The Landscape of Care for Women Veterans with Cancer: An Evidence Map.

BACKGROUND: Women are the fastest growing veteran group in the US and the number of women veterans (WVs) with cancer is rising; however, little is known about this population. Cancer care for WVs is complex and it is essential to understand their unique needs and care coordination challenges to provide evidence-based care. The purpose of this review is to map the quantity, distribution, and characteristics of literature describing cancer and its treatment among WVs. METHODS: We searched MEDLINE (via PubMed), Embase (Elsevier), and Web of Science Core Collection (Clarivate) from inception through January, 2024. Publications were eligible that reported gender-specific data on any aspect of cancer care among WVs. Data was abstracted by a single investigator with over-reading. RESULTS: Forty-six reports were included; 44 were observational and 19 had a women-only sample. There were no interventional reports and no qualitative reports had a patient sample. Breast cancer was the most commonly addressed (n = 19). There were six additional reports on sex-specific cancers. Many reports used large VA databases or previous trial data, creating the potential for patient overlap between reports. Among VA-specific areas of interest, only three reports evaluated the potential implications of racial differences and only two included a transgender population. No reports examined the effects of toxic exposures on cancer. Within the NCI Cancer Control Continuum, crosscutting areas were more commonly represented; over half (25) of the reports addressed epidemiology. There were few reports on focus areas and little overlap between focus and crosscutting areas. DISCUSSION: Existing literature provides an inadequate understanding of the population of WVs with cancer. There is scant information regarding the population of WVs with cancer, their care preferences or experiences, or how to best identify and address unmet healthcare needs. It is imperative to expand research to provide evidence-based care for this population.

Associations between blood pressure control and clinical events suggestive of nutrition care documented in electronic health records of patients with hypertension.

BACKGROUND: Clinical events suggestive of nutrition care found in electronic health records (EHRs) are rarely explored for their associations with hypertension outcomes. METHODS: Longitudinal analysis using structured EHR data from primary care visits at a health system in the US from December 2017-December 2020 of adult patients with hypertension (n = 4,237) tested for associations between last visit blood pressure (BP) control (≤ 140 Systolic BP and ≤ 90 Diastolic BP) and ≥ 1 nutrition care clinical event operationalized as (overweight or obesity (BMI > 25 or 30, respectively) diagnoses, preventive care visits, or provision of patient education materials (PEM)). Descriptive statistics and longitudinal targeted maximum likelihood estimation (LTMLE) models were conducted to explore average treatment effects (ATE) of timing and dose response from these clinical events on blood pressure control overall and by race. RESULTS: The median age was 62 years, 29% were male, 52% were Black, 25% were from rural areas and 50% had controlled BP at baseline. Annual documentation of overweight/obesity diagnoses ranged 3.0-7.8%, preventive care visits ranged 6.2-15.7%, and PEM with dietary and hypertension content were distributed to 8.5-28.8% patients. LTMLE models stratified by race showed differences in timing, dose, and type of nutrition care. Black patients who had nutrition care in Year 3 only compared to none had lower odds for BP control (ATE -0.23, 95% CI: -0.38,-0.08, p = 0.003), preventive visits in the last 2 years high higher odds for BP control (ATE 0.31, 95% CI: 0.07,0.54, p = 0.01), and early or late PEMs had lower odds for BP control (ATE -0.08, 95% CI: -0.15,-0.01, p = 0.03 and ATE -0.23, 95% CI: -0.41,-0.05, p = 0.01, respectively). CONCLUSIONS: In this study, clinical events suggestive of nutrition care are significantly associated with BP control, but are infrequent and effects differ by type, timing, and patient race. Preventive visits appear to have the most effect; additional research should include examining clinical notes for evidence of nutrition care among different populations, which may uncover areas for improving nutrition care for patients with chronic disease.

Are primary care providers' nutrition care and food insecurity screening practices associated with their perceptions of team-based care?

