Understanding social needs screening and demographic data collection in primary care practices serving Maryland Medicare patients.

BACKGROUND: Health outcomes are strongly impacted by social determinants of health, including social risk factors and patient demographics, due to structural inequities and discrimination. Primary care is viewed as a potential medical setting to assess and address individual health-related social needs and to collect detailed patient demographics to assess and advance health equity, but limited literature evaluates such processes. METHODS: We conducted an analysis of cross-sectional survey data collected from n = 507 Maryland Primary Care Program (MDPCP) practices through Care Transformation Requirements (CTR) reporting in 2022. Descriptive statistics were used to summarize practice responses on social needs screening and demographic data collection. A stepwise regression analysis was conducted to determine factors predicting screening of all vs. a targeted subset of beneficiaries for unmet social needs. RESULTS: Almost all practices (99%) reported conducting some form of social needs screening and demographic data collection. Practices reported variation in what screening tools or demographic questions were employed, frequency of screening, and how information was used. More than 75% of practices reported prioritizing transportation, food insecurity, housing instability, financial resource strain, and social isolation. CONCLUSIONS: Within the MDPCP program there was widespread implementation of social needs screenings and demographic data collection. However, there was room for additional supports in addressing some challenging social needs and increasing detailed demographics. Further research is needed to understand any adjustments to clinical care in response to identified social needs or application of data for uses such as assessing progress towards health equity and the subsequent impact on clinical care and health outcomes.

Contextual Factors Relevant to Implementing Social Risk Factor Screening and Referrals in Cancer Survivorship: A Qualitative Study.

Introduction: Social risk factors such as food insecurity and lack of transportation can negatively affect health outcomes, yet implementation of screening and referral for social risk factors is limited in medical settings, particularly in cancer survivorship. Methods: We conducted 18 qualitative, semistructured interviews among oncology teams in 3 health systems in Washington, DC, during February and March 2022. We applied the Exploration, Preparation, Implementation, Sustainment Framework to develop a deductive codebook, performed thematic analysis on the interview transcripts, and summarized our results descriptively. Results: Health systems varied in clinical and support staff roles and capacity. None of the participating clinics had an electronic health record (EHR)-based process for identifying patients who completed their cancer treatment ("survivors") or a standardized cancer survivorship program. Their capacities also differed for documenting social risk factors and referrals in the EHR. Interviewees expressed awareness of the prevalence and effect of social risk factors on cancer survivors, but none employed a systematic process for identifying and addressing social risk factors. Recommendations for increasing screening for social risk factors included designating a person to fulfill this role, improving data tracking tools in the EHR, and creating systems to maintain up-to-date information and contacts for community-based organizations. Conclusion: The complexity of cancer care workflows and lack of reimbursement results in a limited ability for clinic staff members to screen and make referrals for social risk factors. Creating clinical workflows that are flexible and tailored to staffing realities may contribute to successful implementation of a screening and referral program. Improving ongoing communication with community-based organizations to address needs was deemed important by interviewees.

Identifying research practices toward achieving health equity principles within the Cancer Prevention and Control Research Network.

PURPOSE: Although there is national recognition for health equity-oriented research, there is limited guidance for researchers to engage partnerships that promote health equity in cancer research. The Cancer Prevention and Control Research Network's (CPCRN) Health Equity Work Group developed a toolkit to guide researchers in equitable collaborations. METHODS: The CPCRN's Health Equity Work Group collectively outlined health and racial equity principles guiding research collaborations with partners that include communities, community-based organizations, implementing partners in the clinical setting including providers and health care organizations, and policy makers. Using a network-wide survey to crowdsource information around ongoing practices, we leveraged and integrated the network's experience and collaborations. RESULTS: Data from the survey formed the preliminary basis for the toolkit, with a focus on sharing fiscal resources with partners, training and capacity building, collaborative decision-making, community-driven research agenda setting, and sustainability. The final toolkit provides reflection considerations for researchers and collated exemplary resources, supported by the contemporary research. CONCLUSIONS: The toolkit provides a guide to researchers at all experience levels wanting to engage in equitable research collaborations. Future efforts are underway to evaluate whether and how researchers within and outside CPCRN are able to incorporate these principles in research collaborations.

