BACKGROUND

HPV vaccine hesitancy is a key contributor to the sub-optimal HPV vaccination uptake in the United States. We aimed to determine the association between healthcare providers' self-efficacy in HPV vaccination hesitancy counseling and HPV vaccination acceptance after initial and follow-up counseling sessions.

METHODS

Population-based cross-sectional study of healthcare providers (HCPs) practicing in Texas. Logistic regression analyses were used to determine the odds of HPV vaccination acceptance by vaccine-hesitant patients. Additionally, generalized estimating equations were used to compare HPV vaccination acceptance by hesitant patients after follow-up versus initial counseling sessions.

RESULTS

1283 HCPs completed the survey with a mean (SD) age of 47.1 (11.3) years. HCPs who believed that they were very/completely confident in counseling HPV-vaccine-hesitant parents had higher odds of observing HPV vaccination acceptance very often/always after an initial counseling session (adjusted odds ratio (AOR): 3.50; 95% CI: 2.25-5.44) and after follow-up counseling sessions (AOR: 2.58; 95% CI: 1.66-4.00) compared to HCPs that perceived they were not at all/somewhat/moderately confident. The odds of HPV vaccination being accepted very often/always by vaccine-hesitant parents was 61% (AOR: 1.61; 95% CI: 1.32-1.95) higher after follow-up counseling sessions compared to an initial counseling session. The results were similar for the counseling of HPV-vaccine-hesitant adult patients.

CONCLUSIONS

The confidence level of HCPs in counseling hesitant parents and adult patients impacts HPV vaccination acceptance. Importantly, acceptance was higher after follow-up counseling sessions than initial counseling sessions. HCPs should receive training in HPV vaccination counseling to enhance their confidence in counseling hesitant patients and should utilize every visit to counsel hesitant patients.

Sociodemographic Differences in Menthol Cigarette Use in the United States

BACKGROUND

Menthol cigarette use is associated with higher smoking initiation and reduced smoking cessation. We investigated sociodemographic differences in menthol and nonmenthol cigarette use in the United States.

METHODS

We used the most recent available data from the May 2019 wave of the nationally-representative Tobacco Use Supplement to the Current Population Survey. The survey weights were used to estimate the national prevalence of individuals who currently smoke among individuals who use menthol and nonmenthol cigarettes. Survey-weighted logistic regression methods were used to estimate the association of menthol cigarette use with formerly smoking cigarettes and attempting to quit within the past 12 months while adjusting for several sociodemographic factors associated with smoking.

RESULTS

The prevalence of current smoking in individuals who ever smoked menthol cigarettes was higher 45.6% (44.5%-46.6%) compared to 35.8% (35.2%-36.4%) in individuals who ever smoked nonmenthol cigarettes. Non-Hispanics Blacks who used menthol cigarettes had a higher likelihood of being an individual who currently smokes (OR 1.8, 95% CI: [1.6-2.0], P-value <.001) compared to Non-Hispanic Whites who used nonmenthol cigarettes. However, Non-Hispanics Blacks who used menthol cigarettes were more likely to make a quit attempt (OR 1.4, 95%CI: [1.3-1.6], P-value <.001) compared to non-Hispanic Whites who used nonmenthol cigarettes.

CONCLUSIONS

Individuals who currently use menthol cigarettes are more likely to make attempts to quit smoking. However, this did not translate to successfully quitting smoking, as evidenced by the proportion of individuals who formerly smoked within the population which used menthol cigarettes.

Clinical Cancer and Direct-to-Consumer Genetic Test Result-Sharing Behavior: Findings from HINTS 2020

INTRODUCTION

Sharing genetic test results with different stakeholders such as family members, healthcare providers and genetic counselors (HCP/GCs), spouses/partners, and friends is a health behavior of clinical importance in genomic medicine.

METHODS

Using nationally representative population-based data collected from the Health Information National Trends Survey (HINTS 5, cycle 4), we identified the prevalence and factors associated with genetic test result-sharing behavior for high-risk cancer tests, genetic health risk tests, and ancestry tests within four groups: HCP/GCs, first-degree relatives (FDRs), spouse/partner, and friend/other.

