Advance Care Planning for African American Caregivers of Relatives With Dementias: Cluster Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

African-American family caregivers may have insufficient knowledge to make informed end-of-life (EOL) decisions for relatives with dementias. Advance Care Treatment Plan (ACT-Plan) is a community-based education intervention to enhance knowledge of dementia and associated EOL medical treatments, self-efficacy, intentions, and behavior (written EOL care plan). This study evaluated efficacy of the intervention compared to attention control.

RESEARCH DESIGN AND METHODS

In a theoretically based, 2-group, cluster randomized controlled trial, 4 similar Midwestern urban megachurches were randomized to experimental or control conditions. Each church recruited African-American caregivers, enrolling concurrent waves of 5 to 9 participants in 4 weekly 1-hour sessions (358 total: ACT-Plan n = 173, control n = 185). Dementia, cardiopulmonary resuscitation (CPR), mechanical ventilation (MV), and tube feeding (TF) treatments were discussed in ACT-Plan classes. Participants completed assessments before the initial class, after the final class (week 4), and at week 20. Repeated measures models were used to test the intervention effect on changes in outcomes across time, adjusting for covariates as needed.

RESULTS

Knowledge of CPR, MV, TF, and self-efficacy to make EOL treatment decisions increased significantly more in the ACT-Plan group at weeks 4 and 20. Knowledge of dementia also increased more in the ACT-Plan group at both points, reaching statistical significance only at week 20. Intentions to make EOL treatment decisions and actually an advance care plan were similar between treatment arms.

DISCUSSION AND IMPLICATIONS

Findings demonstrate promise for ACT-Plan to increase informed EOL treatment decisions for African American caregivers of individuals with dementias.

Abstract PO-080: Do African American informal caregivers’ breast cancer fear and cultural beliefs predict the dissemination of breast cancer misinformation and lower mammogram uptake among their social networks?

Introduction: African American women experience a disproportionate burden of breast cancer morbidity and mortality. For African American breast cancer survivors, members of their social networks often act as informal caregivers - offering social support and assisting with treatment adherence. They may thus serve as opinion leaders within their own social networks, given their personal experiences with the breast cancer survivor. Nonetheless, informal caregivers are not formally trained and may be vulnerable to breast cancer cultural beliefs and fear related to breast cancer. For this study, we examined: 1) if informal caregivers’ breast cancer cultural beliefs and fear were predictive of breast cancer misinformation shared among their social networks and, 2) if misinformation shared led to lower mammogram uptake among their networks. Methods: This is a secondary analysis of the Offering African Survivors Increased Support (OASIS) study, which assessed African American breast cancer survivors’ experiences with cancer care. To be eligible, subjects had to be: 1) identified as an informal caregiver by a survivor, 2) female, and, 3) of breast cancer screening age (50-74 years). Recruitment took place from Feb 2019 – Mar 2020.

Subjects took part in 60-90 minute in-person or telephone surveys and received an incentive for participation. Validated scales were used in the survey tool to quantify cultural beliefs and fear, spread of breast cancer misinformation, and mammogram uptake. Results: 142 informal caregivers were recruited. All were African American, 56% were 50-62 years of age, 95% had a primary care provider, and 82% had a mammogram in the past year. Overall, 65% reported ≥1 breast cancer cultural belief and all reported breast cancer fear. On average, informal caregivers reported 1.55 (range: 0-15) cultural beliefs and a moderate level of fear (score=19.72, 8-32). 18.3% of informal caregivers shared breast cancer misinformation to their networks.

Informal caregivers who reported ≥1 cultural belief had 74% greater odds of sharing misinformation to their networks (OR=1.74, 95%CI [1.32, 2.29], p<.0001). Among the 341 social network members of informal caregivers who were women and 50-74 years of age, those who received misinformation were 63% less likely to obtain a mammogram (OR=0.37, 95%CI [0.14, 0.94], p=0.04). Conclusion: Informal caregivers who reported breast cancer cultural beliefs were significantly more likely to share breast cancer misinformation to their social networks and social network members who received this misinformation were significantly less likely to receive mammograms. These results may inform planning for health education efforts and community-healthcare interventions that address breast cancer cultural beliefs and promote mammogram uptake among African American women. Future research will assess key themes in breast cancer misinformation shared and differences in misinformation shared from informal caregivers to their networks based on relationship type.