Healthcare utilization in cancer survivors: six-month longitudinal cohort data.

PURPOSE: To describe healthcare utilization and reasons for delaying medical care and to identify factors that influence high healthcare utilization and care delay among cancer survivors. METHODS: Baseline (n = 991) and 6 month follow-up data (n = 777) were collected among breast, prostate, and colorectal cancer survivors from 32 US cancer centers. Participants completed surveys on healthcare utilization (e.g., number of visits to specific providers) and delay of medical care. We categorized participants as high or low users based on median number of visits. We used logistic regression models to examine factors that predicted high healthcare utilization or delay. RESULTS: Survivors reported a median of 10.5 visits to healthcare providers and 28% reported ever delaying medical care over 6 months. Compared to prostate cancer survivors, breast and colorectal survivors were 2.4 times more likely (CI = 1.2-4.8) and 4 times more likely (CI = 2.2-7.3) to be high healthcare users, respectively. A higher quality of life score predicted high healthcare utilization (OR = 2.4, CI = 2.0-2.8) and delay of medical care (OR = 1.8, CI = 1.5-2.2). Black survivors were 1.5 times more likely than White survivors to be high healthcare users (CI = 1.1-2.0) and respondents reporting a race category other than White or Black were 1.8 times more likely to delay care (CI = 1.3-2.5). Lower levels of self-efficacy predicted greater healthcare use (OR = 0.7, CI = 0.6-0.8) and delay (OR = 0.6, CI = 0.5-0.7). CONCLUSION: Our findings suggest that race, education, marital status, cancer type, time since diagnosis, quality of life, and self-efficacy are associated with both high healthcare utilization and delay among cancer survivors.

Testing delivery of components of cognitive behavioral therapy for insomnia to breast cancer survivors by smart speaker: a study protocol.

BACKGROUND: Insomnia is common in breast cancer survivors (BCS), affecting an estimated 30-50% of the 3.8 million BCS in the US. Insomnia is associated with health consequences for cardiometabolic and immune systems, neurobehavioral function, depression, fatigue, and quality of life and may put BCS at particular risk. While pharmacotherapy for insomnia may address symptoms in the short-term, cognitive behavioral therapy for insomnia (CBT-I) is considered the gold standard insomnia treatment. We describe our protocol to determine the efficacy of voice-activated delivery of CBT-I components on insomnia symptoms compared to a sleep education control among BCS. METHODS: We will conduct a 6-week, randomized controlled trial with two arms. Intervention arm participants will receive a smart speaker device and will be asked to engage with the program daily, using a voice-activated speaker with an accompanying smart-phone app. Control participants will have access to a website with basic information about CBT-I, sleep, and breast cancer survivorship and will be asked to engage with the website as desired. DISCUSSION: Our primary outcome is the Insomnia Severity Index total score. Secondary outcomes include sleep diary outcomes (sleep efficiency, wake after sleep onset, sleep onset latency, total sleep time, and sleep quality). This study will provide evidence on a promising modality to deliver elements of CBT-I for BCS experiencing insomnia. Trial Registration ClinicalTrials.gov NCT05233800 Released 3/25/2022.

Cross-Sectional Retrospective Assessments versus Longitudinal Prospective Assessments of Substance Use Change among Young Adults during COVID-19: Magnitude and Correlates of Discordant Findings.