RESULTS

Overall, 68.4% of those who underwent high-risk cancer genetic testing shared their results with FDRs, whereas 89.9% shared with HCP/GCs. In adjusted multivariable analyses, women were nine times more likely than men to share (p = 0.006), and those with a personal history of cancer were less likely to share with HCP/GCs (OR = 0.025, p ≤ 0.001). Of those tested for genetic health risk, 66.5% shared with HCP/GCs, 38.7% with FDRs, 66.6% with a spouse/partner, 12.8% with a friend, and 14.1% did not share results with anyone. Of those who underwent ancestry testing, very few shared results with HCP/GCs (2.6%), whereas modest sharing was reported with FDRs, spouses/partners, and friends.

DISCUSSION

These data add empirical evidence about the population prevalence of genetic information sharing and serve as a metric for public engagement with genetic testing.

A Text-Based Smoking Cessation Intervention for Sexual and Gender Minority Groups: Protocol for a Feasibility Trial

BACKGROUND

Smoking among sexual and gender minority (SGM) groups, which include lesbian, gay, bisexual, transgender, and queer individuals, has been reported to be highly prevalent. This is attributed to several factors, including minority-specific stress and targeted tobacco marketing. Therefore, this population is at an increased risk for tobacco-related diseases. SMS text messaging programs have been found to be effective for smoking cessation and appeal to traditionally hard-to-reach populations over other interventions. It has also been suggested that targeted and tailored interventions could be more effective among SGM smokers because they can be designed to assure a safe, validating health care environment that enhances receptivity to cessation.

OBJECTIVE

The aim of this study is to develop SmokefreeSGM, a text-based smoking cessation program tailored to and tested among SGM smokers.

METHODS

The study consists of three phases, culminating in a feasibility trial. In Phase 1, our research team will collaborate with a Community Advisory Board to develop and pretest the design of SmokefreeSGM. In Phase 2, the tailored text messaging program will be beta tested among 16 SGM smokers. Our research team will use a mixed-methods approach to collect and analyze data from participants who will inform the refinement of SmokefreeSGM. In Phase 3, a feasibility trial will be conducted among 80 SGM smokers either enrolled in SmokefreeSGM or SmokefreeTXT, the original text-based program developed by the National Cancer Institute for the general population. Our research team will examine recruitment, retention, and smoking abstinence rates at 1-, 3-, and 6-month follow-up. Additionally, a qualitative interview will be conducted among 32 participants to evaluate the feasibility and acceptability of the programs (SmokefreeSGM and SmokefreeTXT).

RESULTS

This study received approval from The University of Texas Health Science Center at Houston Committee for the Protection of Human Subjects to begin research on August 21, 2020. Recruitment for the beta testing of SmokefreeSGM (Phase 2) began in January 2022. We estimate that the feasibility trial (Phase 3) will begin in September 2022 and that results will be available in December 2023.

CONCLUSIONS

Findings from this research effort will help reduce tobacco-related health disparities among SGM smokers by determining the feasibility and acceptability of SmokefreeSGM, an SGM-tailored smoking cessation intervention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05029362; https://clinicaltrials.gov/ct2/show/NCT05029362.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/42553.

The influence of parent-child gender on intentions to refuse HPV vaccination due to safety concerns/side effects, National Immunization Survey - Teen, 2010-2019

Amid subpar uptake of HPV vaccination in the United States, gender-generated disparities in HPV vaccination uptake have the potential to perpetuate existing disparities in HPV-associated cancers. Yet few studies have investigated the influence of parent-child gender on intentions to refuse HPV vaccination due to safety concerns/side effects. This study used nationally representative data, spanning 2010-2019, from the National Immunization Survey-Teen (NIS-Teen). NIS-Teen respondents are parents/guardians or primary caregivers of adolescents 13-17 years old living in the United States. Over the study period, intentions to refuse HPV vaccination due to safety concerns rose among all parent-child gender pairings but were highest among respondent mothers regarding their unvaccinated daughters. The results revealed a statistically significant increased likelihood of having intentions to refuse HPV vaccination due to safety concerns among all parent-child combinations compared with father-son pairs. These odds were consistently highest among mother-daughter pairs. In 2019, compared with father-son pairs, fathers were 1.94 (95% CI: 1.21-3.12) times more likely to report the intention to not vaccinate against HPV for their daughters, while mothers were 2.23 (95% CI: 1.57-3.17) and 2.87 (95% CI: 2.02-4.09) times more likely to report intentions to refuse HPV vaccination for their sons and daughters, respectively. These findings were persistent and constantly increased over the 10-year study period. Interventions aimed at correcting gender-based misperceptions and countering misinformation about the safety of the HPV vaccine are warranted.

