Substance use behaviors in adolescent and young adult cancer patients: Associations with mental and physical health.

OBJECTIVE: Cancer diagnosis in adolescents and young adults (AYAs) coincides with the developmental initiation of substance use and emergence of affective disturbance. We examined substance use behaviors and risk-stratified associations with mental and physical health, as well as objective indicators of tobacco and cannabis use and concordance with self-report and medical records. METHODS: AYAs were 15 to 39 years at cancer diagnosis and ≥18 years and ≥6 months postdiagnosis at study enrollment. Risk-stratified groups included nonsmoker/nondrinker, nonsmoker/drinker, smoker/drinker. Assessments included demographics, past year tobacco, alcohol, and cannabis use, depression, anxiety, sleep, and physical activity. Urine analysis provided biochemical verification of tobacco and cannabis use. RESULTS: Participants included 100 AYAs (60% male) with primarily hematological cancers (88%). Past year alcohol, tobacco, and cannabis use prevalence rates were 80%, 15%, and 33%, respectively. A minority (non-users) refrained from both alcohol and tobacco (20%), while most were exclusively alcohol users (65%) or alcohol and tobacco co-users (15%). Relative to other sub-groups, co-users reported more depressive and anxious symptoms, while non-users reported more physical activity. More frequent tobacco and cannabis use were associated with more depressive and anxious symptoms, while more frequent alcohol use was associated with lower physical activity. There were no group differences or associations with sleep quality. There was considerable discordance between tobacco use self-report, biochemical verification, and medical record documentation. CONCLUSIONS: Substance use among AYAs is common and detrimental to mental and physical health, especially among more frequent users and co-users, highlighting the need for early assessment and intervention.

Rates and predictors of psychotherapy utilization after psychosocial evaluation for stem cell transplant.

OBJECTIVE: Although standard of care prior to hematopoietic stem cell transplantation (HSCT) includes a psychosocial evaluation, little is known about the rate and predictors of psychotherapy utilization among patients presenting for pre-HSCT evaluations. This study aimed to examine the proportion of patients undergoing pre-HSCT evaluations who subsequently utilize psychotherapy services and to explore predictive factors, including distress, anxiety, depression, and quality of life (QoL). METHODS: Participants were a cross-sectional sample of 351 HSCT candidates at an NCI-designated comprehensive cancer center. Questionnaires assessing distress, anxiety, depression, and QoL were administered using validated instruments. RESULTS: A subset of patients, representing 14% of the sample, utilized psychotherapy services. Relative to patients who did not utilize psychological services, patients who followed-up with psychotherapy reported significantly more depressive and anxious symptoms (P < .001) and endorsed worse QoL on the Functional Assessment of Cancer Therapy-General. (P = .04). Of note, a subset of patients who utilized psychotherapy services reported low levels of distress (67%), depression (13%), or anxiety (13%); on the other hand, a subset of patients reported moderate-to-high levels of distress (25%), depression (71%), or anxiety (60%) but did not utilize services. CONCLUSIONS: Results indicate that only a small subset of patients presenting for pre-HSCT psychosocial evaluation subsequently utilized psychotherapy services. Most patients who reported psychosocial concerns and who could potentially benefit from intervention did not use psychotherapy services. Further research is necessary to help clarify barriers to psychotherapy service utilization among HSCT patients and to help improve uptake among high-need patients.

Efficacy of a Spanish-Language Self-Administered Stress Management Training intervention for Latinas undergoing chemotherapy.

BACKGROUND: Cancer patients often report increased stress during chemotherapy. Stress management training has been shown to reduce this adverse outcome, but few interventions exist for Spanish-speaking Hispanic and Latina women (Latinas). METHODS: Following community feedback (including focus groups/in-depth interviews), we transcreated the Spanish-Language Self-Administered Stress Management Training (SL-SAT) intervention based on our previously developed and implemented English-based intervention. Latinas about to begin chemotherapy were randomized to SL-SAT (n = 121) or usual care (n = 119). A Spanish-speaking interventionist met with SL-SAT participants who received the SL-SAT toolkit containing instructions in 3 well-established stress management techniques (deep breathing, progressive muscle relaxation and guided imagery, and use of coping self-statements). Usual care participants received an educational booklet about coping with chemotherapy. All patients were instructed by nurses on their chemotherapy medications and given a resource listing of local support groups. Outcomes were obtained at baseline, and 7 and 13 weeks after starting chemotherapy. Primary outcomes included anxiety and depression, cancer-related distress, emotional well-being, and spiritual well-being. Secondary outcomes included functional well-being, social/family well-being, physical well-being, symptom severity, and self-efficacy for managing stress. Data were analyzed by using mixed models. RESULTS: In both groups, improvements were observed in emotional well-being (P = .01), and declines were observed in functional well-being (P = .05), and physical well-being (P < .0001). Symptom severity increased across the follow-up period (P < .001). CONCLUSIONS: To be effective, stress management interventions for Latinas receiving chemotherapy may necessitate more attention from an interventionist, delivery of the intervention over a longer interval, and/or a group-based format.

