The impact of nativity on uterine cancer survival in the public hospital system of Queens, New York.

OBJECTIVE: We studied cis-women with uterine cancer presenting to the two Public Hospitals in Queens, New York from 2006 to 2015 to examine the relationship between nativity (birthplace) and survival. METHODS: A retrospective review of tumor registries identified women diagnosed with uterine cancer between January 1, 2006, and December 31, 2015. Data from 259 women were available for this analysis. RESULTS: Most women were born outside the United States (US) (76% versus 24%). The majority of US-born women were black (68%). Seventy-seven women (30%) were born in Latin America, 76 in the Caribbean Islands (29%) and 44 in Asia/South Asia (17%). Most women presented with stage I/II disease (70%) and endometrioid/mucinous histology (68%) with no significant differences observed among nativity groups. Kaplan-Meier estimated survival curves stratified by birthplace demonstrated significant differences in survival distributions among the groups using the log-rank test (P < 0.0001). The most favorable survival curves were observed among all foreign-born women, whereas the least favorable survival was demonstrated in US-born women. Time to death was analyzed using the Cox proportional hazards model. Adjusting for age of diagnosis, insurance status, stage, and treatment modality, Latin American and Asia/South Asia birthplace was significantly associated with increased survival time. CONCLUSION: An immigrant health paradox was defined for foreign-born Latin American and Asian/South Asian women presenting to the two Public Hospitals of Queens, New York, as women born in these geographic regions were less likely to die at any given time compared to those born in the United States.

Phase III Prospectively Randomized Trial of Perioperative 5-FU After Curative Resection for Colon Cancer: An Intergroup Trial of the ECOG-ACRIN Cancer Research Group (E1292).

BACKGROUND: Studies suggest that adjuvant chemotherapy should be initiated at the earliest possible time. The Eastern Cooperative Oncology Group (ECOG) and Intergroup evaluated the effect of perioperative fluorouracil (5-FU) on overall survival (OS) for colon cancer. PATIENTS AND METHODS: This phase III trial randomized patients to receive continuous infusional 5-FU for 7 days starting within 24 h after curative resection (arm A) or no perioperative 5-FU (arm B). Patients with Dukes' B3 and C disease received adjuvant chemotherapy per standard of care. The primary endpoint of the trial was overall survival in patients with Dukes' B3 and C disease. The secondary objective was to determine whether a week of perioperative infusion would affect survival in patients with Dukes' B2 colon cancer with no additional chemotherapy. RESULTS: From August 1993 to May 2000, 859 patients were enrolled and 855 randomized (arm A: 427; arm B: 428). The trial was terminated early due to slow accrual. The median follow-up is 15.4 years (0.03-20.3 years). Among patients with Dukes' B3 and C disease, there was no statistically significant difference in OS [median 10.3 years (95% CI 8.4, 13.2) for perioperative chemotherapy and 9.3 years (95% CI 5.7, 12.3) for no perioperative therapy, one-sided log-rank p = 0.178, HR = 0.88 (95% CI 0.66, 1.16)] or disease-free survival (DFS). For patients with Dukes' B2 disease, there was also no significant difference in OS (median 16.1 versus 12.9 years) or DFS. There was no difference between treatment arms in operative complications. One week of continuous infusion of 5-FU was tolerable; 18% of arm A patients experienced grade 3 or greater toxicity.

Diffuse Large B-Cell Lymphoma of the Left Upper Extremity Mimicking a Sarcoma.

Diffuse large B-cell lymphoma (DLBCL) can arise in both lymph nodes and extranodal sites. DLBCLs rarely present in the soft tissue of the upper extremity. We report a case of a 64-year-old woman who presented with a large left upper arm mass and underwent surgical resection under the presumptive diagnosis of sarcoma but the final pathology showed DLBCL. Sarcomas are common malignant tumors of the soft tissue of the extremities, but lymphomas also occasionally present as a soft tissue mass. It is important to keep lymphomas in mind in order to avoid unnecessary surgical excisions.

Electronic Geriatric Assessment: Is It Feasible in a Multi-Institutional Study That Included a Notable Proportion of Older African American Patients? (Alliance A171603).

