Iterative Development of an Interactive Website to Support Shared Decision-Making in Metastatic Breast Cancer.

Recent treatment advances have resulted in significantly increased survival times following metastatic breast cancer (MBC) diagnosis. Novel treatment approaches-and their related side effects-have changed the landscape of MBC treatment decision-making. We developed a prototype of an online educational tool to prepare patients with MBC for shared decision-making with their oncologists. We describe the five phases of tool development: (1) in-depth, semi-structured qualitative interviews and (2) feedback on storyboards of initial content with patients with MBC and oncology providers. This was followed by three phases of iterative feedback with patients in which they responded to (3) initial, non-navigable website content and (4) a beta version of the full website. In the final phase (5), patients newly diagnosed with MBC (N = 6) used the website prototype for 1 week and completed surveys assessing acceptability, feasibility, treatment knowledge, preparation for decision-making, and self-efficacy for decision-making. Participants in Phase 1 characterized a cyclical process of MBC treatment decision-making and identified key information needs. Website content and structure was iteratively developed in Phases 2-4. Most participants in Phase 5 (n = 4) accessed the website 2-5 times. All participants who accessed the website at least once (n = 5) felt they learned new information from the website prototype and would recommend it to others newly-diagnosed with MBC. After using the website prototype, participants reported high preparation and self-efficacy for decision-making. This multiphase, iterative process resulted in a prototype intervention designed to support decision-making for MBC patients.

High Financial Hardship among Patients with Advanced Ovarian Cancer.

Ovarian cancer is considered the most fatal and costly gynecologic cancer. Although personalized therapies have improved ovarian cancer prognosis, they have resulted in increased financial toxicity concerns among this population. This study evaluated financial toxicity in patients with advanced ovarian cancer. Using secondary data from a study of barriers to palliative care, financial toxicity (FT) was measured through the Comprehensive Score for Financial Toxicity scale. Univariate and bivariate analyses were used to assess the relationship between selected demographic (i.e., age, race, ethnicity, education, place of birth, insurance type, yearly household income, employment status) and treatment-specific variables (i.e., years since diagnosis, surgery, chemotherapy, radiation, hormonal and targeted therapy) with clinically relevant financial toxicity. Characteristics were compared using Fisher's exact or chi squared tests. A total of 38 participants with advanced ovarian cancer were included in this study; 24% (n = 9) reported clinically significant FT. Income (p = .001), place of birth (p = .048) and employment status (p = .001) were related to FT. Study findings highlight that advanced ovarian cancer patients experience high FT, particularly those with low income, who are not able to work and were born outside the US. Further research using larger datasets and more representative samples is needed to inform intervention development and implementation.

Patterns and Predictors of Referral for Screening Breast MRI: A Mixed-Methods Study.

Introduction: Women with ≥20% lifetime breast cancer risk can receive supplemental breast cancer screening with MRI. We examined factors associated with recommendation for screening breast MRI among primary care providers (PCPs), gynecologists (GYNs), and radiologists. Methods: We conducted a sequential mixed-methods study. Quantitative: Participants (N = 72) reported recommendations for mammogram and breast MRI via clinical vignettes describing hypothetical patients with moderate, high, and very high breast cancer risk. Logistic regressions assessed the relationships of clinician-level factors (gender, specialty, years practicing) and practice-level factors (practice type, imaging facilities available) with screening recommendations. Qualitative: We interviewed a subset of survey participants (n = 17, 17/72 = 24%) regarding their decision-making about breast cancer screening recommendations. Interviews were audio-recorded, transcribed, and analyzed with directed content analysis. Results: Compared with PCPs, GYNs and radiologists were significantly more likely to recommend breast MRI for high-risk (ORs = 4.09 and 4.09, respectively) and very-high-risk patients (ORs = 8.56 and 18.33, respectively). Qualitative analysis identified two key phases along the clinical pathway for high-risk women. Phase 1 was "identifying high-risk women," which included three subthemes (systems for risk assessment, barriers to risk assessment, scope of practice issues). Phase 2 was "referral for screening," which included three subthemes (conflicting guidelines, scope of practice issues, legal implications). Frequency of themes differed between specialties, potentially explaining findings from the quantitative phase. Conclusions: There are significant differences between specialties in supplemental breast cancer screening recommendations. Multilevel interventions are needed to support identification and management of women with high breast cancer risk, particularly for PCPs.