Association of provider HPV vaccination training with provider assessment of HPV vaccination status and recommendation of HPV vaccination

The delivery of strong HPV vaccine recommendations hinges on the expertise of healthcare providers (HCPs) in assessing patients' status and recommending HPV vaccination. We conducted a population-based cross-sectional study of HCPs practicing in Texas to examine the relationship between HPV vaccination training of HCPs and HPV vaccination status assessment and recommendation. Logistic regression analyses were used to assess the association between HCPs' formal training and recency of training in HPV vaccination promotion or counseling with HPV vaccination status assessment and recommendation. Of the 1,283 HCPs who completed the online survey, 43% had received training in HPV vaccination promotion or counseling, 47% often/always assess HPV vaccination status, and 59% often/always recommend HPV vaccination. Compared with HCPs who received no training, those who received training had over four times higher odds (adjusted odds ratio [AOR]: 4.32; 95% CI: 3.06-6.10) of often/always assessing HPV vaccination status and over three and half times higher odds (AOR: 3.66; 95% CI: 2.73-4.90) of often/always recommending HPV vaccination. Furthermore, HCPs who recently received HPV vaccination training had higher odds of HPV vaccination status assessment and recommendations than those without training. Hispanic HCPs had higher odds of often/always assessing HPV vaccination status and recommending vaccination than did non-Hispanic White HCPs. Also, nurses and physician assistants had lower odds of often/always assessing HPV vaccination status and recommending HPV vaccination than did physicians. Targeted and continuous training of HCPs in HPV vaccination promotion or counseling is needed to increase HPV vaccination status assessment, recommendation, and uptake rates.

HPV Vaccination Training of Healthcare Providers and Perceived Self-Efficacy in HPV Vaccine-Hesitancy Counseling

HPV vaccine hesitancy is a key barrier to HPV vaccination. Using a population-based survey of HCPs practicing in Texas we determined the association between formal training of HCPs and perceived self-efficacy in counseling HPV vaccine-hesitant parents and adult patients. A total of 1283 HCPs completed the survey, with 879 providing vaccination services to pediatric patients and 1018 providing vaccination services to adult patients. Among HCPs included in this study, 405 of 577 (70%) and 315 of 505 (62%) perceived they were very/completely confident in counseling HPV vaccine-hesitant parents and adult patients, respectively. Compared to HCPs who received no training, those who received formal training in HPV vaccination promotion or counseling had 2.56 (AOR: 2.56; 95% CI:1.69-3.86) and 2.84 times higher odds (AOR: 2.84; 95% CI:1.87-4.33) of perceiving that they were very/completely confident in counseling HPV vaccine-hesitant parents and adult patients, respectively. Additionally, increasing years of practice and volume of patients seen were positively associated with being very/completely confident in counseling HPV vaccine-hesitant parents and adult patients. On the other hand, nurses were less likely than physicians to be very/completely confident in counseling HPV vaccine-hesitant parents. To increase HPV vaccination uptake, HCPs should receive tailored training to improve their self-efficacy in addressing HPV vaccine-hesitancy.

Sustained reduction of attentional bias to smoking cues by smartphone-delivered attentional bias modification training for smokers

OBJECTIVE

Cigarette smoking is thought to be at least partially maintained by the attentional bias (AB) toward smoking cues that develops as a consequence of drug dependence. This study evaluated the impact of smartphone-delivered, in-home attentional bias modification (ABM) to reduce AB to smoking cues and to reduce smoking behavior and withdrawal-related symptoms when used as an adjunct to conventional smoking cessation treatment.

METHOD

Participants (N = 246) were treatment-seeking smokers who completed up to 13 days of either ABM designed to train attention away from smoking cues, using a modified dot-probe task, or sham training, followed by 8 weeks of nicotine replacement therapy and counseling. Outcomes measured at baseline, 1-day post-ABM training, and 8 weeks post-ABM training included AB to smoking images and words using the dot-probe and smoking Stroop tasks, respectively, along with cigarettes per day, craving, and smoking abstinence.

