Cardiovascular health assessment in routine cancer follow-up in community settings: survivor risk awareness and perspectives.

BACKGROUND: Guidelines recommend cardiovascular risk assessment and counseling for cancer survivors. For effective implementation, it is critical to understand survivor cardiovascular health (CVH) profiles and perspectives in community settings. We aimed to (1) Assess survivor CVH profiles, (2) compare self-reported and EHR-based categorization of CVH factors, and (3) describe perceptions regarding addressing CVH during oncology encounters. METHODS: This cross-sectional analysis utilized data from an ongoing NCI Community Oncology Research Program trial of an EHR heart health tool for cancer survivors (WF-1804CD). Survivors presenting for routine care after potentially curative treatment recruited from 8 oncology practices completed a pre-visit survey, including American Heart Association Simple 7 CVH factors (classified as ideal, intermediate, or poor). Medical record abstraction ascertained CVD risk factors and cancer characteristics. Likert-type questions assessed desired discussion during oncology care. RESULTS: Of 502 enrolled survivors (95.6% female; mean time since diagnosis = 4.2 years), most had breast cancer (79.7%). Many survivors had common cardiovascular comorbidities, including high cholesterol (48.3%), hypertension or high BP (47.8%) obesity (33.1%), and diabetes (20.5%); 30.5% of survivors received high cardiotoxicity potential cancer treatment. Less than half had ideal/non-missing levels for physical activity (48.0%), BMI (18.9%), cholesterol (17.9%), blood pressure (14.1%), healthy diet (11.0%), and glucose/ HbA1c (6.0%). While > 50% of survivors had concordant EHR-self-report categorization for smoking, BMI, and blood pressure; cholesterol, glucose, and A1C were unknown by survivors and/or missing in the EHR for most. Most survivors agreed oncology providers should talk about heart health (78.9%). CONCLUSIONS: Tools to promote CVH discussion can fill gaps in CVH knowledge and are likely to be well-received by survivors in community settings. TRIAL REGISTRATION: NCT03935282, Registered 10/01/2020.

Patterns of neurological adverse events among a retrospective cohort of patients receiving immune checkpoint inhibitors.

Aim: Neurological adverse events (NAEs) are infrequent immune checkpoint inhibitor (ICI) outcomes poorly characterized in extant research, complicating their clinical management. Methods: This study characterized the frequency, severity, patterning and timing of NAEs using a large retrospective registry, including all patients who received at least one dose of an ICI from 2/1/2011-4/7/2022 within our health network. Results: Among 3137 patients, there were 54 NAEs (1.72% any grade; 0.8% grade 3-4). Most NAEs were peripheral (57.4%) versus central (42.6%). Melanoma and renal cell carcinoma were significantly associated with NAEs. Conclusion: The incidence of NAEs was rare though higher than many prior case estimates; the timing was consistent with other AEs. NAEs frequently occurred in tumor types known to favor brain metastases.

Immune checkpoint inhibitors are new drugs for cancer. They boost your body's defenses to fight cancer cells. These drugs can be used alone or with other cancer treatments. Most people are okay with these medicines, but some might have problems in different parts of the body. This can be tricky to figure out. Rarely, there can be issues in the brain or nerves. These side effects are rare, happening in about 2 in every 100 people who use the drugs. They are more common in certain cancers like melanoma and kidney cancer. As doctors learn more about these side effects, they can better predict, treat, and prevent them.

Adapting Connect for Health pediatric weight management program for telehealth in response to the COVID-19 pandemic.