The impact of posttraumatic stress symptoms on social support and social conflict during hematopoietic stem cell transplant.

PURPOSE/OBJECTIVES: Social support and its relationship to psychological distress are of interest in hematopoietic stem cell transplant (HSCT) as patients are dependent on caregivers pre-, during, and posttransplant.  Although social support is critical for managing stress and trauma, posttraumatic stress symptoms (PTSS) may erode social support and evoke conflict and abandonment within the support system. This study aimed to evaluate whether PTSS were associated with lower support and social conflict in a sample of patients undergoing HSCT. DESIGN/METHODS: Prospective relationships between PTSS, perceived social support, and social conflict were assessed in 88 participants across the first three months of HSCT (T0 Baseline; T1 +30; T2 +60; T3 +90). FINDINGS: When individuals experienced increase above their own average levels of PTSS, they reported concurrent increase in social conflict (p < .001) and subsequent increase in social support in the following month (p = .026). CONCLUSION/IMPLICATIONS: Results suggest PTSS during stem cell transplantation may evoke social conflict, but over time, the support system may recalibrate to be more supportive. Patients undergoing HSCT may benefit from family and social-level interventions that specifically target the incidence of interpersonal conflict as it unfolds during the initial stages of HSCT.

Distress, delay of gratification and preference for palliative care in men with prostate cancer.

BACKGROUND: Patient-centered cancer care standards include routine psychosocial distress screening and referral for supportive care services. Although many cancer patients report psychosocial distress that could be alleviated by supportive services including palliative care, patients often decline such services for reasons that are poorly understood. Research on decision-making suggests that during periods of acute distress, individuals have more difficulty prioritizing long-term over immediate gains. Thus, distressed cancer patients may prioritize immediate gains (e.g., avoidance of palliative care discussions in the moment) over longer-term gains (e.g., improved quality of life in the future). METHOD: This study investigated the associations between psychosocial distress, difficulties with delay of gratification (tendency to prioritize short-term over longer-term gains), and preference for palliative care in a sample of 212 men with a history of prostate cancer (94% white men and 27% advanced stage, age M = 62, SD = 8). It was hypothesized that psychosocial distress would be associated with lower preferences for palliative care, and this association would be explained, in part, by difficulty delaying gratification. Self-report measures included the depression anxiety stress scales, delay of gratification inventory, and ratings on an item assessing preferences for palliative care. RESULTS: Consistent with the hypothesis, mediation models confirmed that the association of psychosocial distress with lower preference for palliative care was mediated by delay of gratification. CONCLUSIONS: Findings suggest that distressed prostate cancer patients may benefit from additional support managing the emotional aspects of medical decisions and weighing immediate versus delayed outcomes.

Feasibility and effectiveness of a community-based smoking cessation intervention in a racially diverse, urban smoker cohort.

OBJECTIVES: We evaluated the feasibility, acceptability, and effectiveness, in addition to the effects of a psychoeducation-based orientation on smoking cessation knowledge for Courage to Quit (CTQ), an evidence-based smoking cessation intervention disseminated to racially diverse, urban community sites in Chicago, Illinois. METHODS: Smokers (n = 1494; 55% African American) enrolled in 6-session full (n = 945) or 3-session short (n = 549) versions of CTQ in 2008 to 2012. RESULTS: Orientation improved knowledge of efficacious and nonefficacious treatments. Acceptability was outstanding: more than 90% of participants would recommend CTQ. Feasibility was good: completion rates were 53% in the full and 75% in the short programs. Intent-to-treat quit rates were 19% in the full and 17% in the short programs (completer quit rates were 36% and 22%, respectively). Among completers, smoking cessation medication use was associated with higher quit rates. There were no racial disparities: African Americans and Whites showed similar completion and quit rates. Predictors of successful quitting were higher readiness to quit and smoking cessation medication use. CONCLUSIONS: CTQ is moderately successful in the short term as delivered in community-based settings for urban-dwelling, largely minority smokers. Further evaluation of longer-term outcomes and cost effectiveness is warranted.