RESULTS

We found that ABM training reduced AB to smoking stimuli on both the dot-probe task, ηp² = 0.056, 90% CI [0.024, 0.097], and the smoking Stroop task, ηp² = 0.017, 90% CI [0.002, 0.044], up to 8 weeks after ABM training when covarying for baseline response, but did not concurrently decrease smoking behavior or craving.

CONCLUSIONS

Thirteen days of smartphone-delivered ABM training, as an adjunct to smoking cessation treatment, reduced AB to both modality-specific and cross-modality smoking cues but did not impact smoking-related behavior. While ABM can reduce AB to smoking cues across modalities, it is unclear whether it has therapeutic potential as an adjunct to conventional smoking cessation therapy. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Development, Implementation, and Evaluation of a Distance Learning and Telementoring Program for Cervical Cancer Prevention in Cameroon

IMPORTANCE

Although Africa has the highest burden of cervical cancer in the world, educational resources to achieve the 90-70-90 targets set by the World Health Organization in its strategy to eliminate cervical cancer are lacking in the region.

OBJECTIVES

To adapt, implement, and evaluate the Project Extension for Community Health Care Outcomes (ECHO), an innovative learning tool, to build capacity of clinicians to better incorporate new evidence-based guidelines into cervical cancer control policies and clinical practices.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study assessed knowledge and practices of clinicians and support staff regarding cervical cancer prevention and control and compared them among respondents who had attended Project ECHO sessions (prior ECHO attendees) with those who had not but were planning on attending in the near future (newcomers) as part of the Cameroon Cervical Cancer Prevention Project ECHO. Satisfaction of prior ECHO attendees was also evaluated. Data were analyzed from January to March 2022.

MAIN OUTCOMES AND MEASURES

Main outcomes were practices and knowledge regarding cervical cancer education and prevention and preinvasive management procedures compared among prior ECHO attendees and newcomers.

RESULTS

Of the 75 participants (mean [SD] age, 36.4 [10.0] years; 65.7% [95% CI, 54.3%-77.1%] women) enrolled in this study, 41 (54.7%; 95% CI, 43.1%-66.2%) were prior ECHO attendees, and most were clinicians (55 respondents [78.6%; 95% CI, 68.7%-88.4%]). Overall, 50% (95% CI, 37.8%-62.2%) of respondents reported performing cervical cancer screening with visual inspection of the cervix after application of acetic acid (VIA) and/or visual inspection of the cervix after application of Lugol's iodine (VILI), 46.3% (95% CI, 34.0%-58.5%) of respondents reported performing human papillomavirus (HPV) testing, and 30.3% (95% CI, 18.9%-41.7%) of respondents reported performing cervical cytological examination in their practices, Approximately one-fourth of respondents reported performing cryotherapy (25.4% [95% CI, 14.7%-36.1%]), thermal ablation (27.3% [95% CI, 16.2%-38.3%]) or loop electrosurgical excisional procedure (LEEP, 25.0% [95% CI, 14.4%-35.6%]) for treatment of preinvasive disease. The clinical use of many of these screening and treatment tools was significantly higher among prior ECHO attendees compared with newcomers (VIA/VILI: 63.2% [95% CI, 47.4%-78.9%] vs 33.3% [95% CI, 16.0%-50.6%]; P = .03; cryotherapy: 40.5% [95% CI, 24.3%-56.8%] vs 6.7% [95% CI, 0.0%-15.8%]; P = .002; thermal ablation: 43.2% [95% CI, 26.9%-59.6%] vs 6.9% [95% CI, 0.0%-16.4%]; P = .002). Knowledge about cervical cancer education, prevention, and management procedures was satisfactory in 36.1% (95% CI, 23.7%-48.5%) of respondents; this proportion was significantly higher among prior ECHO attendees (53.8% [95% CI, 37.7%-69.9%]) compared with newcomers (4.5% [95% CI, 0.0%-13.5%]; P < .001). Approximately two-thirds of participants (68.8% [95% CI, 51.8%-85.8%]) reported that they had applied knowledge learned in our ECHO sessions to patient care in their practice or adopted best-practice care through their participation in this ECHO program.

CONCLUSIONS AND RELEVANCE

These findings suggest that the Project ECHO e-learning and telementoring program was associated with improved skills for clinicians and support staff and enhanced quality of care for patients. In the COVID-19 era and beyond, reinforced efforts to strengthen cervical cancer knowledge and best practices through distance learning and collaboration are needed.