BACKGROUND: To address the evolving needs and context changes due to the COVID-19 pandemic, we adapted Connect for Health, an evidence-based, primary care, pediatric weight management intervention. The objective of this study is to describe the planned adaptation process to ensure continued and equitable program uptake during the pandemic. METHODS: Guided by adaptation frameworks, we identified the core functions and forms of Connect for Health and then adapted the intervention in response to a changing healthcare context. We engaged stakeholders and surveyed parents of children with a BMI ≥ 85th percentile and pediatric clinicians and examined their experiences using telehealth for pediatric weight management and needs and preferences. Using multivariable logistic regression, we examined the preferences of parents with limited English proficiency regarding key aspects of pediatric weight management. RESULTS: We surveyed 200 parents and 43% had a primary language of Spanish. Parents wanted care to be a combination of in-person and virtual visits (80%). We found that parents with limited English proficiency had a higher odds ratio of affirming in-person visits are better than virtual visits for ensuring their child's health concern can be taken care of (OR: 2.91; 95% CI: 1.36, 6.21), feeling comfortable when discussing personal information (OR: 3.91; 95% CI: 1.82, 8.43), talking about healthy behaviors and setting goals (OR: 3.09; 95% CI: 1.39, 6.90), and talking about mental health and overall well-being (OR: 4.02; 95% CI: 1.83, 8.87) than parents without limited English proficiency. We surveyed 75 clinicians and 60% felt telehealth was a useful tool to provide care for pediatric weight management. Clinicians felt virtual visits did not pose barriers to all aspects of care. Informed by the surveys and stakeholder input, we made clinician- and family-level adaptations while retaining the program's function. CONCLUSIONS: By engaging stakeholders and adapting the program for telehealth, we optimized the reach and fit of Connect for Health to ensure its continued uptake. We have provided a real-world example of how clinical innovations can evolve and how to systematically plan adaptations in response to changing healthcare contexts. TRIAL REGISTRATION: Clinicaltrials.gov (NCT04042493), Registered on August 2, 2019.

Tobacco use and cancer-related symptom burden: Analysis of the US Population Assessment of Tobacco and Health Study.

BACKGROUND: Understanding the relationship between tobacco use and symptom burden may inform tobacco treatment interventions tailored to the needs of individuals with cancer. METHODS: The study included 1409 adult cancer survivors from Wave 5 of the US Food and Drug Administration Population Assessment of Tobacco and Health (PATH) Study. A multivariate analysis of variance controlling for age, sex, and race/ethnicity assessed the association of cigarette smoking and vaping on cancer-related symptom burden (fatigue, pain, emotional problems) and quality of life (QoL). Generalized linear mixed models controlling for the same factors were used to assess associations among symptom burden, QoL, and quit-smoking intentions, quit-smoking likelihood, and past 12-month smoking quit attempts. RESULTS: Weighted rates of current cigarette smoking and vaping were 14.21% and 2.88%, respectively. Current smoking was associated with greater fatigue (p < .0001; partial η 2  = .02), pain (p < .0001; partial η 2  = .08), emotional problems (p < .0001; partial η 2  = .02), and worse QoL (p < .0001; partial η 2  = .08). Current vaping was associated with greater fatigue (p = .001; partial η 2  = .008), pain (p = .009; partial η 2  = .005), and emotional problems (p = .04; partial η 2  = .003), but not worse QoL (p = .17). Higher cancer symptom burden was not associated with reduced interest in quitting, likelihood of quitting, or odds of past year quit attempts (p > .05 for each). CONCLUSIONS: Among adults with cancer, current smoking and vaping were associated with greater symptom burden. Survivors' interest in and intentions to quit smoking were not related to symptom burden. Future research should examine the role of tobacco cessation in improving symptom burden and QoL.

Patient-Reported Receipt of Oncology Clinician-Delivered Brief Tobacco Treatment (5As) Six Months following Cancer Diagnosis.

INTRODUCTION: Smoking after a cancer diagnosis represents a modifiable health risk. It is recommended that oncology clinicians address tobacco use among their patients using the 5As brief model: Asking about use, Advising users to quit, Assessing willingness to quit, Assisting in quit attempts (counseling and medication), and Arranging follow-up. However, cross-sectional studies have found limited adoption of 5As (especially Assist and Arrange) in oncology settings. Further investigation is needed to understand changes in, and factors associated with, 5As delivery over time. METHODS: Patients recently diagnosed with cancer and reporting current smoking (N = 303) enrolled in a smoking cessation clinical trial and completed three longitudinal surveys; at pre-intervention baseline and 3- and 6-month follow-up post-enrollment. Patient-level correlates of 5As receipt at baseline, 3 months, and 6 months were identified using multilevel regression models. RESULTS: At baseline, patient-reported rates of 5As receipt from oncology clinicians ranged from 85.17% (Ask) to 32.24% (Arrange). Delivery declined from baseline to 6-month follow-up for all 5As, with the largest declines observed for Ask, Advise, Assess, and Assist-Counseling. Diagnosis of a smoking-related cancer was associated with greater odds of 5As receipt at baseline but lower odds at 6-month follow-up. At each time point, female gender, religiosity, advanced disease, cancer-related stigma, and smoking abstinence were associated with lower odds of 5As receipt, while reporting a recent quit attempt prior to enrollment was associated with higher odds of 5As receipt. CONCLUSION: Oncology clinicians' 5As delivery declined over time. Clinician delivery of the 5As varied based on patients' sociodemographics, clinical and smoking characteristics, and psychosocial factors.

