Development and pilot testing of an mHealth behavioral cancer pain protocol for medically underserved communities

The purpose of this study was to refine and test a mobile-health behavioral cancer pain coping skills training protocol for women with breast cancer and pain from medically underserved areas. Three focus groups (Phase 1) were used to refine the initial protocol. A single-arm pilot trial (Phase 2) was conducted to assess feasibility, acceptability, and changes in outcomes. The intervention was delivered at a community-based clinic via videoconferencing technology. Participants were women (N?=?19 for Phase 1 and N?=?20 for Phase 2) with breast cancer and pain in medically underserved areas. Major themes from focus groups were used to refine the intervention. The refined intervention demonstrated feasibility and acceptability. Participants reported significant improvement in pain severity, pain interference, and self-efficacy for pain management. Our intervention is feasible, acceptable, and likely to lead to improvement in pain-related outcomes for breast cancer patients in medically underserved areas.

• Implications for Psychosocial Oncology Practice

• Breast cancer patients being treated in medically underserved areas have a dearth of exposure to behavioral interventions that may improve their ability to manage pain.

• Evidence from this single-arm pilot trial suggests that our mobile-health behavioral cancer pain coping skills training protocol is acceptable and feasible in this vulnerable population.

• Appropriately adapted mobile-health technologies may provide an avenue to reach underserved patients and implement behavioral interventions to improve pain management.

     

Effectiveness of a clinic-based colorectal cancer screening promotion program for underserved Hispanics

BACKGROUND:

Hispanics in the United States are less likely than other groups to receive screening services for colorectal cancer.

METHODS:

The authors conducted a clinic‐based individual randomized trial that enrolled Hispanic patients ages 50 to 79 years who had been seen in the Seattle‐based community clinic in the past 5 years. A total of 501 patients met the eligibility criteria and were randomized to 1 of 3 conditions: 1) usual care; 2) mailed fecal occult blood test (FOBT) card and instructions on how to complete the test (mailed FOBT only); and 3) mailed FOBT card and instructions on how to complete the test, telephone reminders, and home visits (mailed FOBT and outreach). The authors assessed postintervention differences in rates of FOBT screening in intervention and usual care groups using computerized medical records reviewed from June 2007 to March 2008.

RESULTS:

Data analysis occurred between November 2008 and September 2009. Nine‐month postintervention screening rates were 26% among patients who received the mailed packet only intervention (P < .001 compared with usual care) and 31% in the group that received the mailed packet and outreach intervention (P < .001 compared with usual care). This compared with 2% in the group that received usual care. Screening rates in the mailed FOBT only group and in the mailed FOBT and outreach group were not significantly different (P = .28).

CONCLUSIONS:

Culturally appropriate clinic‐based interventions may increase colorectal cancer screening among underserved Hispanics. Cancer 2011. © 2010 American Cancer Society.     

Breast reconstructive surgery in medically underserved women with breast cancer

BACKGROUND:

Breast reconstructive surgery can improve mastectomy patients' emotional relationships and social functioning, but it may be underutilized in low‐income, medically underserved women. This study assessed the impact of patient‐physician communication on rates of breast reconstructive surgery in low‐income breast cancer (BC) women receiving mastectomy.

METHODS:

A cross‐sectional, California statewide survey was conducted of women with income less than 200% of the Federal Poverty Level and receiving BC treatment through the Medicaid Breast and Cervical Cancer Treatment Program. A subset of 327 women with nonmetastatic disease who underwent mastectomy was identified. Logistic regression was used for data analysis. The chief dependent variable was receipt of or planned breast reconstructive surgery by patient report at 6 months after diagnosis; chief independent variables were physician interactive information giving and patient perceived self‐efficacy in interacting with physicians.

RESULTS:

Greater physician information giving about BC and its treatment and greater patient perceived self‐efficacy positively predicted breast reconstructive surgery (OR = 1.12, P = .04; OR = 1.03, P = .01, respectively). The observed negative effects of language barriers and less acculturation among Latinas and lower education at the bivariate level were mitigated in multivariate modeling with the addition of the patient‐physician communication and self‐efficacy variables.

CONCLUSIONS:

Empowering aspects of patient‐physician communication and self‐efficacy may overcome the negative effects of language barriers and less acculturation for Latinas, as well as of lower education generally, on receipt of or planned breast reconstructive surgery among low‐income women with BC. Intervening with these aspects of communication could result in breast reconstructive surgery rates more consistent with the general population and in improved quality of life among this disadvantaged group. Cancer 2009. © 2009 American Cancer Society.     

