Population screening shows risk of inherited cancer and familial hypercholesterolemia in Oregon.

The Healthy Oregon Project (HOP) is a statewide effort that aims to build a large research repository and influence the health of Oregonians through providing no-cost genetic screening to participants for a next-generation sequencing 32-gene panel comprising genes related to inherited cancers and familial hypercholesterolemia. This type of unbiased population screening can detect at-risk individuals who may otherwise be missed by conventional medical approaches. However, challenges exist for this type of high-throughput testing in an academic setting, including developing a low-cost high-efficiency test and scaling up the clinical laboratory for processing large numbers of samples. Modifications to our academic clinical laboratory including efficient test design, robotics, and a streamlined analysis approach increased our ability to test more than 1,000 samples per month for HOP using only one dedicated HOP laboratory technologist. Additionally, enrollment using a HIPAA-compliant smartphone app and sample collection using mouthwash increased efficiency and reduced cost. Here, we present our experience three years into HOP and discuss the lessons learned, including our successes, challenges, opportunities, and future directions, as well as the genetic screening results for the first 13,670 participants tested. Overall, we have identified 730 pathogenic/likely pathogenic variants in 710 participants in 24 of the 32 genes on the panel. The carrier rate for pathogenic/likely pathogenic variants in the inherited cancer genes on the panel for an unselected population was 5.0% and for familial hypercholesterolemia was 0.3%. Our laboratory experience described here may provide a useful model for population screening projects in other states.

REPRESENT recommendations: improving inclusion and trust in cancer early detection research.

Detecting cancer early is essential to improving cancer outcomes. Minoritized groups remain underrepresented in early detection cancer research, which means that findings and interventions are not generalisable across the population, thus exacerbating disparities in cancer outcomes. In light of these challenges, this paper sets out twelve recommendations to build relations of trust and include minoritized groups in ED cancer research. The Recommendations were formulated by a range of stakeholders at the 2022 REPRESENT consensus-building workshop and are based on empirical data, including a systematic literature review and two ethnographic case studies in the US and the UK. The recommendations focus on: Long-term relationships that build trust; Sharing available resources; Inclusive and accessible communication; Harnessing community expertise; Unique risks and benefits; Compensation and support; Representative samples; Demographic data; Post-research support; Sharing results; Research training; Diversifying research teams. For each recommendation, the paper outlines the rationale, specifications for how different stakeholders may implement it, and advice for best practices. Instead of isolated recruitment, public involvement and engagement activities, the recommendations here aim to advance mutually beneficial and trusting relationships between researchers and research participants embedded in ED cancer research institutions.

Equitable implementation of lung cancer screening: avoiding its potential to mirror existing inequities among people who use tobacco.

PURPOSE: Lung cancer is the leading cause of cancer death, but the advent of lung cancer screening using low-dose computed tomography offers a tremendous opportunity to improve lung cancer outcomes. Unfortunately, implementation of lung cancer screening has been hampered by substantial barriers and remains suboptimal. Specifically, the commentary emphasizes the intersectionality of smoking history and several important sociodemographic characteristics and identities that should inform lung cancer screening outreach and engagement efforts, including socioeconomic considerations (e.g., health insurance status), racial and ethnic identity, LGBTQ + identity, mental health history, military experience/veteran status, and geographic residence in addressing specific community risk factors and future interventions in efforts to make strides toward equitable lung cancer screening. METHODS: Members of the Equitable Implementation of Lung Cancer Screening Interest Group with the Cancer Prevention and Control Network (CPCRN) provide a critical commentary based on existing literature regarding smoking trends in the US and lung cancer screening uptake to propose opportunities to enhance implementation and support equitable distribution of the benefits of lung cancer screening. CONCLUSION: The present commentary utilizes information about historical trends in tobacco use to highlight opportunities for targeted outreach efforts to engage communities at high risk with information about the lung cancer screening opportunity. Future efforts toward equitable implementation of lung cancer screening should focus on multi-level implementation strategies that engage and work in concert with community partners to co-create approaches that leverage strengths and reduce barriers within specific communities to achieve the potential of lung cancer screening.

Rural research capacity: a co-created model for research success.