Citation Format: Nyahne Q. Bergeron, Mona Strahan, Shaila Strayhorn, Anita Rong, Misael Villegas, Nancy Rayas, Stephanie Jara, Izalia Ruiz, Aditya Khanna, Dana Villines, Karriem Watson, Carol Ferrans, Yamilé Molina. Do African American informal caregivers’ breast cancer fear and cultural beliefs predict the dissemination of breast cancer misinformation and lower mammogram uptake among their social networks? [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-080.

Abstract A023: Do African American informal caregivers’ breast cancer fear and cultural misconceptions predict the spread of breast cancer misinformation among their social networks?

Introduction: African American women experience a disproportionate burden of breast cancer morbidity and mortality. Members of African American breast cancer survivors’ social networks often act as informal caregivers, offering psychosocial support, sharing important information, and assisting with treatment adherence. They may thus serve as opinion leaders within their own social networks, especially if they are also women and are within the recommended age for breast cancer screening. Nonetheless, informal caregivers are not formally trained and may be vulnerable to cultural misconceptions and higher levels of fear through their firsthand experiences as caregivers. Understanding the relationship between breast cancer cultural misconceptions, fear and the spread of misinformation among the social networks is crucial; yet, little research has been done in this area. Methods: This is a secondary analysis of the Offering African Survivors Increased Support (OASIS) study, which assesses African American breast cancer survivors’ experiences with cancer care. To be eligible, participants had to be: 1) identified as a support person by a survivor; 2) female; and, 3) 50-74 years old. We used the validated Ferrans Cultural Beliefs and Champion Breast Cancer Fear scales to quantify cultural misconceptions and fear retrospectively. For social network dissemination, we used a modified Burt’s General Social Survey instrument and coded open-ended fields regarding communication between caregivers and up to 5 network caregivers. Results: 30 informal caregivers were surveyed. Sixty percent reported at least one cultural misconception, the most common misconception being “If breast cancer is cut open in surgery, it will grow faster.” Approximately 33% further disseminated cultural misconceptions to 2 or more people within their networks. After adjusting for education, our multivariable linear regression suggested that informal caregivers who report greater breast cancer fear (Std B = 0.46, p = .008) and more misconceptions (Std B = 0.44, p = .02) disseminated cultural misconceptions to more people within their network. Conclusion: Informal caregivers that reported greater misconceptions and fear related to breast cancer were significantly more likely to share breast cancer misinformation to their social networks. These results show the value of initiatives in clinical and community settings that address these misconceptions and support increased breast cancer screening. Future research will assess the specific recipients of miscommunication (e.g., family, friends) and how this miscommunication is associated with the likelihood of obtaining breast cancer screening among their networks.

Citation Format: Nyahne Q Bergeron, Mona Strahan, Shaila Strayhorn, Aditya Khanna, Dana Villines, Karriem Watson, Carol Ferrans, Yamile Molina. Do African American informal caregivers’ breast cancer fear and cultural misconceptions predict the spread of breast cancer misinformation among their social networks? [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 A023.

Changes in the racial disparity in breast cancer mortality in the ten US cities with the largest African American populations from 1999 to 2013: The reduction in breast cancer mortality disparity in Chicago

PURPOSE

Assess progress made to reduce racial disparity in breast cancer mortality in Chicago compared to nine other cities with largest African American populations and the US.

METHODS

The Non-Hispanic Black (NHB) and Non-Hispanic White (NHW) female breast cancer mortality rates and rate ratios (RR) (disparity) were compared between 1999 and 2005 and 2006 and 2013.

RESULTS

Between the two periods, the NHB breast cancer mortality rate in Chicago decreased by 13.9% (95% CI [-13.81, -13.92] compared to 7.7% (95% CI [-7.52, -7.83]) for NHW. A drop of 20% in the disparity was observed, from 51% (RR: 1.51, 95% CI [-7.52, -7.83]) to 41% (RR: 1.41, 95% CI [1.30, 1.52]). Whereas from 1999 to 2005 Chicago's disparity was above that of the U.S., from 2006 to 2013, it is now slightly lower. For the remaining nine cities and the US, the mortality disparity either grew or remained the same.

CONCLUSIONS

Chicago's improvement in NHB breast cancer mortality and disparity reduction occurred in the context of city-wide comprehensive public health initiatives and shows promise as a model for other cities with high health outcome disparities.

Abstract B03: Cultural beliefs among Latina women: The role of acculturation and impact on timeliness of breast cancer care

Purpose: Certain cultural beliefs related to breast cancer may act as a barrier to a woman seeking breast cancer preventive services or timely follow-up for a breast symptom. In the Breast Cancer Care in Chicago study, Hispanic patients held considerably more cultural beliefs compared to African-American or non-Hispanic White patients. For Hispanics, holding beliefs that are inconsistent with health care seeking behavior may lead to low or delayed utilization of care regardless of access. This study explores factors associated with breast cancer beliefs among Hispanic women and how this might lead to delays in seeking care or receiving treatment for breast cancer.

