It's Not Always Easy: Cancer Survivorship Care in Primary Care Settings.

By 2040, an anticipated 26.1 million people with a history of cancer will be part of the healthcare system. The purpose of this study was to explore Missouri-based non-oncology clinicians' perspectives on caring for patients with a history of cancer to identify needs of rural-based clinicians to optimize their patients' survivorship care. Using an interpretive qualitative descriptive approach, we conducted semi-structured interviews with 17 non-oncology clinicians. We encouraged clinicians to discuss their approach to caring for patients with a history of cancer and invited them to talk about what might help them increase their knowledge of survivorship care best practices. Through interpretive qualitative descriptive analysis methods including first level coding and constant comparison, we found there is consensus that cancer survivorship care is important; however, training that now guides our clinicians occurred mostly during residency, if at all. Clinicians relied on previous patient encounters and oncology notes combined with their patients' personal account of treatment history to inform the best next steps. Clinicians expressed strong interest in having a simple protocol of their patient's treatment with prompts of known long-term cancer treatment-related effects and a patient-centric follow-up monitoring schedule (mandatory vs recommended vs optional). Clinicians expressed interest in educational opportunities about cancer care and ability for curbside consults with oncologists. They consistently noted the limited resources available in rural areas and that rural patients may have different preferences and approaches to cancer survivorship. There is a clear opportunity to improve non-oncology clinicians' knowledge of the needs of people with a history of cancer as well as their own knowledge base and self-efficacy, especially in rural settings.

Maternal COVID vaccination and breastfeeding during a pandemic: Habitus and health behavior decision making.

OBJECTIVE: To examine the influence of habitus on women's health behavior regarding breastfeeding and subsequent COVID-19 vaccination. DESIGN: A qualitative descriptive design, guided by Pierre Bourdieu's concept of habitus. SAMPLE: Eighteen women who were postpartum, breastfeeding, and vaccinated against COVID- 19 either during pregnancy or while breastfeeding postpartum. MEASURES: Individual semi-structured interviews. RESULTS: Two major themes shaped participants' habitus: health-focused knowledge, and attitudes and beliefs. Attitudes and beliefs included five subthemes: (1) exposure/acceptance/expectations from family, (2) community acceptance of breastfeeding and COVID-19 vaccination, (3) socioeconomic status, (4) easily accessed support, and (5) outside experiences and exposure. DISCUSSION: An individual's habitus impacts one's knowledge, attitudes, and beliefs and interacts with past behaviors when discussing options for infant feeding and health promoting behaviors such as vaccinations. A better understanding of how health care providers assess and utilize habitus in clinical management is needed.

Intrauterine Fetal Demise in the Third Trimester of Pregnancy Associated With Mild Infection With the SARS-CoV-2 Delta Variant Without Protection From Vaccination.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has a higher infection rate in pregnant women than age-matched adults. With increased infectivity and transmissibility, the Delta variant is predominant worldwide. METHODS: In this study, we describe intrauterine fetal demise in unvaccinated women with mild symptoms of SARS-CoV-2 Delta variant infection. RESULTS: Histology and elevated proinflammatory responses of the placenta suggest that fetal demise was associated with placental malperfusion due to Delta variant infection. CONCLUSIONS: This study suggests that the Delta variant can cause severe morbidity and mortality to fetuses. Vaccination should continue to be advocated and will likely continue to reduce SARS-CoV-2 infection risks for pregnant women and their fetuses.

Coronavirus Disease 2019 (COVID-19) Disease Severity: Pregnant vs Nonpregnant Women at 82 Facilities.

