Cardio-oncology disparities: Interplay of psychosocial stress, inflammation, and cardiometabolic health among Black breast cancer survivors.

Black breast cancer (BC) survivors have a lower survival rate at every stage of the disease, largely due to a higher BC mortality rate of 41 %, more aggressive forms of BC, cardiovascular comorbidities, and stress related to structural inequities. An underexplored factor is Black women's increased risk for cardiometabolic syndrome (CM), exacerbating cardio-oncology disparities. Many factors associated with increased risk for CM are modifiable through lifestyle behavior interventions and generally fail to improve outcomes among Black women. This lack of efficacy is likely due to the interventions' failure to address the cumulative effects of long-term exposure to psychosocial stressors unique to Black women using cultural frameworks. The protocol design of an 8-week pilot study was presented at the inaugural UF Health Cardio-Oncology Symposium, "Emerging Topics in Cardio-Oncology." Twenty-six selfreported Black BC survivors will be randomized using a two-group parallel random assignment experimental design, and study details are reported on ClinicalTrials.gov (#NCT05473026). Our primary aim is to assess the feasibility and acceptability of a culturally relevant gratitude journaling intervention to manage stress and promote goalsetting techniques. The second aim is to test the preliminary efficacy of the intervention on stress, inflammatory biomarkers (TNF-α, IL-6, GDF15, CRP), dispositional gratitude, spiritual well-being, and a culturally relevant framework (Superwoman Schema) to examine stressors unique to Black women. If found to be effective, this clinical trial will provide evidence of a viable non-pharmacological intervention for managing psychosocial stressors, improving CM risk, and reducing cardio-oncology disparities.

Comparison of serum metabolomics in women with breast Cancer Prior to Chemotherapy and at 1 year: cardiometabolic implications.

OBJECTIVE: Early-stage breast cancer (BC) is the second most common malignancy in women, worldwide. Early-detection and treatment advances have led to 5-year survival rates of 90% for early-stage breast cancer. However, the long-term morbidity of breast cancer remains high, with a majority of survivors facing increased risk of cardiometabolic conditions as well as secondary cancers. In particular, African American women with breast cancer experience higher morbidity and mortality than other women. Metabolomics is the comprehensive study of metabolites in biological samples to elucidate the role of monosaccharides, amino acids, and their respective metabolic pathways. Although some studies have found differential metabolites in women with breast cancer compared to normal controls, there has been little study of women with breast cancer across time and the active treatment trajectory. This study examines and compares the serum metabolomic profile of women with BC, prior to initial chemotherapy and at 1 year after inception of chemotherapy. METHODS: This study examined serum metabolites through a secondary analysis of a longitudinal parent study (EPIGEN) of women diagnosed with early-stage BC. Participants were evaluated across 5 time points: prior to their receipt of chemotherapy (T1), at the time of their 4th chemotherapy treatment (T2), 6 months after the initiation of chemotherapy (T3), one year after the initiation of chemotherapy (T4) and two years after the initiation of chemotherapy (T5). This analysis focused on the metabolomic data from 70 participants from T1 to T4. Using ultra high-pressure liquid chromatography high resolution mass spectrometry (UHPLC-HRMS), we performed Friedman Rank Sum Test followed by Nemenyi post-hoc pairwise tests to identify which metabolite levels differed between time points, focusing on metabolites with a Benjamini-Hochberg false discovery rate (FDR) from the overall Friedman test < 0.05 and then specifically examined the p-values from the T1 vs. T4 pairwise comparison. RESULTS: The untargeted serum metabolomics yielded a total of 2,395 metabolites identified on the basis of the accurate mass and MS/MS fragmentation, 1,264 of which were significant after Friedman's test (FDR < 0.05). The analysis then focused on the levels of 124 metabolites from the T1 vs. T4 post-hoc comparison that had a combined FDR < 0.05 and fold change (FC) > 2.0. Metabolite set enrichment analysis (MSEA) as part of Metaboanalyst 3.0 was performed to identify pathways that were significantly altered. The known metabolites identified from the functional analysis were used to evaluate the up and down regulated pathways. The 40metabolites from the Functional Analysis were mainly attributed to amino acids (specifically lysine regulation), fatty acids (particularly unsaturated) and steroid hormone synthesis (lysophosphatidic acid). CONCLUSION: There were multiple significant changes in the serum metabolomic profile of women with breast cancer at one-year post inception of chemotherapy compared to pre-chemotherapy, most notably associated with lysine degradation, branched-chain amino acid synthesis, linoleic acid metabolism, tyrosine metabolism and biosynthesis of unsaturated fatty acids as the top 5 metabolic pathways. Some of these changes could be associated with metabolic perturbations that are consistent with heightened risk of cardiometabolic morbidity. Our results provide new insights into the mechanisms underlying potential heightened cardiovascular health risks in this population.

