Local governments and other public health entities often need population health measures at the county or subcounty level for activities such as resource allocation and targeting public health ...interventions, among others. Information collected via national surveys alone cannot fill these needs. We propose a novel, two-step method for rescaling health survey data and creating small area estimates (SAEs) of smoking rates using a Behavioral Risk Factor Surveillance System survey administered in 2015 to participants living in Allegheny County, Pennsylvania, USA.
The first step consisted of a spatial microsimulation to rescale location of survey respondents from zip codes to tracts based on census population distributions by age, sex, race, and education. The rescaling allowed us, in the second step, to utilize available census tract-specific ancillary data on social vulnerability for small area estimation of local health risk using an area-level version of a logistic linear mixed model. To demonstrate this new two-step algorithm, we estimated the ever-smoking rate for the census tracts of Allegheny County.
The ever-smoking rate was above 70% for two census tracts to the southeast of the city of Pittsburgh. Several tracts in the southern and eastern sections of Pittsburgh also had relatively high (> 65%) ever-smoking rates.
These SAEs may be used in local public health efforts to target interventions and educational resources aimed at reducing cigarette smoking. Further, our new two-step methodology may be extended to small area estimation for other locations and health outcomes.
Reports continue to show that Blacks with curable lung or breast cancer complete treatment less often than similar Whites contributing to worse survival. ACCURE is an intervention trial designed to ...address this problem.
A pragmatic, quality improvement trial comparing an intervention group to retrospective and concurrent controls. Patients with early stage breast or lung cancer aged 18 to 85 were enrolled (N = 302) at 2 cancer centers between April 2013 and March 2015 for the intervention component. Data from patients seen between January 2007 and December 2012 with these diagnoses were obtained to establish control completion rates. Concurrent data for non-study patients were used to identify secular trends. The intervention included: a real time registry derived from electronic health records of participants to signal missed appointments or unmet care milestones, a navigator, and clinical feedback. The primary outcome was "Treatment Complete", a composite variable representing completion of surgery, recommended radiation and chemotherapy for each patient.
The mean age in the intervention group was 63.1 years; 37.1% of patients were Black. Treatment completion in retrospective and concurrent controls showed significant Black-White differences (Blacks (B) 79.8% vs. Whites (W) 87.3%, p < 0.001; 83.1% B vs. 90.1% W, p < 0.001, respectively). The disparity lessened within the intervention (B 88.4% and W 89.5%, p = 0.77). Multivariate analyses confirmed disparities reduction. OR for Black-White disparity within the intervention was 0.98 (95% CI 0.46-2.1); Black completion in the intervention compared favorably to Whites in retrospective (OR 1.6; 95% CI 0.90-2.9) and concurrent (OR 1.1; 95% CI 0.59-2.0) controls.
A real time registry combined with feedback and navigation improved completion of treatment for all breast and lung cancer patients and narrowed disparities. Similar multi-faceted interventions could mitigate disparities in the treatment of other cancers and chronic conditions.
Purpose
Disparities in cancer care persist between patients living in rural versus urban areas. The COVID-19 pandemic may have impacted concerns related to care and personal health differently in ...rural cancer patients. Using survey data collected from cancer patients in western Pennsylvania, we examined pandemic-related distress, concerns related to cancer care, impact on personal health, and the extent to which these differed by urban–rural residence.
Methods
Patients filled out an initial survey in August–December 2020; a second survey was completed in March 2021. The following patient concerns related to the pandemic were evaluated: threat of COVID-19 to their health, pandemic-related distress, perceptions of cancer care, and vaccine hesitancy. Multivariable logistic regression models were used to examine relationships between these outcomes and urban–rural residence as well as patient-related factors, including anxiety symptoms and social support.
Results
The study sample included 1,980 patients, 17% resided in rural areas. COVID-19 represented a major or catastrophic threat to personal health for 39.7% of rural and 49.0% of urban patients (
p
= 0.0017). Patients with high general anxiety were 10-times more likely to experience pandemic-related distress (
p
< 0.001). In the follow-up survey (
n
= 983), vaccine hesitancy was twice as prevalent among rural patients compared to urban (
p
= 0.012).
