Primary Prevention of Cancer: A Multilevel Approach to Behavioral Risk Factor Reduction in Racially and Ethnically Minoritized Groups

ABSTRACT

Cancer continues to be the second most common cause of death in the United States. Racially and ethnically minoritized populations continue to experience disparities in cancer prevention compared with majority populations. Multilevel interventions-from policy, communities, health care institutions, clinical teams, families, and individuals-may be uniquely suited to reducing health disparities through behavioral risk factor modification in these populations. The aim of this article is to provide a brief overview of the evidence for primary prevention among racially and ethnically minoritized subpopulations in the United States. We focus on the epidemiology of tobacco use, obesity, diet and physical activity, alcohol use, sun exposure, and smoking, as well as increasing uptake of the Human Papillomavirus Vaccine (HPV), as mutable behavioral risk factors. We describe interventions at the policy level, including raising excise taxes on tobacco products; within communities and with community partners, for safe greenways and parks, and local healthful food; health care institutions, with reminder systems for HPV vaccinations; among clinicians, by screening for alcohol use and providing tailored weight reduction approaches; families, with HPV education; and among individuals, routinely using sun protection. A multilevel approach to primary prevention of cancer can modify many of the risk factors in racially and ethnically minoritized populations for whom cancer is already a burden.

Care of Cancer Survivors: Special Issues for Colorectal Cancer Survivors

Colorectal cancer (CRC) survival is influenced by numerous factors, including age, sex, race and ethnicity, familial cancer syndromes, stage and location of tumor, and comorbid conditions. The 5-year survival rate for patients with stage I CRC is 91%, but it is only 15% for patients with stage IV CRC. These survivors may experience multiple health issues. Gastrointestinal dysfunction is common, even years after treatment. This can include chronic diarrhea, occurring in approximately half of patients, and fecal incontinence, which is common after radiation therapy. Bladder dysfunction can occur due to surgical injury or radiation therapy. Many patients also experience sexual dysfunction. Standard therapies can be used to manage many of these symptoms and conditions. Patients with colostomy typically experience decreased quality of life. Referral to an ostomy therapist or wound, ostomy, and continence nurse may be beneficial. Pelvic radiation therapy can reduce bone mineral density (BMD) and increase fracture risk, so patients with rectal cancer who have received such therapy should undergo BMD monitoring. CRC survivors should undergo surveillance for recurrent CRC with interval colonoscopy, measurement of carcinoembryonic antigen levels, and computed tomography scan of the chest, abdomen, and/or pelvis. The intervals for and duration of surveillance depend on the cancer stage. Family physicians can help support CRC survivors through survivorship programs, shared care models, multidisciplinary interventions, and community partnerships.

HPV vaccination initiation among white, black and Middle East North African (MENA) males

Objectives

US males initiate HPV vaccination at older ages than females and currently have low population coverage. We aim to describe the prevalence and predictors of HPV vaccination initiation among males of White, Black, and Middle-Eastern/North-African (MENA) descent in southeast Michigan.

Methods

We conducted three community-based surveys in 2019 that provided primary data via self report. Using population weights and multivariate modeling, we measured the prevalence and predictors of HPV vaccine initiation in each race/ethnicity of men (age 18–34 years) analyzed.

Results

The vaccine initiation rates were 44.5 % (95 % CI: 44.4, 44.6) for White men, 46.2 % (46.0, 46.4) for Black men, and 23.2 % (22.8, 23.6) for MENA men, (p < 0.001). Being a student, compared to unemployed or disabled, was significantly associated with HPV vaccine initiation across all three races/ethnicities. Married men of any race/ethnicity were unlikely to be vaccinated. MENA men born in the US and having some college education were also more likely to initiate HPV vaccination.

Conclusions

White, Black, and MENA men are not vaccinated in accord with Healthy (Healthy People 2030, 2022) goals. Each race/ethnicity has different predictors of vaccination.

HPV-Vaccine Hesitancy in Colombia: A Mixed-Methods Study

In Colombia, the uptake rate of the HPV vaccine dropped from 96.7% after its introduction in 2013 to 9% in 2020. To identify the behavioural components of HPV-vaccine hesitancy in females aged 15 and under and their families, we conducted a convergent mixed-methods study in which 196 parents/caregivers responded to an online questionnaire and 10 focus groups were held with 13 of these parents/caregivers, and 50 age-eligible girls. The study is novel as it is the first to explore the factors influencing HPV-vaccine hesitancy alongside the COVID vaccine within an integrative model of behaviour change, the capability-opportunity-motivation-behaviour (COM-B) model. We found that COVID-19 has had an impact on the awareness of HPV and HPV vaccination. Lack of information about the vaccination programs, concerns about vaccine safety and the relationship between HPV and sexuality could be related to vaccine hesitancy. Trust in medical recommendations and campaigns focused on the idea that vaccination is a way of protecting daughters from cervical cancer could improve HPV vaccine uptake.

Perceived Severity of COVID-19 in a Longitudinal Study in Detroit, Michigan

Objective

To slow down the spread of SARS-CoV-2, many countries have instituted preventive approaches (masks, social distancing) as well as the distribution of vaccines. Adherence to these preventive measures is crucial to the success of controlling the pandemic but decreased perceptions of disease severity could limit adherence. The aim of our study was to observe changes in perceived personal severity and perceived community severity; the study also explored their predictors.

Methods

In a longitudinal study from an address-based probability survey in Detroit, we asked participants to rate their perceived severity of COVID-19 for themselves and for their community. In our analysis, 746 participants were queried across 5 waves of the Detroit Metro Area Communities Study surveys from March 31 to October 27 in 2020. We tested for trends in changes of self-reported perceived severity for themselves and for their community; we assessed the effects of different predictors of the two severities through mixed effects logistic regression models.

Results

Our results highlight that the overall levels of perceived community and personal severity were decreasing over time even though both severities were fluctuating with rising confirmed case counts. Compared with non-Hispanic (NH) White Detroiters, NH Black Detroiters reported a higher perceived personal severity (OR: 5.30, 95% CI: 2.97, 9.47) but both groups reported similar levels of perceived community severity. We found steeper declines in perceived severity in NH White than NH Black Detroiters over time; the impact of education and income on perceived severity was attenuated in NH Black Detroiters compared with NH White Detroiters.

Conclusions

Our findings suggested that perceived severity for COVID-19 decreased through time and was affected by different factors among varied racial/ethnic groups. Future interventions to slow the pace of the pandemic should take into account perceived personal and community severities among varied ethnic/racial subgroups.

US women screen at low rates for both cervical and colorectal cancers than a single cancer: a cross-sectional population-based observational study

Background:

Using screen counts, women 50–64 years old have lower cancer screening rates for cervical and colorectal cancers (CRC) than all other age ranges. This paper aims to present woman-centric cervical cancer and CRC screenings to determine the predictor of being up-to-date for both.