Poor Subjective Sleep Quality Among Patients with Cancer and Comorbid Depression: An Opportunity to Inform Screening and Intervention.

OBJECTIVE: Sleep disturbances are under-identified and under-treated in oncology settings, especially for underserved populations and those with psychiatric comorbidities. This study examined the prevalence and correlates of poor subjective sleep quality as well as clinical sleep recommendations among a socioeconomically and ethnically diverse population of patients with cancer referred for depression management. METHODS: Participants were 140 adults with cancer who screened positive for depression through routine, practice-based assessment with the Patient Health Questionnaire (PHQ-9 ≥ 8) and were referred to a study of collaborative care for depression. Demographics, clinical characteristics, subjective sleep quality, and sleep recommendations received were self-reported by patients prior to intervention. Sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI), general health status was measured using the Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10, and depressive symptoms were measured using the PHQ-9. RESULTS: Of 138 patients with complete data, 123 (89.1%) reported poor sleep quality, and 87 (63%) met the threshold for possible insomnia. The strongest correlates of poor subjective sleep were female gender (ß = 0.19, p = .02), greater depressive symptom severity (ß = 0.28, p = .001), and worse physical health (ß = -0.19, p = .04). Of 118 patients reporting problems with sleep since their cancer diagnosis, 95 discussed the issue with a medical provider; medications were recommended most often (37; 38.9%); only 9 (9.5%) received recommendations for cognitive-behavioral therapy for insomnia (CBT-I) or other CBT. CONCLUSIONS: Patients with cancer seeking treatment for depression report very high rates of poor subjective sleep quality and insomnia, underscoring the importance of providing and referring to guideline-concordant sleep interventions in oncology supportive care contexts.

Developing an ACT-based intervention to address lung cancer stigma: Stakeholder recommendations and feasibility testing in two NCI-designated cancer centers.

Objective: Few psychosocial interventions have been tailored to meet the unique needs of patients diagnosed with lung cancer. This pilot study developed and tested a six-week intervention for reducing lung cancer stigma.Design and Subjects: Guided by qualitative interviews conducted with 9 lung cancer patients and 5 thoracic oncology care providers, Acceptance and Commitment Therapy was adapted for treatment of lung cancer stigma (ACT-LCS). In a subsequent single arm pilot study, 22 lung cancer patients reporting high levels of stigma completed the intervention.Setting: NCI-designated cancer centers in the Southwestern and Eastern United States.Results: Of 46 eligible patients, 22 provided consent, with 20 completing the intervention (10 in-person, 10 telehealth). Overall stigma decreased across timepoints, largely driven by reductions in internalized stigma. There were also significant reductions in social isolation, sleep disturbance, and fatigue.Conclusions: The ACT-LCS protocol demonstrates preliminary feasibility and acceptability. This intervention may be particularly suited for helping patients navigate feelings associated with internalized stigma.

Identifying Barriers to Advocacy Among Patients With Lung Cancer: The Role of Stigma-Related Interpersonal Constraint.

OBJECTIVES: To examine whether aspects of disease-specific stigma are barriers to advocacy among individuals with lung cancer. SAMPLE & SETTING: 266 patients with lung cancer treated at two National Cancer Institute-designated comprehensive cancer centers in the United States. METHODS & VARIABLES: Patients completed a cross-sectional survey. Demographic, clinical, and stigma-related correlates of advocacy were also explored. RESULTS: In multivariable analyses, lower levels of patient advocacy were reported by older patients and those with higher levels of constrained disclosure (i.e., avoidance of or discomfort in disclosing one's lung cancer status). IMPLICATIONS FOR NURSING: Avoidance of discussing lung cancer (constrained disclosure) may be a barrier to patient involvement in advocacy. Additional research is needed to examine this relationship, reduce stigma, and promote inclusivity for individuals with lung cancer.