BACKGROUND: Screening for food insecurity (FI) and providing nutrition care are important management strategies for chronic diseases, but rates are low. Aspects of team-based care and providers' nutrition competence may help inform interventions to improve these services. The objectives of this study were to describe US primary care providers' FI screening and nutrition care practices (counselling, referrals, and time spent counselling) and test for associations with scored measures of their perceptions of team-based care (care continuity, patient-centredness, coordination with external providers and resources) and nutrition competence (confidence counselling and attitudes towards nutrition). METHODS: Cross-sectional online survey data of primary care providers were described and analysed for associations using Wilcoxon rank sum tests. RESULTS: Of provider respondents (N = 92), 35% (n = 32) worked in clinics that screen for FI and had higher team perceptions (P = 0.006) versus those who do not. Those who reported counselling >30% patients about nutrition (57%, n = 52) and referring >10% patients to nutrition professionals (24%, n = 22) had significantly better attitudes towards nutrition (P = 0.013 and P = 0.04, respectively) compared with those with lower counselling and referral rates. Half (n = 46) of the providers reported spending >3-min counselling each patient about nutrition and had higher patient-centred care (P = 0.004) and nutrition competence (P < 0.001) compared with those who spent less time counselling. CONCLUSION: Providers in clinics that screen for FI had higher overall perceptions of team-based care, but their nutrition competence was not significantly different. Meanwhile, reported more time counselling was associated with a culture of patient-centredness. Promoting team-based care may be a mechanism for improving FI screening and nutrition care.

A cross-sectional analysis of associations between lifestyle advice and behavior changes in patients with hypertension or diabetes: NHANES 2015-2018.

Clinicians supporting patients in lifestyle behavior change is an important strategy to help reduce chronic disease burden. Using National Health and Nutrition Examination Survey (NHANES) data from 2015 to 2018, this study assessed rates of and associations between patient-reported receipt of lifestyle behavior change advice and corresponding self-reported behavior change for four different lifestyle behaviors: 1) weight loss, 2) increase physical activity, 3) reduce sodium, and 4) reduce fat and calories. Adult survey respondents with hypertension and/or diabetes (n = 4716) who received lifestyle advice ranged from 43% to 58%, with the most common recommendation being to increase physical activity. Between 61% and 73% of respondents reported currently modifying health behaviors, with the greatest number reporting weight loss. Multiple logistic regression models were used to test associations for each lifestyle behavior advice-behavior change pair, adjusting for demographic characteristics. Compared to those who received no advice, respondents who received advice had significantly higher odds of reporting losing weight (aOR: 1.93; 95% CI: 1.51, 2.48); increasing physical activity (aOR 2.02; 95% CI: 1.73, 2.37); reducing dietary sodium (aOR 4.95; 95% CI: 3.93, 6.25); and reducing intake of fat/cal (aOR 3.57; 95% CI: 2.86, 4.45). This study utilized population level data to lend further evidence that provider advice about lifestyle behaviors for patients who have hypertension or diabetes may influence patient behavior. However, prevalence of advice is low, and differences in rates of behavior change exist across socioeconomic status and race/ethnicity, indicating a need to further research how providers might better support patients with varying social needs.

Recalibrating the Genetics and Epidemiology of Colorectal Cancer Consortium (GECCO) Environmental Risk Score for Use in US Veterans.

BACKGROUND: Risk for colorectal cancer (CRC) may accumulate through multiple environmental factors. Understanding their effects, along with genetics, age and family history, could allow improvements in clinical decisions for screening protocols. We aimed to extend previous work by recalibrating an environmental risk score (e-Score) for CRC among a sample of US Veteran participants of the Million Veteran Program (MVP). METHODS: Demographic, lifestyle, and CRC data from 2011-2022 were abstracted from survey responses and health records of 227,504 male MVP participants. Weighting for each environmental factor's effect size was recalculated using VA training data to create a recalibrated e-Score. This recalibrated score was compared with the original weighted e-Score in a validation sample of 113,752 (n cases=590). Nested multiple logistic regression models tested associations between quintiles for recalibrated and original e-Scores. Likelihood Ratio Tests were used to compare model performance. RESULTS: Age (p<0.0001), education (p<0.0001), diabetes (p<0.0001), physical activity (p<0.0001), smoking (p<0.0001), NSAID use (p<0.0001), calcium (p=0.015), folate (p=0.020), and fruit consumption (p=0.019) were significantly different between CRC case and control groups. In the validation sample, the recalibrated e-Score model significantly improved the base model performance (p<0.001), but the original e-Score model did not (p=0.07). The recalibrated e-Score model quintile 5 was associated with significantly higher odds for CRC compared with quintile 1 (Q5 vs Q1: 1.79, 95% CI: 1.38-2.33). CONCLUSIONS: Multiple environmental factors, and the recalibrated e-Score quintiles were significantly associated with CRC cases. IMPACT: A recalibrated, Veteran-specific e-Score could be used to help personalize CRC screening and prevention strategies.

