A Social-Ecological Review of Cancer Disparities in Kentucky

Disparities in Advanced Stage Colorectal Cancer Outcomes in Appalachia: A Comprehensive Review

The Appalachian region consists of over 26 million Americans, of whom almost 2.5 million live in rural areas. Various social determinants of health including but not limited to rural living conditions and geographic isolation, food insecurity, and low income contribute to disparate health outcomes compared to the rest of the country. Obesity, hypertension, diabetes, stroke, and chronic heart diseases are all more prevalent in Appalachia. These comorbidities, combined with the aforementioned social vulnerabilities, place the Appalachian population at increased risk of higher cancer incidence and poorer outcomes. Lung, cervical, breast, penile, prostate, colorectal, and head and neck cancers are all shown to have higher rates and poorer outcomes within Appalachia relative to the country. Advanced staged colorectal cancer patients are a unique population that may be even further impacted by the social inequities in Appalachia, given the resource-intensive and multi-disciplinary approach required for effective treatment. Unfortunately, there is a dire lack of investigation into the incidence and outcomes of advanced stage colorectal cancer in Appalachian residents. This review summarizes the existing literature on disparate cancer outcomes in the Appalachian population, with a focus on advanced stage colorectal cancer. We also propose various approaches that could decrease malignancy rates and improve outcomes, such as dietary adjustments, screening tools, and public educational endeavors. We also acknowledge the role high-volume centers can play in working towards accessible care and the potential for collaborations between large institutions within Appalachian regions to spur the change that is greatly needed.

The mediating role of social support in behavioral changes and weight loss outcomes among overweight Appalachian adults

Social support plays a key role in behavioral changes, especially in Appalachian populations. We examined the mediating effect of social support in behavioral changes and corresponding weight loss outcomes among Appalachian adults. Data were from a group-randomized trial that compared a 12-month faith-based weight loss intervention to an active control group among overweight Appalachian adults in churches. Participants from the weight loss intervention who completed the 12-month assessment were the focus of this analysis. Baseline and 12-month data on weight, social support for eating habits (SSEH) and physical activity (SSPA) from family, friends, and church family, physical activity, and dietary intake were collected. Logistic and linear regression models evaluated mediating effects of SSEH and SSPA on the association between intervention attendance and behavioral changes and corresponding weight loss outcomes. Most participants (n = 243) were female (76.2%), white (97.5%), and married or living with a partner (81.2%). After the 12-month intervention, participants lost weight (1.1 ± 0.3 kg), increased fruit and vegetable intake (0.4 ± 0.1servings/day), reduced caloric intake (322.9 ± 42.2 kcal/day), improved SSEH from family, and increased SSPA from the church family (all P < 0.05). Increased SSEH from family mediated 62% of the association between intervention attendance and fruit and vegetable servings per day. Each 100 kcal decrease in caloric intake was associated with decreased weight and BMI at 12-months (0.2 ± 0.1 kg, P = 0.003; 0.1 ± 0.02 kg/m2, P = 0.002). Our study demonstrated the mediation effect of social support for healthy eating on the association between intervention attendance and fruit and vegetable intake, which underscored the critical role of social support and calorie intake among Appalachian populations in losing weight. The study was pre-registered at clinicaltrials.gov (#NCT02121691).

Outcomes of Brain Metastasis from Lung Cancer

Background/Objectives: Little information has been published on patients diagnosed with brain metastasis secondary to lung cancer. Correlating outcome patterns (hospice care, lost to follow-up, death before hospice care or treatment) and specific characteristics of treated and untreated patients may identify subsets of patients who may benefit from treatment. Methods: We evaluated data from the Kentucky Cancer Registry and identified 284 cases who were diagnosed with brain metastasis secondary to non-small cell lung cancer (NSCLC) between 1 August 2016, and 31 December 2019. We evaluated type and timing of treatment received, as well as focused on those patients who did not receive treatment. For those patients who did not receive treatment, various characteristics that may have impacted their decision or ability to undergo follow-up were also evaluated. This included social history, disease burden, as well as oncology treatment timelines. Lastly, due to the high smoking rate in Kentucky, we conducted an analysis of patient tobacco use. Results: Our results show that 61 cases (21.8%) never received treatment for lung cancer with brain metastasis. Further analysis of the non-treated cases demonstrated that 19 cases (31.1%) never met with an oncology team while in the hospital or after discharge; 14 of the 61 cases (23.0%) were too sick to receive treatment and died prior to having the option of treatment; and 47 of the 61 cases (77.0%) may have had the option of treatment but declined. Conclusions: Historically, patients with brain metastases have faced poor prognoses and limited treatment options. However, advancements in systemic chemoimmunotherapy and targeted therapies have introduced new treatment possibilities, offering improved symptom control and the potential for prolonged survival. This analysis is crucial for identifying potential barriers to care, optimizing resource allocation, and guiding future research.

An examination of cancer literacy among Appalachian versus non-Appalachian Kentucky college students

OBJECTIVE

Examine factors contributing to high rates of Appalachian female cancer incidences and mortalities by examining cancer literacy and associated sociological influences among Appalachian university students.

PARTICIPANTS

This study evaluated Appalachian and non-Appalachian undergraduate students in Eastern Kentucky.

METHODS

A Qualtrics survey was disseminated which categorized questions into three parts: demographic, female focused cancer literacy, and cancer care access.

RESULTS

Overall cancer literacy was low (67.45%, 139 respondents); no difference was found in Appalachian standing. Male students had lower scores (p < 0.05), and both cancer-related majors (p < 0.001) and enhanced academic years (p < 0.05) improved cancer literacy. Limited awareness of mobile cancer screening units was found across respondents, along with, decreased access to health services indicated by Appalachian students (p < 0.05).

CONCLUSIONS

College students represent a population in need of enhanced cancer education. Improving knowledge about accessing healthcare including cancer screenings could reduce Appalachian cancer rates.

Educating and Retaining the Cancer-Focused Biomedical Workforce from Rural Appalachian Kentucky: The Impact of Experiential Learning and Scholarship Funding

Kentucky postsecondary education levels are significantly below the national level, with lower levels in the Appalachian region of the state. Health disparities, including high cancer incidence and mortality, make educating and retaining students from the region a priority. The Appalachian Career Training in Oncology (ACTION) program offers cancer-related experiential opportunities and scholarships to Appalachian students. This study examines the ACTION program and its scholarship impact on undergraduate and professional school students' decisions to attend the University of Kentucky, pursue a career in science/medicine, and pay for schooling. Thirty-three ACTION participants and alumni received scholarships through a need-based application process in academic years 2023-2024 and 2024-2025. All students receiving the scholarship were asked to complete a REDCap survey. The survey evaluated both quantitative and qualitative variables, such as the impact of various factors on college decision, the influence of ACTION programs on career choice, and the effect of ACTION scholarship on financial burden. The two most influential factors affecting students' college choice are finances and experiential opportunities. Students in both the high school and undergraduate programs said their experiences significantly encouraged them to attend the University of Kentucky and pursue a career in science/medicine. Although the scholarship did not eliminate financial concerns, it lessened the burden. The ACTION program and scholarship encouraged Appalachian Kentucky students to attend the University of Kentucky and ameliorated financial concerns. This research demonstrates the program's positive impact on rural, Appalachian students and provides evidence for similar programs that may benefit underserved communities.

