Mail-Based Self-Sampling to Complete Colorectal Cancer Screening: Accelerating Colorectal Cancer Screening and Follow-up Through Implementation Science

Introduction

Leveraging cancer screening tests, such as the fecal immunochemical test (FIT), that allow for self-sampling and postal mail for screening invitations, test delivery, and return can increase participation in colorectal cancer (CRC) screening. The range of approaches that use self-sampling and mail for promoting CRC screening, including use of recommended best practices, has not been widely investigated.

Methods

We characterized self-sampling and mail strategies used for implementing CRC screening across a consortium of 8 National Cancer Institute Cancer Moonshot Initiative Accelerating Colorectal Cancer Screening and Follow-up through Implementation Science (ACCSIS) research projects. These projects serve diverse rural, urban, and tribal populations in the US.

Results

All 8 ACCSIS projects leveraged self-sampling and mail to promote screening. Strategies included organized mailed FIT outreach with mailed invitations, including FIT kits, reminders, and mailed return (n = 7); organized FIT-DNA outreach with mailed kit return (n = 1); organized on-demand FIT outreach with mailed offers to request a kit for mailed return (n = 1); and opportunistic FIT-DNA with in-clinic offers to be mailed a test for mailed return (n = 2). We found differences in patient identification strategies, outreach delivery approaches, and test return options. We also observed consistent use of Centers for Disease Control and Prevention Summit consensus best practice recommendations by the 7 projects that used mailed FIT outreach.

Conclusion

In research projects reaching diverse populations in the US, we observed multiple strategies that leverage self-sampling and mail to promote CRC screening. Mail and self-sampling, including mailed FIT outreach, could be more broadly leveraged to optimize cancer screening.

Accelerating Colorectal Cancer Screening and Follow-up through Implementation Science (ACCSIS) in Appalachia: protocol for a group randomized, delayed intervention trial

Appalachian regions of Kentucky and Ohio are hotspots for colorectal cancer (CRC) mortality in the USA. Screening reduces CRC incidence and mortality; however, screening uptake is needed, especially in these underserved geographic areas. Implementation science offers strategies to address this challenge. The aim of the current study was to conduct multi-site, transdisciplinary research to evaluate and improve CRC screening processes using implementation science strategies. The study consists of two phases (Planning and Implementation). In the Planning Phase, a multilevel assessment of 12 health centers (HC) (one HC from each of the 12 Appalachian counties) was conducted by interviewing key informants, creating community profiles, identifying HC and community champions, and performing HC data inventories. Two designated pilot HCs chose CRC evidence-based interventions to adapt and implement at each level (i.e., patient, provider, HC, and community) with evaluation relative to two matched control HCs. During the Implementation Phase, study staff will repeat the rollout process in HC and community settings in a randomized, staggered fashion in the remaining eight counties/HCs. Evaluation will include analyses of electronic health record data and provider and county surveys. Rural HCs have been reluctant to participate in research because of concerns about capacity; however, this project should demonstrate that research does not need to be burdensome and can adapt to local needs and HC abilities. If effective, this approach could be disseminated to HC and community partners throughout Appalachia to encourage the uptake of effective interventions to reduce the burden of CRC.

Characteristics of patient navigation programs in the Cancer Moonshot ACCSIS colorectal cancer screening initiative

BACKGROUND

Although patient navigation has shown promise for increasing participation in colorectal cancer screening and follow-up, little evidence is available to guide implementation of patient navigation in clinical practice. We characterize 8 patient navigation programs being implemented as part of multi-component interventions of the National Cancer Institute's Cancer Moonshot Accelerating Colorectal Cancer Screening and Follow-Up Through Implementation Science (ACCSIS) initiative.

METHODS

We developed a data collection template organized by ACCSIS framework domains. The template was populated by a representative from each of the 8 ACCSIS research projects. We report standardized descriptions of 1) the socio-ecological context in which the navigation program was being conducted, 2) navigation program characteristics, 3) activities undertaken to facilitate program implementation (eg, training), and 4) outcomes used in program evaluation.

