COVID-19 Stay-At-Home Orders and Secondhand Smoke in Public Housing

INTRODUCTION

This study aimed to better understand the inequitable impact of the pandemic by examining the associations between stay-at-home orders and indoor smoking in public housing, measured by ambient particulate matter at the 2.5-micron threshold, a marker for secondhand smoke.

METHODS

Particulate matter at the 2.5-micron threshold was measured in 6 public-housing buildings in Norfolk, VA from 2018 to 2022. Multilevel regression was used to compare the 7-week period of the Virginia stay-at-home order in 2020 with that period in other years.

RESULTS

Indoor particulate matter at the 2.5-micron threshold was 10.29 μg/m3 higher in 2020 (95% CI=8.51, 12.07) than in the same period in 2019, a 72% increase. Although particulate matter at the 2.5-micron threshold improved in 2021 and 2022, it remained elevated relative to the level in 2019.

CONCLUSIONS

Stay-at-home orders likely led to increased indoor secondhand smoke in public housing. In light of evidence linking air pollutants, including secondhand smoke, with COVID-19, these results also provide further evidence of the disproportionate impact of the pandemic on socioeconomically disadvantaged communities. This consequence of the pandemic response is unlikely to be isolated and calls for a critical examination of the COVID-19 experience to avoid similar policy failures in future public health crises.

A complex systems model of breast cancer etiology: The Paradigm II Model

BACKGROUND

Complex systems models of breast cancer have previously focused on prediction of prognosis and clinical events for individual women. There is a need for understanding breast cancer at the population level for public health decision-making, for identifying gaps in epidemiologic knowledge and for the education of the public as to the complexity of this most common of cancers.

METHODS AND FINDINGS

We developed an agent-based model of breast cancer for the women of the state of California using data from the U.S. Census, the California Health Interview Survey, the California Cancer Registry, the National Health and Nutrition Examination Survey and the literature. The model was implemented in the Julia programming language and R computing environment. The Paradigm II model development followed a transdisciplinary process with expertise from multiple relevant disciplinary experts from genetics to epidemiology and sociology with the goal of exploring both upstream determinants at the population level and pathophysiologic etiologic factors at the biologic level. The resulting model reproduces in a reasonable manner the overall age-specific incidence curve for the years 2008-2012 and incidence and relative risks due to specific risk factors such as BRCA1, polygenic risk, alcohol consumption, hormone therapy, breastfeeding, oral contraceptive use and scenarios for environmental toxin exposures.

CONCLUSIONS

The Paradigm II model illustrates the role of multiple etiologic factors in breast cancer from domains of biology, behavior and the environment. The value of the model is in providing a virtual laboratory to evaluate a wide range of potential interventions into the social, environmental and behavioral determinants of breast cancer at the population level.

Developing a peer-led intervention to promote COVID-19 testing in low-income housing settings

Background

The Housing Collaborative project at Eastern Virginia Medical School has developed a method of adapting public health guidance from public housing communities, which face tremendous health challenges in cardiometabolic health, cancer, and other major health conditions. In this paper, we describe how academic and community partners in the Housing Collaborative came together to do this work with a focus on COVID-19 testing in the context of the emerging pandemic.

Methods

The academic team used virtual community engagement methods to interact with the Housing Collaborative Community Advisory Board (HCCAB) and a separate cohort of research participants (N = 102) recruited into a study of distrust in COVID-19 guidance. We conducted a series of 44 focus group interviews with participants on related topics. Results from these interviews were discussed with the HCCAB. We used the collaborative intervention planning framework to inform adaptation of public health guidance on COVID-19 testing delivered in low-income housing settings by including all relevant perspectives.

Results

Participants reported several important barriers to COVID-19 testing related to distrust in the tests and those administering them. Distrust in housing authorities and how they might misuse positive test results seemed to further undermine decision making about COVID-19 testing. Pain associated with testing was also a concern. To address these concerns, a peer-led testing intervention was proposed by the Housing Collaborative. A second round of focus group interviews was then conducted, in which participants reported their approval of the proposed intervention.

Conclusion

Although the COVID-19 pandemic was not our initial focus, we were able to identify a number of barriers to COVID-19 testing in low-income housing settings that can be addressed with adapted public health guidance. We struck a balance between community input and scientific rigor and obtained high quality, honest feedback to inform evidence-based recommendations to guide decisions about health.

Housing Insecurity Among Patients With Cancer

Social determinants of health are the economic and environmental conditions under which people are born, live, work, and age that affect health. These structural factors underlie many of the long-standing inequities in cancer care and outcomes that vary by geography, socioeconomic status, and race and ethnicity in the United States. Housing insecurity, including lack of safe, affordable, and stable housing, is a key social determinant of health that can influence-and be influenced by-cancer care across the continuum, from prevention to screening, diagnosis, treatment, and survivorship. During 2021, the National Cancer Policy Forum of the National Academies of Science, Engineering, and Medicine sponsored a series of webinars addressing social determinants of health, including food, housing, and transportation insecurity, and their associations with cancer care and patient outcomes. This dissemination commentary summarizes the formal presentations and panel discussions from the webinar devoted to housing insecurity. It provides an overview of housing insecurity and health care across the cancer control continuum, describes health system interventions to minimize the impact of housing insecurity on patients with cancer, and identifies challenges and opportunities for addressing housing insecurity and improving health equity. Systematically identifying and addressing housing insecurity to ensure equitable access to cancer care and reduce health disparities will require ongoing investment at the practice, systems, and broader policy levels.

A Critical Theoretical Approach to Cancer Disparities: Breast Cancer and the Social Determinants of Health

Breast cancer is the most commonly experienced cancer among women. Its high rates of incidence and survival mean that a number of women will live it for periods of their lifetimes. Group differences in breast cancer incidence and mortality occur by race and ethnicity. For example, while white women are slightly more likely to be diagnosed with breast cancer, Black women are 40% more likely to die from the disease. In this article, rather than focusing the discussion on individual-level factors like health behaviors that have the potential to blame Black women and those living in poverty for their conditions, we view breast cancer disparities through the lens of Critical Race Theory, taking a historical perspective. This allows us to delve beyond individual risk factors to explore social determinants of breast cancer disparities at the population level, paying special attention to the myriad ways in which social factors, notably views of race and discriminatory public policies, over time have contributed to the disproportionate breast cancer mortality experienced by Black women. We suggest ways of addressing breast cancer disparities, including methods of training healthcare professionals and public policy directions, that include rather than marginalize Black and lower socioeconomic status women.

