Effectiveness of provider communication training for increasing human papillomavirus vaccine initiation at a safety-net health system.

Background: Strong provider recommendation can increase uptake of human papillomavirus (HPV) vaccination. Therefore, we developed and implemented a provider education intervention on communication strategies for recommending HPV vaccination with clinic-level audit and feedback (HPV: Communicating about HPV to Adults and Teens [HPV CHAT]). We aimed to evaluate the effect of HPV CHAT on HPV vaccine uptake in seven family medicine and pediatric clinics in a large urban health system (USA). Methods: We used a quasi-experimental design, where the eligible population included people aged 9-26 years with at least one encounter in June 2020-February 2023 at one of the participating community health clinics. We used interrupted time-series analysis to assess changes in the prevalence of HPV vaccine uptake. We used segmented Poisson regression with a log link function to estimate prevalence ratios (PR) and 95% confidence limits (CL) for level (immediate) and slope (over time) changes with adjustment for seasonality using Fourier transformation. Results: Our study population comprised 60,328 observations in which the median age was 17 years (interquartile range: 13-21). A majority (58%) were female and 87% were racial/ethnic minorities. Overall, we observed no sizeable effect of the intervention on HPV vaccination uptake. Nonetheless, heterogeneity was observed by age group with modest increases in individuals aged 9-12 and 13-17 years. Conclusion: Our provider feedback intervention had minimal effect on increasing prevalence of HPV vaccination in seven family medicine and pediatric clinics. Novel strategies are needed to address provider barriers related to HPV vaccination.

Evaluation of a human papillomavirus vaccination training implementation in clinical and community settings across different clinical roles.

Improving human papillomavirus (HPV) vaccination is a national priority but uptake declined following the coronavirus pandemic. A strong predictor of HPV vaccination in the USA is a strong provider recommendation. Therefore, we developed a brief, asynchronous training on HPV vaccine recommendations in clinical and community settings as part of a multisite quality improvement initiative. This paper aims to describe the implementation and initial outcomes of the training provided. A 20-minute training on HPV vaccine bundled recommendations, motivational interviewing, and brief responses to patient concerns (Communicating about HPV vaccination to Adults and Teens; HPV CHAT) was implemented at seven safety-net clinics, two practice-based research network clinics, and nine county immunization clinics. We integrated training with clinical care teams; thus, we assessed immediate training outcomes across their different clinical roles compared to pre-training. In April-May 2022, HPV CHAT training was launched. One hundred eighty-seven people participated in the training and completed the pre-/postevaluation surveys. Knowledge about the HPV vaccine guidelines improved with notable changes in correctly reporting vaccine eligibility (P < .05). A significant change in participants' confidence when addressing safety concerns and answering questions about the HPV vaccine (clinicians, 26.8% and 17.1%; nurses, 29.0% and 23.2%, and clinical staff, 18.2% and 37.7%) was observed. At post-test, more than 85% of clinicians and nurses reported their plan to routinely recommend the HPV vaccine. This quality improvement initiative demonstrated implementation feasibility of a brief HPV vaccine training that improved provider and clinical staff knowledge, confidence, and intention to routinely recommend HPV vaccination.

The human papillomavirus (HPV) vaccine is key to cancer prevention. Despite this fact, HPV vaccination is not widely accepted. Studies have shown that a strong recommendation can lead to HPV vaccination. Therefore, virtual educational training (Communicating about HPV vaccination to Adults and Teens; HPV CHAT) was developed to equip clinicians, nurses, and clinical staff with communication tools to support HPV recommendation and respond to patient concerns. HPV CHAT, a quality improvement initiative, was launched across numerous community and county clinical teams. To capture HPV CHAT training impact, pre- and post-evaluation surveys were disseminated alongside the training to capture training impact. After HPV CHAT implementation, training participants reported a positive impact on confidence and knowledge items; these findings were observed across all clinical roles in varying degrees. Overall, this quality improvement initiative successfully improved communication skill self-efficacy and knowledge across different clinical roles. This paper discusses training implementation strategies and the changes in knowledge and confidence after participating in the training.

Risk-management decision-making data from a community-based sample of racially diverse women at high risk of breast cancer: rationale, methods, and sample characteristics of the Daughter Sister Mother Project survey.