RESULTS

ACCSIS patient navigation programs varied broadly in their socio-ecological context and settings, the populations they served, and how they were implemented in practice. Six research projects adapted and implemented evidence-based patient navigation programs; the remaining projects developed new programs. Five projects began navigation when patients were due for initial colorectal cancer screening; 3 projects began navigation later in the screening process, when patients were due for follow-up colonoscopy after an abnormal stool-test result. Seven projects relied on existing clinical staff to deliver the navigation; 1 hired a centralized research navigator. All project researchers plan to evaluate the effectiveness and implementation of their programs.

CONCLUSIONS

Our detailed program descriptions may facilitate cross-project comparisons and guide future implementation and evaluation of patient navigation programs in clinical practice.

Older cancer survivors' perspectives and use of telehealth in their cancer survivorship care in the United States: A ResearchMatch® sample

INTRODUCTION

COVID-19 has resulted in reliance on telecommunication technologies for the provision of supportive cancer care. However, research on the use of these resources among older adults, who are the majority of cancer survivors, is limited. The objective of this study was to gather information on older cancer survivors' perspectives and use of telehealth their cancer survivorship care in the United States.

MATERIALS AND METHODS

Potential participants were recruited through ResearchMatch® from December 2020-January 2021. Online semi-structured interviews were conducted. Descriptive statistics were used to analyze the participants' demographic and health characteristics. Content analysis were conducted by two independent coders for identification of common themes. Coding agreement was reached through consensus, and count comparisons of participant responses were made.

RESULTS

The majority of respondents (n = 21; mean age = 73.5 ± 4.9) were female (57%), White (90%), and had a variety of cancer diagnoses. Participants reported using a variety of technology devices and telehealth products. Older cancer survivors (n = 10) endorsed telehealth video use for physical health concerns and basic check-ups, but some (n = 4) preferred in-person visits for major concerns and sensitive issues (e.g., mental health). Half of participants reported mobile health app use; however, ten participants did not use these apps as they felt the technology was not useful. Barriers to health technology use included missing face-to-face connections with providers, lack of familiarity with the technology, and perceived lack of utility and personalized telehealth platforms. Lastly, video-based conferencing and social media site use among seventeen participants was reported for social interaction during the COVID-19 pandemic.

DISCUSSION

These findings suggest that older cancer survivors utilize online platforms for their general health; however, they prefer in-person visits for serious issues and value personalization with telehealth. Despite from a highly educated sample of ResearchMatch® participants, these results can be used to inform clinicians and researchers about the appropriateness and provision of telehealth-based supportive care among older cancer survivors.

Strategies to improve diversity, equity, and inclusion in clinical trials

There is a growing need for diversity, equity, and inclusion (DEI) in cancer care, particularly with respect to equal access and accrual to clinical trials. This commentary describe steps taken to address disparities in the authors' own clinical practice and proposes actions at the patient, provider, community, and institution levels to improve DEI in clinical trials.

Development of a multilevel intervention to increase colorectal cancer screening in Appalachia

BACKGROUND

Colorectal cancer (CRC) screening rates are lower in Appalachian regions of the United States than in non-Appalachian regions. Given the availability of various screening modalities, there is critical need for culturally relevant interventions addressing multiple socioecological levels to reduce the regional CRC burden. In this report, we describe the development and baseline findings from year 1 of "Accelerating Colorectal Cancer Screening through Implementation Science (ACCSIS) in Appalachia," a 5-year, National Cancer Institute Cancer MoonshotSM-funded multilevel intervention (MLI) project to increase screening in Appalachian Kentucky and Ohio primary care clinics.