[Association of physical activity with fatigue and functional capacity in patients with rheumatoid arthritis]

BACKGROUND

Patients with rheumatoid arthritis (RA) tend to be less physically active. Physical activity has been shown to have a positive impact on disease activity and quality of life and is recommended by the European League Against Rheumatism (EULAR) as an integral component of standard treatment.

OBJECTIVE

A cross-sectional analysis of RA patients was carried out assessing disease activity, functional capacity and fatigue associated with physical activity.

MATERIAL AND METHODS

Physical activity, functional capacity and the global fatigue index (GFI) were examined using standardized questionnaires: the international physical activity questionnaire short form (IPAQ-SF), the functional questionnaire Hannover (FFbH) and the multidimensional assessment of fatigue (MAF). The data were evaluated using SPSS 26 (IBM, Armonk, NY, USA). The level of significance was tested with bivariate and partial correlations and nonparametric tests.

RESULTS

In total 164 patients were included in the study. The majority of the patients were female (127/164; 77%) and the median age of the cohort was 58.3 years (range 21-86 years). The median duration of disease-related symptoms at inclusion was 169 months (range 0-713 months). Physical activity was low in 39%, moderate in 37% and high in 24%. Patients reporting higher levels of physical activity reported significantly lower GFI (p < 0.001), functional limitations (p < 0.001) and disease activity (p = 0.045) scores than those with less physical activity.

CONCLUSION

Physical activity in RA patients was significantly correlated with functional capacity and levels of fatigue. In order to reduce the proportion of patients with low physical activity, the possibilities for functional training should be expanded and the patients should be encouraged to undertake sporting activities.

Searching beyond the Lamppost to Reduce Breast Cancer Disparities

Racial and ethnic differences in breast cancer occur by race/ethnicity in both incidence and mortality rates. Women of lower socioeconomic status likewise have poorer outcomes. When race alone is considered, incidence rates in the United States are highest among White women (130.8 per 100,000), with Black women close behind (126.7 per 100,000). Incidence is lowest among Asian/Pacific Islander women, at 93.2 per 100,000. Mortality differences are more pronounced, with Black women 40% more likely to die from breast cancer than White women (28.4 per 100,000 and 20.3 per 100,000, respectively). Mortality rates for Asian/Pacific Islander women (11.5 per 100,000) are far lower than for Black and White women. When age is considered, additional differences between Black and White women appear, in part accounted for by types of breast cancer experienced. Women of other racial/ethnic groups and socioeconomic status have received less scientific attention. In this article, we provide a brief overview of the evidence for social determinants of breast cancer and argue that the current reliance on race over racism and ethnicity contributes to our inability to eliminate breast cancer disparities in the United States and elsewhere in the world. We suggest alternatives to the current approach to research in breast cancer disparities.

Transdisciplinary research outcomes based on the Transdisciplinary Research on Energetics and Cancer II initiative experience

Intractable public health problems are influenced by interacting multi-level factors. Dynamic research approaches in which teams of scientists collaborate beyond traditional disciplinary, institutional, and geographic boundaries have emerged as promising strategies to address pressing public health priorities. However, little prior work has identified, defined, and characterized the outcomes of transdisciplinary (TD) research undertaken to address public health problems. Through a mixed methods approach, we identify, define, and characterize TD outcomes and their relevance to improving population health using the Transdisciplinary Research on Energetics and Cancer (TREC) II initiative as a case example. In Phase I, TREC II leadership (n = 10) identified nine initial TD outcomes. In Phase II (web-based survey; n = 23) and Phase III (interviews; n = 26; and focus groups, n = 23) TREC members defined and characterized each outcome. The resulting nine outcomes are described. The nine complementary TD outcomes can be used as a framework to evaluate progress toward impact on complex public health problems. Strategic investment in infrastructure that supports team development and collaboration, such as a coordination center, cross-center working groups, annual funded developmental projects, and face-to-face meetings, may foster achievement of these outcomes. This exploratory work provides a basis for the future investigation and development of quantitative measurement tools to assess the achievement of TD outcomes that are relevant to solving multifactorial public health problems.

Abstract D094: Associations among state-level racial inequality, individual-level unfair treatment, and incident breast cancer in a risk-enriched cohort

Background: There is a small but growing body of evidence suggesting that structural inequality is associated with racial disparities in breast cancer stage at diagnosis and mortality. Less is known about the potential relationship between structural inequality and breast cancer incidence or subtypes. To address this gap, we developed a multidimensional state-level measure of racial inequality and assessed whether higher levels of inequality are associated with 1) higher odds of an invasive breast cancer diagnosis, and 2) among those diagnosed, higher odds of an estrogen receptor negative (ER-) vs. positive (ER+) tumor. Methods: The Sister Study is a longitudinal cohort of women who had a sister diagnosed with breast cancer, but did not have a personal history of the disease at enrollment. Leveraging this cohort, we generated state-level composite scores (range = 1-5) summarizing differences between non-Hispanic white and black residents across four domains: educational attainment, employment & occupational status, political participation, and incarceration. Data for the racial inequality measure were drawn from publicly available sources and linked to the participants’ state of residence at the time of enrollment. An individual-level measure of unfair treatment due to race was included as a proximal exposure to racial inequality. Invasive breast cancer diagnoses and subtypes were recorded through September 2016. The final analytic sample was limited to non-Hispanic white (n= 38,760) and black (n=4,061) Sister Study participants and their states of residence (n=40). Two-level population average models were constructed to assess the relationship among state- and individual-level factors and the odds of 1) an invasive breast cancer diagnosis (n=1,475) and 2) ER subtype among women with invasive breast cancer (1,278 ER+ cases; 197 ER- cases). Results: Adjusting for self-reported race, education, age, and epidemiologic risk factors (e.g., breast feeding history, menopausal status), we found that women residing in states with higher levels of racial inequality did not have higher odds of invasive breast cancer. However, among women diagnosed with an invasive breast cancer, we found higher odds of ER- vs. ER+ subtype among women living in states with higher levels of racial inequality (OR range = 1.7 – 2.6 for inequality composite scores of 3-5 vs. 1; p-values of &lt;0.001 to 0.04). The proximal measure of unfair treatment due to race was also a significant factor in the fully-adjusted model, with women reporting 2 or more incidents of unfair treatment having a 2.6 times higher odds of an ER- diagnosis than women reporting no such incidents. Conclusions: In this relatively small sample of invasive breast cancer cases, structural and interpersonal experiences with racial inequality were associated with greater odds of the ER- vs. ER+ subtype, but not with the overall odds of an invasive breast cancer diagnosis. Reanalysis using a longer follow-up period may provide greater insight into this novel association.