Perceived risk of harm from monthly cannabis use among US adolescents: National Survey on drug Use and Health, 2017.

There has been a steady increase in cannabis use among US adolescents over the past decade. Perceptions of risk, specifically the belief that cannabis use is not harmful, may contribute to this increased use. The purpose of this study was to evaluate parental, school, and peer influence as protective factors in perceiving there is risk of harm from monthly cannabis use. Using the 2017 National Survey on Drug Use and Health (NSDUH), the study outcome was self-reported perceived risk of harm from monthly cannabis use amongst adolescents between ages 12 and 17. The exposures were parental monitoring and support, perception of school importance, extracurricular activity participation, peer attitudes towards cannabis use, and perception of peer cannabis use. Of 12,024 eligible adolescents, about 80% reported perceived risk of harm from monthly cannabis use. Multiple logistic regression models suggest the perception of risk of harm from monthly cannabis use was significantly associated with perception of peers using cannabis, perception of peers' disapproval of cannabis use, perception of school importance, and participation in extracurricular activities. Adolescents who perceived that monthly cannabis use was risky had high parental monitoring, low perception of peer use, high perception of peers' disapproval of cannabis use, high perception of school importance, and participated more in extracurricular activities. These findings suggest substance use prevention programs targeting adolescent attitudes and beliefs would benefit from leveraging peer influence, promoting extracurricular activities, and enhancing schoolwork to be more meaningful.

Engaging rural communities in cancer prevention and control research: Development and preliminary insights from a community-based research registry.

OBJECTIVE: To report on the development and preliminary findings of a community-based cancer registry, including the community-engaged approach to recruitment, participant profile, and distribution of cancer risk factors by race/ethnicity and geography. METHODS: Community outreach and engagement best practices were used to recruit a diverse convenience sample of Virginia residents (≥18 years) that oversampled residents living in rural areas, defined as Rural-Urban Continuum Codes (RUCC) 4-9 and African American (AA)/Black residents. Multiple survey administration methods included electronic (e-survey) and in-person survey by community-based staff. RESULTS: At the time of this analysis, 595 participants are enrolled; 73% are rural, 46% are AA/Black. AA/Black participants reported similar education but lower income (p < 0.01) and health literacy (p < 0.01), lower alcohol use (p < 0.001), fewer sedentary behaviors (p = 0.01), but greater BMI (p < 0.05) compared to White participants. Rural residents reported significantly lower household income (p < 0.001) and greater use of Medicaid (p = 0.01) compared to urban participants. Biennial mammography was reported by 82% of women aged 45-74 years old and colonoscopy by 77% of participants ≥50 years old. Tobacco use was reported by 17%; no differences in cancer screening or tobacco use were identified by geography or by race. CONCLUSION AND RELEVANCE: Community engagement strategies successfully enrolled diverse residents within the cancer service area. AA/Black participants reported fewer cancer risk behaviors, similar educational attainment but lower income and health literacy compared to White respondents. Nuanced examinations of interactions among multilevel factors are needed to understand how individual, community, and institutional factors converge to maintain cancer disparities among AA/Black Virginians. Additional findings indicate a need for tobacco cessation, lung cancer screening, obesity treatment, and prevention initiatives.