METHODS

Project development was theory-driven and included the establishment of both an external Scientific Advisory Board and a Community Advisory Board to provide guidance in conducting formative activities in two Appalachian counties: one in Kentucky and one in Ohio. Activities included identifying and describing the study communities and primary care clinics, selecting appropriate evidence-based interventions (EBIs), and conducting a pilot test of MLI strategies addressing patient, provider, clinic, and community needs.

RESULTS

Key informant interviews identified multiple barriers to CRC screening, including fear of screening, test results, and financial concerns (patient level); lack of time and competing priorities (provider level); lack of reminder or tracking systems and staff burden (clinic level); and cultural issues, societal norms, and transportation (community level). With this information, investigators then offered clinics a menu of EBIs and strategies to address barriers at each level. Clinics selected individually tailored MLIs, including improvement of patient education materials, provision of provider education (resulting in increased knowledge, p = .003), enhancement of electronic health record (EHR) systems and development of clinic screening protocols, and implementation of community CRC awareness events, all of which promoted stool-based screening (i.e., FIT or FIT-DNA). Variability among clinics, including differences in EHR systems, was the most salient barrier to EBI implementation, particularly in terms of tracking follow-up of positive screening results, whereas the development of clinic-wide screening protocols was found to promote fidelity to EBI components.

CONCLUSIONS

Lessons learned from year 1 included increased recognition of variability among the clinics and how they function, appreciation for clinic staff and provider workload, and development of strategies to utilize EHR systems. These findings necessitated a modification of study design for subsequent years.

TRIAL REGISTRATION

Trial NCT04427527 is registered at https://clinicaltrials.gov and was registered on June 11, 2020.

Abstract PO-253: Increasing colorectal cancer screening in rural underserved communities with multilevel interventions: Formative evaluation of accelerating colorectal cancer screening and follow-up through implementation science in Appalachia

Background: Colorectal cancer (CRC) screening is lower in Appalachian regions of Kentucky and Ohio than in their non-Appalachian counterparts, with lower screening contributing to increased CRC incidence and mortality. To address CRC disparities in these underserved regions, researchers from the University of Kentucky and The Ohio State University partnered with two federally qualified health centers (FQHCs) to develop and implement multilevel interventions (MLIs) during year one of a 5-year National Cancer Institute funded Cancer Moonshot project to increase CRC screening and follow-up in Appalachian Kentucky and Ohio. Methods: Drawing from the Model for the Analysis of Population Health and Health Disparities and using a social determinants of health framework, researchers selected and partnered with Community Advisory Boards (CAB) to guide project formation in two Appalachian counties, one in Kentucky and one in Ohio. These formative activities included creating community profiles, conducting key informant interviews with clinic and community champions, and completing data inventories to assess clinic capacity, ultimately resulting in two primary care clinics being selected for pilot year implementation activities. Results: Key informant interviews revealed barriers to CRC screening at multiple levels: patient (e.g., fear of screening results), provider (e.g., competing priorities), clinic (e.g., lack of reminder or tracking systems), and community (e.g., cultural norms). Clinic champions were provided with menus of evidence-based interventions (EBIs) to address barriers at each level and were encouraged to select locally relevant, implementable EBIs. Clinics chose to implement the following EBIs: improved patient education materials (patient-level), additional provider education (provider-level), improvement of electronic health record (EHR) reporting and creation of clinic-wide screening protocols (clinic-level), and provision of interactive screening education at community events (community- level). Conclusion: Results from pilot year activities were used to refine the project approach for years two through five. Project activities will be expanded to 10 more Appalachian counties in Kentucky and Ohio using a design wherein counties will be paired by participating clinic patient volume. As in pilot year activities, clinic/community champions will be encouraged to select EBIs appropriate to their patients, providers, clinics, and communities. To measure clinical outcomes, self- reported screening will be monitored using data from county-wide telephone surveys with additional data from clinic EHRs. Using an MLI approach may be well- received in underserved rural Appalachian communities and may ultimately be successful at reducing CRC screening disparities.

