Thoughts and consideration regarding immigrant clinicians: is cultural preservation influencing providers' practice in HPV vaccination.

Immigrant clinicians are vital to population healthcare delivery and therefore population health. One in four physicians in the USA is foreign-born and notably represented in family and pediatric medicine-specialties charged with administering childhood/adolescent vaccines, such as human papillomavirus vaccine (HPVV). Our examination suggests there may be unique cultural and socialization factors that influence clinician HPVV recommendation practice; however, immigrant clinicians have not been adequately engaged within the national HPVV agenda. Given the volume and significance of immigrant clinicians, engagement of these clinicians, in both community and nation-wide efforts to increase HPVV, is a necessary step for improving and achieving the national health goal of optimizing HPVV for cancer prevention.

Why individual-level interventions are not enough: Systems-level determinants of oral anticancer medication adherence.

Nonadherence to oral anticancer medications (OAMs) in the United States is as low as 33% for some cancers. The reasons for nonadherence to these lifesaving medications are multifactorial, yet the majority of studies focus on patient-level factors influencing uptake and adherence. Individually based interventions to increase patient adherence have not been effective, and this warrants attention to factors at the payor, pharmaceutical, and clinical systems levels. Based on the authors' research and clinical experiences, this commentary brings fresh attention to the long-standing issue of OAM nonadherence, a growing quality-of-care issue, from a systems perspective. In this commentary, the key driving factors in pharmaceutical and payor systems (state and federal laws, payor/insurance companies, and pharmaceutical companies), clinical systems (hospitals and providers), and patient contexts that have trickle-down effects on patient adherence to OAMs are outlined. In the end, the authors' recommendations include examining the influence of laws governing OAM drug pricing, OAM supply, and provider reimbursement; reducing the need for prior authorization of long-approved OAMs; identifying cost-effective ways for providers to monitor nonadherence; examining issues of provider bias in OAM prescriptions; and further elucidating in which contexts patients are likely to be able to adhere. These recommendations offer a starting point for an examination of the chain of systems influencing patient adherence and may help to finally resolve persistently high levels of OAM nonadherence.

Exploring the efficacy of a paraprofessional delivered telephonic psychoeducational intervention on emotional well-being in African American breast cancer survivors.

PURPOSE: African American breast cancer survivors (AABCS) are underserved in medical and psychosocial care despite greater disease burden. We evaluated the effectiveness of a telephonic psycho-educational intervention trial on improving emotional well-being (EWB) in a sample of AABCS. METHODS: Secondary data analyses with 40 AABCS who reported elevated distress were randomly assigned to the intervention or control group. We used Wilcoxon signed rank tests to measure pre- to post-intervention score changes in individual EWB items (FACT-G). Independent t tests compared changes in mean scores between the intervention and control groups. RESULTS: Overall emotional well-being, as well as emotions pertaining to sadness, coping, and nervousness, showed some improvements as a result of the intervention. Changes in the subscale total score and all except one subscale item had clinically meaningful effect sizes (d ≥ 0.35). Statistically significant between-group differences in mean score changes were observed. CONCLUSIONS: Our results and approach advance supportive care interventions by illuminating the benefits and limitations of a paraprofessional delivered, licensed professional supervised psycho-educational intervention. Additionally, as emotional well-being is multifaceted, the individual item analysis approach used in this study provides insight into specific areas of improvement and vulnerability within the emotional well-being domain of health-related quality of life (HRQOL). Our findings can facilitate the development of culturally responsive and patient-centered survivorship care, psychosocial-oncology interventions and care-tailored to the emotional well-being and unmet needs of medically vulnerable and underserved patients.

Exploring the association between diabetes and breast cancer morbidity: considerations for quality care improvements among Latinas.

OBJECTIVE: Cancer and diabetes are two severe chronic illnesses that often co-occur. In cancer patients, diabetes increases the risk for treatment complexities and mortality. Yet patient-reported outcomes with co-occurring chronic illness are understudied. DESIGN: This preliminary study investigated the association of diabetes with breast cancer-related morbidity among underserved Latina breast cancer survivors (BCS). PARTICIPANTS: 137 Latina BCS were recruited from the California Cancer Registry and hospitals.Setting and Main Outcome Measure(s): BCS completed a self-administered mailed questionnaire assessing demographic and medical characteristics e.g. Type2 diabetes mellitus (T2DM). RESULTS: 28% Latina BCS reported co-occurring T2DM at twice the general population rate. Diabetes was most prevalent among Latina BCS > 65 years (43%). Latina BCS with diabetes were more likely to report advanced cancer staging at diagnosis (P = 0.036) and more lymphedema symptoms (P = 0.036). Results suggest non-significant but lower general health and greater physical functioning limitations among BCS with T2DM. CONCLUSIONS: This study has relevance for precision population medicine by (i) consideration of routine diabetes screening in Latina BCS, (ii) underscoring attention to disease co-occurrence in treatment planning and care delivery and (iii) informing follow-up care and survivorship care planning e.g. patient self-management, oncology and primarily care surveillance and specialty care. Our findings can inform providers, survivors and caregivers about the impact of disease co-occurrence that influence clinically and patient responsive care for both initial treatment and long-term follow-up care to address disparities.

