Global cancer stigma research: a U.S. National Cancer Institute workshop report.

Stigma is a social process characterized by negative beliefs, attitudes, and stereotypes associated with a specific attribute or characteristic that leads to discrimination and social exclusion. Stigma manifests across the cancer control continuum and remains a key challenge for cancer prevention and control worldwide. In this commentary, we provide an overview of the U.S. National Cancer Institute's (NCI) Global Cancer Stigma Research Workshop, a multi-disciplinary international conference held virtually in September 2022, which focused on the intersection of cancer and stigma. The meeting was unique in its convening of researchers, advocates, clinicians, and non-governmental and governmental organizations, who-as a collective-provided overarching topics, cross-cutting considerations, and future directions for the cancer stigma research community to consider, which we describe herein. In summary, studying cancer stigma comprehensively requires a holistic, adaptive, and multifaceted approach-and should consider interrelated factors and their intersection within diverse cultural and social contexts worldwide. Collectively, there was a call for: an inclusive approach, encouraging researchers and practitioners to identify and measure cancer stigma as a driver for cancer health inequities globally; an expansion of existing research methodology to include diversity of experiences, contexts, and perspectives; and collaborations among diverse stakeholders to develop more effective strategies for reducing stigma and improving cancer outcomes. Such efforts are essential to cultivating effective and equitable approaches to preventing and treating cancer worldwide.

Disparities in cancer clinical trials information-seeking: Findings from the National Cancer Institute's Cancer Information Service.

OBJECTIVE: To better understand cancer clinical trials (CCT) information-seeking, a necessary precursor to patient and provider engagement with CCT. METHODS: Data from the National Cancer Institute's Cancer Information Service (CIS) were used to examine CCT information-seeking patterns over a 5-year period. Descriptive and logistic regression analyses were conducted to examine characteristics of CIS inquiries and their associations with having a CCT discussion. RESULTS: Between September 2018 - August 2023, 117,016 CIS inquiries originated from cancer survivors, caregivers, health professionals, and the general public; 27.5 % of these inquiries included a CCT discussion (n = 32,160). Among CCT discussions, 35.5 % originated from survivors, 53.5 % from caregivers, 6.1 % from the public, and 4.9 % from health professionals. Inquiries in Spanish had lower odds of a CCT discussion (OR=.26, [.25-.28]), whereas inquiries emanating from the CIS instant messaging (OR=2.29, [2.22-2.37]) and email (OR=1.24, [1.18-1.30]) platforms were associated with higher odds of discussing CCT compared to the telephone. Individuals who were male, younger, insured, and had higher income and education had significantly higher odds of a CCT discussion while those who were non-Hispanic Black and living in rural locales had significantly lower odds. CONCLUSIONS: Disparities in CCT information-seeking may contribute to downstream CCT participation. PRACTICE IMPLICATIONS: Quality, language-concordant health information is needed to enable equitable awareness of - and ultimately engagement in - CCT.

National Cancer Institute-funded grants focused on synchronous telehealth cancer care delivery: a portfolio analysis.

BACKGROUND: Telehealth use increased during the COVID-19 pandemic and remains a complementary source of cancer care delivery. Understanding research funding trends in cancer-related telehealth can highlight developments in this area of science and identify future opportunities. METHODS: Applications funded by the US National Cancer Institute (NCI) between fiscal years 2016 and 2022 and focused on synchronous patient-provider telehealth were analyzed for grant characteristics (eg, funding mechanism), cancer focus (eg, cancer type), and study features (eg, type of telehealth service). Of 106 grants identified initially, 60 were retained for coding after applying exclusion criteria. RESULTS: Almost three-quarters (73%) of telehealth grants were funded during fiscal years 2020-2022. Approximately 67% were funded through R01 or R37 mechanism and implemented as randomized controlled trials (63%). Overall, telehealth grants commonly focused on treatment (30%) and survivorship (43%); breast cancer (12%), hematologic malignancies (10%), and multiple cancer sites (27%); and health disparity populations (ie, minorities, rural residents) (73%). Both audio and video telehealth were common (65%), as well as accompanying mHealth apps (20%). Telehealth services centered on psychosocial care, self-management, and supportive care (88%); interventions were commonly delivered by mental health professionals (30%). CONCLUSION: NCI has observed an increase in funded synchronous patient-provider telehealth grants. Trends indicate an evolution of awards that have expanded across the cancer control continuum, applied rigorous study designs, incorporated additional digital technologies, and focused on populations recognized for disparate cancer outcomes. As telehealth is integrated into routine cancer care delivery, additional research evidence will be needed to inform clinical practice.