Urgent Need for Novel Investigations of Treatments to Quit E-cigarettes: Findings from a Systematic Review.

E-cigarette use has been increasing globally over the past decade. Many use e-cigarettes as an alternative or method to quit cigarette smoking, whereas others use these products recreationally. As technology has advanced, many individuals have reported symptoms of dependence on these products and continue to use them beyond achieving abstinence from smoking. Despite individuals reporting interest in quitting, little is known about e-cigarette cessation. This systematic review sought to identify and evaluate all human subjects literature published on the outcome of e-cigarette cessation through September 2021. Of the 79 articles identified, 56 were cross-sectional, 6 were qualitative, 5 were cohort studies, 3 were experimental, 2 were mixed methods, and 7 reported intervention or case studies of e-cigarette cessation. Results showed youth generally had high intent to quit e-cigarettes, whereas results were mixed with adult samples. Youth were motivated to quit e-cigarettes by health concerns, whereas adults were motivated to quit e-cigarettes by cost, lack of satisfaction, and psychologic factors. Adults were more likely to report past e-cigarette quit attempts, most commonly "cold turkey." Few interventions tested strategies for e-cigarette cessation, with a majority targeted for youth. Given the lack of information on e-cigarette cessation, recommendations for future studies are outlined.

Implementation Evaluation of HUGS/Abrazos During the COVID-19 Pandemic: A Program to Foster Resiliency in Pregnancy and Early Childhood.

Early life adversity can significantly impact child development and health outcomes throughout the life course. With the COVID-19 pandemic exacerbating preexisting and introducing new sources of toxic stress, social programs that foster resilience are more necessary now than ever. The Helping Us Grow Stronger (HUGS/Abrazos) program fills a crucial need for protective buffers during the COVID-19 pandemic, which has escalated toxic stressors affecting pregnant women and families with young children. HUGS/Abrazos combines patient navigation, behavioral health support, and innovative tools to ameliorate these heightened toxic stressors. We used a mixed-methods approach, guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, to evaluate the implementation of the HUGS/Abrazos program at Massachusetts General Hospital from 6/30/2020-8/31/2021. Results of the quality improvement evaluation revealed that the program was widely adopted across the hospital and 392 unique families were referred to the program. The referred patients were representative of the communities in Massachusetts disproportionately affected by the COVID-19 pandemic. Furthermore, 79% of referred patients followed up with the initial referral, with sustained high participation rates throughout the program course; and they were provided with an average of four community resource referrals. Adoption and implementation of the key components in HUGS/Abrazos were found to be appropriate and acceptable. Furthermore, the implemented program remained consistent to the original design. Overall, HUGS/Abrazos was well adopted as an emergency relief program with strong post-COVID-19 applicability to ameliorate continuing toxic stressors while decreasing burden on the health system.

Effects of the First 1000 Days Program, a systems-change intervention, on obesity risk factors during pregnancy.

BACKGROUND: First 1000 Days is a systems-oriented program starting in early pregnancy lasting through the first 24 months of infancy focused on preventing obesity and related risk factors among low income, mother-infant pairs. The program was developed in partnership with stakeholders to create an infrastructure for system-wide change. It includes screening for adverse health behaviors and socio-contextual factors, patient navigation and educational materials to support behavior change and social needs, and individualized health coaching for women at highest risk of obesity and has been shown to reduce excess gestational weight gain for women who were overweight at the start of their pregnancy. The purpose of this study was to examine changes from the first to third trimester for women participating in the First 1000 Days Program. METHODS: We collected information through self-administered questionnaires during the first and third trimester of gestation and from electronic health records relating to obesity risk factors. Measures collected included behavior (i.e., diet, physical activity and screen time) and psychosocial (i.e., anxiety) outcomes, as well as enrollment in Women, Infant, and Children (WIC) program. We examined the extent to which participation in the program was associated with changes in behaviors and psychosocial outcomes among women during pregnancy. RESULTS: Women completed surveys at their initial and third trimester prenatal visits (n = 264). Mean age (SD) was 30.2 (5.51) years and 75% had an annual household income of <$50,000. Mean pre-pregnancy body mass index (BMI) was 27.7 kg/m2 and 64% started pregnancy with a BMI ≥ 25 kg/m2. In multivariable adjusted models, we observed decreases in intake of sugary-drinks (- 0.95 servings/day; 95% CI: - 1.86, - 0.03) and in screen time (- 0.21 h/day; 95% CI: - 0.40, - 0.01), and an increase in physical activity (0.88 days/week; 95% CI: 0.52, 1.23) from the first to third trimester. We also observed a decrease in pregnancy-related anxiety score (- 1.06 units; 95% CI: - 1.32, - 0.79) and higher odds of enrollment in Women, Infant, and Children (WIC) program (OR: 2.58; 95% CI: 1.96, 3.41). CONCLUSIONS: Our findings suggest that a systems-oriented prenatal intervention may be associated with improvements in behaviors and psychosocial outcomes during pregnancy among low-income mothers. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT03191591 ; Retrospectively registered on June 19, 2017).