A framework and process for community-engaged, mixed-methods cancer needs assessments

PURPOSE

Community health needs assessments are required for most state and local public health agencies and non-profit hospitals. Typically based on community health improvement planning models, these assessments encompass overall community health and multiple diseases to inform program planning. National Cancer Institute (NCI)-designated Cancer Centers and community-based cancer-focused programs share the goal of reducing cancer burden in the catchment areas they serve. However, to date, no published models exist to guide cancer-specific needs assessments for a determined geographic area that can inform both public health and research initiatives. The purpose of this article is to outline a cancer needs assessment (CNA) framework and community-engaged, mixed-methods process, along with a case study of how we applied it in Kentucky.

METHODS

We convened a steering committee of key organizational partners to provide input throughout the process. We developed a conceptual framework of multi-level determinants affecting cancer-related outcomes. We incorporated both quantitative and qualitative data gathered through a variety of means, including a novel application of group concept mapping to guide definition of priorities.

RESULTS

The resulting CNA has helped guide strategic planning and priorities for Kentucky's Cancer Action Plan, Markey Cancer Center, state agencies, and community-based organizations.

CONCLUSION

This framework and process can be used collaboratively by cancer center Community Outreach and Engagement offices, public health agencies, oncology programs, and community partners to plan impactful cancer control programs and research in their catchment areas. Universities can also use them to inform the planning of community engagement and health equity research efforts.

Phase I Safety and Feasibility Pilot of Hepatic Artery Infusion Chemotherapy in a Rural Catchment Area Using The Codman Vascular Catheter with The Medtronic SynchroMed II Pump for Intrahepatic Cancers

BACKGROUND

Discontinuation of the Codman 3000 pump in 2018 left no Food and Drug Administration (FDA)-approved hepatic artery infusion (HAI) device for unresectable colorectal liver metastases (uCLM) and intrahepatic cholangiocarcinoma (uIHC). Historically, HAI has been performed at academic medical centers in large metropolitan areas, which are often inaccessible to rural patients. Consequently, feasibility of dissemination of HAI to rural populations is unknown.

PATIENTS AND METHODS

Under an FDA investigational device exemption, we opened the only HAI program in Kentucky and enrolled patients with uCLM and uIHC in a phase I clinical trial. The trial examined the safety of the hybrid Codman catheter/Medtronic SynchroMed II pump (hCMP) combination, defined as successful completion of one cycle of HAI chemotherapy. Rural feasibility was assessed by number of missed pump fills appointments.

RESULTS

A total of 21 patients (n = 17 uCLM, n = 4 uIHC) underwent hCMP implantation before accrual was stopped early owing to FDA approval of the Intera 3000 pump. 20/21 (95%) patients met the primary safety endpoint. Serious adverse events (AEs) included a grade 5 coronavirus disease 2019 (COVID-19) infection (n = 1) and a grade 3 catheter erosion into the bowel (n = 1). Biliary sclerosis developed in two patients (9.5%). Median distance to infusion center was 47.6 miles (2-138 miles), and 62% were from Appalachia, yet there were no missed pump fill appointments. The 2-year overall survival was 82.4% (uCLM) and 50% (uIHC).

CONCLUSIONS

The hCMP device had an acceptable safety profile. Despite the complexity of starting a new HAI program, early results showed feasibility for HAI delivery in a rural catchment area and comparable outcomes to larger urban-based HAI centers.

Cancer disparities in Appalachian Kentucky

PURPOSE

Cancer is the second leading cause of death in the United States, and the disease burden is elevated in Appalachian Kentucky, due in part to health behaviors and inequities in social determinants of health. This study's goal was to evaluate Appalachian Kentucky's cancer burden compared to non-Appalachian Kentucky, and Kentucky compared to the United States (excluding Kentucky).

METHODS

The following data were analyzed: annual all-cause and all-site cancer mortality rates from 1968 to 2018; 5-year all-site and site-specific cancer incidence and mortality rates from 2014 to 2018; aggregated screening and risk factor data from 2016 to 2018 for the United States (excluding Kentucky), Kentucky, non-Appalachian Kentucky, and Appalachian Kentucky; and human papilloma virus vaccination prevalence by sex from 2018 for the United States and Kentucky.

FINDINGS

Since 1968, the United States has experienced a large decrease in all-cause and cancer mortality, but the reduction in Kentucky has been smaller and slower, driven by even smaller and slower reductions within Appalachian Kentucky. Appalachian Kentucky has higher overall cancer incidence and mortality rates and higher rates for several site-specific cancers compared to non-Appalachian Kentucky. Contributing factors include screening rate disparities and increased rates of obesity and smoking.

CONCLUSIONS

Appalachian Kentucky has experienced persistent cancer disparities, including elevated all-cause and cancer mortality rates for 50+ years, widening the gap between this region and the rest of the country. In addition to addressing social determinants of health, increased efforts aimed at improving health behaviors and increased access to health care resources could help reduce this disparity.

Differences in obesity-related health behaviors and health outcomes by rural and Appalachian residency

PURPOSE

Obesity and health behaviors are the major modifiable contributors to cancer and health disparities. We examined the differences in obesity-related health behaviors, and health outcomes by rural and Appalachian residency in Ohio.

METHODS

Cross-sectional survey data from the 2011-2019 Behavioral Risk Factor Surveillance System were obtained from the Ohio Department of Health. County-level identifiers were used to classify urban non-Appalachian, urban Appalachian, rural non-Appalachian, and rural Appalachian residency. Self-reported weight, height, health behaviors, and health conditions were used. Logistic regression was used to assess the difference in health behaviors and health outcomes by rural and Appalachian residency. All analyses incorporated with sample weights.

RESULTS

Among Ohio residents, compared to urban non-Appalachian residents, urban Appalachian and rural Appalachian residents had a higher prevalence of obesity, hypertension, high cholesterol, and cardiovascular diseases, as well as lower rates of healthy diet and physical activity. No difference was found in trends of obesity and obesity-related health outcomes in 2011-2019 by rural and Appalachian residency. However, rural Appalachian residents had a greater increase in obesity, hypertension, and diabetes, whereas rural non-Appalachian had favorable changes in obesity-related health behaviors. Additionally, associations between health behaviors and obesity-related health outcomes differed by rural and Appalachian residency.

CONCLUSIONS

Findings underscore the importance of distinguishing between urban non-Appalachian, urban Appalachian, rural non-Appalachian, and rural Appalachian populations when assessing health disparities. While the trends of obesity and obesity-related health outcomes did not differ, the association between health behaviors and obesity-related outcomes differed by rural and Appalachian residency.

A Qualitative Study of Participant Perceptions of a Cancer Research Education Program

Kentucky ranks first in the nation in cancer incidence and mortality rates, with the greatest burden of disease being in the Appalachian region. The cancer disparities in the Appalachian region of the state are tied to high poverty rates, low education attainment, low health care access, and high rates of poor health behaviors, such as tobacco use. The University of Kentucky (UK) Markey Cancer Center (MCC) developed the Appalachian Career Training in Oncology (ACTION) program to address the cancer and education disparities in the region. ACTION is a two-year program that focuses on cancer education and training for high school and undergraduate students from Appalachian Kentucky and features a variety of cancer-focused training activities, including faculty-mentored cancer research, clinical shadowing opportunities, cancer education activities, career development support, and community outreach projects. ACTION has been funded by the National Cancer Institute as a Youth Enjoy Science R25 research education program since 2018. The qualitative study herein used a semi-structured interview approach to identify participants' perceptions of the program including the influential aspects that have helped students pursue their desired academic career paths. Ten ACTION alumni were chosen to participate in the study, including students currently in medical school, graduate school, physician assistant school, and pharmacy school. Thematic analysis generated five themes: motivation for participation, career development, mentorship and future opportunities, knowledge gained, and program improvements. Overall, this study demonstrates that the ACTION program is having a significant impact on students' career preparation.