Oncology mental health providers' adaptation of an evidence-based intervention: A mixed-methods study.

BACKGROUND: Adaptations are intentional modifications maximizing the fit of an evidence-based intervention (EBI) in new context. Little is known about EBI adaptation within psychosocial oncology. Guided by the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME), this mixed-methods study describes oncology mental health providers' planned adaptations to a psychosocial oncology EBI and examines the relationship between planned adaptations and longitudinal EBI usage. METHODS: Providers (N = 128) were social workers (47%) and psychologists (40%) practicing in community settings (44%) or academic medical centers (41%). They attended a 3-day training on a multicomponent psychosocial oncology EBI, the Biobehavioral Intervention (BBI). During training, providers prepared an "adaptation plan" describing necessary adaptations to BBI and rationales for change. Qualitative data from adaptation plans were analyzed using directed content analysis. Linear mixed models examined the relationship between adaptation characteristics (number, similarity to the manualized BBI) and EBI usage across 12 months post-training. RESULTS: Three sets of qualitative themes reflecting FRAME elements emerged: (1) content modifications (e.g., shortening/condensing, selecting elements, adding/removing elements); (2) contextual changes (e.g., alternative group formats); and (3) reasons for adaptations (e.g., organization/setting, provider, and recipient factors). Neither number of adaptations nor adaptation similarity were associated with BBI usage across 12 months post-training. CONCLUSIONS: To our knowledge, this study is the first to characterize oncology mental health providers' planned adaptations to a psychosocial oncology EBI. Planned adaptations did not increase usage, but importantly they did not decrease usage. The adaptation process enabled providers to make thoughtful adaptation choices, with implementation successful irrespective of setting constraints.

Relationship between area-level socioeconomic status and health-related quality of life among cancer survivors.

Area-level socioeconomic status (SES) impacts cancer outcomes, such as stage at diagnosis, treatments received, and mortality. However, less is known about the relationship between area-level SES and health-related quality of life (HRQOL) for cancer survivors. To assess the additive value of area-level SES data and the relative contribution of area- and individual-level SES for estimating cancer survivors' HRQOL, we conducted a secondary analysis of data from a population-based survey study of cancer survivors (the Measuring Your Health [MY-Health] Study). Multilevel multinomial logistic regression models were used to examine the relationships between individual-level SES, area-level SES as measured by the Centers for Disease Control and Prevention's Social Vulnerability Index, and HRQOL group membership (high, average, low, or very low HRQOL). Area-level SES did not significantly increase model estimation accuracy compared to models using only individual-level SES. However, area-level SES could be an appropriate proxy when the individual-level SES is missing.

Self-reported barriers to screening breast MRI among women at high risk for breast cancer.

BACKGROUND: Annual screening breast MRI is recommended for women at high (≥ 20% lifetime) breast cancer risk, but is underutilized. Guided by the Health Services Utilization Model (HSUM), we assessed factors associated with screening breast MRI among high-risk women. METHODS: From August 2020-January 2021, we recruited an online convenience sample of high-risk women ages 25-85 (N = 232). High-risk was defined as: pathogenic genetic mutation in self or first-degree relative; history of lobular carcinoma in situ; history of thoracic radiation; or estimated lifetime risk ≥ 20%. Participants self-reported predisposing factors (breast cancer knowledge, health locus of control), enabling factors (health insurance type, social support), need factors (perceived risk, screening-supportive social norms, provider recommendation), and prior receipt of screening breast MRI. Multivariable logistic regression analysis with backward selection identified HSUM factors associated with receipt of screening breast MRI. RESULTS: About half (51%) of participants had received a provider recommendation for screening breast MRI; only 32% had ever received a breast MRI. Breast cancer knowledge (OR = 1.15, 95% CI = 1.04-1.27) and screening-supportive social norms (OR = 2.21, 95% CI = 1.64-2.97) were positively related to breast MRI receipt. No other HSUM variables were associated with breast MRI receipt (all p's > 0.1). CONCLUSIONS: High-risk women reported low uptake of screening breast MRI, indicating a gap in guideline-concordant care. Breast cancer knowledge and screening-supportive social norms are two key areas to target in future interventions. Data were collected during the COVID-19 pandemic and generalizability of results is unclear. Future studies with larger, more heterogeneous samples are needed to replicate these findings.