Across borders: thoughts and considerations about cultural preservation among immigrant clinicians.

Immigrant clinicians make up 20-28% of the health workforce in many high-income countries, including Australia, Britain, Canada and the USA. Yet, the preserved culture of immigrant clinicians remains largely invisible in the medical literature and discourse. Research on immigrant clinicians primarily attends to medical professional requirements for the adopted country (medical board examination eligibility, fellowship training and licensing). Cultural preservation among immigrant clinicians has not been adequately considered or studied. This paper highlights this notable gap in healthcare delivery and health services research relevant to immigrant clinicians. We propose it is worthwhile to explore possible relationships between immigrant clinicians' preserved culture and clinical practices and outcomes since immigrant clinicians cross borders with their academic training as well as their culture. The sparse literature regarding immigrant clinicians suggests culture influences health beliefs, attitudes about the meaning of illness and clinical practice decisions. Additionally, immigrant clinicians are more likely to serve rural, low-income populations; communities with high density of ethnic minorities and immigrants; and areas with primary care shortage. Therefore, cultural preservation among immigrant clinicians may have important implications for public health and health disparities. This area of inquiry is important, if not urgent, in health services research.

Health-related quality of life and care satisfaction outcomes: Informing psychosocial oncology care among Latina and African-American young breast cancer survivors.

OBJECTIVE: When breast cancer occurs in young women, the medical, physical, psychosocial, and overall impacts can be more severe warranting targeted medical and psychosocial oncology care. Yet, despite their risk for poorer survival and survivorship outcomes, little research has focused on this group with critical gaps concerning ethnic minorities who are particularly medically vulnerable. Therefore, this preliminary study examined demographic characteristics and patient centered outcomes, ie, health-related quality of life (HRQOL), quality care satisfaction to inform targeted psychosocial oncology care among African-American and Latinas young breast cancer survivors (YBCS). METHODS: A total of 116 African-American and Latina YBCS aged ≥21 to 50 years were recruited from cancer registries and community agencies. Based on prior research and the literature, Latinas were categorized into English language proficient (ELP) and Spanish language proficient (SLP) based on their choice of language to conduct the study including completion of the measures. RESULTS: SLP Latinas reported lower educational attainment and income (P < 0.001) and were more likely to report having a mastectomy (P < 0.01) but less likely to report breast reconstruction (P < 0.05). Satisfaction with care was correlated with patient-provider communication and overall HRQOL (P < 0.01) and physical, social/family, emotional and functional wellbeing (P < 0.01). SLP Latinas had lower emotional wellbeing than African-American YBCS (P < 0.01) and lower functional wellbeing than ELP Latina YBCS (P < 0.05). SLP Latina YBCS were less satisfied with their care compared with African-American and ELP Latina YBCS (P < 0.01). Financial toxicity seems to directly influence both access to care and quality care and survivorship outcomes. CONCLUSIONS: Investigating demographic characteristics and medical outcomes including HRQOL outcomes and satisfaction with care among ethnic minority YBCS is needed to advance the science as well as assist health professionals with precision care delivery. Greater translational and patient-centered research must focus on at-risk population such as YBCS to inform precision psychosocial oncology care and reduce health disparities.

A Review and Considerations on Palliative Care Improvements for African Americans With Cancer.

Hospice and Palliative care benefits are infrequently realized by African American patients with cancer. With the increasing recognition of the critical role of early utilization of palliative services for optimal and quality patient care, it is important to acknowledge disparities and barriers to access that minority patients may face. The purpose of this paper is to discuss the status of palliative care delivery for African American patients within the structure and framework of the clinical practice guideline domains established by the National Consensus Project for Palliative Care. This perspectives paper describes the different aspects of palliative care and the interplay with African American culture. Here, we also attempt to identify the multilevel barriers (health care system and provider level) to palliative care among African Americans as a required step toward decreasing the disparities in access, coverage, utilization, and benefit of palliative care. Furthermore, this paper may serve as an educational guide for health care workers who care for African American patients with cancer.

Distress Screening: Evaluating a Protocol for Gynecologic Cancer Survivors
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BACKGROUND: A gynecologic cancer diagnosis and subsequent treatment may cause significant morbidity, leading to increased distress levels and poorer quality of life (QOL) for survivors. Clinicians have explored opportunities to integrate comprehensive distress management protocols into clinical settings using existing supportive care resources.
. OBJECTIVES: The aims were to improve multidisciplinary management of distress using a clinical pathway for gynecologic cancer survivors and to improve patient satisfaction with distress management.
. METHODS: This study is phase II of a quality improvement initiative to assess distress using the National Comprehensive Cancer Network Distress Thermometer and Patient Related Outcome Measures Information Systems QOL tool and to evaluate the use of a clinical pathway to identify and link gynecologic cancer survivors to multidisciplinary supportive care resources. The data were compared to results from phase I of this study with data triangulation that included medical record audits.
. FINDINGS: Thirty-five percent of survivors reported distress scores of 5 or greater. The use of a clinical pathway model for universal distress screening increased referrals to multidisciplinary service teams from 19 to 34, with a 32% increase in social work referrals. Patients appreciated the comprehensive approach the healthcare team used to treat cancer and help improve QOL.