County-Level Trends in Cervical Cancer Incidence, Stage at Diagnosis, and Mortality in Kentucky

This cross-sectional study evaluates recent trends in rates of cervical cancer incidence and incidence-based mortality among women in Appalachian and non-Appalachian Kentucky counties.

Lung and Colorectal Cancer Disparities in Appalachian Kentucky: Spatial Analysis on the Influence of Education and Literacy

Low educational attainment and high cancer incidence and mortality rates have long been a challenge in Appalachian Kentucky. Prior studies have reported disparities in cancer incidence and mortality between Appalachian and non-Appalachian populations, but the influence of education on this disparity has not been extensively studied. Herein, all cancers and two cancer sites with available screenings (colorectal and lung) were joined with education indicators (educational attainment and literacy) and one geographic indicator across all 120 Kentucky counties. This dataset was used to build choropleth maps and perform simple linear and spatial regression to assess statistical significance and to measure the strength of the linear relationship between county-level education and cancer-related outcomes in Appalachian and non-Appalachian Kentucky. Among all cancer sites, age-adjusted cancer incidence and mortality was higher in Appalachian versus non-Appalachian Kentucky. The percentage of the population not completing high school was positively correlated with increased colorectal and lung cancer incidence and mortality in Appalachia. Similarly, counties with a higher percentage of the population lacking basic literacy had the strongest correlation with colorectal and lung cancer incidence and mortality, which were concentrated in Appalachian Kentucky. Our findings suggest a need for implementing interventions that increase educational attainment and enhance basic literacy as a means of improving cancer outcomes in Appalachia.

Impact of the Appalachian Career Training in Oncology (ACTION) Program on Undergraduate Participants

Kentucky ranks first in the nation in cancer incidence and mortality. The Appalachian region of the state experiences the highest cancer disparities due to inequities in many social determinants of health. As a strategy for addressing cancer and education disparities in the region, the Appalachian Career Training in Oncology (ACTION) Program at the University of Kentucky Markey Cancer Center engaged 16 Appalachian-native undergraduate student participants annually in cancer-related activities. Students were recruited on an annual basis for the 2-year ACTION program. Entry, mid-point, and exit surveys were administered to participants. Classical test theory and exploratory factor analysis were used to examine the instruments used for program evaluation, whereas repeated measures ANOVA, paired t-tests, chi-squared, and post hoc analyses were used to analyze 6 years of survey data. There was a significant increase in participants' understanding of cancer-related topics among the entry, midpoint, and exit surveys (p < .001) and a significant increase in comfort with research, clinical, and outreach activities between entry and midpoint and entry and exit (p < .001), but not between midpoint and exit. With respect to research skills and perceptions of the program, increases in mean scores were observed between midpoint and exit, but these increases were not statistically significant (p = .167, p = 223, respectively). ACTION increased participants' understanding of cancer-related topics; comfort with research, clinical, and outreach activities; and research skills. These data suggest that ACTION has a significant impact on participants.

Piloting an Oral History Approach to Investigate Cancer Perspectives Among Residents of Appalachian Kentucky

Introduction

Kentucky ranks first in the U.S. in overall cancer incidence and mortality rates. Areas of the state that fall within the Appalachian Region, along Kentucky's eastern border, experience disproportionately high rates of cancer compared to non-Appalachian counties. Purpose: This pilot study investigates whether oral history interviews can be used to understand perspectives on cancer among residents of Appalachian Kentucky.

Methods

In 2020, participants (n = 5) who identified as being from and/or having strong connections to Appalachian Kentucky were recruited to participate in this pilot study. Participants included individuals working in cancer-related fields, oncology professionals, and those with personal cancer experience. Using an oral history approach, subjects were asked about challenges within Appalachia that contribute to high rates of cancer regionally. Interviews were analyzed using qualitative content analysis, and data were condensed into themes, subthemes, and subtopics. Relational content analysis was then used to illustrate relationships between the problems being faced in Appalachia and their contributing factors, with potential solutions to those problems.

Results

Six key themes emerged from analysis of the oral history interviews: (1) problems being faced in Appalachia; (2) contributing factors; (3) potential solutions; (4) Appalachian disposition; (5) experiences with and thoughts on cancer; and (6) defining success v. the future without changes (intervention). A further 25 subthemes were identified from within these themes. Taken together, these themes and subthemes point to potential areas for specific intervention to shift Appalachia's cancer burden.

Implications

This pilot study demonstrates potential benefit in using oral history interviews to elucidate Appalachian Kentuckians' perspectives on cancer. From the nuanced insights gained through this method, a set of culturally appropriate interventions were identified that could address the disproportionate cancer burden in the region. Future studies using an oral history approach could aim to reveal other specific aspects of how cancer impacts individuals, families, and communities.

Using Culturally Focused Storytelling to Empower Appalachian Kentucky Youth to Understand and Address Cancer Disparities in Their Communities

Kentucky has the highest cancer incidence and mortality rates in the nation with the Appalachian region of the state being most affected. These rates are driven by health behaviors and inequities in social determinants of health. Herein, Appalachian Kentucky students with the University of Kentucky's Appalachian Career Training in Oncology (ACTION) program were engaged in a storytelling exercise by writing culturally framed essays. Students discussed their personal experiences with cancer and their thoughts on the causes of and potential solutions to Appalachian Kentucky's cancer disparities. Content analysis was used to identify common themes, subthemes, and subtopics in the essays regarding cancer types, causes of cancer in Appalachia, and solutions to the high cancer rates. Common cancer types experienced by the students included breast, lung, and prostate. The most frequently identified themes that drive cancer rates in Appalachian Kentucky were identified as geography, environmental factors, tobacco use, education, poverty, prevention, and mistrust. Common proposed solutions to decrease cancer rates were to increase education and awareness, screening, and tobacco cessation. Overall, through storytelling, youth gained a better understanding of cancer in their communities and envisioned culturally tailored, community-based intervention strategies that can aid in reducing the cancer burden in Appalachian Kentucky.

Examining Psychological and Knowledge Barriers to Colorectal Cancer Screening in Rural Appalachian Kentucky

While recent rates of colorectal cancer (CRC) screening have improved in Appalachian Kentucky due to public health efforts, they remain lower compared to both KY as a whole, and the USA. Suboptimal screening rates represent a missed opportunity to engage in early detection and prevention. The purpose of this study is to determine the impact that lack of knowledge has on psychological barriers (e.g., fear and embarrassment) to CRC screening as well as the potential effect of a psychosocial intervention to reduce these barriers. Participants were recruited through faith-based organizations and other community sites. After randomizing participants to either an early or delayed group, a faith-based group education and motivational interviewing intervention was administered. Existing and pilot tested instruments were used to assess knowledge and potential psychological barriers. Data were analyzed using paired t tests and linear regression. We hypothesized that (1) psychological barriers are associated with inadequate knowledge and (2) the intervention, by improving knowledge, could reduce these barriers and increase screening rates. There was a small but significant reduction in psychological barriers (-0.11, p value = 0.015) and moderate increases in CRC knowledge scores (+0.17, p value = 0.06). There was no evidence that the intervention affected these measures (+0.10, p value = 0.58). The relationship between lower barrier scores and increased knowledge was significant at follow up (-0.05, 95% CI (-0.09, -0.00)). An increase in CRC knowledge was correlated with a small but significant decrease in psychological barriers, although there was no evidence that these changes were associated with one another. Future cognitive-based interventions may be effective in increasing CRC knowledge and reducing barriers, but new intervention approaches should be considered.