Methods: Data were obtained from a population-based sample of 181 urban Hispanic women recruited as part of the Breast Cancer Care in Chicago study. Women were ages 30-79 and had been diagnosed with primary in situ or invasive breast cancer. Interviews included a 15 item cultural beliefs scale spanning a range of beliefs regarding the meaning of a breast lump, importance of treatment, and the role of faith – beliefs that could be inconsistent with motivation to seek timely health care. We dichotomized the total number of beliefs at the sample mean, such that patients holding 3 or more beliefs (index) were compared to patients holding fewer than 3 beliefs (referent). Potential demographic, sociocultural, parental, and care utilization factors were examined, as were measures of acculturation and cultural isolation. An acculturation scale was created based on patient country of origin and language, and parents' country of origin and education. Possible scores ranged from 0-6 (low acculturation=0, high acculturation > 1). Prolonged treatment delay was defined as a time from first clinical visit to first breast cancer treatment exceeding 60 days (sample median), and prolonged total delay was defined as a time from initial symptom detection (self-detected or clinically detected) to first treatment exceeding 90 days (sample median). Logistic regression with model-based standardization was used to estimate confounder-adjusted risk differences for prolonged delay by number of beliefs held.

Results: Seventy-five percent of women held 1 or more beliefs. Beliefs most commonly held were: 1) Faith in God can protect you from breast cancer (48%); 2) If a breast lump is touched or pressed often, the lump will turn out to be breast cancer (30%); and 3) If breast cancer is cut open in surgery, it will grow faster (28%). Fifty percent of the sample had an acculturation score of zero (Mean= 1). Lower acculturation was associated with greater beliefs: patients who were older, born outside the US, did not speak English as a primary language, or whose parents were less educated or born outside the US tended to hold more beliefs (p<0.05). Patients with less income, less education, and lacking private health insurance also tended to hold more beliefs (p<0.05). Both treatment delay (57% vs. 43%, p=0.07) and total delay (59% vs. 32%, p=0.0005) were more common for women holding 3 or more beliefs vs. two or less. After adjusting for age, education, income and acculturation, holding 3 or more beliefs was associated with a 30 percentage point increased risk of prolonged total delay (RD=0.29, 95% CI: 0.12, 0.48) and a 13 percentage point increased risk of prolonged treatment delay (RD=0.13, 95% CI: -0.03, 0.32).

Conclusions: Cultural beliefs may predispose certain Hispanic women who are less acculturated and of lower SES to prolong seeking care for breast symptoms and may influence delays in receiving diagnosis and treatment for breast cancer.

Citation Format: Rani I. Gallardo, Garth Rauscher, Carol Ferrans. Cultural beliefs among Latina women: The role of acculturation and impact on timeliness of breast cancer care. [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 B03. doi:10.1158/1538-7755.DISP13-B03

Towards a unified taxonomy of health indicators: academic health centers and communities working together to improve population health

The Clinical and Translational Science Awards (CTSA) program represents a significant public investment. To realize its major goal of improving the public's health and reducing health disparities, the CTSA Consortium's Community Engagement Key Function Committee has undertaken the challenge of developing a taxonomy of community health indicators. The objective is to initiate a unified approach for monitoring progress in improving population health outcomes. Such outcomes include, importantly, the interests and priorities of community stakeholders, plus the multiple, overlapping interests of universities and of the public health and health care professions involved in the development and use of local health care indicators.The emerging taxonomy of community health indicators that the authors propose supports alignment of CTSA activities and facilitates comparative effectiveness research across CTSAs, thereby improving the health of communities and reducing health disparities. The proposed taxonomy starts at the broadest level, determinants of health; subsequently moves to more finite categories of community health indicators; and, finally, addresses specific quantifiable measures. To illustrate the taxonomy's application, the authors have synthesized 21 health indicator projects from the literature and categorized them into international, national, or local/special jurisdictions. They furthered categorized the projects within the taxonomy by ranking indicators with the greatest representation among projects and by ranking the frequency of specific measures. They intend for the taxonomy to provide common metrics for measuring changes to population health and, thus, extend the utility of the CTSA Community Engagement Logic Model. The input of community partners will ultimately improve population health.

A psychoeducational intervention (SWEEP) for depressed women with diabetes

BACKGROUND

Clinically significant depression is present in 25 % of individuals with type 2 diabetes, its risk being doubled in women.