Cognitive functioning in men receiving androgen deprivation therapy for prostate cancer: a systematic review and meta-analysis.

PURPOSE: Prior research examining the impact of androgen deprivation therapy (ADT) for prostate cancer on cognitive performance has found inconsistent relationships. The purpose of this study was to systematically review the existing literature and determine the effect of ADT on performance across seven cognitive domains using meta-analysis. METHODS: A search of PubMed Medline, PsycINFO, Cochrane Library, and Web of Knowledge/Science databases yielded 157 unique abstracts reviewed by independent pairs of raters. Fourteen studies with a total of 417 patients treated with ADT were included in the meta-analysis. Objective neuropsychological tests were categorized into seven cognitive domains: attention/working memory, executive functioning, language, verbal memory, visual memory, visuomotor ability, and visuospatial ability. RESULTS: Separate effect sizes were calculated for each cognitive domain using pairwise comparisons of patients who received ADT with (1) prostate cancer patient controls, (2) noncancer controls, or (3) ADT patients' own pre-ADT baselines. Patients treated with ADT performed worse than controls or their own baseline on visuomotor tasks (g = -0.67, p = .008; n = 193). The magnitude of the deficits was larger in studies with a shorter time to follow-up (p = .04). No significant effect sizes were observed for the other six cognitive domains (p = .08-.98). CONCLUSIONS: Prostate cancer patients who received ADT performed significantly worse on visuomotor tasks compared to noncancer control groups. These findings are consistent with the known effects of testosterone on cognitive functioning in healthy men. Knowledge of the cognitive effects of ADT may help patients and providers better understand the impact of ADT on quality of life.

Validity of the multidimensional fatigue symptom inventory-short form in an African-American community-based sample.

OBJECTIVES: This study examined the psychometric properties of the Multidimensional Fatigue Symptom Inventory-Short Form (MFSI-SF) in a community-based sample of African-Americans. DESIGN: A sample of 340 African-Americans (116 men, 224 women) ranging in age from 18-81 years were recruited from the community (e.g., churches, health fairs, and beauty salons). Participants completed a brief demographic survey, the MFSI-SF and the Positive and Negative Affect Schedule. RESULTS: The structural validity of the MFSI-SF for a community-based sample of African-Americans was not supported. The five dimensions of fatigue (General, Emotional, Physical, Mental, Vigor) found for Whites in prior research were not found for African-Americans in this study. Instead, fatigue, while multidimensional for African-Americans, was best represented by a unique four-four profile in which general and emotional fatigue are collapsed into a single dimension and physical fatigue, mental fatigue, and vigor are relatively distinct. Hence, in the absence of modifications, the MFSI-SF cannot be considered to be structurally invariant across ethnic groups. A modified four-factor version of the MFSI-SF exhibited excellent internal consistency reliability and evidence supports its convergent validity. Using the modified four-factor version, gender, and age were not meaningfully associated with MFSI-SF scores. CONCLUSION: Future research should further examine whether modifications to the MFSI-SF would, as the findings suggest, improve its validity as a measure of multidimensional fatigue in African-Americans.

Courage to Quit® rolling group: Implementation in an urban medical center in primarily low-income Black smokers.

BACKGROUND: Continuous "rolling" tobacco group treatments may help reduce cessation disparities by increasing access among underserved people who smoke cigarettes. We evaluated the implementation of a rolling enrollment adaptation of an evidence-based tobacco treatment group intervention, Courage to Quit®-Rolling (CTQ®-R). METHODS: The 4-session CTQ®-R incorporating psychoeducation, motivational enhancement, and cognitive behavioral skills was evaluated by examining feasibility and preliminary program outcomes with a pre-post design using the SQUIRE method in a sample of 289 primarily low-income, Black people who smoke. Feasibility was measured by examining program retention. Paired t-tests evaluated changes in behavioral intentions and knowledge about smoking cessation and differences in average daily cigarettes smoked from first to last session attended. RESULTS: CTQ-R was feasible to implement in an urban medical center program enrolling primarily low-income Black people who smoke, with 52% attending at least 2 sessions and 24% completing the full program. Participants demonstrated improvements in knowledge of smoking cessation strategies and confidence in quitting (ps < .004). Preliminary effectiveness analyses showed a 30% reduction in average daily cigarette use, with group completers reporting greater reduction than non-completers. CONCLUSIONS: CTQ®-R is feasible and showed preliminary effectiveness for increasing knowledge about stop smoking skills and reducing cigarette smoking. IMPLICATIONS: A rolling enrollment smoking group treatment is feasible and may be effective among people who smoke who face historical and systemic barriers to tobacco treatment engagement. Evaluation in other settings and over longer periods of time is needed.

