LGBTQ+ cancer: priority or lip service? A qualitative content analysis of LGBTQ+ considerations in U.S. state, jurisdiction, and tribal comprehensive cancer control plans.

The National Comprehensive Cancer Control Program, a Centers for Disease Control and Prevention funded program, supports cancer coalitions across the United States (US) in efforts to prevent and control cancer including development of comprehensive cancer control (CCC) plans. CCC plans often focus health equity within their priorities, but it is unclear to what extent lesbian, gay, bisexual, transgender, queer/questioning, plus (LGBTQ+) populations are considered in CCC plans. We qualitatively examined to what extent LGBTQ+ populations were referenced in 64 U.S. state, jurisdiction, tribes, and tribal organization CCC plans. A total of 55% of CCC plans mentioned LGBTQ+ populations, however, only one in three CCC plans mentioned any kind of LGBTQ+ inequity or LGBTQ+ specific recommendations. Even fewer plans included mention of LGBTQ+ specific resources, organizations, or citations. At the same time almost three fourths of plans conflated sex and gender throughout their CCC plans. The findings of this study highlight the lack of prioritization of LGBTQ+ populations in CCC plans broadly while highlighting exemplar plans that can serve as a roadmap to more inclusive future CCC plans. Comprehensive cancer control plans can serve as a key policy and advocacy structure to promote a focus on LGBTQ+ cancer prevention and control.

"Pathways": A hope-enhancing intervention for patients undergoing treatment for advanced lung cancer.

OBJECTIVE: Observational data suggest hope is associated with the quality of life and survival of people with cancer. This trial examined the feasibility, acceptability, and preliminary outcomes of "Pathways," a hope intervention for people in treatment for advanced lung cancer. METHODS: Between 2020 and 2022, we conducted a single-arm trial of Pathways among participants who were 3-12 weeks into systemic treatment. Pathways consisted of two individual sessions delivered during infusions and three phone calls in which participants discussed their values, goals, and goal strategies with a nurse or occupational therapist. Participants completed standardized measures of hope and goal interference pre- and post-intervention. Feasibility was defined as ≥60% of eligible patients enrolling, ≥70% of participants completing three or more sessions, ≥70% of participants completing post-assessments, and mean acceptability ratings ≥7 out of 10 on intervention relevance, helpfulness, and convenience. Linear regression fixed effects models with covariates modeled pre-post changes in complete case analysis and multiple imputation models. RESULTS: Fifty two participants enrolled: female (59.6%), non-Hispanic White (84.6%), rural (75.0%), and with low educational attainment (51.9% high school degree or less). Except for enrollment (54%), feasibility and acceptability markers were surpassed (77% adherence, 77% retention, acceptability ratings ≥8/10). There was moderate improvement in hope and goal interference from pre-to post-intervention (d = 0.51, p < 0.05 for hope; d = -0.70, p < 0.005 for goal interference). CONCLUSIONS: Strong feasibility, acceptability, and patient-reported outcome data suggest Pathways is a promising intervention to increase hope and reduce cancer-related goal interference during advanced lung cancer treatment.

Equitable implementation of lung cancer screening: avoiding its potential to mirror existing inequities among people who use tobacco.

PURPOSE: Lung cancer is the leading cause of cancer death, but the advent of lung cancer screening using low-dose computed tomography offers a tremendous opportunity to improve lung cancer outcomes. Unfortunately, implementation of lung cancer screening has been hampered by substantial barriers and remains suboptimal. Specifically, the commentary emphasizes the intersectionality of smoking history and several important sociodemographic characteristics and identities that should inform lung cancer screening outreach and engagement efforts, including socioeconomic considerations (e.g., health insurance status), racial and ethnic identity, LGBTQ + identity, mental health history, military experience/veteran status, and geographic residence in addressing specific community risk factors and future interventions in efforts to make strides toward equitable lung cancer screening. METHODS: Members of the Equitable Implementation of Lung Cancer Screening Interest Group with the Cancer Prevention and Control Network (CPCRN) provide a critical commentary based on existing literature regarding smoking trends in the US and lung cancer screening uptake to propose opportunities to enhance implementation and support equitable distribution of the benefits of lung cancer screening. CONCLUSION: The present commentary utilizes information about historical trends in tobacco use to highlight opportunities for targeted outreach efforts to engage communities at high risk with information about the lung cancer screening opportunity. Future efforts toward equitable implementation of lung cancer screening should focus on multi-level implementation strategies that engage and work in concert with community partners to co-create approaches that leverage strengths and reduce barriers within specific communities to achieve the potential of lung cancer screening.

