A catchment and location-allocation analysis of mammography access in Delaware, US: implications for disparities in geographic access to breast cancer screening.

BACKGROUND: Despite a 40% reduction in breast cancer mortality over the last 30 years, not all groups have benefited equally from these gains. A consistent link between later stage of diagnosis and disparities in breast cancer mortality has been observed by race, socioeconomic status, and rurality. Therefore, ensuring equitable geographic access to screening mammography represents an important priority for reducing breast cancer disparities. Access to breast cancer screening was evaluated in Delaware, a state that experiences an elevated burden from breast cancer but is otherwise representative of the US in terms of race and urban-rural characteristics. We first conducted a catchment analysis of mammography facilities. Finding evidence of disparities by race and rurality, we next conducted a location-allocation analysis to identify candidate locations for the establishment of new mammography facilities to optimize equitable access. METHODS: A catchment analysis using the ArcGIS Pro Service Area analytic tool characterized the geographic distribution of mammography sites and Breast Imaging Centers of Excellence (BICOEs). Poisson regression analyses identified census tract-level correlates of access. Next, the ArcGIS Pro Location-Allocation analytic tool identified candidate locations for the placement of additional mammography sites in Delaware according to several sets of breast cancer screening guidelines. RESULTS: The catchment analysis showed that for each standard deviation increase in the number of Black women in a census tract, there were 68% (95% CI 38-85%) fewer mammography units and 89% (95% CI 60-98%) fewer BICOEs. The more rural counties in the state accounted for 41% of the population but only 22% of the BICOEs. The results of the location-allocation analysis depended on which set of screening guidelines were adopted, which included increasing mammography sites in communities with a greater proportion of younger Black women and in rural areas. CONCLUSIONS: The results of this study illustrate how catchment and location-allocation analytic tools can be leveraged to guide the equitable selection of new mammography facility locations as part of a larger strategy to close breast cancer disparities.

Racial disparities in triple negative breast cancer: toward a causal architecture approach.

BACKGROUND: Triple negative breast cancer (TNBC) is an aggressive subtype of invasive breast cancer that disproportionately affects Black women and contributes to racial disparities in breast cancer mortality. Prior research has suggested that neighborhood effects may contribute to this disparity beyond individual risk factors. METHODS: The sample included a cohort of 3316 breast cancer cases diagnosed between 2012 and 2020 in New Castle County, Delaware, a geographic region of the US with elevated rates of TNBC. Multilevel methods and geospatial mapping evaluated whether the race, income, and race/income versions of the neighborhood Index of Concentration at the Extremes (ICE) metric could efficiently identify census tracts (CT) with higher odds of TNBC relative to other forms of invasive breast cancer. Odds ratios (OR) and 95% confidence intervals (CI) were reported; p-values < 0.05 were significant. Additional analyses examined area-level differences in exposure to metabolic risk factors, including unhealthy alcohol use and obesity. RESULTS: The ICE-Race, -Income-, and Race/Income metrics were each associated with greater census tract odds of TNBC on a bivariate basis. However, only ICE-Race was significantly associated with higher odds of TNBC after adjustment for patient-level age and race (most disadvantaged CT: OR = 2.09; 95% CI 1.40-3.13), providing support for neighborhood effects. Higher counts of alcohol and fast-food retailers, and correspondingly higher rates of unhealthy alcohol use and obesity, were observed in CTs that were classified into the most disadvantaged ICE-Race quintile and had the highest odds of TNBC. CONCLUSION: The use of ICE can facilitate the monitoring of cancer inequities and advance the study of racial disparities in breast cancer.

Momentary Partner Involvement in Diabetes Self-Care and Continuously Measured Glucose: A Dynamic Analysis.

OBJECTIVE: This study examined the dynamic, real-time associations between partner involvement in diabetes self-care and continuous glucose monitor (CGM) metrics in adults with type 2 diabetes. METHODS: For 1 week, 63 participants wore Dexcom G4 CGMs and provided momentary reports of partner involvement in diabetes self-care five times per day. Dynamic structural equation models were used to estimate the reciprocal lagged effects of partner involvement on next-hour CGM metrics (and vice versa). RESULTS: Partner involvement predicted improved next-hour glucose control for five of six CGM metrics in analyses adjusted for time-varying covariates. The hour after partner involvement, the model predicted a 26.34 mg/dl decrease in glucose level (standardized ß = -0.19), 30% greater odds of meeting target time in target range ( ß = 0.07), 48% higher odds of target time below target range (TBR; ß = 0.04; the only nonsignificant effect), 47% greater odds of target time above target range (ß = 0.11), a 4.20 unit decrease in glucose standard deviation ( ß = -0.19), and a 0.01 unit decrease in glucose coefficient of variation ( ß = -0.08; all p values < .05). There was less consistent support for the reverse pathway, with only two metrics significantly related to next-hour partner involvement: glucose level ( ß = 0.15) and TBR ( ß = 0.21), such that having higher levels and meeting target TBR were significantly predictive of next-hour partner involvement. CONCLUSIONS: This is the first study showing that partner involvement in daily diabetes management predicts short-term glucose control. More research is needed to understand how partners influence glycemic control and evaluate interventions that promote their involvement in diabetes care.