PURPOSE: The United States' National Institutes of Health (NIH) have long challenged academia to improve clinical trial enrollment, especially in underrepresented populations; inclusive of geography, age, disability status, racial and ethnic minorities. It has been shown that rural and urban residents enrolled in clinical trials have similar outcomes, yet, rural healthcare systems struggle to provide opportunities to rural residents to participate in clinical trials when infrastructure is limited or unsupportive of research programs and/or research staffing levels are insufficient. To fully address the barriers to clinical trial access in rural areas, it is not adequate to simply open more trials. Community receptivity of research as well as organizational and community capacity must be considered. This project was determined by the Oregon Health and Science University's Institutional Review Board to be generalizable research across the chosen counties and was approved to operate under a waiver of written consent. Participants received a cash incentive in appreciation for their time and verbally agreed to participate after reviewing a project information sheet. METHODS: The research team co-created a community-responsive approach to the receipt, review, and acceptance of clinical trials in a rural community setting. An adapted 5 step Implementation Mapping approach was used to develop a systematic strategy intended to increase the success, and therefore, the number of clinical trials offered in a rural community. RESULTS: The research team and participating rural community members pilot-tested the implementation of a co-designed research review strategy, inclusive of a Regional Cultural Landscape and three co-created project submission and feasibility review forms, with a cancer early detection clinical trial. The proposed clinical trial required engagement from primary care and oncology. Utilizing the research review strategy demonstrated strong researcher-community stakeholder communication and negotiation, which resulted in early identification and resolution of potential barriers, hiring a local clinical research coordinator, and timely trial opening. CONCLUSION: To the knowledge of the research team, the work described is the first to use a community-engaged approach for creating a clinical trial implementation strategy directly supportive of rural-sitting community stakeholders in receiving, reviewing, and approving cancer-related clinical trials in their community. Participating community members and leaders had the chance to negotiate research protocol changes or considerations directly with researchers interested in conducting a cancer clinical trial in their rural setting.

Disparities in pancreatic cancer care and research in Native Americans: Righting a history of wrongs.

Disparities in pancreatic cancer incidence and outcomes exist in Native American populations. These disparities are multifactorial, difficult to quantify, and are influenced by historical, socioeconomic, and health care structural factors. The objective of this article was to assess these factors and offer a call to action to overcome them. The authors reviewed published data on pancreatic cancer in Native American populations with a focus on disparities in incidence, outcomes, and research efforts. The historical context of the interactions between Native Americans and the United States health care system was also analyzed to form actionable items to build trust and collaboration. The incidence of pancreatic cancer in Native Americans is higher than that in the general US population and has the worst survival of any major racial or ethnic group. These outcomes are influenced by a patient population with often poor access to high-quality cancer care, historical trauma potentially leading to reduced care utilization, and a lack of research focused on etiologies and comorbid conditions that contribute to these disparities. A collaborative effort between nontribal and tribal leaders and cancer centers is key to addressing disparities in pancreatic cancer outcomes and research. More population-level studies are needed to better understand the incidence, etiologies, and comorbid conditions of pancreatic cancer in Native Americans. Finally, a concerted, focused effort should be undertaken between nontribal and tribal entities to increase the access of Native Americans to high-quality care for pancreatic cancer and other lethal malignancies.

Identify factors for insufficient (> 2 yr) mammogram screening among Oregonian women.

PURPOSE: Women with breast cancer diagnosed from mammogram screenings have a lower mortality risk than women diagnosed from symptoms. Currently, the U.S Preventive Services Task Force recommends biannual screening for women aged 50-74 years old. In this study, we aimed to identify factors associated with inadequate screening defined as "no mammogram screening within past 2 years" to guide cancer prevention and early detection efforts. METHODS: This study utilized area-based probabilistic sampling survey data, collected across Oregon in 2019. Dataset weights were calculated using a raking approach. Demographic and behavior information were collected with existing validated questionnaire items from national surveys. Weighted multivariable logistic regression analyses with missing-value imputations were conducted to identify factors associated with inadequate mammogram screening. RESULTS: The study included 254 women 50-74 years old without previous breast or ovarian cancer history. 19.29% of the sample reported no mammogram within two years, including 1.57% with no previous mammograms. Following unadjusted analyses, the significant factors included education, occupation status, health insurance and smoking and were therefore included into the adjusted model. In the multivariate adjusted model education remained significant while occupation status, health insurance and smoking were no longer significant. Compared to women with a college graduate degree, women with less than college graduate degree were at higher risk of inadequate screening [OR (95% CI) = 3.23 (1.54, 6.74)]. CONCLUSIONS: Lack of education was significantly associated with inadequate mammogram screening even after adjusting for occupation status, health insurance and smoking, which should prompt further outreach and education.