Significance: Findings regarding changes in substance use since COVID-19 have been mixed, potentially due to differences in methods used to assess change. Thus, we compared changes in substance use per retrospective self-report at one time-point (March-May 2020) versus prospective, longitudinal self-report across 2 time-points (Sept-Dec 2019; March-May 2020), and identified predictors of discordance. Methods: We analyzed data from a longitudinal study of 1,082 young adults from 6 metropolitan areas. Across cigarettes, e-cigarettes, marijuana, and alcohol, participants were categorized as Increasers (increased based on both methods), Decreasers/Stable (decreased/same per both methods), Over-reporters (decreased/same per longitudinal data/increased via retrospective report), or Under-reporters (increased per longitudinal data/decreased/same via retrospective report). We identified predictors (e.g., sociodemographics, pre-pandemic substance use levels) of Under-reporting. Results: In this sample (Mage=24.77; 45.7% male, 32.1% sexual minority, 4.0% Black, 12.4% Asian, 12.6% Hispanic), longitudinal data indicated that the proportions of cigarette, e-cigarette, marijuana, and alcohol users who increased their use were 43.3%, 41.7%, 52.6%, and 55.6%, respectively. Examining concordance/discordance groups, Under-reporters accounted for between 17.7% (alcohol) and 26.8% (e-cigarette) of users; over-reporters comprised among the smallest proportions of each group (17.4% for alcohol to 22.2% for marijuana). Multivariable regression indicated that predictors of Under-reporting were less pre-pandemic use across substances; being older for e-cigarettes; and being older, male, and Asian for alcohol. Conclusions: Findings highlight methodological variability as a potential reason for mixed findings regarding pandemic-related substance use change and underscore the need for rigorously designed research to accurately assess the population impact of COVID-19 and other historical events.

Trajectories of fatigue in a population-based sample of older adult breast, prostate, and colorectal cancer survivors: an analysis using the SEER-MHOS data resource.

PURPOSE: Fatigue is one of the most common and distressing symptoms experienced by cancer survivors. Understanding fatigue trajectories from pre- to post-diagnosis could inform fatigue prevention and management strategies. METHODS: We used the Surveillance, Epidemiology and End Results Medicare Health Outcomes Survey (SEER-MHOS) linked data resource to characterize fatigue trajectories and their predictors 1214 older adult survivors of breast, colorectal, or prostate cancer. Fatigue was measured prior to the cancer diagnosis (T0) and at two timepoints after diagnosis (T1: mean = 20 months and T2: mean = 39 months post-diagnosis). Latent growth curve modeling and mixed effects models for repeated measurements were used to investigate fatigue experiences before and after a cancer diagnosis. RESULTS: Overall, mean fatigue T-scores declined (T0 = 50, T1 = 46, and T2 = 45) indicating worsening fatigue over time. Four latent trajectory subgroups were identified: severe fatigue worsening over time (8.2% of sample), severe fatigue persisting over time (14.4%), no fatigue pre-diagnosis and mild fatigue post-diagnosis (44.4%), and not fatigued (33%). Age, cancer stage, comorbidities, and depressed mood predicted membership in the two trajectory groups experiencing severe fatigue that persisted or that worsened post-diagnosis. Older age, advanced cancer stage at diagnosis, and depressed mood were significantly associated with worsening fatigue from T1 to T2 (all p < 0.0001). CONCLUSIONS: Evaluating cancer patients for depressive symptoms and considering prior fatigue levels, age, comorbid conditions, and cancer stage may help providers anticipate fatigue trajectories and implement pre-emptive strategies to lessen fatigue impact.

Defining a patient-centered approach to cancer survivorship care: development of the patient centered survivorship care index (PC-SCI).

PURPOSE: This study presents the validation of an index that defines and measures a patient-centered approach to quality survivorship care. METHODS: We conducted a national survey of 1,278 survivors of breast, prostate, and colorectal cancers to identify their priorities for cancer survivorship care. We identified 42 items that were "very important or absolutely essential" to study participants. We then conducted exploratory and confirmatory factor analyses (EFA/CFA) to develop and validate the Patient-Centered Survivorship Care Index (PC-SCI). RESULTS: A seven-factor structure was identified based on EFA on a randomly split half sample and then validated by CFA based on the other half sample. The seven factors include: (1) information and support in survivorship (7 items), (2) having a medical home (10 items) (3) patient engagement in care (3 items), (4) care coordination (5 items), (5) insurance navigation (3 items), (6) care transitions from oncologist to primary care (3 items), and (7) prevention and wellness services (5 items). All factors have excellent composite reliabilities (Cronbach's alpha 0.84-0.94, Coefficient of Omega: 0.81-0.94). CONCLUSIONS: Providing quality post-treatment care is critical for the long-term health and well-being of survivors. The PC-SCI defines a patient-centered approach to survivorship care to complement clinical practice guidelines. The PC-SCI has acceptable composite reliability, providing the field with a valid instrument of patient-centered survivorship care. The PC-SCI provides cancer centers with a means to guide, measure and monitor the development of their survivorship care to align with patient priorities of care. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT02362750 , 13 February 2015.