The longitudinal course of emotional and cognitive factors of fear of cancer recurrence in breast cancer patients and their partners.

OBJECTIVE: Although fear of cancer recurrence (FCR) has been conceptualized as a multidimensional construct with emotional and cognitive components, little work has distinguished or assessed both components. Further, most existing research has not included intimate partners of cancer patients, although they also experience FCR. This study aimed to (1) determine whether FCR is better conceptualized as a singular or multidimensional construct at the within-person level over time and (2) model the corresponding trajectories in patients and their partners. METHODS: Female early stage breast cancer patients and their partners (N = 78 couples) completed up to five assessments over the first year post-diagnosis tapping both emotional and cognitive elements of FCR. Multilevel confirmatory factor analysis was used to evaluate FCR's factor structure, and multivariate latent growth curve modeling was used to estimate trajectories of emotional and cognitive FCR. RESULTS: FCR was best conceptualized as two distinct but related emotional and cognitive factors. In patients and partners, emotional FCR decreased over the first year post-diagnosis on average, while cognitive FCR did not change over time. CONCLUSIONS: Findings support the conceptualization of FCR as a multidimensional construct and underscore the potential importance of distinguishing emotional and cognitive components of FCR in future research.

Fear of Cancer Recurrence and Sleep in Couples Coping With Early-Stage Breast Cancer.

BACKGROUND: Fear of cancer recurrence (FCR) and sleep disturbance are common in cancer survivors. Yet, little research has examined their relationship, and even less is known about what links may exist between these variables among the intimate partners of cancer survivors. PURPOSE: This study examines the relationship between FCR and sleep disturbance in breast cancer survivors and their partners. Using daily sleep data collected at two distinct periods early in survivorship-the completion of adjuvant treatment and the first post-treatment mammogram-higher survivor and partner FCR was hypothesized to predict greater sleep disturbance. METHODS: Breast cancer survivors and intimate partners (N = 76 couples; 152 individuals) each reported sleep duration, sleep quality, sleep onset latency, and wake after sleep onset each morning of two 21-day sleep diary bursts during the first year post-diagnosis. Three validated measures formed latent FCR factors for survivors and partners, which were used to predict average daily sleep. RESULTS: Across both sleep diary bursts, survivor FCR was associated with their own reduced sleep duration, reduced sleep quality, and greater sleep onset latency. Survivor FCR was also associated with their partners' reduced sleep quality and greater sleep onset latency. Partner FCR was associated with their own reduced sleep duration, reduced sleep quality, and greater sleep onset latency. Partner FCR was also associated with survivors' reduced sleep quality. CONCLUSIONS: Findings revealed intrapersonal and interpersonal associations between FCR and sleep disturbance, addressing gaps in knowledge on FCR and an outcome with known short- and long-term implications for health and mortality.

Daily partner responsiveness and everyday sleep outcomes in breast cancer survivors and their partners.

PURPOSE: Breast cancer (BC) survivors and their intimate partners face several adverse consequences from the cancer experience, including sleep disturbance, which is a common side effect of BC and its treatment. Sleep has been conceptualized and examined as an individual phenomenon despite most adults sharing a bed/room with a partner. Limited research has examined the associations between daily relationship processes and sleep in couples coping with cancer. Using an intensive longitudinal design, the present study examined the daily, within-person links between attempted and perceived partner responsiveness and subjective sleep. METHODS: Immediately following adjuvant treatment, 72 early-stage BC survivors and their intimate partners (144 paired individuals) reported on daily attempted and perceived partner responsiveness each evening and subjective sleep each morning for 21 consecutive days. RESULTS: Survivor and partner reports of partner responsiveness were associated with their own subjective sleep, such that greater attempted and perceived partner responsiveness were associated with improvements in one's own subjective sleep. Effects of one participant's partner responsiveness on their partner's sleep were not observed. CONCLUSIONS: Findings suggest that among couples coping with early-stage BC, increased partner responsiveness is associated with subsequent improvements in subjective sleep. IMPLICATIONS FOR CANCER SURVIVORS: Sleep disturbance is a serious concern for BC survivors and their intimate partners. Future research should assess intimacy processes as a potential method to improve BC survivor and partner sleep.