Diet-Driven Inflammation and Insulinemia and Risk of Interval Breast Cancer.

Interval breast cancers (IBCs) emerge after a non-suspicious mammogram and before the patient's next scheduled screen. Risk factors associated with IBC have not been identified. This study evaluated if the empirical dietary inflammatory pattern (EDIP) or empirical dietary index for hyperinsulinemia (EDIH) scores are associated with IBC compared to screen-detected breast cancer. Data were from women 50-79 years-old in the Women's Health Initiative cohort who completed food frequency questionnaires at baseline (1993-98) and were followed through March 31, 2019 for breast cancer detection. Women were identified as having either IBC diagnosed within 1-year after their last negative screening mammogram (N = 317) or screen-detected breast cancer (N = 1,928). Multivariable-adjusted logistic regression analyses were used to estimate odds ratios for risk of IBC compared to screen-detected cancer in dietary index tertiles. No associations were observed between EDIP or EDIH and IBC. Odds ratios comparing the highest to the lowest dietary index tertile were 1.08; 95%CI, 0.78-1.48 for EDIP and 0.92; 95%CI, 0.67-1.27 for EDIH. The null associations persisted when stratified by BMI categories. Findings suggest that diet-driven inflammation or insulinemia may not be substantially associated with IBC risk among postmenopausal women. Future studies are warranted to identify modifiable factors for IBC prevention.

How cancer programs identify and address the financial burdens of rural cancer patients.

PURPOSE: Financial toxicity is associated with negative patient outcomes, and rural populations are disproportionately affected by the high costs of cancer care compared to urban populations. Our objective was to (1) understand cancer programs' perceptions of rural-urban differences in cancer patients' experiences of financial hardship, (2) evaluate the resources available to cancer patients across the rural-urban continuum, and (3) determine how rural and urban health care teams assess and address financial distress in cancer patients. METHODS: Seven research teams within the Cancer Prevention and Research Control Network conducted semi-structured interviews with cancer program staff who have a role in connecting cancer patients with financial assistance services in both rural and urban counties. Interviews were audio-recorded and transcribed. We identified themes using descriptive content and thematic analysis. RESULTS: We interviewed 35 staffs across 29 cancer care programs in seven states, with roughly half of respondents from programs in rural counties. Participants identified differences in rural and urban patients' experiences of financial hardship related to distance required to travel for treatment, underinsurance, and low socioeconomic status. Insufficient staffing was an identified barrier to addressing rural and urban patients' financial concerns. CONCLUSIONS: Improved financial navigation services could mitigate the effects of financial toxicity experienced by cancer patients, particularly rural patients, throughout treatment and survivorship. Future research is needed to improve how cancer programs assess financial hardship in patients and to expand financial navigation services to better serve rural cancer patients.

Sulforaphane Bioavailability and Chemopreventive Activity in Men Presenting for Biopsy of the Prostate Gland: A Randomized Controlled Trial.

Previous studies suggest compounds such as sulforaphane (SFN) derived from cruciferous vegetables may prevent prostate cancer development and progression. This study evaluated the effect of broccoli sprout extract (BSE) supplementation on blood histone deacetylase (HDAC) activity, prostate RNA gene expression, and tissue biomarkers (histone H3 lysine 18 acetylation (H3K18ac), HDAC3, HDAC6, Ki67, and p21). A total of 98 men scheduled for prostate biopsy were allocated into either BSE (200 µmol daily) or a placebo in our double-blind, randomized controlled trial. We used nonparametric tests to evaluate the differences of blood HDAC activity and prostate tissue immunohistochemistry biomarkers between treatment groups. Further, we performed RNA-Seq analysis on the prostate biopsies and identified 40 differentially expressed genes correlated with BSE treatment, including downregulation of two genes previously implicated in prostate cancer development, AMACR and ARLNC1. Although urine and plasma SFN isothiocyanates and individual SFN metabolites were statistically higher in the treatment group, our results did not show a significant difference in HDAC activity or prostate tissue biomarkers. This study indicates BSE supplementation correlates with changes in gene expression but not with several other prostate cancer biomarkers. More research is required to fully understand the chemopreventive effects of BSE supplementation on prostate cancer.