Methods:

We used the Behavioral Risk Factor Surveillance System (BRFSS), an annual survey to guide health policy in the United States, to explore the up-to-date status of dual cervical cancer and CRC screening for women 50–64 years old. We categorized women into four mutually exclusive categories: up-to-date for dual-screening, each single screen, or neither screen. We used multinomial multivariate regression modeling to evaluate the predictors of each category.

Results:

Among women ages 50–64 years old, dual-screening was reported for 58.2% (57.1–59.4), cervical cancer screening alone (27.1% (26.0–28.2)), CRC screening alone (5.4% (4.9–5.9)), and neither screen (9.3% (8.7–9.9)). Age, race, education, income, and chronic health conditions were significantly associated with dual-screening compared to neither screen. Hispanic women compared to non-Hispanic White women were more likely to be up-to-date with cervical cancer screening than dual-screening (adjusted odds ratio [aOR] = 1.39 (1.10, 1.77)). Compared to younger women, those 60–64 years are significantly more likely to be up-to-date with CRC screening than dual-screening (aOR = 1.75 (1.30, 2.35)).

Conclusions:

Screening received by each woman shows a much lower rate of dual-screening than prior single cancer screening rates. Addressing dual-screening strategies rather than single cancer screening programs for women 50–64 years may increase both cancer screening rates.

Funding:

This work was supported by NIH through the Michigan Institute for Clinical and61 Health Research UL1TR002240 and by NCI through The University of Michigan Rogel Cancer62 Center P30CA046592 grants.

Routine screenings for cervical and colorectal cancers save lives by detecting cancers at an early stage when they are more treatable and more likley to cure. Most cancer screening in the United States is focused on single cancer screening programs, often held at community health fairs, pop-up screening vans and other settings, without coordination with the individuals’ primary care doctors.

This is problematic because the primary care physician cannot counsel if the results are abnormal and advise when the next routine screen is appropriate. This leads to gaps in women not being informed that they are due for routine screening and gaps to act on any abnormal screening results. This is especially problematic for women aged 50 to 64, who are less likely to screen for either cancer alone compared to other age groups.

Currently, 86% of women in the United States are up to date with cervical cancer screening, and 64% are up to date with colorectal cancer screening. However, it is not clear how many women in this age group receive both screens, compared to a single screen or neither screen.

Harper et al. analyzed data from over 40,000 women aged 50 to 64, collected in a United States health survey in 2018. This study revealed that only 59% of the women reported being up to date with cervical and colorectal cancer screenings. Compared to women who did not screen at all, women completing both screens were more educated, had higher incomes, and were more likely to have other chronic conditions such as arthritis, diabetes, depression and other cancers.

These findings reveal that the number of women aged 50 to 64 in the United States, who are up to date with both cancer screenings, is still well below national targets. Harper et al. propose that shifting towards a women-centric focus, with primary care physicians or health care systems responsible for managing screening efforts, could decrease cancer incidence and mortality. In future, self-test kits for both cancers should help encourage more women to have both screens in a comfortable environment. This change in focus will also allow primary care physicians to notify women at appropriate intervals to attend routine screening and immediate follow-ups in the case of abnormal results.

Understanding national trends in COVID-19 vaccine hesitancy in Canada: results from five sequential cross-sectional representative surveys spanning April 2020-March 2021

OBJECTIVE

To examine rates of vaccine hesitancy and their correlates among Canadian adults between April 2020 and March 2021.

DESIGN

Five sequential cross-sectional age, sex and province-weighted population-based samples who completed online surveys.

SETTING

Canada.

PARTICIPANTS

A total of 15 019 Canadians aged 18 years and over were recruited through a recognised polling firm (Leger Opinion). Respondents were 51.5% female with a mean age of 48.1 (SD 17.2) years (range 18-95 years) and predominantly white (80.8%).

PRIMARY AND SECONDARY OUTCOME MEASURES

Rates of vaccine hesitancy over the five surveys (time points) and their sociodemographic, clinical and psychological correlates.

RESULTS

A total of 42.2% of respondents reported some degree of vaccine hesitancy, which was lowest during surveys 1 (April 2020) and 5 (March 2021) and highest during survey 3 (November 2020). Fully adjusted multivariate logistic regression analyses revealed that women, those aged 50 and younger, non-white, those with high school education or less, and those with annual household incomes below the poverty line in Canada were significantly more likely to report vaccine hesitancy, as were essential and healthcare workers, parents of children under the age of 18 and those who do not get regular influenza vaccines. Endorsing prevention behaviours as important for reducing virus transmission and high COVID-19 health concerns were associated with 77% and 54% reduction in vaccine hesitancy, respectively. Having high personal financial concerns was associated with 1.33 times increased odds of vaccine hesitancy.

CONCLUSIONS

Results highlight the importance of targeting vaccine efforts to specific groups by emphasising the outsized health benefits compared with risks of vaccination. Future research should monitor changes in vaccine intentions and behaviour to better understand underlying factors.

Patient-centered home cancer screening attitudes during SARS-CoV-2 pandemic

COVID-19 has caused disruptions in health care, in particular cancer screenings. The primary aim of our work was to evaluate the degree to which populations were accepting of home-based screenings for colorectal cancer (CRC) and cervical cancer (primary HPV testing). Three groups of adults having distinct health burdens which may affect acceptance of home-based cancer screening were identified through outpatient electronic medical records as follows as either having survived a COVID hospitalization, having been positive for non-COVID respiratory illness or having type 2 diabetes. 132 respondents (58% female) completed an online survey with hypothetical cases about their acceptance of home-based CRC or cervical cancer screening. Among females, urine and vaginal screening for primary HPV testing was acceptable to 64% and 59%, respectively. Among both males and females, CRC home screening with fecal immunochemical test (FIT) or Cologuard was acceptable to 60% of the respondents. When adjusting for education, women with a positive attitude toward home-based urine /vaginal screening were 49 times and 23 times more likely to have a positive attitude toward CRC screening (aOR=48.7 (95% CI: 7.1, 337) and aOR=23.2 (95% CI: 3.8, 142), respectively). This report indicates that home-based cancer screens for CRC and primary HPV testing are acceptable to men and women and may allow for greater compliance with screening in the future.