"It doesn't really apply to what I'm going through": a mixed-methods study of barriers to palliative care among patients with advanced ovarian cancer.

PURPOSE: Palliative care aims to provide symptom relief and general support for patients with serious illness. Despite experiencing significant treatment side effects, specialty palliative care is under-utilized by patients with advanced ovarian cancer. We explored barriers to palliative care in this population. METHODS: We conducted a sequential mixed-methods study. Qualitative: we interviewed patients with advanced ovarian cancer (N = 7). Guided by the Social Ecological Model (SEM), interviews assessed intrapersonal, interpersonal, organizational, and policy-level barriers to receipt of specialty palliative care. Interviews were audio-recorded, transcribed, and analyzed with directed content analysis. Quantitative: patients with advanced ovarian cancer (N = 38) completed self-report surveys assessing knowledge about, attitudes towards, and prior experiences with specialty palliative care. Descriptive statistics were used to characterize survey responses. RESULTS: Qualitative analysis identified barriers to specialty palliative care at each SEM level. Intrapersonal factors (e.g., knowledge, attitudes) were most frequently discussed. Other common barriers included insurance coverage and distance/travel time. Survey responses indicated most participants were aware of palliative care (74%) but had mixed attitudes towards palliative care and did not feel they needed for palliative care. No survey respondents had received a physician recommendation for palliative care, and a sizable minority (29%) thought palliative care referral should only take place when patients have no remaining treatment options. CONCLUSION: Among patients with advanced ovarian cancer, barriers to specialty palliative care exist at multiple levels. Our results underscore the potential value of a multilevel intervention to support receipt of palliative care in this population.

Patterns of Screening Mammography and Breast MRI During the COVID-19 Pandemic: A Retrospective, Chart-Review Study.

Objective: This study examined patterns of breast cancer screening during the COVID-19 pandemic. Methods: This retrospective study was approved by the Georgetown University IRB. Review of electronic medical records identified screening mammograms and breast MRIs between March 13, 2018 and December 31, 2020, for female patients aged 18 to 85 years. Descriptive statistics characterized patterns of breast cancer screening before and during the COVID-19 pandemic. Logistic regression analyses examined whether receipt of breast MRI differed over time and demographic and clinical factors associated with receipt of breast MRI in 2020. Results: Data included 47 956 mammography visits in 32 778 patients and 407 screening breast MRI visits in 340 patients. After an initial decrease following the declaration of the COVID-19 pandemic, both screening mammograms and screening breast MRI demonstrated early recovery. Although the mammography receipt remained sustained, the receipt of screening breast MRI decreased in late 2020. Odds of having a breast MRI did not differ between 2018 and 2019 (OR = 1.07; 95% CI = 0.92%-1.25%; P = 0.384) but were significantly lower in 2020 versus 2019 (OR = 0.76; 95% CI = 0.61%-0.94%; P = 0.011). No demographic or clinical factors were associated with receipt of breast MRI during the COVID-19 pandemic (all P-values ≥0.225). Conclusion: Breast cancer screening decreased following the declaration of the COVID-19 pandemic. Although both procedures demonstrated early recovery, the rebound in screening breast MRI was not sustained. Interventions promoting return to screening breast MRI may be needed for high-risk women.

Assessing the Relationship Between Motherhood and Cervical Cancer Screening and Prevention Behaviors.

Background: National guidelines recommend Papanicolaou (Pap) testing and human papillomavirus (HPV) vaccination for cervical cancer prevention; however, certain subgroups may be at risk for underutilization. Prior studies have identified motherhood as a predictor of health outcomes, but this research has not been extended to cervical cancer prevention. Informed by the Health Belief Model, we explored the relationship between motherhood, health beliefs, and Pap testing and HPV vaccination. Methods: This study used an observational, cross-sectional design. Participants assigned female at birth (N = 417) completed an online survey assessing motherhood, health beliefs (perceived risk, perceived benefits, perceived barriers, and self-efficacy), and prior Pap testing and HPV vaccination. Bootstrapped mediation analyses determined whether motherhood was associated with prior Pap testing and HPV vaccination and whether health beliefs mediated these relationships. Results: Of mothers (25%), 75% were up-to-date with Pap testing and 36% had previously received ≥1 dose of the HPV vaccine. There was no direct effect of motherhood on Pap testing (p = 0.873) or HPV vaccination (p = 0.921) and no significant indirect effects via health beliefs (ps ≥ 0.096). However, perceived benefits and self-efficacy were significantly related to both Pap testing (ps ≤ 0.003) and HPV vaccination (ps ≤ 0.010). Mothers reported lower self-efficacy for HPV vaccination than nonmothers (p = 0.035). Discussion: Consistent with nationwide statistics, most eligible participants were up-to-date with Pap testing and HPV vaccination. Although motherhood was not significantly associated with either behavior, mothers reported lower self-efficacy for HPV vaccination. Perceived benefits and self-efficacy may be important targets for future interventions aiming to increase cervical cancer prevention and screening behaviors.