PURPOSE

To examine the effectiveness of the Study of Women's Emotions and Evaluation of a Psychoeducational (SWEEP), a group therapy for depression treatment based on cognitive behavioral therapy principles that was developed for women with type 2 diabetes was conducted.

METHODS

Women with significantly elevated depression symptoms (Center for Epidemiologic Studies Depression Scale ≥16) were randomized to SWEEP (n = 38) or usual care (UC, n = 36).

RESULTS

Multilevel modeling indicated that SWEEP was more effective than UC in reducing depression (mean difference of -15 vs. -7, p < .01), decreasing trait anxiety (mean difference of -15 vs. -5, p < .01), and improving anger expression (mean difference of -12 vs. -5, p < .05). Although SWEEP and UC had improvements in fasting glucose (mean difference of -24 vs. -1 mg/dl) and HbA1c (mean difference of -0.4 vs. -0.1 %), there were no statistically significant differences between groups.

CONCLUSIONS

SWEEP was more effective than UC for treating depressed women with type 2 diabetes. Addition of group therapy for depression meaningfully expands the armamentarium of evidence-based treatment options for women with diabetes.

Does glycemic variability impact mood and quality of life?

BACKGROUND

Diabetes is a chronic condition that significantly impacts quality of life. Poor glycemic control is associated with more diabetes complications, depression, and worse quality of life. The impact of glycemic variability on mood and quality of life has not been studied.

METHODS

A descriptive exploratory design was used. Twenty-three women with type 2 diabetes wore a continuous glucose monitoring system for 72 h and completed a series of questionnaires. Measurements included (1) glycemic control shown by glycated hemoglobin and 24-h mean glucose, (2) glycemic variability shown by 24-h SD of the glucose readings, continuous overall net glycemic action (CONGA), and Fourier statistical models to generate smoothed curves to assess rate of change defined as "energy," and (3) mood (depression, anxiety, anger) and quality of life by questionnaires.

RESULTS

Women with diabetes and co-morbid depression had higher anxiety, more anger, and lower quality of life than those without depression. Certain glycemic variability measures were associated with mood and quality of life. The 24-h SD of the glucose readings and the CONGA measures were significantly associated with health-related quality of life after adjusting for age and weight. Fourier models indicated that certain energy components were significantly associated with depression, trait anxiety, and overall quality of life. Finally, subjects with higher trait anxiety tended to have steeper glucose excursions.

CONCLUSIONS

Data suggest that greater glycemic variability may be associated with lower quality of life and negative moods. Implications include replication of the study in a larger sample for the assessment of blood glucose fluctuations as they impact mood and quality of life.

The association of quality of life with potentially remediable disruptions of circadian sleep/activity rhythms in patients with advanced lung cancer

BACKGROUND

Cancer patients routinely develop symptoms consistent with profound circadian disruption, which causes circadian disruption diminished quality of life. This study was initiated to determine the relationship between the severity of potentially remediable cancer-associated circadian disruption and quality of life among patients with advanced lung cancer.

METHODS

We concurrently investigated the relationship between the circadian rhythms of 84 advanced lung cancer patients and their quality of life outcomes as measured by the EORTC QLQ C30 and Ferrans and Powers QLI. The robustness and stability of activity/sleep circadian daily rhythms were measured by actigraphy. Fifty three of the patients in the study were starting their definitive therapy following diagnosis and thirty one patients were beginning second-line therapy. Among the patients who failed prior therapy, the median time between completing definitive therapy and baseline actigraphy was 4.3 months, (interquartile range 2.1 to 9.8 months).

RESULTS

We found that circadian disruption is universal and severe among these patients compared to non-cancer-bearing individuals. We found that each of these patient's EORTC QLQ C30 domain scores revealed a compromised capacity to perform the routine activities of daily life. The severity of several, but not all, EORTC QLQ C30 symptom items correlate strongly with the degree of individual circadian disruption. In addition, the scores of all four Ferrans/Powers QLI domains correlate strongly with the degree of circadian disruption. Although Ferrans/Powers QLI domain scores show that cancer and its treatment spared these patients' emotional and psychological health, the QLI Health/Function domain score revealed high levels of patients' dissatisfaction with their health which is much worse when circadian disruption is severe. Circadian disruption selectively affects specific Quality of Life domains, such as the Ferrans/Powers Health/Function domain, and not others, such as EORTC QLQ C30 Physical Domain.

CONCLUSIONS

These data suggest the testable possibility that behavioral, hormonal and/or light-based strategies to improve circadian organization may help patients suffering from advanced lung cancer to feel and function better.