How well do covariates perform when adjusting for sampling bias in online COVID-19 research? Insights from multiverse analyses

COVID-19 research has relied heavily on convenience-based samples, which-though often necessary-are susceptible to important sampling biases. We begin with a theoretical overview and introduction to the dynamics that underlie sampling bias. We then empirically examine sampling bias in online COVID-19 surveys and evaluate the degree to which common statistical adjustments for demographic covariates successfully attenuate such bias. This registered study analysed responses to identical questions from three convenience and three largely representative samples (total N = 13,731) collected online in Canada within the International COVID-19 Awareness and Responses Evaluation Study ( www.icarestudy.com ). We compared samples on 11 behavioural and psychological outcomes (e.g., adherence to COVID-19 prevention measures, vaccine intentions) across three time points and employed multiverse-style analyses to examine how 512 combinations of demographic covariates (e.g., sex, age, education, income, ethnicity) impacted sampling discrepancies on these outcomes. Significant discrepancies emerged between samples on 73% of outcomes. Participants in the convenience samples held more positive thoughts towards and engaged in more COVID-19 prevention behaviours. Covariates attenuated sampling differences in only 55% of cases and increased differences in 45%. No covariate performed reliably well. Our results suggest that online convenience samples may display more positive dispositions towards COVID-19 prevention behaviours being studied than would samples drawn using more representative means. Adjusting results for demographic covariates frequently increased rather than decreased bias, suggesting that researchers should be cautious when interpreting adjusted findings. Using multiverse-style analyses as extended sensitivity analyses is recommended.

Patient-Centered Home Cancer Screening Attitudes During COVID-19 Pandemic

The COVID-19 pandemic disrupted health care delivery of cancer screenings. The primary aim of our work was to evaluate the degree to which populations were accepting of home-based screenings for colorectal cancer (CRC) and cervical cancer (ie, primary human papillomavirus [HPV] testing). Three groups of adults having distinct health burdens that may affect acceptance of home-based cancer screening were identified through outpatient electronic medical records: those having survived a COVID-19 hospitalization; those having been positive for a non-COVID-19 respiratory illness; or those having type 2 diabetes. A total of 132 respondents (58% female) completed an online survey with hypothetical cases about their acceptance of home-based CRC or cervical cancer screening. Among women respondents, urine and vaginal screening for primary HPV testing was acceptable to 64% and 59%, respectively. Among both men and women, at-home CRC screening with fecal immunochemical test or Cologuard^® was acceptable to 60% of the respondents. When adjusting for education, women with a positive attitude toward home-based urine and vaginal screening were 49 times and 23 times more likely, respectively, to have a positive attitude toward CRC screening. These findings indicate that home-based cancer screens for CRC and primary HPV testing are acceptable to men and women and may allow for greater compliance with screening in the future.

Effect of vaccine effectiveness and safety on COVID-19 vaccine acceptance in Detroit, Michigan, July 2020

This study examined whether future COVID-19 vaccine acceptance differed based on an experimental manipulation of the vaccine safety and effectiveness profile. Data come from the Detroit Metro Area Community Study, a population-based study conducted July 15-20, 2020. Participants were asked whether they would get a new COVID-19 vaccine after being randomly assigned information about the vaccine's effectiveness (50% or 95%) and chance of fever (5% or 20%). Among 1,117 Detroiters, 51.3% would accept a COVID-19 vaccine that is 50% effective and 77.1% would accept a vaccine that is 95% effective. Women and adults ≥65 were more accepting of a vaccine; Black Detroiters were less accepting. Believing vaccines to be important, effective, and safe was associated with higher acceptance. Uptake of a COVID-19 may be limited, depending on perceived vaccine effectiveness and general attitudes toward vaccines. Public health approaches to modifying these attitudes will be especially important in the Black community.

Predictors of screening for cervical and colorectal cancer in women 50-65 years old in a multi-ethnic population

Middle Eastern/North Africa (MENA) women are often not identified in cancer screening studies. The aim of this study was to determine the rates and predictors of cervical and colorectal cancer (CRC) screening for women 50-65 years of three race/ethnicities. White, black and MENA women of Southeast Michigan were surveyed once in 2019 for demographics, health care barriers, chronic diseases, and cancer screening updates using in-person, telephone, and online methods. Descriptive statistics and multivariate multinomial logistic regression were used to predict up-to-date colorectal cancer and cervical cancer screening. All analyses were adjusted by local population weights for comparability and generalizability. 394 women participated with 54% up-to-date on both screenings, 21% for cervical cancer screening alone, and 12% for CRC alone. Women more likely to be up-to-date for only cervical cancer screening compared to both cancer screens are younger (aOR 0.83 (95% CI 0.76, 0.92), are of MENA descent (7.97 (2.46, 25.76) and have no insurance (9.41 (1.07, 82.92). There are no predictors for women being up-to-date for CRC screening alone compared to both screens. Among women 50-65 years old, being up-to-date in cervical cancer screening is unrelated to being up-to-date for CRC screening. Compared to Healthy People 2020, there are significant gaps in cervical and CRC screening among women 50-65 years old of all races, but particularly among women of MENA descent who are even less likely to have CRC screening than cervical cancer screening.

Health Care Coordination Theoretical Frameworks: a Systematic Scoping Review to Increase Their Understanding and Use in Practice

BACKGROUND

Care coordination is crucial to avoid potential risks of care fragmentation in people with complex care needs. While there are many empirical and conceptual approaches to measuring and improving care coordination, use of theory is limited by its complexity and the wide variability of available frameworks. We systematically identified and categorized existing care coordination theoretical frameworks in new ways to make the theory-to-practice link more accessible.

METHODS

To identify relevant frameworks, we searched MEDLINE®, Cochrane, CINAHL, PsycINFO, and SocINDEX from 2010 to May 2018, and various other nonbibliographic sources. We summarized framework characteristics and organized them using categories from the Sustainable intEgrated chronic care modeLs for multi-morbidity: delivery, FInancing, and performancE (SELFIE) framework. Based on expert input, we then categorized available frameworks on consideration of whether they addressed contextual factors, what locus they addressed, and their design elements. We used predefined criteria for study selection and data abstraction.

RESULTS

Among 4389 citations, we identified 37 widely diverse frameworks, including 16 recent frameworks unidentified by previous reviews. Few led to development of measures (39%) or initiatives (6%). We identified 5 that are most relevant to primary care. The 2018 framework by Weaver et al., describing relationships between a wide range of primary care-specific domains, may be the most useful to those investigating the effectiveness of primary care coordination approaches. We also identified 3 frameworks focused on locus and design features of implementation that could prove especially useful to those responsible for implementing care coordination.

DISCUSSION

This review identified the most comprehensive frameworks and their main emphases for several general practice-relevant applications. Greater application of these frameworks in the design and evaluation of coordination approaches may increase their consistent implementation and measurement. Future research should emphasize implementation-focused frameworks that better identify factors and mechanisms through which an initiative achieves impact.