Implementation of electronic patient-reported outcomes and biometrics surveillance for the management of chemotherapy-related symptom burden: Results from a decentralized feasibility pilot study

425

Background: Monitoring patient-reported outcomes (PROs) in the ambulatory setting is an effective modality for chemotherapy-related symptom management. However, much is unknown about the utility of active surveillance of vital signs (i.e. biometrics) in this context. Such an undertaking is also highly complex with technology, workflow, and patient experience components. This decentralized pilot study aimed to investigate the implementation and feasibility of nurse-led active surveillance of chemotherapy-related symptom burden via the electronic collection of PROs and biometrics. Methods: Consecutive adult patients with gastrointestinal (GI) or thoracic cancer, at high risk for emergency room (ER) visits based on published criteria, were approached. Consenting patients performed daily reporting of symptom burden via the Patient reported Outcomes version of the Common Terminology Criteria for Adverse Events and biometrics over a one-month period. Biometric data (pulse, blood pressure, oxygen saturation, weight, and temperature) was captured via Bluetooth-enabled sensors which were integrated with a HIPAA-compliant, secure tablet interface that also enabled the provision of self-care materials and video conferencing. Data, including pre-specified threshold alerts, were sent to a web-based dashboard monitored by a registered nursing team, who triaged patient alerts based on standard operating procedures. Acceptability, appropriateness, and feasibility were measured via validated instruments. Program adherence was defined as the completion of > 70% of PRO survey and biometric reporting requirements ≥ 4 days per week. Patient satisfaction, technology ease of use, and ER admission rates were also collected. Results: Over an eight-month period, thirty-six patients consented to participate, and twenty-five (60% GI) completed the study. Participants had a mean age of 58.0 (range 36-74), mean ECOG score of 0.88, were 52% female, and were predominantly stage IV or recurrent disease (72%). Program adherence rate was 73% and mean scores for acceptability, feasibility, and appropriateness were 4.63, 4.56, and 4.46 respectively. Alert distribution were 28% PROs, 70% biometrics and 2% patient-initiated communication. System usability scale and Net Promoter Score were 88 and 55 respectively. Scores for patient satisfaction score and technology ease of use were 94% and 100% respectively. The rate of ER visits over the pilot period was 8%. Conclusions: Implementation of active surveillance of chemotherapy-related symptom burden via self-reporting of PROs and biometrics is highly acceptable, feasible, and appropriate to patients. It is also associated with low ER visitation rates relative to historical values and high rates of patient satisfaction and ease of use. Clinical trial information: NCI202107464.

Use of breast surveillance between women with pathogenic variants and variants of uncertain significance in breast cancer susceptibility genes

BACKGROUND

Use of surveillance mammography and magnetic resonance imaging (MRI) has been understudied among women with variant of uncertain significance (VUS) compared to pathogenic and likely pathogenic variants (P/LP).

METHODS

Using data from two cancer settings, we calculated use of risk-reducing mastectomy (RRM) and surveillance during each 13-month span after genetic testing up to 6 years afterwards for a cohort of genetically elevated risk women.

RESULTS

Of 889 women, VUS carriers were less likely to undergo RRM compared to those with P/LP (hazard ratio [HR], 0.17; p = <.001) and high-risk women were more likely to undergo RRM than average-risk women (HR, 3.91; p = .005). Longitudinally, surveillance use among unaffected women decreased from 49.8% in the first year to 31.2% in the sixth year after genetic testing. In comparison, a greater proportion of women with a personal history of breast cancer underwent surveillance, which increased from 59.3% in the first year to 63.6% in the sixth year after genetic testing. Mammography rates did not differ between women with P/LP and VUS within the first 13 months after genetic testing and up to 4 years afterward. Over the first 4 years after genetic testing, women with VUS were less likely to undergo annual MRIs compared to P/LP.

CONCLUSION

The authors found that VUS, whether in high or moderate penetrance breast cancer susceptibility genes, was associated with lower use of annual breast MRI compared to P/LP variants and equivalent use of annual mammography. These results add important evidence regarding VUS-related breast surveillance.

Effect of dexamethasone on dyspnoea in patients with cancer (ABCD): a parallel-group, double-blind, randomised, controlled trial

BACKGROUND

Systemic corticosteroids are commonly prescribed for palliation of dyspnoea in patients with cancer, despite scarce evidence to support their use. We aimed to assess the effect of high-dose dexamethasone versus placebo on cancer-related dyspnoea.