Behavioral beliefs about genetic counseling among high-risk Latina breast cancer survivors in Florida and Puerto Rico.

Compared with non-Hispanic White women, Latina women are less likely to receive genetic counseling (GC) and testing (GT) following BC diagnosis. This study used secondary data analysis to explore beliefs about GC among Latina BC survivors in and outside the US mainland. GC/GT-naïve, high-risk, Spanish-preferring Latina BC survivors (n = 52) in FL and PR completed the Behavioral Beliefs about GC scale. Participants reported high positive beliefs about GC (M = 4.19, SD = 0.92); the majority agreed that GC was beneficial to understand cancer risk (90%) and promote discussion (87%) in their family. Participants reported low-to-moderate scores for barriers (Ms = 1.53-3.40; SDs = 0.59-0.90). The most frequently endorsed barriers were desire for additional GC information (M = 3.44; SD = 0.90), and GC logistic concerns (M = 2.71; SD = 0.80). No statistically significant differences for barriers and benefits scales were identified by place of residence (all ps ≥ 0.12). These findings highlight the importance of delivering culturally sensitive GC information to high-risk Latina BC survivors.

Using Protection Motivation Theory to Predict Intentions for Breast Cancer Risk Management: Intervention Mechanisms from a Randomized Controlled Trial.

The purpose of this study is to evaluate the direct and indirect effects of a web-based, Protection Motivation Theory (PMT)-informed breast cancer education and decision support tool on intentions for risk-reducing medication and breast MRI among high-risk women. Women with ≥ 1.67% 5-year breast cancer risk (N = 995) were randomized to (1) control or (2) the PMT-informed intervention. Six weeks post-intervention, 924 (93% retention) self-reported PMT constructs and behavioral intentions. Bootstrapped mediations evaluated the direct effect of the intervention on behavioral intentions and the mediating role of PMT constructs. There was no direct intervention effect on intentions for risk-reducing medication or MRI (p's ≥ 0.12). There were significant indirect effects on risk-reducing medication intentions via perceived risk, self-efficacy, and response efficacy, and on MRI intentions via perceived risk and response efficacy (p's ≤ 0.04). The PMT-informed intervention effected behavioral intentions via perceived breast cancer risk, self-efficacy, and response efficacy. Future research should extend these findings from intentions to behavior. ClinicalTrials.gov Identifier: NCT03029286 (date of registration: January 24, 2017).

Developing theory-driven narrative messages with personal stories: A step-by-step guide.

OBJECTIVE: Narratives are commonly utilized in health promotion and behavior change interventions due to their efficacy over didactic or expository interventions. While grounding narratives in behavioral theory may render them more effective, balancing the integration of theoretical and creative aspects of the narrative development process while maintaining authenticity is challenging. Thus, this manuscript describes a rigorous process through which researchers can intentionally integrate theory and personal stories for health interventions. METHODS: The process for creating theory-driven narratives involves the following steps: (1) defining the purpose of the narratives, (2) selecting a guiding theory, (3) collecting personal testimonials, (4) immersing self into testimonials, (5) identifying central narratives and important variations, (6) considering additional theories, (7) piecing quotes into cohesive stories, (8) filling in the gaps, and (9) checking for resonance. RESULTS: To exemplify this step-by-step process, we provide a case study from our research involving the development of a psychoeducational intervention to model information seeking strategies for managing cancer-related uncertainty among women who have recently tested positive for pathogenic genetic variants that increase risk for hereditary breast and ovarian cancer. CONCLUSIONS: We discuss special considerations for developing theory-driven narrative interventions and reflect on how this rigorous step-by-step process can be adapted by other researchers.