Incorporating Theory into Practice: Reconceptualizing Exemplary Care Coordination Initiatives from the US Veterans Health Delivery System

This perspective paper seeks to lay out an efficient approach for health care providers, researchers, and other stakeholders involved in interventions aimed at improving care coordination to partner in locating and using applicable care coordination theory. The objective is to learn from relevant theory-based literature about fit between intervention options and coordination needs, thereby bringing insights from theory to enhance intervention design, implementation, and troubleshooting. To take this idea from an abstract notion to tangible application, our workgroup on models and measures from the Veterans Health Administration (VA) State of the Art (SOTA) conference on care coordination first summarizes our distillation of care coordination theoretical frameworks (models) into three common conceptual domains-context of an intervention, locus in which an intervention is applied, and specific design features of the intervention. Then we apply these three conceptual domains to four cases of care coordination interventions ("use cases") chosen to represent various scopes and stages of interventions to improve care coordination for veterans. Taken together, these examples make theory more accessible and practical by demonstrating how it can be applied to specific cases. Drawing from theory offers one method to anticipate which intervention options match a particular coordination situation.

A 6-year update of the health policy and advocacy priorities of the Society of Behavioral Medicine

Government policy affects virtually every topic of interest to health behavior researchers, from research funding to reimbursement for clinical services to application of evidence to impact health outcomes. This paper provides a 6-year update on the expansion of Society of Behavioral Medicine's (SBM) public policy and advocacy agenda and proposed future directions. SBM's Health Policy Council is responsible for ensuring coordination of the policy-related activities of the Health Policy Committee (HPC), the Civic and Public Engagement Committee (CPEC), and the Scientific and Professional Liaison Council (SPLC). These committees and councils have written letters to Congress, signed onto advocacy letters with hundreds of organizations, and developed and disseminated 15 health policy briefs, the majority of which have been presented to legislative staffers on Capitol Hill. With the assistance of the SPLC, SBM has collaborated on policy efforts with like-minded organizations to increase the impact of the Society's policy work. Moving forward, SBM plans to continue to increase efforts to disseminate policy work more broadly and develop long-term relationships with Congressional staffers. SBM leadership realizes that to remain relevant, demonstrate impact, and advance the role of behavioral medicine, we must advance a policy agenda that reflects our mission of better health through behavior change.

An Individualized Approach to Cancer Screening Decisions in Older Adults: A Multilevel Framework

Guidelines for optimal cancer screening in older adults remain unclear, particularly for adults over the age of 75. While cancer screening in older adults may benefit some in good health, it may cause unnecessary burdens in others with limited life expectancy. Thus, a systematic approach to enable individualized cancer screening decisions in older adults is needed. We suggest a framework that guides such decisions through evidence-based approaches from multiple interactions, and that involves the patient, clinician, and healthcare system. An individualized approach considers differences in disease risk rather than the chronological age of the patient. This paper presents a comprehensive framework that depicts the independent and converging levels of influences on individualized cancer screening decisions in older adults. This Individualized Decisions for Screening (IDS) framework recognizes the reality of these interrelationships, including the tensions that arise when behaviors and outcomes are valued differently at the patient, clinician, and healthcare organization levels. Person-centered approaches are essential to advancing multilevel research of individualized cancer screening decisions among older adults.

Effectiveness of a provider-focused intervention to improve HPV vaccination rates in boys and girls

BACKGROUND

HPV vaccination is universally recommended for boys and girls, yet vaccination rates remain low nationwide.

METHODS

We conducted a provider-focused intervention that included repeated contacts, education, individualized feedback, and strong quality improvement incentives to raise HPV vaccination rates at two federally qualified community health centers. To estimate the effectiveness of the intervention, rates of initiation of vaccination, and completion of the next needed HPV vaccination (dose 1, 2 or 3) among boys and girls ages 11-21 were compared at baseline and two follow-up periods in two intervention health centers (n4093 patients) and six control health centers (n9025 patients). We conducted multivariable logistic regression accounting for clustering by practice.

RESULTS

Girls and boys in intervention practices significantly increased HPV vaccine initiation during the active intervention period relative to control practices (girls OR 1.6, boys OR 11; p<0.001 for both). Boys at intervention practices were also more likely to continue to initiate vaccination during the post-intervention/maintenance period (OR 8.5; p<0.01). Girls and boys at intervention practices were more also likely to complete their next needed HPV vaccination (dose 1, 2 or 3) than those at control practices (girls OR 1.4, boys OR 23; p<0.05 for both). These improvements were sustained for both boys and girls in the post-intervention/maintenance period (girls OR 1.6, boys OR 25; p<0.05 for both).

CONCLUSIONS

Provider-focused interventions including repeated contacts, education, individualized feedback, and strong quality improvement incentives have the potential to produce sustained improvements in HPV vaccination rates.

Conducting rapid, relevant research: lessons learned from the My Own Health Report project

The lengthy and uncertain translation of research into clinical practice is well documented. Much of the current "gold standard" clinical research is slow, expensive, and lacks perceived relevance for practitioners and decision makers. In contrast, we summarize experiences conducting the My Own Health Report (MOHR) project to collect and address patient reported measures using principles of rapid, relevant pragmatic research. The methods used for rapid design and fielding of the MOHR project to improve attention to health behaviors and mental health are detailed. Within the multisite, pragmatic, implementation-focused MOHR study, we describe the four phases of the research and the key decisions made and actions taken within each. We provide concrete examples of how relevant research can be conducted transparently to rapidly provide information to practitioners. Data were collected and analyzed in 2013. The multisite (seven research centers partnered with 18 clinics) cluster randomized pragmatic delayed intervention trial was conducted in less than 18 months from receipt of funding applications to completion of data collection. Phases that were especially accelerated included funding and review, and recruitment and implementation. Conducting complex studies rapidly and efficiently is a realistic goal. Key lessons learned for prevention research include use of existing research networks; use of web-based assessment/feedback tools that are tailored to fit local needs; engaging relevant stakeholders early on and throughout the process to minimize need for redesign; and making pragmatic decisions that balance internal and external validity concerns rather than waiting for perfect solutions.

Communication of genetic test results to family and health-care providers following disclosure of research results

PURPOSE

Few studies have examined methods to promote communication following the return of DNA mismatch repair genetic test results obtained during research. The purpose of the present study was to evaluate a telephone protocol for returning research results of DNA mismatch repair gene testing to identify Lynch syndrome.

METHODS

We invited individuals with known DNA mismatch repair mutations in their family, who were enrolled in the Colon Cancer Family Registry at the Mayo Clinic, to participate in this study. Participants completed surveys before and 6 months after DNA mismatch repair test result disclosure.

RESULTS

Among 107 participants, 79% opted to learn their DNA mismatch repair test results; of these, 44 (41%) carried DNA mismatch repair mutations. After disclosure, 54% reported screening for any type of cancer. Among carriers, >74% reported communicating results to family; communication was predicted by baseline confidence in coping with the genetic test result (Z = 1.97; P = 0.04). Result disclosure to a physician was predicted by greater perceived cancer risk (Z = 2.08; P = 0.03) and greater intention to share results with family (Z = 3.07; P = 0.002).

CONCLUSION

Research versus clinically based gene disclosure presents challenges. A telephone disclosure process for the return of research-based results among Lynch syndrome families led to high rates of result uptake and participant communication of results to providers and family members.