Citation Format: Aaron J. Kruse-Diehr, Jill M. Oliveri, Mira L. Katz, Mark Cromo, Robin C. Vanderpool, Michael L. Pennell, Darrell M. Gray II, Paul L. Reiter, Bin Huang, Gregory S. Young, Darla Fickle, Melinda Rogers, David Gross, Sue Russell, Electra D. Paskett, Mark Dignan. Increasing colorectal cancer screening in rural underserved communities with multilevel interventions: Formative evaluation of accelerating colorectal cancer screening and follow-up through implementation science in Appalachia [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-253.

A randomized study to prevent lymphedema in women treated for breast cancer: CALGB 70305 (Alliance)

BACKGROUND

Lymphedema affects many women who are treated for breast cancer. We examined the effectiveness of an education-only (EO) versus education plus sleeve compression/exercise intervention (lymphedema education and prevention [LEAP]) on lymphedema incidence and range of motion (ROM) in a group-randomized trial across 38 cooperative group sites.

METHODS

The treating institution was randomly assigned to either EO or LEAP by a study statistician. All patients at a treating institution participated in the same intervention (EO or LEAP) to minimize contamination bias. Participants completed surveys, arm volume measurements, and self-reported ROM assessments before surgery and at 12 and 18 months after surgery. Lymphedema was defined as a ≥10% difference in limb volume at any time post-surgery up to 18 months after surgery or diagnosis by a health provider. Cochran-Mantel-Haenszel tests were used to compare lymphedema-free rates between groups, stratified by lymph node surgery type. Self-reported ROM differences were compared between groups.

RESULTS

A total of 554 participants (56% LEAP) were included in the analyses. At 18 months, lymphedema-free rates were 58% (EO) versus 55% (LEAP) (P = .37). ROM for both arms was greater in LEAP versus EO at 12 months; by 18 months, most women reported full ROM, regardless of group. In LEAP, only one-third wore a sleeve ≥75% of the time; 50% performed lymphedema exercises at least weekly.

CONCLUSION

Lymphedema incidence did not differ by intervention group at 18 months. Poor adherence in the LEAP group may have contributed. However, physical therapy may speed recovery of ROM. Further research is needed to effectively reduce the incidence and severity of lymphedema in patients who have breast cancer.

Health-related quality of life outcomes for the LEAP study-CALGB 70305 (Alliance): A lymphedema prevention intervention trial for newly diagnosed breast cancer patients

BACKGROUND

Lymphedema is an adverse effect of breast cancer treatment that causes swelling and pain in the arm and hand. We tested 2 lymphedema prevention interventions and their impact on health-related quality of life (HRQOL) in a group-randomized trial at 38 cooperative group sites within the United States.

METHODS

Patients were recruited before breast surgery. Sites were randomly assigned to education-only (EO) lymphedema prevention or education plus exercise and physical therapy (LEAP). Lymphedema was defined as a ≥10% difference in arm volume at any time from baseline to 18 months postsurgery. HRQOL was assessed using the Functional Assessment of Cancer Therapy-Breast plus 4 lymphedema items (FACT-B+4). Longitudinal mixed model regression analysis, adjusting for key demographic and clinical variables, examined participants' HRQOL by intervention group and lymphedema status.

RESULTS

A total of 547 patients (56% LEAP) were enrolled and completed HRQOL assessments. The results revealed no differences between the interventions in preventing lymphedema (P = .37) or HRQOL (FACT-B+4 total score; P = .8777). At 18 months, the presence of lymphedema was associated with HRQOL at borderline significance (P = .0825). However, African American patients reported greater lymphedema symptoms (P = .0002) and better emotional functioning (P = .0335) than patients of other races or ethnicities. Lower HRQOL during the intervention was associated with younger age (P ≤ .0001), Eastern Cooperative Oncology Group performance status >0 (P = .0002), ≥1 positive lymph nodes (P = .0009), having no education beyond high school (P < .0001), having undergone chemotherapy (P = .0242), and having had only axillary node dissection or sentinel node biopsy versus both (P = .0007).

