Breast cancer screening attitudes, beliefs, and behaviors of Zuni Pueblo women: identifying cornerstones for building effective mammogram screening intervention programs.

PURPOSE: Breast cancer is the leading form of cancer and has the second highest mortality rate of cancers for American Indian/Alaska Native (AI/AN) women. Early screening is critical. This study examines the breast cancer-related knowledge, beliefs, and behaviors of Zuni women in the Southwest United States (U.S.). METHODS: In 2020 and 2021, a survey was administered to better understand cancer screening patterns in Zuni Pueblo; 110 women from 50 to 75 years of age were recruited to respond to the breast cancer screening portion. Inclusion criteria included self-identifying as AI, a member of the Zuni tribe, or married to a Zuni tribal member, and meeting the age and gender requirements. Descriptive statistics and bivariate analyses were conducted examining the associations between measures of breast cancer knowledge, beliefs, and behaviors and breast cancer screening status (never, ever/non-compliant, and ever/compliant). RESULTS: Of survey participants, 47.3% have had a breast cancer screening and are up-to-date, 39.1% have had a screening in the past but are not up-to-date, and 13.6% have never been screened. Age was the only statistically significant socioeconomic predictor of breast cancer screening; the median (interquartile range) ages of each group are 62 (54, 68) ever/compliant, 56 (54, 68) ever/non-compliant, and 53 (51, 55) never (p-value < 0.001). Significant differences by health status and access to medical care include having a regular health care provider and going to see a provider for routine check-ups. The survey also shows differences in knowledge about breast cancer risk factors, beliefs, and behaviors. Women across all three screening statuses reported that they would get screened if encouraged by a health care provider. CONCLUSION: While survey respondents report a relatively high rate of ever having had a breast cancer screening, less than half are compliant with screening guidelines, which shows there is an opportunity to improve breast cancer screening rates. With culturally tailored interventions, providers have the potential to improve breast cancer screening for Zuni women.

Colorectal Cancer Screening Among Adults in Zuni Pueblo: Factors Associated with FOBT and Colonoscopy Utilization.

Although strategies to mitigate barriers to colorectal cancer (CRC) screening have proven successful in some parts of the US, few of these strategies have been studied in rural, American Indian communities that may exhibit unique culturally driven attitudes toward and knowledge of colorectal cancer and experience increased barriers to healthcare access. In this study, we describe the results of a survey among CRC screen-eligible members of Zuni Pueblo (N = 218) on an array of questions regarding CRC screening behaviors, knowledge, satisfaction with and access to healthcare services, social support for CRC screening, perceptions toward FOBT, and preference for evidence-based interventions or strategies for improving CRC screening rates. Results from the multivariable model suggest age, having a regular healthcare provider, and harboring fewer negative perceptions toward FOBT are key drivers of ever completing CRC screening. Respondents reported strong support for Community Guide-recommended interventions and strategies for increasing CRC screening for nearly all proposed interventions. Results confirm the need for multilevel, multicomponent interventions, with a particular focus on improving Zuni Pueblo community members' access to a regular source of care, improving knowledge of CRC risk factor, and addressing negative perceptions toward CRC screening. These results provide critical, community-specific insight into better understanding the drivers of low guideline-adherent screening rates and inform local healthcare providers and community leaders of context-specific strategies to improve CRC screening in Zuni Pueblo.

Health Literacy, Health Numeracy, and Cancer Screening Patterns in the Zuni Pueblo: Insights from and Limitations of "Standard" Questions.

American Indians experience disparities in cancer screening, stage at disease diagnoses, and 5-year cancer survival. This study investigates how health literacy and health numeracy may be linked to cancer screening behaviors of Zuni Pueblo members using a survey exploring screening behaviors related to breast, cervical, and colorectal cancers. As part of a larger community-based cancer prevention and control project, Zuni Health Initiative staff conducted surveys from October 2020 through April 2021 of 281 participants (men ages 50-75 and women ages 21-75) from the Zuni Pueblo. Bivariate and multivariable analyses investigated associations between health literacy/numeracy measures and cancer screening behaviors. Bivariate analyses showed some associations between distinct measures of health literacy/numeracy and colorectal cancer (CRC) screening, including both colonoscopy (health literacy) and fecal occult blood testing (FOBT) (health numeracy), as well as cervical cancer screening (health literacy). There were no statistically significant associations between health literacy/numeracy measures and mammogram screening for breast cancer. In multivariable analyses, there were no consistent patterns between health literacy/numeracy and screening for any cancer. There are some individual findings worth noting, such as statistically significant findings for health numeracy and FOBT (those reporting lower health numeracy were less likely to report FOBT). An important finding of this study is that questions used to assess health literacy/numeracy did not identify associations aligned with previous research. We reflect on the ways the "standard" questions may not be sufficiently tailored to the Zuni experience and may contribute to health equity barriers.