BACKGROUND: Pregnancy has been reported to be a risk factor for severe COVID-19. We evaluated the impact of pregnancy on severe COVID-19 and mortality in an electronic medical record (EMR) database that enabled exclusion of labor and delivery (L&D) encounters. METHODS: In this retrospective cohort study, EMRs from 82 healthcare facilities in the Cerner COVID-19 Datamart were analyzed. The study comprised 38 106 individuals aged 18-45 years old with COVID-19 who had emergency department, urgent care, or inpatient encounters from December 2019 to September 2020. Subgroups were balanced through propensity score weights for age, race, smoking status, and number of comorbidities. The primary outcome was COVID-19-related mortality; secondary outcomes were markers of severe COVID-19: intubations, mechanical ventilation, use of vasopressors, diagnosis of sepsis, and diagnosis of acute respiratory distress syndrome. RESULTS: In comparing pregnant and nonpregnant women, no statistical differences were found for markers of severe COVID-19, after adjusting for age, smoking, race, and comorbidities. The adjusted odds of an inpatient encounter were higher for pregnant vs nonpregnant women (adjusted odds ratio [aOR], 13.2; 95% confidence interval [CI], 11.6-15.3; P < .001), but notably lower after excluding L&D encounters (aOR, 2.3; 95% CI, 1.89-2.88; P < .001). In comparison to women without L&D encounters, hospitalization was significantly more likely for men. CONCLUSIONS: We did not find an increased risk of severe COVID-19 or mortality in pregnancy. Hospitalization does not necessarily indicate severe COVID-19 in pregnancy, as half of pregnant patients with COVID-19 were admitted for L&D encounters in this study.

A systematic review of the translation and validation methods used for the national comprehensive cancer network distress thermometer in non-English speaking countries.

OBJECTIVE: The National Comprehensive Cancer Network (NCCN) distress thermometer (DT) was developed as a brief screening tool for detecting distress in cancer patients. Conceptually, distress was considered a more acceptable and inclusive term than other psychological terms such as depression or anxiety. It is used extensively in the United States and other English-speaking countries. We aim to describe the translation and validation methods of the DT and describe the recommended cutoff scores used to identify cancer patients experiencing clinically significant distress. METHODS: Nine bibliographic databases were searched using keywords to identify original research studies for non-English speaking countries' cancer patients. Full articles were independently assessed for inclusion and data extraction by two authors. RESULTS: The review of 4442 articles yielded 39 articles that validated the DT. We identified 20 languages in 25 countries. In all but one country, investigators were able to agree upon a word or phrase that meant distress in their native language that was subsequently validated against standardized instruments. Asian, Middle Eastern and European counties recommended cutoff score of 4 or 5 to identify clinically significant distress; however, European Union countries had a range of 2 to 7. CONCLUSIONS: Use of the translated DT with non-English speaking cancer patients provides a simple and quick tool to identify high distress. Similar to NCCN, the cutoff score of 4 or 5 was suggested by 78% of the studies; however, more studies of different types of cancer and within and among more countries will strengthen a recommended global DT cutoff score.

Implementing Educational and Systems-Level Changes to Improve Cancer Screening Rates Among State Employees in Missouri.

As of 2022, only 51% of active eligible state employees in Missouri have been screened for colorectal cancer and 67% for breast cancer, despite having state-sponsored health insurance. In fall 2020, the Missouri Department of Health and Senior Services Comprehensive Cancer Program partnered with the Missouri Cancer Consortium to create a strategy to improve cancer screening rates among state employees. The project was designed to include 3 phases: 1) a colorectal cancer education phase, 2) an expanded education phase that included additional cancers, and 3) a proposed intervention phase that will include screening events. In the first phase, in 2020, colorectal cancer educational materials were sent to all state employees. In the second phase, in 2022, educational resources were expanded to include additional cancers and screening tools. In both initiatives, educational materials and information on current screening recommendations were distributed to approximately 40,000 state employees. A database of screening rates was developed to monitor screening rates and challenge state employees to complete screenings. Evidence-informed interventions were implemented with a focus on health equity. We used a regional approach to identify geographic areas with the greatest need. These efforts will support the next phase of the project, which involves planning breast and colorectal cancer screening events. Policy changes will be encouraged to remove systems-level barriers that discourage employees from being screened for cancer. Recommended tools and strategies can be adopted by similar organizations with complex, multitier employee structures.

SARS-CoV-2 show no infectivity at later stages in a prolonged COVID-19 patient despite positivity in RNA testing.