Exercise and weight loss interventions and miRNA expression in women with breast cancer.

PURPOSE: Obesity and weight gain are associated with comorbidities including a higher risk of tumor recurrence and cancer-related deaths among breast cancer (BC) survivors; however, the underlying mechanisms linking obesity and cancer are poorly understood. Given the lack of clinically validated BC biomarkers, obesity and weight-loss studies utilize serum biomarkers as the intermediary outcomes of tumor recurrence. Studies have indicated microRNAs (miRNA)s are reliable biomarkers for cancer. We hypothesized that miRNA expression correlates with obesity and weight loss amongst BC survivors. This would yield insight into the biological pathways by which this association occurs, enabling more precise development of therapeutics. PATIENTS AND METHODS: We correlated baseline body mass index (BMI) with serum miRNA expression in 121 BC survivors enrolled in the Hormones and Physical Exercise (HOPE) trial. We then analyzed expression of the 35 most abundant miRNAs from HOPE in a six-month randomized controlled weight-loss trial (Lifestyle, Exercise, and Nutrition; LEAN) in 100 BC survivors. Ingenuity pathway analysis (IPA) software was used to identify biological pathway targets of the BMI-associated and intervention-responsive miRNAs using predictive biomarkers. RESULTS: Pearson correlations in HOPE identified eight miRNAs associated with BMI, including miR-191-5p (r = - 0.22, p = 0.016) and miR-122-5p (r = 0.25, p = 0.0048). In the LEAN validation study, levels of miR-191-5p significantly increased during the six-month intervention (p = 0.082). Ingenuity Pathway Analysis identified "Estrogen-mediated S-phase entry" (HOPE p = 0.003; LEAN p < 0.001) and "Molecular mechanisms of cancer" (HOPE p = 0.02; LEAN p < 0.001) as the top canonical pathways that significantly correlated with BMI-associated and intervention-responsive miRNAs and contain obesity and cancer-relevant genes including the E2F family of transcription factors and CCND1, which have been implicated in sporadic BC. CONCLUSION: While the association between obesity and BC recurrence and mortality has been demonstrated in the literature, mechanisms underlying the link between weight gain and cancer are unclear. Using two independent clinical trials, we identified novel miRNAs associative to BMI and weight loss that contribute to the development of cancer. Predictive modeling of miRNA targets identified multiple canonical pathways associated with cancer, highlighting potential mechanisms explaining the link between BMI and increased cancer risk.

Mindfulness-based interventions and cognitive function among breast cancer survivors: a systematic review.

BACKGROUND: Breast cancer survivors have an elevated risk of cognitive impairment compared to age-matched women without cancer. Causes of this impairment are complex, including both treatment and psychological factors. Mindfulness-based interventions, which have been shown to improve cognitive function in the general population, may be one approach to mitigate cognitive impairment in this survivor population. Our objective was to conduct a systematic literature review of studies on the effect of mindfulness-based interventions on cognition among breast cancer survivors. METHODS: We conducted searches of three electronic databases (Scopus, PubMed and Cochrane Database of Systematic Reviews) in September 2017 for studies pertaining mindfulness and cognitive function among breast cancer survivors. Abstracts were manually searched by two reviewers and additional articles were identified through reference lists. RESULTS: A total of 226 articles were identified through our systematic search and six met inclusion criteria for this review. The reviewed studies lacked consistency in terms of the cognition domains studied (e.g. executive function, recent memory, etc) and in the measures used to assess cognition. Of the included studies, two found no association between mindfulness interventions and cognitive function, two found improvement that was not sustained at the follow-up, and another two found sustained improvement at 2- or 6-months. CONCLUSIONS: Mindfulness-based interventions have shown some evidence for improving cognition among breast cancer survivors, but further research using validated and comprehensive cognitive assessments is needed. More research is also needed related to the timing, duration and content of mindfulness interventions.