Public perception of predictive cancer genetic testing and research in Oregon.

The potential for using widespread genetic testing to inform health care has become a viable option, particularly for heritable cancers. Yet, little is known about how to effectively communicate the benefits and risks of both personal genetic testing and participation in biorepositories that aid scientific advancements. Nationwide efforts are engaging communities in large genetic studies to better estimate the population-wide prevalence of heritable cancers but have been met with hesitance or declination to participate in some communities. To successfully engage an Oregon population in longitudinal research that includes predictive genetic testing for pathogenic or likely pathogenic variants associated with an increased risk for cancer, researchers conducted 35 focus groups (two of which were held in Spanish) in 24 of Oregon's 36 counties to better understand knowledge and attitudes related to genetic testing and willingness to participate in longitudinal genetic research. A total of 203 adults (mean = 45.6 years; range 18-88), representing a range of education levels and prior knowledge of genetic research, participated in the focus groups. The majority (85%) of participants reported personal or family diagnoses of cancer (e.g., self, family, friends). A majority (87%) also reported a strong interest in cancer genetic testing and receiving genetic information about themselves. Nearly all focus groups (94%, 33 of 35 sites) included participant discussion citing their families (e.g., children, close relatives, and extended family members) as key motivators for participation in genetic research. For example, participants reported interest in increasing personal knowledge about their own and their families' cancer risks in order to respond proactively, if a pathogenic variant was found. While most focus groups (94%, 33 of 35 sites) included participant discussion describing barriers to predictive genetic, testing such as concerns about outcomes, the desire to learn about health risks in oneself mitigated or outweighed those fears for many participants. Other commonly reported concerns were related to potential mistrust of insurance companies, researchers, or institutions, or lack of knowledge about genetics, genetic testing, or genetic research. Participants, particularly in rural areas, highlighted critical factors for research recruitment, such as trust, personal interaction, public education about genetic research, and clear communication about study goals and processes. Our statewide findings reflect that public interest in predictive cancer genetic testing and cancer genetic research can surpass lack of knowledge of the complex topics, particularly when benefits for self and family are emphasized and when study considerations are well articulated.

An Evidence-Based Walking Program in Oregon Communities: Step It Up! Survivors.

Physical activity can help mitigate the long-term symptoms and side effects of cancer and its treatment, but most cancer survivors are not active enough to achieve these benefits. An evidence-based strategy to promote physical activity among adults is a community group-based walking program. However, many evidence-based programs do not achieve intended population health outcomes because of the challenges of real-world implementation. We used the Interactive Systems Framework for Dissemination and Implementation to conceptualize implementation of a capacity-building intervention to support delivery of a community group-based walking program. We adapted an evidence-based guide for community group-based walking programs for cancer survivors and their support network. We provided a capacity-building intervention (technical assistance and small-grant funding) and evaluated this implementation intervention. We assessed effectiveness of the intervention by measuring adoption, acceptability, appropriateness, feasibility, fidelity, implementation costs, and penetration through monthly progress reports, site visit observations, interviews, and a final report. Eight organizations received a small grant and technical assistance and implemented Step It Up! Survivors (SIUS). SIUS helped cancer survivors increase their physical activity, establish social connections, and be part of a supportive environment. Despite receiving monthly technical assistance, some grantees experienced challenges in recruiting participants, developing community partnerships, and adhering to the prescribed implementation plan. Implementation facilitators included community partners and specific components (eg, incentives for participants, webinars). Organizations needed different amounts and types of assistance with adaptation and implementation. Overall fidelity to SIUS ranged from 64% to 88%. Some integrated SIUS within existing organizational programming for sustainability. The provision of funding and technical assistance was a successful implementation intervention. Our results suggest a need to better tailor technical assistance while organizations are in the process of adapting, implementing, and sustaining an evidence-based program in their local communities.

Identifying and characterizing cancer survivors in the US primary care safety net.