BACKGROUND: To understand the dynamics that limit use of risk-management options by women at high risk of breast cancer, there is a critical need for research that focuses on patient perspectives. Prior research has left important gaps: exclusion of high-risk women not in risk-related clinical care, exclusion of non-white populations, and lack of attention to the decision-making processes that underlie risk-management choices. Our objective was to create a more inclusive dataset to facilitate research to address disparities related to decision making for breast cancer risk management. METHODS: The Daughter Sister Mother Project survey collects comprehensive information about the experiences of women at high risk of breast cancer. We collected novel measures of feelings about and reactions to cancer screenings; knowledge, barriers, and facilitators of risk-management options; beliefs related to cancer risk and risk management; and involvement with loved ones who had cancer. Eligible individuals were non-Hispanic white and non-Hispanic Black adult women who self-identified as having high risk of breast cancer and had no personal history of cancer. Between October 2018 and August 2019, 1053 respondents completed the online survey. Of these, 717 were confirmed through risk prediction modeling to have a lifetime breast cancer risk of ≥ 20%. Sociodemographic characteristics of this sample were compared to those of nationally representative samples of the US population: the 2019 Health Information National Trends Survey and the Pew Research Center report: Jewish Americans in 2020. RESULTS: The sample of 717 women at objectively high risk of breast cancer was largely (95%) recruited from non-clinical sources. Of these respondents, only 31% had seen a genetic counselor, 34% had had genetic testing specific to breast cancer risk, and 35% had seen at least one breast or cancer care specialist. The sample includes 35% Black respondents and 8% with Ashkenazi Jewish ancestry. Although encompassing a substantial range of ages, incomes, and education levels, respondents are overall somewhat younger, higher-income, and more educated than the US population as a whole. CONCLUSIONS: The DSM dataset offers comprehensive data from a community-based, diverse sample of women at high risk of breast cancer. The dataset includes substantial proportions of Black and Ashkenazi Jewish women and women who are not already in clinical care related to their breast cancer risk. This sample will facilitate future studies of risk-management behaviors among women who are and are not receiving high-risk care, and of variations in risk-management experiences across race and ethnicity.

Survival After Implementation of a Decision Support Tool to Facilitate Evidence-Based Cancer Treatment.

PURPOSE: Decision support tools (DSTs) to facilitate evidence-based cancer treatment are increasingly common in care delivery organizations. Implementation of these tools may improve process outcomes, but little is known about effects on patient outcomes such as survival. We aimed to evaluate the effect of implementing a DST for cancer treatment on overall survival (OS) among patients with breast, colorectal, and lung cancer. METHODS: We used institutional cancer registry data to identify adults treated for first primary breast, colorectal, or lung cancer between December 2013 and December 2017. Our intervention of interest was implementation of a commercial DST for cancer treatment, and outcome of interest was OS. We emulated a single-arm trial with historical comparison and used a flexible parametric model to estimate standardized 3-year restricted mean survival time (RMST) difference and mortality risk ratio (RR) with 95% confidence limits (CLs). RESULTS: Our study population comprised 1,059 patients with cancer (323 breast, 318 colorectal, and 418 lung). Depending on cancer type, median age was 55-60 years, 45%-67% were racial/ethnic minorities, and 49%-69% were uninsured. DST implementation had little effect on survival at 3 years. The largest effect was observed among patients with lung cancer (RMST difference, 1.7 months; 95% CL, -0.26 to 3.7; mortality RR, 0.95; 95% CL, 0.88 to 1.0). Adherence with tool-based treatment recommendations was >70% before and >90% across cancers. CONCLUSION: Our results suggest that implementation of a DST for cancer treatment has nominal effect on OS, which may be partially attributable to high adherence with evidence-based treatment recommendations before tool implementation in our setting. Our results raise awareness that improved process outcomes may not translate to improved patient outcomes in some care delivery settings.

Racial differences in prevention decision making among U.S. women at high risk of breast cancer: A qualitative study.

PURPOSE: Women at high risk of breast cancer face complex decisions about how to manage those risks. Substantial gaps in current knowledge include how women make these decisions and how decision making may differ across sub-populations. Among these critical gaps are the questions of (a) whether racial differences exist between the experiences of high-risk women navigating breast cancer risk, and (b) what consequences those racial differences might have on women's ability to manage their cancer risks. The present study is designed to address these questions directly. METHODS: Fifty semi-structured interviews were conducted with high-risk Black (n = 20) and white women (n = 30) between May 2015 and March 2016 in person in Ohio and by phone. Transcribed data were analyzed using grounded theory methods. MAIN FINDINGS: Our analyses suggest that many of the core decision-making dynamics high-risk women navigate differ by race. The experiences of white and Black women in our study differ in terms of (a) contextualizing risk-how women make sense of their own breast cancer risk, the degree to which they worry about risk, and how they prioritize risk within the contexts of their broader lives; (b) conceptualizing risk management-how, how much, and from whom women learn about and conceptualize their options for preventing cancer and/or ensuring that cancer gets diagnosed early; and (c) constraints-the external barriers women face throughout their decision-making and risk-management processes. In sum, the Black women we interviewed reported feeling less well-situated to consider and cope actively with breast cancer risk, less well-informed about risk-management options, and more constrained in their use of these options. CONCLUSIONS: High-risk women's accounts of the complex dynamics that shape breast cancer prevention decisions suggest that these dynamics vary substantially by race, such that Black women may experience disadvantages relative to whites.