Cervical Cancer Knowledge and Screening Patterns in Zuni Pueblo Women in the Southwest United States.

American Indian women experience cervical cancer disparities, including later-stage diagnosis and a higher cervical cancer mortality rate. These disparities are interconnected and linked to cervical cancer screening disparities. Cervical cancer when identified early is highly treatable. Individual- and health system-level factors often contribute to gaps in cervical cancer screening. To better understand the source of these inequities experienced by American Indian women, specifically Zuni women, this paper examines how knowledge about cervical cancer and related risk factors is linked to cervical cancer screening for Zuni women using primary data gathered by the Zuni Health Initiative in 2020 and 2021. We find that of the women who completed the survey (n = 171), women with greater cervical cancer knowledge are statistically significantly more likely to have received cervical cancer screening. Closer examination of knowledge on the specific risk factors for cervical cancer provides evidence upon which to develop a cervical cancer education intervention.

Piloting the Sexual and Gender Minority Cancer Curricular Advances for Research and Education (SGM Cancer CARE) Workshop: Research Training in the Service of SGM Cancer Health Equity.

The purpose of this study is to describe the context, curriculum design, and pilot evaluation of the educational program "Sexual and Gender Minority Cancer Curricular Advances for Research and Education" (SGM Cancer CARE), a workshop for early-career researchers and healthcare providers interested in gaining knowledge and skills in sexual and gender minority (SGM) cancer research and healthcare advocacy. A needs assessment of a sample of clinicians and researchers (n = 104) and feedback from an Advisory Board informed the curriculum design of the SGM Cancer CARE workshop. Four SGM-tailored modules, focusing on epidemiology, clinical research, behavioral science and interventions, and community-based participatory approaches, were developed and tested in a 2.5-day virtual format among 19 clinicians and researchers. A fifth module to provide feedback to participants on brief presentations about their SGM cancer research ideas or related efforts was added later. A mixed-methods evaluation comprised of pre- and post-modular online evaluation surveys and virtual focus groups was used to determine the degree to which the workshop curriculum met participant needs. Compared to pre-module evaluations, participants reported a marked increase in SGM cancer research knowledge in post-module scores. Quantitative results were supported by our qualitative findings. In open field response survey questions and post-workshop focus groups, participants reported being extremely pleased with the content and delivery format of the SGM Cancer CARE workshop. Participants did regret not having the opportunity to connect with instructors, mentors, and colleagues in person. The SGM Cancer CARE curriculum was shown to increase the knowledge, skills, and level of preparedness of early-career clinicians and scientists to conduct culturally relevant and appropriate research needed to improve care for SGM persons across the cancer care continuum from prevention to survivorship.

Patient, provider, and nurse preferences of patient reported outcomes (PRO) and side effect management during cancer treatment of underrepresented racial and ethnic minority groups, rural and economically disadvantaged patients: a mixed methods study.

PURPOSE: The purpose of this study was to evaluate patient, oncologist and nurse perspectives on side effects and patient reported outcomes (PROs) with the question of how to optimize side effect management and PRO tools in this unique population. METHODS: This pilot study utilized a mixed method explanatory design. Patients receiving intravenous (IV) chemotherapy from June to August 2020 were surveyed about side effect burden and PRO system preferences. Providers and nurses (PN) completed complementary surveys. Semi-structured phone interviews were conducted among a subset of each group. RESULTS: Of 90 patient surveys collected; 51.1% minority, 35.6% rural, and 40.0% income < $30,000, 48% felt side effect management was a significant issue. All patients reported access to a communication device but 12.2% did not own a cell phone; 68% smart phone, 20% cell phone, 22% landline, 53% computer, and 39% tablet. Patients preferred a response to reported side effects within 0-3 h (73%) while only 29% of the 55 PN surveyed did (p < 0.0001). Interviews reinforced that side effect burden was a significant issue, the varied communication devices, and a PRO system could improve side effect management. CONCLUSION: In a non-White, rural and low-income patient population, 87.8% of patients reported owning a cell phone. Although all agreed side effect management was a prominent issue, expectations between patients and PN differed substantially. Qualitative data echoed the above and providing concrete suggestions to inform development of a PRO program and side effect mitigation strategies among a diverse patient population.