PURPOSE: This study determined whether an electronic version of the geriatric assessment is feasible in a multi-institutional, diverse setting. METHODS: Ten sites within the Alliance for Clinical Trials in Oncology participated. Patients who had active cancer or a history of cancer and were 65 years of age or older were eligible. The geriatric assessment was completed with an electronic data capture system that had been loaded onto iPads. Feasibility was defined a priori as completion in at least 70% of patients either with or without help. To enhance racial diversity, the original sample size was later changed and augmented by 50% with the intention of increasing enrollment of older minority patients. RESULTS: A total of one hundred fifty-four patients were registered with a median age of 72 years (range, 65-91 years). Forty-three (28%) identified themselves as African American or Black. One hundred forty-one patients (92%) completed the electronic geriatric assessment. Feasibility was observed across all subgroups, regardless of race, education, performance status, comorbidities, and cognition; 124 patients (81%) completed the geriatric assessment without help. Reasons for not completing the geriatric assessment are as follows: clinic visit did not occur (n = 6), no iPad connection to the Internet (n = 3), patient declined (n = 2), prolonged hospitalization (n = 1), and patient died (n = 1). Reasons for needing help, as reported by study personnel, were as follows: the patient preferred that research personnel ask the questions (n = 9), vision problem (n = 3), lack of comfort with the iPad (n = 2), questions were not clear (n = 1), less proficient in English (n = 1), and challenge in pressing the green button to go to the next question (n = 1). CONCLUSION: The electronic geriatric assessment is feasible in a multi-institutional setting that includes a notable proportion of African American or Black patients.

The Influence of Vitamin D on Mammographic Density: Results from CALGB 70806 (Alliance) a Randomized Clinical Trial.

Current therapies for breast cancer prevention only prevent estrogen receptor positive (ER+) disease and toxicity limits use of these agents. Vitamin D is a potential prevention therapy for both ER+ and ER- disease and is safe with few side effects. This study evaluates the effect of 1-year of vitamin D supplementation on mammographic density (MD), a biomarker of breast cancer risk in a multicenter randomized controlled trial. Premenopausal women with ≥25% MD and no history of cancer were randomly assigned to 2,000 international units (IU) of vitamin D or placebo orally daily for 1 year. Change in percent MD was evaluated using Cumulus software after all participants completed treatment. Three hundred women enrolled between January 2011 and December 2013 with a mean age of 43 and diverse ethnicity [14% Hispanic, 12% African American (AA)]. Supplementation significantly increased vitamin D levels compared with placebo (14.5 ng/mL vs. -1.6 ng/mL; P < 0.0001) with all participants on the vitamin D arm achieving vitamin D sufficiency at 12 months. Vitamin D was safe and well tolerated. After adjustment for baseline MD, the mean between-arm difference (vitamin D vs. placebo) at 1 year was -0.75 (-0.26, 1.76; P = 0.56). A greater effect was seen for women with ≥50% MD and AA women, although neither reached significance. This randomized controlled trial demonstrated significant improvement in vitamin D levels with 2,000 IU for 1 year, with 100% of supplemented women achieving sufficiency. However, a null effect was seen regarding change in MD for premenopausal women (the primary outcome of the study). PREVENTION RELEVANCE: Current therapies for breast cancer prevention only prevent estrogen receptor positive (ER+) disease and are underutilized due to toxicity and side effects. Vitamin D is a potential prevention therapy for both ER+ and ER- disease and is safe with few side effects.

Utilizing Cultural and Ethnic Variables in Screening Models to Identify Individuals at High Risk for Gastric Cancer: A Pilot Study.