Coordinating cancer care: Measurement and intervention approaches across the cancer continuum

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Background: According to a landmark study by the Institute of Medicine, patients with cancer often receive poorly coordinated care in multiple settings from many providers. Lack of coordination is associated with poor symptom control, medical errors, and higher costs. The aims of this presentation are to: (1) describe the state-of-the science on cancer care coordination measures and intervention outcomes from a systematic review and meta-analysis of empirical papers published between 1980-2013; (2) explore the implications of these findings from the patient, provider, healthcare system, and national policy perspectives. No similar review has yet been published. Methods: Of 1,241 abstracts collected from a systematic search of PubMed, MeEMBASE, Medline, CINAHL, and Cochrane Library, 50 studies met the inclusion criteria. Each study had US or Canadian participants; comparison or control groups, measures, times, samples, and/or interventions. Two raters independently applied a standardized search strategy and coding scheme. Eight studies (14 outcomes) met the additional criteria for the meta-analysis. We used the Care Coordination Atlas (McDonald, 2010) definition of care coordination. Results: Overall, coordination improved cancer care across 83% (44) of the measured outcomes. Interventions led to more appropriate healthcare use (g = 0.37 [95% CI = 0.29 – 0.46]; I2= 0.00) across screening (patient navigation), treatment (home telehealth, nurse case management and education), and end-of-life care (early palliation). Measures varied considerably in psychometric quality and were limited in focus. They included; rates of guideline compliance (screening), timeliness of care (diagnosis), health-related quality of life (treatment), cancer-related distress (survivorship), and home death (end-of-life). Conclusions: The findings revealed effective interventions across the cancer continuum from screening to end-of-life. More, and better measures are needed across the cancer continuum. We discuss the implications of these findings for more and better measures, approaches to implement effective interventions in clinical settings, and to develop supportive policy (and reimbursement) contexts.

Psychosocial approaches to participation in BRCA1/2 genetic risk assessment among African American women: a systematic review

Breast cancer is a significant health concern for African American women. Nonetheless, uptake of genetic risk assessment (including both genetic counseling and testing) for breast cancer gene mutations among these populations remains low. This paper systematically reviews cognitive (i.e., beliefs) and affective (i.e., emotions) factors influencing BRCA1/2 genetic risk assessment among African American women as well as psychosocial interventions to facilitate informed decision making in this population. A systematic search of CINAHL, PubMed, and PsycINFO was undertaken, yielding 112 published studies. Of these, 18 met the eligibility criteria. African American woman are likely to participate in genetic risk assessment if they are knowledgeable about cancer genetics, perceive a high risk of developing breast cancer, have low expectancies of stigmatization from medical professionals, view themselves as independent from family, and have fatalistic beliefs and a future temporal orientation. Anticipated negative affective responses, such as an inability to “handle” the results of testing, are barriers to uptake. Specific perceptions, beliefs, and emotional factors are associated with genetic risk assessment among African American women. Understanding these factors is key in the development of interventions to facilitate informed decision making in this population.

Challenges in cervical cancer prevention: a survey of U.S. obstetrician-gynecologists

BACKGROUND

Current cervical cancer prevention recommendations include human papillomavirus (HPV) vaccination, Pap and HPV co-testing, and Pap testing at 3- to 5-year intervals.

PURPOSE

To examine attitudes, practice patterns, and barriers related to HPV vaccination and cervical cancer screening guidelines among U.S. obstetrician-gynecologists.

METHODS

In 2011-2012, a national sample of members of the American Congress of Obstetricians and Gynecologists responded to a 15-item (some with multiple parts) questionnaire assessing sociodemographic characteristics, clinical practices, and perceived barriers to HPV vaccination and cervical cancer screening. Multivariate logistic regression was used to identify factors associated with guideline adherence. Analyses were conducted in 2012.

RESULTS

A total of 366 obstetrician-gynecologists participated. Ninety-two percent of respondents offered HPV vaccination to patients, but only 27% estimated that most eligible patients received vaccination. Parent and patient refusals were commonly cited barriers to HPV vaccination. Approximately half of respondents followed guidelines to begin cervical cancer screening at age 21 years, discontinue screening at age 70 years or after hysterectomy, and appropriately utilize Pap and HPV co-testing. Most physicians continued to recommend annual Paps (74% aged 21-29 years, 53% aged ≥30 years). Physicians felt that patients were uncomfortable with extended screening intervals and were concerned that patients would not come for annual exams without concurrent Paps. Solo practitioners were less likely to follow both vaccination and screening guidelines than those in group practices.

CONCLUSIONS

This survey of obstetrician-gynecologists indicates persistent barriers to the adoption of HPV vaccination and cervical cancer screening guidelines. Interventions to promote guideline adherence may help improve the quality of cervical cancer prevention.

Cancer care coordination systematic review and meta-analysis: Twenty-two years of empirical studies

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Background: To our knowledge, no systematic review of empirical papers describing cancer care coordination interventions has yet been conducted. The aim of this presentation is to describe the methods and findings from a systematic review and meta-analysis of all empirical papers describing cancer care coordination published between 1990-2012. Methods: Of 1241 abstracts collected from a search of PubMed and EMBASE, 108 studies were retrieved and reviewed; 49 were included in the systematic review. Each study had US or Canadian adult or child participants; each paper had comparison or control groups, measures, samples, and/or interventions. Two researchers independently applied a standardized search strategy, coding scheme, and on-line coding program to each study. Eight RCT’s met additional criteria for meta-analysis; a random effects estimation model was used for data analysis. Results: Among the 49 articles included in our systematic review, those that included implicit or explicit definitions of cancer care coordination described four components: (1) roles and models for communication and transfer of care between primary care physicians and oncologists during active treatment and survivorship; (2) care navigation through designated personnel or telecommunication processes among care team members; (3) treatment summaries and survivorship care plans; and (4) multidisciplinary communication accompanying patient and practice management within the framework of the Chronic Care Model (N=14). We found a medium-sized effect of cancer care coordination on care usage outcomes among the randomized clinical trials (e.g., reduced Emergency Department visits; g = 0.37 [95% CI = 0.29 - 0.44], I2= .000. Fail-safe N = 86). Conclusions: The findings from this current systematic review and meta-analysis will contribute to the evidence base on strategies that can improve the coordination of cancer care, particularly for patients with multiple chronic conditions, and thereby advance the goals of health care reform in the US.