Divergent Diels-Alder Reactions in the Biosynthesis and Synthesis of Endiandric-Type Tetracycles: A Computational Study.

Endiandric acids and related polyketide natural products arise from polyene precursors and occur naturally as fused and bridged tetracycles. In some cases, the intramolecular Diels-Alder reactions that produce fused and bridged tetracycles result from a diene tether that may act as either a 4π or 2π component in the cycloaddition. To examine the preference for fused or bridged products, we applied density functional theory (using the M06-2X and B3LYP functionals) to reactants with various substituents for both fused and bridged transition states. Fused products were generally preferred except when disfavored by extreme steric hindrance (e.g., a tert-butyl group). These computational results are consistent with experimental data and suggest the existence of as-yet undiscovered natural products.

Developing questions to assess and measure patients' perceived survival benefit from adjuvant endocrine therapy in breast cancer: a mixed methods pilot study.

This mixed method study developed multiple question types to understand and measure women's perceived benefit from adjuvant endocrine therapy. We hypothesis that patients do not understand this benefit and sought to develop the questions needed to test this hypothesis and obtain initial patient estimates. From 8/2022 to 3/2023, qualitative interviews focused on assessing and modifying 9 initial varied question types asking about the overall survival (OS) benefit from adjuvant endocrine therapy. Subsequent focus groups modified and selected the optimal questions. Patients' self-assessment of their OS benefit was compared to their individualized PREDICT model results. Fifty-three patients completed the survey; 42% Hispanic, 30% rural, and 47% with income < $39,999 per year. Patients reported adequate health care literacy (61.5%) and average confidence about treatment and medication decisions 49.4 (95% CI 24.4-59.5). From the original 9 questions, 3 modified questions were ultimately found to capture patients' perception of this OS benefit, focusing on graphical and prose styles. Patients estimated an OS benefit of 42% compared to 4.4% calculated from the PREDICT model (p < 0.001). In this group with considerable representation from ethnic minority, rural and low-income patients, qualitative data showed that more than one modality of question type was needed to clearly capture patients' understanding of treatment benefit. Women with breast cancer significantly overestimated their 10-year OS benefit from adjuvant endocrine therapy compared to the PREDICT model.

Developing Questions to Assess and Measure Patients' Perceived Survival Benefit from Adjuvant Endocrine Therapy in Breast Cancer: A Mixed Methods Pilot Study.

Purpose: This mixed methods study developed multiple question types to understand and measure women's perceived benefit from adjuvant endocrine therapy. We hypothesis that patients do not understand this benefit and sought to develop the questions needed to test this hypothesis and obtain initial patient estimates. Methods: From 8/2022 to 3/2023, qualitative interviews focused on assessing and modifying 9 initial varied question types asking about the overall survival (OS) benefit from adjuvant endocrine therapy. Subsequent focus groups modified and selected the optimal questions. Patients' self-assessment of their OS benefit was compared to their individualized PREDICT model results. Results: Fifty-three patients completed the survey; 42% Hispanic, 30% rural, and 47% with income <$39,999 per year. Patients reported adequate health care literacy (61.5%) and average confidence about treatment and medication decisions 49.4 (95% CI 24.4-59.5). From the original 9 questions, 3 modified questions were ultimately found to capture patients' perception of this OS benefit, focusing on graphical and prose styles. Patients estimated an OS benefit of 42% compared to 4.4% calculated from the PREDICT model (p < 0.001). Conclusion: In this group with considerable representation from ethnic minority, rural and low-income patients, qualitative data showed that more than one modality of question type was needed to clearly capture patients' understanding of treatment benefit. Women with breast cancer significantly overestimated their 10-year OS benefit from adjuvant endocrine therapy compared to the PREDICT model.

Differing Experiences of Nutrition Care During Treatment Among Oncology Nurses, Providers, and Patients.

BACKGROUND: Provision of nutrition care for patients with cancer represents a key component of holistic oncology care. However, information is limited about the use and perceptions of registered dietitian-led nutrition care in the oncology setting. OBJECTIVES: This study aimed to better understand the experiences and expectations of patients and healthcare workers regarding nutrition care during outpatient cancer treatment. METHODS: Oncology care team members (N = 55) and patients (N = 90) completed a survey about their knowledge of and interest in nutrition care. A subset of participants completed semistructured interviews to capture experiences with and perspectives on nutrition care practices. FINDINGS: The majority of patients (n = 73) reported experiencing at least one nutrition impact symptom, but only 14 indicated that they frequently discussed nutrition during provider visits. In addition, 40 oncology care team members indicated frequently discussing nutrition at visits, although 13 were unaware of local nutrition resources.