Data envelopment analysis to evaluate the efficiency of tobacco treatment programs in the NCI Moonshot Cancer Center Cessation Initiative.

BACKGROUND: The Cancer Center Cessation Initiative (C3I) is a National Cancer Institute (NCI) Cancer Moonshot Program that supports NCI-designated cancer centers developing tobacco treatment programs for oncology patients who smoke. C3I-funded centers implement evidence-based programs that offer various smoking cessation treatment components (e.g., counseling, Quitline referrals, access to medications). While evaluation of implementation outcomes in C3I is guided by evaluation of reach and effectiveness (via RE-AIM), little is known about technical efficiency-i.e., how inputs (e.g., program costs, staff time) influence implementation outcomes (e.g., reach, effectiveness). This study demonstrates the application of data envelopment analysis (DEA) as an implementation science tool to evaluate technical efficiency of C3I programs and advance prioritization of implementation resources. METHODS: DEA is a linear programming technique widely used in economics and engineering for assessing relative performance of production units. Using data from 16 C3I-funded centers reported in 2020, we applied input-oriented DEA to model technical efficiency (i.e., proportion of observed outcomes to benchmarked outcomes for given input levels). The primary models used the constant returns-to-scale specification and featured cost-per-participant, total full-time equivalent (FTE) effort, and tobacco treatment specialist effort as model inputs and reach and effectiveness (quit rates) as outcomes. RESULTS: In the DEA model featuring cost-per-participant (input) and reach/effectiveness (outcomes), average constant returns-to-scale technical efficiency was 25.66 (SD = 24.56). When stratified by program characteristics, technical efficiency was higher among programs in cohort 1 (M = 29.15, SD = 28.65, n = 11) vs. cohort 2 (M = 17.99, SD = 10.16, n = 5), with point-of-care (M = 33.90, SD = 28.63, n = 9) vs. no point-of-care services (M = 15.59, SD = 14.31, n = 7), larger (M = 33.63, SD = 30.38, n = 8) vs. smaller center size (M = 17.70, SD = 15.00, n = 8), and higher (M = 29.65, SD = 30.99, n = 8) vs. lower smoking prevalence (M = 21.67, SD = 17.21, n = 8). CONCLUSION: Most C3I programs assessed were technically inefficient relative to the most efficient center benchmark and may be improved by optimizing the use of inputs (e.g., cost-per-participant) relative to program outcomes (e.g., reach, effectiveness). This study demonstrates the appropriateness and feasibility of using DEA to evaluate the relative performance of evidence-based programs.

Distress, depression, anxiety, and resilience in patients with cancer and caregivers.

OBJECTIVE: Resilience is the ability to cope and function despite adversity, such as a cancer diagnosis, and has been conceptualized as the other end of a distress-resilience continuum. There are known associations among resilience, distress, depression, and anxiety-yet the nature of the associations is not well characterized. Less is known about the relationship among these variables for caregivers. We examined these associations in a convenience sample from a clinical setting with these hypotheses: (a) patients and nondyadic caregivers will report elevated, comparable levels of distress, depression, and anxiety, and (b) resilience will moderate the effect of distress on depression and anxiety. METHOD: Participants were patients with a cancer diagnosis (n = 328) and nondyadic caregivers (n = 169). Participants completed a demographic/clinical questionnaire and self-report measures (National Comprehensive Cancer Network Distress Thermometer, Patient-Reported Outcomes Measurement Information System anxiety and depression measures, and Brief Resilience Scale). The statistical plan for this cross-sectional study included moderation analyses and various tests of association. RESULTS: Patients and caregivers reported comparable levels of resilience and elevated distress; patients exhibited more severe depression and anxiety. There was no evidence for a moderating effect of resilience. For both groups, the model of distress predicting depression/anxiety exhibited improved fit when including resilience. Distress and resilience share variance in the prediction of depression/anxiety among patients. CONCLUSIONS: Distress, depression, and anxiety are common in patients with cancer but also in cancer caregivers. Resilience appears to be an important variable to consider alongside distress and may enhance our understanding of the relationships among distress and depression/anxiety, especially for individuals with cancer. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Mixed-methods economic evaluation of the implementation of tobacco treatment programs in National Cancer Institute-designated cancer centers.