Implications of generating genetic test results for colon cancer in the international, population-based colon cancer family registry

3567

Background: The ability to genotype large numbers of people rapidly and inexpensively for research purposes highlights the need to develop guidelines for providing medically-relevant research results - including unanticipated findings - to study participants. The Colon Cancer Family Registry (C-CFR) is the oldest and largest international colon cancer population-based registry; its experience managing genetic research findings can offer guidance to clinicians and researchers. The C-CFR has enrolled 10,019 cases with colon cancer and 24,708 family members in six registries in the US, Canada, Australia, and New Zealand. Deleterious (“high risk”) germline mutations have been identified in DNA mismatch repair (MMR) genes (MLH1, MSH2, MSH6, PMS2) and the MutYH gene. The aims of this presentation are to: (1) report the uptake of genetic test results by C-CFR participants; (2) systematically compare disclosure protocols and barriers to uptake by registry; (3) make recommendations to guide clinicians and researchers. Methods: Uptake of genetic test results was calculated from data collected by the C-CFR; key investigators (KIs) from each registry completed a survey about disclosure decision-making; KIs also took part in discussions to generate recommendations. Results: Registry-wide molecular testing has identified deleterious MMR germline mutations for at least one member of 424 families (4%) and 48 biallelic MutYH gene carriers. Uptake of test results ranged from 56-86% (n= 1542) across registries. Barriers to disclosure include: (1) lack of pre-existing notification protocols; (2) logistics of re-consent; (3) limited involvement of genetic counselors at some registries; (4) in the US, the requirement that genetic testing be performed in a CLIA approved laboratory; (5) IRBs declining approval; and (6) budget constraints. Conclusions: Based on our international registry’s findings we recommend that researchers generating genetic information establish plans for disclosure at the outset; obtain subject consent a priori; consider subject knowledge and disclosure preferences; provide guidance and budget for clinical follow-up; and involve genetic counselors.

Multilevel interventions and racial/ethnic health disparities

To examine the impact of multilevel interventions (with three or more levels of influence) designed to reduce health disparities, we conducted a systematic review and meta-analysis of interventions for ethnic/racial minorities (all except non-Hispanic whites) that were published between January 2000 and July 2011. The primary aims were to synthesize the findings of studies evaluating multilevel interventions (three or more levels of influence) targeted at ethnic and racial minorities to reduce disparities in their health care and obtain a quantitative estimate of the effect of multilevel interventions on health outcomes among these subgroups. The electronic database PubMed was searched using Medical Subject Heading terms and key words. After initial review of abstracts, 26 published studies were systematically reviewed by at least two independent coders. Those with sufficient data (n = 12) were assessed by meta-analysis and examined for quality using a modified nine-item Physiotherapy Evidence Database coding scheme. The findings from this descriptive review suggest that multilevel interventions have positive effects on several health behavior outcomes, including cancer prevention and screening, as well improving the quality of health-care system processes. The weighted average effect size across studies for all health behavior outcomes reported at the individual participant level (k = 17) was odds ratio (OR) = 1.27 (95% confidence interval [CI] = 1.11 to 1.44); for the outcomes reported by providers or organizations, the weighted average effect size (k = 3) was OR = 2.53 (95% CI = 0.82 to 7.81). Enhanced application of theories to multiple levels of change, novel design approaches, and use of cultural leveraging in intervention design and implementation are proposed for this nascent field.

Meta-analysis of psychosocial interventions to reduce pain in patients with cancer

PURPOSE

Pain is one of the most common, burdensome, and feared symptoms experienced by patients with cancer. American Pain Society standards for pain management in cancer recommend both pharmacologic and psychosocial approaches. To obtain a current, stable, and comprehensive estimate of the effect of psychosocial interventions on pain-an important clinical topic-we conducted a meta-analysis of randomized controlled studies among adult patients with cancer published between 1966 and 2010.

METHODS

Three pairs of raters independently reviewed 1,681 abstracts, with a systematic process for reconciling disagreement, yielding 42 papers, of which 37 had sufficient data for meta-analysis. Studies were assessed for quality using a modified seven-item Physiotherapy Evidence Database (PEDro) coding scheme. Pain severity and interference were primary outcome measures.

RESULTS

Study participants (N = 4,199) were primarily women (66%) and white (72%). The weighted averaged effect size across studies for pain severity (38 comparisons) was 0.34 (95% CI, 0.23 to 0.46; P < .001), and the effect size for pain interference (four comparisons) was 0.40 (95% CI, 0.21 to 0.60; P < .001). Studies that monitored whether treatment was delivered as intended had larger effects than those that did not (P = .04).

CONCLUSION

Psychosocial interventions had medium-size effects on both pain severity and interference. These robust findings support the systematic implementation of quality-controlled psychosocial interventions as part of a multimodal approach to the management of pain in patients with cancer.

Costs and cost effectiveness of a health care provider-directed intervention to promote colorectal cancer screening

PURPOSE

Colorectal cancer (CRC) screening remains underutilized in the United States. Prior studies reporting the cost effectiveness of randomized interventions to improve CRC screening have not been replicated in the setting of small physician practices. We recently conducted a randomized trial evaluating an academic detailing intervention in 264 small practices in geographically diverse New York City communities. The objective of this secondary analysis is to assess the cost effectiveness of this intervention.

METHODS

A total of 264 physician offices were randomly assigned to usual care or to a series of visits from trained physician educators. CRC screening rates were measured at baseline and 12 months. The intervention costs were measured and the incremental cost-effectiveness ratio (ICER) was derived. Sensitivity analyses were based on varying cost and effectiveness estimates.

RESULTS

Academic detailing was associated with a 7% increase in CRC screening with colonoscopy. The total intervention cost was $147,865, and the ICER was $21,124 per percentage point increase in CRC screening rate. Sensitivity analyses that varied the costs of the intervention and the average medical practice size were associated with ICERs ranging from $13,631 to $36,109 per percentage point increase in CRC screening rates.

CONCLUSION

A comprehensive, multicomponent academic detailing intervention conducted in small practices in metropolitan New York was clinically effective in improving CRC screening rates, but was not cost effective.

Abstract B15: HPV vaccinations among a multi-ethnic female outpatient clinic sample

B15

Background

High risk types of HPV are necessary though not sufficient causes of the vast majority of cervical cancers. With the approval by FDA of the HPV vaccine among women age 9-26, dissemination is critical. Fewer than one-third of the US population has heard of HPV. Few know about its association with cervical cancer, and how to prevent its spread. Yet, physician recommendation is key to vaccination.

Methods

The study examines vaccination intentions and practices among a sample of 235 multi-ethnic/racial, urban primary care physicians who are enrolled in an RCT of an educational intervention. Intention was measured via self-report prior to FDA approval. Vaccination rates were assessed two years post-FDA vaccine approval, among their multi-ethnic female patients, age 18-26, using medical audit.