Smoking Cessation, Version 3.2022, NCCN Clinical Practice Guidelines in Oncology.

Although the harmful effects of smoking after a cancer diagnosis have been clearly demonstrated, many patients continue to smoke cigarettes during treatment and beyond. The NCCN Guidelines for Smoking Cessation emphasize the importance of smoking cessation in all patients with cancer and seek to establish evidence-based recommendations tailored to the unique needs and concerns of patients with cancer. The recommendations contained herein describe interventions for cessation of all combustible tobacco products (eg, cigarettes, cigars, hookah), including smokeless tobacco products. However, recommendations are based on studies of cigarette smoking. The NCCN Smoking Cessation Panel recommends that treatment plans for all patients with cancer who smoke include the following 3 tenets that should be done concurrently: (1) evidence-based motivational strategies and behavior therapy (counseling), which can be brief; (2) evidence-based pharmacotherapy; and (3) close follow-up with retreatment as needed.

Palliative care use and utilization determinants among patients treated for advanced stage lung cancer care in the community and academic medical setting.

PURPOSE: Despite clinical guidelines, palliative care is underutilized during advanced stage lung cancer treatment. To inform interventions to increase its use, patient-level barriers and facilitators (i.e., determinants) need to be characterized, especially among patients living in rural areas or those receiving treatment outside academic medical centers. METHODS: Between 2020 and 2021, advanced stage lung cancer patients (n = 77; 62% rural; 58% receiving care in the community) completed a one-time survey assessing palliative care use and its determinants. Univariate and bivariate analyses described palliative care use and determinants and compared scores by patient demographic (e.g., rural vs. urban) and treatment setting (e.g., community vs. academic medical center) factors. RESULTS: Roughly half said they had never met with a palliative care doctor (49.4%) or nurse (58.4%) as part of cancer care. Only 18% said they knew what palliative care was and could explain it; 17% thought it was the same as hospice. After palliative care was distinguished from hospice, the most frequently cited reasons patients stated they would not seek palliative care were uncertainty about what it would offer (65%), concerns about insurance coverage (63%), difficulty attending multiple appointments (60%), and lack of discussion with an oncologist (59%). The most common reasons patients stated they would seek palliative care were a desire to control pain (62%), oncologist recommendation (58%), and coping support for family and friends (55%). CONCLUSION: Interventions should address knowledge and misconceptions, assess care needs, and facilitate communication between patients and oncologists about palliative care.

Implementation strategies preferred by primary care clinicians to facilitate cancer prevention and control activities.

Key clinical and community members need to be involved in the identification of feasible and impactful implementation strategies for translation of evidence-based interventions into practice. While a wide range of implementation strategies has been developed, there is little research on their applicability for cancer prevention and control (CPC) efforts in primary care. We conducted a survey of primary care physicians to identify implementation strategies they perceive as most feasible and impactful. The survey included both primary prevention behavior change counseling and cancer screening issues. Analyses contrasted ratings of feasibility and impact of nine implementation strategies, and among clinicians in different settings with a focus on comparisons between clinicians in rural vs. non-rural settings. We recruited a convenience sample of 326 respondents from a wide range of practice types from four practice-based research networks in 49 states and including 177 clinicians in rural settings. Ratings of impact were somewhat higher than those for feasibility. Few of the nine implementation strategies were high on both impact and feasibility. Only 'adapting to my practice' was rated higher than a 4 ("moderate") on both impact and feasibility. There were relatively few differences between rural and non-rural clinicians or associated with other clinician or setting characteristics. There is considerable variability in perceived impact and feasibility of implementation strategies for CPC activities among family medicine clinicians. It is important to assess both feasibility and impact of implementation strategies as well as their generalizability across settings. Our results suggest that optimal strategies to implement evidence-based CPC activities will likely need to be adapted for primary care settings. Future research is needed to replicate these findings and identify practical, implementation partner informed implementation strategies.