BACKGROUND: The Cancer Center Cessation Initiative (C3I) was launched in 2017 as a part of the NCI Cancer Moonshot program to assist NCI-designated cancer centers in developing tobacco treatment programs for oncology patients. Participating centers have implemented varied evidence-based programs that fit their institutional resources and needs, offering a wide range of services including in-person and telephone-based counseling, point of care, interactive voice response systems, referral to the quitline, text- and web-based services, and medications. METHODS: We used a mixed methods comparative case study design to evaluate system-level implementation costs across 15 C3I-funded cancer centers that reported for at least one 6-month period between July 2018 and June 2020. We analyzed operating costs by resource category (e.g., personnel, medications) concurrently with transcripts from semi-structured key-informant interviews conducted during site visits. Personnel salary costs were estimated using Bureau of Labor Statistics wage data adjusted for area and occupation, and non-wage benefits. Qualitative findings provided additional information on intangible resources and contextual factors related to implementation costs. RESULTS: Median total monthly operating costs across funded centers were $11,045 (range: $5129-$20,751). The largest median operating cost category was personnel ($10,307; range: $4122-$19,794), with the highest personnel costs attributable to the provision of in-person program services. Monthly (non-zero) cost ranges for other categories were medications ($17-$573), materials ($6-$435), training ($96-$516), technology ($171-$2759), and equipment ($10-$620). Median cost-per-participant was $466 (range: $70-$2093) and cost-per-quit was $2688 (range: $330-$9628), with sites offering different combinations of program components, ranging from individually-delivered in-person counseling only to one program that offered all components. Site interviews provided context for understanding variations in program components and their cost implications. CONCLUSIONS: Among most centers that have progressed in tobacco treatment program implementation, cost-per-quit was modest relative to other prevention interventions. Although select centers have achieved similar average costs by offering program components of various levels of intensity, they have varied widely in program reach and effectiveness. Evaluating implementation costs of such programs alongside reach and effectiveness is necessary to provide decision makers in oncology settings with the important additional information needed to optimize resource allocation when establishing tobacco treatment programs.

Acculturation and depressive symptoms in Muslim university students: personal-family acculturation match.

The relationships of personal acculturation and of personal-family acculturation match to depressive symptoms were investigated in a sample of 68 Muslim university students. Two dimensions of personal and family acculturation were assessed: heritage and mainstream culture identification. Participants completed the Vancouver Index of Acculturation (Ryder, Alden, & Paulhus, 2000 ) and the depressive disorder subscale of the Psychiatric Diagnostic Screening Questionnaire (Zimmerman & Mattia, 1999 ). For personal acculturation, individuals with high personal heritage culture identification reported fewer lifetime (but not past-year) depressive symptoms. In contrast, individuals with high personal mainstream culture identification reported more past-year (but not lifetime) depressive symptoms. The hypothesis that a match between personal and family acculturation orientation would be associated with fewer depressive symptoms was supported for heritage culture identification only. For past-year depression, the two match conditions (low or high personal and family heritage culture identification) were associated with significantly fewer depressive symptoms than a low personal/high family mismatch but did not differ from a high personal/low family mismatch. For lifetime depression, a high personal/high family match was associated with significantly fewer depressive symptoms than all other conditions. Findings suggests that, for Muslims, a match of high personal and high family heritage culture identification may act as a protective factor for the experience of depressive symptoms both in the short term (past year) and in the long term (lifetime).

Associations Between Personality and End-of-Life Care Preferences Among Men With Prostate Cancer: A Clustering Approach.

