Improving Physician Recommendations for Human Papillomavirus Vaccination: The Role of Professional Organizations.

BACKGROUND: To address low human papillomavirus (HPV) vaccination coverage, the American Academy of Family Physicians (AAFP) and the American Academy of Pediatrics (AAP) have launched national campaigns encouraging physicians to deliver strong HPV vaccine recommendations. We surveyed family physicians and pediatricians to examine the impact of these efforts on physicians' recommendation practices. METHODS: A national sample of family physicians and pediatricians (n = 776) completed our online survey in 2014. The survey assessed reach, content, and influence of AAFP and AAP communications about HPV vaccination. The survey also assessed quality of physicians' communication practices for recommending HPV vaccination. RESULTS: Forty-seven percent of family physicians reported receiving information on HPV vaccination from AAFP, whereas 62% of pediatricians reported receiving information from AAP. Among physicians reached by AAFP or AAP, most reported receiving the message to give strong recommendations to adolescent boys (71%) and girls (78%). Although receiving information was not associated with HPV vaccine recommendation quality, receiving the message to give strong recommendations correlated with delivering higher-quality recommendations for boys (odds ratio, 4.19, 95% confidence interval, 2.64-6.64) and girls (odds ratio, 3.15, 95% confidence interval, 1.91-5.18). Over half of physicians reported improving their HPV vaccine communication after receiving information from AAFP (69%) or AAP (53%). CONCLUSIONS: Our findings suggest that it is important for AAFP and AAP to communicate the need for strong HPV vaccine recommendations. Given that many physicians reported improving their recommendation practices, professional organizations stand to contribute to increasing HPV vaccination coverage, but they will likely need to increase the intensity of quality improvement efforts to do so.

The effect of a decision aid intervention on decision making about coronary heart disease risk reduction: secondary analyses of a randomized trial.

BACKGROUND: Decision aids offer promise as a practical solution to improve patient decision making about coronary heart disease (CHD) prevention medications and help patients choose medications to which they are likely to adhere. However, little data is available on decision aids designed to promote adherence. METHODS: In this paper, we report on secondary analyses of a randomized trial of a CHD adherence intervention (second generation decision aid plus tailored messages) versus usual care in an effort to understand how the decision aid facilitates adherence. We focus on data collected from the primary study visit, when intervention participants presented 45 minutes early to a previously scheduled provider visit; viewed the decision aid, indicating their intent for CHD risk reduction after each decision aid component (individualized risk assessment and education, values clarification, and coaching); and filled out a post-decision aid survey assessing their knowledge, perceived risk, decisional conflict, and intent for CHD risk reduction. Control participants did not present early and received usual care from their provider. Following the provider visit, participants in both groups completed post-visit surveys assessing the number and quality of CHD discussions with their provider, their intent for CHD risk reduction, and their feelings about the decision aid. RESULTS: We enrolled 160 patients into our study (81 intervention, 79 control). Within the decision aid group, the decision aid significantly increased knowledge of effective CHD prevention strategies (+21 percentage points; adjusted p<.0001) and the accuracy of perceived CHD risk (+33 percentage points; adjusted p<.0001), and significantly decreased decisional conflict (-0.63; adjusted p<.0001). Comparing between study groups, the decision aid also significantly increased CHD prevention discussions with providers (+31 percentage points; adjusted p<.0001) and improved perceptions of some features of patient-provider interactions. Further, it increased participants' intentions for any effective CHD risk reducing strategies (+21 percentage points; 95% CI 5 to 37 percentage points), with a majority of the effect from the educational component of the decision aid. Ninety-nine percent of participants found the decision aid easy to understand and 93% felt it easy to use. CONCLUSIONS: Decision aids can play an important role in improving decisions about CHD prevention and increasing patient-provider discussions and intent to reduce CHD risk.

Women's intentions to receive cervical cancer screening with primary human papillomavirus testing.