Results

Prior to the approval of the vaccine, findings revealed strong intention to vaccinate among physicians, at 92% extremely or somewhat likely to vaccinate. Multivariate analyses of primary care physicians revealed that those who regularly performed recto-pelvic examinations on asymptomatic women (β=0.21, p=0.03), and those who were more familiar with the ACS screening guidelines held stronger intentions to vaccinate (β=0.24, p=0.01) than did comparable others. Female primary care physicians had stronger intentions to vaccinate for HPV than male providers (β=0.21, p=0.03). Two years post-approval, 10% of multi-ethnic female patients age 18-26 have received at least one inoculation, 2% have received the entire 3-dose protocol. Major barriers are awareness, cost, and availability of the vaccine. Conclusions: The findings reveal stronger intentions to vaccinate than contemporaneous population-based surveys (80%), but similar predictors in gender and knowledge. The rate of vaccination is comparable to the 14% for the Hepatitis B vaccine among children one year post-approval, but much lower than among pediatricians in a Boston metropolitan hospital (57%) during a similar period of time. This is the first study to observe vaccination intentions among urban physicians working in under-resourced communities, and to systematically report the HPV vaccination uptake among their young adult female patients. Targeted dissemination strategies to urban primary care physicians in under-resourced areas, with tailored messages, are critical. In addition to exploring the pragmatic issues in disseminating the vaccine, we will examine the ethical, political, and social contexts for population-based HPV vaccine inoculations.

Citation Information: Cancer Prev Res 2008;1(7 Suppl):B15.

Exploring older women's approaches to cervical cancer screening

The purpose of this qualitative study (N = 98, 11 focus groups) is to investigate how low-income, African American and Hispanic older women make decisions about cervical cancer screening. Using the health belief model to guide content analysis of transcripts, we found that primary barriers to screening were; embarrassment with, fear of, and pain from the test, difficulty in accessing screening, stigma associated with Medicaid coverage, and prior negative experiences with cancer detection. Women experienced cues to screening from their own bodies, in symptoms, and relied on spiritual beliefs to support them in coping with their health problems. Enhanced understanding of these factors could increase uptake of cervical cancer screening among the unscreened and underscreened.

Awareness of genetic testing for cancer among United States Hispanics: the role of acculturation

BACKGROUND

The purpose of this study was to determine how acculturation affected awareness of genetic testing for cancer among Hispanic Americans.

METHODS

Subjects were 10,883 Hispanic respondents from the 2000 and 2005 National Health Interview Surveys. Acculturation was measured with language use and the length of time subjects had lived in the US. Weighted logistic regression was used to determine subjects' awareness of genetic susceptibility testing.

RESULTS

Greater use of English (adjusted odds ratio, OR = 1.25, 95% confidence interval, CI = 1.15-1.36) was associated with increased awareness of genetic testing. Residence in the US for less than 5 years (adjusted OR = 0.55, 95% CI 0.36-0.83) was associated with lower awareness of testing.

CONCLUSIONS

To better inform diverse American groups about genetic testing, intercultural variations and language skills must be taken into account.

Implementing academic detailing for breast cancer screening in underserved communities

BACKGROUND

African American and Hispanic women, such as those living in the northern Manhattan and the South Bronx neighborhoods of New York City, are generally underserved with regard to breast cancer prevention and screening practices, even though they are more likely to die of breast cancer than are other women. Primary care physicians (PCPs) are critical for the recommendation of breast cancer screening to their patients. Academic detailing is a promising strategy for improving PCP performance in recommending breast cancer screening, yet little is known about the effects of academic detailing on breast cancer screening among physicians who practice in medically underserved areas. We assessed the effectiveness of an enhanced, multi-component academic detailing intervention in increasing recommendations for breast cancer screening within a sample of community-based urban physicians.

METHODS

Two medically underserved communities were matched and randomized to intervention and control arms. Ninety-four primary care community (i.e., not hospital based) physicians in northern Manhattan were compared to 74 physicians in the South Bronx neighborhoods of the New York City metropolitan area. Intervention participants received enhanced physician-directed academic detailing, using the American Cancer Society guidelines for the early detection of breast cancer. Control group physicians received no intervention. We conducted interviews to measure primary care physicians' self-reported recommendation of mammography and Clinical Breast Examination (CBE), and whether PCPs taught women how to perform breast self examination (BSE).

RESULTS

Using multivariate analyses, we found a statistically significant intervention effect on the recommendation of CBE to women patients age 40 and over; mammography and breast self examination reports increased across both arms from baseline to follow-up, according to physician self-report. At post-test, physician involvement in additional educational programs, enhanced self-efficacy in counseling for prevention, the routine use of chart reminders, computer- rather than paper-based prompting and tracking approaches, printed patient education materials, performance targets for mammography, and increased involvement of nursing and other office staff were associated with increased screening.

CONCLUSION

We found some evidence of improvement in breast cancer screening practices due to enhanced academic detailing among primary care physicians practicing in urban underserved communities.

Intraurban influences on physician colorectal cancer screening practices

BACKGROUND

Community social and economic resources influence colorectal (CRC) screening decisions by physicians and patients. The aim of this study is to systematically assess the differences in screening recommendations of primary care physicians within two urban communities that are distinct in socioeconomic characteristics.

METHODS

Two-hundred-sixty-four primary care community (i.e., not hospital-based) physicians were stratified by community. Using self-report questionnaires, we examined primary care physicians' CRC screening practices, knowledge of risk factors and perceived physician and patient barriers to screening, Physicians practicing in upper-socioeconomic status (SES) communities were compared with those of participants practicing in lower SES communities.

RESULTS

Physicians practicing in low-SES urban communities were significantly more likely to screen with fecal occult blood test than were physicians in upper-SES areas. Alternatively, upper-SES physicians were significantly more likely to recommend screening colonoscopy than were lower-SES physicians. The number of physicians (N=11) who screened for CRC using the double-contrast barium enema were few.

CONCLUSIONS

Community-level SES influences physician cancer screening practices. Further understanding of these relationships may guide the development of interventions targeted to specific neighborhoods within urban areas.

Decision making in cancer primary prevention and chemoprevention

BACKGROUND

We know very little about how individuals decide to undertake, maintain, or discontinue cancer primary prevention or chemoprevention.

PURPOSE

The aims of this article are to (a) examine whether and, if so, how traditional health behavior change models are relevant for decision making in this area; (b) review the application of decision aids to forming specific, personal choices between options; and (c) identify the challenges of evaluating these decision processes to suggest areas for future research.

METHODS

Theoretical models and frameworks derived from the health behavior change and decision-making fields were applied to cancer primary prevention choices. Decision aids for the human papillomavirus (HPV) vaccine, Hormone Replacement Therapy (HRT), and tamoxifen were systematically examined.

RESULTS

Traditional concepts such as decisional balance and cues to action are relevant to understanding cancer primary prevention choices; Motivational Interviewing, Self-Determination Theory, and the Preventive Health Model may also explain the facilitators of decision making. There are no well-tested HPV vaccine decision aids, although there have been some studies on aids for HPV testing. There are several effective decision aids for HRT and tamoxifen; evidence-based decision aid components have also been identified.