Preferences for CPSTF-Recommended Intervention Approaches for Increasing Cancer Screening Among Screen-Eligible Adults in Zuni Pueblo, USA.

We identified preferences toward Community Preventive Services Task Force (CPSTF)-recommended intervention approaches among screen-eligible Zuni Pueblo members in New Mexico, USA and assessed if there were significant differences in those preferences, with the goal of informing the selection of intervention approaches for use in the Zuni Pueblo. We utilize data from a population-based survey (n = 280) focused on 15 CPSTF-recommended intervention approaches designed to improve screening for cervical, breast, and/or colorectal cancer screening. Model-adjusted results suggest some intervention approaches garnered significantly higher support than others. We offer six, data-driven recommendations for consideration by public health practitioners as they endeavor to improve cancer prevention in the Zuni Pueblo. This study provides a replicable model for other public health practitioners and health services researchers to incorporate community preferences in community-level intervention approach selection.

American Indian/Alaska Native and black colon cancer patients have poorer cause-specific survival based on disease stage and anatomic site of diagnosis.

OBJECTIVES: Studies of race-specific colon cancer (CC) survival differences between right- vs. left-sided CC typically focus on Black and White persons and often consider all CC stages as one group. To more completely examine potential racial and ethnic disparities in side- and stage-specific survival, we evaluated 5-year CC cause-specific survival probabilities for five racial/ethnic groups by anatomic site (right or left colon) and stage (local, regional, distant). METHODS: We obtained cause-specific survival probability estimates from National Cancer Institute's population-based Surveillance, Epidemiology, and End Results (SEER) for CC patients grouped by five racial/ethnic groups (Non-Hispanic American Indian/Alaska Native [AIAN], Non-Hispanic Asian/Pacific Islander [API], Hispanic, Non-Hispanic Black [NHB], and Non-Hispanic White [NHW]), anatomic site, stage, and other patient and SEER registry characteristics. We used meta-regression approaches to identify factors that explained differences in cause-specific survival. RESULTS: Diagnoses of distant-stage CC were more common among NHB and AIAN persons (>22 %) than among NHW and API persons (< 20 %). Large disparities in anatomic site-specific survival were not apparent. Those with right-sided distant-stage CC had a one-year cause-specific survival probability that was 16.4 % points lower (99 % CI: 12.2-20.6) than those with left-sided distant-stage CC; this difference decreased over follow-up. Cause-specific survival probabilities were highest for API, and lowest for NHB, persons, though these differences varied substantially by stage at diagnosis. AIAN persons with localized-stage CC, and NHB persons with regional- and distant-stage CC, had significantly lower survival probabilities across follow-up. CONCLUSIONS: There are differences in CC presentation according to anatomic site and disease stage among patients of distinct racial and ethnic backgrounds. This, coupled with the reality that there are persistent survival disparities, with NHB and AIAN persons experiencing worse prognosis, suggests that there are social or structural determinants of these disparities. Further research is needed to confirm whether these CC cause-specific survival disparities are due to differences in risk factors, screening patterns, cancer treatment, or surveillance, in order to overcome the existing differences in outcome.

Improving Sexual and Gender Minority Cancer Care: Patient and Caregiver Perspectives From a Multi-Methods Pilot Study.