We explored the potential impact of human papillomavirus (HPV) testing on women's intentions to be screened for cervical cancer in a cohort of Canadian women. Participants aged 25-65 years from an ongoing trial were sent a questionnaire to assess women's intentions to be screened for cervical cancer with HPV testing instead of Pap smears and to be screened every 4 years or after 25 years of age. We created scales for attitudes about HPV testing, perceived behavioral control, and direct and indirect subjective norms. Demographic data and scales that were significantly different (p < 0.1) between women who intended to be screened with HPV and those who did not intend were included in a stepwise logistic regression model. Of the 2,016 invitations emailed, 1,538 were received, and 981 completed surveys for a response rate of 63% (981/1,538). Eighty-four percent of women (826/981) responded that they intended to attend for HPV-based cervical cancer screening, which decreased to 54.2% when the screening interval was extended, and decreased further to 51.4% when screening start was delayed to age of 25. Predictors of intentions to undergo screening were attitudes (odds ratio [OR]: 1.22; 95% confidence interval [CI]: 1.15, 1.30), indirect subjective norms (OR: 1.02; 95% CI: 1.01, 1.03) and perceived behavioral control (OR: 1.16; 95% CI: 1.10; 1.22). Intentions to be screened for cervical cancer with HPV testing decreased substantially when the screening interval was extended and screening started at age of 25. Use of primary HPV testing may optimize the screening paradigm, but programs should ensure robust planning and education to mitigate any negative impact on screening attendance rates.

The US President's Cancer Panel: A Model For Gathering Country-Level Input to Inform Cancer Control Policy and Program Initiatives.

PURPOSE: The President's Cancer Panel (Panel) is a federal advisory committee charged with monitoring the US National Cancer Program and reporting directly to the US President. Since its creation a half century ago, the Panel has gathered input from individuals and organizations across the US cancer community and beyond and recommended actions to accelerate progress against cancer. The Panel is unique in its structure and function, and merits examination for its potential applicability in other settings worldwide. METHODS: We present an overview of the general President's Cancer Panel model and describe the noteworthy and unique characteristics of the Panel that help achieve its charge. We also detail the specific processes, outputs, and achievements of the Panel appointed by President Barack Obama, which served between 2012 and 2018. RESULTS: From 2012 to 2018, the Panel focused on three topics that addressed timely issues in cancer prevention and control: (1) HPV vaccination for cancer prevention, (2) connected health and cancer, and (3) value and affordability of cancer drug treatment. The Panel held 11 meetings with 165 participants who provided diverse perspectives on these issues. Four reports were delivered to the president, which were cited about 270 times in the literature. Over 20 collaborator activities, including commitments of funding, can be linked to the recommendations published in these reports. CONCLUSION: The US President's Cancer Panel highlights the importance of independent advisory bodies within a national cancer control program and of national leadership support for the cancer community. The structure and function of the Panel could be applicable in other settings worldwide.

Effectiveness of a patient and practice-level colorectal cancer screening intervention in health plan members: the CHOICE trial.

BACKGROUND: Colorectal cancer (CRC) screening reduces CRC incidence and mortality but is underused. Effective interventions to increase screening that can be implemented broadly are needed. METHODS: A controlled trial was conducted to evaluate a patient-level and practice-level intervention to increase the use of recommended CRC screening tests among health plan members. The patient-level intervention was a patient decision aid and included stage-targeted brochures that were mailed to health plan members. Intervention practices received academic detailing to prepare practices to facilitate CRC testing once patients were activated by the decision aid. We used patient surveys and claims data to assess CRC test completion. RESULTS: Among 443 active participants, 75.8% were ages 52 to 59 years, 80.9% were white, 62.1% were women, and 46.4% had college degrees or greater education. Among 380 active participants with known screening status at 12 months based on survey results, 39% in the intervention group reported receiving CRC screening compared with 32.2% in the usual care group (unadjusted odds ratio [OR], 1.34; 95% confidence interval; [CI], 0.88-2.05; P = .17). After adjusting for baseline differences and accounting for clustering, the effect was somewhat larger (OR, 1.64; 95% CI, 0.98-2.73; P = .06). Claims analysis produced similar effects for active participants. The intervention was more effective in those who had incomes >$50,000 (OR, 2.16; 95% CI, 1.07-4.35) than in those who had lower incomes (OR, 1.25; 95% CI, 0.53-2.94; P = .03 for interaction). CONCLUSIONS: Interventions combining a patient-directed decision aid and practice-directed academic detailing had a modest but statistically nonsignificant effect on CRC screening rates among active participants.

A randomized trial of an intervention to improve use and adherence to effective coronary heart disease prevention strategies.