Barriers and facilitators to cervical cancer screening among under-screened women in Cuenca, Ecuador: the perspectives of women and health professionals

Background

Cervical cancer screening is a cost-effective method responsible for reducing cervical cancer-related mortality by 70% in countries that have achieved high coverage through nationwide screening strategies. However, there are disparities in access to screening. In Ecuador, although cervical cancer is the second most common cancer in women, only 58.4% of women of reproductive age have ever been screened for cervical cancer.

Methodology

A qualitative study was performed to understand the current barriers to screening and to identify strategies that could increase uptake in Azuay province, Ecuador. Seven focus group discussions (FGDs) were conducted with under-screened women and health professionals (HPs). The FGDs were recorded and transcribed. Content analysis was done using the socio-ecological framework to categorize and analyse the data.

Results

Overall, 28 women and 27 HPs participated in the study. The two groups perceived different barriers to cervical cancer screening. The HPs considered barriers to be mainly at the policy level (lack of a structured screening plan; lack of health promotion) and the individual level (lack of risk perception; personal beliefs). The women identified barriers mainly at organizational level, such as long waiting times, lack of access to health centres, and inadequate patient–physician communication. Both groups mentioned facilitators at policy level, such as national campaigns promoting cervical cancer screening, and at community and individual level, including health literacy and women’s empowerment.

Conclusions

The women considered access to health services the main barrier to screening, while the HPs identified a lack of investment in screening programmes and cultural patterns at the community level as major obstacles. To take an integrated approach to cervical cancer prevention, the perspectives of both groups should be taken into account. Additionally, new strategies and technologies, such as self-administered human papillomavirus (HPV) testing and community participation, should be implemented to increase access to cervical cancer screening.

The increasing incidence of stage IV cervical cancer in the USA: what factors are related?

OBJECTIVE

Cervical cancer (International Federation of Gynecology and Obstetrics (FIGO)) stage IVA-B (distant stage) is a rare diagnosis with an approximate 5 year survival rate of 17% and with limited treatment options. The objective of this study was to determine the trends in distant stage cervical cancer in the USA and identify possible factors related to these trends.

METHODS

Data were obtained from the United States Cancer Statistics program from 2001 to 2018. Rates of cervical cancer screening and vaccination were evaluated using the Behavioral Risk Factor Surveillance System and TeenVaxView. SEER*Stat 8.3.8.9.2 and Joinpoint regression program 4.9.0.0 were used to calculate incidence trends.

RESULTS

Over the last 18 years, 29 715 women were diagnosed with distant stage cervical carcinoma. Black women have disproportionately higher rates at 1.55/100 000 versus 0.92/100 000 in White women (p<0.001). When examining the trends over time, there has been an annual increase in distant stage cervical cancer at a rate of 1.3% per year (p<0.001). The largest increase is seen in cervical adenocarcinoma with an average annual percent change of 2.9% (p<0.001). When performing an intersection analysis of race, region and age, White women in the South aged 40-44 have the highest rise in distant cervical cancer at a rate of 4.5% annually (p<0.001). Using the Behavioral Risk Factor Surveillance System and TeenVax data, compared with Black women, we found that White women have a nearly two-fold higher rate of missed or lack of guideline screening, 26.6% vs 13.8%. White teenagers (13-17 years) have the lowest human papillomavirus vaccination rate at 66.1% compared with others at 75.3%.

CONCLUSIONS

Black women have a higher incidence of distant stage disease compared with White women. However, White women have a greater annual increase, particularly in adenocarcinomas. Compared with Black women, White women also have lower rates of guideline screening and vaccination.

The Impact of the Appalachian Career Training in Oncology (ACTION) Program on High School Participants

OBJECTIVE

Kentucky ranks first in the nation in cancer incidence and mortality. The Appalachian region of the state experiences the highest cancer disparities due to inequities in many social determinants of health as well as poor health behaviors. As a strategy for addressing cancer and education disparities in the region, the Appalachian Career Training in Oncology (ACTION) Program at the University of Kentucky Markey Cancer Center engages Appalachian-native high school students in cancer education, research, and outreach activities.

METHODS

Entry and exit surveys were administered to participants. Classical test theory and exploratory factor analysis were used to examine the instruments used for program evaluation, whereas repeated measures ANOVA was used to determine if there were significant differences in means between entry and exit timepoints.

RESULTS

There was an increase in students' understanding and comfort with cancer-related topics between entry and exit survey administrations. Students indicated that the program improved their research skills and career planning skills. Furthermore, students had positive perceptions of all aspects of the program.

CONCLUSION

Data suggest that ACTION has a positive impact on high school students. Specifically, results show increased understanding and comfort with cancer-related topics, research skills, and career planning.

The Use of Virtual Research Experiences for Appalachian Career Training in Oncology (ACTION) Program High School Participants During the COVID-19 Pandemic

OBJECTIVE

Kentucky has the highest cancer incidence and mortality rates in the nation, with rates greatest in the Appalachian region due to poor health behaviors and inequities in social determinants of health. The Appalachian Career Training in Oncology (ACTION) Program at the University of Kentucky Markey Cancer Center engages 20 Appalachian-native high school students annually in cancer education, research, and outreach activities. During the COVID-19 pandemic, programming was disrupted, and alternative activities were implemented, including virtual research experiences.

METHODS

The program's goals were to improve students' biology and cancer content knowledge and research skills and help students make career decisions. Virtual laboratories were used to help accomplish these goals. This study aimed to evaluate the use of virtual laboratories embedded in the program and determine if such experiences helped reach the program's goals. A survey was used to measure students' perceptions of the virtual labs.

RESULTS

Results indicated that students perceived they gained content knowledge, obtained research skills, and considered entering science and cancer-related careers.

CONCLUSION

The decision to incorporate virtual laboratories into the ACTION programming during the COVID-19 pandemic was a sound instructional choice. Evidence provided herein gives researchers and program developers information necessary to consider using virtual labs in their programs.

Early Cancer Research Education for Underrepresented Middle School Students: A Case Study of Experiences from Youth Enjoy Science Programs

Cancer is the second leading cause of death in the United States, and marginalized communities are disproportionately affected. There is a significant need to address cancer disparities and the determinants of health that are associated with those disparities. Increasing the diversity of the cancer research workforce is a potential mechanism to address health disparities. The National Cancer Institute's Youth Enjoy Science Research Education Program provides funding to engage middle school, high school, and undergraduate students from underrepresented student populations in cancer research education programming, conduct cancer education outreach to communities, and provide cancer research curricula to kindergarten through grade 12 educators. The ultimate goal of these programs is to motivate, prepare, and support students in pursuing cancer research careers. Herein, we describe how three academic institutions with YES Programs - the University of Kentucky, the University of Nebraska Medical Center, and Case Western Reserve University - provide cancer education programming to middle school students. Descriptions of each institutions' programing are provided. Common and unique elements were determined through an evaluation of the three programs. Although each program was developed independently, they have more common than unique elements. We provide insight into the development of middle school programs for other academic institutions.