Ethnic Differences in Survival Among Lung Cancer Patients: A Systematic Review.

Background: Despite a substantially worse risk factor profile, Hispanics in the United States experience lower incidence of many diseases and longer survival than non-Hispanic Whites (NHWs), an epidemiological phenomenon known as the Hispanic Health Paradox (HHP). This systematic review evaluated the published longitudinal literature to address whether this pattern extends to lung cancer survival. Methods: Searches of Medline, PubMed, Embase, Web of Science, and the Cochrane Library were conducted for publications dated from January 1, 2000, to July 18, 2018. Records were restricted to articles written in English, employing a longitudinal design, and reporting a direct survival comparison (overall survival [OS], cancer-specific survival [CSS]) between NHW and Hispanic lung cancer patients. Results: A final sample of 29 full-text articles were included, with 28 fully adjusted models of OS and 21 of CSS included. Overall, 26 (92.9%) OS models and 20 (95.2%) CSS models documented either no difference (OS = 16, CSS = 11) or a Hispanic survival advantage (OS = 10, CSS = 9). Both larger studies and those including foreign-born Hispanics were more likely to show a Hispanic survival advantage, and 2 studies of exclusively no-smokers showed a survival disadvantage. A number of reporting gaps were identified including Hispanic background and sociodemographic characteristics. Conclusions: Hispanics exhibit similar or better survival in the context of lung cancer relative to NHWs despite a considerably worse risk factor profile. These findings support the HHP in the context of lung cancer. Further research is needed to understand the potential mechanisms of the HHP as it relates to lung cancer.

Twelve-Month Outcomes of the First 1000 Days Program on Infant Weight Status.

OBJECTIVES: To examine the effects of the First 1000 Days intervention on the prevalence of infant overweight and maternal postpartum weight retention and care. METHODS: Using a quasi-experimental design, we evaluated the effects of the First 1000 Days program among 995 term, low-income infants and their mothers receiving care in 2 intervention community health centers and 650 dyads in 2 comparison health centers. The program includes staff training, growth tracking, health and behavioral screening, patient navigation, text messaging, educational materials, and health coaching. Comparison centers implemented usual care. Infant outcomes were assessed at 6 and 12 months, including weight-for-length z score and overweight (weight for length ≥97.7th percentile). We also examined maternal weight retention and receipt of care 6 weeks' post partum. RESULTS: The mean birth weight was 3.34 kg (SD 0.45); 57% of infants were Hispanic; 66% were publicly insured. At 6 months, infants had lower weight-for-length z scores (ß: -.27; 95% confidence interval [CI]: -.39 to -.15) and lower odds of overweight (adjusted odds ratio [OR]: 0.46; 95% CI: 0.28 to 0.76) than infants in comparison sites; differences persisted at 12 months (z score ß: -.18; 95% CI: -.30 to -.07; adjusted OR for overweight: 0.60; 95% CI: 0.39 to 0.92). Mothers in the intervention sites had modestly lower, but nonsignificant, weight retention at 6 weeks' post partum (ß: -.51 kg; 95% CI: -1.15 to .13) and had higher odds (adjusted OR: 1.50; 95% CI: 1.16 to 1.94) of completing their postpartum visit compared with mothers in the comparison sites. CONCLUSIONS: An early-life systems-change intervention combined with coaching was associated with improved infant weight status and maternal postpartum care.

Fostering Resilience in Pregnancy and Early Childhood During the COVID-19 Pandemic: The HUGS/Abrazos Program Design and Implementation.