Fear of Cancer Recurrence and Inhibited Disclosure: Testing the Social-Cognitive Processing Model in Couples Coping With Breast Cancer.

BACKGROUND: Withholding cancer-related concerns from one's partner (protective buffering) and feeling that one's partner is inaccessible or unresponsive to such disclosure (social constraints) are two interpersonal interaction patterns that separately have been linked to poorer adjustment to cancer. PURPOSE: Guided by the Social-Cognitive Processing Model, we examined the joint effects of social constraints and protective buffering on fear of cancer recurrence (FCR) in survivors and spouses. Social constraints and protective buffering were hypothesized to emerge as independent predictors of higher FCR. METHODS: Early-stage breast cancer survivors and spouses (N = 79 couples; 158 paired individuals) completed up to five repeated measures of FCR, social constraints, protective buffering, and relationship quality during the year postdiagnosis. A second-order growth curve model was estimated and extended to test the time-varying, within-person effects of social constraints and protective buffering on a latent FCR variable, controlling for relationship quality. RESULTS: As hypothesized, greater social constraints and protective buffering significantly (p < .05) predicted higher concurrent FCR at the within-person level, controlling for global relationship quality and change in FCR over time. The fixed effects were found to be similar for both survivors and spouses. CONCLUSIONS: Findings suggest that interaction patterns resulting in inhibited disclosure are associated with greater FCR for both survivors and spouses, consistent with the Social-Cognitive Processing Model. This work adds to the growing body of research highlighting the social context of FCR.

Spousal Influence on Diabetes Self-care: Moderating Effects of Distress and Relationship Quality on Glycemic Control.

BACKGROUND: Spouses often attempt to influence patients' diabetes self-care. Spousal influence has been linked to beneficial health outcomes in some studies, but to negative outcomes in others. PURPOSE: We aimed to clarify the conditions under which spousal influence impedes glycemic control in patients with type 2 diabetes. Spousal influence was hypothesized to associate with poorer glycemic control among patients with high diabetes distress and low relationship quality. METHODS: Patients with type 2 diabetes and their spouses (N = 63 couples) completed self-report measures before patients initiated a 7-day period of continuous glucose monitoring. Mean glucose level and coefficient of variation (CV) were regressed on spousal influence, diabetes distress, relationship quality, and their two- and three-way interactions. RESULTS: The three-way interaction significantly predicted glucose variability, but not mean level. Results revealed a cross-over interaction between spousal influence and diabetes distress at high (but not low) levels of relationship quality, such that spousal influence was associated with less variability among patients with low distress, but more among those with high distress. Among patients with high distress and low relationship quality, a 1 SD increase in spousal influence predicted a difference roughly equivalent to the difference between the sample mean CV and a CV in the unstable glycemia range. CONCLUSIONS: This was the first study to examine moderators of the link between spousal influence and glycemic control in diabetes. A large effect was found for glucose variability, but not mean levels. These novel results highlight the importance of intimate relationships in diabetes management.

Theta Oscillations Index Frontal Decision-Making and Mediate Reciprocal Frontal-Parietal Interactions in Willed Attention.

Attention can be attracted reflexively by sensory signals, biased by learning or reward, or focused voluntarily based on momentary goals. When voluntary attention is focused by purely internal decision processes (will), rather than instructions via external cues, we call this "willed attention." In prior work, we reported ERP and fMRI correlates of willed spatial attention in trial-by-trial cuing tasks. Here we further investigated the oscillatory mechanisms of willed attention by contrasting the event-related EEG spectrogram between instructional and choice cues. Two experiments were conducted at 2 different sites using the same visuospatial attention paradigm. Consistent between the 2 experiments, we found increases in frontal theta power (starting at ~500 ms post cue) for willed attention relative to instructed attention. This frontal theta increase was accompanied by increased frontal-parietal theta-band coherence and bidirectional Granger causality. Additionally, the onset of attention-related posterior alpha power lateralization was delayed in willed attention relative to instructed attention, and the amount of delay was related to the timing of frontal theta increase. These results, replicated across 2 experiments, suggest that theta oscillations are the neuronal signals indexing decision-making in the frontal cortex, and mediating reciprocal communications between the frontal executive and parietal attentional control regions during willed attention.