NCCN Guidelines® Insights: Lung Cancer Screening, Version 1.2022.

The NCCN Guidelines for Lung Cancer Screening recommend criteria for selecting individuals for screening and provide recommendations for evaluation and follow-up of lung nodules found during initial and subsequent screening. These NCCN Guidelines Insights focus on recent updates to the NCCN Guidelines for Lung Cancer Screening.

A Daily Assessment Study of Smoking Cessation After a Head and Neck Cancer Diagnosis.

INTRODUCTION: This intensive longitudinal study describes key events in the process of smoking cessation after a new head and neck cancer (HNC) diagnosis. Prior longitudinal studies show some cancer patients quit, while others continue to smoke, but details about the pattern in which these discrete outcomes arise are scarce. This study is meant to help rectify this gap in the literature. AIMS AND METHODS: Participants were 42 HNC patients who reported current smoking at enrollment. Participants were recruited from an outpatient oncology clinic and completed a baseline questionnaire prior to begin a 30-day daily assessment. RESULTS: Few participants (9.52%) achieved 30-day continuous abstinence from smoking. On average, participants reported 9.64 ± 11.93 total days of abstinence. Nearly, all (94.44%, n = 34) participants made at least one quit attempt, with an average of 16.94 ± 11.30 quit attempt days. Fewer participants were able to achieve a 24-hour quit attempt (52.78%, n = 19), with a corresponding average of 5.50 ± 8.69 24-hour days. The median time to first 24-hour quit attempt was 13 days after enrollment. Based on smoking behavioral patterns, participants were categorized into five groups, the most common being "persistent attempters," which involved unsuccessful quit attempts throughout the study. Only 45% of participants (n = 19) used evidence-based treatment, the most common being cessation medication. CONCLUSIONS: This intensive longitudinal study found that cancer diagnosis can spur a lot of efforts to quit smoking. Unfortunately, this study suggests that many quit attempts are short lived, possibly a result of an absence or insufficient use of evidence-based treatments. IMPLICATIONS: For adults who are current smokers at the time of cancer diagnosis, there is a high likelihood of persistent cigarette smoking and use of other tobacco products in the weeks and months after a cancer diagnosis. Furthermore, this study shows that while a lot of quit attempts may occur, few are successful, which may be partly attributable to the low use of evidence-based tobacco treatment. Future research with cancer patients should aim to identify predictors of quit attempts and abstinence as well as treatment utilization.

Ranked determinants of telemedicine diabetic retinopathy screening performance in the United States primary care safety-net setting: an exploratory CART analysis.

BACKGROUND: Diabetic retinopathy (DR) is a leading cause of blindness worldwide, despite easy detection and effective treatment. Annual screening rates in the USA remain low, especially for the disadvantaged, which telemedicine-based DR screening (TDRS) during routine primary care has been shown to improve. Screening rates from such programs have varied, however, pointing to inconsistent implementation and unaddressed barriers. This work seeks to identify and prioritize modifiable barriers for targeted intervention. METHODS: In this final phase of an exploratory mixed-methods study, we developed, validated, and administered a 62-item survey to multilevel stakeholders involved with TDRS in primary care safety-net clinics. Survey items were aligned with previously identified determinants of clinic-level screening and mapped to the Consolidated Framework for Implementation Research (CFIR). Classification and Regression Tree (CART) analyses were used to identify and rank independent variables predictive of individual-level TDRS screening performance. RESULTS: Overall, 133 of the 341 invited professionals responded (39%), representing 20 safety-net clinics across 6 clinical systems. Respondents were predominately non-Hispanic White (77%), female (94%), and between 31 and 65 years of age (79%). Satisfaction with TDRS was high despite low self-reported screening rates. The most important screening determinants were: provider reinforcement of TDRS importance; explicit instructions by providers to staff; effective reminders; standing orders; high relative priority among routine diabetic measures; established TDRS workflows; performance feedback; effective TDRS champions; and leadership support. CONCLUSIONS: In this survey of stakeholders involved with TDRS in safety-net clinics, screening was low despite high satisfaction with the intervention. The best predictors of screening performance mapped to the CFIR constructs Leadership Engagement, Compatibility, Goals & Feedback, Relative Priority, Champions, and Available Resources. These findings facilitate the prioritization of implementation strategies targeting determinants of TDRS performance, potentially increasing its public health impact.