Sitting, physical activity, and serum oestrogen metabolism in postmenopausal women: the Women's Health Initiative Observational Study.

BACKGROUND: Prolonged sitting and lower levels of physical activity have been associated with increased levels of parent oestrogens (oestrone and oestradiol), the key hormones in female cancers, in postmenopausal women. However, it is unknown whether sitting and physical activity are associated with circulating oestrogen metabolite levels. METHODS: Among 1804 postmenopausal women enrolled in the Women's Health Initiative Observational Study, 15 serum oestrogens/oestrogen metabolites were quantified using liquid chromatography-tandem mass spectrometry. Physical activity and sitting were self-reported via questionnaire. Using baseline, cross-sectional data, geometric means (GM) of oestrogens/oestrogen metabolites (pmol l-1) were estimated using inverse probability weighted linear regression, adjusting for potential confounders and stratified on menopausal hormone therapy (MHT) use. RESULTS: Longer time spent sitting (⩾10 vs ⩽5h per day) was associated with higher levels of unconjugated oestrone, independent of moderate- to vigorous-intensity physical activity and body mass index, among both never/former (GM=70.6 vs 57.7) and current MHT users (GM=242 vs 179) (P-trend ⩽0.03). Among never/former MHT users, sitting (⩾10 vs ⩽5h per day) was positively associated with 2-methoxyestradiol (GM=16.4 vs 14.4) and 4-methoxyestradiol (GM=2.36 vs 1.98) (P-trend ⩽0.04), independent of parent oestrogens. Inverse associations between moderate- to vigorous-intensity physical activity (⩾15 vs 0 metabolic equivalent task-hours per week) and parent oestrogens were found as expected. After adjustment for parent oestrogens, physical activity was not associated with oestrogen metabolites. CONCLUSIONS: Our data suggest that prolonged sitting and lower moderate- to vigorous-intensity physical activity are associated with higher levels of postmenopausal oestrogens/oestrogen metabolites, the oestrogen metabolism patterns that have previously been associated with higher endometrial and breast cancer risk.

Body mass index, physical activity, and television time in relation to mortality risk among endometrial cancer survivors in the NIH-AARP Diet and Health Study cohort.

PURPOSE: Endometrial cancer (EC) survivors are the second largest group of female cancer survivors in the USA, with high prevalence of obesity and physical inactivity. While higher pre-diagnosis body mass index (BMI) has been associated with higher all-cause and disease-specific mortality, pre-diagnosis physical activity has shown mixed evidence of an association with mortality. However, the association between BMI, physical activity, and TV viewing measured after diagnosis and mortality risk among EC survivors is unknown. METHODS: We identified 580 women with EC in the NIH-AARP Diet and Health Study who completed a post-diagnosis questionnaire on BMI, leisure time moderate- to vigorous-intensity physical activity (MVPA), and TV viewing. We used Cox proportional hazards regression to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for mortality. RESULTS: With a median follow-up time of 7.1 years, we observed 91 total deaths. We found a positive association between BMI ([Formula: see text] = 2.14, 95% CI 1.08-4.24 and mortality, and no statistically significant association between TV viewing (HR5+ vs. <3 h/day = 1.46, 95% CI 0.86-2.46) and mortality nor MVPA with mortality (HR15+ vs. 0 MET h/week = 0.72, 95% CI 0.43-1.21) after adjusting for tumor characteristics and demographic factors. Further adjustment for lifestyle and health status attenuated BMI associations ([Formula: see text] = 1.47, 95% CI 0.71-3.07), but strengthened the association between TV viewing and mortality (HR5+ vs. <3 h/day = 2.28, 95% CI 1.05-4.95). CONCLUSIONS: Our results suggest that higher post-diagnosis BMI and TV viewing may be associated with higher mortality risk among EC patients, but that there may be complicated interrelationships between lifestyle factors of BMI, PA, and TV viewing and the mediating role of health status that need to be clarified.