METHODS

The parallel-group, double-blind, randomised, controlled ABCD (Alleviating Breathlessness in Cancer Patients with Dexamethasone) trial was done at the at the University of Texas MD Anderson Cancer Center and the general oncology clinic at Lyndon B Johnson General Hospital (both in Houston, TX, USA). Ambulatory patients with cancer, aged 18 years or older, and with an average dyspnoea intensity score on an 11-point numerical rating scale (NRS; 0=none, 10=worst) over the past week of 4 or higher were randomly assigned (2:1) to receive dexamethasone 8 mg orally every 12 h for 7 days followed by 4 mg orally every 12 h for 7 days, or matching placebo capsules for 14 days. Pharmacists did permuted block randomisation with a block size of six, and patients were stratified by baseline dyspnoea score (4-6 vs 7-10) and study site. Patients, research staff, and clinicians were masked to group assignment. The primary outcome was change in dyspnoea NRS intensity over the past 24 h from baseline to day 7 (±2 days). Analyses were done by modified intention-to-treat (ie, including all patients who were randomly assigned and started the study treatment, regardless of whether they completed the study). Enrolment was stopped after the second preplanned interim analysis, when the futility criterion was met. This study is registered with ClinicalTrials.gov (NCT03367156) and is now completed.

FINDINGS

Between Jan 11, 2018, and April 23, 2021, we screened 2867 patients, enrolled 149 patients, and randomly assigned 128 to dexamethasone (n=85) or placebo (n=43). The mean change in dyspnoea NRS intensity from baseline to day 7 (±2 days) was -1·6 (95% CI -2·0 to -1·2) in the dexamethasone group and -1·6 (-2·3 to -0·9) in the placebo group, with no significant between-group difference (mean 0 [95% CI -0·8 to 0·7]; p=0·48). The most common all-cause grade 3-4 adverse events were infections (nine [11%] of 85 patients in the dexamethasone group vs three [7%] of 43 in the placebo group), insomnia (seven [8%] vs one [2%]), and neuropsychiatric symptoms (three [4%] vs none [0%]). Serious adverse events, all resulting in hospital admissions, were reported in 24 (28%) of 85 patients in the dexamethasone group and in three (7%) of 43 patients in the placebo group. No treatment-related deaths occurred in either group.

INTERPRETATION

High-dose dexamethasone did not improve dyspnoea in patients with cancer more effectively than placebo and was associated with a higher frequency of adverse events. These data suggest that dexamethasone should not be routinely given to unselected patients with cancer for palliation of dyspnoea.

FUNDING

US National Cancer Institute.

Financial Toxicities Persist for Cancer Survivors Irrespective of Current Cancer Status: An Analysis of Medical Expenditure Panel Survey

This study estimates the out-of-pocket (OOP) expenditures for different cancer types among survivors with current vs no current cancer condition and across sex, which is understudied in the literature. This is a cross-sectional study of Medical Expenditure Panel Survey data for 2009-2018 where the primary outcome was the average per year OOP expenditure incurred by cancer survivors. Of 189 285 respondents, 15 010 (7.93%) were cancer survivors; among them, 46.28% had a current cancer condition. Average per year OOP expenditure for female survivors with a current condition of breast cancer ($1730), lung cancer ($1679), colon cancer ($1595), melanoma ($1783), non-Hodgkin lymphoma ($1656), nonmelanoma/other skin cancer (NMSC, $2118) and two or more cancers ($2310) were significantly higher than that of women with no history of cancer ($853, all P < .05). Similarly, average per year OOP expenditure for male survivors with a current condition of prostate cancer ($1457), lung cancer ($1131), colon cancer ($1471), melanoma ($1474), non-Hodgkin's lymphoma ($1653), NMSC ($1789), and bladder cancer ($2157) were significantly higher compared with the men with no history of cancer ($621, all P < .05). These differences persisted in survivors with no current cancer condition for breast cancer among women; prostate, lung, colon, and bladder cancer among men; and melanoma, NMSC, and two or more cancers among both sexes. OOP expenditure varied across cancer types and by sex for survivors with and without a current cancer condition. These findings highlight the need for targeted interventions for cancer survivors.