Cardiotoxicity among socioeconomically marginalized breast cancer patients.

PURPOSE: Evidence of cardiotoxicity risk related to anthracycline or trastuzumab exposure is largely derived from breast cancer cohorts that under-represent socioeconomically marginalized women, who may be at increased risk of cardiotoxicity because of high prevalence of cardiovascular disease risk factors. Therefore, we aimed to estimate cardiotoxicity risk among socioeconomically marginalized breast cancer patients treated with anthracyclines or trastuzumab and describe clinical consequences of cardiotoxicity. METHODS: We linked electronic health records with institutional registry data from a Comprehensive Community Cancer Program within a safety-net health system. Eligible patients were adult females, diagnosed with first primary invasive breast cancer between 2013 and 2017, and initiated anthracyclines or trastuzumab as part of first-line therapy. We estimated cumulative incidence (risk) of cardiotoxicity with corresponding 95% confidence limits (CL) using the Aalen-Johansen estimator with death as competing risk. RESULTS: Our study population comprised 169 women with breast cancer (103 initiated anthracyclines and 66 initiated trastuzumab). Cumulative incidence of cardiotoxicity was 21% (95% CL: 12%, 32%) at one year and 25% (95% CL: 15%, 35%) at three years among women who initiated trastuzumab, whereas cumulative incidence was 3.9% (95% CL: 1.3%, 8.9%) at one year and 5.9% (95% CL: 2.4%, 12%) at three years among women who initiated anthracyclines. More than half of patients with cardiotoxicity experienced interruption of cancer treatment. CONCLUSION: Our findings suggest high risk of cardiotoxicity among socioeconomically marginalized breast cancer patients after initiation of anthracyclines or trastuzumab. Strategies are needed for optimizing cancer treatment effectiveness while minimizing cardiotoxicity in this population.

Timing of adjuvant chemotherapy initiation and mortality among colon cancer patients at a safety-net health system.

BACKGROUND: Prior studies reported survival benefits from early initiation of adjuvant chemotherapy for stage III colon cancer, but this evidence was derived from studies that may be sensitive to time-related biases. Therefore, we aimed to estimate the effect of initiating adjuvant chemotherapy ≤8 or ≤ 12 weeks on overall and disease-free survival among stage III colon cancer patients using a study design that helps address time-related biases. METHODS: We used institutional registry data from JPS Oncology and Infusion Center, a Comprehensive Community Cancer Program. Eligible patients were adults aged < 80 years, diagnosed with first primary stage III colon cancer between 2011 and 2017, and received surgical resection with curative intent. We emulated a target trial with sequential eligibility. We subsequently pooled the trials and estimated risk ratios (RRs) along with 95% confidence limits (CL) for all-cause mortality and recurrence or death at 5-years between initiators and non-initiators of adjuvant chemotherapy ≤8 or ≤ 12 weeks using pseudo-observations and a marginal structural model with stabilized inverse probability of treatment weights. RESULTS: Our study population comprised 222 (for assessing initiation ≤8 weeks) and 310 (for assessing initiation ≤12 weeks) observations, of whom the majority were racial/ethnic minorities (64-65%), or uninsured with or without enrollment in our hospital-based medical assistance program (68-71%). Initiation of adjuvant chemotherapy ≤8 weeks of surgical resection did not improve overall survival (RR for all-cause mortality = 1.04, 95% CL: 0.57, 1.92) or disease-free survival (RR for recurrence or death = 1.07, 95% CL: 0.61, 1.88). The results were similar for initiation of adjuvant chemotherapy ≤12 weeks of surgical resection. CONCLUSIONS: Our results suggest that the overall and disease-free survival benefits of initiating adjuvant chemotherapy ≤8 or ≤ 12 weeks of surgical resection may be overestimated in prior studies, which may be attributable to time-related biases. Nevertheless, our estimates were imprecise and differences in population characteristics are an alternate explanation. Additional studies that address time-related biases are needed to clarify our findings.