CONTEXT: Increased focus on patient-centered care models has contributed to greater emphasis on improving quality of life at the end of life through personalized medicine. However, little is known about individual-level factors impacting end-of-life care preferences. OBJECTIVES: To examine whether the five-factor model of personality explains variation in preferences for end-of-life care in men with prostate cancer. METHODS: Two hundred twelve men with a prostate cancer diagnosis (mean age = 62 years) completed a measure of the five-factor model of personality--spanning the personality dimensions of neuroticism, agreeableness, extraversion, openness, and conscientiousness--and reported on end-of-life care preferences. Cluster analyses were used to partition the sample into groups with similar care preferences. Analyses of variance and Chi-square tests were used to evaluate differences in care preferences among the groups. RESULTS: Cluster analyses revealed three groups of participants: "comfort-oriented patients," "service-accepting patients," and "service-reluctant patients." Most (67%) were comfort oriented, preferring palliative care and opposing life support services. A subset of patients were service accepting (17%), preferring both palliative care and life support, or were service reluctant (16%), preferring neither. Service-reluctant patients endorsed significantly higher levels of neuroticism (emotional instability and negativity) than comfort-oriented patients. Comfort-oriented patients endorsed significantly higher levels of agreeableness than service-accepting patients and service-reluctant patients. CONCLUSION: Findings suggest that personality traits are associated with specific health care preferences. Individuals high on neuroticism are likely to report reluctance toward all forms of end-of-life care and may benefit from in-depth information about the process and likely outcomes of receiving life support and palliative care services.

Evaluation of the psychometric properties of the PROMIS Cancer Fatigue Short Form with cancer patients.

OBJECTIVE: Fatigue is common among cancer patients and adversely impacts quality of life. As such, it is important to measure fatigue accurately in a way that is not burdensome to patients. The 7-item Patient Reported Outcome Measurement Information System (PROMIS) Cancer Fatigue Short Form scale was recently developed using item response theory (IRT). The current study evaluated the psychometric properties of this scale in two samples of cancer patients using classical test theory (CTT). METHODS: Two samples were used: 121 men with prostate cancer and 136 patients scheduled to undergo hematopoietic cell transplantation (HCT) for hematologic cancer. All participants completed the PROMIS Cancer Fatigue Short Form as well as validated measures of fatigue, vitality, and depression. HCT patients also completed measures of anxiety, perceived stress, and a clinical interview designed to identify cases of cancer-related fatigue. RESULTS: PROMIS Cancer Fatigue Short Form items loaded on a single factor (CFI=0.948) and the scale demonstrated good internal consistency reliability in both samples (Cronbach's alphas>0.86). Correlations with psychosocial measures were significant (p values<.0001) and in the expected direction, offering evidence for convergent and concurrent validity. PROMIS Fatigue scores were significantly higher in patients who met case definition criteria for cancer-related fatigue (p<.0001), demonstrating criterion validity. CONCLUSION: The current study provides evidence that the PROMIS Cancer Fatigue Short Form is a reliable and valid measure of fatigue in cancer patients.

Do community health worker interventions improve rates of screening mammography in the United States? A systematic review.

BACKGROUND: Community health workers (CHW) are lay individuals who are trained to serve as liaisons between members of their communities and health care providers and services. METHODS: A systematic review was conducted to synthesize evidence from all prospective controlled studies on effectiveness of CHW programs in improving screening mammography rates. Studies reported in English and conducted in the United States were included if they: (i) evaluated a CHW intervention designed to increase screening mammography rates in women 40 years of age or older without a history of breast cancer; (ii) were a randomized controlled trial (RCT), case-controlled study, or quasi-experimental study; and (iii) evaluated a CHW intervention outside of a hospital setting. RESULTS: Participation in a CHW intervention was associated with a statistically significant increase in receipt of screening mammography [risk ratio (RR): 1.06 (favoring intervention); 95% CI: 1.02-1.11, P = 0.003]. The effect remained when pooled data from only RCTs were included in meta-analysis (RR: 1.07; 95% CI: 1.03-1.12, P = 0.0005) but was not present using pooled data from only quasi-experimental studies (RR: 1.03; 95% CI: 0.89-1.18, P = 0.71). In RCTs, participants recruited from medical settings (RR: 1.41; 95% CI: 1.09-1.82, P = 0.008), programs conducted in urban settings (RR: 1.23; 95% CI: 1.09, 1.39, P = 0.001), and programs where CHWs were matched to intervention participants on race or ethnicity (RR: 1.58, 95% CI: 1.29-1.93, P = 0.0001) showed stronger effects on increasing mammography screening rates. CONCLUSIONS: CHW interventions are effective for increasing screening mammography in certain settings and populations. IMPACT: CHW interventions are especially associated with improvements in rate of screening mammography in medical settings, urban settings, and in participants who are racially or ethnically concordant with the CHW.