Citation Format: Erin Linnenbringer, Sarah Humble, Sarah Gehlert, Dale P Sandler. Associations among state-level racial inequality, individual-level unfair treatment, and incident breast cancer in a risk-enriched cohort [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr D094.

Abstract B018: Exploring racial disparities in breast reconstruction after mastectomy at an NCI-Designated Cancer Center

Introduction: Breast reconstruction after mastectomy is an important component of comprehensive breast cancer care due to its positive effects on quality of life for breast cancer survivors. Yet, African American women are significantly less likely to receive breast reconstruction compared to Caucasian women. Due to the positive impact breast reconstruction has on quality of life in breast cancer patients, these disparities have implications for survivorship in African American women who already bear the excess burden of breast cancer mortality. We previously reported the presence of breast reconstruction disparities at Siteman Cancer Center, a large, urban National Cancer Institute-designated Comprehensive Cancer Center located in St. Louis, Missouri. The purpose of this study was to further understand these disparities by assessing breast reconstruction rates, patterns, and predictors by race.

Methods: Sociodemographic, clinical, and treatment data were obtained for women who received mastectomy for definitive surgical treatment for breast cancer from 2000 to 2012. Statistical tests were used to compare the data between African American and Caucasian women. Logistic regression was used to identify significant predictors of breast reconstruction stratified by race.

Results: African American women had significantly higher proportions of public insurance, more aggressive tumors, unilateral mastectomies, and modified radical mastectomies. These are characteristics that reduce the odds of receiving breast reconstruction. African American women had a significantly lower breast reconstruction rate and higher proportion of autologous-based breast reconstruction, which has higher complication rates than implant-based breast reconstruction. Adjuvant radiation was a significant predictor in Caucasian, but not in African American women.

Conclusion: African American and Caucasian women varied in rate and type of breast reconstruction. These disparities may be due to racial differences in sociodemographic, clinical, and treatment factors. Additionally, since the predictors of breast reconstruction varied by race, the underlying mechanisms for the receipt of breast reconstruction may vary in African American women. Future research should focus on further examining the determinants of the breast reconstruction, by modality, and the role breast reconstruction disparities play in clinical outcomes and quality of life in African American women.

Citation Format: Shahnjayla K. Connors, Melody G. Goodman, Terence Myckatyn, Julie Margenthaler, Sarah Gehlert. Exploring racial disparities in breast reconstruction after mastectomy at an NCI-Designated Cancer Center [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr B018.

Challenges Associated With Living Remotely From a Pediatric Cancer Center: A Qualitative Study

PURPOSE

Pediatric patients with cancer who live in rural communities face disparate access to medical services compared with those in urban areas. Our objectives were to use qualitative methods to describe how living in a rural setting during receipt of treatment at an urban cancer center affects a patient's clinical course and to identify feasible areas of intervention to enhance service to these families.

MATERIALS AND METHODS

We conducted semistructured interviews of caregivers of pediatric patients with cancer who received treatment at an urban pediatric hospital in the Midwest. Questions focused on how distance between home residence and cancer-treating hospital affected cancer treatment.

RESULTS

Eighteen caregiver interviews were conducted. Five multithemed domains were identified; two related to receipt of emergent care at local hospitals, one related to the impact that distance had on the family, and two related to managing and coping with a pediatric cancer diagnosis.

CONCLUSION

Rural families of pediatric patients with cancer face unique challenges in addition to those previously identified for pediatric patients with cancer, most notably increased travel time to their cancer centers and increased time spent in community hospitals to receive emergent care. We recommend feasible steps to improve the care of rural children with cancer, including improved parental anticipatory guidance about unanticipated emergent visits to local hospitals, outreach to local hospitals, and medical visit coordination.

Social factors matter in cancer risk and survivorship

Greater attention to social factors, such as race/ethnicity, socioeconomic position, and others, are needed across the cancer continuum, including breast cancer, given differences in tumor biology and genetic variants have not completely explained the persistent Black/White breast cancer mortality disparity. In this commentary, we use examples in breast cancer risk assessment and survivorship to demonstrate how the failure to appropriately incorporate social factors into the design, recruitment, and analysis of research studies has resulted in missed opportunities to reduce persistent cancer disparities. The conclusion offers recommendations for how to better document and use information on social factors in cancer research and care by (1) increasing education and awareness about the importance of inclusion of social factors in clinical research; (2) improving testing and documentation of social factors by incorporating them into journal guidelines and reporting stratified results; and (3) including social factors to refine extant tools that assess cancer risk and assign cancer care. Implementing the recommended changes would enable more effective design and implementation of interventions and work toward eliminating cancer disparities by accounting for the social and environmental contexts in which cancer patients live and are treated.

Smokers' unprompted comments on cigarette additives during conversations about the genetic basis for nicotine addiction: a focus group study

Background

Research designed to elicit smokers’ cognitive and affective reactions to information about chemicals that tobacco companies add to cigarettes (“additives”) found that knowledge is limited. However, little is known about smokers’ unprompted thoughts and feelings about additives. Such information could be used to shape future communication efforts. We explored the content and possible functions of spontaneous statements about cigarette additives made by smokers during a study examining reactions to learning about the genetic link to nicotine addiction.

Methods

Adult smokers (N = 84) were recruited from a medium-sized Midwestern city. Focus groups (N = 13) were conducted between April-September 2012. Data were analyzed by 2 coders using thematic analysis.

Results

Comments about cigarette additives arose without prompting by the focus group moderator. Three main themes were identified: (1) discussing additives helped participants navigate the conceptual link between smoking and genetics, (2) additives were discussed as an alternative mechanism for addiction to cigarettes, and (3) additives provided an alternative mechanism by which cigarette smoking exacerbates physical harm. Notably, discussion of additives contained a pervasive tone of mistrust illustrated by words like “they” and “them,” by statements of uncertainty such as “you don’t know what they’re putting into cigarettes,” and by negative affective verbalizations such as “nasty” and “disgusting”.

Conclusions

Participants had distinct beliefs about cigarette additives, each of which seemed to serve a purpose. Although mistrust may complicate communication about the health risks of tobacco use, health communication experts could use smokers’ existing beliefs and feelings to better design more effective anti-smoking messages.

Caregiver and pediatric provider perspectives on symptom-based inhaled corticosteroid therapy in asthma

OBJECTIVES

Guidelines recommend that healthcare providers adjust the dose of inhaled corticosteroids (ICS) in asthma patients based on the degree of symptom severity and control. Symptom-based, intermittent ICS therapy (use of ICS together with short acting bronchodilators- symptom-based adjustment: SBA) has been demonstrated to be comparable to guideline-based management by providers in controlled clinical trials. We sought input from African American caregivers and pediatricians on the acceptability and barriers for this alternative management strategy.