BACKGROUND: Primary care providers must understand the use patterns, clinical complexity, and primary care needs of cancer survivors to provide quality health care services. However, to the authors' knowledge, little is known regarding the prevalence and health care needs of this growing population, particularly in safety net settings. METHODS: The authors identified adults with a history of cancer documented in primary care electronic health records within a network of community health centers (CHCs) in 19 states. The authors estimated cancer history prevalence among >1.2 million patients and compared sex-specific site distributions with national estimates. Each survivor was matched to 3 patients without cancer from the same set of clinics. The demographic characteristics, primary care use, and comorbidity burden then were compared between the 2 groups, assessing differences with absolute standardized mean differences (ASMDs). ASMD values >0.1 denote meaningful differences between groups. Generalized estimating equations yielded adjusted odds ratios (aORs) for select indicators. RESULTS: A total of 40,266 cancer survivors were identified (prevalence of 3.0% of adult CHC patients). Compared with matched cancer-free patients, a higher percentage of survivors had ≥6 primary care visits across 3 years (62% vs 48%) and were insured (83% vs 74%) (ASMD, >0.1 for both). Cancer survivors had excess medical complexity, including a higher prevalence of depression, asthma/chronic obstructive pulmonary disease, and liver disease (ASMD, >0.1 for all). Survivors had higher odds of any opioid prescription (aOR, 1.23; 95% CI, 1.19-1.27) and chronic opioid therapy (aOR, 1.27; 95% CI, 1.23-1.32) compared with matched controls (P < .001 for all). CONCLUSIONS: Identifying cancer survivors and understanding their patterns of utilization and physical and mental comorbidities present an opportunity to tailor primary health care services to this population.

Polymorphisms in oxidative stress pathway genes and prostate cancer risk.

PURPOSE: Age-related factors including oxidative stress play an important role in prostate carcinogenesis. We hypothesize that germline single-nucleotide polymorphisms (SNPs) in oxidative stress pathway are associated with prostate cancer (PCa) risk. In this study, we aim to examine which of these SNPs is associated with PCa. METHODS: Participants included in this analyses came from the "Genetic Susceptibility, Environment and Prostate Cancer Risk Study" conducted at the Veterans Affairs Portland Health Care System. After applying exclusion criteria, 231 PCa cases and 382 prostate biopsy-negative controls who had genotyping data on twenty-two single-nucleotide polymorphisms (SNPs) in six genes (MAPK14, NRF2, CAT, GPX1, GSTP1, SOD2, and XDH) associated with oxidative stress pathway were included in the analyses. The genotyping of SNPs was conducted by the Illumina BeadXpress VeraCode platform. We investigated these SNPs in relation to overall and aggressive PCa risk using logistic regression models controlling for relevant covariates. RESULTS: One SNP in the MAPK14 (rs851023) was significantly associated with incident PCa risk. Compared to men carrying two copies of allele A, the presence of one or two copies of the G allele was associated with decreased risk of PCa [OR (95% CI) 0.19 (0.06-0.51)]. There was no statistically significant association between other SNPs in the NRF2, CAT, GPX1, GSTP1, SOD2, and XDH genes and PCa risk. CONCLUSIONS: The MAPK14 gene SNP rs851023 was associated with PCa and aggressive PCa risk after multiple comparison adjustment. Further studies in other populations or functional studies are needed to validate the finding.

The Cancer Prevention and Control Research Network: Accelerating the implementation of evidence-based cancer prevention and control interventions.

This editorial provides a high level overview of the articles included in this supplement.

An application of the Science Impact Framework to the Cancer Prevention and Control Research Network from 2014-2018.

The Cancer Prevention and Control Research Network (CPCRN) is a strategic collaborative effort focused on accelerating the dissemination and implementation of evidence-based cancer prevention and control interventions to communities. In 2014, the CPCRN Coordinating Center began collecting information in alignment with the Centers for Disease Control and Prevention's (CDC) Science Impact Framework. The Science Impact Framework is a CDC-developed approach to trace and link CDC science to events and/or actions recognized as influential to public health, beyond peer-reviewed publications. The purpose of this paper is to highlight the impact of CPCRN activities using key indicators guided by the CDC's Science Impact Framework. We reviewed annual progress reports submitted by CPCRN centers from 2014 to 2019 to identify the impact indicators. The CPCRN activities were linked to four domains from the Science Impact Framework and its key indicators: Disseminating Science (presentations, training, general communication, and other communication reports), Creating Awareness (requests for expertise, and feedback), Catalyzing Action (grant applications, partnerships and collaborations, research & development, advocacy groups, office practice/point of care changes, and technology creating), and Effecting Change (building public health practice, creation of registries/surveillance, legal/policy changes, and change instilled). Overall, CPCRN activities demonstrate impact beyond peer-reviewed publications and thus should continue building scientific impact to ultimately influence health outcomes.