Identifying persons at high risk for gastric cancer is needed for targeted interventions for prevention and control in low-incidence regions. Combining ethnic/cultural factors with conventional gastric cancer risk factors may enhance identification of high-risk persons. Data from a prior case-control study (40 gastric cancer cases and 100 controls) were used. A "conventional model" using risk factors included in the Harvard Cancer Risk Index's gastric cancer module was compared with a "parsimonious model" created from the most predictive variables of the conventional model as well as ethnic/cultural and socioeconomic variables. Model probability cutoffs aimed to identify a cohort with at least 10 times the baseline risk using Bayes' Theorem applied to baseline U.S. gastric cancer incidence. The parsimonious model included age, U.S. generation, race, cultural food at ages 15-18 years, excessive salt, education, alcohol, and family history. This 11-item model enriched the baseline risk by 10-fold, at the 0.5 probability level cutoff, with an estimated sensitivity of 72% [95% confidence interval (CI), 64-80], specificity of 94% (95% CI, 90-97), and ability to identify a subcohort with gastric cancer prevalence of 128.5 per 100,000. The conventional model was only able to reach a risk level of 9.8 times baseline with a corresponding sensitivity of 31% (95% CI, 23-39) and specificity of 97% (95% CI, 94-99). Cultural and ethnic data may add important information to models for identifying U.S. individuals at high risk for gastric cancer, who then could be targeted for interventions to prevent and control gastric cancer. The findings of this pilot study remain to be validated in an external dataset.

Measurement invariance of intuitive cancer risk perceptions across diverse populations: The Cognitive Causation and Negative Affect in Risk scales.

Intuitive cancer risk perceptions may inform strategies to motivate cancer prevention behaviors. This study evaluated factor structure and measurement invariance of two new measures of intuitive cancer risk, the Cognitive Causation and Negative Affect in Risk scales. Single- and multiple-group confirmatory factor analysis models were fit to responses from three diverse samples. The confirmatory factor analysis models fit the data well, with all comparative fit indices (CFI) ≥ 0.94. Items flagged by chi-square difference tests as potentially non-invariant were largely invariant between samples according to practical fit indices (e.g. ΔCFI). These novel scales may be particularly relevant in diverse, underserved populations.

Promoting Accrual of Older Patients with Cancer to Clinical Trials: An Alliance for Clinical Trials in Oncology Member Survey (A171602).

BACKGROUND: There are multiple known individual- and practice-level barriers to enrollment of older patients with cancer to clinical trials, but little is known about how the clinical research workforce feels about potential higher-level strategy changes aimed to promote increased enrollment of older patients. SUBJECTS, MATERIALS, AND METHODS: We invited all 11,351 Alliance for Clinical Trials in Oncology ("Alliance") members to participate in an anonymous, web-based survey to examine awareness of current accrual patterns for older patients to clinical trials, to ascertain consensus on how to tackle enrollment challenges, and to provide the impetus for high-level changes to improve clinical trial accrual of older patients with cancer. RESULTS: During the period from February 28, 2017, to June 16, 2017, 1,146 Alliance members participated (response rate = 10%), including a national diverse sample of physicians, nurses, administrative/clinical research staff, and patient advocates with representation from community, academic, and rural sites. Overall, one third felt that >50% of clinical trial enrollees should be age ≥65, and 64.9% felt the Alliance could improve upon enrollment of older patients. The four most commonly ranked strategies to improve enrollment of older patients were creating more dedicated trials for this population (36.3%), minimizing exclusion criteria focused on comorbidity (35.5%), developing independent strategies for those aged ≥65 and for those aged ≥70 (33.2%), and requiring that most/all Alliance trials have a specific expansion cohort of older patients (30.0%). CONCLUSION: We anticipate that the recommendations from >1,000 Alliance members will continue to propel important strategy changes aimed to improve accrual of older patients with cancer to clinical trials. IMPLICATIONS FOR PRACTICE: This survey of the Alliance for Clinical Trials membership sought opinions on potential, large-scale, national strategies to improve accrual of older adults with cancer. Consensus was found around multiple strategies, including creating more dedicated trials for older patients, developing less stringent eligibility criteria, and mandating expansion cohorts of older patients within broader Alliance trials. It is anticipated that the recommendations from >1,000 Alliance members will continue to propel important strategy changes aimed to improve accrual of older patients with cancer to clinical trials.

Examining Intuitive Cancer Risk Perceptions in Haitian-Creole and Spanish-Speaking Populations.

