Implementing digital systems to facilitate genetic testing for hereditary cancer syndromes: An observational study of 4 clinical workflows.

PURPOSE: National efforts have prioritized the identification of effective methods for increasing case ascertainment and delivery of evidence-based health care for individuals at elevated risk for hereditary cancers. METHODS: This study examined the uptake of genetic counseling and testing following the use of a digital cancer genetic risk assessment program implemented at 27 health care sites in 10 states using 1 of 4 clinical workflows: (1) traditional referral, (2) point-of-care scheduling, (3) point-of-care counseling/telegenetics, and (4) point-of-care testing. RESULTS: In 2019, 102,542 patients were screened and 33,113 (32%) were identified as at high risk and meeting National Comprehensive Cancer Network genetic testing criteria for hereditary breast and ovarian cancer, Lynch syndrome, or both. Among those identified at high risk, 5147 (16%) proceeded with genetic testing. Genetic counseling uptake was 11% among the sites with workflows that included seeing a genetic counselor before testing, with 88% of patients proceeding with genetic testing after counseling. Uptake of genetic testing across sites varied significantly by clinical workflow (6% referral, 10% point-of-care scheduling, 14% point-of-care counseling/telegenetics, and 35% point-of-care testing, P < .0001). CONCLUSION: Study findings highlight the potential heterogeneity of effectiveness attributable to different care delivery approaches for implementing digital hereditary cancer risk screening programs.

Mental imagery-based self-regulation: Effects on physical activity behaviour and its cognitive and affective precursors over time.

OBJECTIVES: (1) Test whether a mental imagery-based self-regulation intervention increases physical activity behaviour over 90 days; (2) Examine cognitive and affective precursors of change in physical activity behaviour. DESIGN: A randomized control trial with participants (N = 500) randomized to one of six intervention conditions in a 3 (risk communication format: bulleted list, table, risk ladder) x 2 (mental imagery behaviour: physical activity, active control [sleep hygiene]) factorial design. METHODS: After receiving personalized risk estimates via a website on a smartphone, participants listened to an audiorecording that guided them through a mental imagery activity related to improving physical activity (intervention group) or sleep hygiene behaviour (active control). Participants received text message reminders to complete the imagery for 3 weeks post-intervention, 4 weekly text surveys to assess behaviour and its cognitive and affective precursors, and a mailed survey 90 days post-baseline. RESULTS: Physical activity increased over 90 days by 19.5 more minutes per week (95%CI: 2.0, 37.1) in the physical activity than the active control condition. This effect was driven by participants in the risk ladder condition, who exercised 54.8 more minutes (95%CI 15.6, 94.0) in the physical activity condition than participants in the active control sleep hygiene group. Goal planning positively predicted physical activity behaviour (b = 12.2 minutes per week, p = 0.002), but self-efficacy, image clarity, and affective attitudes towards behaviours did not (p > 0.05). CONCLUSIONS: Mental imagery-based self-regulation interventions can increase physical activity behaviour, particularly when supported by personalized disease risk information presented in an easy-to-understand format.

Comparison of Teleintegrated Care and Telereferral Care for Treating Complex Psychiatric Disorders in Primary Care: A Pragmatic Randomized Comparative Effectiveness Trial.