Inpatient coronavirus disease 2019 (COVID-19) cases present enormous costs to patients and health systems in the United States. Many hospitalized patients may continue testing COVID-19 positive even after the resolution of symptoms. Thus, a pressing concern for clinicians is the safety of discharging these asymptomatic patients if they have any remaining infectivity. This case report explores the viral viability in a patient with persistent COVID-19 over the course of a 2-month hospitalization. Positive nasopharyngeal swab samples were collected and isolated in the laboratory and analyzed by quantitative reverse-transcription polymerase chain reactions (qRT-PCR), and serology was tested for neutralizing antibodies throughout the hospitalization period. The patient experienced waning symptoms by hospital day 40 and had no viable virus growth by hospital day 41, suggesting no risk of infectivity, despite positive RT-PCR results which prolonged his hospital stay. Notably, this case showed infectivity for at least 24 days after disease onset, which is longer than the discontinuation of transmission-based precautions recommended by the Center for Disease Control and Prevention. Thus, our findings suggest that the timeline for discontinuing transmission-based precautions may need to be extended for patients with severe and prolonged COVID-19 disease. Additional large-scale studies are needed to draw definitive conclusions on the appropriate clinical management for these patients. ​.

Health risk assessment of volatile organic compounds at daycare facilities.

Children are particularly vulnerable to many classes of the volatile organic compounds (VOCs) detected in indoor environments. The negative health impacts associated with chronic and acute exposures of the VOCs might lead to health issues such as genetic damage, cancer, and disorder of nervous systems. In this study, 40 VOCs including aldehydes and ketones, aliphatic hydrocarbons, esters, aromatic hydrocarbons, cyclic terpenes, alcohols, and glycol ethers were identified and qualified in different locations at the University of Missouri (MU) Child Development Laboratory (CDL) in Columbia, Missouri. Our results suggested that the concentrations of the VOCs varied significantly among classrooms, hallways, and playground. The VOCs emitted from personal care and cleaning products had the highest indoor levels (2-ethylhexanol-1, 3-carene, homomenthyl salicylate with mean concentration of 5.15 µg/m3 , 1.57 µg/m3 , and 1.47 µg/m3 , respectively). A cancer risk assessment was conducted, and none of the 95th percentile dose estimates exceeded the age-specific no significant risk levels (NSRL) in all classrooms. Dimensionless toxicity index scores were calculated for all VOCs using a novel web-based framework called Toxicological Prioritization Index (ToxPi), which integrates multiple sources of toxicity data. According to the method, homomenthyl salicylate, benzothiazole, 2-ethylhexyl salicylate, hexadecane, and tridecane exhibited diverse toxicity profiles and ranked as the five most toxic indoor VOCs. The findings of this study provide critical information for policy makers and early education professionals to mitigate the potentially negative health impacts of indoor VOCs in the childcare facilities.

The Influence of Telehealth for Better Health Across Communities.

Rapid spread of coronavirus disease 2019 (COVID-19) forced an abrupt shift in the traditional US health care delivery model to meet the needs of patients, staff, and communities. Through federal policy changes on telehealth, patient care shifted from in-person to telephone or video visits, and health care providers reached out to patients most at risk for exacerbation of chronic disease symptoms. ECHO (Extension for Community Healthcare Outcomes), a videoconferencing peer learning application, engaged health care providers across Missouri in the treatment and management of complex COVID-19-positive patients. Re-envisioning health care in the digital age includes robust utilization of telehealth to enhance care for all.

Breaking bad news of a breast cancer diagnosis over the telephone: an emerging trend.