Financial hardship among rural cancer survivors: An analysis of the Medical Expenditure Panel Survey.

Some cancer survivors report spending 20% of their annual income on medical care. Undue financial burden that patients face related to the cost of care is referred to as financial hardship, which may be more prevalent among rural cancer survivors. This study examined contrasts in financial hardship among 1419 rural and urban cancer survivors using the 2011 Medical Expenditure Panel Survey supplement - The Effects of Cancer and Its Treatment on Finances. We combined four questions, creating a measure of material financial hardship, and examined one question on financial worry. We conducted multivariable logistic regression analyses, which produced odds ratios (OR) for factors associated with financial hardship and worry, and then generated average adjusted predicted probabilities. We focused on rural and urban differences classified by metropolitan statistical area (MSA) designation, controlling for age, education, race, marital status, health insurance, family income, and time since last cancer treatment. More rural cancer survivors reported financial hardship than urban survivors (23.9% versus 17.1%). However, our adjusted models revealed no significant impact of survivors' MSA designation on financial hardship or worry. Average adjusted predicted probabilities of financial hardship were 18.6% for urban survivors (Confidence Interval [CI]: 11.9%-27.5%) and 24.2% for rural survivors (CI: 15.0%-36.2%). For financial worry, average adjusted predicted probabilities were 19.9% for urban survivors (CI: 12.0%-31.0%) and 18.8% for rural survivors (CI: 12.1%-28.0%). Improving patient-provider communication through decision aids and/or patient navigators may be helpful to reduce financial hardship and worry regardless of rural-urban status.

Rural-urban differences in financial burden among cancer survivors: an analysis of a nationally representative survey.

PURPOSE: Rural cancer survivors may disproportionately experience financial problems due to their cancer because of greater travel costs, higher uninsured/underinsured rates, and other factors compared to their urban counterparts. Our objective was to examine rural-urban differences in reported financial problems due to cancer using a nationally representative survey. METHODS: We used data from three iterations of the National Cancer Institute's Health Information and National Trends Survey (2012, 2014, and 2017) to identify participants who had a previous or current cancer diagnosis. Our outcome of interest was self-reported financial problems associated with cancer diagnosis and treatment. Rural-urban status was defined using 2003 Rural-Urban Continuum Codes. We calculated weighted percentages and Wald chi-square statistics to assess rural-urban differences in demographic and cancer characteristics. In multivariable logistic regression models, we examined the association between rural-urban status and other factors and financial problems, reporting the corresponding adjusted predicted probabilities. FINDINGS: Our sample included 1359 cancer survivors. Rural cancer survivors were more likely to be married, retired, and live in the Midwest or South. Over half (50.5%) of rural cancer survivors reported financial problems due to cancer compared to 38.8% of urban survivors (p = 0.02). This difference was attenuated in multivariable models, 49.3 and 38.7% in rural and urban survivors, respectively (p = 0.06). CONCLUSIONS: A higher proportion of rural survivors reported financial problems associated with their cancer diagnosis and treatment compared to urban survivors. Future research should aim to elucidate these disparities and interventions should be tested to address the cancer-related financial problems experienced by rural survivors.

Does a transition to accountable care in Medicaid shift the modality of colorectal cancer testing?