CONCLUSION

The tested interventions did not differ in preventing lymphedema or in HRQOL outcomes. African American women reported greater HRQOL impacts due to lymphedema symptoms than women of other races or ethnicities.

Comparative Effectiveness of Two Interventions to Increase Colorectal Cancer Screening for Those at Increased Risk Based on Family History: Results of a Randomized Trial

BACKGROUND

First-degree relatives (FDR) of patients with colorectal cancer are at risk for colorectal cancer, but may not be up to date with colorectal cancer screening. We sought to determine whether a one-time recommendation about needing colorectal cancer screening using patient navigation (PN) was better than just receiving the recommendation only.

METHODS

Participants were FDRs of patients with Lynch syndrome-negative colorectal cancer from participating Ohio hospitals. FDRs from 259 families were randomized to a website intervention (528 individuals), which included a survey and personal colorectal cancer screening recommendation, while those from 254 families were randomized to the website plus telephonic PN intervention (515 individuals). Primary outcome was adherence to the personal screening recommendation (to get screened or not to get screened) received from the website. Secondary outcomes examined who benefited from adding PN.

RESULTS

At the end of the 14-month follow-up, 78.6% of participants were adherent to their recommendation for colorectal cancer screening with adherence similar between arms (P = 0.14). Among those who received a recommendation to have a colonoscopy immediately, the website plus PN intervention significantly increased the odds of receiving screening, compared with the website intervention (OR: 2.98; 95% confidence interval, 1.68-5.28).

CONCLUSIONS

Addition of PN to a website intervention did not improve adherence to a colorectal cancer screening recommendation overall; however, the addition of PN was more effective in increasing adherence among FDRs who needed screening immediately.

IMPACT

These findings provide important information as to when the additional costs of PN are needed to assure colorectal cancer screening among those at high risk for colorectal cancer.

Insurance Stability and Cancer Screening Behaviors

Background: Disparities in rates of cancer screening are observed in underserved populations. Lack of stable health insurance may contribute to these disparities. The goal of this study was to examine the association between insurance stability and up-to-date cancer screening in underserved populations.

Methods and Findings: We enrolled 333 community participants aged 40–74 years across four different sites in three states: Chinese Americans in Boston, Massachusetts; Hispanics in Columbus, Ohio; Appalachian populations from Ohio's Appalachian counties; and Blacks and African Americans in Philadelphia, Pennsylvania. Self-reported screening rates were 77.9% for breast cancer, 71.1% for cervical cancer, and 67.7% for colorectal cancer (CRC). Screening rates fell short of Health People 2020 targets for breast, colorectal, and cervical cancer screenings. Being currently insured was associated with current CRC screenings (69.7% among insured vs. 30.7% among uninsured, p=0.0055), but not with breast or cervical cancer screenings. Stable 12-month insurance coverage was not statistically associated with up-to-date screenings.

Conclusion: Having current insurance was associated with CRC screening; stability of insurance was not associated with cancer screening. Insurance coverage alone is not the main driver of cancer screening.

Cancer Care Delivery and Women's Health: The Role of Patient Navigation

Background

Patient navigation (PN) is a patient-centered health-care service delivery model that assists individuals, particularly the medically underserved, in overcoming barriers (e.g., personal, logistical, and system) to care across the cancer care continuum. In 2012, the American College of Surgeons Commission on Cancer (CoC) announced that health-care facilities seeking CoC-accreditation must have PN processes in place starting January 1, 2015. The CoC mandate, in light of the recent findings from centers within the Patient Navigation Research Program and the influx of PN interventions, warrants the present literature review.

Methods

PubMed and Medline were searched for studies published from January 2010 to October 2015, particularly those recent articles within the past 2 years, addressing PN for breast and gynecological cancers, and written in English. Search terms included patient navigation, navigation, navigator, cancer screening, clinical trials, cancer patient, cancer survivor, breast cancer, gynecological cancer, ovarian cancer, uterine cancer, vaginal cancer, and vulvar cancer.