PURPOSE: This study evaluated how breast cancer diagnoses were shared with patients. METHODS: Current members of the Dr. Susan Love Research Foundation's Army of Women cohort were sent one email with a link to a survey assessing how their breast cancer diagnosis was communicated, a description of their support system during treatment, basic demographic information, and breast cancer diagnosis details. RESULTS: Participants (n = 2896) were more likely to be given their diagnosis over the telephone in more recent years (OR 1.07, 95% CI 1.06-1.08). Up until about 10 years ago (1967-2006), breast cancer diagnoses were communicated in person more often than by telephone. Since 2006, more than half of participants learned about their diagnosis over the telephone. From 2015 to 2017, almost 60% of participants learned about their diagnosis over the telephone. Among those who heard the news in person, a steady 40% were alone. Characteristics of those who received the news over the telephone included having identified support members, heterosexual identity, and a diagnosis of in situ breast cancer. CONCLUSIONS: Receiving a telephone call about breast cancer diagnosis may be the norm rather than the exception in health care today. Trends in practice, as well as current best practices based primarily on expert opinion, may not provide optimal care for women diagnosed with breast cancer. Patient outcome research to guide future practice, such as the impact of modes of delivery of bad news, is urgently needed to determine appropriate patient-centered approaches for notification of breast cancer diagnoses.

Unmet support needs of sexual and gender minority breast cancer survivors.

PURPOSE: This study explored sources of stress and support experienced by sexual and gender minority (SGM) breast cancer survivors and the impact of treatment on their lives. METHODS: SGM breast cancer survivors were identified through purposive and referral sampling and invited to participate in a web-based survey containing both closed- and open-ended items. Sixty-eight SGM breast cancer survivors aged 18-75 years completed the survey between May 2015 and January 2016. RESULTS: Bivariate analyses of quantitative data reveal that queer-identified (in either sexual orientation or gender identity (SOGI)) SGM survivors are more likely to report having bilateral mastectomy without reconstruction and to think that disclosing SOGI to providers affected their care. Queer-identified SGM survivors are also more likely to use LGBT-specific support groups and to report that their current level of social support is below average. Thematic analysis of qualitative comments revealed themes related to self-disclosure of SOGI to providers, need for recognition and support of partners, need for appropriate social supports for patients and partners, and impact of breast cancer treatment on intimate relationships. CONCLUSION: This study provides quantitative and qualitative evidence that many SGM breast cancer patients face a dearth of appropriate social supports, both from breast cancer survivor organizations and from within the medical system. These findings confirm the need for research on the physical and emotional effects of breast cancer treatment on SGM breast cancer survivors, as well as further exploration of the social support needs and experiences of SGM breast cancer patients and their partners.

Sexual and gender minority breast cancer patients choosing bilateral mastectomy without reconstruction: "I now have a body that fits me".

Sexual and gender minority (SGM) breast cancer patients have begun embracing the choice to "go flat" or opt out of reconstruction after bilateral mastectomy, though little is known about this population. SGM breast cancer survivors were identified through purposive and referral sampling and invited to participate in a web-based survey containing both closed- and open-ended items. Of the sixty-eight SGM breast cancer survivors aged 18-75 years who completed the survey between May 2015 and January 2016, 25 percent reported "going flat" (flattoppers®). Bivariate analyses revealed that flattoppers® were significantly more likely to have been diagnosed in the past five years, to identify as genderqueer, to have disclosed their sexual orientation or gender identity (SOGI) to providers, and to report participating in lesbian, gay, bisexual, or transgender cancer support groups, compared to other participants. More flattoppers® believed that SOGI mattered in terms of getting the support they needed regarding their cancer; this difference was not statistically significant. Thematic analysis of qualitative comments from flattoppers® revealed themes related to reasons for making this treatment choice, interactions with health-care providers around treatment choice, and physical and emotional outcomes of treatment choice. Providers would benefit from training about SOGI as they relate to treatment choices.

Sexual and gender minority's social media user characteristics: Examining preferred health information.

The authors examined the influence of social media involvement on health issues in sexual and gender minorities (SGMs). Demographic and technological characteristics of social media users and nonusers were identified, and the influence of social media involvement on these factors was assessed for its potential to influence health information needs and preferences. A survey of 2,274 SGM individuals revealed that age, sexual orientation, number of Internet access points, and use of smartphones predicted levels of social media involvement. Results suggest that a broader range of traditional and nontraditional communication channels is needed to meet a diversity of health information needs in SGMs.

Can Smoke-Free Policies Reduce Tobacco Use Disparities of Sexual and Gender Minorities in Missouri?