Approaches for Measuring Inclusive Demographics Across Youth Enjoy Science Cancer Research Training Programs

The National Cancer Institute's (NCI) Youth Enjoy Science Program (YES) funds initiatives to support the cancer research training and career ambitions of middle school through undergraduate students from populations underrepresented in the biomedical sciences. The program has funded 16 institutions nationally as of January 2022. Given the program's focus on increasing diversity within the cancer research workforce, demographic characteristics of YES trainees provide essential information about the populations being served and program effectiveness. Six programs formed an interest group focused on trainee demographics and surveyed all YES grantees about their demographic data practices. Fifteen programs (94%) completed the survey. Survey data were analyzed through descriptive statistics and thematic coding. Findings revealed considerable variability in programs' approach to demographic data, including which demographics were measured, how they were operationalized, and when and how the data were collected. Half of YES programs (53%) could report underrepresented populations in biomedical research among trainees using consistent definitions. Most programs described efforts to improve their demographic data practices; however, challenges remained for the vast majority. In consideration of these findings, we offer recommendations for inclusive demographic data practices to better define and retain underrepresented populations in biomedical sciences.

Designing a Framework for Remote Cancer Care Through Community Co-design: Participatory Development Study

BACKGROUND

Recent shifts to telemedicine and remote patient monitoring demonstrate the potential for new technology to transform health systems; yet, methods to design for inclusion and resilience are lacking.

OBJECTIVE

The aim of this study is to design and implement a participatory framework to produce effective health care solutions through co-design with diverse stakeholders.

METHODS

We developed a design framework to cocreate solutions to locally prioritized health and communication problems focused on cancer care. The framework is premised on the framing and discovery of problems through community engagement and lead-user innovation with the hypothesis that diversity and inclusion in the co-design process generate more innovative and resilient solutions. Discovery, design, and development were implemented through structured phases with design studios at various locations in urban and rural Kentucky, including Appalachia, each building from prior work. In the final design studio, working prototypes were developed and tested. Outputs were assessed using the System Usability Scale as well as semistructured user feedback.

RESULTS

We co-designed, developed, and tested a mobile app (myPath) and service model for distress surveillance and cancer care coordination following the LAUNCH (Linking and Amplifying User-Centered Networks through Connected Health) framework. The problem of awareness, navigation, and communication through cancer care was selected by the community after framing areas for opportunity based on significant geographic disparities in cancer and health burden resource and broadband access. The codeveloped digital myPath app showed the highest perceived combined usability (mean 81.9, SD 15.2) compared with the current gold standard of distress management for patients with cancer, the paper-based National Comprehensive Cancer Network Distress Thermometer (mean 74.2, SD 15.8). Testing of the System Usability Scale subscales showed that the myPath app had significantly better usability than the paper Distress Thermometer (t63=2.611; P=.01), whereas learnability did not differ between the instruments (t63=-0.311; P=.76). Notable differences by patient and provider scoring and feedback were found.

CONCLUSIONS

Participatory problem definition and community-based co-design, design-with methods, may produce more acceptable and effective solutions than traditional design-for approaches.

Role of Self-Sampling for Cervical Cancer Screening: Diagnostic Test Properties of Three Tests for the Diagnosis of HPV in Rural Communities of Cuenca, Ecuador

Background: HPV primary screening has shown effectiveness for cancer prevention; however, gynaecological examination is considered uncomfortable. Self-sampling methods increase the acceptance of screening. The aim of this study is to compare the sensitivity and specificity of clinician sampling versus vaginal and urine self-sampling for HPV diagnosis. Methods: A diagnostic test study was conducted in a rural parish of Cuenca, Ecuador. A total of 120 women participated. Each participant self-collected urine and vaginal samples and underwent clinician sampling for HPV testing. The latter was considered as the golden standard. All three samples were processed with the same amplification and hybridization protocol for HPV detection (Hybribio) following the manufacturer’s instructions. Results: Characteristics of the participants were: median age 35 years; 40.8% married; 46.7% had a primary level of education; and median age of sexual onset, 17.6 years. The prevalence of any type of HPV with clinician sampling was 15.0%, 17.5% with urine sampling and 18.3% with vaginal self-sampling. Self-sampling sensitivity reached 94.4% (IC 74.2–99.9), and specificity 92.1% (IC 85.2–95.9). Urine sampling had a sensitivity of 88.8% (IC 67.2, 96.9), and specificity 94.1% (IC 67.2–96.9). The negative predictive value was 98.9% (IC 94.2–99.8) for vaginal self-sampling and 97.6% (IC 92.6–99.4) for urine sampling. Conclusions: This study shows that vaginal and urine self-sampling methods have similar sensitivity and specificity compared with clinician sampling for the diagnosis of HPV. The correlation between HPV genotypes among the three tests is satisfactory.

Psychological factors among Appalachian women with abnormal Pap results

PURPOSE

Women who receive an abnormal Pap result may experience negative psychological factors. The purpose of this study is to assess the baseline occurrence of negative psychological factors and evaluate the relationships between psychological factors and demographic characteristics among Appalachian women who received abnormal Pap results.

METHODS

We conducted a secondary analysis of data collected from Appalachia Kentucky women (N = 521) ages ≥18 enrolled in an intervention. Data included sociodemographics, Beck depression and anxiety inventories, fatalism, and personal control measures. Multiple variable logistic regression was used to investigate the association between demographics and psychological factors.

FINDINGS

Participants were predominantly White (96.2%), with mean age 28.93 ± 11.03 years, and the majority (77%) had yearly income below $20,000. Depression was reported by 34.6% (n = 173); 10% (n = 50) experienced moderate or severe anxiety; 20.6% (n = 107) had fatalistic beliefs; and 55.1% (n = 289) believed they lacked personal control over cancer. Women with lower income had higher occurrence of depression (P = .003). Women with moderate to severe anxiety were significantly older than those with low to moderate depression (34.44 vs 28.34, P < .001). Controlling for other variables, as age increased, the odds of fatalistic beliefs increased, OR (95%) = 1.042 (1.022, 1.062). When education level increased, the odds of fatalistic beliefs decreased, OR (95%) = 0.873 (0.800, 0.952).

CONCLUSIONS

Given the high occurrence of depression, anxiety, and fatalistic beliefs among this population, health care providers should assess for underlying mental health diagnoses and psychological distress during each patient encounter and provide recommendations to address them.

Age and Medicare Insurance are Barriers to Telemedicine Access—A Quality Improvement Project

Background

Telehealth use has had widespread expansion and adoption over the past two years. This study aims to evaluate access to telehealth essentials (TE) using a novel metric.

Methods

This single institute study surveyed outpatient surgical patients to determine their access to TE. Generalized linear mixed models were used to determine the relationship of demographic and county-level variables on access to four TE.

Results

138 patients were surveyed. Sixty-six (47.8%) were from Appalachian Kentucky. In the survey cohort, 122 (88.4%) had smart phones, 109 (80.7%) had devices with video messaging capabilities, 106 (80.9%) had cellular reception, and 112 (82.4%) had access to WiFi. Increasing age and Medicare insurance were the most consistent predictors of lack of access to TE.

Conclusion

Rural Appalachian Kentucky has access to TE. Telehealth has the potential to decrease the healthcare inequity in rural populations, but incompletely address this inequity for the aging population.