Disparities in Telehealth Offer and Use among U.S. Adults: 2022 Health Information National Trends Survey.

Objective: Understanding the sources of telehealth disparities can inform efforts to ensure equity. This study examines disparities in telehealth offer and use to understand the role of health care providers in increasing telehealth access. Methods: This cross-sectional analysis of the 2022 Health Information National Trends Survey (n = 5,295) used survey-weighted proportions to characterize telehealth use and multivariable logistic regressions to test associations of sociodemographic and social determinants with (1) telehealth offer and (2) use among those offered the option. Results: Among U.S. adults, 57% were offered telehealth, 80% of whom used it. Technology difficulties and privacy concerns were barriers for 15%-20% of U.S. adults. Compared to telehealth users, most nonusers preferred in-person care (25% versus 84%). Age, education, geographic location, and broadband internet access were related to telehealth offer, whereas no significant disparities emerged in telehealth use. Conclusions: Telehealth use is widespread, but structural and provider-level engagement are needed to achieve equity.

Perceptions of HPV-Linked Oropharyngeal Cancer Risk Messages Among a Sample of Young Adult Men in the US: A Pilot Study.

Awareness of risk for oropharyngeal cancer from oral human papillomavirus (HPV) infection is low among men in the United States. This pilot study tested messages communicating oral HPV and oropharyngeal cancer risk among a sample of U.S. young adult men (aged 18-26). Six oral HPV and cancer risk messages were tested in an online survey. Participants (N = 68) were randomly assigned to one of two message sets, each containing three unique text-based messages. Participants evaluated messages separately based on various measures (e.g., perceived message effectiveness [PME], novelty). One-way repeated measures ANOVAs were used to assess evaluation differences within message sets. Participants provided open-ended feedback about each message, which were synthesized into overarching themes. Participants were receptive to the risk messages, rating them high on PME (mean range = 3.72-4.25 out of 5) and other measures. Analyses identified three high-performing messages. For example, participants rated a message about HPV-linked oropharyngeal cancer risk rates in men versus women higher on attention and novelty than two other messages in the same set (both ps < .05). Participants were shown three messages (instead of all six) in each message set to minimize survey fatigue. Common themes from open-ended feedback were that participants liked the short-form structure of the messages and that the messages used gender-tailored language. In conclusion, oral HPV and oropharyngeal cancer risk messages may be useful for increasing risk awareness among men in the U.S. Further work should test such messages in rigorous experimental contexts to assess their efficacy in modifying other health outcomes, such as HPV vaccination behaviors.

Contributions to Research and Practice Made by the National Cancer Institute's Health Communication and Informatics Research Branch.

The Health Communication and Informatics Research Branch at the U.S. National Cancer Institute was founded in 1999 in response to increasing evidence demonstrating a link between effective health communication and improved cancer-related outcomes and in recognition of the rapid and dramatic technological changes that were transforming health communication at the turn of the 21st century. For the past 25 years, the Health Communication and Informatics Research Branch has been conducting and supporting research at the forefront of emerging cancer communication trends and technologies, making numerous contributions to health communication science, public health, and cancer control practice. In this essay, we provide a brief history of the branch and the context that led to its establishment, discuss contributions made by the branch to health communication research and practice through key projects and initiatives, and conclude by highlighting health communication and informatics research priorities that offer opportunities for significant impact going forward in light of the challenges posed by the current communication environment.

Analysis of Telehealth Discussion Trends on Reddit (2019-2022).

Introduction: Use of telehealth increased during the COVID-19 pandemic and continues to be a popular health resource. This study analyzed the frequency and sentiment of telehealth discussions on Reddit. Methods: The data set included 13,071 publicly available Reddit submissions containing keywords related to telehealth over a 3-year period. We identified 173 unique subreddit communities, which were coded into mutually exclusive categories: (1) general telehealth, (2) individual care, (3) professional, (4) news, and (5) COVID-19. The Vader lexicon-based machine was used to assign sentiment scores. Results: Most subreddits were coded as individual care (n = 112), professional (n = 26), and news (n = 22). The frequency of submissions increased during the first 2 months of the pandemic and dropped in June 2020, but remained consistent through October 2022. Most Reddit submissions were positive in sentiment (56%). Conclusion: Findings show a mostly positive view of telehealth among Reddit users and an increase in telehealth-related discussions since the COVID-19 pandemic.

Rationale, Procedures, and Response Rates for a Pilot Study to Sample Cancer Survivors for NCI's Health Information National Trends Survey: HINTS-SEER 2021.