Everyday protective buffering predicts intimacy and fear of cancer recurrence in couples coping with early-stage breast cancer.

OBJECTIVE: Patient and spouse/partner mutual self-disclosure is central for maintaining intimacy and cognitive processing when transitioning to life after cancer. Protective buffering inhibits self-disclosure and is defined as efforts to protect one's partner from upset and burden by hiding or denying cancer-related concerns. Intimacy and fear of cancer recurrence (FCR) are important determinants of individual and couple adaptation following cancer. Links between protective buffering and intimacy have not been examined in the context of daily life, and links with FCR have not been studied. We hypothesized that protective buffering is associated with decreased intimacy and increased FCR at a daily, within-person level. METHODS: Sixty-nine early-stage breast cancer (BC) survivors and their spouses completed electronic diaries for 21 consecutive days at the end of adjuvant treatment. Patients and spouses reported on daily protective buffering, intimacy, and FCR. Dyadic multilevel path modeling was used to estimate within-person effects. Patient and spouse protective buffering on one's own as well as one's partner's same-day intimacy and FCR were examined, controlling for previous levels of intimacy and FCR. RESULTS: Protective buffering was associated with decreased intimacy and increased FCR for the individual reporting buffering that same day. Patient and spouse protective buffering was also linked to decreased intimacy for her/his partner that same day. Moreover, patient protective buffering predicted increased spouse FCR that same day. CONCLUSIONS: Findings supported a daily, within-person link between buffering, intimacy, and FCR, suggesting open disclosure of cancer-related concerns may be a relevant target for interventions for adaptation to BC.

Checking Behavior, Fear of Recurrence, and Daily Triggers in Breast Cancer Survivors.

BACKGROUND: Fear of cancer recurrence (FCR) is a top ongoing concern of breast cancer (BC) survivors and thus the focus of recent intervention development. The Self-Regulation Model of FCR (Lee-Jones C, Humphris G, Dixon R, Hatcher MB. Fear of cancer recurrence-a literature review and proposed cognitive formulation to explain exacerbation of recurrence fears. Psychooncology. 1997;6:95-105.) states that everyday cancer-related events trigger FCR, which, in turn, leads to specific behavioral responses, including checking the body for signs or symptoms of cancer. Links between triggering events, FCR, and checking behavior have not yet been studied in the context of daily life or at the within-person level. PURPOSE: The goal of this study was to examine whether FCR has a within-person link with daily checking behavior and whether FCR mediates the link between triggering events and checking behavior. METHODS: Seventy-two early-stage BC survivors completed daily diaries over a 21-day period approximately 5 months after BC surgery. FCR, checking behavior, and triggering events were assessed each evening. RESULTS: Multilevel modeling results indicated that FCR predicted greater odds of same-day, but not next-day, checking behavior. We found that daily FCR significantly mediated the same-day effect of triggering events on checking behavior. These average within-person effects varied substantially between patients and were not explained by momentary negative affect. CONCLUSIONS: Findings support the within-person relationship between triggering events, FCR, and checking behavior posited by guiding theory, and can inform FCR intervention development.

Threat sensitivity and fear of cancer recurrence: a daily diary study of reactivity and recovery as patients and spouses face the first mammogram post-diagnosis.

OBJECTIVES: Fear of cancer recurrence (FCR) is a top concern of breast cancer (BC) survivors and their spouses, yet little is known about responses to FCR triggers in daily life. We examined whether a biologically based individual difference-threat sensitivity-predicted FCR in couples facing the first post-diagnosis mammogram (MMG). We hypothesized that threat sensitivity would predict greater FCR reactivity before the MMG and higher peak FCR on the MMG day, controlling for global anxiety. We also explored the link between threat sensitivity and FCR recovery after MMG. DESIGN AND SAMPLE: Fifty-seven early-stage BC patients and their spouses completed cross-sectional measures of threat sensitivity and global anxiety. Couples then reported daily FCR during a 3-week diary period that began 2 weeks before the patient's MMG appointment. METHODS: Multilevel actor-partner interdependence modeling was used to estimate within-person random slopes of FCR before (reactivity) and after (recovery) the MMG. Random intercepts captured individual differences in peak FCR on the MMG day. Patient and spouse threat sensitivity and anxiety were entered as predictors of reactivity, peak, and recovery. FINDINGS: FCR increased leading to MMG; however, inconsistent with hypotheses, this reactivity was not significantly predicted by threat sensitivity. Actor, but not partner, effects for peak FCR emerged, such that patients and spouses with greater threat sensitivity had greater FCR on the MMG day. FCR decreased after the MMG, and spouse, but not patient, threat sensitivity predicted slower recovery for both partners. CONCLUSIONS: Findings lend preliminary support for the role of threat sensitivity in the experience of FCR as couples confront threatening events in BC survivorship. Implications for psychosocial providers: MMGs can be a triggering event for couples. Threat sensitivity may help identify those who are likely to experience elevations in FCR during this stressful period.