Factors associated with parental COVID-19 vaccine attitudes and intentions among a national sample of United States adults ages 18-45.

PURPOSE: This study explored factors associated with parents' attitudes and intentions to seek information about the COVID-19 vaccine for their children (ages 0-18) and intentions to vaccinate their age-eligible children. DESIGN AND METHODS: As part of an anonymous online cross-sectional survey, parents' vaccine attitudes, COVID-19 vaccine intentions for their children, health literacy, health numeracy, and sociodemographic variables were assessed. Multivariable ordered logistic regression models identified factors associated with parents' COVID-19 vaccine intentions for their children. RESULTS: Parents/guardians (n = 963) were mostly White (82.3%), insured (88.0%), and college graduates (57.3%). Men reported higher intentions than women to seek information about the COVID-19 vaccine for their children (p = 0.003) and higher intentions to vaccinate their children (p = 0.049). Parental characteristics associated with increased intentions to have their children vaccinated included higher educational attainment (p < 0.001), more positive general vaccine attitudes (p < 0.001), preference for health information in a language other than English (p = 0.006), higher income (p = 0.048), having health insurance (p = 0.05), health literacy (p = 0.024), and health numeracy (p = 0.049). CONCLUSIONS: Multiple sociodemographic characteristics including male gender, higher health literacy and numeracy, and language preference are noteworthy factors associated with parental COVID-19 vaccine intentions that could inform the planning and implementation of educational interventions. PRACTICE IMPLICATIONS: Nurses are important sources of trusted information and play an important role in parent/family health education and in understanding myriad factors that may improve attitudes and enhance readiness toward vaccine uptake. Our findings emphasize the potential value of examining tailored/targeted COVID-19 vaccine education according to key influencing factors.

A multilevel, low literacy dual language intervention to promote colorectal cancer screening in community clinics in Florida: A randomized controlled trial.

One of the largest disparities in cancer mortality in the United States occurs with colorectal cancer (CRC). The objectives of this multilevel two-arm intervention trial were to compare the efficacy of two interventions to promote CRC screening (CRCS) with fecal immunochemical test (FIT) and examine sociodemographic and psychosocial predictors of FIT screening. Individuals ages 50-75 (n = 326) who were not up-to-date with CRCS, could understand English or Spanish, and were at average CRC risk were recruited from two federally qualified health centers (FQHCs) in Florida. Prior to intervention, CRCS rates in the FQHCs were 27.1% and 32.9%, respectively. Study enrollment occurred April 2018-November 2019. System-level intervention components included leveraging electronic medical record (EMR) systems and delivering patient reminders. Participants were randomized to C-CARES (education+FIT) or C-CARES Plus (C-CARES+personalized coaching [for those not completing FIT within 90 days]). Primary outcome was completed FIT returned <1 year. Primary outcome analyses were performed using logistic regression. 225 participants completed FIT (69.0% [95% CI: 64.0-74.0%]), with no significant difference in FIT uptake by intervention arm (67.3% C-CARES Plus vs. 70.8% C-CARES; p = .49). FIT uptake was significantly higher among patients who received intervention materials in Spanish (77.2%) compared to those who received materials in English (63.2%, p < .01). The personalized coaching in the C-CARES Plus arm did not appear to provide added benefit beyond the C-CARES intervention. Multilevel approaches that include EMR prompts, reminders, FIT access, and provision of low-literacy, language-concordant education can support efforts to improved community clinics' CRCS rates. Future efforts should focus on repeat FIT screening. Trial registration: The trial was registered at ClinicalTrials.gov (NCT03906110).

"Be Strong My Sista'": Sentiments of Strength From Black Women With Chronic Pain Living in the Deep South.