METHODS

Focus group interviews of caregivers and individual interviews with community providers of African-American children ages 6-17 years with mild-moderate persistent asthma were conducted by trained facilitators to assess perceptions of how asthma affects children and their caregivers, and of SBA as a management strategy. Interview data were transcribed and analyzed using inductive thematic based coding.

RESULTS

Twenty-six parents participated in six focus groups. Fourteen pediatricians were interviewed. Caregivers reported facing financial burden and difficulty with tracking medications. Caregivers and pediatricians were favorable about SBA, citing its potential for decreased use of medications and cost and similarity to actual care provided. Some caregivers voiced concern that SBA would not be as effective as daily ICS. Caregivers suggested that education on symptom recognition and close communication between physician and patient would facilitate the implementation of SBA.

CONCLUSIONS

SBA was generally viewed favorably by caregivers and providers of African American children. However, concerns regarding effectiveness of SBA were voiced by both caregivers and providers. Patient education and provider-patient communication is important in implementing this alternative asthma management strategy.

Seeing Beyond the Margins: Challenges to Informed Inclusion of Vulnerable Populations in Research

Although the importance of including vulnerable populations in medical research is widely accepted, identifying how to achieve such inclusion remains a challenge. Ensuring that the language of informed consent is comprehensible to this group is no less of a challenge. Although a variety of interventions show promise for increasing the comprehensibility of informed consent and increasing a climate of exchange, consensus is lacking on which interventions should be used in which situations and current regulations provide little guidance. We argue that the notion of individual autonomy — a foundational principle of informed consent — may be too narrow for some vulnerable populations by virtue of its failure to acknowledge their unique histories and current circumstances. It has a different meaning for members of structured groups like American Indians than for unstructured groups, such as African Americans, whose complicated histories foster group identity. Ensuring broad participation in research and selecting appropriate methods for obtaining informed consent — namely, methods aligned with the source of vulnerability and level of risk — require new ways of thinking that might produce guidelines for matching informed consent models and processes with subpopulations.

Telomere Length and Neighborhood Circumstances: Evaluating Biological Response to Unfavorable Exposures

Background: Multilevel frameworks suggest neighborhood circumstances influence biology; however, this relationship is not well studied. Telomere length (TL) shortening has been associated with individual-level and neighborhood-level exposures and disease and may provide insights into underlying biologic mechanisms linking neighborhood with biology. To support neighborhood-biology investigations, we sought to determine the independent effect of neighborhood exposures on TL using standard multilevel linear regression models and quantile regression, a nonlinear, social science method applicable for testing the biologic hypothesis that extremes of the TL distribution are related to poor outcomes.Methods: In a multicenter, cross-sectional study, blood TL was measured in 1,488 individuals from 127 census tracts in three U.S. regions using terminal restriction fragment assays. Multilevel linear and quantile regression models were adjusted for individual-level race, education, perceived stress, and depression. Neighborhood exposures included population density, urban/residential crowding, residential stability/mobility, and socioeconomic status.Results: TL was not associated with any neighborhood variable using linear models, but quantile regression revealed inverse associations between population density and urban crowding at the lower tails of the TL distribution [5th (population density P = 0.03; urban crowding P = 0.002), 50th (both P < 0.001), 75th percentiles (both P < 0.001)]. TL was related to residential stability at the upper tail (95th percentile P = 0.006).Conclusions: Findings support the use of nonlinear statistical methods in TL research and suggest that neighborhood exposures can result in biological effects.Impact: TL may serve as an underlying example of a biologic mechanism that can link neighborhood with biology, thus supporting multilevel investigations in future studies. Cancer Epidemiol Biomarkers Prev; 26(4); 553-60. ©2017 AACRSee all the articles in this CEBP Focus section, "Geospatial Approaches to Cancer Control and Population Sciences."

Combining Community-Engaged Research with Group Model Building to Address Racial Disparities in Breast Cancer Mortality and Treatment

Although patterns of African American and white women breast cancer incidence and mortality in St. Louis, Missouri is consistent with those seen elsewhere in the United States, rates vary greatly across zip codes within the city of St. Louis. North St. Louis, whose neighborhoods are primarily African American, exhibits rates of breast cancer mortality that are among the highest in the city and the state as a whole. Based on information that up to 50% of women in North St. Louis with a suspicious diagnosis of breast cancer never enter treatment, we conducted three 2-hour group model building sessions with 34 community stakeholders (e.g., breast cancer survivors or family members or caregivers and community support members such as navigators) to identify the reasons why African American women do not begin or delay breast cancer treatment. Participant sessions produced a very rich and dynamic causal loop diagram of the system producing disparities in breast cancer mortality in St. Louis. The diagram includes 8 major subsystems, causal links between system factors, and feedback loops, all of which shed light on treatment delays/initiation. Our work suggests that numerous intersecting factors contribute to not seeking treatment, which in turn may contribute to African American and white disparities in mortality.

Development of Plain Language Supplemental Materials for the Biobank Informed Consent Process

The US Department of Health and Human Services addresses clear communication in the informed consent process as part of the Notice of Proposed Rulemaking for revisions to the Common Rule. However, prior research has shown that participants may not fully comprehend research studies despite completion of an informed consent process. Our main goal was to provide plain language information about donation processes to a cancer biobank to supplement an informed consent form. We developed and conducted cognitive testing with supplemental brochures that clearly communicated information about three different models for consent (notice, broad and study-specific) to future use of biospecimens. During the brochure development process, we conducted qualitative, semi-structured, individual, in-person cognitive interviews among 14 women to examine participants' perceptions of the brochures. Each participant provided feedback regarding the understandability, graphics and layout, and cultural appropriateness of the brochures. Our findings demonstrate that these methods may be used to tailor consent form brochures, such as the ones developed here, to other populations. This study therefore adds to our understanding of how best to present content to help women from two different racial groups make informed decisions about participation in a cancer biobank.