BACKGROUND: Efficacious strategies for the primary prevention of coronary heart disease (CHD) are underused, and, when used, have low adherence. Existing efforts to improve use and adherence to these efficacious strategies have been so intensive that they are impractical for clinical practice. METHODS: We conducted a randomized trial of a CHD prevention intervention (including a computerized decision aid and automated tailored adherence messages) at one university general internal medicine practice. After obtaining informed consent and collecting baseline data, we randomized patients (men and women age 40-79 with no prior history of cardiovascular disease) to either the intervention or usual care. We then saw them for two additional study visits over 3 months. For intervention participants, we administered the decision aid at the primary study visit (1 week after baseline visit) and then mailed 3 tailored adherence reminders at 2, 4, and 6 weeks. We assessed our outcomes (including the predicted likelihood of angina, myocardial infarction, and CHD death over 10 years (CHD risk) and self-reported adherence) between groups at 3 month follow-up. Data collection occurred from June 2007 through December 2009. All study procedures were IRB approved. RESULTS: We randomized 160 eligible patients (81 intervention; 79 control) and followed 96% to study conclusion. Mean predicted CHD risk at baseline was 11.3%. The intervention increased self-reported adherence to chosen risk reducing strategies by 25 percentage points (95% CI 8% to 42%), with the biggest effect for aspirin. It also changed predicted CHD risk by -1.1% (95% CI -0.16% to -2%), with a larger effect in a pre-specified subgroup of high risk patients. CONCLUSION: A computerized intervention that involves patients in CHD decision making and supports adherence to effective prevention strategies can improve adherence and reduce predicted CHD risk.

A tribute to Robert Croyle, PhD, Director, Division of Cancer Control and Population Sciences.

At the beginning of Dr. Robert Croyle's 18th and final year as director of the National Cancer Institute's (NCI) Division of Cancer Control and Population Sciences (DCCPS), before his retirement in December 2021, it is fitting to review some of his and the division's many accomplishments and pay tribute to him as one of the government's most effective leaders. The focus of this article is on Dr. Croyle's contributions in the behavioral and related domains and his and the division's impact on the landscape of cancer control and population sciences. Dr. Croyle joined DCCPS in 1998 as associate director for behavioral research. He became acting director of DCCPS in 2001 and then director in 2003. DCCPS is a formidable NCI division, with broad mandates and responsibilities and many partners from multiple sectors. The division conducts and supports an integrated program of the highest-quality genetic, epidemiological, behavioral, social, applied, survivorship, surveillance, and health care delivery cancer research. The division's notable successes in implementation science and the dissemination of evidence-based findings and products, use of cancer research consortia, and partnerships across National Institutes of Health and with external federal and nongovernmental organizations are among many that reflect Dr. Croyle's visionary leadership.

When genomic and standard test results diverge: implications for breast cancer patients' preference for chemotherapy.

PURPOSE: We examined how women incorporate potentially differing genomic and standard assessments of breast cancer recurrence risk into chemotherapy decisions. METHODS: 165 women previously treated for early-stage breast cancer indicated their interest in chemotherapy regimens to prevent recurrence of breast cancer in response to six hypothetical vignettes that presented breast cancer recurrence risk estimates from standard criteria and a genomic test, some of which were discordant. RESULTS: Standard and genomic test results each elicited greater interest in chemotherapy when they indicated high rather than low risk for recurrence (89% vs. 26%, and 87% vs. 22%, respectively, Ps < 0.001). Genomic test results had a larger impact on chemotherapy preferences than standard measures to predict recurrence. CONCLUSIONS: Some women may be reluctant to forgo chemotherapy when genomic tests indicate low recurrence risk but standard criteria suggest high risk. Additional research including replication of the findings of this small, vignette-based study is needed.

Health literacy and cancer risk perception: implications for genomic risk communication.

BACKGROUND: As new genomic technology expands the number of medical tests available to physicians and patients, identifying gaps in our understanding of how best to communicate risk is increasingly important. We examined how health literacy informs breast cancer survivors' understanding of and meaning assigned to recurrence risks yielded by genomic tests. METHODS: Study participants were posttreatment female breast cancer survivors (N =163) recruited at a university breast cancer clinic. We assessed their health literacy (using REALM) and their interpretation of hypothetical recurrence risk results from a genomic test, presented in several verbal and numerical formats. Analyses controlled for women's objective recurrence risk, age, income, and race. RESULTS: Women with lower health literacy gave higher mean estimates of recurrence risk for a hypothetical group of women with early-stage breast cancer than did women with higher health literacy (52% v. 30%, P < 0:001). Women with lower health literacy also gave more variable estimates in this and several other tasks. When making chemotherapy decisions using risks presented in verbal formats, decisions by women with lower health literacy were less sensitive to the difference between low and high recurrence risk. Ease of understanding of risk formats differed by health literacy. CONCLUSIONS: Health literacy affected the meanings women assigned to recurrence risk when presented in certain formats. The greater variability in responding by women with lower health literacy supports the hypothesis that they have less precise mental representations of risk, but more research is needed to rule out other possible explanations.