Using Implementation Science to Disseminate a Lung Cancer Screening Education Intervention Through Community Health Workers.

National lung cancer screening with low dose computed tomography (LDCT) uptake is suboptimal. One factor contributing to slow uptake is lack of awareness. Trained Community Health Workers (CHWs) may be effective in increasing lung cancer screening awareness among disparate populations, however little is known about the processes necessary to scale an intervention for implementation by CHWs in a new area. We examined implementation processes with the RE-AIM framework and pilot tested a CHW-delivered lung cancer education intervention based on the Health Belief Model. We measured pre-post participant knowledge, attitudes and beliefs regarding cancer screening, lung cancer stigma, and intent to obtain LDCT screening. We used community-engaged strategies to collaborate with a local health system, to identify CHWs. CHWs were trained to recruit participants and deliver the one-session lung cancer education intervention. Seven CHWs and eight community sites participated. Participants (n = 77) were female (53%) primarily low income (62.9%); tobacco use was high (36.9%). Post intervention changes in lung cancer screening knowledge (p = < .0001), attitudes regarding lung cancer screening benefit (p = .034) and lung cancer stigma. (p = .024) We learned important lessons that will be useful in subsequent scaling. Collaborating with a local health system is a promising method to disseminate a lung cancer screening education intervention.

Development of a Plain Language Decision Support Tool for Cancer Clinical Trials: Blending Health Literacy, Academic Research, and Minority Patient Perspectives.

Despite the promise of clinical trials for improving cancer care, less than 5% of all cancer patients participate. Racial/ethnic minorities continue to be underrepresented in cancer clinical trials (CCTs). To address this gap, we developed a plain language, web-based decision support tool (CHOICES DST) in English and Spanish to support decision-making about CCTs among Blacks and Hispanics. In phase 1 (information collection), we conducted qualitative interviews with 45 cancer patients, completed a thorough literature review, and reviewed results from a telephone survey of 1100 cancer patients. In phase 2 (content generation), we created the first iteration of the CHOICES DST. In phase 3 (usability testing), we gathered user experience and acceptability data from a small sample of cancer survivors (n = 9). The Knowledge, Empowerment, and Values Clarification (KEV) model of decision-making was developed based on data from phase 1. The KEV model and other phase 1 data allowed us to create the CHOICES DST platform. Usability testing of the CHOICES DST showed highly favorable responses from users, satisfaction with content, ease of navigation, and a desire to use the tool. Qualitative results identified addressable points that would benefit from content and navigation-related alterations. The final version of the CHOICES DST was well received and understood by Black and Hispanic participants, and adheres to the mandates for plain language communication. This research provides preliminary data that CHOICES DST holds promise for improving knowledge of CCTs and potentially improving informed decision-making about participation in trials.

Tobacco Use Assessment and Treatment in Cancer Patients: A Scoping Review of Oncology Care Clinician Adherence to Clinical Practice Guidelines in the U.S.

BACKGROUND: Smoking after a cancer diagnosis negatively impacts health outcomes; smoking cessation improves symptoms, side effects, and overall prognosis. The Public Health Service and major oncology organizations have established guidelines for tobacco use treatment among cancer patients, including clinician assessment of tobacco use at each visit. Oncology care clinicians (OCCs) play important roles in this process (noted as the 5As: Asking about tobacco use, Advising users to quit, Assessing willingness to quit, Assisting in quit attempts, and Arranging follow-up contact). However, OCCs may not be using the "teachable moments" related to cancer diagnosis, treatment, and survivorship to provide cessation interventions. MATERIALS AND METHODS: In this scoping literature review of articles from 2006 to 2017, we discuss (1) frequency and quality of OCCs' tobacco use assessments with cancer patients and survivors; (2) barriers to providing tobacco treatment for cancer patients; and (3) the efficacy and future of provider-level interventions to facilitate adherence to tobacco treatment guidelines. RESULTS: OCCs are not adequately addressing smoking cessation with their patients. The reviewed studies indicate that although >75% assess tobacco use during an intake visit and >60% typically advise patients to quit, a substantially lower percentage recommend or arrange smoking cessation treatment or follow-up after a quit attempt. Less than 30% of OCCs report adequate training in cessation interventions. CONCLUSION: Intervention trials focused on provider- and system-level change are needed to promote integration of evidence-based tobacco treatment into the oncology setting. Attention should be given to the barriers faced by OCCs when targeting interventions for the oncologic context. IMPLICATIONS FOR PRACTICE: This article reviews the existing literature on the gap between best and current practices for tobacco use assessment and treatment in the oncologic context. It also identifies clinician- and system-level barriers that should be addressed in order to lessen this gap and provides suggestions that could be applied across different oncology practice settings to connect patients with tobacco use treatments that may improve overall survival and quality of life.