Invited commentary: meta-physical activity and the search for the truth.

Measurement error in self-reported data from questionnaires is a well-recognized challenge in studies of physical activity and health. In this issue of the Journal, Lim et al. (Am J Epidemiol. 2015;181(9):648-655) used data from accelerometers in a small measurement study to correct self-reported physical activity data from a larger study of adults from New York City and to develop an error correction model. They showed that correction of measurement error in self-reported physical activity levels strengthened the associations of physical activity with both obesity and diabetes by 30%-50% compared with using the self-reported questionnaire data alone. Thus, Lim et al. demonstrated a method to improve potentially biased estimates of the association between self-reported physical activity and disease. However, as this field develops, we feel it is important to call attention to a sometimes overlooked problem that occurs when comparing these instruments: Questionnaires and accelerometers are often calibrated (i.e., designed) to measure different types of physical activity, and accelerometers are still subject to measurement error. Thus, physical activity estimates corrected with an imperfect accelerometer measurement might over- or undercorrect the strength of the associations. We take this opportunity to further comment on physical activity measurement in epidemiologic studies and the implications for research.

Menopausal hormone therapy and mortality among endometrial cancer patients in the NIH-AARP Diet and Health Study.

BACKGROUND: While menopausal hormone therapy (MHT) is an established endometrial cancer risk factor, its relationship with mortality among endometrial cancer patients is understudied. METHODS: Within the NIH-AARP Diet and Health Study, we examined the associations of pre-diagnosis MHT use with 10-year all-cause and endometrial cancer-specific mortality among 890 endometrial cancer patients. We used Cox proportional hazards regression models to estimate hazard ratios (HRs) and 95 % confidence intervals (CIs) adjusted for tumor characteristics, treatment, and other risk factors. RESULTS: Endometrial cancer cases were diagnosed a median of 4.6 years (range 0.0-10.1 years) after the second risk factor questionnaire was completed. We identified a total of 241 deaths, of which 104 were due to endometrial cancer. Compared with non-MHT use, pre-diagnosis use of estrogen plus progestin therapy (EPT)-only was associated with lower 10-year all-cause (HR 0.65, 95 % CI 0.43-0.99, based on 29 deaths) and endometrial cancer-specific mortality (HR 0.51, 95 % CI 0.26-0.98, based on 11 deaths). Recency of MHT use, assessed approximately 5 years prior to the endometrial cancer diagnosis, was associated with mortality. Compared with non-MHT users, former ET users had higher all-cause (HR 1.71, 95 % CI 1.02-2.88, based on 18 deaths) and endometrial cancer-specific mortality (HR 2.17, 95 % CI 0.96-4.90, based on 8 deaths), whereas current EPT users had nonsignificant lower risks of death. CONCLUSION: Based on small numbers, we observed that pre-diagnosis use of EPT was related to lower mortality among endometrial cancer patients. Future studies examining the biological mechanisms underlying this association are warranted.

Impact of changes in television viewing time and physical activity on longevity: a prospective cohort study.