Frustrated and confused: the American public rates its cancer-related information-seeking experiences.

BACKGROUND: Ensuring access to high-quality cancer-related information is important for the success of cancer prevention and control efforts. OBJECTIVE: We conducted a population-based assessment of the barriers faced by people searching for cancer information. DESIGN: Cross-sectional data from the National Cancer Institute's 2003 Health Information National Trends Survey. PARTICIPANTS: A nationally representative sample of individuals in the USA (n = 6,369). MEASUREMENTS: We assessed whether respondents had ever sought cancer-related information and examined ratings of their information-seeking experiences and beliefs regarding causes of cancer and its prevention. Linear and logistic regression models were estimated to determine predictors of negative experiences and associations between experiences and cancer beliefs. RESULTS: Nearly one half (44.9%) of Americans had searched for cancer information. Many reported negative experiences, including the search process requiring a lot of effort (47.7%), expressing frustration (41.3%), and concerns about the quality of the information found (57.7%). Respondents lacking health insurance or a high school education experienced the greatest difficulty. Compared to those reporting the most positive experiences, information seekers reporting more negative experiences were more likely to report that almost everything caused cancer [odds ratio (OR) 2.0, 95% confidence interval (CI) 1.5-2.6], that not much can be done to prevent cancer (OR 2.7, 95% CI 1.9-3.8), and that it is hard to know which cancer prevention recommendations to follow (OR 3.2, 95% CI 2.3-4.5). CONCLUSIONS: While a significant proportion of the American public searches for cancer information, suboptimal experiences are common. Facilitation of information seeking will be critical for promoting informed decision making in cancer prevention and control.

Client-directed interventions to increase community access to breast, cervical, and colorectal cancer screening a systematic review.

Most major medical organizations recommend routine screening for breast, cervical, and colorectal cancers. Screening can lead to early detection of these cancers, resulting in reduced mortality. Yet not all people who should be screened are screened, either regularly or, in some cases, ever. This report presents the results of systematic reviews of effectiveness, applicability, economic efficiency, barriers to implementation, and other harms or benefits of interventions designed to increase screening for breast, cervical, and colorectal cancers by increasing community access to these services. Evidence from these reviews indicates that screening for breast cancer (by mammography) has been increased effectively by reducing structural barriers and by reducing out-of pocket client costs, and that screening for colorectal cancer (by fecal occult blood test) has been increased effectively by reducing structural barriers. Additional research is needed to determine whether screening for cervical cancer (by Pap test) can be increased by reducing structural barriers and by reducing out-of-pocket costs, whether screening for colorectal cancer (fecal occult blood test) can be increased by reducing out-of-pocket costs, and whether these interventions are effective in increasing the use of other colorectal cancer screening procedures (i.e., flexible sigmoidoscopy, colonoscopy, double contrast barium enema). Specific areas for further research are also suggested in this report.

Interventions to increase recommendation and delivery of screening for breast, cervical, and colorectal cancers by healthcare providers systematic reviews of provider assessment and feedback and provider incentives.

Most major medical organizations recommend routine screening for breast, cervical, and colorectal cancers. Screening can lead to early detection of these cancers, resulting in reduced mortality. Yet not all people who should be screened are screened, either regularly or, in some cases, ever. This report presents results of systematic reviews of effectiveness, applicability, economic efficiency, barriers to implementation, and other harms or benefits of two provider-directed intervention approaches to increase screening for breast, cervical, and colorectal cancers. These approaches, provider assessment and feedback, and provider incentives encourage providers to deliver screening services at appropriate intervals. Evidence in these reviews indicates that provider assessment and feedback interventions can effectively increase screening by mammography, Pap test, and fecal occult blood test. Health plans, healthcare systems, and cancer control coalitions should consider such evidence-based findings when implementing interventions to increase screening use. Evidence was insufficient to determine the effectiveness of provider incentives in increasing use of any of these tests. Specific areas for further research are suggested in this report, including the need for additional research to determine whether provider incentives are effective in increasing use of any of these screening tests, and whether assessment and feedback interventions are effective in increasing other tests for colorectal cancer (i.e., flexible sigmoidoscopy, colonoscopy, or double-contrast barium enema).

Client-directed interventions to increase community demand for breast, cervical, and colorectal cancer screening a systematic review.