OBJECTIVE: The purpose of this study is to explore the associations between smoke-free policies, current and former smoking status, personal smoking restrictions, and intention to quit among sexual and gender minority (SGM) and non-SGM individuals in Missouri. AIMS AND METHODS: The current analysis derives from the Out, Proud and Healthy project. Chi-squares examined differences between SGM (N = 2210) and non-SGM (N = 586) respondents and former (N = 836) and current (N = 1960) smokers on smoking-related variables. Odds ratios and 95% confidence intervals from logistic regression identified variables associated with former (vs. current) smoking. RESULTS: SGM current smokers (25%) were significantly more likely than SGM former smokers (19%) to live in a community without a smoke-free policy. Among SGM current smokers, significantly greater intention to quit was seen in those living in a smoke-free community with a smoke-free policy of two or more years (94%) compared with those living in a community without a smoke-free policy (76%). CONCLUSIONS: Living in an area with smoke-free policies is related to greater intention to quit among SGM current smokers, greater support for smoke-free policies, and lower smoking prevalence for this community. The SGM community may collectively accrue greater public health benefits from the adoption of smoke-free policies than the non-SGM community. IMPLICATIONS: Prior to this study, no data are available regarding current and former smoking status among SGM individuals following the implementation of a local smoke-free policy. The purpose of this study was to explore the relationship between smoke-free policies, current and former smoking status, and intention to quit among SGM and non-SGM individuals in Missouri. This study finds evidence of lower current smoking prevalence and greater intentions to quit among SGM current smokers who live in communities with smoke-free policies. The SGM community may collectively accrue greater public health benefits from the adoption of smoke-free policies than the non-SGM community.

Dietary cadmium intake and risk of prostate cancer: a Danish prospective cohort study.

BACKGROUND: Cadmium is classified as a human lung carcinogen based on evidence from high-exposure occupational settings. Though cadmium has no physiological role, increasing evidence suggests cadmium may mimic steroid hormones. This dual ability of being carcinogenic and hormone-like makes cadmium a concern for hormone-related cancers. Causes of prostate cancer are not clear, but steroid hormones, particularly androgens and probably estrogens, may be involved. Cadmium has been positively associated with prostate cancer in occupationally exposed men. In non-occupationally exposed populations, diet and smoking are the main sources of cadmium exposure. The aim of this study was to investigate the association between dietary cadmium intake and prostate cancer risk in Danish men. METHODS: Dietary cadmium intake was estimated in the Danish Diet, Cancer and Health cohort at baseline 1993-97. The estimates were based on a 192 item semi-quantitative food frequency questionnaire and cadmium contents in all food items. Among 26,778 men we identified 1,567 prostate cancer cases from baseline through December 31, 2010 using the Danish Cancer Registry. The association between dietary cadmium intake and prostate cancer risk was analysed using Cox regression models. RESULTS: We did not find an association between dietary cadmium intake and prostate cancer risk (adjusted incidence rate ratio per 10 µg day(-1) = 0.98 (95% CI = 0.88-1.10)). The association did not differ according to aggressiveness of prostate cancer. Educational level, smoking status, BMI, zinc or iron intake did not modify the association. CONCLUSIONS: In our study, we did not find an association between dietary cadmium intake and prostate cancer risk in a cohort of Danish men.

Smoking initiation, tobacco product use, and secondhand smoke exposure among general population and sexual minority youth, Missouri, 2011-2012.