Through the Lens: Youth Experiences with Cancer in Rural Appalachian Kentucky Using Photovoice

Rural Appalachian Kentucky experiences disproportionately high cancer incidence and mortality rates. This cancer burden is due to social determinants of health and cultural factors prominent in the region. The firsthand experiences of community members-especially young people-can highlight these factors and identify areas for improvement. The purpose of this study was to encourage Appalachian Kentucky youth to consider determinants of cancer and visualize the effects that cancer has on their families or communities by asking them to take photographs of cancer-related objects around them. Content analysis was performed on 238 photographs submitted by 25 students, and photographs were organized into themes, subthemes, and subtopics. The six themes that emerged were risk factors and exposures, marketing, awareness and support, health care, experiences, and metaphorical representations. Many of the submitted photographs aligned with cultural, environmental and/or situational factors prevalent in Appalachian Kentucky. Of the submitted photographs, 54 were displayed as an installment in two Kentucky art galleries. Viewer comments at the exhibitions demonstrated that young community members can educate and motivate change in those around them. Ultimately, this project demonstrates that young community members can recognize cancer-related issues around them and connect personal experiences back to the larger Appalachian Kentucky cancer disparity while also having an impact on other community members.

The Appalachian Career Training in Oncology (ACTION) Program: Preparing Appalachian Kentucky High School and Undergraduate Students for Cancer Careers

The Appalachian Career Training In ONcology or ACTION Program is a National Cancer Institute (NCI) Youth Enjoy Science (YES) research education grant program that recruits and trains early-career undergraduate and high school students from underrepresented, socioeconomically distressed areas of Appalachian Kentucky in cancer research and outreach. The two-year program is a multifaceted experience that includes participation in cross-disciplinary, mentored cancer research projects. In addition to research projects, participants also shadow faculty mentors in clinical medical settings, engage in multiple types of educational activities, and participate in cancer-focused outreach projects within their communities. Participants also engage in peer-to-peer networking and receive career mentorship, training, and coaching. Highlights of program activities include a student-led photovoice project to promote cancer awareness and participant publications including a book featuring participant essays focused on their experiences and thoughts on cancer. Initial impact data show high school participants have a higher than state and county average four-year college-going rate and all undergraduate participants are gaining positive outcomes related to educational and career attainment. This article provides an overview of the significant benefits of the ACTION Program, the program's activities, and highlights from program implementation. Potential impacts of the program and barriers to implementation are also shared.

Neoadjuvant Therapy in Stage II/III Rectal Cancer: A Retrospective Study in a Disparate Population and the Effect on Survival

BACKGROUND

Kentucky has one of the highest rectal cancer incidences in the United States. High poverty rates have led to poor insurance coverage and inadequate access to care. The treatment of locally advanced rectal cancer utilizes a multimodal regimen requiring regular access to expert care. The rate of receipt of neoadjuvant therapy in Kentucky is unknown.

OBJECTIVE

This study aimed to evaluate the rate and factors associated with the receipt of neoadjuvant therapy for localized advanced rectal cancer in Kentucky and the effect on overall survival.

DESIGN

This is a retrospective database review.

SETTINGS

This study was conducted by utilizing the Kentucky Cancer Registry at an academic center.

PATIENTS

All patients diagnosed with stage II/III rectal adenocarcinoma from 2005 to 2015 in the Commonwealth of Kentucky were included.

MAIN OUTCOME MEASURES

The primary outcomes measured were the factors associated with nonreceipt of neoadjuvant therapy and overall survival.

RESULTS

Of 1896 patients, only 46.8% received neoadjuvant therapy. Factors associated with not receiving neoadjuvant therapy included older age, female sex, low education level, high poverty level, and treatment at nonacademic centers. Survival analysis demonstrated significantly improved survival in patients receiving neoadjuvant therapy compared with other treatment regimens.

LIMITATIONS

This study was limited by the retrospective nature of the review and by unmeasured confounders.

CONCLUSIONS

Our study was the first to evaluate the factors behind the low rates of neoadjuvant therapy for locally advanced rectal cancer in Kentucky. Neoadjuvant therapy in this population is beneficial for survival; efforts should be made in policy and education with focus on older patients, female patients, and treatment at nonacademic centers. Centralization of rectal cancer care improves outcomes, but we must be aware of the effect it may have on disparate populations with poor access. See Video Abstract at http://links.lww.com/DCR/B596.

TERAPIA NEOADYUVANTE EN EL MANEJO DEL CNCER DE RECTO EN ESTADIO II / III UN ESTUDIO RETROSPECTIVO EN UNA POBLACIN DISPAR Y EL EFECTO EN LA SUPERVIVENCIA

ANTECEDENTES:El estado de Kentucky tiene una de las mayores incidencias de cáncer de recto en los EE. UU. Debido a una alta tasa de pobreza, el porcentaje de la población que cuenta con seguro de salud, es muy limitado, y por lo tanto el acceso a una atención de alto nivel es muy bajo. El tratamiento del cáncer de recto localmente avanzado, es multidisciplinario, lo que exige acceso y disponibilidad a un grupo experto. Se desconoce la tasa de pacientes que reciben terapia neoadyuvante en Kentucky.OBJETIVO:Establecer la tasa y los factores asociados con el uso de terapia neoadyuvante en el tratamiento del cáncer de recto localmente avanzado en Kentucky, y su efecto en la supervivencia global.DISEÑO:Revisión retrospectiva de una base de datos.ESCENARIO:Este estudio se llevó a cabo utilizando el Registro de Cáncer de Kentucky en un centro académico.PACIENTES:Se incluyen todos los pacientes diagnosticados con adenocarcinoma de recto, de la Mancomunidad (Commonwealth) de Kentucky, en estadio II / III entre 2005 y 2015.PRINCIPALES MEDIDAS DE RESULTADO:Establecer los factores asociados con el hecho de no recibir terapia neoadyuvante; y establecer la supervivencia global.RESULTADOS:De 1896 pacientes evaluados, solo el 46,8% recibió terapia neoadyuvante. Los factores asociados, para no haber recibido terapia neoadyuvante fueron: la edad avanzada, sexo femenino, bajo nivel educativo, alto nivel de pobreza y tratamiento en centros no académicos. El análisis de la supervivencia mostró una supervivencia significativamente mejor en los pacientes que recibieron terapia neoadyuvante en comparación con otros esquemas de tratamiento.LIMITACIONES:Revisión retrospectiva, factores de confusión no medidos.CONCLUSIONES:Nuestro estudio ha sido el primero en evaluar los factores determinantes de las bajas tasas de terapia neoadyuvante para el tratamiento del cáncer de recto localmente avanzado en Kentucky. La terapia neoadyuvante mejora y favorece la supervivencia en esta población, por lo tanto se deben hacer esfuerzos en las políticas de salud, así como en educación, enfocados a los pacientes mayores, pacientes femeninas y tratamiento en centros no académicos. El centralizar la atención del cáncer de recto, mejora los resultados, pero debemos ser conscientes del efecto que puede tener en poblaciones desiguales económicamente, con acceso deficiente a la posibilidad de recibir atención de alto nivel. Consulte Video Resumen en http://links.lww.com/DCR/B596.