The National Cancer Institute's (NCI) Health Information National Trends Survey (HINTS) is a nationally representative survey of U.S. adults in which 12-17% of respondents report a cancer history. To increase representation from adult cancer survivors, in 2021, NCI sampled survivors from three Surveillance, Epidemiology, and End Results (SEER) program cancer registries: Iowa, New Mexico, and the Greater Bay Area. Sampling frames were stratified by time since diagnosis and race/ethnicity, with nonmalignant tumors and non-melanoma skin cancers excluded. Participants completed a self-administered postal questionnaire. The overall response rate for HINTS-SEER (N = 1,234) was 12.6%; a non-response bias analysis indicated few demographic differences between respondents and the pool of sampled patients in each registry. Most of the sample was 10+ years since diagnosis (n = 722; 60.2%); 392 respondents were 5 to < 10 years since diagnosis (29.6%); and 120 were < 5 years since diagnosis (10.2%). Common cancers included male reproductive (n = 304; 24.6%), female breast (n = 284; 23.0%), melanoma (n = 119; 9.6%), and gastrointestinal (n = 106; 8.6%). Tumors were mostly localized (67.8%; n = 833), with 22.4% (n = 282) regional, 6.2% (n = 72) distant, and 3.7% (n = 47) unknown. HINTS-SEER data are available by request and may be used for secondary analyses to examine a range of social, behavioral, and healthcare outcomes among cancer survivors.

Community Outreach and Engagement at U.S. Cancer Centers: Notes from the Third Cancer Center Community Impact Forum.

Community outreach and engagement (COE) is a fundamental activity of cancer centers as they aim to reduce cancer disparities in their geographic catchment areas. As part of COE, NCI-Designated Cancer Centers must monitor the burden of cancer in their catchment area, implement and evaluate evidence-based strategies, stimulate catchment area relevant research, support clinical trial enrollment, and participate in policy and advocacy initiatives, in addition to other responsibilities. The Cancer Center Community Impact Forum (CCCIF) is a national annual meeting of COE professionals who work at or with cancer centers across the country. CCCIF grew out of earlier discussions at American Society of Preventive Oncology (ASPO) annual meetings, where COE was often discussed, but not exclusively. The third annual CCCIF meeting-hosted by the Sidney Kimmel Cancer Center at Thomas Jefferson University-was held in June 2022 in Philadelphia, PA, where more than 200 participants listened to dynamic presentations across 12 COE-related panel sessions. CCCIF leadership and ASPO AD/PL Workshop Planners worked together on the agenda. The 12 sessions used a COE lens to focus on: Diversity, Equity, and Inclusion; Policy; State Cancer Coalitions; Evaluation and Metrics; Implementation Science; In-reach; Outreach; Training and Education; Funding, Personnel and Resources; Clinical Trials; Innovative Methods; and Lessons from the COVID-19 pandemic. This article is a summary of main points and key lessons from each session, as well as a summary of overarching themes that were evident across the sessions.

Understanding Cannabis-Related Information Needs: An Analysis of Inquiries to the National Cancer Institute's Cancer Information Service.

Purpose: Given increased cannabis use for medical and nonmedical purposes alike, there is growing public interest related to the potential risks and benefits of cannabis use, particularly related to cancer. The purpose of this descriptive study was to analyze cannabis inquiries to the National Cancer Institute's Cancer Information Service (CIS). Materials and Methods: From September 2018 to June 2023, 190,070 noncannabis and 425 cannabis inquiries were documented by the CIS. Cannabis inquiries were delineated into two categories: nonmedical cannabis (NMC, n=240) or medical cannabis (MC, n=185). Chi-square tests were performed to determine differences between noncannabis and cannabis inquiries and descriptive analyses were used to identify patterns within cannabis-specific inquiries. Results: Statistically significant differences between noncannabis and cannabis inquiries were observed. In addition, there were variations in MC and NMC inquiries. For example, 73% of MC inquiries originated from cancer survivors and caregivers, whereas almost half of NMC inquiries (48%) were from individuals identifying as tobacco users. MC and NMC inquiries also differed by CIS access channel (e.g., instant chat, telephone), language used (English vs. Spanish), discussions of cancer continuum phases and cancer sites, and referrals provided to individuals for additional information and resources. Conclusion: Cannabis-related information needs of the public-as documented by the CIS-varied by several factors. Health information sources such as the CIS can help address cannabis-related questions and concerns, while noting differences in who is inquiring, how, and why.