Most major medical organizations recommend routine screening for breast, cervical, and colorectal cancers. Screening can lead to early detection of these cancers, resulting in reduced mortality. Yet not all people who should be screened are screened, either regularly or, in some cases, ever. This report presents the results of systematic reviews of effectiveness, applicability, economic efficiency, barriers to implementation, and other harms or benefits of interventions designed to increase screening for breast, cervical, and colorectal cancers by increasing community demand for these services. Evidence from these reviews indicates that screening for breast cancer (mammography) and cervical cancer (Pap test) has been effectively increased by use of client reminders, small media, and one-on-one education. Screening for colorectal cancer by fecal occult blood test has been increased effectively by use of client reminders and small media. Additional research is needed to determine whether client incentives, group education, and mass media are effective in increasing use of any of the three screening tests; whether one-on-one education increases screening for colorectal cancer; and whether any demand-enhancing interventions are effective in increasing the use of other colorectal cancer screening procedures (i.e., flexible sigmoidoscopy, colonoscopy, double contrast barium enema). Specific areas for further research are also suggested in this report.

The interaction of post-traumatic growth and post-traumatic stress symptoms in predicting depressive symptoms and quality of life.

OBJECTIVE: We sought to explore whether post-traumatic growth (PTG) (positive change or benefit finding resulting from trauma) moderates relationships between post-traumatic stress symptoms (PTSS) and both depression and quality of life (QOL) among breast cancer survivors. METHODS: We interviewed 161 women previously treated for early stage breast cancer. We assessed PTG using the Post-traumatic Growth Inventory, PTSS using the PTSD Checklist, depressive symptoms using the CES-D and QOL using the FACT-B. RESULTS: Higher PTSS was associated with greater depressive symptoms and lower QOL (p<0.01). The relationship between PTSS and depression was attenuated among women with higher levels of PTG (PTSS x PTG interaction, p<0.05). The same pattern of results was found for QOL (interaction p<0.01). CONCLUSIONS: We report the novel finding that PTG moderated relationships between PTSS and both depression and QOL. We speculate that finding positive meaning in response to a distressing event, such as diagnosis of cancer, may be psychologically protective and could indirectly influence the long-term occurrence of depressive symptoms and impaired QOL.

Research for North Carolina: The University Cancer Research Fund.

In 2008 an estimated 40,000 North Carolinians will be diagnosed with cancer. This disease is the number one cause of death in our state and will claim more than 17,000 lives this year. North Carolina is swimming against a demographic tide of growth and aging that will bring 80,000 new cancer cases by 2050, despite continued improvements in cancer prevention, early detection, and treatment. By establishing the University Cancer Research Fund, North Carolina has taken a bold, nation-leading step forward toward improving the future health and well-being of its citizens. Research that creates new knowledge, turns that knowledge into advances in treatment, screening, and prevention, and then ensures delivery of those advances across the state-that research is the key that unlocks the doors to a new and better future. The Fund will make that research possible. As has often been the case, North Carolina was ahead of the national curve by creating the UCRF in July 2007. In November 2007, Texas passed a $3 billion bond referendum to provide $300 million annually to support cancer research over the next decade. In 2005, California passed a $3 billion bond referendum to support stem cell research. Perhaps noting the downturn in federal funding for biomedical research, other states are watching these states' investments to see if they improve their citizens' health and make researchers nationally competitive. We will rigorously evaluate the UCRF to show the nation that North Carolina has taken a bold and wise step. The North Carolina General Assembly and the people of North Carolina have presented the University of North Carolina at Chapel Hill, the UNC Lineberger Comprehensive Cancer Center, the North Carolina Cancer Hospital, and UNC Health Care with an astounding opportunity and responsibility. We embrace that opportunity and that responsibility and pledge ourselves to our shared vision of a better future for the citizens of North Carolina.

Retention and use of breast cancer recurrence risk information from genomic tests: the role of health literacy.

BACKGROUND: New genomic technology now allows physicians to provide women with individualized and highly accurate breast cancer recurrence risk estimates that are a key factor in adjuvant (after surgery) therapy decisions. Because these genomic tests are so new, little is known about how well patients understand the tests and their results. METHOD: We interviewed 163 stage I or II breast cancer patients at a routine follow-up appointment. We assessed their health literacy (using the Rapid Estimate of Adult Learning in Medicine) as well as their knowledge of and attitudes towards a genomic test that identifies risk of recurrence in hormone receptor-positive, node-negative breast cancer (the OncoType Dx Recurrence Score). RESULTS: Women with lower health literacy recalled less of the information provided about the recurrence risk test than women with higher health literacy. Health literacy was not related to the amount of additional information women desired. Women with higher health literacy preferred to have a more active role in decisions about the test. IMPLICATIONS: Health literacy may affect women's capacity to learn about the new genomic tests as well as their desire for informed participation in their medical care.