BACKGROUND: Television viewing is a highly prevalent sedentary behavior among older adults, yet the mortality risks associated with hours of daily viewing over many years and whether increasing or decreasing viewing time affects mortality is unclear. This study examined: 1) the long-term association between mortality and daily viewing time; 2) the influence of reducing and increasing in television viewing time on longevity and 3) combined effects of television viewing and moderate-to-vigorous physical activity (MVPA) on longevity. METHODS: Participants included 165,087 adults in the NIH-AARP Diet and Health (aged 50-71 yrs) who completed questionnaires at two-time-points (Time 1: 1994-1996, and Time 2: 2004-2006) and were followed until death or December 31, 2011. Multivariable-adjusted Cox proportional hazards regression was used to estimate Hazard Ratios and 95% confidence intervals (CI) with self-reported television viewing and MVPA and all-cause mortality. RESULTS: Over 6.6 years of follow-up, there were 20,104 deaths. Compared to adults who watched < 3 h/day of television at both time points, mortality risk was 28% greater (CI:1.21,1.34) those who watched 5+ h/day at both time-points. Decreasing television viewing from 5 + h/day to 3-4 h/d was associated with a 15% reduction in mortality risk (CI:0.80, 0.91) and decreasing to <3 h/day resulted in an 12% lower risk (CI:0.79, 0.97). Conversely, adults who increased their viewing time to 3-4 h/day had an 17% greater mortality risk (CI:1.10, 1.24) and those who increased to 5+ h/day had a 45% greater risk (CI:1.32, 1.58), compared to those who consistently watched <3 h/day. The lowest mortality risk was observed in those who were consistently active and watched < 3 h/day of television. CONCLUSIONS: We confirm that prolonged television viewing time was associated with greater mortality in older adults and demonstrate for the first time that individuals who reduced the amount of time they spent watching television had lower mortality. Our findings provide new evidence to support behavioral interventions that seek to reduce sedentary television viewing in favor of more physically active pursuits, preferably MVPA. Given the high prevalence of physical inactivity and prolonged television viewing in older adults, favorable changes in these two modifiable behaviors could have substantial public health impact. TRIAL REGISTRATION: ClinicalTrials.gov number, NCT00340015.

Physical activity and cancer-specific mortality in the NIH-AARP Diet and Health Study cohort.

Higher physical activity levels have been associated with a lower risk of developing various cancers and all-cancer mortality, but the impact of pre-diagnosis physical activity on cancer-specific death has not been fully characterized. In the prospective National Institutes of Health-AARP Diet and Health Study with 293,511 men and women, we studied prediagnosis moderate to vigorous intensity leisure time physical activity (MVPA) in the past 10 years and cancer-specific mortality. Over a median 12.1 years, we observed 15,001 cancer deaths. Using Cox proportional hazards regression, we estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for MVPA with cancer mortality overall and by 20 specific cancer sites, adjusting for relevant risk factors. Compared to participants reporting never/rare MVPA, those reporting >7 hr/week MVPA had a lower risk of total cancer mortality (HR = 0.89, 95% CI 0.84-0.94; p-trend <0.001). When analyzed by cancer site-specific deaths, comparing those reporting >7 hr/week of MVPA to those reporting never/rare MVPA, we observed a lower risk of death from colon (HR = 0.70; 95% CI 0.57-0.85; p-trend <0.001), liver (0.71; 0.52-0.98; p-trend = 0.012) and lung cancer (0.84; 0.77-0.92; p-trend <0.001) and a significant p-trend for non-Hodgkins lymphoma (0.80; 0.62-1.04; p-trend = 0.017). An unexpected increased mortality p-trend with increasing MVPA was observed for death from kidney cancer (1.42; 0.98-2.03; p-trend = 0.016). Our findings suggest that higher prediagnosis leisure time physical activity is associated with lower risk of overall cancer mortality and mortality from multiple cancer sites. Future studies should confirm observed associations and further explore timing of physical activity and underlying biological mechanisms.

Prediagnostic lifestyle factors and survival after colon and rectal cancer diagnosis in the National Institutes of Health (NIH)-AARP Diet and Health Study.