Circadian clock manipulation for cancer prevention and control and the relief of cancer symptoms

Life has evolved on this planet with regular daily spans of direct solar energy availability alternating with nocturnal spans of dark. Virtually every earth-borne life form has factored this circadian pattern into its biology to ensure the temporal coordination with its resonating environment, a task essential for its individual survival and that of its species. The first whole genome inspections of mutations in human colon and breast cancer have observed specific retained clock gene mutations. Single nucleotide polymorphisms within the genes of clock, clock-controlled, and melatonin pathways have been found to confer excess cancer risk or protection from cancer. Experimental studies have shown that specific core clock genes (Per2 and Per1) are tumor suppressors because their genetic absence doubles tumor numbers, and decreasing their expression in cancer cells doubles cancer growth rate, whereas their overexpression decreases cancer growth rate and diminishes tumor numbers. Experimental interference with circadian clock function increases cancer growth rate, and clinical circadian disruption is associated with higher cancer incidence, faster cancer progression, and shorter cancer patient survival. Patients with advanced lung cancer suffering greater circadian activity/sleep cycle disruption suffer greater interference with function, greater anxiety and depression, poorer nighttime sleep, greater daytime fatigue, and poorer quality of life than comparable patients who maintain good circadian integration. We must now determine whether strategies known to help synchronize the circadian clocks of normal individuals can do so in advanced cancer patients and whether doing so allows cancer patients to feel better and/or live longer. Several academic laboratories and at least 2 large pharmaceutical firms are screening for small molecules targeting the circadian clock to stabilize its phase and enhance its amplitude and thereby consolidate and coordinate circadian organization, which in turn is likely to help prevent and control human cancer. These drugs and strategies can, in turn, be used to make cancer patients with advanced disease feel and function more normally.

The clinical significance of quality of life assessments in oncology: a summary for clinicians

BACKGROUND

A series of six manuscripts with an introduction appeared in the Mayo Clinic Proceedings, based upon the collective effort of 30 individuals with an interest and expertise in assessing the clinical significance of quality of life (QOL) assessments. The series of manuscripts described the state of the science of QOL assessments in oncology clinical research and practice and included extensive literature and theoretical justification for the continued inclusion of QOL in oncology clinical research and practice.

OBJECTIVES

The purpose of this paper is to produce a summary of these articles and to supplement these works with additional information that was gleaned from subsequent meetings and discussions of this material. The primary aim of this paper is to present a cogent and concise description for clinicians to facilitate the incorporation of QOL assessments into oncology clinical research and practice. The theoretical discussion is supplemented with an example of how the various ideas can be operationalized in an oncology clinical trial.

Fatigue and physical activity in patients undergoing hematopoietic stem cell transplant

PURPOSE/OBJECTIVES

To examine the patterns of fatigue, physical activity, health status, and quality of life before and after high-dose chemotherapy and hematopoietic stem cell transplantation (HSCT) and to examine the feasibility of obtaining real-time fatigue and physical activity data.

DESIGN

Prospective, repeated measures.

SETTING

Two midwestern academic medical centers.

SAMPLE

Convenience sample of autologous or allogeneic patients undergoing HSCT (N = 20 baseline, N = 17 post-transplant).

METHODS

Subjects were assessed over a five-day period before and after HSCT for a total of 10 days. Subjects rated fatigue intensity three times daily and wore a wrist actigraph to measure physical activity. At the end of both five-day periods, subjects completed measures of perceived health status (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30) and life satisfaction Quality of Life Index).

MAIN RESEARCH VARIABLES

Fatigue, physical activity, perceived health status, and quality of life.

FINDINGS

Study results indicate that fatigue significantly increased and physical activity decreased following high-dose chemotherapy and HSCT. The decline coincided with diminished physical, emotional, role, and cognitive functioning. The symptoms that patients experienced (i.e., fatigue, pain, nausea and vomiting, sleep disturbances, appetite loss, and diarrhea) increased during the acute post-transplant period. No significant changes in life satisfaction were found.

CONCLUSIONS

The study findings suggest that patients receiving high-dose chemotherapy followed by HSCT experience increased fatigue, reduced physical activity, diminished functioning, and poorer quality of life immediately after transplant. Findings demonstrate that real-time fatigue and physical activity data can feasibly be collected in acutely ill patients.

IMPLICATIONS FOR NURSING

Patients undergoing HSCT require considerable supportive nursing care immediately following transplant. Clinicians and researchers need to strive for effective symptom management to improve the likelihood of successful outcomes.