Importance: Only one-third of patients with complex psychiatric disorders engage in specialty mental health care, and only one-tenth receive adequate treatment in primary care. Scalable approaches are critically needed to improve access to effective mental health treatments in underserved primary care settings. Objective: To compare 2 clinic-to-clinic interactive video approaches to delivering evidence-based mental health treatments to patients in primary care clinics. Design, Setting, and Participants: This pragmatic comparative effectiveness trial used a sequential, multiple-assignment, randomized trial (SMART) design with patient-level randomization. Adult patients treated at 24 primary care clinics without on-site psychiatrists or psychologists from 12 federally qualified health centers in 3 states who screened positive for posttraumatic stress disorder and/or bipolar disorder and who were not already receiving pharmacotherapy from a mental health specialist were recruited from November 16, 2016, to June 30, 2019, and observed for 12 months. Interventions: Two approaches were compared: (1) telepsychiatry/telepsychology-enhanced referral (TER), where telepsychiatrists and telepsychologists assumed responsibility for treatment, and (2) telepsychiatry collaborative care (TCC), where telepsychiatrists provided consultation to the primary care team. TER included an adaptive intervention (phone-enhanced referral [PER]) for patients not engaging in treatment, which involved telephone outreach and motivational interviewing. Main Outcomes and Measures: Survey questions assessed patient-reported outcomes. The Veterans RAND 12-item Health Survey Mental Component Summary (MCS) score was the primary outcome (range, 0-100). Secondary outcomes included posttraumatic stress disorder symptoms, manic symptoms, depressive symptoms, anxiety symptoms, recovery, and adverse effects. Results: Of 1004 included participants, 701 of 1000 (70.1%) were female, 660 of 994 (66.4%) were White, and the mean (SD) age was 39.4 (12.9) years. Baseline MCS scores were 2 SDs below the US mean; the mean (SD) MCS scores were 39.7 (14.1) and 41.2 (14.2) in the TCC and TER groups, respectively. There was no significant difference in 12-month MCS score between those receiving TCC and TER (ß = 1.0; 95% CI, -0.8 to 2.8; P = .28). Patients in both groups experienced large and clinically meaningful improvements from baseline to 12 months (TCC: Cohen d = 0.81; 95% CI, 0.67 to 0.95; TER: Cohen d = 0.90; 95% CI, 0.76 to 1.04). For patients not engaging in TER at 6 months, there was no significant difference in 12-month MCS score between those receiving PER and TER (ß = 2.0; 95% CI, -1.7 to 5.7; P = .29). Conclusions and Relevance: In this comparative effectiveness trial of patients with complex psychiatric disorders randomized to receive TCC or TER, significantly and substantially improved outcomes were observed in both groups. From a health care system perspective, clinical leadership should implement whichever approach is most sustainable. Trial Registration: ClinicalTrials.gov Identifier: NCT02738944.

A special issue addressing healthful food access and food insecurity: risk factors, behavioral variables, interventions, and measurement.

This article introduces a special issue in Translational Behavioral Medicine that focuses on translational aspects of food insecurity research. The purpose of this special issue was to add to the evidence base to inform short- and intermediate-term intervention development and implementation and to spark additional future discourse around these important topics. The special issue included 12 articles and 2 commentaries roughly evenly split across four topic areas, including subpopulation food insecurity risk factors; food behaviors and psychosocial variables; implementation and/or evaluation of food insecurity interventions; and food insecurity-related measurement issues. The articles in this special issue offer a number of contributions to the translational literature specific to food insecurity. They add to our understanding that depression, stress, and social isolation (sometimes related to language barriers) may play a large role in individuals' food insecurity experience. The articles explored the differences between food insecure and food secure households in relation to food and grocery shopping behaviors, and nutritional self-efficacy. In addition, authors described the implementation and/or efficacy of interventions meant to promote healthful diets and food access among food insecure populations. And finally, several studies explored current measurement issues such as intra-household subjectivity, disconnect between perceived and objective measures of food access, and a need for more holistic and nutrition-focused measurement approaches. While there are deeper systemic factors driving food insecurity, the findings provided in this special issue can help guide those addressing the current challenges faced by food insecure households that struggle to achieve healthful diets.

Cancer control planners' perceptions and use of evidence-based programs.

The Cancer Prevention and Control Research Network surveyed 282 cancer control planners to inform its efforts to increase the use of evidence-based cancer control programs (EBPs; programs that have been scientifically tested and have successfully changed behavior). Respondents included planners from organizations in state Comprehensive Cancer Control coalitions as well as other governmental and nongovernmental organizations and community-based coalitions. Respondents provided information about personal and organizational characteristics, their cancer control programs, their attitudes toward EBPs, and their awareness and use of Web-based resources for EBPs. Although findings showed strong preferences for cancer control programs that have been shown to work, less than half of respondents (48%) had ever used EBP resources. Regardless of whether they had used EBP resources, almost all respondents (97%) indicated that further training would help them and their organizations adopt and adapt EBPs for use in their communities. The most frequently endorsed training needs were finding and securing additional resources (such as funding and technical assistance), followed by adapting EBPs for cultural appropriateness. The Cancer Prevention and Control Research Network consortium is using these findings to develop a Web-based interactive training and decision support tool that is responsive to the needs identified by the survey respondents.

Comprehensive cancer screening among unmarried women aged 40-75 years: results from the cancer screening project for women.