Black-White Disparities in Breast Cancer Subtype: The Intersection of Socially Patterned Stress and Genetic Expression

Hormone receptor negative (HR-) breast cancer subtypes are etiologically distinct from the more common, less aggressive, and more treatable form of estrogen receptor positive (ER+) breast cancer. Numerous population-based studies have found that, in the United States, Black women are 2 to 3 times more likely to develop HR- breast cancer than White women. Much of the existing research on racial disparities in breast cancer subtype has focused on identifying predisposing genetic factors associated with African ancestry. This approach fails to acknowledge that racial stratification shapes a wide range of environmental and social exposures over the life course. Human stress genomics considers the role of individual stress perceptions on gene expression. Yet, the role of structurally rooted biopsychosocial processes that may be activated by the social patterning of stressors in an historically unequal society, whether perceived by individual black women or not, could also impact cellular physiology and gene expression patterns relevant to HR- breast cancer etiology. Using the weathering hypothesis as our conceptual framework, we develop a structural perspective for examining racial disparities in breast cancer subtypes, integrating important findings from the stress biology, breast cancer epidemiology, and health disparities literatures. After integrating key findings from these largely independent literatures, we develop a theoretically and empirically guided framework for assessing potential multilevel factors relevant to the development of HR- breast cancer disproportionately among Black women in the US. We hypothesize that a dynamic interplay among socially patterned psychosocial stressors, physiological & behavioral responses, and genomic pathways contribute to the increased risk of HR- breast cancer among Black women. This work provides a basis for exploring potential alternative pathways linking the lived experience of race to the risk of HR- breast cancer, and suggests new avenues for research and public health action.

"I don't believe it." Acceptance and skepticism of genetic health information among African-American and White smokers

RATIONALE

Effective translation of genomics research into practice depends on public acceptance of genomics-related health information.

OBJECTIVE

To explore how smokers come to accept or reject information about the relationship between genetics and nicotine addiction.

METHODS

Thirteen focus groups (N = 84) were stratified by education (seven < Bachelor's degree, six ≥ Bachelor's degree) and race (eight black, five white). Participants viewed a 1-min video describing the discovery of a genetic variant associated with increased risk of nicotine addiction and lung cancer. Next, they provided their opinions about the information. Two coders analyzed the data using grounded theory.

RESULTS

Pre-video knowledge about why people smoke cigarettes and what genetic risk means informed beliefs about the relationship between genes and addiction. These beliefs were not always consistent with biomedical explanations, but formed the context through which participants processed the video's information. This, in turn, led to information acceptance or skepticism. Participants explained their reactions in terms of the scientific merits of the research and used their existing knowledge and beliefs to explain their acceptance of or skepticism about the information.

CONCLUSION

Laypeople hold complex understandings of genetics and addiction. However, when lay and biomedical explanations diverge, genetics-related health information may be rejected.

Agency, social and healthcare supports for adults with intellectual disability at the end of life in out-of-home, non-institutional community residences in Western nations: A literature review

BACKGROUND

The nature and quality of end-of-life care received by adults with intellectual disabilities in out-of-home, non-institutional community agency residences in Western nations is not well understood.

METHOD

A range of databases and search engines were used to locate conceptual, clinical and research articles from relevant peer-reviewed journals.

RESULTS

The present authors present a literature review of the agency, social and healthcare supports that impact end-of-life care for adults with intellectual disabilities. More information is needed about where people with intellectual disabilities are living at the very end of life and where they die.

CONCLUSIONS

The support needs for adults with intellectual disabilities will change over time, particularly at the end of life. There are some areas, such as removing barriers to providing services, staff training, partnerships between agencies and palliative care providers, and advocacy, where further research may help to improve the end-of-life care for adults with intellectual disabilities.

Barriers and Strategies to Participation in Tissue Research Among African-American Men

Before the burgeoning field of biospecimen collection can advance prevention and treatment methods, researchers must access diverse molecular data samples. However, minorities, especially African-American men, remain reticent to join these studies. This study, using theory-based approaches, investigated African-American men's barriers to participating in biorepository research. Fourteen focus groups were conducted among 70 African-American men (ages 40 to 80). The groups were stratified by prostate cancer history and educational attainment background. Participants identified perceived factors that promoted or hindered study participation when questioned about their knowledge and attitudes about biospecimen research. Ninety-four percent of participants indicated never participating in a study that collected biological samples. Barriers to their participation included lack of knowledge and understanding regarding biospecimen research practices and uses. In addition, they extensively cited a prevalent mistrust of the medical community and discomfort with study recruitment practices. African-American males were more willing to participate in biorepository studies with physician endorsement or if they understood that participation could benefit future generations. Men also wanted more recruitment and advertising done in familiar places.

Breast reconstruction after mastectomy at a comprehensive cancer center

Background

Breast reconstruction after mastectomy is an integral part of breast cancer treatment that positively impacts quality of life in breast cancer survivors. Although breast reconstruction rates have increased over time, African American women remain less likely to receive breast reconstruction compared to Caucasian women. National Cancer Institute-designated Comprehensive Cancer Centers, specialized institutions with more standardized models of cancer treatment, report higher breast reconstruction rates than primary healthcare facilities. Whether breast reconstruction disparities are reduced for women treated at comprehensive cancer centers is unclear. The purpose of this study was to further investigate breast reconstruction rates and determinants at a comprehensive cancer center in St. Louis, Missouri.

Methods

Sociodemographic and clinical data were obtained for women who received mastectomy for definitive surgical treatment for breast cancer between 2000 and 2012. Logistic regression was used to identify factors associated with the receipt of breast reconstruction.

Results

We found a breast reconstruction rate of 54 % for the study sample. Women who were aged 55 and older, had public insurance, received unilateral mastectomy, and received adjuvant radiation therapy were significantly less likely to receive breast reconstruction. African American women were 30 % less likely to receive breast reconstruction than Caucasian women.

Conclusion

These findings suggest that racial disparities in breast reconstruction persist in comprehensive cancer centers. Future research should further delineate the determinants of breast reconstruction disparities across various types of healthcare institutions. Only then can we develop interventions to ensure all eligible women have access to breast reconstruction and the improved quality of life it affords breast cancer survivors.

Toward a Modern Science of Obesity at Washington University: How We Do It and What is the Payoff?

In our Cancer Prevention Program at Washington University in Saint Louis (WUSTL), we have made extraordinary efforts to create the kind of cancer prevention and control program that is both translational and transdisciplinary in nature, to accelerate the march from basic discoveries to population change. Here we present an overview of our obesity-related research currently ongoing in our Center, paying particular attention to both the translational- transdisciplinary process and to community-based participatory research. We end with our future directions for improving obesity-related cancer outcomes research. Cancer Prev Res; 9(7); 503-8. ©2016 AACR.