Conclusions
The extent to which perceptions of the threat of COVD-19 to personal health and vaccine hesitancy exacerbates rural–urban disparities in cancer care and prognosis warrants further study. Cancer patients may be vulnerable to heightened anxiety and distress triggered by the pandemic.
Rural populations experience a disproportionate cancer burden relative to urban populations. One possibility is that rural populations are more likely to hold counterproductive cancer beliefs such as ...fatalism and information overload that undermine prevention and screening behaviors.
Between 2016 and 2020, 12 U.S. cancer centers surveyed adults in their service areas using online and in-person survey instruments. Participants (
= 10,362) were designated as rural (
= 3,821) or urban (
= 6,541). All participants were 18 and older (M = 56.97, SD = 16.55), predominately non-Hispanic White (81%), and female (57%). Participants completed three items measuring cancer fatalism ("It seems like everything causes cancer," "There's not much you can do to lower your chances of getting cancer," and "When I think about cancer, I automatically think about death") and one item measuring cancer information overload ("There are so many different recommendations about preventing cancer, it's hard to know which ones to follow").
Compared with urban residents, rural residents were more likely to believe that (i) everything causes cancer (OR = 1.29; 95% CI, 1.17-1.43); (ii) prevention is not possible (OR = 1.34; 95% CI, 1.19-1.51); and (iii) there are too many different recommendations about cancer prevention (OR = 1.26; 95% CI, 1.13-1.41), and cancer is always fatal (OR = 1.21; 95% CI, 1.11-1.33).
Compared with their urban counterparts, rural populations exhibited higher levels of cancer fatalism and cancer information overload.
Future interventions targeting rural populations should account for higher levels of fatalism and information overload.
Background
Advances in early diagnosis and curative treatment have reduced high mortality rates associated with non‐small cell lung cancer. However, racial disparity in survival persists partly ...because Black patients receive less curative treatment than White patients.
Methods
We performed a 5‐year pragmatic, trial at five cancer centers using a system‐based intervention. Patients diagnosed with early stage lung cancer, aged 18‐85 were eligible. Intervention components included: (1) a real‐time warning system derived from electronic health records, (2) race‐specific feedback to clinical teams on treatment completion rates, and (3) a nurse navigator. Consented patients were compared to retrospective and concurrent controls. The primary outcome was receipt of curative treatment.
Results
There were 2841 early stage lung cancer patients (16% Black) in the retrospective group and 360 (32% Black) in the intervention group. For the retrospective baseline, crude treatment rates were 78% for White patients vs 69% for Black patients (P < 0.001); difference by race was confirmed by a model adjusted for age, treatment site, cancer stage, gender, comorbid illness, and income‐odds ratio (OR) 0.66 for Black patients (95% CI 0.51‐0.85, P = 0.001). Within the intervention cohort, the crude rate was 96.5% for Black vs 95% for White patients (P = 0.56). Odds ratio for the adjusted analysis was 2.1 (95% CI 0.41‐10.4, P = 0.39) for Black vs White patients. Between group analyses confirmed treatment parity for the intervention.
Conclusion
A system‐based intervention tested in five cancer centers reduced racial gaps and improved care for all.
A multi‐faceted intervention tested in five cancer centers using the transparency of race‐specific data feedback, real‐time warnings derived from EHRs, and patient‐centered navigation improved care for both Black and White patients while reducing racial differences. Application of this system‐based, pragmatic approach at a health system level could have positive effects on treatment completion, equity and overall outcomes.
Purpose
Health-related quality of life (HRQOL) and pain are important supportive cancer care outcomes. The patient-provider relationship, a modifiable care experience, has been linked to healthcare ...outcomes; however, less is known about associations between patient-provider relationship and supportive care outcomes in cancer patients. We examined the role of multiple aspects of the patient-provider relationship in explaining patterns of HRQOL and pain among breast and lung cancer patients.