BACKGROUND: Few studies have examined the relationship of lifestyle factors with mortality among patients with colorectal cancer. METHODS: Among NIH-AARP Diet and Health study participants, 4213 colon and 1514 rectal cancer cases were identified through linkage to state cancer registries and determined date and cause of death using the National Death Index. Lifestyle factors were assessed at baseline and included: healthy diet (measured by Healthy Eating Index 2005 [HEI-2005]), body mass index (BMI), physical activity, alcohol consumption and smoking. The association of factors was examined individually and combined into a lifestyle score with 5-year mortality from all-causes, colorectal cancer, and cardiovascular disease (CVD). Relative risks (RRs) and 95% confidence intervals (CIs) were estimated using Cox proportional hazards models. RESULTS: Among colon cancer survivors, smokers had increased risk of total mortality (RR = 1.74; 95% CI = 1.45-2.08) and colorectal cancer mortality (RR = 1.46; 95% CI = 1.17-1.82), compared to never smokers. Obese (BMI, ≥ 30) individuals had increased risk of all death (RR = 1.19; 95% CI = 1.02-1.39) and CVD death (RR = 1.84; 95% CI = 1.05-3.23), compared to normal weight (BMI, 18.5 to < 25) individuals. Compared to those with the lowest lifestyle score, those with the highest score had a 34% lower risk of all-cause mortality (RR = 0.66; 95% CI = 0.50-0.87). Among rectal cancer survivors, individuals in the highest quintile of HEI-2005 scores had reduced all-cause mortality (RR = 0.60; 95% CI = 0.42-0.86) compared to those in the lowest. Higher combined lifestyle scores were associated with a 46% lower risk of total mortality (0.54; 0.32-0.91). CONCLUSIONS: Healthier lifestyle before cancer diagnosis was associated with improved overall survival after diagnosis with colorectal cancer.

A novel voice interactive sleep log: concurrent validity with actigraphy and sleep diaries.

This is a preliminary validation study of a novel approach to an interactive sleep data collection platform. We compared actigraphy, paper and pencil logs, and the novel voice interactive sleep log in a sample of 17 breast cancer survivors with insomnia symptoms and also report qualitative data on acceptability. We used correlation coefficients and Bland Altman plots to evaluate convergent validity across these measures and report means for acceptability ratings. The sleep log data collected via paper and pencil vs the voice interactive measure had comparable mean values and variable validity coefficients across key sleep variables compared to actigraphy except for wake after sleep onset, where the voice-interactive system had fair concurrent validity with actigraphy. The voice interactive sleep log has several advantages over pencil and paper logs and actigraphy as it reduces patient burden, automatically calculates sleep variables, documents the timeliness of response and provides daily feedback to respondents on calculated sleep metrics. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Identifier: NCT05233800. CITATION: Lewin D, Starling CM, Zhou ES, Greenberg D, Shaw C, Arem H. A novel voice interactive sleep log: concurrent validity with actigraphy and sleep diaries. J Clin Sleep Med. 2024;20(2):309-312.

Barriers and facilitators to screen for and address social needs in primary care practices in Maryland: a qualitative study.

Background: Social needs screening can help modify care delivery to meet patient needs and address non-medical barriers to optimal health. However, there is a need to understand how factors that exist at multiple levels of the healthcare ecosystem influence the collection of these data in primary care settings. Methods: We conducted 20 semi-structured interviews involving healthcare providers and primary care clinic staff who represented 16 primary care practices. Interviews focused on barriers and facilitators to awareness of and assistance for patients' social needs in primary care settings in Maryland. The interviews were coded to abstract themes highlighting barriers and facilitators to conducting social needs screening. The themes were organized through an inductive approach using the socio-ecological model delineating individual-, clinic-, and system-level barriers and facilitators to identifying and addressing patients' social needs. Results: We identified several individual barriers to awareness, including patient stigma about verbalizing social needs, provider frustration at eliciting needs they were unable to address, and provider unfamiliarity with community-based resources to address social needs. Clinic-level barriers to awareness included limited appointment times and connecting patients to appropriate community-based organizations. System-level barriers to awareness included navigating documentation challenges on the electronic health record. Conclusions: Overcoming barriers to effective screening for social needs in primary care requires not only practice- and provider-level process change but also an alignment of community resources and advocacy of policies to redistribute community assets to address social needs.