TREC to WHERE? Transdisciplinary Research on Energetics and Cancer

When information is exchanged across disciplinary boundaries, resources are shared, and discipline-specific approaches are altered to achieve a common scientific goal, we create a new intellectual space for transdisciplinary research. This approach, fostered heavily by multiple NCI-funded initiatives, has the potential to forge new understanding of major public health issues. By breaking down disciplinary barriers, we work toward making real, meaningful, and lasting forward motion in addressing key public health issues. One of the transdisciplinary initiatives of the NCI is TREC: Transdisciplinary Research on Energetics and Cancer. In this article, we review the goals and scope of TREC, as well as the ways in which the initiative promotes transdisciplinary science. A particular focus is on multiple examples of the most unique aspect of the initiative: the funding of developmental projects across multiple TREC centers, toward the goal of incubating high-risk science that has the potential to translate into major leaps forward in understanding energetics in cancer. As we enter an era of greater focus on investigator-initiated science, new approaches may be needed to ensure that the peer review process is not solely organized along disciplinary lines. Inclusion of expertise regarding transdisciplinarity, as well as representation from multiple scientific disciplines within a panel, may allow transdisciplinary research to receive an educated hearing. The body of researchers trained to work in a transdisciplinary research space is ideally suited to address these challenges.

Race, Ethnicity, Psychosocial Factors, and Telomere Length in a Multicenter Setting

Background

Leukocyte telomere length(LTL) has been associated with age, self-reported race/ethnicity, gender, education, and psychosocial factors, including perceived stress, and depression. However, inconsistencies in associations of LTL with disease and other phenotypes exist across studies. Population characteristics, including race/ethnicity, laboratory methods, and statistical approaches in LTL have not been comprehensively studied and could explain inconsistent LTL associations.

Methods

LTL was measured using Southern Blot in 1510 participants from a multi-ethnic, multi-center study combining data from 3 centers with different population characteristics and laboratory processing methods. Main associations between LTL and psychosocial factors and LTL and race/ethnicity were evaluated and then compared across generalized estimating equations(GEE) and linear regression models. Statistical models were adjusted for factors typically associated with LTL(age, gender, cancer status) and also accounted for factors related to center differences, including laboratory methods(i.e., DNA extraction). Associations between LTL and psychosocial factors were also evaluated within race/ethnicity subgroups (Non-hispanic Whites, African Americans, and Hispanics).

Results

Beyond adjustment for age, gender, and cancer status, additional adjustments for DNA extraction and clustering by center were needed given their effects on LTL measurements. In adjusted GEE models, longer LTL was associated with African American race (Beta(β)(standard error(SE)) = 0.09(0.04), p-value = 0.04) and Hispanic ethnicity (β(SE) = 0.06(0.01), p-value = 0.02) compared to Non-Hispanic Whites. Longer LTL was also associated with less than a high school education compared to having greater than a high school education (β(SE) = 0.06(0.02), p-value = 0.04). LTL was inversely related to perceived stress (β(SE) = -0.02(0.003), p<0.001). In subgroup analyses, there was a negative association with LTL in African Americans with a high school education versus those with greater than a high school education(β(SE) = -0.11(0.03), p-value<0.001).

Conclusions

Laboratory methods and population characteristics that differ by center can influence telomere length associations in multicenter settings, but these effects could be addressed through statistical adjustments. Proper evaluation of potential sources of bias can allow for combined multicenter analyses and may resolve some inconsistencies in reporting of LTL associations. Further, biologic effects on LTL may differ under certain psychosocial and racial/ethnic circumstances and could impact future health disparity studies.

Differences in preferences for models of consent for biobanks between Black and White women

Biobanks are essential resources, and participation by individuals from diverse groups is needed. Various models of consent have been proposed for secondary research use of biospecimens, differing in level of donor control and information received. Data are needed regarding participant preferences for models of consent, particularly among minorities. We conducted qualitative semi-structured interviews with 60 women to examine their attitudes about different models of consent. Recruitment was stratified by race (Black/White) and prior biobank participation (yes/no). Two coders independently coded interview transcripts. Qualitative thematic analysis was conducted using NVivo 10. The majority of Black and White participants preferred "broad" consent (i.e., blanket permission for secondary research use of biospecimens), and the second most preferred model for both groups was "study-specific" consent (i.e., consent for each future research study). The qualitative analysis showed that participants selected their most preferred model for 3 major reasons: having enough information, having control over their sample, and being asked for permission. Least preferred was notice model (i.e., participants notified that biospecimens may be used in future research). Attitudes toward models of consent differed somewhat by race and prior biobank participation. Participants preferred models of consent for secondary research use of biospecimens that provided them with both specific and general information, control over their biospecimens, and asked them to give permission for use. Our findings suggest that it will be important for researchers to provide information about future uses of biospecimens to the extent possible and have an explicit permission step for secondary research use.

A Framework for Training Transdisciplinary Scholars in Cancer Prevention and Control

Traditionally, postdoctoral training programs largely have focused efforts within a single discipline or closely related fields. Yet, addressing the complex questions around cancer prevention and control increasingly requires the ability to work and communicate across disciplines in order to gain a perspective that encompasses the multilevel and multifaceted issues involved with this public health issue. To address this complexity, a transdisciplinary training program was implemented to cultivate the professional and scientific development of the postdoctoral fellows in Washington University in St Louis School of Medicine's Division of Public Health Sciences and NCI-funded centers (Community Networks Program Center and Transdisciplinary Research in Energetics in Cancer Center). Fellows are matched with primary mentors and assemble a multidisciplinary mentoring team. Structured programs support the transition of fellows from disciplinary trainees to independent transdisciplinary scholars and provide exposure to multiple disciplines. This article describes the training program, challenges encountered in implementation, solutions to those problems, and the metrics employed to evaluate the program's success. The goal of the program is to train emerging investigators in the conceptual bases, language, and practices that underlie a transdisciplinary perspective on cancer prevention and control research, to create an infrastructure for continued cross-discipline dialogue and collaboration, and to develop disseminable strategies for such training.