OBJECTIVES: We explored self-reported rates of individual on-schedule breast, cervical, and colorectal cancer screenings, as well as an aggregate measure of comprehensive screenings, among unmarried women aged 40-75 years. We compared women who partner with women (WPW) or with women and men (WPWM) to women who partner exclusively with men (WPM). We also compared barriers to on-schedule cancer screenings between WPW/WPWM and WPM. METHODS: Comparable targeted and respondent-driven sampling methods were used to enroll 213 WPW/WPWM and 417 WPM (n = 630). Logistic regression models were computed to determine if partner gender was associated with each measure of on-schedule screening after controlling for demographic characteristics, health behaviors, and cancer-related experiences. RESULTS: Overall, 74.3% of women reported on-schedule breast screening, 78.3% reported on-schedule cervical screening, 66.5% reported on-schedule colorectal screening, and 56.7% reported being on-schedule for comprehensive screening. Partner gender was not associated with any of the measures of on-schedule screening in multivariable analyses. However, women who reported ever putting off, avoiding, or changing the place of screenings because of sexual orientation were less likely to be on-schedule for comprehensive screening. Women who reported barriers associated with taking time from work and body image concerns were also less likely to be on-schedule for comprehensive screening. CONCLUSIONS: Barriers to cancer screening were comparable across types of examinations as well as between WPW/WPWM and WPM. Developing health promotion programs for unmarried women that address concomitant detection and prevention behaviors may improve the efficiency and effectiveness of healthcare delivery and ultimately assist in reducing multiple disease risks.

Colorectal cancer screening practices of primary care physicians in Washington State.

BACKGROUND: Colorectal cancer screening reduces death from colorectal cancer, but screening rates are low. While research has identified barriers to screening from the patient perspective, less research has addressed screening from the physician perspective. METHODS: The Washington Comprehensive Cancer Control Partnership conducted a survey of primary care physicians in Washington State to measure their knowledge, attitudes, and practices for colorectal cancer screening of average-risk patients. The survey was mailed to a simple random sample of 700 primary care physicians in Washington State. Sixty-nine percent of the eligible physicians in the sample participated. RESULTS: Most respondents (76%) recommended one or more colorectal cancer screening tests in agreement with American Cancer Society guidelines, and 93% perceived patient anxiety about colorectal cancer screening tests to be a significant barrier to screening. Ninety percent of physicians reported using the fecal occult blood test (FOBT) as a screening test, but most did not report performing any tracking or using any mechanism to encourage their patients to complete and return FOBT kits. CONCLUSIONS: These findings suggest three intervention approaches to increase colorectal cancer screening in primary care settings: improve physicians' knowledge about current screening guidelines (especially appropriate age and screening intervals), encourage physicians to strongly recommend screening to patients, and help physicians adopt tracking systems to follow screening to completion.

Sex differences in motives for use of complementary and alternative medicine among cancer patients.

CONTEXT: There is evidence that the prevalence of complementary and alternative medicine (CAM) use is increasing especially among women. However, little is known about why there are sex differences in the use of CAM. OBJECTIVE: This study investigated sex differences in motivations for use of CAM among adult cancer patients. DESIGN: A population-based telephone survey of CAM use. SETTINGS AND PARTICIPANTS: 178 male and 178 female cancer patients randomly selected from a statewide Cancer Surveillance System in Washington State. MAIN OUTCOME MEASURES: Demographics, complementary and alternative medicine use, lifestyle changes and four psychosocial variables: desire for personal control; internal locus of control; symptom distress; and perceived health status. RESULTS: Overall, 81.5% of women and 59.0% of men used some type of CAM. After adjusting for age and income, the relative odds that an alternative therapy user was female was 2.2 (95% CI 1.4-3.3)for alternative dietary supplements, 5.0 (95% CI 2.3-11.2) for categories of alternative providers, 2.2 (95% CI 1.2-4.2) for focused mental therapies and 1.4 (95% CI 0.9-2.2) for lifestyle changes. CAM use was positively associated with desire for personal control among both men and women (P = 0.05). However, the association of two factors, dissatisfaction with a conventional provider and cancer-related symptom distress with alternative dietary supplement use, was only modestly different for men and women (P < 0.10 for interaction). High cancer related symptom distress score and dissatisfaction with a conventional provider predicted increased dietary supplement use for men, but decreased dietary supplement use for women. CONCLUSIONS: Clinicians should be aware that men and women differ considerably in their use of CAM, which may reflect differences in their psychological needs as they cope with their cancer diagnosis and treatment.