Population screening for colorectal cancer: the implications of an ageing population

Population screening for colorectal cancer (CRC) has recently commenced in the United Kingdom supported by the evidence of a number of randomised trials and pilot studies. Certain factors are known to influence screening cost-effectiveness (e.g. compliance), but it remains unclear whether an ageing population (i.e. demographic change) might also have an effect. The aim of this study was to simulate a population-based screening setting using a Markov model and assess the effect of increasing life expectancy on CRC screening cost-effectiveness. A Markov model was constructed that aimed, using a cohort simulation, to estimate the cost-effectiveness of CRC screening in an England and Wales population for two timescales: 2003 (early cohort) and 2033 (late cohort). Four model outcomes were calculated; screened and non-screened cohorts in 2003 and 2033. The screened cohort of men and women aged 60 years were offered biennial unhydrated faecal occult blood testing until the age of 69 years. Life expectancy was assumed to increase by 2.5 years per decade. There were 407 552 fewer people entering the model in the 2033 model due to a lower birth cohort, and population screening saw 30 345 fewer CRC-related deaths over the 50 years of the model. Screening the 2033 cohort cost £96 million with cost savings of £43 million in terms of detection and treatment and £28 million in palliative care costs. After 30 years of follow-up, the cost per life year saved was £1544. An identical screening programme in an early cohort (2003) saw a cost per life year saved of £1651. Population screening for CRC is costly but enables cost savings in certain areas and a considerable reduction in mortality from CRC. This Markov simulation suggests that the cost-effectiveness of population screening for CRC in the United Kingdom may actually be improved by rising life expectancies.     

Cervical cancer screening in medically underserved California Latina and non-Latina women: Effect of age and regularity of Pap testing

Background: This study focuses on age, race/ethnicity and regular cervical cancer screening of medically underserved Latina and non-Latina women enrolled in California's Cancer Detection Programs: Every Woman Counts (CDP: EWC). Methods: Data from a cohort of women were evaluated for regularity of screening and ethnicity utilizing multi-category logistic regression models to investigate Pap test and biopsy results. Results: There was no statistically significant difference among medically underserved Latina or non-Latina women in Pap test result and stage of cervical cancer after controlling for age and screening regularity. Rarely/never Pap-tested women were more likely to have ‘SIL/ASC’ (odds ratio = 1.19; 95% confidence interval = 1.08, 1.31) compared to women who were screened regularly. Medically underserved 25–39-year-old women were also more likely to be identified with ‘SIL/ASC’ (odds ratio = 1.64; 95% confidence interval = 1.50, 1.79) than women 50 and over. Younger were more likely to have low-grade ‘HPV/Condylomata, Atypia/CINI/LSIL’ (odds ratio = 2.48; 95% confidence interval = 1.66, 3.72) and high-grade ‘CIN II/III/HSIL/CI/Other Cancers’ (odds ratio = 1.53; 95% confidence interval = 1.08, 2.16) than women age 40 and above, similar to rarely/never Pap-tested women. Conclusions: Women were more likely to be identified with high-grade precancerous cervical lesions and cancer process when they did not have regular screening, Ethnic differences in screening outcomes seem to be minimized by participation in a program that provides consistent screening resources to the medically underserved women who enroll. These findings support prevention strategies that expand screening to all medically underserved younger women or that provide HPV vaccination at an early age.     

The prospects for mass population screening in colorectal cancer

Screening leads to an increased detection of tumours localized to the bowel at the time of surgical treatment which are likely to have an improved prognosis. However, because of the biases associated with screening it would be unwise to advocate a nationwide programme until the results of the controlled trials now in progress are available. At the present time the detection of occult blood in the faeces is the only feasible method of population screening. Haemoccult is a reliable, well tried test but lacks sensitivity. Several new chemical and immunological tests are available but require further evaluation.     