Results

Consistent with prior reviews, PN was shown to be effective in helping women who receive cancer screenings, receive more timely diagnostic resolution after a breast and cervical cancer screening abnormality, initiate treatment sooner, receive proper treatment, and improve quality of life after cancer diagnosis. However, several limitations were observed. The majority of PN interventions focused on cancer screening and diagnostic resolution for breast cancer. As observed in prior reviews, methodological rigor (e.g., randomized controlled trial design) was lacking.

Conclusion

Future research opportunities include testing PN interventions in the post-treatment settings and among gynecological cancer patient populations, age-related barriers to effective PN, and collaborative efforts between community health workers and patient navigators as care goes across segments of the cancer control continuum. As PN programs continue to develop and become a standard of care, further research will be required to determine the effectiveness of cancer PN across the cancer care continuum, and in different patient populations.

Evaluating the stage of change model to a cervical cancer screening intervention among Ohio Appalachian women

Cervical cancer incidence and mortality rates are disproportionally high among women living in Appalachia Ohio. This study used the Transtheoretical Model to examine screening barriers before and after a lay health advisor (LHA) intervention (2005-2009) to increase cervical cancer screening rates. Ohio Appalachian women (n = 90) who were in need of a Pap test, based on risk-appropriate guidelines, were randomized to a 10-month LHA intervention and received two in-person visits, two phone calls, and four mailed postcards targeted to the participant's stage of change. Findings revealed that 63% had forward stage movement 10 months after the intervention. The most frequently reported screening barriers were time constraints, forgetting to make an appointment, and cost. Women who reported the following barriers-doctor not recommending the test; being unable to afford the test; and being embarrassed, nervous, or afraid of getting a Pap test-were less likely to be in the action stage. Understanding the stages of change related to Pap testing and reported barriers among this underserved population may help inform researchers and clinicians of this population's readiness for change and how to set realistic intervention goals.

Breast cancer-related lymphedema: risk factors, prevention, diagnosis and treatment

SUMMARY 

Lymphedema is one of the late effects of breast cancer treatment that affects many breast cancer survivors. Despite an increased focus on morbidity among this survivor population, our understanding of risk reduction, prevention, diagnosis and treatment of lymphedema remain poorly understood. This article provides an overview of the current state of the research (2009–2014) on breast cancer-related lymphedema and offers future directions for research. A greater emphasis must be placed on reducing the impact of lymphedema to improve the quality of life for breast cancer survivors.

Validation of self-reported colorectal cancer screening behaviors among Appalachian residents

OBJECTIVES

We determined the validity of self-reported colorectal cancer (CRC) screening data provided by Appalachian Ohio residents and identified correlates of providing accurate data.

DESIGN AND SAMPLE

We conducted cross-sectional telephone interviews between September 2009 and April 2010. Our study included Appalachian Ohio residents (n = 721) ages 51-75 years.

MEASURES

We compared self-reported CRC screening data to medical records to determine validity. Multivariable logistic regression was used to identify correlates of providing accurate self-reported screening data.

RESULTS

About 68% of participants self-reported having any CRC screening test within recommended guidelines, whereas medical records indicated that only 49% were within guidelines (concordance = 0.76). Concordance was higher for flexible sigmoidoscopy and fecal occult blood test compared with colonoscopy, although sensitivity and positive predictive value were much higher for colonoscopy. Participants overreported CRC screening behaviors for all tests. Participants who had a regular checkup in the last 2 years (OR = 2.78, 95% CI: 1.15-6.73), or who self-rated their health as good or better (OR = 1.88, 95% CI: 1.12-3.16) were more likely to provide accurate screening data.