BACKGROUND: Health care reform is changing preventive services delivery. This study explored trajectories in colorectal cancer (CRC) testing over a 5-year period that included implementation of 16 Medicaid Accountable Care Organizations (ACOs, 2012) and Medicaid expansion (2014) - two provisions of the Affordable Care Act (ACA) - within the state of Oregon, USA. METHODS: Retrospective analysis of Oregon's Medicaid claims for enrollee's eligible for CRC screening (50-64 years) spanning January 2010 through December 2014. Our analysis was conducted and refined April 2016 through June 2018. The analysis assessed the annual probability of patients receiving CRC testing and the modality used (e.g., colonoscopy, fecal testing) relative to a baseline year (2010). We hypothesized that CRC testing would increase following Medicaid ACO formation - called Coordinated Care Organizations (CCOs). RESULTS: A total of 132,424 unique Medicaid enrollees (representing 255,192 person-years) met inclusion criteria over the 5-year study. Controlling for demographic and regional factors, the predicted probability of CRC testing was significantly higher in 2014 (+ 1.4 percentage points, p < 0.001) compared to the 2010 baseline but not in 2012 or 2013. Increased fecal testing using Fecal Occult Blood Tests (FOBT) or Fecal Immunochemical Tests (FIT) played a prominent role in 2014. The uptick in statewide fecal testing appears driven primarily by a subset of CCOs. CONCLUSIONS: Observed CRC testing did not immediately increase following the transition to CCOs in 2012. However increased testing in 2014, may reflect a delay in implementation of interventions to increase CRC screening and/or a strong desire by newly insured Medicaid CCO members to receive preventive care.

A systematic review of clinic and community intervention to increase fecal testing for colorectal cancer in rural and low-income populations in the United States - How, what and when?

BACKGROUND: Interventions to improve fecal testing for colorectal cancer (CRC) exist, but are not yet routine practice. We conducted this systematic review to determine how implementation strategies and contextual factors influenced the uptake of interventions to increase Fecal Immunochemical Tests (FIT) and Fecal Occult Blood Testing (FOBT) for CRC in rural and low-income populations in the United States. METHODS: We searched Medline and the Cochrane Library from January 1998 through July 2016, and Scopus and clinicaltrials.gov through March 2015, for original articles of interventions to increase fecal testing for CRC. Two reviewers independently screened abstracts, reviewed full-text articles, extracted data and performed quality assessments. A qualitative synthesis described the relationship between changes in fecal testing rates for CRC, intervention components, implementation strategies, and contextual factors. A technical expert panel of primary care professionals, health system leaders, and academicians guided this work. RESULTS: Of 4218 citations initially identified, 27 unique studies reported in 29 publications met inclusion criteria. Studies were conducted in primary care (n = 20, 74.1%), community (n = 5, 18.5%), or both (n = 2, 7.4%) settings. All studies (n = 27, 100.0%) described multicomponent interventions. In clinic based studies, components that occurred most frequently among the highly effective/effective study arms were provision of kits by direct mail, use of a pre-addressed stamped envelope, client reminders, and provider ordered in-clinic distribution. Interventions were delivered by clinic staff/community members (n = 10, 37.0%), research staff (n = 6, 22.2%), both (n = 10, 37.0%), or it was unclear (n = 1, 3.7%). Over half of the studies lacked information on training or monitoring intervention fidelity (n = 15, 55.6%). CONCLUSIONS: Studies to improve FIT/FOBT in rural and low-income populations utilized multicomponent interventions. The provision of kits through the mail, use of pre-addressed stamped envelopes, client reminders and in-clinic distribution appeared most frequently in the highly effective/effective clinic-based study arms. Few studies described contextual factors or implementation strategies. More robust application of guidelines to support reporting on methods to select, adapt and implement interventions can help end users determine not just which interventions work to improve CRC screening, but which interventions would work best in their setting given specific patient populations, clinical settings, and community characteristics. TRIAL REGISTRATION: In accordance with PRISMA guidelines, our systematic review protocol was registered with PROSPERO, the international prospective register of systematic reviews, on April 16, 2015 (registration number CRD42015019557 ).

Scaling Up and Tailoring the "Putting Public Health in Action" Training Curriculum.

Despite access to a growing menu of evidence-based interventions, public health practitioners continue to underuse them, in part because practitioners may require new knowledge, skills, and resources to do so. Numerous foundations, universities, governmental agencies, and consultants are providing trainings to address the gaps in practitioners' capacity. To most significantly affect population health, these trainings need to reach practitioners who may have limited access to on-site trainings. Despite the number of organizations offering trainings, little is known about how to scale up trainings to efficiently extend their reach or how to tailor trainings to the needs of different intervention. The Cancer Prevention and Control Research Network and its collaborating centers have developed a training curriculum and delivered it in both in-person and distance formats to a range of audiences. The purpose of this article is to describe the training curriculum and findings from the Network's evaluation of approaches used to scale up delivery of the "Putting Public Health Evidence in Action" curriculum and tailor content for specific evidence-based interventions.