Predicting breast cancer risk in a racially diverse, community-based sample of potentially high-risk women.

BACKGROUND: Identifying women with high risk of breast cancer is necessary to study high-risk experiences and deliver risk-management care. Risk prediction models estimate individuals' lifetime risk but have rarely been applied in community-based settings among women not yet receiving specialized care. Therefore, we aimed: (1) to apply three breast cancer risk prediction models (i.e., Gail, Claus, and IBIS) to a racially diverse, community-based sample of women, and (2) to assess risk prediction estimates using survey data. METHODS: An online survey was administered to women who were determined by a screening instrument to have potentially high risk for breast cancer. Risk prediction models were applied using their self-reported family and medical history information. Inclusion in the high-risk subsample required ≥20% lifetime risk per ≥1 model. Descriptive statistics were used to compare the proportions of women identified as high risk by each model. RESULTS: N = 1053 women were initially eligible and completed the survey. All women, except one, self-reported the information necessary to run at least one model; 90% had sufficient information for >1 model. The high-risk subsample included 717 women, of which 75% were identified by one model only; 96% were identified by IBIS, 3% by Claus, <1% by Gail. In the high-risk subsample, 20% were identified by two models and 3% by all three models. CONCLUSIONS: Assessing breast cancer risk using self-reported data in a community-based sample was feasible. Different models identify substantially different groups of women who may be at high risk for breast cancer; use of multiple models may be beneficial for research and clinical care.

Impact of prognostic factor distributions on mortality disparities for socioeconomically disadvantaged cancer patients.

PURPOSE: We aimed to assess whether differences in the distributions of prognostic factors explain reported mortality disparities between urban safety-net and Surveillance, Epidemiology, and End Results (SEER) cancer populations. METHODS: We used data from SEER and a safety-net cancer center in Texas. Eligible patients were adults aged ≤64 years and diagnosed with first primary female breast, colorectal, or lung cancer between 2008 and 2016. We estimated crude and adjusted risk differences (RD) in 3- and 5-year all-cause mortality (1- and 3-year for lung cancer), where adjustment was based on entropy balancing weights that standardized the distribution of sociodemographic and tumor characteristics between the two populations. RESULTS: Our study populations comprised 1914 safety-net patients and 389,709 SEER patients. For breast cancer, the crude 3- and 5-year mortality RDs between safety-net and SEER populations were 7.7% (95% confidence limits [CL]: 4.3%, 11%) and 11% (95% CL: 6.7%, 16%). Adjustment for measured prognostic factors reduced the mortality RDs (3-year adjusted RD = 0.049%, 95% CL: -2.6%, 2.6%; 5-year adjusted RD = 5.6%, 95% CL: -0.83%, 12%). We observed similar patterns for colorectal and lung cancer albeit less magnitude. CONCLUSIONS: Sociodemographic and tumor characteristics may largely explain early mortality disparities between safety-net and SEER populations but not late mortality disparities.

Financial constraints on genetic counseling and further risk-management decisions among U.S. women at elevated breast cancer risk.

Clinical guidelines recommend that women at high risk of breast cancer should consider various risk-management options, which remain widely underutilized. We conducted semi-structured, qualitative interviews with 50 high-risk women to understand how financial constraints affect use of genetic counseling, genetic testing, and further risk-management decisions. Inductive analyses revealed three categories of health-related financial constraint: (a) lack of insurance, (b) underinsurance, and (c) other financial constraints (e.g., medical debt, raising children, managing comorbidities). Various breast cancer risk-management actions were limited by these financial constraints, including genetic counseling, genetic testing, enhanced screening, and prophylactic surgeries. Women's narratives also identified complex relationships between financial constraint and perceptions of healthcare providers and insurance companies, particularly as related to bias, price transparency, and potential genetic discrimination. Results from this study have implications for further research and expansion of genetic counseling services delivery to more economically and racially diverse women.

Spiritual health locus of control and life satisfaction among African American breast cancer survivors.