Purpose: Up to 1 million lesbian, gay, bisexual, and transgender (i.e., sexual and gender minority, SGM) individuals in the United States have histories of cancer. This medically underserved population is diverse, with complex sexualities and gender identities, and distinct health concerns. SGM persons experience disproportionate risks for, and rates of, anal, breast, cervical, colorectal, endometrial, lung, and prostate cancers, in addition to cancers affecting transgender persons who have undergone sex-reassignment. SGM individuals are linked by shared experiences of stigmatization as a minority population for which little cancer research has been conducted. SGM cancer patients frequently report reluctance to seek healthcare, have poorer outcomes following diagnosis, engage in elevated risk behaviors (i.e. smoking and alcohol use) even after cancer diagnosis, have difficulty making emotional adjustment to illness, and experience higher rates of psychological distress. They report less satisfaction with cancer care, deficiencies in patient-centeredness and shared decision-making, gaps in care, and social isolation. Minority stress resulting from experiences of anti-SGM sentiment and discrimination affects cancer patients and their informal cancer caregivers. Our paper presents findings from a pilot study to identify gaps and opportunities to improve cancer care for SGM patients and caregivers at the University of New Mexico Comprehensive Cancer Center. Methods: Between June 2020 and July 2021, we used a multi-methods research design informed by ecological theory to collect qualitative and quantitative data regarding cancer patient and caregiver quality of life (QoL) and experiences of cancer and survivorship care. We used PROMIS measures distributed via REDCap to assess QoL (i.e., fatigue, pain interference, pain intensity, anxiety, depression, emotional support, social isolation, and companionship), and conducted in-depth semi-structured interviews. We recruited 10 SGM cancer patients and 8 heterosexual, cisgender (H/C) patient matches, and their self-identified informal cancer caregivers (n=36, dyad total n=18). Interviews ranged from 1 to 2 hours, were audio-recorded and transcribed for analysis. The study was approved by the University of New Mexico Human Research Protections Office Institutional Review Board. Results: Results of the PROMIS QoL assessments indicated that SGM patients reported greater anxiety [mean (SD) = 54.5 (8.8)] and depression [mean (SD) = 49.3 (4.8)] than H/C patients [mean (SD)=51.6 (7.5) and 45.4 (6.8) respectively], while heterosexual, cisgender (H/C) patients reported higher fatigue [mean (SD) =52.04 (8.18)] and stronger pain intensity than SGM patients [mean (SD)=48.3 (9.1) and 37.8 (9.1) respectively]. SGM patients reported higher levels of social isolation [mean (SD) = 48.3 (7.3) vs. 42.1 (7.4) for H/C patients, whereas H/C patients reported more emotional support (mean (SD) =57.5 (9.3) vs. 53.0 (6.9)] and companionship [mean (SD) = 55.2 (8.6) vs. 51.5 (11.0)]. SGM and H/C differences in caregiver QoL were most notable with regards to higher levels of fatigue [mean (SD) = 47.1 (6.0) for SGM, and 42.4 (11.5) for H/C] and companionship [mean (SD) = 55.3 (6.0) for SGM, and 50.9 (5.5) for H/C]. Qualitative interviews supported our quantitative results. SGM patients and caregivers articulated experiences of anti-SGM stigma and discrimination contributing to minority stress that influenced their initial cancer care encounters. SGM dyads had more trepidation and/or medical mistrust during initial cancer care encounters when compared to H/C patients and caregivers. SGM patients questioned care that was not culturally responsive to SGM preferences, while H/C patients were more apt to identify gaps in communication and perceived lack of clarity regarding cancer care delivery. Although SGM patients experienced high satisfaction with their cancer care once they developed trust with their providers, they discussed desires to have more direct conversations with their oncologists about their sexual orientation and gender identities and sexual health. All patients and providers in the study (SGM and H/C) appreciated their oncology care teams. All patients and caregivers relied on social networks comprised of friends and family, although SGM patients and caregivers had smaller social networks and relied less on biological family, and single SGM individuals experienced challenges accessing cancer care and struggled with social isolation. We discovered too, that all caregivers, regardless of Sexual Orientation and Gender Identity (SOGI), perceived a lack of support and information pertaining to their loved one's treatment, side effects and best way to provide care. Conclusions: This study demonstrates that prior stigmatizing experiences contribute to minority stress and medical mistrust for SGM cancer patients and their informal caregivers across the cancer care experience. Findings point to specific gaps in SGM cancer patient care, including lack of conversation about patient SOGI, inadequate staff and oncology provider SGM specific knowledge and cultural competence/cultural humility training, and insufficient patient supports for those who lack social support during cancer care treatment. Further, this study reveals inadequacies in SGM specific support, and overall support services for informal cancer caregivers. Additional research is required to develop targeted interventions to address minority stress and clinic environment concerns to improve cancer care for SGM patients. Importantly, while there were differences between SGM and H/C experiences of cancer treatment, significant similarities also emerged. Caregiver expressed consensus about the current lack of support and guidance for informal caregivers of cancer patients. Future work should focus on providing caregiver-specific resources in the clinic setting and facilitating support groups for caregivers to network with one another, as well as for tailoring SGM specific caregiver support services. Our findings highlight areas for improving cancer care for the SGM community, as well as a broader population of patients and caregivers.