Provider discussion of genetic counseling among high-risk Spanish-preferring Latina breast cancer survivors.

Among high-risk breast cancer (BC) survivors, genetic counseling (GC) and genetic testing (GT) may inform cascade testing and risk management. Compared to non-Hispanic White BC survivors, Spanish-preferring Latina BC survivors are less likely to report discussing GC with a healthcare provider. However, few studies have examined Latinas' experiences with GC/GT, particularly outside of the mainland USA. This study aimed to compare frequency of provider discussion of GC between Spanish-preferring Latina BC survivors living in Florida (FL) and Puerto Rico (PR). We conducted secondary data analysis of baseline assessments from a randomized pilot of an educational intervention for Spanish-preferring Latina BC survivors. Participants (N = 52) were GC/GT-naive, but met clinical criteria for GC/GT referral. Participants self-reported sociodemographic, clinical, and cultural variables, including previous provider discussion of GC. Descriptive statistics characterized frequency of GC discussion. Logistic regression examined the relationships between sociodemographic, clinical, and cultural characteristics and GC discussion. Only 31% of participants reported previous GC discussion. More participants from PR reported having GC discussions (43% vs. 21% in the mainland USA). In multivariable analyses, greater likelihood of GC discussion was associated with PR (vs. mainland USA) residence (odds ratio [OR] = 6.00, p = .03), older age at baseline (OR = 1.19, p = .04), and younger age at BC diagnosis (OR = 0.80, p = .03). Few high-risk Spanish-preferring Latina BC survivors in the mainland USA and PR had discussed GC with their providers. These results highlight a gap in the implementation of evidence-based genetics guidelines. Provider-directed interventions may be needed to increase uptake of GC/GT among Latina BC survivors.

Some families have changes in the BRCA genes that increase their risk for developing breast cancer compared to those who do not have these gene changes. Through genetic testing, we can identify breast cancer survivors who have these gene changes so their families can take action to prevent future cancers. Breast cancer survivors who are diagnosed at a young age, or who have a strong family history of breast and ovarian cancer, are eligible for genetic counseling and BRCA testing. Yet, compared to women from other racial and ethnic groups, fewer Latina breast cancer survivors have genetic counseling and testing. This study explored frequency of healthcare providers' discussion about genetic counseling among Spanish-preferring Latina breast cancer survivors living in Florida and Puerto Rico. Although all participants were eligible, only 3 out of 10 indicated that a provider previously discussed genetic counseling with them. Participants who were living in Puerto Rico, older at study entry, or younger at the time of their breast cancer diagnosis were more likely to have discussed genetic counseling with a healthcare provider. Healthcare providers are important for identifying and referring high-risk Spanish-preferring Latinas for genetic counseling in and outside the mainland USA.

Characteristics associated with healthcare disruptions during the COVID-19 pandemic for women in the United States at high risk for breast cancer.

Delays in healthcare, including breast cancer screening, were documented during the coronavirus disease 2019 (COVID-19) pandemic. However, no studies have examined the impact of COVID-19 on healthcare among women at high (≥20 % lifetime) risk for breast cancer. This study fills that gap. Between August 2020 and January 2021, high-risk women (N = 225) living in the United States (US) completed an online survey assessing COVID-related healthcare disruptions. Descriptive statistics characterized the frequency of breast cancer screening (mammogram and breast magnetic resonance imaging [MRI]) since the beginning of the COVID-19 pandemic. Multivariable linear regression analysis with backward selection examined demographic characteristics associated with COVID-related healthcare disruptions. Since March 2020, 40 % of participants had received a mammogram and 12 % had received a screening breast MRI. On average, participants reported low levels of COVID-related healthcare disruptions (M = 1.97 on a 0-4 scale, higher = more disruptions). Participants who were younger (ß = -0.21, p = 0.002) and not working (ß = 0.18, p = 0.009) reported more COVID-related healthcare disruptions. Compared to non-Hispanic White participants, those from any other racial or ethnic group reported fewer COVID-related healthcare disruptions (ß = -0.15, p = 0.020). Although few high-risk women received breast cancer screening after the declaration of the COVID-19 pandemic, they reported overall low levels of COVID-related healthcare disruptions. Results identify subgroups of high-risk women whose healthcare may have been more affected by the pandemic. Efforts to encourage US women at high risk for breast cancer to return to routine preventive care (including breast cancer screening) may need to be targeted towards women who are younger, not working, and non-Hispanic White.