Methods
Our analysis included 283 breast and lung cancer patients from two cancer centers. Clinical data and survey data on patient sociodemographic factors, physical and mental HRQOL, pain, and patient-physician relationship (i.e., doctor’s respectfulness, time spent with doctors, patient involvement in decision-making, satisfaction with care, and following doctor’s advice/treatment plan) were collected at baseline and during treatment. We estimated adjusted modified Poisson regression models to assess associations between patient-physician relationship factors and physical and mental HRQOL and pain.
Results
Compared with patients reporting suboptimal respect from doctors, patients reporting optimal respect were less likely to report below average physical HRQOL (adjusted risk ratio (ARR), 0.73; 95%CI, 0.62–0.86), below average mental HRQOL (ARR, 0.71; 95%CI, 0.54–0.93), and moderate-to-severe pain (ARR, 0.53; 95%CI, 0.35–0.79). Patients reporting optimal involvement in care decision-making and patients who reported following their doctor’s advice/treatment plan were less likely to report below average mental HRQOL than their respective counterparts (ARR, 0.64; 95%CI, 0.50–0.83; ARR, 0.65; 95%CI, 0.48–0.86).
Conclusion
Multiple patient-physician relationship factors account for variations in HRQOL and pain in cancer patients. These findings provide insight into potential targets for improving the patient-provider relationship and supportive cancer care outcomes.
Appalachians experience increased rates of cancer incidence and mortality compared to non-Appalachians. Many factors may contribute to the elevated cancer burden, including lack of knowledge and ...negative beliefs about the disease.
Three National Cancer Institute (NCI)-designated cancer centers with Appalachian counties in their respective population-based geographic service areas-Kentucky, Ohio, and Pennsylvania-surveyed their communities to better understand their health profiles, including 5 items assessing cancer beliefs. Weighted univariate and bivariate statistics were calculated for each of the 3 state's Appalachian population and for a combined Appalachian sample. Weighted multiple linear regression was used to identify factors associated with a cancer beliefs composite score. Data from the combined Appalachian sample were compared to NCI's Health Information National Trends Survey (HINTS).
Data from 1,891 Appalachian respondents were included in the analysis (Kentucky = 798, Ohio = 112, Pennsylvania = 981). Significant differences were observed across the 3 Appalachian populations related to income, education, marital status, rurality, perceptions of present income, and body mass index (BMI). Four of 5 cancer beliefs were significantly different across the 3 states. Education, BMI, perceptions of financial security, and Kentucky residence were significantly associated with a lower composite score of cancer beliefs. When comparing the combined Appalachian population to HINTS, 3 of 5 cancer belief measures were significantly different.
Variations in cancer beliefs were observed across the 3 states' Appalachian populations. Interventions should be tailored to specific communities to improve cancer knowledge and beliefs and, ultimately, prevention and screening behaviors.
After the US Surgeon General declared youth electronic cigarette (e-cigarette) use an epidemic in 2018, the number of youth e-cigarette users continued to surge, growing from 3.8 million in 2018 to ...over 5 million 2019. Youth who use e-cigarettes are at a substantially higher risk of transitioning to traditional cigarettes, becoming regular cigarette smokers, and increasing their risk of developing tobacco-related cancer. A majority of youth are misinformed about e-cigarettes, often believing they are not harmful or contain no nicotine. Middle school students using e-cigarettes have been affected by its normalization leading to influence by their peers. However, social and group dynamics can be leveraged for a school-based peer-led intervention to identify and recruit student leaders to be anti-e-cigarette champions to prevent e-cigarette initiation. This study outlines a project to use social network analysis to identify student opinion-leaders in schools and train them to conduct anti-e-cigarette programming to their peers.
In the 2019-2020 academic school year, 6th grade students from nine schools in the Pittsburgh area were recruited. A randomized controlled trial (RCT) was conducted with three arms-expert, elected peer-leader, and random peer-leader-for e-cigarette programming. Sixth grade students in each school completed a network survey that assessed the friendship networks in each class. Students also completed pre-intervention and post-intervention surveys about their intention-to-use, knowledge, and attitudes towards e-cigarettes. Within each peer-led arm, social network analysis was conducted to identify peer-nominated opinion leaders. An e-cigarette prevention program was administered by (1) an adult content-expert, (2) a peer-nominated opinion leader to assigned students, or (3) a peer-nominated opinion leader to random students.