CONCLUSIONS

Many participants failed to provide accurate CRC screening data, and validity varied greatly across individual CRC screening tests. Future CRC screening studies among Appalachian residents should use medical records, if possible, to determine screening histories.

Cancer-Related Lymphedema Risk Factors, Diagnosis, Treatment, and Impact: A Review

Purpose

Cancer-related lymphedema (LE) is an incurable condition associated with lymph-involved cancer treatments and is an increasing health, quality of life (QOL), and cost burden on a growing cancer survivor population. This review examines the evidence for causes, risk, prevention, diagnosis, treatment, and impact of this largely unexamined survivorship concern.

Methods

PubMed and Medline were searched for cancer-related LE literature published since 1990 in English. The resulting references (N = 726) were evaluated for strength of design, methods, sample size, and recent publication and sorted into categories (ie, causes/prevention, diagnosis, treatment, and QOL). Sixty studies were included.

Results

Exercise and physical activity and sentinel lymph node biopsy reduce risk, and overweight and obesity increase risk. Evidence that physiotherapy reduces risk and that lymph node status and number of malignant nodes increase risk is less strong. Perometry and bioimpedence emerged as attractive diagnostic technologies, replacing the use of water displacement in clinical practice. Swelling can also be assessed by measuring arm circumference and relying on self-report. Symptoms can be managed, not cured, with complex physical therapy, low-level laser therapy, pharmacotherapy, and surgery. Sequelae of LE negatively affect physical and mental QOL and range in severity. However, the majority of reviewed studies involved patients with breast cancer; therefore, results may not be applicable to all cancers.

Conclusion

Research into causes, prevention, and effect on QOL of LE and information on LE in cancers other than breast is needed. Consensus on definitions and measurement, increased patient and provider awareness of signs and symptoms, and proper and prompt treatment/access, including psychosocial support, are needed to better understand, prevent, and treat LE.

Trust and distrust among Appalachian women regarding cervical cancer screening: a qualitative study

OBJECTIVE

To explore Appalachian women's perceptions of trust and distrust of healthcare providers and the medical care system as they relate to views about cervical cancer and screening.

METHODS

Thirty-six Ohio Appalachia female residents participated in community focus groups conducted by trained facilitators. Discussion topics included factors related to cervical cancer, and the issues of trust and distrust in medical care. The tape-recorded focus groups were transcribed and analyzed to identify salient themes.

RESULTS

Five themes emerged related to trust in healthcare. Patient-centered communication and encouragement from a healthcare provider led women to trust their physicians and the medical care system. In contrast, lack of patient-centered communication by providers and perceptions of poor quality of care led to distrust. Physician gender concordance also contributed to trust as women reported trust of female physicians and distrust of male physicians; trust in male physicians was reported to be increased by the presence of a female nurse.

CONCLUSIONS

Important factors associated with trust and distrust of providers and the medical care system may impact health-seeking behaviors among underserved women.

PRACTICE IMPLICATIONS

Opportunities to improve patient-centered communication around the issues of prevention and cervical cancer screening (such as providing patient-focused information about access to appropriate screening tests) could be used to improve patient care and build patients' trust.

Evaluating the efficacy of lay health advisors for increasing risk-appropriate Pap test screening: a randomized controlled trial among Ohio Appalachian women

BACKGROUND

Cervical cancer is a significant health disparity among women in Ohio Appalachia. The goal of this study was to evaluate the efficacy of a lay health advisor (LHA) intervention for improving Papanicolaou (Pap) testing rates, to reduce cervical cancer, among women in need of screening.

METHODS

Women from 14 Ohio Appalachian clinics in need of a Pap test were randomized to receive either usual care or an LHA intervention over a 10-month period. The intervention consisted of two in-person visits with an LHA, two phone calls, and four postcards. Both self-report and medical record review (MRR) data (primary outcome) were analyzed.