Racial differences in colorectal cancer screening practices and knowledge within a low-income population

BACKGROUND: Although colorectal cancer (CRC) is the third leading cause of cancer death among US women and is particularly deadly among African Americans, CRC screening rates remain low. Within a low-income population of women, the authors examined racial differences in practices, knowledge, and barriers related to CRC screening. METHODS: Face-to-face interviews were conducted with 941 women (white, n= 186; African American, n= 755) older than age 50 years who were living in subsidized housing communities in 11 cities in North and South Carolina. Women were asked questions about their CRC screening history and their knowledge and beliefs concerning CRC screening. RESULTS: Half (49%) of the women interviewed were within CRC screening guidelines, and this did not vary by race (P= .17). However, African American women were half as likely as white women to report having had a screening colonoscopy within the past 10 years (odds ratio [OR], 0.46; P< .001). Awareness of tests for CRC was low overall (39%) and was lower among African Americans than whites (OR, 0.44; P< .001). Compared with white women, African American women were less likely to report embarrassment as a barrier (OR, 0.59; P= .008) and more likely to report lack of insurance coverage (OR, 1.75; P= .098). CONCLUSIONS: Efforts must continue to increase women's knowledge of both CRC screening tests and colon cancer risk factors. Among these low-income women, routine encounters with the healthcare system may present opportunities to reduce deficits in CRC knowledge and to improve overall CRC screening rates.     

Timeliness and follow-up patterns of cervical cancer detection in a cohort of medically underserved California women

Introduction  

This study examines factors associated with timely follow-up after Pap test in a program providing cervical cancer detection services to medically underserved California women.     

Validity of self-reports of breast cancer treatment in low-income, medically underserved women with breast cancer

Few studies have assessed the agreement between subjects’ self-report and medical records among patients with breast cancer (BC), and none has addressed this issue in low-income women with BC. We assessed the level of agreement between self-report and medical records data for key BC treatment and prognostic characteristics using correct proportion and the Kappa statistic, among 726 low-income BC patients. Unconditional regression was used to investigate the association between accuracy of self-report and potential explanatory factors. Overall agreement between self-report and medical records was 95.3–99.6% for BC treatments including surgery, chemotherapy, radiotherapy and hormone therapy (Kappa = 0.79–0.99). Specific agreement was 87–89.5% for surgery type (Kappa = 0.51–0.96); 86.3% for chemotherapy completion (Kappa = 0.46) and 98.7% for radiotherapy completion (Kappa = 0.43); 95.2% for medical oncologist consultation (Kappa = 0.59) and 96% for radiation oncologist consultation; 97.3% for metastasis (Kappa = 0.56); and 93.6% for recurrence (Kappa = 0.30). When accepting answers within 15 days of the medical record date, 78.2% of women correctly reported surgery date, yet only around 55% of women correctly reported the start and/or end date of radiotherapy. Older age, less education, BC recurrence and poor patient–physician communication were associated with the lesser accuracy of patients’ self-report compared to medical records (P < 0.05). The results of this study suggest that self-reporting of key treatment and prognostic information is relatively accurate among low-income women with BC. Self-report seems to be a reliable source for accurate information when medical record review is unavailable or unfeasible. Interventions to enhance patient–physician communication may facilitate more accurate information reporting among vulnerable populations.     

天津市大肠癌筛查初步结果分析

目的：在40～74岁天津市自然人群中开展大肠癌筛查,评价问卷调查、大便潜血检查（stooloccultbloodtest ,FOB ）和全结肠镜检查的筛查效果,为探索大肠癌筛查策略提供参考。方法：筛查方法采用问卷调查结合FOB 的两步筛查模式,经初筛确定的高危人群行全结肠镜检查明确诊断。结果：2012年5 月至2014年12月,实际完成初筛2 117 304 例,初筛顺应性39.72% ;检出高危人群126 118 例,高危人群比例5.96% ;全结肠镜检查25837 例,检出腺瘤8 095 例,进展期腺瘤1 236 例、伴中重度异型增生的其他病变134 例、早期癌112 例、晚期癌336 例,早诊率为81.52% 。结论：天津市大肠癌筛查方案可以显著浓缩大肠癌高危人群,提高全结肠镜检查的阳性率,节省医疗资源。     

Factors affecting attitudes toward colorectal cancer screening in the primary care population

Background:

Colorectal cancer (CRC) is a major cause of death in the United Kingdom. Regular screening could significantly reduce CRC-related morbidity and mortality. However, screening programmes in the United Kingdom have to date seen uptake rates of less than 60%. Attitudes towards screening are the primary factors determining patient uptake.

Methods:

A questionnaire was sent to people aged 50–69 years who were registered with general practices in the West Midlands. A total of 11 355 people (53%) completed the questionnaire. Multivariable logistic regression analyses were performed to identify those factors (gender, age, ethnicity, deprivation, number of symptoms, and their duration) that most strongly contributed to negative/positive attitudes in the primary care population.