The experience of chronic pain is influenced by gender, race, and age but is understudied in older Black women. Society and family alike expect Black older women to display superhuman strength and unwavering resilience. This qualitative study examined the narratives of 9 rural- and urban-dwelling Black older women to identify the ways in which they displayed strength while living with chronic osteoarthritis pain. Their "herstories" parallel the 5 characteristics of the Superwoman Schema/Strong Black Woman. Two additional characterizations emerged: spiritual submission for strength and code switching to suffering Black woman; these may be unique to Black Americans with pain.

Race Moderates the Relationship Between Perceived Social Support and Self-care Confidence in Patients With Heart Failure.

BACKGROUND: African Americans are at the highest risk of developing heart failure (HF) compared with other races and are hospitalized at 7 to 8 times the rate of Whites. Poor overall self-care, low self-care confidence, and lower levels of perceived social support are factors related to increased risk for hospitalizations in HF. Yet, limited evidence is available regarding the factors that may differentially impact self-care confidence by race in patients with HF. OBJECTIVE: The aim of this study was to examine to what extent race moderates the relationship between perceived social support and self-care confidence. METHOD: This is a secondary analysis of cross-sectional data from African American and White patients with HF in North America (n = 429). Patients completed the Multidimensional Scale of Perceived Social Support and the Self-Care Confidence Scale of the Self-Care of Heart Failure Index. A moderation analysis was conducted using hierarchal linear regression. RESULTS: Sample mean age was 60.8 ± 11.5 years, 22.4% were African American, and 54.7% were in New York Heart Association class I or II. Moderation analyses yielded a significant interaction of perceived social support and race, showing White patients, not African Americans, have significantly different self-care confidence scores depending on level of social support: White, b = 0.224, 95% confidence interval [0.046-0.094], t = 5.65, and P < .001; African American, b = -0.776, 95% confidence interval [-0.049 to 0.060], t = 0.212, and P = .832. CONCLUSIONS: Our findings show a variable effect of perceived social support on self-care confidence as a function of race, suggesting the need for further research to develop and test interventions tailored to race and levels of social support in HF.

Equity in Genomics: A Brief Report on Cardiovascular Health Disparities in African American Adults.

BACKGROUND: African Americans are more likely to die from cardiovascular disease (CVD) than all other populations in the United States. Although technological advances have supported rapid growth in applying genetics/genomics to address CVD, most research has been conducted among European Americans. The lack of African American representation in genomic samples has limited progress in equitably applying precision medicine tools, which will widen CVD disparities if not remedied. PURPOSE: This report summarizes the genetic/genomic advances that inform precision health and the implications for cardiovascular disparities in African American adults. We provide nurse scientists recommendations for becoming leaders in developing precision health tools that promote population health equity. CONCLUSIONS: Genomics will continue to drive advances in CVD prevention and management, and equitable progress is imperative. Nursing should leverage the public's trust and its widespread presence in clinical and community settings to prevent the worsening of CVD disparities among African Americans.

Defining the social determinants of health for nursing action to achieve health equity: A consensus paper from the American Academy of Nursing.

BACKGROUND: The 2019-2020 American Academy of Nursing (Academy, 2019) policy priorities document states that "they have a clear and distinct focus on social determinants of health and uses this lens to advance policies and solutions within each of the three overarching priorities" PURPOSE: This consensus paper seeks to establish conceptual clarity and consensus for what social determinants of health mean for nursing, with emphasis on examples of health policies that advance planetary health equity and improve planetary health-related quality of life. METHODS: Volunteers from five Expert Panels of the Academy met via videoconference to determine roles and refine the focus of the paper. After the initial discussion, the first draft of the conceptual framework was written by the first three authors of the paper and, after discussion via videoconference with all the co-authors, successive drafts were developed and circulated for feedback. Consensus was reached when all authors indicated acceptance of what became the final version of the conceptual framework. FINDINGS: A conceptual framework was developed that describes how the social determinants of health can be addressed through nursing roles and actions at the individual, family, and population levels with a particular focus on the role of health policy. The paper provides a specific health policy example for each of the six key areas of the social determinants of health to illustrate how nurses can act to improve population health. DISCUSSION: Nursing actions can support timely health policy changes that focus on upstream factors in the six key areas of the social determinants of health and thus improve population health. The urgent need to eliminate systematic and structural racism must be central to such policy change if equity in planetary health-related quality of life is to be attained.