BACKGROUND: There is a developing emphasis on intuition and affect in the illness risk perception process, yet there have been no available strategies to measure these constructs in non-English speakers. This study examined the comprehensibility and acceptability of translations of cancer risk beliefs in Haitian-Creole and Spanish. METHOD: An established, iterative, team-based translation process was employed. Cognitive interviews (n = 20 in Haitian-Creole speakers; n = 23 in Spanish speakers) were conducted in an inner-city primary care clinic by trained interviewers who were native speakers of each language. Use of an established coding scheme for problematic terms and ambiguous concepts resulted in rewording and dropping items. RESULTS: Most items (90% in the Haitian-Creole version; 87% in the Spanish version) were highly comprehensible. DISCUSSION: This work will allow for further research examining health outcomes associated with risk perceptions across diverse, non-English language subgroups, paving the way for targeted risk communication with these populations.

Deliberative and intuitive risk perceptions as predictors of colorectal cancer screening over time.

Cancer risk perceptions may involve intuitions-including both affect as well as gut-level thoughts about risk-and deliberative risk magnitudes. Yet, little research has examined the potentially diverse relations between risk perceptions and behavior across time. A highly diverse primary care sample (N = 544, aged ≥50) was utilized to compare how deliberative and intuitive perceptions of risk relate to chart-confirmed colorectal cancer screening at cross-sectional and prospective time points. At baseline, deliberative and intuitive risk perceptions were negatively associated with chart-confirmed colorectal cancer screening adherence in bivariable but not multivariable analyses. Among those who were non-adherent with colorectal cancer screening at baseline, deliberative and intuitive risk perceptions were positively associated with prospective uptake of chart-confirmed colorectal cancer screening adherence at 12-months in bivariable analyses; only deliberative risk perceptions remained significant in the multivariable model. This study indicates that diverse risk perceptions are differentially important for screening at different time points.

Health literacy, information seeking, and trust in information in Haitians.

OBJECTIVES: To assess heath literacy, health information seeking, and trust in health-related information among Haitian immigrants seen in primary care. METHODS: Health literacy was measured by the Brief Health Literacy Screen (BHLS); items on health information use were from the 2007 Health Information National Trends Survey. RESULTS: BHLS scores differed according to age, education, and survey language. Participants with lower levels of health literacy tended to be more likely to place "a lot" or "some" trust in family and friends and religious organizations and leaders as sources of information about health or medical topics. CONCLUSIONS: Constructing a culturally-tailored and appropriate intervention regarding health promotion requires understanding how the population accesses and conveys health information.

Examining intuitive risk perceptions for cancer in diverse populations.

In this article we examine intuitive dimensions of personal cancer risk likelihood, which theory and empirical evidence indicate may be important elements in the risk perception process. We draw on data from a study of risk perceptions in three social groups, university students, men living in the community, and primary care patients living in urban area. The study took place in 2007-2011, in New York State (Garden City and New York City) and Boston, Massachusetts. This study used items developed from categories identified in prior qualitative research specifying emotions and attitudes activated in cancer risk determination to examine perception of cancer risks. Across three samples - university students (N=568), community men (N=182), and diverse, urban primary care patients (N=127) - we conducted exploratory factor and construct analyses. We found that the most reliable two factors within the five-factor solution were Cognitive Causation, tapping beliefs that risk thoughts may encourage cancer development, and Negative Affect in Risk, assessing negative feelings generated during the risk perception process. For these factors, there were high levels of item endorsement, especially in minority groups, and only modest associations with established cancer risk perception and worry assessments, indicating novel content. These items may prove useful in measuring and comparing intuitive cancer risk perceptions across diverse population subgroups.

Beyond demographics: differences in patient activation across new immigrant, diverse language subgroups.