Results:

Fourteen percent of respondents had a negative attitude towards screening. Men, older people, and those with Indian ethnic backgrounds were more likely to have negative attitudes toward screening, whereas people with Black-Caribbean ethnic background, people with multiple symptoms and those reporting abdominal pain, bleeding, and tiredness were more likely to have a positive attitude.

Conclusion:

Culturally relevant screening strategies should aim to increase knowledge of the symptoms and signs related to bowel cancer among South Asian ethnic groups in the United Kingdom. It is also important to find ways to increase the acceptability of screening among asymptomatic patients.     

Evaluation of an immunochemical fecal occult blood test with automated reading in screening for colorectal cancer in a general average-risk population

Colorectal cancer screening is a high public health priority in all industrialized countries. However, the low sensitivity of the common guaiac screening test (HemoccultII) makes practitioners and public health decision makers reluctant to set up a national screening program. In recent years, immunochemical tests based on the use of a specific antibody have been found to be more sensitive than the HemoccultII test. However, for screening purposes, any gain in sensitivity is of interest only if specificity and positive predictive value are satisfactory. Our aim was to assess the performance of an immunochemical test with an automated reading technique (Magstream 1000) for different hemoglobin content cut-off points. The study was carried out in the general population aged 50-74 years in the geographic area of Cotentin (Normandy, France). From 1 January 2001 to 31 December 2002, 7,421 one-time screening tests (Magstream) were administered by general practitioners and occupational physicians to patients at the end of regular consultations. Colonoscopy was proposed to the 434 people with a positive test. All cancers occurring in the study population between 1 January 2001 and 31 December 2003 were collected by general practitioners, gastroenterologists and the local registry. At the usual positivity threshold (20 ng hemoglobin/ml), screening sensitivity and specificity at 2 years of follow-up with 95% CIs were, respectively, 0.85 (0.72-0.98) and 0.94 (0.94-0.95). If the hemoglobin content cut-off point had been set at 50 ng/ml instead of the usual cut-off, positivity would have been 3.1% and positive predictive value for a cancer or a large adenoma would have been 0.49, with sensitivity of 0.68-0.83 and specificity of 0.97. Our results suggest that use of an immunochemical test with an automated reading technique could improve the prospects for mass-screening for colorectal cancer since it offers a promising alternative to guaiac tests.     

Performance of individual and joint risk stratification by an environmental risk score and a genetic risk score in a colorectal cancer screening setting

Early detection of colorectal neoplasms can reduce the disease burden of colorectal cancer by timely intervention of individuals at high risk. Our aim was to evaluate a joint environmental-genetic risk score as a risk stratification tool for early detection of advanced colorectal neoplasm (ACRN). Known environmental risk factors and high-risk genetic loci were summarized into risk scores for ACRN in 1014 eligible participants of a screening study. The performances of single and joint environmental-genetic scores were evaluated with estimates and 95% confidence intervals (CI) of the absolute risk, relative risk and predictive ability using the area under the curve (AUC). Individuals with higher environmental risk scores showed increasing ACRN risk, with 3.1-fold for intermediate risk and 4.8-fold for very high risk, compared to the very low environmental risk group. Similarly, individuals with higher genetic risk scores showed increasing ACRN risk, with 2.2-fold for intermediate risk and 3.5-fold for very high risk, compared to the lowest genetic risk group. Moreover, the joint environmental–genetic score improved the ACRN risk stratification and showed higher predictive values (AUC = 0.64; 95%CI = 0.60–0.67) with substantial difference (p = 0.0002) compared to the single environmental score (0.58; 0.55–0.62). The integration of environmental and genetic factors looks promising for improving targeting individuals at high-risk of colorectal neoplasm. Applications in practical screening programs require optimization with additional genetic and other biomarkers involved in colorectal carcinogenesis.     

Does a screening questionnaire for familial and hereditary colorectal cancer risk work in a health insurance population?