Is attendance at an ovarian cancer screening clinic a worry-reducing event? Findings from pre- to post-screening.

OBJECTIVE: Many studies have examined the relationship between worry and cancer screening. Due to methodological inconsistencies, results of these studies have varied and few conclusions can be made when generalizing across studies. The purpose of the current study was to better understand the worry-cancer screening relationship using a prospective research design. METHOD: 180 women enrolled in an annual ovarian cancer (OC) screening clinic completed surveys at three time points-pre-screening, day of screening, and post-screening-using three measures of cancer-specific worry. RESULTS: OC worry was highest in the weeks prior to screening and mere presentation at a screening clinic was associated with a significant worry decline. Observed elevations in worry following abnormal screening were not universal and varied by the instrument used to measure worry. CONCLUSIONS: In contrast to our hypotheses, it appears that mere presentation at a cancer screening clinic may be a worry-reducing event. Receipt of abnormal results was not necessarily associated with increased worry.

High trait shame undermines the protective effects of prevalence knowledge on state shame following HPV/CIN diagnosis in women.

Human papillomavirus (HPV), and the related, cervical intraepithelial neoplasia (CIN), are common yet poorly understood physical conditions. The diagnosis of HPV often elicits shame and guilt, which in turn may undermine psychological and physical health. The current study compared shame and guilt responses to diagnosis among two groups: women diagnosed with HPV/CIN and women diagnosed with Epstein-Barr Virus (EBV/IM). Eighty women recently diagnosed with HPV/CIN or EBV/IM completed measures of shame- and guilt-proneness, shame and guilt following diagnosis, and disease knowledge including prevalence estimates (HPV and EBV, respectively). HPV/CIN (vs. EBV/IM) predicted more diagnosis-related shame and guilt. Estimates of high prevalence interacted with diagnosis and shame-proneness to predict diagnosis-related shame. Simple slope analyses indicated that in women with HPV/CIN reporting low-to-average shame-proneness, high prevalence estimates reduced diagnosis-related shame; however, women high in shame-proneness experienced high diagnosis-related shame regardless of more accurate prevalence estimates. Women high in shame-proneness appear to be particularly vulnerable to HPV-related shame even when they are aware that it is very common.

Examining evidence of lung cancer stigma among health-care trainees.

BACKGROUND: Innovations in lung cancer control and care have started to transform the landscape of lung cancer outcomes, but lung cancer stigma and biases have been implicated as a deterrent to realizing the promise of these innovations. Research has documented lung cancer stigma among the general public and lung cancer survivors (self-blame), as well as clinicians across many disciplines. However, studies have not explored lung cancer stigma in health-care trainees. These data seek to address that gap and inform efforts to prevent the emergence or mitigate the presence of lung cancer stigma among future clinicians. METHODS: Using clinical vignettes and a 2x2 factorial design, this investigation evaluated the impact of a history of smoking (yes vs no) and cancer diagnosis (lung vs colorectal) on perceptions of the described patient among 2 groups of preclinical health-care trainees (medical = 94 and nursing = 138). A charitable giving paradigm also asked participants to donate provided funds to 1 of 2 cancer advocacy organizations: one serving the lung cancer community and one serving the colorectal cancer community. RESULTS: In study 1, results revealed a consistent pattern of statistically significant and medium to large effect size differences regarding stigmatized perceptions (eg, higher stigmatizing behavior, increased pity, greater anger, and less helping) for individuals with a history of smoking but no reliable differences regarding cancer diagnosis. Analysis of data from nursing trainees in study 2 showed a similar pattern of statistically significant and medium to large effects pertaining to stigma behavior and perceptions of individuals who had a history of smoking depicted in the vignettes. The charitable giving paradigm did not identify any reliable difference between the groups in either study. CONCLUSIONS: Findings revealed a consistent pattern of health-care trainee perceptions that varied by smoking status but much less evidence that the cancer diagnosis contributed to different perceptions. This suggests that efforts to integrate consideration of stigma and biases in health-care training needs to adopt an approach that seeks to mitigate or eliminate stigmatizing perceptions and behaviors toward individuals with a history of smoking.