Anxiety and depression among Black breast cancer survivors: Examining the role of patient-provider communication and cultural values.

OBJECTIVE: Breast cancer survivors frequently experience anxiety and depression post-treatment. Patient-provider communication and cultural values may impact these psychological outcomes. We examined the impact of patient-provider communication and cultural values on anxiety and depression among Black breast cancer survivors. METHODS: Using an observational, cross-sectional design, 351 survivors self-reported patient-provider communication (quality, confidence), cultural values (religiosity, collectivism, future time orientation), anxiety, and depression. Patients were categorized into high, moderate, and low levels of communication and cultural values. Separate linear regressions examined the effect of levels of communication and cultural values on anxiety and depression, controlling for sociodemographic variables. RESULTS: A subset of breast cancer survivors reported clinically significant symptoms of anxiety (40%) and depression (20%). Communication was associated with anxiety (ß = -0.14, p = 0.01) and depression (ß = -0.10, p = 0.04). Specifically, women reporting higher levels of communication quality/confidence reported lower levels of anxiety and depression. There was a trend towards a significant association between cultural values and depression (ß = -0.09, p = 0.06). CONCLUSIONS: Black breast cancer survivors experience poor psychological functioning. Effective patient-provider communication may reduce anxiety and depression post-treatment. PRACTICE IMPLICATIONS: Patient-provider relationships and patient empowerment may be key components of cancer survivorship. Special attention should be paid to patient-centered communication for Black breast cancer survivors.

Socioeconomic disparities in psychosocial service recommendation and receipt among young Black breast cancer survivors.

PURPOSE: Black cancer survivors are less likely to receive desired psychological services than non-Hispanic White survivors. Black cancer survivors with low socioeconomic status may face additional barriers to receipt of psychological services. This study examined socioeconomic disparities in psychological service recommendation, attempts to access, and receipt among Black breast cancer (BC) survivors. METHODS: Black BC survivors (n = 249) completed surveys at baseline (T1) and follow-up (T2; M 1.6 years post-T1). At T1, participants reported socioeconomic characteristics (employment, income, insurance, and education) and psychological symptoms (hospital anxiety and depression scale [HADS]). Self-reported address was used to identify area deprivation index (ADI), a composite measure of neighborhood socioeconomic disadvantage (least disadvantaged = 1; most disadvantaged = 10). At T2, participants reported provider recommendations for, attempts to access, and receipt of psychological services. Logistic regressions examined relationships between socioeconomic characteristics and psychological service variables, controlling for baseline psychological symptoms. RESULTS: In multivariable analyses, being employed was associated with a lower likelihood of attempts to access (OR = 0.25) and receipt of (OR = 0.37) psychological services, above and beyond the effect of psychological symptoms. Univariate analyses demonstrated that participants from more disadvantaged areas (i.e., higher ADI) were more likely to receive psychological services (OR = 1.20), but this effect became non-significant in multivariable analyses. CONCLUSION: Results highlight the importance of an intersectional perspective in considering mental health care disparities; both race/ethnicity and socioeconomic status should be incorporated when considering barriers and facilitators of psychological care.

Affect regulation as a moderator of intentions for breast cancer chemoprevention.

Women at high risk for breast cancer (BC) may consider chemoprevention for risk reduction, but uptake is low. This study examined the role of affect regulation (the attempt to alter or control one's emotions) in decision-making about BC chemoprevention. A cross-sectional, single group design was used. High-risk women (N = 81) were surveyed. Moderation analyses specified cancer-specific distress as the independent variable, affect regulation (cognitive reappraisal or expressive suppression) as the moderator, and chemoprevention intentions (yes = 1, unsure = 0, no = -1) as the dependent variable. Cognitive reappraisal significantly moderated the relationship between cancer-specific distress and chemoprevention intentions (p = 0.03), but expressive suppression did not (p = 0.31). For the 44% of participants who were highest on reappraisal, higher cancer-specific distress was associated with greater intentions for chemoprevention. For the remaining 56%, there was no relationship between cancer-specific distress and chemoprevention intentions. Cognitive reappraisal may play an important role in decisions regarding uptake of chemoprevention.