PIEPER C., KOLANKOWSKA I. & JÖCKEL K.‐H. (2012) European Journal of Cancer Care Does a screening questionnaire for familial and hereditary colorectal cancer risk work in a health insurance population? The aim of our study was to evaluate actual prevalence, uptake and first experiences with a questionnaire developed for early detection of colorectal cancer (CRC) in persons with familial/hereditary risk. A cross sectional study in an insurance population aged 30–54 years was conducted. Subjects with ICD‐10 codes C00 to C97 and D37 to D48 were excluded. A standardised questionnaire was sent to 12 139 subjects. Three months later, subjects with a reported family history were followed by a second questionnaire. An additional telephone survey was performed to validate responses. Nineteen per cent met the inclusion criteria (mean age 45 ± 7 years, 38% men). Three hundred and seventy‐three subjects (16%) were followed by a second questionnaire. Of these, 248 (66%) returned. Forty‐four per cent were already aware of their increased risk of developing CRC. Awareness was associated with knowledge of CRC. One hundred subjects (41%) reported that they had informed their general practitioner (GP) or gastroenterologist. A colonoscopy or stool test was recommended to 92. Subjects who found out about their increased risk for the first time, reported significantly less frequent physician contact (GP: 20% vs. 34%, gastroenterologist: 8% vs. 21%). Results indicate that there is a need for a structured, person at risk‐adapted, statutory early detection program.     

Determinants of breast cancer knowledge among newly diagnosed, low-income, medically underserved women with breast cancer

BACKGROUND: Among women with breast cancer (BC), greater BC knowledge has been associated with greater participation in treatment decision-making, patient satisfaction, and survival. The objective of this study was to identify modifiable determinants associated with BC knowledge. METHODS: Data were collected from a telephone survey of medically underserved women with BC in California (n = 909). The dependent variable for analysis was BC knowledge. The modifiable determinants that were assessed included 1) physician-patient discussion of BC topics, 2) receipt of written BC-related material, 3) self-efficacy in interacting with physicians, 4) physician emotional support, 5) discussions with a BC survivor, and 6) office visit support by relatives/friends. Multivariate linear regression was used to examine the effect of those determinants on BC knowledge while controlling for socioeconomic factors, clinical characteristics, and treatment received. RESULTS: The average knowledge score was 6.9 (standard deviation, 2.3; range, 0-10). In multivariate analyses among women with less physician emotional support, those with the greatest self-efficacy had higher knowledge scores than those with the least self-efficacy (8.2 vs 5.4; P < .001). For women with low self-efficacy, those with more physician emotional support had higher knowledge scores than those with less physician emotional support when the analysis was controlled for confounding factors (6.3 vs 5.4; P < .001); physician information-giving had no effect on BC knowledge. CONCLUSIONS: The study findings suggested significant associations of patient self-efficacy and physician emotional support with BC knowledge; physician emotional support appeared to be more important than physician informational support. Further research will be needed to investigate whether interventions that target these 2 domains may be effective in increasing BC knowledge in disadvantaged populations.     

Implementation of a national colorectal cancer screening program

There is no direct evidence that colonoscopy screening reduces mortality from colorectal cancer. However, results from studies using fecal occult blood testing and sigmoidoscopy, along with the fact that colonoscopy is performed after positive primary screening tests, support this assumption. Colonoscopy every 10 years is the preferred strategy in terms of clinical outcomes and cost effectiveness. The purpose of this article is to present the methodology used for the implementation of an opportunistic colonoscopy colorectal cancer screening program in Poland. We also review recent literature on challenges related to colonoscopy screening including recruitment, acceptance, and quality of the procedure.     

Breast cancer screening in an urban population in northern Italy

A mammographic and clinical screening for breast cancer started in June 1987 in the Health District of Brescia, Northern Italy, including the town and 23 surrounding municipalities. This paper describes the organization and the results of the first 12 months of screening. Of 7791 invited women aged 50-60 years, 5217 (67%) agreed to participate. There was a trend for response rates to decline with increasing age and education. Of the 5217 women examined, 66 (1.3%) were referred for biopsy and 64 (1.2%) underwent this procedure. A histologically confirmed malignancy was found in 42 women, corresponding to a prevalence of 8.1/1000. Positive predictive value of the screening was 65.6%. Among the 42 breast cancers, 4.8% were carcinoma in situ and 42.9% invasive tumors up to 10 mm in size. According to the p-TNM classification, 92.9% of all cancers were either TIS or in stage T1, 4.8% were in T2 and one tumor was classified in T4. Lymph node involvement was assessed in 41 cases, and 71.4% of all cancers detected by screening were negative for lymph node metastasis. In comparison, the classification of tumors found in women of the same age group and living in Brescia, histologically diagnosed in the urban hospitals during 1986, one year before the beginning of the screening, was as follows: 7.1% carcinoma in situ, and 16.7% invasive tumors up to 10 mm in size. 38.1%, 2.4% and 2.4% of all tumors were in stages T2, T3 and T4 respectively.