Pregnancy and early childhood pose unique sensitivity to stressors such as economic instability, poor mental health, and social inequities all of which have been magnified by the COVID-19 pandemic. In absence of protective buffers, prolonged exposure to excessive, early adversity can lead to poor health outcomes with significant impact lasting beyond the childhood years. Helping Us Grow Stronger (HUGS/Abrazos) is a community-based program, designed and launched at the time of the COVID-19 surge in the Spring of 2020, that combines emergency relief, patient navigation, and direct behavioral health support to foster family resilience and mitigate the negative impacts of COVID-related toxic stress on pregnant women and families with children under age 6. Through a targeted referral process, community health workers provide resource navigation for social needs, and a social worker provides behavioral health support. The use of innovative tools such as a centralized resource repository, community health workers with specialized knowledge in this age range, and a direct referral system seeks to assist in streamlining communication and ensuring delivery of quality care. We aim to serve over 300 families within the 1st year. The HUGS/Abrazos program aims to fill an important void by providing the necessary tools and interventions to support pregnant women and young families impacted by adversity exacerbated by the COVID-19 pandemic.

Patient-reported financial toxicity, quality of life, and health behaviors in insured US cancer survivors.

PURPOSE: Fighting cancer is a costly battle, and understanding the relationship between patient-reported financial toxicity (FT) and health outcomes can help inform interventions for post-treatment cancer survivors. METHODS: Stages I-III solid tumor, insured US cancer survivors (N = 103) completed a survey addressing FT (as measured by the standardized COST measure) and clinically relevant health outcomes (including health-related quality of life [HRQOL] and adherence to recommended survivorship health behaviors). Univariate and multivariate analyses were used to assess demographic and disease-specific correlates of FT, and to assess the predictive value of FT on HRQOL and adherence to survivorship health behaviors. RESULTS: Approximately 18% of respondents noted FT levels associated with significant financial burden. In univariate analyses, after correcting for multiple comparisons, greater FT was associated with unpartnered status, non-retirement, and lower level of educational attainment. Greater FT was also significantly associated with HRQOL components of anxiety, fatigue, pain, physical functioning, and social functioning. FT was not significantly associated with any measured survivorship health behaviors. In multivariate analyses, FT was found to be a meaningful predictor of patient-reported anxiety, fatigue, physical functioning, and social functioning above and beyond theoretically and statistically relevant demographic characteristics. CONCLUSIONS: Although overall levels of FT were lower among cancer survivors in this sample, as compared with active treatment patients assessed in previous studies, financial burden continued to be a concern for a significant minority of cancer survivors and was associated with components of reduced HRQOL. Further research is needed to understand FT among underinsured survivors and those treated in community oncology settings. IMPLICATIONS FOR CANCER SURVIVORS: Incorporation of FT assessment into survivorship care planning could enhance clinical assessment of survivors' FT vulnerability, help address the dynamic and persistent challenges of survivorship, and help identify those most in need of intervention across the cancer care continuum.

Use of Telehealth to Enhance Care in a Family-Centered Childhood Obesity Intervention.

Family-centered childhood obesity interventions have been found to be effective. We describe the use of telehealth for tailored behavior change support in a family-centered randomized trial. Children of 2 to 12 years with body mass index ≥85th percentile were randomized to Enhanced Primary Care (EPC) or Enhanced Primary Care + Coaching (EPC + C). EPC + C received 6 health coach visits (in-person or by video or phone call) over 1 year. Telehealth modalities included interactive text messaging, video calls, and an online community resource map. There were 360 children randomized to the EPC + C arm; 87% of parents completed ≥1 health coaching contacts. Overall, 93% parents were sent text messages of which 99% responded at least once. About 72% parents were very satisfied with the message content and 97% were satisfied with information provided about community health resources. The high level of participant engagement and satisfaction suggests that telehealth is feasible and acceptable in family-centered childhood obesity programs.

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

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

Strengthening integration of clinical and public health systems to prevent maternal-child obesity in the First 1,000Days: A Collective Impact approach.