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

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

Abstract A04: Differences in preferences for models of informed consent may affect racial composition of biobanks

Biobanks are essential resources for advancing cancer research. Research conducted with stored biospecimens can provide critical societal benefits, including advancements in oncogenomics, pharmacogenetics, and enhanced medical treatments and improved health outcomes. In order for biobanks to provide broad societal benefits and address health disparities, participation by individuals from diverse groups is needed. Various models of informed consent have been proposed for future research use of biobanked specimens, differing in level of donor control and amount of information received. Data are needed regarding how different consent models might affect participation in biobanks, particularly for individuals from racial and ethnic minority groups. We therefore conducted semi-structured interviews with 60 women to examine their attitudes and preferences for different models of informed consent for secondary research uses of biospecimens. Recruitment was stratified by race (Black/White) and prior biobank participation (yes/no). Two coders independently coded all interview transcripts; analysis was based on consensus codes. The qualitative thematic analysis was conducted using NVivo. The results showed that the majority of Black and White participants preferred “broad” consent, which requires separate blanket permission for biospecimens to be used in multiple future research studies and provides participants with general information about possible future studies. More Black participants than White participants preferred “study specific” consent, which requires separate consent for each future research study and provides specific information about that study. We found that reasons for preferring a particular model of consent often differed by race. For example, Black participants more often spoke of the importance of being informed of what was happening with their sample, of research study activities, or being informed or notified if their sample was used. In reference to “study specific” consent, one Black participant said, “[Study-specific] continuously keeps you updated which is… you know you gotta be happy with constantly getting the updates.” In contrast, White participants often felt that giving permission once for their sample to be used in multiple future research studies (broad consent), rather than before each future study (study specific consent), was sufficient. In reference to why she liked “broad” consent, one White participant noted, “Well because they ask me once and then they have my permission to use my sample in multiple future studies.” Feeling respected was also an important factor affecting preferences among Black participants. One Black participant spoke about “broad” consent, “[Y]ou're being courteous, and you're asking me, 'Will you also say yes to this?' ” There were some common themes across racial groups. Both Black and White participants felt that the notice model, in which participants are notified that their biospecimens may be used in research, violated their rights. One White participant commented, “I don't think it respects the… individual and what right they have to do with their body or their own tissue.” These findings are essential to develop informed consent processes for biobanks that address the information most important to individuals from various racial and ethnic minority groups and allow them to make informed decisions about biobank participation.

Citation Format: Katherine Brown, Bettina Drake, Hannah Perkins, Leslie Wolf, James DuBois, Sarah Gehlert, Melody Goodman, Kimberly Kaphingst. Differences in preferences for models of informed consent may affect racial composition of biobanks. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr A04.

Abstract IA37: Integrated multilevel interventions to address the African American and white disparity in breast cancer mortality

African-American women have a higher death rate from breast cancer than white women (30.8 deaths per 100,000 during 2006 through 2010 for African-American females versus 22.7 per 100,000 for white females during that same period), despite the fact that their rate of incidence is lower (118.4 per 100,000 during 2006 through 2010 for African-American females versus 127.3 per 100,000 for white females during that same period).1 Mortality rates for African-American and white women began to diverge from one another in the early 1980s, and although rates of mortality from breast cancer have decreased for both African-American and white women since the 1990s, the decrease has been greater for white women than for African-American women (a decline in breast cancer death rate of 1.6% from 2001 to 2010 for African-American females compared to a decline of 1.8% for white females during that same period).

The determinants of breast cancer disparities occur at multiple levels of influence, from the cellular to the societal.2 Warnecke et al.3 proposed a multi-level scheme of influence on cancer disparities, with the following six levels that interact with one another in complex ways just beginning to be appreciated: biological/genetic pathways, individual risk factors, social relationships, neighborhoods, institutions, and social conditions and policies. We have written elsewhere4,5 that interventions that fail to take all levels into consideration may affect individual outcomes without making a dent in disparities at the population level.

In this presentation, we will outline a project that began on the Chicago's South Side and followed African-American women newly-diagnosed with breast cancer who were living in 15 predominantly African-American neighborhoods. An intervention plan was developed based on research in this and three other projects of the University of Chicago's Center for Interdisciplinary Research. The plan has been extended to African-American breast cancer survivors living in the City of St. Louis. Interventions with a range of community partners from community-based organizations, to the region's largest federally-qualified health center (People's Health Centers), to the St. Louis City Department of Health will be described that target the individual, neighborhood, and institutional levels of influence on African-American and white disparities in breast cancer mortality.

References:

1 DeSantis C, Ma J, Bryan L, Jemal A. Breast cancer statistics.Ca Cancer J Clin.2013; 64(1):52-62.

2 Hiatt RA, Porco TC, Balke K, Balmain A, Barlow J, et al. A multilevel model of postmenopausal breast cancer incidence. Cancer Epidemiol Biomarkers Prev. 2014;23(10):2078-92.

3 Warnecke RB, Oh A, Gehlert S, Lurie N, Rebbeck T, Paskett E, et al. Approaching health disparities from a population perspective: The NIH Centers for Population Health and Health Disparities. Am J Public Health, 2008;98:1608-15.

4 Gehlert S, Mininger C, Sohmer D, & Berg K. (Not so) gently down the stream: Choosing targets to ameliorate health disparities. Health & Social Work. 2008;33:163-7.

5 Gehlert S, & Colditz G. Cancer disparities: Unmet challenges in the elimination of disparities. Cancer Epidemiol Biomarkers Prev. 2011;20(9):1809-14.

Citation Format: Sarah Gehlert. Integrated multilevel interventions to address the African American and white disparity in breast cancer mortality. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr IA37.

A method for achieving reciprocity of funding in community-based participatory research

BACKGROUND

The St. Louis Komen Project was conceived to address disparities in breast cancer treatment and outcomes between African-American and White women in St. Louis, Missouri. Our goal was to apportion tasks and funding through a process to which all researcher partners had input and to which all could agree, thus eliminating institutionalized inequalities.

METHODS

This paper describes the collaborative process and resulting division of responsibilities, determination of costs, and ultimate allocation of funds and resources, as well as the documentation employed to achieve funding reciprocity and equal accountability.

RESULTS

Both communication and documentation are critical. Although the Memoranda of Understanding employed are not a panacea, they codify roles and expectations and promote trust. The process of developing financial transparency set the tone for subsequent steps in the research process.

CONCLUSIONS

The exhaustive planning process and project-specific procedures developed by its partners have helped the project foster reciprocity, facilitate participation, and equitably distribute resources.

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

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

Smokers' beliefs about the tobacco control potential of "a gene for smoking": a focus group study

Background

Several genetic variations associated with nicotine dependence and lung cancer exist. Translating this knowledge into tobacco control policy relies on smokers’ perceptions of the implications of the research. This study explored smokers’ beliefs about the tobacco control uses for research examining genomics, smoking, and addiction.

Method

Smokers (N = 85) participated in one of thirteen focus groups and one interview, stratified by race (eight black, six white) and education (seven < Bachelor’s degree, seven ≥ Bachelor’s degree). Data were analyzed by two independent coders using standard analysis and validation techniques.