Improving Multi-site Interaction Through Remote Learning Technology: Report from a Training Program to Increase Underrepresented Undergraduate and Medical Students in Health Disparities Research.

Since 2018, we have evaluated the effectiveness of various teaching technologies for training young investigators on translational research in cancer health disparities. The Southeast Partnership for Improving Research and Training in Cancer Health Disparities (SPIRIT-CHD) unites Moffitt Cancer Center and the Louisiana State University Health Sciences Center. One of the main components of the SPIRIT-CHD is the Cancer Research Education Program (CREP) for training undergraduate and medical students from underrepresented backgrounds. The CREP utilizes a web-based didactic curriculum to engage students at both institutions in biobanking, precision medicine, and cancer health disparities topics. We report experiences from our cross-institutional cancer education program, specifically evaluating the cohorts' satisfaction and learning gains using various communication technologies and instructional approaches. Trainees completed a survey with questions evaluating the curriculum and technology. Trainees reported satisfaction with the flipped classroom model (FCM) content and overall program (mean score = 3.2, SD = 0.79), and would recommend the program to peers. Yet, despite improved program delivery, trainees felt interaction between the two sites (mean score = 1.5, SD = 0.85) and engagement with faculty (mean score = 2.80, SD = 1.14) could be improved. The technology with the highest reported use was e-mail, with a mean score of 4.6 (SD = 0.52). LinkedIn and Twitter had the lowest frequency of use with mean scores at 1.90 (SD = 0.99) and 1.30 (SD = 1.34). Our study highlights the successes and challenges of remote learning using technology to increase interaction and engagement among trainees and faculty in a multi-site cancer research training program.

Cardio-Oncology Health Disparities: Social Determinants of Health and Care for Black Breast Cancer Survivors.

BACKGROUND: Black women experience higher rates of cardiotoxicity and cardiovascular disease (CVD)-related comorbidities than White women. These racial and ethnic disparities are primarily from the earlier onset of CVD risk factors, social determinants of health (SDOH), and cardiotoxicity screening and surveillance disparities. OBJECTIVES: This article discusses the role of SDOH in cardio-oncology and strategies to prevent and detect adverse cardiovascular outcomes among Black breast cancer survivors. METHODS: Preliminary case study findings are presented, including treatment exposures to cardiotoxicity and SDOH in cardio-oncology influencing health outcomes in Black breast cancer survivors. FINDINGS: Nurses can address SDOH and racial disparities in cardio-oncology by being mindful of Black breast cancer survivors' increased burden of CVD risk factors, evaluating barriers to receive preventive care and cardio-oncology rehabilitation, practicing cultural humility, and adhering to evidence-based guidelines for behavioral risk management for Black breast cancer survivors.

Mindfulness-based stress reduction for breast cancer survivors (MBSR(BC)): evaluating mediators of psychological and physical outcomes in a large randomized controlled trial.

MBSR(BC) is known to have a positive impact on psychological and physical symptoms among breast cancer survivors (BCS). The cognitive mechanisms of "how" MBSR(BC) works was addressed in a recent study that found that there was strong consistent evidence that reduced emotional reactivity is a mediator and moderate consistent evidence that mindfulness, rumination, and worry were mediators. The purpose of this study, as part of a larger R01 trial, was to test whether positive effects achieved from the MBSR(BC) program were mediated through changes in increased mindfulness, decreased fear of breast cancer recurrence, and perceived stress. Female BCS > 21 years diagnosed with Stage 0-III breast cancer were randomly assigned to a 6-week MBSR(BC) or a Usual Care (UC)regimen. Potential mediators of 6- and 12-week outcomes were identified by analysis of covariance (ANCOVA), followed by formal mediational analyses of main effects of MBSR(BC) on 6- and 12-week outcomes, including percentage of total effects explained. Among 322 BCS (167 MBSR(BC) and 155 UC), fear of recurrence and perceived stress, but not mindfulness, mediated reductions in anxiety and fatigue at weeks 6 and 12, partially supporting our hypothesis of cognitive mechanisms of MBSR(BC). TRIAL REGISTRATION: Registration Number: NCT01177124 http://www.ClinicalTrials.gov.