INTRODUCTION: Obesity interventions may be most effective if they begin in the earliest stages of life, support changes across family, clinical, and public health systems, and address socio-contextual factors. METHODS: The First 1000Days is a systematic program starting in early pregnancy lasting through the first 24months of infancy to prevent obesity among low-income mother-infant pairs in three community health centers in Massachusetts. The program uses a Collective Impact approach to create the infrastructure for sustained, system-wide changes for obesity prevention across early life clinical and public health services, including Obstetrics, Pediatrics, Adult Medicine, Behavioral Health, Nutrition, Community Health, the Women, Infants and Children (WIC) program, and the Maternal, Infant and Childhood Home Visiting program. Program components include 1) staff and provider training; 2) enhanced gestational weight gain and infant overweight tracking; 3) universal screening of adverse health behaviors and socio-contextual factors; 4) universal patient navigation to support individual behavior change and social needs, while strengthening integration of clinical and public health services; 5) individualized health coaching for mother-infant pairs at high risk of obesity; and 6) educational materials to support behavior change. RESULTS: A quasi-experimental evaluation design will examine changes, between 2015 and 2019, in gestational weight gain and prevalence of infant overweight from 0 to 24months of age. CONCLUSIONS: The First 1000Days program will examine the effectiveness of an early life obesity prevention program for mother-infant pairs. If successful, the program could provide a model for chronic disease prevention and health promotion among vulnerable families starting in early life.

Comparative Effectiveness of Clinical-Community Childhood Obesity Interventions: A Randomized Clinical Trial.

IMPORTANCE: Novel approaches to care delivery that leverage clinical and community resources could improve body mass index (BMI) and family-centered outcomes. OBJECTIVE: To examine the extent to which 2 clinical-community interventions improved child BMI z score and health-related quality of life, as well as parental resource empowerment in the Connect for Health Trial. DESIGN, SETTING, AND PARTICIPANTS: This 2-arm, blinded, randomized clinical trial was conducted from June 2014 through March 2016, with measures at baseline and 1 year after randomization. This intent-to-treat analysis included 721 children ages 2 to 12 years with BMI in the 85th or greater percentile from 6 primary care practices in Massachusetts. INTERVENTIONS: Children were randomized to 1 of 2 arms: (1) enhanced primary care (eg, flagging of children with BMI ≥ 85th percentile, clinical decision support tools for pediatric weight management, parent educational materials, a Neighborhood Resource Guide, and monthly text messages) or (2) enhanced primary care plus contextually tailored, individual health coaching (twice-weekly text messages and telephone or video contacts every other month) to support behavior change and linkage of families to neighborhood resources. MAIN OUTCOMES AND MEASURES: One-year changes in age- and sex-specific BMI z score, child health-related quality of life measured by the Pediatric Quality of Life 4.0, and parental resource empowerment. RESULTS: At 1 year, we obtained BMI z scores from 664 children (92%) and family-centered outcomes from 657 parents (91%). The baseline mean (SD) age was 8.0 (3.0) years; 35% were white (n = 252), 33.3% were black (n = 240), 21.8% were Hispanic (n = 157), and 9.9% were of another race/ethnicity (n = 71). In the enhanced primary care group, adjusted mean (SD) BMI z score was 1.91 (0.56) at baseline and 1.85 (0.58) at 1 year, an improvement of -0.06 BMI z score units (95% CI, -0.10 to -0.02) from baseline to 1 year. In the enhanced primary care plus coaching group, the adjusted mean (SD) BMI z score was 1.87 (0.56) at baseline and 1.79 (0.58) at 1 year, an improvement of -0.09 BMI z score units (95% CI, -0.13 to -0.05). However, there was no significant difference between the 2 intervention arms (difference, -0.02; 95% CI, -0.08 to 0.03; P = .39). Both intervention arms led to improved parental resource empowerment: 0.29 units (95% CI, 0.22 to 0.35) higher in the enhanced primary care group and 0.22 units (95% CI, 0.15 to 0.28) higher in the enhanced primary care plus coaching group. Parents in the enhanced primary care plus coaching group, but not in the enhanced care alone group, reported improvements in their child's health-related quality of life (1.53 units; 95% CI, 0.51 to 2.56). However, there were no significant differences between the intervention arms in either parental resource empowerment (0.07 units; 95% CI, -0.02 to 0.16) or child health-related quality of life (0.89 units; 95% CI, -0.56 to 2.33). CONCLUSIONS AND RELEVANCE: Two interventions that included a package of high-quality clinical care for obesity and linkages to community resources resulted in improved family-centered outcomes for childhood obesity and improvements in child BMI. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT02124460.