Health Information in 2023 (and Beyond): Confronting Emergent Realities With Health Communication Science.

This Viewpoint describes how health communication science can be used to improve response to health challenges by providing credible health information to the public.

Accelerating Colorectal Cancer Screening and Follow-up through Implementation Science (ACCSIS) in Appalachia: protocol for a group randomized, delayed intervention trial.

Appalachian regions of Kentucky and Ohio are hotspots for colorectal cancer (CRC) mortality in the USA. Screening reduces CRC incidence and mortality; however, screening uptake is needed, especially in these underserved geographic areas. Implementation science offers strategies to address this challenge. The aim of the current study was to conduct multi-site, transdisciplinary research to evaluate and improve CRC screening processes using implementation science strategies. The study consists of two phases (Planning and Implementation). In the Planning Phase, a multilevel assessment of 12 health centers (HC) (one HC from each of the 12 Appalachian counties) was conducted by interviewing key informants, creating community profiles, identifying HC and community champions, and performing HC data inventories. Two designated pilot HCs chose CRC evidence-based interventions to adapt and implement at each level (i.e., patient, provider, HC, and community) with evaluation relative to two matched control HCs. During the Implementation Phase, study staff will repeat the rollout process in HC and community settings in a randomized, staggered fashion in the remaining eight counties/HCs. Evaluation will include analyses of electronic health record data and provider and county surveys. Rural HCs have been reluctant to participate in research because of concerns about capacity; however, this project should demonstrate that research does not need to be burdensome and can adapt to local needs and HC abilities. If effective, this approach could be disseminated to HC and community partners throughout Appalachia to encourage the uptake of effective interventions to reduce the burden of CRC.

We conducted a multi-site study to evaluate and improve CRC screening processes using implementation science strategies at multiple levels including the patient, provider, health center, and community. Our goals were to increase rates of guideline-recommended CRC screening, follow-up, and referral-to-care in an Appalachian, medically underserved population.

"It's just not easy to understand": A mixed methods study of health insurance literacy and insurance plan decision-making in cancer survivors.

BACKGROUND: Understanding cancer survivors' health insurance decision-making is needed to improve insurance choice, potentially resulting in reduced financial hardship. METHODS: This explanatory mixed methods study assessed health insurance decision-making in cancer survivors. Health Insurance Literacy Measure (HILM) captured HIL. Quantitative eye-tracking data collected from two simulated health insurance plan choice sets gauged dwell time (seconds), or interest, in benefits. Dwell time differences by HIL were estimated using adjusted linear models. Qualitative interviews explored survivors' insurance decision-making choices. RESULTS: Cancer survivors (N = 80; 38% breast cancer) had a median age of 43 at diagnosis (IQR 34-52). When comparing traditional and high-deductible health plans, survivors were most interested in drug costs (median dwell time 58 s, IQR 34-109). When comparing health maintenance organization and preferred provider organization plans, survivors were most interested in test/imaging costs (40s, IQR 14-67). Survivors with low versus high HIL had more interest in deductible (ß = 19 s, 95% CI 2-38) and hospitalization costs (ß = 14 s, 95% CI 1-27) in adjusted models. Survivors with low versus high HIL more often ranked out-of-pocket (OOP) maximums and coinsurance as the most important and confusing benefits, respectively. Interviews (n = 20) revealed survivors felt alone "to do their own research" about insurance choices. OOP maximums were cited as the deciding factor since it is "how much money is going to be taken out of my pocket." Coinsurance was considered "rather than a benefit, it's a hindrance." CONCLUSION: Interventions to aid in health insurance understanding and choice are needed to optimize plan choice and potentially reduce cancer-related financial hardship.

Influence of depression on breast cancer treatment and survival: A Kentucky population-based study.