INTRODUCTION: Research indicates disparities in risky health behaviors between heterosexual and sexual minority (referred to as LGBQ; also known as lesbian, gay, bisexual, queer, and questioning) youth. Limited data are available for tobacco-use-related behaviors beyond smoking status. We compared data on tobacco age of initiation, product use, and secondhand smoke exposure between general population and LGBQ youth. METHODS: Data for general population youth were from the statewide, representative 2011 Missouri Youth Tobacco Survey, and data for LGBQ youth were from the 2012 Out, Proud and Healthy survey (collected at Missouri Pride Festivals). Age-adjusted Cochran-Mantel-Haenszel tests were used to examine differences between general population (N = 1,547) and LGBQ (N = 410) youth, aged 14 to 18 years. Logistic regression models identified variables associated with current smoking. RESULTS: The 2 groups differed significantly on many tobacco-use-related factors. General population youth initiated smoking at a younger age, and LGBQ youth did not catch up in smoking initiation until age 15 or 16. LGBQ youth (41.0%) soon surpassed general population youth (11.2%) in initiation and proportion of current smokers. LGBQ youth were more likely to use cigars/cigarillos, be poly-tobacco users, and be exposed to secondhand smoke (SHS) in a vehicle (for never smokers). Older age (odds ratio [OR] = 1.39, 95% confidence interval [95% CI] = 1.18-1.62), female sex (OR = 1.64, 95% CI = 1.13-2.37), LGBQ identity (OR = 3.86, 95% CI = 2.50-5.94), other tobacco product use (OR = 8.67, 95% CI = 6.01-12.51), and SHS exposure in a vehicle (OR = 5.97, 95% CI = 3.83-9.31) all significantly increased the odds of being a current smoker. CONCLUSION: This study highlights a need for the collection of data on sexual orientation on youth tobacco surveys to address health disparities among LGBQ youth.

Place-based exposure and cataract risk in the Beaver Dam cohort.

According to the Centers for Disease Control and Prevention, with an aging U.S. population an estimated 30 million people will be diagnosed with cataract by 2020. Several modifiable risk factors have been identified for nuclear cataract, cortical cataract, and posterior subcapsular cataract (PSC), including smoking, diabetes, and steroid medications. In the study described here, the authors evaluated residential location as a potential proxy of risk factors for cataracts in the Beaver Dam Eye Study cohort established in 1987. Cataract risk was calculated using general estimating equation modeling to account for correlation between eyes. Fifteen-year cumulative incidence rates were calculated for each type of cataract by eye. Of the 4926 study participants, 3253 seen at the baseline examination were included in the analyses. Compared to urban residents, the odds ratio (95% confidence interval) for rural participants' risk of cortical, nuclear, and PSC was 0.92 (0.73, 1.16), 0.85 (0.69, 1.06), and 0.71 (0.48, 1.05), respectively, adjusting for age, sex, educational status, and smoking status. The lowest cumulative incidences were for those living in rural areas, compared to edge or urban areas for all three types of cataracts.

Prediction models for COVID-19 disease outcomes.

SARS-CoV-2 has caused over 6.9 million deaths and continues to produce lasting health consequences. COVID-19 manifests broadly from no symptoms to death. In a retrospective cross-sectional study, we developed personalized risk assessment models that predict clinical outcomes for individuals with COVID-19 and inform targeted interventions. We sequenced viruses from SARS-CoV-2-positive nasopharyngeal swab samples between July 2020 and July 2022 from 4450 individuals in Missouri and retrieved associated disease courses, clinical history, and urban-rural classification. We integrated this data to develop machine learning-based predictive models to predict hospitalization, ICU admission, and long COVID.The mean age was 38.3 years (standard deviation = 21.4) with 55.2% (N = 2453) females and 44.8% (N = 1994) males (not reported, N = 4). Our analyses revealed a comprehensive set of predictors for each outcome, encompassing human, environment, and virus genome-wide genetic markers. Immunosuppression, cardiovascular disease, older age, cardiac, gastrointestinal, and constitutional symptoms, rural residence, and specific amino acid substitutions were associated with hospitalization. ICU admission was associated with acute respiratory distress syndrome, ventilation, bacterial co-infection, rural residence, and non-wild type SARS-CoV-2 variants. Finally, long COVID was associated with hospital admission, ventilation, and female sex.Overall, we developed risk assessment models that offer the capability to identify patients with COVID-19 necessitating enhanced monitoring or early interventions. Of importance, we demonstrate the value of including key elements of virus, host, and environmental factors to predict patient outcomes, serving as a valuable platform in the field of personalized medicine with the potential for adaptation to other infectious diseases.