CONCLUSIONS

Additional theory-based empirical research on decision making in cancer primary prevention and chemoprevention, particularly at the interface of psychology and behavioral economics, is suggested.

Delays in breast cancer diagnosis and treatment by racial/ethnic group

BACKGROUND

Although white women have the highest incidence of breast cancer, African American, followed by Hispanic, American Indian/Alaskan Native, and Asian American or Pacific Islander, women have higher death rates from the disease. Timely initiation of treatment has been shown to improve survival, and may help to lessen the mortality differences among racial/ethnic groups.

METHODS

The purpose of this study was to describe time delays in the initial diagnosis and treatment of primary breast carcinoma across diverse ethnic/racial groups. Data are from the Surveillance, Epidemiology, and End Results-Medicare database. Women in this study were diagnosed as having breast cancer between January 1, 1992, and December 31, 1999. Billing claims from outpatient and inpatient visits were used. A total of 49 865 female Medicare recipients 65 years and older were enrolled in the study. Racial/ethnic groups were compared in their diagnostic, treatment, and clinical delay (ie, women with a diagnostic and treatment delay).

RESULTS

African American women experienced the greatest diagnostic, treatment, and clinical delay. After controlling for other predictors, compared with white women, African American women had a 1.39-fold odds (95% confidence interval, 1.18-1.63) of diagnostic delay beyond 2 months, a 1.64-fold odds (95% confidence interval, 1.40-1.91) of treatment delay beyond 1 month, and a 2.24-fold odds (95% confidence interval, 1.75-2.86) of having a combined clinical delay.

CONCLUSIONS

In a population-based study, African American women experienced the most delays in initial diagnosis and initiation of breast cancer treatment, relative to women of other racial/ethnic subgroups. Despite the limitations of a claims database, the magnitude and direction of the findings are consistent across the research, suggesting the critical importance of reducing these delays.

Health care access among individuals involved in same-sex relationships

OBJECTIVES

We used data from the National Health Interview Survey to compare health care access among individuals involved in same-sex versus opposite-sex relationships.

METHODS

We conducted descriptive and logistic regression analyses from pooled data on 614 individuals in same-sex relationships and 93418 individuals in opposite-sex relationships.

RESULTS

Women in same-sex relationships (adjusted odds ratio [OR]=0.60; 95% confidence interval [CI]=0.39, 0.92) were significantly less likely than women in opposite-sex relationships to have health insurance coverage, to have seen a medical provider in the previous 12 months (OR=0.66; 95% CI=0.46, 0.95), and to have a usual source of health care (OR=0.50; 95% CI=0.35, 0.71); they were more likely to have unmet medical needs as a result of cost issues (OR=1.85; 95% CI=1.16, 2.96). In contrast, health care access among men in same-sex relationships was equivalent to or greater than that among men in opposite-sex relationships.

CONCLUSIONS

In this study involving a nationwide probability sample, we found some important differences in access to health care between individuals in same-sex and opposite-sex relationships, particularly women.

Effectiveness of academic detailing on breast cancer screening among primary care physicians in an underserved community

BACKGROUND

Urban minority groups, such as those living in northern Manhattan and the South Bronx, are generally underserved with regard to breast cancer prevention and screening practices. Primary care physicians are critical for the recommendation of mammography and clinical breast examinations to their patients.

DESIGN

Two medically underserved communities were matched and block randomized. The aim of the study was to assess the efficacy of academic detailing in increasing recommendations for breast cancer screening in community-based primary care physicians.

SETTING/PARTICIPANTS

Ninety-four primary care community-based (ie, not hospital-based) physicians in northern Manhattan were compared with 74 physicians in the South Bronx who received no intervention.

INTERVENTION

INTERVENTION participants received multicomponent physician-directed education, academic detailing, using the American Cancer Society guidelines for the early detection of breast cancer.

MAIN OUTCOME MEASURES

We administered interviews to ask about primary care physicians' recommendation of mammography and clinical breast examination. They were also queried about their knowledge of major risk factors and perceived barriers to breast cancer screening. We conducted medical audits of 710 medical charts 2 years before and after the intervention.

RESULTS

Using a mixed models linear analysis, we found a statistically significant intervention effect on the recommendation of mammography and clinical breast examination (according to medical audit) by female patients age 40 and over. INTERVENTION group physicians correctly identified significantly more risk factors for breast cancer, and significantly fewer barriers to practice, than did comparison physicians.

CONCLUSIONS

We found some evidence of improvement in breast cancer screening practices due to academic detailing among primary care physicians practicing in urban underserved communities.

A model of stage of change to recommend colonoscopy among urban primary care physicians

Theory is little used in the prediction of physician cancer screening stage of change. Structural equation modeling was used to evaluate the theoretical predictors of stage of change to recommend colonoscopy among 235 urban physicians. Constructs from the theory of planned behavior, social-cognitive theory, and the transtheoretical model were systematically tested. As predicted, contextual factors, such as the physicians' ages, their race-ethnicities, patient race-ethnicity, and office-related barriers to preventive care were associated with stage of change through self-efficacy, normative beliefs, and negative behavioral beliefs. The findings demonstrate the relevance of these models to studying the behavior of physicians and support the development of interventions that are tailored to normative beliefs and specific physician cognitions for colonoscopy recommendation.

Treatment for Breast Cancer in Patients with Alzheimer's Disease

OBJECTIVES

To report use of breast cancer treatment (surgery, radiation, and chemotherapy) by patients with Alzheimer's disease (AD).

DESIGN

Retrospective cohort study.

SETTING

Surveillance, Epidemiology, and End Results (SEER) is a population-based cancer registry covering 14% of the U.S. population.

PARTICIPANTS

Fifty thousand four hundred sixty breast cancer patients aged 65 and older, of whom 1,935 (3.8%) had a diagnosis of AD before or up to 6 months after cancer diagnosis.

MEASUREMENTS

Diagnosis of AD was taken from International Classification of Diseases, Ninth Revision, diagnostic codes accompanying Medicare billing claims between 1992 and 1999. The SEER program reported surgery and radiation. Chemotherapy was taken from Medicare billing records.

RESULTS

Subjects with AD were diagnosed with breast cancer at later stages, when tumors were larger and the likelihood of lymph node involvement had increased. Patients with AD had a lower likelihood of surgery (odds ratio (OR)=0.60, 95% confidence interval (CI)=0.46-0.81), radiation (OR=0.31, 95% CI=0.23-0.41), and chemotherapy (OR=0.44, 95% CI=0.34-0.58) than those without AD.

CONCLUSION

Overall, AD patients receive less treatment for breast cancer than do comparable female Medicare beneficiaries. Chemotherapy and radiation are administered less frequently to women with AD than to other comparable patients. It is unclear whether suboptimal medical care has an effect on their survival. Further research on the effect of screening and treatment decision-making for these patients is warranted.