BACKGROUND: Depression is common among breast cancer patients and can affect concordance with guideline-recommended treatment plans. Yet, the impact of depression on cancer treatment and survival is understudied, particularly in relation to the timing of the depression diagnosis. METHODS: The Kentucky Cancer Registry data was used to identify female patients diagnosed with primary invasive breast cancer who were 20 years of age or older in 2007-2011. Patients were classified as having no depression, depression pre-cancer diagnosis only, depression post- cancer diagnosis only, or persistent depression. The impact of depression on receiving guideline-recommended treatment and survival was examined using multivariable logistic regression and Cox regression, respectively. RESULTS: Of 6054 eligible patients, 4.1%, 3.7%, and 6.2% patients had persistent depression, depression pre-diagnosis only, and depression post-diagnosis only, respectively. A total of 1770 (29.2%) patients did not receive guideline-recommended cancer treatment. Compared to patients with no depression, the odds of receiving guideline-recommended treatment were decreased in patients with depression pre-diagnosis only (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.54-1.04) but not in patients with post-diagnosis only or persistent depression. Depression post-diagnosis only (hazard ratio, 1.51; 95% CI, 1.24-1.83) and depression pre-diagnosis only (hazard ratio, 1.26; 95% CI, 0.99-1.59) were associated with worse survival. No significant difference in survival was found between patients with persistent depression and patients with no depression (p > .05). CONCLUSIONS: Neglecting depression management after a breast cancer diagnosis may result in poorer cancer treatment concordance and worse survival. Early detection and consistent management of depression is critical in improving patient survival.

Understanding Associations of Personal Values With Support for Tobacco and Alcohol Control Policies.

INTRODUCTION: This cross-sectional analysis of the 2020 Health Information National Trends Survey (N=3,604) examines the associations of personal values with tobacco and alcohol control policy support, which may inform policy-related communication efforts. METHODS: Respondents selected which of 7 value options they considered most important in their daily life and rated their support for 8 proposed tobacco and alcohol control policies (1=strongly oppose, 5=strongly support). Weighted proportions for each value were described across sociodemographic characteristics, smoking status, and alcohol use. Weighted bivariate and multivariable regressions tested the associations of values with mean policy support (alpha=0.89). Analyses occurred from 2021 to 2022. RESULTS: The most frequently selected values were assuring my family is safe and secure (30.2%), being happy (21.1%), and making my own decisions (13.6%). Selected values varied across sociodemographic and behavioral characteristics. For example, people with lower education and incomes were overrepresented among those selecting making my own decisions and keeping myself in good health. After adjusting for sociodemographics, smoking, and alcohol use, people selecting family safety (ß=0.20, 95% CI=0.06, 0.33) or religious connection (ß=0.34, 95% CI=0.14, 0.54) as most important reported higher policy support than those selecting making their own decisions, the value associated with the lowest mean policy support. Mean policy support did not significantly differ across any other value comparisons. CONCLUSIONS: Personal values are associated with support for alcohol and tobacco control policies, with making my own decisions associated with the lowest policy support. Future research and communication efforts may consider aligning tobacco and alcohol control policies with the idea of supporting autonomy.

Advancing rapid cycle research in cancer care delivery: a National Cancer Institute workshop report.

Generating actionable research findings quickly and efficiently is critical for improving the delivery of cancer-related care and outcomes. To address this issue, the National Cancer Institute convened subject matter experts, researchers, clinicians, and patients for a 2-day virtual meeting in February 2022. The purpose of this meeting was to identify how rapid cycle interventional research methods can be used to generate findings useful in improving routine clinical practice. The meeting yielded an initial conceptualization of rapid cycle interventional research as being comprised of 6 key elements: use of iterative study designs; reliance on proximal primary outcomes; early and continued engagement with community and clinical partners; use of existing data sources to measure primary outcomes; facilitative features of the study setting and context; and consideration of appropriate rigor relative to intended use of findings. The meeting also identified the types of study designs that can be leveraged to conduct rapid cycle interventional research and provided examples of these; considered this approach from the perspective of key partners; described the clinical and data infrastructure, research resources, and key collaborations needed to support this work; identified research topics best addressed using this approach; and considered needed methodological advances. The National Cancer Institute is committed to exploring opportunities to encourage further development and application of this research approach as a means for better promoting improvements in the delivery of cancer-related care.

Using Behavioral Science to Address COVID-19 Vaccine Hesitancy Among Cancer Survivors: Communication Strategies and Research Opportunities.

Due to cancer survivors' increased vulnerability to complications from COVID-19, addressing vaccine hesitancy and improving vaccine uptake among this population is a public health priority. However, several factors may complicate efforts to increase vaccine confidence in this population, including the underrepresentation of cancer patients in COVID-19 vaccine trials and distinct recommendations for vaccine administration and timing for certain subgroups of survivors. Evidence suggests vaccine communication efforts targeting survivors could benefit from strategies that consider factors such as social norms, risk perceptions, and trust. However, additional behavioral research is needed to help the clinical and public health community better understand, and more effectively respond to, drivers of vaccine hesitancy among survivors and ensure optimal protection against COVID-19 for this at-risk population. Knowledge generated by this research could also have an impact beyond the current COVID-19 pandemic by informing future vaccination efforts and communication with cancer survivors more broadly.