Does sharing good news buffer fear of bad news? A daily diary study of fear of cancer recurrence in couples approaching the first mammogram post-diagnosis.

OBJECTIVE: The core of fear of cancer recurrence (FCR)-a top concern of couples after successful breast cancer (BC) treatment-is fear of death. Daily relationship processes may be instrumental in regulating FCR as triggers of existential distress are encountered. We tested the hypothesis that daily capitalization, the process of sharing good news (capitalization attempts) to a partner perceived as responsive (responsiveness), buffers patient and spouse FCR as they confront the first mammogram post-diagnosis. METHODS: Fifty-seven early-stage BC survivors and their spouses reported daily FCR, capitalization, and positivity of the disclosed event during a 3-week diary period beginning 2 weeks before the first annual mammogram post-diagnosis. Dyadic multilevel path models estimated within-person effects of patient and spouse capitalization on same-day FCR, controlling for event positivity. RESULTS: Before the mammogram, capitalization attempts were unrelated to FCR, but for patients, responsiveness was predictive of greater same-day FCR. After the mammogram, for both partners, attempts were predictive of greater same-day FCR, yet responsiveness was predictive of lower FCR. CONCLUSIONS: Findings were largely inconsistent with the hypothesis that capitalization buffers existential distress. However, results revealed novel insights about daily dyadic processes that may characterize within-person adaptation to existential threat. Potential explanations for the differential links between capitalization and FCR based on timing (before versus after threat) and capitalization component (attempts versus responsiveness) are discussed.

Fear of cancer recurrence: a theoretical review and its relevance for clinical presentation and management.

BACKGROUND: There is increasing recognition of the unique physical and psychosocial concerns of the growing population of cancer survivors. An emerging literature demonstrates that fear of cancer recurrence (FCR) is a problematic long-term and late effect for cancer survivors. In fact, FCR is a top concern, and this article provides a necessary synthesis of the extant research evidence and theory. METHODS: Literature searches were conducted using databases including MEDLINE and PsychINFO using specified search terms including 'fear of recurrence' and 'worry about recurrence'. A comprehensive narrative review summarizes early empirical findings on FCR including current definitions, assessment tools, clinical presentations, quality of life impact, prevalence, trajectory and risk factors. This paper also critically reviews the relevant theoretical frameworks to best understand these findings and considers multiple psychosocial treatment models that may have relevance for addressing FCR in the clinical setting. RESULTS: There is evidence of substantial prevalence and quality of life impact of FCR. Several theories (e.g. self-regulation model of illness, a family-based model, uncertainty in illness theory, social-cognitive processing theory, terror management theory) directly or indirectly help conceptualize FCR and inform potential treatment options for those with clinically significant distress or impairment resulting from FCR. CONCLUSIONS: Further investigation into FCR is warranted to promote evidence-based care for this significant cancer survivorship concern.

Group therapy processes and treatment outcomes in 2 couple-focused group interventions for breast cancer patients.

BACKGROUND: There has been little attention paid to the role of therapeutic processes in group therapy outcomes for cancer patients participating in group. The goal was to evaluate the contribution of 3 group processes-group climate (conflict, engagement, and avoidance) working alliance and therapeutic realizations-to the outcomes of 2 couple-focused approaches to group treatment. METHODS: Three hundred and two women with early stage breast cancer and their partners were randomized to one of 2 conditions: an 8-session enhanced couple-focused group (ECG) intervention or a couples' support group participated. Couples completed measures of depressive symptoms and well-being before and 6 months after group. Group process measures were completed after sessions 4 and 8. RESULTS: Support group participants (both patients and partners) perceived higher engagement and less avoidance than ECG participants. Conflict, working alliance, and therapeutic realizations did not differ. Group engagement, working alliance, and therapeutic realizations increased, and group conflict decreased over the course of both treatments. Greater conflict was associated with more posttreatment anxiety and lower well-being, and engagement was associated with higher posttreatment well-being. Patients whose partners reported higher conflict reported greater posttreatment anxiety. Working alliance was associated with posttreatment anxiety for ECG patients and with well-being among participants whose partners reported higher working alliance. CONCLUSIONS: Fostering a positive group environment bolsters treatment efficacy for women with early stage breast cancer and their partners attending couple-focused groups. Facilitating the leader-member alliance bolsters treatment efficacy. Improving engagement with one member of a couple impacts the other member.