This study is the first to evaluate the feasibility of leveraging social network analysis to identify 6th grade opinion leaders to lead a school-based e-cigarette intervention.
ClinicalTrials.gov NCT04083469 . Registered on September 10, 2019.
The increased incidence of diseases, including metabolic syndrome and infertility, may be related to exposure to the mixture of chemicals, which are ubiquitous in the modern environment ...(environmental chemicals, ECs). Xeno-detoxification occurs within the liver which is also the source of many plasma proteins and growth factors and plays an important role in the regulation of homeostasis.
The objective of this study was to investigate the effects of ECs on aspects of liver function, in a well characterized ovine model of exposure to a real-life EC mixture.
Four groups of sheep (n = 10–12/sex/treatment) were maintained long-term on control or sewage sludge-fertilized pastures: from conception to culling at 19 months of age in females and from conception to 7 months of age and thereafter in control plots until culling at 19 months of age in males. Environmental chemicals were measured in sheep livers and RNA and protein extracts were assessed for exposure markers. Liver proteins were resolved using 2D differential in-gel electrophoresis and differentially expressed protein spots were identified by liquid chromatography/tandem mass spectroscopy.
Higher levels of polycyclic aromatic hydrocarbons (PAHs) and lower levels of polychlorinated biphenyls (PCBs) in the livers of control males compared to control females indicated sexually dimorphic EC body burdens. Increased levels of the PAHs Benzoaanthracene and chrysene and reduced levels of PCB 153 and PCB 180 were observed in the livers of continuously exposed females. EC exposure affected xenobiotic and detoxification responses and the liver proteome in both sexes and included major plasma-secreted and blood proteins, and metabolic enzymes whose pathway analysis predicted dysregulation of cancer-related pathways and altered lipid dynamics. The latter were confirmed by a reduction in total lipids in female livers and up-regulation of cancer-related transcript markers in male livers respectively by sewage sludge exposure.
Our results demonstrate that chronic exposure to ECs causes major physiological changes in the liver, likely to affect multiple systems in the body and which may predispose individuals to increased disease risks.
•Chronic exposure to environmental chemicals affects liver physiology.•Proteomic measurements showed widespread dysregulation in the exposed livers.•Exposure dysregulated important plasma proteins such as albumin and transferrin•Reduction in total lipids in the exposed female livers•Increase in cancer markers in the exposed male livers
There are persistent disparities in the delivery of cancer treatment, with Black patients receiving fewer of the recommended cancer treatment cycles than their White counterparts on average. To ...enhance racial equity in cancer care, innovative methods that apply antiracist principles to health promotion interventions are needed. The parent study for the current analysis, the Accountability for Cancer Care through Undoing Racism and Equity (ACCURE) intervention, was a system-change intervention that successfully eliminated the Black–White disparity in cancer treatment completion among patients with early-stage breast and lung cancer. The intervention included specially trained nurse navigators who leveraged real-time data to follow-up with patients during their treatment journeys. Community and academic research partners conducted thematic analysis on all clinical notes (n = 3,251) written by ACCURE navigators after each contact with patients in the specialized navigation arm (n = 162). Analysis was informed by transparency and accountability, principles adapted from the antiracist resource Undoing Racism and determined as barriers to treatment completion through prior research that informed ACCURE. We identified six themes in the navigator notes that demonstrated enhanced accountability of the care system to patient needs. Underlying these themes was a process of enhanced data transparency that allowed navigators to provide tailored patient support. Themes include (1) patient-centered advocacy, (2) addressing system barriers to care, (3) connection to resources, (4) re-engaging patients after lapsed treatment, (5) addressing symptoms and side effects, and (6) emotional support. Future interventions should incorporate transparency and accountability mechanisms and examine the impact on racial equity in cancer care.
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