Characterizing Health Literacy Among Spanish Language-Preferring Latinos Ages 50-75.

BACKGROUND: Cultural background, language, and literacy are factors that may affect access, healthcare utilization, and cancer screening behaviors. OBJECTIVE: This study aimed to characterize health literacy among Spanish-preferring Hispanic/Latino individuals ages 50-75 and examine associations between sociodemographic characteristics, health beliefs, and health literacy. METHODS: Participants self-identified as Hispanic/Latino, preferring health information in Spanish, were ages 50-75 years old, at average risk for colorectal cancer (CRC), not up to date with CRC screening, and enrolled in a CRC screening education intervention trial. Sociodemographic characteristics, health beliefs, and health literacy (i.e., difficulty understanding written health information and confidence completing health forms) were assessed at baseline. Descriptive and logistic regression analyses were performed. RESULTS: Fifty-three percent of participants reported either sometimes having difficulty or always having difficulty with written health information, and 25% reported always asking for help or being not so confident in completing health forms. Univariate predictors of adequate health literacy for written health information were lower cancer worry and lower religious beliefs. Higher educational attainment predicted confidence in completing health forms. CONCLUSIONS: Findings highlight the need for interventions that address health beliefs and health literacy among Hispanic/Latino patients who have low confidence in completing written forms and difficulty understanding written information and reinforce the use of plain language and salient design features when developing patient education materials.

"A Charge to Keep I Have": Black Pastors' Perceptions of Their Influence on Health Behaviors and Outcomes in Their Churches and Communities.

The Black church has become a necessary refuge and haven for hope in turbulent times in the USA. In recent years, the Black pastors' role has evolved into the position of a leading figure in addressing health disparities in the church and community. Therefore, the purpose of this qualitative study was to gain a more extensive understanding of Black pastors' perceptions of their influence on health behaviors and outcomes in their churches and communities. Due to limited research in this area, a phenomenological qualitative paradigm was used to add to future research. In-depth, semi-structured interviews were conducted with 12 Black pastors. Four themes emerged: Pastoral Self-Reflection of Health; Misperception of Health Awareness from Congregants; Pastoral Leadership that Encourages Health Promotion; and the Importance of Community Resources and Health Programs. Overall, pastors viewed health as a holistic approach and included the importance of spirituality in their perspectives. According to pastors, there are suggestions for more access to resources, community partnerships, and education to address the lack of participation among black congregants.

Exercise Interventions in Cardio-Oncology Populations: A Scoping Review of the Literature.

BACKGROUND: Cardiac toxicity in patients with cancer results from treatment-related damage to the cardiovascular system by chemotherapy, targeted agents, or thoracic radiation. Cardio-oncology patients with co-occurring cancer and cardiovascular disease frequently experience fatigue. Exercise is recommended in clinical guidelines to manage fatigue during or after cancer treatment. PURPOSE: The purpose of this article is to conduct a scoping review of the exercise randomized clinical trials in cardio-oncology patients, focusing on the components and effects of exercise interventions on patient cardiovascular and fatigue outcomes. METHODS: A scoping review methodological framework was deemed appropriate and used. Key words for search included "cancer," "oncology," "cardio-oncology," "heart failure," "physical activity," and "exercise." Search involved systematic searches of large databases (PubMed, MEDLINE, Cochrane Review, and CINAHL) and hand searches of reference lists, key journals, webpages, and experts in the field using snowballing techniques. RESULTS: There were 12 randomized clinical trials included in this review. Study characteristics, accordance of exercise protocols with recommendations, specific exercise training components, and cardiovascular and fatigue outcomes were mapped. CONCLUSIONS: Recommendations for addressing the gaps included focusing on non-breast-cancer patients with cardiac toxicity risks, developing precision-based prescriptions based on various medical and physiological characteristics, and adding fatigue symptom experience as an outcome variable.

A Structural Equation Model of Gratitude, Self-efficacy, and Medication Adherence in Patients With Stage B Heart Failure.