RESULTS

Of the 286 women, 145 and 141 were randomized to intervention and usual care arms, respectively. According to MRR, more women in the LHA arm had a Pap test by the end of the study compared with those randomized to usual care (51.1% vs. 42.0%; OR = 1.44, 95% CI: 0.89-2.33; P = 0.135). Results of self-report were more pronounced (71.3% vs. 54.2%; OR = 2.10, 95% CI: 1.22-3.61; P = 0.008).

CONCLUSIONS

An LHA intervention showed some improvement in the receipt of Pap tests among Ohio Appalachian women in need of screening. Although biases inherent in using self-reports of screening are well known, this study also identified biases in using MRR data in clinics located in underserved areas.

IMPACT

LHA interventions show promise for improving screening behaviors among nonadherent women from underserved populations.

Exercise and dietary change after diagnosis and cancer-related symptoms in long-term survivors of breast cancer: CALGB 79804

OBJECTIVE

Improving diet and exercise can reduce survivors' risk of cancer-related fatigue, poor physical functioning, and potential recurrence. A cancer diagnosis can represent a 'teachable moment', leading survivors to make positive changes in diet and exercise behaviors; however, little is known about how often this occurs or about factors that enhance or limit survivors' ability to make these changes. This cross-sectional descriptive study investigated both the prevalence and clustering of self-reported changes in diet and exercise and how these changes related to ongoing cancer-related symptoms, social support, and stressful life events among long-term breast cancer survivors.

METHODS

Survivors (n=227, response rate=72%) of a prior Cancer and Leukemia Group B treatment trial, on average 12 years post-diagnosis, completed a mailed survey assessing health behavior changes since diagnosis and current symptoms, social support, and stressful life events.

RESULTS

Over half of survivors reported making positive exercise or diet changes since diagnosis: over 25% reported making exercise and diet changes. Analyses of covariance models showed that survivors who reported increasing their exercise also reported lower fatigue. Trends were also found between increased fruit and vegetable intake and decreased fatigue and between increased exercise and increased social support.

CONCLUSIONS

These results underscore the need for health promotion efforts among survivors. Exercise promotion is especially needed since more survivors attempted to change dietary behaviors than exercise on their own. Further, fatigue may limit survivors' ability to change their health behaviors; alternatively, survivors who increase their exercise may experience less fatigue.

Arm/hand swelling and perceived functioning among breast cancer survivors 12 years post-diagnosis: CALGB 79804

INTRODUCTION

Lymphedema is an under-reported and debilitating consequence of axillary node dissection among breast cancer survivors. This study describes the characteristics of arm and hand swelling in relation to perceived physical and mental health functioning among breast cancer survivors 9-16 years post-diagnosis who previously participated in a clinical trial coordinated by the Cancer and Leukemia Group B (CALGB 8541).

METHODS

Eligible survivors of CALGB 8541 completed questionnaires assessing demographics, arm/hand swelling, perceived physical functioning, and mental health.

RESULTS

Two hundred forty-five women (94% white, mean age = 63, on average 12.4 years post-diagnosis) completed questionnaires (participation rate = 78%). Seventy-five women (31%) reported arm/hand swelling since their surgery. Of these women, 76% reported current swelling and half reported constant swelling, mainly in the upper arm. Swelling was reported as mild or moderate in 88% of the women. Women who reported severe swelling had significantly worse physical functioning and trended toward worse depressive symptoms and poorer mental health (lower mental SF-36 scores) as well. Activity-limiting swelling was also significantly associated with worse physical functioning. Although swelling interfered with wearing clothing (36%) and perceptions about general appearance (32%), only 37% of women sought treatment for swelling.

CONCLUSIONS

Arm/hand swelling is a chronic problem for a subgroup of long-term survivors of breast cancer, negatively affecting physical functioning.

IMPLICATIONS FOR CANCER SURVIVORS

Educational efforts are needed as part of a comprehensive survivorship care plan to raise awareness about lymphedema so that survivors may identify this complication, seek treatment early, and potentially improve their physical functioning.