A Brief Educational Intervention Enhances Basic Cancer Literacy Among Kentucky Middle and High School Students

Kentucky experiences the highest overall cancer incidence and mortality rates in the USA with the greatest burden in the eastern, Appalachian region of the state. Cancer disparities in Kentucky are driven in part by poor health behaviors, poverty, lack of health care access, low education levels, and low health literacy. Individuals with inadequate health literacy are less likely to participate in preventive measures such as obtaining screenings and making healthy lifestyle choices, thus increasing their chances of developing and dying from cancer. By increasing cancer literacy among youth and adults, it may be possible to decrease cancer disparities across Kentucky. This study aimed to establish connections with middle and high schools in Kentucky that would facilitate pilot implementation of a brief cancer education intervention and assessment of cancer health literacy among these student populations. A baseline pretest cancer literacy survey consisting of 10 items was given to 349 participants, followed by the delivery of a cancer education presentation. Immediately following the presentation, participants were given a posttest with identical items to the pretest. Participants were primarily Caucasian (89.4%), female (68.7%), and in 10th through 12th grade (80.5%). Significant (p < 0.0001) increases in both average and median percent of correctly marked items were observed between the pretest and posttest (average, pretest = 56% versus posttest = 85%; median, pretest = 60% versus posttest = 90%). The scores for all individual items increased after the brief intervention. The results demonstrated a significant increase in cancer literacy levels immediately after the pilot educational intervention. We suggest that it may be possible to improve cancer literacy rates in Kentucky by integrating cancer education into middle and high school science and/or health education curricula. This could ultimately drive changes in behaviors that may help lower cancer incidence and mortality rates. Plans for future interventional studies measuring long-term cancer knowledge retention and resultant behavioral changes among middle and high school students as well as the feasibility of integrating cancer education into middle and high school curricula are also discussed.

Eliminating hepatitis C in a rural Appalachian county: protocol for the Kentucky Viral Hepatitis Treatment Study (KeY Treat), a phase IV, single-arm, open-label trial of sofosbuvir/velpatasvir for the treatment of hepatitis C

OBJECTIVES

The overall goal of the Kentucky Viral Hepatitis Treatment Study (KeY Treat) is to eliminate hepatitis C transmission from a county in Appalachian Kentucky by removing the barriers to accessing hepatitis C virus (HCV) treatment.

METHODS/ANALYSIS

KeY Treat is a phase IV, open-label, single-arm clinical trial of sofosbuvir/velpatasvir (SOF/VEL) for the treatment of viraemic HCV infections. Those eligible for KeY Treat are at least 18 years of age, viraemic and are residents of the target county. Pregnant women are not eligible. Rapid HCV RNA screening is used to determine eligibility, and those with a quantifiable viral load (VL) consenting to participate initiate SOF/VEL on the same day. All pharmacologic treatment and related medical care is provided free of charge using a non-specialist provider model. Follow-up visits occur at 2, 6 and 12 weeks during treatment to assess medication adherence (measured via VL and self-report), side effects and engagement in risk behaviours. Post-treatment visits occur at 12 weeks (sustained virologic response (SVR12) visit), 6 months and 12 months post-treatment completion to assess re-infection. A control county has also been identified, and prevalence and incidence of chronic HCV infections will be compared with the target community longitudinally. The primary outcome to assess elimination is SVR12. However, several outcomes will be measured to assess the effectiveness of removing the barriers to HCV treatment, including treatment entry, completion and re-infection. Analyses will be conducted via a generalised linear model framework that can incorporate flexible covariate adjustment and multiple outcome types with a compatible link function. Mathematical modelling will be completed assessing the impact and cost-effectiveness of the intervention.

ETHICS AND DISSEMINATION

KeY Treat has been approved by the Institutional Review Board at the University of Kentucky. Results from KeY Treat will be presented at conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03949764.

Training Appalachian Kentucky Youth Cancer Advocates

OBJECTIVES

Kentucky has the highest cancer incidence and mortality rates in the United States, with the Appalachian region experiencing the highest of those rates. Cancer advocacy, which is defined as providing support to cancer patients and their communities, represents a means of decreasing the cancer cases in Appalachian Kentucky. This exploratory study examined the effects of advocacy training and experiential learning on Appalachian high school students' cancer advocacy attitudes and self-efficacy.

METHODS

The design of this study was a mixed-methods, one-group repeated measure with a group of participants from the Appalachian Career Training in Oncology (ACTION) Program (N = 9). The study assessed advocacy attitudes and self-efficacy before and after participants were provided advocacy training and participated in an advocacy event.

RESULTS

Participating students' attitudes and self-efficacy did not substantially change following the training and their participation in an advocacy event. Through their comments after the event, however, students seem eager to use their voices to influence the actions of state legislators. At the same time, they worry about the apathy of their community members to their cancer advocacy message.

CONCLUSIONS

Youth represent potentially powerful agents of advocacy that could help address the cancer burden in Kentucky. Participants in this study likely overestimated their advocacy abilities before learning more about advocacy and participating in the process. As such, additional trainings are likely necessary to increase students' self-efficacy, encourage them to share their stories, and help them overcome perceived barriers.

Description of a Lung Cancer Hotspot: Disparities in Lung Cancer Histology, Incidence, and Survival in Kentucky and Appalachian Kentucky

INTRODUCTION

Kentucky is recognized as the state with the highest lung cancer burden for more than 2 decades, but how lung cancer differs in Kentucky relative to other US populations is not fully understood.

PATIENTS AND METHODS

We examined lung cancer reported to the Surveillance, Epidemiology, and End Results (SEER) Program by Kentucky and the other SEER regions for patients diagnosed between 2012 and 2016. Our analyses included histologic types, incidence rates, stage at diagnosis, and survival in Kentucky and Appalachian Kentucky relative to other SEER regions.

RESULTS

We found that both squamous cell carcinomas and small-cell lung cancers represent larger proportions of lung cancer diagnoses in Kentucky and Appalachian Kentucky than they do in the SEER registries. Furthermore, age-adjusted cancer incidence rates were higher in Kentucky for every subtype of lung cancer examined. Most notably, for Appalachian women the rate of small-cell carcinomas was 3.5-fold higher, and for Appalachian men the rate of squamous cell carcinoma was 3.1-fold higher, than the SEER rates. In Kentucky, lung cancers were diagnosed at later stages and lung cancer survival was lower for adenocarcinoma and neuroendocrine carcinomas than in SEER registries. Squamous cell carcinomas and small-cell carcinomas were most lethal in Appalachian Kentucky.

CONCLUSION

Together, these data highlight the considerable disparities among lung cancer cases in the United States and demonstrate the continuing high burden and poor survival of lung cancer in Kentucky and Appalachian Kentucky. Strategies to identify and rectify causes of these disparities are discussed.

Evidence for Cancer Literacy Knowledge Retention among Kentucky Middle and High School Students after a Brief Educational Intervention

OBJECTIVES

Although cancer is seen in every state in the United States, it does not affect every geographic area and population equally. Kentucky has the highest cancer incidence and mortality rates in the country, with an unusually high number of cases localized in its Appalachian region. Risk factors such as sun exposure, tobacco use, poor diet/exercise, poverty, and lack of access to healthcare centers contribute to this disparity. Because education levels in the area are low, cancer literacy (defined as how well a person can understand the advice of a healthcare professional and make appropriate lifestyle decisions) also is low. In this study, we examined the short-term and long-term effects of a brief cancer-related intervention on the cancer literacy of Kentucky middle and high school students.

METHODS

This study targeted middle and high school students in Kentucky. We administered an online 10-item cancer literacy pretest, followed by a brief educational intervention and a posttest to 164 students at six Kentucky middle and high schools. This posttest also included questions asking how likely students would be to change their habits or to encourage others to change their habits as a result of the intervention. All of the participating students also were sent a 3-month follow-up online survey with items identical to the pretest; 48 students completed the 3-month follow-up test, leading to a response rate of 29.2%. The data were summarized as frequencies, averages, median, and confidence intervals (CIs) of correctly marked answers. A paired t test was used to test for significance.