Purpose: To examine the relationships between spiritual health locus of control (SHLOC) and satisfaction with life in African American (AA) breast cancer survivors (BCS).Methods: A total of 118 AABCS completed a mailed survey. Logistic regression models were used to examine relationships among variables of interest.Results: Annual income and SHLOC were significantly associated with life satisfaction. In unadjusted analyses, high overall SHLOC increased the odds (odds ratio [OR] = 2.8) of being satisfied with life. The adjusted relationships between SHLOC and life satisfaction differed by income level. Among survivors with lower incomes, high spiritual life/faith and God's grace subscale scores increased the odds of life satisfaction, when compared to those with higher incomes.Conclusions: Our data indicated that high overall SHLOC was significantly related to higher odds of life satisfaction. Further, SHLOC may serve as a resource to bolster life satisfaction, especially in low-income AA BCS.

CE: Assessing and Managing Spiritual Distress in Cancer Survivorship.

More than 67% of people diagnosed with cancer in the United States are alive five years after receiving the diagnosis; but even if they are cancer free, the effects of the disease and its treatment will remain with them for the rest of their lives. Distress, which can be of a psychological, social, physical, or spiritual nature, is common among cancer survivors. Spiritual distress is a broad concept that is not necessarily associated with any specific religious beliefs, practices, or affiliations. Both religious and nonreligious people may have a strong sense of spirituality and may experience spiritual distress at various points throughout cancer survivorship. But clinicians often neglect to explore the spiritual components of distress, and despite the well-established association between spiritual well-being and quality of life, few of the instruments designed to assess the care needs of cancer survivors address spiritual needs. Through a composite clinical case, this article illustrates how nurses can incorporate into practice evidence-based recommendations for assessing and managing spiritual distress in cancer survivors.

The efficacy and cost-effectiveness of patient navigation programs across the cancer continuum: A systematic review.

Published studies regarding patient navigation (PN) and cancer were reviewed to assess quality, determine gaps, and identify avenues for future research. The PubMed and EMBASE databases were searched for studies investigating the efficacy and cost-effectiveness of PN across the cancer continuum. Each included article was scored independently by 2 separate reviewers with the Quality Assessment Tool for Quantitative Studies. The current review identified 113 published articles that assessed PN and cancer care, between August 1, 2010, and February 1, 2018, 14 of which reported on the cost-effectiveness of PN programs. Most publications focused on the effectiveness of PN in screening (50%) and diagnosis (27%) along the continuum of cancer care. Many described the effectiveness of PN for breast cancer (52%) or colorectal cancer outcomes (51%). Most studies reported favorable outcomes for PN programs, including increased uptake of and adherence to cancer screenings, timely diagnostic resolution and follow-up, higher completion rates for cancer therapy, and higher rates of attending medical appointments. Cost-effectiveness studies showed that PN programs yielded financial benefits. Quality assessment showed that 75 of the 113 included articles (65%) had 2 or more weak components. In conclusion, this review indicates numerous gaps within the PN and cancer literature where improvement is needed. For example, more research is needed at other points along the continuum of cancer care outside of screening and diagnosis. In addition, future research into the effectiveness of PN for understudied cancers outside of breast and colorectal cancer is necessary along with an assessment of cost-effectiveness and more rigorous reporting of study designs and results in published articles.

The Association of Percent Body Fat and Lean Mass With HbA1c in US Adults.

CONTEXT: Body fat and body composition distribution patterns affect diabetes risk and glycemic control, but most studies use proxy measures (e.g., body mass index). OBJECTIVE: This study examined the association of percent body fat and lean mass with glycated hemoglobin (HbA1c) in US adults. DESIGN: The National Health and Nutrition Examination Survey (NHANES) is a program of cross-sectional studies that enroll nationally representative samples of the US civilian noninstitutionalized population. SETTING: NHANES is designed to assess the health status of adults and children throughout the United States. PARTICIPANTS: This study included 11,125 participants aged 18 to 69 years from the 1999 through 2006 NHANES, comprising 846 persons with diagnosed diabetes and 10,125 without diabetes. MAIN OUTCOME MEASURES: Total and abdominal (trunk) percent body fat and lean mass were measured using dual-energy x-ray absorptiometry. Linear and logistic regression analyses were used to examine their association with HbA1c. RESULTS: Among those without diagnosed diabetes, total and trunk percent body fat, as well as trunk and total lean mass, were strongly associated with elevated HbA1c; odds ratios per 5% increment for the association of percent body fat with HbA1c >5.7% (39 mmol/mol) ranged from 1.60 to 2.01 across age and sex categories. Among adults with diabetes, higher total percent fat was associated with higher HbA1c in males age <40 years and higher trunk fat was associated with higher HbA1c in females across age categories. CONCLUSIONS: Lifestyle interventions to lower HbA1c should consider targeting both weight loss and body composition.