The federal government promotes "patient-centered medical homes" to plan care with respect to patients' cultures and values and support patients' self-care efforts. To promote self-care, the medical home would be best utilized by activated, engaged patients. The objective of this study was to measure and compare patient activation scores in English-, Spanish-, and Haitian Creole-speaking patients seen at an inner-city hospital ambulatory care practice. Patient activation was measured using the patient activation measure (PAM). Mean PAM scores and activation levels differed according to survey language (p < 0.001). US-born participants had higher mean PAM scores than persons born outside of the US. Participants living in the US longer had higher mean PAM scores than participants newer to the US. Levels of activation and mean PAM scores increased with greater comfort reading, speaking, and thinking in English. The mean PAM (SD) score of 61.5 (16.5) for Haitian Creole-speaking Caribbean Blacks was significantly lower than the mean PAM score of 68.8 (15.6) for English-speaking Caribbean Blacks (p value = 0.006). Although mean PAM scores did not significantly differ between Haitian Creole and Spanish speakers, PAM stages differed according to language of survey completion (p < 0.001), with a greater percentage of Haitian Creole speakers being categorized as stage 1 (least activated) as well as stage 4 (most activated). Spanish and Haitian Creole speakers have lower mean PAM scores than English speakers. Mean PAM scores did not differ between Hispanics and non-Hispanics or according to race, illustrating the need to examine the role of language and culture on patient activation.

Do community-based patient assistance programs affect the treatment and well-being of patients with breast cancer?

PURPOSE: Patients with breast cancer who need adjuvant treatments often fail to receive them. High-quality, community-based patient-assistance programs are an underused, inexpensive resource to help patients with cancer obtain needed therapy. We sought to determine whether connecting women to patient-assistance programs would reduce underuse of adjuvant therapies. METHODS: We conducted a randomized trial of 374 women (190 assigned intervention [INT], 184 to usual care [UC]) with early-stage breast cancer who underwent surgery between October 2006 and August 2009. After initial needs assessment, individualized action plans were created to connect INT patients with targeted patient-assistance programs; UC patients received an informational pamphlet. Main outcome measures were receiving adjuvant treatment and obtaining help. RESULTS: High rates of INT and UC patients received treatment: 87% INT versus 91% UC women who underwent lumpectomy received radiotherapy (P = .39); 93% INT versus 86% UC women with estrogen receptor (ER) -negative tumors ≥ 1 cm received chemotherapy (P = .42); 92% INT versus 93% UC women with ER-positive tumors ≥ 1 cm received hormonal therapy (P = .80). Many women reported needs: 63% had informational; 55%, psychosocial; and 53%, practical needs. High rates of INT patients with needs connected with a program within 2 weeks (92%). At 6 months, INT and UC women used patient-assistance programs at similar rates (75% v 76%; P = .54). Women with informational or psychosocial needs were more likely to receive help (relative risk [RR], 1.77; 95% CI, 1.51 to 1.90 and RR, 1.37; 95% CI, 1.06 to 1.61, respectively). CONCLUSION: INT and UC patients received high rates of adjuvant treatment regardless of trial assignment. Patients with breast cancer who connect to relevant patient assistance programs receive useful informational and psychosocial but not practical help.

Sustaining CBPR partnerships to address health disparities in times of economic instability.

In unstable economic environments, CBPR partnerships in underserved communities may face unanticipated obstacles that threaten success and sustainability. This report describes challenges experienced by HealthLink, a CBPR partnership to address cancer disparities in Queens, N.Y., and how HealthLink adapted. Recommendations for designing CBPR partnerships to overcome unexpected challenges are provided.

Establishing a general medical outpatient clinic for cancer survivors in a public city hospital setting.

INTRODUCTION: Many cancer centers and community hospitals are developing novel models of survivorship care. However, few are specifically focused on services for socio-economically disadvantaged cancer survivors. AIMS: To describe a new model of survivorship care serving culturally diverse, urban adult cancer patients and to present findings from a feasibility evaluation. SETTING: Adult cancer patients treated at a public city hospital cancer center. PROGRAM DESCRIPTION: The clinic provides comprehensive medical and psychosocial services for patients within a public hospital cancer center where they receive their oncology care. PROGRAM EVALUATION: Longitudinal data collected over a 3-year period were used to describe patient demographics, patient needs, and services delivered. Since inception, 410 cancer patients have been served. Demand for services has grown steadily. Hypertension was the most frequent comorbid condition treated. Pain, depression, cardiovascular disease, hyperlipidemia, and bowel dysfunction were the most common post-treatment problems experienced by the patients. Financial counseling was an important patient resource. DISCUSSION: This new clinical service has been well-integrated into its public urban hospital setting and constitutes an innovative model of health-care delivery for socio-economically challenged, culturally diverse adult cancer survivors.