Using User-Centered Design to Facilitate Adherence to Annual Lung Cancer Screening: Protocol for a Mixed Methods Study for Intervention Development.

BACKGROUND: Lung cancer is the leading cause of cancer-related death in the United States, with the majority of lung cancer occurrence diagnosed after the disease has already metastasized. Lung cancer screening (LCS) with low-dose computed tomography can diagnose early-stage disease, especially when eligible individuals participate in screening on a yearly basis. Unfortunately, annual adherence has emerged as a challenge for academic and community screening programs, endangering the individual and population health benefits of LCS. Reminder messages have effectively increased adherence rates in breast, colorectal, and cervical cancer screenings but have not been tested with LCS participants who experience unique barriers to screening associated with the stigma of smoking and social determinants of health. OBJECTIVE: This research aims to use a theory-informed, multiphase, and mixed methods approach with LCS experts and participants to develop a set of clear and engaging reminder messages to support LCS annual adherence. METHODS: In aim 1, survey data informed by the Cognitive-Social Health Information Processing model will be collected to assess how LCS participants process health information aimed at health protective behavior to develop content for reminder messages and pinpoint options for message targeting and tailoring. Aim 2 focuses on identifying themes for message imagery through a modified photovoice activity that asks participants to identify 3 images that represent LCS and then participate in an interview about the selection, likes, and dislikes of each photo. A pool of candidate messages for multiple delivery platforms will be developed in aim 3, using results from aim 1 for message content and aim 2 for imagery selection. The refinement of message content and imagery combinations will be completed through iterative feedback from LCS experts and participants. RESULTS: Data collection began in July 2022 and will be completed by May 2023. The final reminder message candidates are expected to be completed by June 2023. CONCLUSIONS: This project proposes a novel approach to facilitate adherence to annual LCS through the development of reminder messages that embrace content and imagery representative of the target population directly in the design process. Developing effective strategies to increase LCS adherence is instrumental in achieving optimal LCS outcomes at individual and population health levels. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/46657.

Effective Communication About Lung Cancer Screening Without Iatrogenic Stigma: A Brief Report Case Study Using the Lung Cancer Stigma Communications Assessment Tool of LungTalk.

Introduction: Stigma thwarts progress in lung cancer risk reduction and control and adversely affects patients across the entire lung cancer care continuum. In developing and disseminating patient and public-facing interventions to increase lung screening, we must be cognizant of how communications have the potential for further stigmatization of at-risk populations. Creation of the Lung Cancer Stigma Communications Assessment Tool (LCS-CAT) version 1 was supported by the American Cancer Society's National Lung Cancer Roundtable to help content developers identify, remove, and replace potentially stigmatizing language and imagery from materials designed to engage individuals across the lung cancer continuum. Methods: The LCS-CAT considers language, imagery, and context and was used to audit a public-facing health communication and decision support tool called LungTalk. Results: The audit performed by two behavioral scientists revealed multiple issues in all three areas, and specific feedback and alternatives were identified. Conclusions: Applying the LCS-CAT to LungTalk was a productive process that helped remove potentially stigmatizing language and imagery from this tool designed to engage individuals in the process of making an informed decision about lung screening. To support destigmatization of lung cancer, communication creators should consider a stigma biopsy on all public-facing campaigns for lung screening to help identify, eliminate, and replace messages that could compromise engagement with the lung cancer screening opportunity.

Lung cancer screening in rural primary care practices in Colorado: time for a more team-based approach?