BACKGROUND: Consistent self-care slows the progression of heart failure (HF). Gratitude, the practice of appreciating the positive aspects of life, may influence self-efficacy, which in turn is known to improve self-care. However, little is known about the relationships among gratitude, self-efficacy, and medication adherence in HF. OBJECTIVE: The aim of this study was to test a model to determine if self-efficacy mediates the relationship between gratitude and medication adherence in asymptomatic patients with HF. METHOD: This is a secondary analysis of data from a prospective observational study. Data were analyzed using a structural equation model to examine associations between gratitude, cardiac-specific self-efficacy, and medication adherence in 153 patients with HF. Gratitude, self-efficacy, and medication adherence were assessed using the Gratitude Questionnaire-6, Cardiac Self-efficacy Scale-Maintain Function Subscale, and the Morisky Medication Adherence Scale, respectively. RESULTS: Patient mean (SD) age was 66 (11) years, and 95% of the participants were men. Patients were primarily white (79%), black (12%), or Asian (6%). Gratitude exerted an indirect effect on medication adherence through self-efficacy (b = 0.16; P < .05). Gratitude was positively related to self-efficacy (b = 0.50; P < .05), and self-efficacy was positively related to medication adherence (b = 0.31; P < .05). The model fit was acceptable (comparative fit index = 0.92, Tucker-Lewis index = 0.90, root-mean-square error of approximation = 0.08). CONCLUSION: In this study, we found evidence that self-efficacy was a mechanism through which gratitude was associated with medication adherence in asymptomatic patients with HF, suggesting a way to improve self-care nonpharmacologically. Future work will examine whether gratitude intervention results in improved self-care.

Psychometrics of the Gratitude Questionnaire-6 in African-Americans at Risk for Cardiovascular Disease.

Psychometrics of the Gratitude Questionnaire-6, which measures dispositional gratitude, was originally estimated in healthy college students. The purpose of this study was to examine the scales' factor structure, convergent/divergent validity, and reliability among 298 AA adults at risk for CVD in the community. Analyses were performed using bivariate correlations, exploratory factor analysis, and confirmatory factor analysis. The scale demonstrated acceptable estimates for internal consistency (Cronbach's α = 0.729). Our exploratory factor analysis results yielded a one-factor structure consistent with the original instrument, and the confirmatory factor analysis model was a good fit. Convergent/divergent validity was supported by the association with positive affect (coefficient = 0.482, 95% CI = [0.379, 0.573], spiritual well-being (coefficient = 0.608, 95% CI = [0.519, 0.685], and depressive symptoms (coefficient = -0.378, 95% CI = [-0.475, -0.277]. Findings supported the scale's reliability and convergent/divergent validity among AAs at risk for CVD.

Mindfulness, Anxiety Symptoms, and Quality of Life in Heart Failure.

BACKGROUND: An estimated 6.5 million American adults live with heart failure (HF). Elevated anxiety symptoms may worsen HF symptoms and contribute to decreases in overall quality of life (QOL). Mindfulness has been associated with better psychological health with lower levels of anxiety symptoms. Mindfulness may be a modifiable target for reducing anxiety symptoms and increasing QOL in patients with HF. OBJECTIVE: The objective of this study is to examine the relationships among anxiety symptoms, dispositional mindfulness, and QOL in patients with symptomatic HF. METHODS: In this cross-sectional study, we conducted a secondary analysis of baseline data from 70 participants. We performed descriptive statistics, bivariate Pearson correlations, and multiple linear regression. RESULTS: The sample included 70 individuals with a mean age of 65 ± 10.5 years, 89% male, mean left ejection fraction of 45.7 ± 13.6, mean total QOL of 36.9 ± 21.7, mean total mindfulness of 82.2 ± 12.8, and mean anxiety of 4.8 ± 2.9. In multiple regression analyses, total mindfulness was significantly associated with lower anxiety (ß = -0.491, P < .01), greater observational mindfulness was significantly associated with lower anxiety (ß = -0.377, P < .01), and greater nonreactivity to inner experience was significantly associated with lower anxiety (ß = -0.320, P < .05). Lower anxiety was associated with greater total QOL (ß = 0.488, P < .01), greater physical QOL (ß = 0.381, P < .01), and greater emotional QOL (ß = 0.639, P < .01). CONCLUSIONS: Mindfulness may be a way of improving both anxiety symptoms and QOL in this population.