Results

Nearly all groups suggested using genetic information for youth-oriented tobacco prevention education. Beliefs about the effectiveness of such actions varied. Many participants believed that providing smokers personalized genetic testing results or informing them about the existence of a gene would not motivate people to quit. All smokers emphasized the need for improved smoking cessation treatment options. Using genomics research to develop gene therapies and personalized drug treatments were also mentioned, yet perceptions of such treatments were mixed. Whereas some participants viewed the possibility positively, others expressed concern about cost and access. Participants who were skeptical of the effectiveness of using genetic information for tobacco control noted that the harms of tobacco use are widely known and genetic information does not add much of a deterrent.

Conclusion

Participants generated several possible tobacco control uses for genomics research findings. Our findings suggest that tobacco control experts should consult with smokers prior to implementing tobacco control measures. The potential public health benefits of genetics and genomics research related to tobacco use cannot be realized until communication strategies that are most likely to encourage and support tobacco avoidance decisions, and minimize mistrust and backlash, are identified.

Abstract A04: Preferences for models of informed consent for secondary research uses of biospecimens among diverse women

Background: Research with stored biospecimens can provide substantial societal benefits. Yet achieving translational research goals and reducing health disparities require the participation of large numbers of people from diverse populations in biobanks. One key ethical issue with biobanks is informed consent for secondary research use of biospecimens. Various models of consent have been proposed for using biospecimens for studies not planned when samples are collected. These models differ in the level of donor control and the amount of information received. Limited empirical data exist regarding the attitudes of potential biospecimen donors related to different models of consent, particularly from groups underrepresented in research, including individuals from racial and ethnic minority groups.

Methods: We conducted semi-structured individual interviews with 60 women seeking breast health services in the St. Louis region, stratifying recruitment by race (Black/White) and prior biobank participation. The interviews focused on participant preferences for four different models of informed consent for secondary research uses of biospecimens (i.e., study-specific, broad, opt-out, notice models of consent), factors affecting consent model preferences, and perceived benefits and concerns of donating biospecimens for research. Two independent coders are coding each interview transcript; the qualitative thematic analysis is based on consensus codes.

Results: Participants prefer models of informed consent that allow for more control and provide more information, irrespective of race. The least preferred model, notice model, informs participants that their samples may be used in future research. The most preferred model, broad consent, allows for future use of samples in multiple research studies once participants have given their permission. Preliminary analysis has shown that Black and White women had many similar reasons for preferring this model, citing their trust in research and desire to help others. However, while White women mentioned their trust in research and the importance of research as factors affecting their consent model preference, Black women put greater emphasis on the importance of consent and being asked permission. One White participant noted for broad consent, “That's when you feel that you're confident with the individuals that you've donated to will follow a strict protocol and do the best they can for a goal that's written, well documented.” One Black participant noted for broad consent, “I don't need to have any control over the, over it. The only control I needed was to be able to make the decision that said, sure you can use it.”

Conclusion: The most widely used consent model (notice model) is the least preferred among both Black and White women, while consent models providing more control and information ranked higher. These qualitative data will be used to develop educational materials with the purpose of making the informed consent process more accessible for prospective biobank participants. Recently, the US Department of Health and Human Services sought input on their proposal to change regulations governing the type of consent processes that can be used for research use of biospecimens. Findings from this study investigating preferences for consent for biobank participation among a diverse sample can therefore be used to inform future policy.

Citation Format: Katherine Brown, Bettina F. Drake, Sarah Gehlert, Leslie Wolf, James DuBois, Hannah Perkins, Melody S. Goodman, Kimberly Kaphingst. Preferences for models of informed consent for secondary research uses of biospecimens among diverse women. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr A04. doi:10.1158/1538-7755.DISP13-A04

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

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

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

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

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

Citation Format: Lailea Noel, Melody Goodman, Shahnjayla K. Connors, Dwayne Butler, Ron McMullen, Cheryl Oliver, Isaac McCullough, Sarah Gehlert. Identifying system-level barriers to breast cancer treatment which lead to health disparities for vulnerable communities: A qualitative approach. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr A86. doi:10.1158/1538-7755.DISP13-A86

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

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

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

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

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

Citation Format: Shahnjayla K. Connors, Melody Goodman, Neeraja Chavakula, Lailea Noel, Sarah Gehlert. Treatment delay among African American women in St. Louis, Missouri. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr C49. doi:10.1158/1538-7755.DISP13-C49

Racial disparities in risk of second breast tumors after ductal carcinoma in situ

The purpose of the study was to examine the impact of race/ethnicity on second breast tumors among women with ductal carcinoma in situ (DCIS). We identified 102,489 women diagnosed with primary DCIS between 1988 and 2009 from the 18 NCI-SEER Registries. Cox proportional hazard regression was used to estimate race/ethnicity-associated relative risks (RRs) and their 95 % confidence intervals (CI) of ipsilateral breast tumors (IBT; defined as DCIS or invasive carcinoma in the ipsilateral breast) and contralateral breast tumors (CBT; defined as DCIS or invasive carcinoma in the contralateral breast). Overall, 2,925 women had IBT and 3,723 had CBT. Compared with white women, black (RR 1.46; 95 % CI 1.29-1.65), and Hispanic (RR 1.18; 95 % CI 1.03-1.36) women had higher IBT risk, which was similar for invasive IBT and ipsilateral DCIS. A significant increase in IBT risk among black women persisted, regardless of age at diagnosis, treatment, tumor grade, tumor size, and histology. The CBT risk was significantly increased among black (RR 1.21; 95 % CI 1.08-1.36) and Asian/PI (RR 1.16; 95 % CI 1.02-1.31) women compared with white women. The association was stronger for invasive CBT among black women and for contralateral DCIS among Asian/PI women (P heterogeneity < 0.0001). The black race-associated CBT risk was more pronounced among women ≥50 years at diagnosis and those with comedo DCIS; in contrast, a significant increase in risk among Asian/PI women was restricted to those <50 years and those with noncomedo DCIS. Racial/ethnic differences in risks of second breast tumors after DCIS could not be explained by pathologic features and treatment.

Advancing Transdisciplinary Research: The Transdisciplinary Research on Energetics and Cancer Initiative

Strategies for constructing and maintaining cross-disciplinary teams are in their infancy. We outline strategies to support one form, transdisciplinary research, in a major initiative of the National Cancer Institute, the Transdisciplinary Research in Energetics and Cancer 2 (TREC2) initiative. Discussion of the TREC2 sites' experiences with transdisciplinarity is structured around a conceptual model that identifies four iterative phases of transdisciplinary research. An active coordination center, regular face-to-face meetings, and input from external advisors were instrumental in moving TREC2 to the translation phase. The possibilities for advancements in the science of energetics and cancer increased as investigator ties became denser. TREC2 can be seen as a flagship effort in transdisciplinary science that provides lessons on moving ideas from development to translation.