BACKGROUND: Despite lung cancer being a leading cause of death in the United States and lung cancer screening (LCS) being a recommended service, many patients eligible for screening do not receive it. Research is needed to understand the challenges with implementing LCS in different settings. This study investigated multiple practice members and patient perspectives impacting rural primary care practices related to LCS uptake by eligible patients. METHODS: This qualitative study involved primary care practice members in multiple roles (clinicians n = 9, clinical staff n = 12 and administrators n = 5) and their patients (n = 19) from 9 practices including federally qualified and rural health centers (n = 3), health system owned (n = 4) and private practices (n = 2). Interviews were conducted regarding the importance of and ability to complete the steps that may result in a patient receiving LCS. Data were analyzed using a thematic analysis with immersion crystallization then organized using the RE-AIM implementation science framework to illuminate and organize implementation issues. RESULTS: Although all groups endorsed the importance of LCS, all also struggled with implementation challenges. Since assessing smoking history is part of the process to identify eligibility for LCS, we asked about these processes. We found that smoking assessment and assistance (including referral to services) were routine in the practices, but other steps in the LCS portion of determining eligibility and offering LCS were not. Lack of knowledge about screening and coverage, patient stigma, and resistance and practical considerations such as distance to LCS testing facilities complicated completion of LCS compared to screening for other types of cancer. CONCLUSIONS: Limited uptake of LCS results from a range of multiple interacting factors that cumulatively affect consistency and quality of implementation at the practice level. Future research should consider team-based approaches to conduct of LCS eligibility and shared decision making.

Communication with physicians and family about breast Cancer recurrence.

Objective: Adequate physician-patient communication about cancer recurrence is vital to quality of life and to informed decision-making related to survivorship care. The current study was guided by a cognitive-affective framework to examine communication with family and physicians about breast cancer recurrence risk. Methods: A survey of recently-diagnosed, early-stage breast cancer patients in Appalachia investigated physician-patient and familial communication about breast cancer recurrence risk. Results: Over 30% of participants reported not talking to family or physicians about breast cancer recurrence risk. Younger patients reported more conversations, and speaking with physicians was associated with greater perception risk factors associated with recurrence risk. Greater worry about recurrence was associated with more communication with family and plans to talk to family, physicians, and friends about recurrence risk in the future. Conclusion: Additional supports for patients and physicians are needed to improve understanding of breast cancer recurrence risk and risk factors for recurrence. Innovation: Family communication about breast cancer recurrence risk is understudied. The combination of physician and family communication adds novelty to our analysis.

Lung cancer survivors' views on telerehabilitation following curative intent therapy: a formative qualitative study.

OBJECTIVES: To inform personalised home-based rehabilitation interventions, we sought to gain in-depth understanding of lung cancer survivors' (1) attitudes and perceived self-efficacy towards telemedicine; (2) knowledge of the benefits of rehabilitation and exercise training; (3) perceived facilitators and preferences for telerehabilitation; and (4) health goals following curative intent therapy. DESIGN: We conducted semi-structured interviews guided by Bandura's Social Cognitive Theory and used directed content analysis to identify salient themes. SETTING: One USA Veterans Affairs Medical Center. PARTICIPANTS: We enrolled 20 stage I-IIIA lung cancer survivors who completed curative intent therapy in the prior 1-6 months. Eighty-five percent of participants had prior experience with telemedicine, but none with telerehabilitation or rehabilitation for lung cancer. RESULTS: Participants viewed telemedicine as convenient, however impersonal and technologically challenging, with most reporting low self-efficacy in their ability to use technology. Most reported little to no knowledge of the potential benefits of specific exercise training regimens, including those directed towards reducing dyspnoea, fatigue or falls. If they were to design their own telerehabilitation programme, participants had a predominant preference for live and one-on-one interaction with a therapist, to enhance therapeutic relationship and ensure correct learning of the training techniques. Most participants had trouble stating their explicit health goals, with many having questions or concerns about their lung cancer status. Some wanted better control of symptoms and functional challenges or engage in healthful behaviours. CONCLUSIONS: Features of telerehabilitation interventions for lung cancer survivors following curative intent therapy may need to include strategies to improve self-efficacy and skills with telemedicine. Education to improve knowledge of the benefits of rehabilitation and exercise training, with alignment to patient-formulated goals, may increase uptake. Exercise training with live and one-on-one therapist interaction may enhance learning, adherence, and completion. Future work should determine how to incorporate these features into telerehabilitation.