Barriers and facilitators to taking CDK4/6 inhibitors among patients with metastatic breast cancer: a qualitative study.

PURPOSE: Most studies of adherence to treatment for breast cancer have focused on early-stage patients. Findings from these studies may not generalize to patients with metastatic breast cancer (MBC). The objective of this study was to identify barriers and facilitators of adherence to cyclin-dependent kinase 4/6 (CDK4/6) inhibitors among patients with MBC, guided by the social ecologic model (SEM). METHODS: Patients with MBC (N = 25), their caregivers (N = 9), and oncology providers (N = 13) completed semi-structured qualitative interviews exploring their experiences with CDK4/6 inhibitors. Interviews were audio-recorded, transcribed verbatim, and analyzed by three raters using a combined deductive and inductive approach. RESULTS: Qualitative analysis identified barriers and facilitators of adherence at each SEM level. Intrapersonal and interpersonal factors were most frequently discussed. Intrapersonal factors included knowledge/beliefs about CDK4/6 inhibitors, side effects, and establishing a routine. Interpersonal factors included effective communication with/coordination by the care team, support from family and friends, and information from other patients with MBC. Although less frequently discussed, policy factors (i.e., cost of CDK4/6 inhibitors) were of great concern to patients, caregivers, and providers. CONCLUSION: Barriers to adherence to CDK4/6 inhibitors exist at multiple levels. Our results underscore the potential value of a multilevel intervention (e.g., patient education, evidence-based strategies for symptom management, tips for open and assertive communication with providers, information about financial resources/support available, and so on) to support adherence in this population.

Health Literacy in Surgical Oncology Patients: An Observational Study at a Comprehensive Cancer Center.

BACKGROUND: Low health literacy is associated with increased resource use and poorer outcomes in medical and surgical patients with various diseases. This observational study was designed to determine (1) the prevalence of low health literacy among surgical patients with cancer at an NCI-designated Comprehensive Cancer Center (CCC), and (2) associations between health literacy and clinical outcomes. METHODS: Patients receiving surgery (N=218) for gastrointestinal (60%) or genitourinary cancers (22%) or sarcomas (18%) were recruited during their postsurgical hospitalization. Patients self-reported health literacy using the Brief Health Literacy Screening Tool (BRIEF). Clinical data (length of stay [LoS], postacute care needs, and unplanned presentation for care within 30 days) were abstracted from the electronic medical records 90 days after surgery. Multivariate linear and logistic regressions were used to examine the relationship between health literacy and clinical outcomes, adjusting for potential confounding variables. RESULTS: Of 218 participants, 31 (14%) showed low health literacy (BRIEF score ≤12). In regression analyses including 212 patients with complete data, low health literacy significantly predicted LoS (ß = -1.82; 95% CI, -3.00 to -0.66; P=.002) and postacute care needs (odds ratio [OR], 0.25; 95% CI, 0.07-0.91). However, health literacy was not significantly associated with unplanned presentation for care in the 30 days after surgery (OR, 0.51; 95% CI, 0.20-1.29). CONCLUSIONS: This study demonstrates the prevalence of low health literacy in a surgical cancer population at a high-volume NCI-designated CCC and its association with important clinical outcomes, including hospital LoS and postacute care needs. Universal screening and patient navigation may be 2 approaches to mitigate the impact of low health literacy on postsurgical outcomes.

Improving our model of cascade testing for hereditary cancer risk by leveraging patient peer support: a concept report.

Consensus and evidence suggest that cascade testing is critical to achieve the promise of cancer genetic testing. However, barriers to cascade testing include effective family communication of genetic risk information and family members' ability to cope with genetic risk. These barriers are further complicated by the developmental needs of unaffected family members during critical windows for family communication and adaptation. Peer support could address these barriers. We provide two illustrative examples of ongoing BRCA1/2-related clinical trials that apply a peer support model to improve family communication and functioning. Peer support can augment currently available genetic services to facilitate adjustment to and effective use of cancer genetic risk information. Importantly, this scalable approach can address the presence of cancer risk within families across multiple developmental stages. This applies a family-centered perspective that accommodates all potentially at-risk relatives. This peer support model can be further applied to emerging topics in clinical genetics to expand reach and impact.