Hospice patients' attitudes regarding spiritual discussions with their doctors.

The purpose of this study was to assess hospice patients' attitudes regarding the discussion of spiritual issues with their physicians. We conducted in-depth interviews using open-ended questions on living with illness, spirituality and religion, and physician-patient relationships. The interviews were audiotaped, transcribed, and analyzed for dominant themes. The following dominant themes were identified: (1) treating the whole person, (2) treating with sensitivity, (3) favorable attitudes toward religious or spiritual discussions with doctors, and (4) no "preaching." Our findings suggest that patients do not expect physicians to be their primary spiritual advisors; however, physicians should be aware of and comfortable communicating with patients about religious or spiritual issues. More training in this topic may enhance the care physicians provide to patients near the end of life.

Changes in diet, physical activity, and supplement use among adults diagnosed with cancer.

OBJECTIVE: To investigate the prevalence and predictors of changes in diet, physical activity, and dietary supplement use among cancer patients. Design/subjects Telephone interviews of a population-based sample of 126 breast, 114 prostate, and 116 colorectal cancer patients from the state of Washington. ANALYSIS: Logistic regression was used to estimate the odds ratio as a measure of the association of participant characteristics with lifestyle changes in the 12 months before the interview. RESULTS: Overall, 66.3% of patients reported making lifestyle changes: 40.4% made one or more dietary changes, 20.8% added new physical activity, and 48.0% started taking new dietary supplements. Compared with men, women were 2.2 times more likely to take new dietary supplements (P <.01). Compared with patients aged 35 to 59, those aged 60 to 69 and 70 or older were statistically significantly less likely to make dietary changes (odds ratio = 0.39 and 0.54, respectively) or to take new supplements (odds ratio = 0.42 and 0.69, respectively). Compared with patients who received only one medical treatment, those receiving three or more treatments were more likely to make dietary changes (odds ratio = 2.6) or to start new physical activity (odds ratio = 3.0). Patients diagnosed 12 to 24 months before the interview were as likely to report making lifestyle changes as those diagnosed within one year of the interview. Having a stronger desire for personal control or internal locus of control predicted use of new dietary supplements (P for trend <.05 for both). Applications/conclusions Cancer survivors are likely to be making lifestyle changes and represent a group that could benefit from counseling on diet and physical activity.

Types of alternative medicine used by patients with breast, colon, or prostate cancer: predictors, motives, and costs.

OBJECTIVE: Assess predictors and costs of various types of alternative medicine used by adult patients with cancer. DESIGN, LOCATION, SUBJECTS: Telephone survey of 356 patients with colon, breast, or prostate cancer identified from the population-based Cancer Surveillance System of western Washington. RESULTS: Overall, 70.2% of patients used at least one type of alternative medicine, with 16.6% seeing alternative providers, 19.1% using mental/other therapy, and 64.6% taking dietary supplements. Compared to males, females were five times more likely to see an alternative provider and about twice as likely to use mental therapies or supplements (p < 0.05 for all). Older patients were less likely to use mental/other therapy. Higher education (but not income) was associated with use of all types of alternative medicine. Patients with multiple medical treatments were two times more likely to take dietary supplements compared to patients having only surgery (p < 0.01). Varying by the type of alternative therapy, 83%-97% of patients reported that they used alternative medicine for general health and well-being while 8% to 56% reported use for treatment of cancer. Almost all patients reported that the alternative therapy improved their well-being. Expenditures for alternative medicine averaged $68 per user per year, but ranged from $4 to $14,659. CONCLUSIONS: Given the high prevalence of use and that patients believed that alternative medicine improved their well-being, clinicians should show an open mind toward these treatment choices and encourage frank discussion. Familiarity and some knowledge regarding use of alternative medicine is important in cases where interactions between conventional and alternative medicine may occur. It is also important to identify potential patient needs for mental health support beyond conventional care and support patients who want to make healthful lifestyle changes. Longitudinal investigations are urgently needed to investigate associations of alternative medicine use with survival and quality of life in patients with cancer.