RESULTS

We observed an increase in the overall average test score from 50.2% (95% CI 47.8%-52.6%) on the pretest to 77.1% (95% CI 74.6%-79.7%) on the posttest immediately following the intervention. There also was an increase in the average number of correct responses on each item. The 3-month follow-up test similarly showed average test score improvement (75.4%). When asked how likely students would be to change their habits as a result of the intervention on a scale from 1 to 10 (1 = extremely unlikely, 10 = extremely likely), the median was 6. When asked how likely students would be to encourage another to change their habits, the median was an 8.

CONCLUSIONS

These results provide evidence that a brief educational intervention can increase cancer literacy, improve cancer knowledge retention, and encourage behavior change in Appalachian Kentucky students. Increasing cancer literacy may result in increased participation in preventive cancer screenings and improved health habits, which could ultimately lower cancer rates in the region.

Factors Contributing to Delay in Specialist Care After Colorectal Cancer Diagnosis in Kentucky

BACKGROUND

Abundant studies have associated colorectal cancer (CRC) treatment delay with advanced diagnosis and worse mortality. Delay in seeking specialist is a contributor to CRC treatment delay. The goal of this study is to investigate contributing factors to 14-d delay from diagnosis of CRC on colonoscopy to the first specialist visit in the state of Kentucky.

METHODS

The Kentucky Cancer Registry (KCR) database linked with health administrative claims data was queried to include adult patients diagnosed with stage I-IV CRC from January 2007 to December 2012. The dates of the last colonoscopy and the first specialist visit were identified through the claims. Bivariate and logistic regression analysis was performed to identify factors associated with delay to CRC specialist visit.

RESULTS

A total of 3927 patients from 100 hospitals in Kentucky were included. Approximately, 19% of patients with CRC visited a specialist more than 14 d after CRC detection on colonoscopy. Delay to specialist (DTS) was found more likely in patients with Medicaid insurance (OR 3.1, P < 0.0001), low and moderate education level (OR 1.4 and 1.3, respectively, P = 0.0127), and stage I CRC (OR 1.5, P < 0.0001). There was a higher percentage of delay to specialist among Medicaid patients (44.0%) than Medicare (18.0%) and privately insured patients (18.8%).

CONCLUSIONS

We identified Medicaid insurance, low education attainment, and early stage CRC diagnosis as independent risk factors associated with 14-d delay in seeking specialist care after CRC detection on colonoscopy.

Barn-Raising on the Digital Frontier: The L.A.U.N.C.H. Collaborative

A meta-analysis of oncology papers from around the world revealed that cancer patients who lived more than 50 miles away from hospital centers routinely presented with more advanced stages of disease at diagnosis, exhibited lower adherence to prescribed treatments, presented with poorer diagnoses, and reported a lower quality of life than patients who lived nearer to care facilities. Connected health approaches-or the use of broadband and telecommunications technologies to evaluate, diagnose, and monitor patients beyond the clinic-are becoming an indispensable tool in medicine to overcome the obstacle of distance.

Human Papilloma Virus-Associated Cervical Cancer and Health Disparities

Cervical cancer develops through persistent infection with high-risk human papilloma virus (hrHPV) and is a leading cause of death among women worldwide and in the United States. Periodic surveillance through hrHPV and Pap smear-based testing has remarkably reduced cervical cancer incidence worldwide and in the USA. However, considerable discordance in the occurrence and outcome of cervical cancer in various populations exists. Lack of adequate health insurance appears to act as a major socioeconomic burden for obtaining cervical cancer preventive screening in a timely manner, which results in disparate cervical cancer incidence. On the other hand, cervical cancer is aggressive and often detected in advanced stages, including African American and Hispanic/Latina women. In this context, our knowledge of the underlying molecular mechanism and genetic basis behind the disparate cervical cancer outcome is limited. In this review, we shed light on our current understanding and knowledge of racially disparate outcomes in cervical cancer.

Epidemiology and Implementation of Cancer Prevention in Disparate Populations and Settings

Successful cancer prevention strategies must be tailored to support usability. In this article, we will focus on cancer prevention strategies in populations that differ by race and ethnicity, place and location, sexual orientation and gender identity, and age by providing examples of effective approaches. An individual may belong to none of these categories, to all of these categories, or to some. This intersectionality of belonging characterizes individuals and shapes their experiences. Even within a category, broad diversity exists. Effective cancer prevention strategies comprehensively engage the community at multiple levels of influence and may effectively include lay health workers and faith-based cancer education interventions. Health system efforts that integrate cancer health with other health promotion activities show promise. At the individual physician level, culturally literate approaches have demonstrated success. For example, when discussing cancer screening tests with older adults, clinicians should indicate whether any data suggest that the screening test improves quality or quantity of life and the lag time to benefit from the screening test. This will allow older adults to make an informed cancer screening decision based on a realistic understanding of the potential benefits and risks and their values and preferences. Addressing individual and health system bias remains a challenge. Quality improvement strategies can address gaps in quality of care with respect to timeliness of care, coordination of care, and patient experience. The time is ripe for research on effective and interdisciplinary prevention strategies that harness expertise from preventive medicine, behavioral medicine, implementation science, e-health, telemedicine, and other diverse fields of health promotion.

Cancer-Related Beliefs and Perceptions in Appalachia: Findings from 3 States

BACKGROUND

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.

METHODS

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).

RESULTS

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.

CONCLUSIONS

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.

Impact of the Affordable Care Act on Colorectal Cancer Screening, Incidence, and Survival in Kentucky

BACKGROUND

Kentucky ranks first in the US in cancer incidence and mortality. Compounded by high poverty levels and a high rate of medically uninsured, cancer rates are even worse in Appalachian Kentucky. Being one of the first states to adopt the Affordable Care Act (ACA) Medicaid expansion, insurance coverage markedly increased for Kentucky residents. The purpose of our study was to determine the impact of Medicaid expansion on colorectal cancer (CRC) screening, diagnosis, and survival in Kentucky.

STUDY DESIGN

The Kentucky Cabinet for Health and Family Services and the Kentucky Cancer Registry were queried for individuals (≥20 years old) undergoing CRC screening (per US Preventative Services Task Force) or diagnosed with primary invasive CRC from January 1, 2011 to December 31, 2016. Colorectal cancer screening rates, incidence, and survival were compared before (2011 to 2013) and after (2014 to 2016) ACA implementation.

RESULTS

Colorectal cancer screening was performed in 930,176 individuals, and 11,441 new CRCs were diagnosed from 2011 to 2016. Screening for CRC increased substantially for Medicaid patients after ACA implementation (+230%, p < 0.001), with a higher increase in screening among the Appalachian (+44%) compared with the non-Appalachian (+22%, p < 0.01) population. The incidence of CRC increased after ACA implementation in individuals with Medicaid coverage (+6.7%, p < 0.001). Additionally, the proportion of early stage CRC (stage I/II) increased by 9.3% for Appalachians (p = 0.09), while there was little change for non-Appalachians (-1.5%, p = 0.60). Colorectal cancer survival was improved after ACA implementation (hazard ratio 0.73, p < 0.01), particularly in the Appalachian population with Medicaid coverage.

CONCLUSIONS

Implementation of Medicaid expansion led to a significant increase in CRC screening, CRC diagnoses, and overall survival in CRC patients with Medicaid, with an even more profound impact in the Appalachian population.