Psychological distress as a mediator of the association between disease severity and occupational functioning among employed spouses of women recently diagnosed with breast cancer.

OBJECTIVE: The purpose was to evaluate whether patient and spouse cancer-specific distress mediated the association between cancer severity and occupational functioning among employed spouses of women diagnosed with breast cancer. We examined whether sociodemographic characteristics, lower spouse-reported marital quality, and lower spouse self-rated health were associated with poorer spouse occupational functioning. METHODS: One hundred forty-three currently employed spouses of women diagnosed with breast cancer were administered measures of socioeconomic status, occupational functioning (work absenteeism, low productivity, and poor performance), cancer-specific distress, marital quality, and self-rated health. Patients completed measures of cancer-related distress and functional impairment and cancer stage were collected from medical charts. RESULTS: In the model evaluating work absenteeism, greater patient functional impairment was associated with more absenteeism, but there was no evidence of a mediating effect for either partners' cancer-specific distress. Higher cancer stage and more functional impairment were associated with higher spouse cancer-specific distress, which in turn predicted poorer work productivity. Patient cancer-specific distress did not mediate the association between patient functional impairment or cancer stage and spouse work productivity. Finally, higher cancer stage was associated with more spouse cancer-specific distress, which in turn predicted poorer work performance. There were no direct or indirect effects of the patient's functional impairment on spouse work performance. CONCLUSIONS: Distressed spouses are more likely to have poorer work productivity after their partners' breast cancer diagnosis. These spouses may need assistance in managing their distress and the patient's functional impairment to ensure that their work productivity is not adversely affected.

Cancer-specific Relationship Awareness, Relationship Communication, and Intimacy Among Couples Coping with Early Stage Breast Cancer.

If couples can maintain normalcy and quality in their relationship during the cancer experience, they may experience greater relational intimacy. Cancer-specific relationship awareness, which is an attitude defined as partners focusing on the relationship and thinking about how they might maintain normalcy and cope with cancer as a couple or "team", is one factor that may help couples achieve this goal. The main aim of this study was to evaluate the associations between cancer-specific relationship awareness, cancer-specific communication (i.e., talking about cancer's impact on the relationship, disclosure, and responsiveness to partner disclosure), and relationship intimacy and evaluate whether relationship communication mediated the association between relationship awareness and intimacy. Two hundred fifty four women diagnosed with early stage breast cancer and their partners completed measures of cancer-specific relationship awareness, relationship talk, self-and perceived partner disclosure, perceived partner responsiveness, and relationship intimacy. Results indicated that patients and spouses who were higher in cancer-specific relationship awareness engaged in more relationship talk, reported higher levels of self-disclosure, and perceived that their partner disclosed more. Their partners reported that they were more responsive to disclosures. Relationship talk and perceived partner responsiveness mediated the association between cancer-specific relationship awareness and intimacy. Helping couples consider ways they can maintain normalcy and quality during the cancer experience and framing coping with cancer as a "team" effort may facilitate better communication and ultimately enhance relationship intimacy.

Reducing Breast Cancer Disparities with Precision Public Health: A New Strategy to Improve Prevention and Advance Health Equity in Delaware Hotspots.

While Black and White women are diagnosed with breast cancer (BC) at similar rates, Black women die from BC at a 40% higher rate. This disparity is even more pronounced for younger Black women, who die from BC at nearly twice the rate as younger White women. Black-White differences in BC mortality are largely attributable to health care and tumor biology factors. Black women face greater barriers to accessing BC screening and are twice as likely to be diagnosed with the aggressive triple-negative breast cancer (TNBC) subtype. Delaware leads the US for the incidence of late-stage BC diagnosed among younger women and TNBC. This commentary begins with a discussion of precision public health, an emerging framework that builds on and complements recent advances in precision medicine. Next, a new precision public health initiative designed to reduce BC disparities in Delaware by targeting local hotspots with prevention interventions is presented. Finally, next steps are considered for implementation, evaluation, and new research activities.