Gender differences in correlates of colorectal cancer screening among Black Medicare beneficiaries in Baltimore

Study protocol for developing #CuttingCRC: a barbershop-based trial on masculinity barriers to care and colorectal cancer screening uptake among African-American men using an exploratory sequential mixed-methods design

INTRODUCTION

Colorectal cancer (CRC) is preventable, as screening leads to the identification and removal of precancerous polyps. African-American men consistently have the highest CRC mortality rates, and their CRC-screening uptake remains low for complex reasons. Culture-specific masculinity barriers to care may contribute to the low uptake among African-American men. Examining these barriers to care is vital as CRC screening may challenge cultural role expectations of African-American men, whose tendency is to delay help-seeking medical care. Barbershops provide a pathway for reaching African-American men with masculinity barriers to care who are not regularly receiving healthcare services and CRC screening. This study aims to develop and pilot test a theory-driven, culture-specific, barbershop-based intervention targeting masculinity barriers to care and CRC-screening uptake among African-American men ages 45-75.

METHODS AND ANALYSIS

Guided by the theory of planned behaviour and the behaviour change wheel, we will use a multistage mixed-methods study design, beginning with an exploratory sequential approach to validate items for subsequent use in a pilot mixed-methods intervention. First, we will collect and analyse qualitative data from focus groups, cognitive interviews and expert item review to validate and test a culture-specific Masculinity Barriers to Care Scale (MBCS) among African-American men. Next, we will administer the MBCS to our target population as an online quantitative survey and evaluate the association between scores and CRC-screening uptake. Then, we will consider existing evidence-based approaches, our integrated results (qualitative +quantitative), and community input to design a culture-specific, behavioural intervention aimed at increasing CRC-screening uptake among African-American men and feasible for barbershop delivery. We will test the peer intervention in a pilot study with a two-arm cluster randomised design (six barbershops, randomised by site) to reduce contamination and account for barbershop culture differences. Our primary outcomes for the pilot are recruitment, sample size estimation, preliminary efficacy and acceptability.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the University of Utah Institutional Review Board (00113679), who will also be responsible for receiving communication updates regarding important protocol modifications. To ensure confidentiality, data dispersed to project team members will be blinded of any identifying participant information. Study results will be disseminated through publications in peer-reviewed journals, community dialogue sessions, and presentations at conferences.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier: NCT03733197 (Pre-results);https://clinicaltrials.gov/ct2/show/NCT03733197.

Medical Mistrust and Colorectal Cancer Screening Among African Americans

Despite well-documented benefits of colorectal cancer (CRC) screening, African Americans are less likely to be screened and have higher CRC incidence and mortality than Whites. Emerging evidence suggests medical mistrust may influence CRC screening disparities among African Americans. The goal of this systematic review was to summarize evidence investigating associations between medical mistrust and CRC screening among African Americans, and variations in these associations by gender, CRC screening type, and level of mistrust. MEDLINE, CINAHL, Web of Science, PsycINFO, Google Scholar, Cochrane Database, and EMBASE were searched for English-language articles published from January 2000 to November 2016. 27 articles were included for this review (15 quantitative, 11 qualitative and 1 mixed methods study). The majority of quantitative studies linked higher mistrust scores with lower rates of CRC screening among African Americans. Most studies examined mistrust at the physician level, but few quantitative studies analyzed mistrust at an organizational level (i.e. healthcare systems, insurance, etc.). Quantitative differences in mistrust and CRC screening by gender were mixed, but qualitative studies highlighted fear of experimentation and intrusiveness of screening methods as unique themes among African American men. Limitations include heterogeneity in mistrust and CRC measures, and possible publication bias. Future studies should address methodological challenges found in this review, such as limited use of validated and reliable mistrust measures, examination of CRC screening outcomes beyond beliefs and intent, and a more thorough analysis of gender roles in the cancer screening process.

Obesity and the receipt of influenza and pneumococcal vaccination: a systematic review and meta-analysis

BACKGROUND

Obesity is a risk factor for inadequate receipt of recommended preventive care services. The objective of this study was to assess the relationship between increasing body mass index and receipt of influenza and pneumococcal vaccinations. A systematic review of the PubMed, Embase, and Web of Science databases was conducted from January 1966 to May 2015 for cohort and cross-sectional studies that assessed the relationship between body mass index and the receipt of vaccinations for influenza and pneumococcus. Separate meta-analyses by obesity classification were performed using a random effects model.

RESULTS

Six cross-sectional and three cohort studies were included. Average vaccine uptake was 50.4 % for influenza vaccination and 34.6 % for pneumococcal vaccination. Compared to normal weight patients, combined odds ratio (95 % confidence interval) for influenza vaccination was 1.11 (95 % CI 0.97-1.25) for obese (≥30 kg/m(2)) patients. When the outcome was reported by obesity class, combined odds ratios of influenza vaccination were 1.13 (95 % CI 1.02-1.24) for Class I (30-34.9 kg/m(2)) obesity, 1.21 (95 % CI 1.05-1.37) for Class II obesity (35-39.9 kg/m(2)), and 1.19 (95 % CI 0.95-1.42) for Class III obesity (≥40 kg/m(2)) patients. Compared to normal weight patients, combined odds ratio of pneumococcal vaccination were 1.20 (95 % CI 1.13-1.27) for obese patients. When the outcome was reported by obesity class, combined odds ratios were 1.08 (95 % CI 1.04-1.13) for Class I obesity patients, 1.13 (95 % CI 1.10-1.16) for Class II obesity patients, and 1.26 (95 % CI 1.15-1.38) for Class III obesity patients for pneumococcal vaccination.

CONCLUSIONS

Combined findings from the current literature suggest that adults with obesity are more likely than non-obese peers to receive vaccination for influenza and pneumococcus. However, suboptimal vaccination coverage was observed across all body sizes, so future interventions should focus on improving vaccination rates for all adults.

Effect of Patient Navigation on Breast Cancer Screening Among African American Medicare Beneficiaries: A Randomized Controlled Trial

BACKGROUND

There is growing evidence that patient navigation improves breast cancer screening rates; however, there are limited efficacy studies of its effect among African American older adult women.

OBJECTIVE

To evaluate the effect of patient navigation on screening mammography among African American female Medicare beneficiaries in Baltimore, MD.

DESIGN

The Cancer Prevention and Treatment Demonstration (CPTD), a multi-site study, was a randomized controlled trial conducted from April 2006 through December 2010.

SETTING

Community-based and clinical setting.

PARTICIPANTS

The CPTD Screening Trial enrolled 1905 community-dwelling African American female Medicare beneficiaries who were ≥65 years of age and resided in Baltimore, MD. Participants were recruited from health clinics, community centers, health fairs, mailings using Medicare rosters, and phone calls.

INTERVENTIONS

Participants were randomized to either: printed educational materials on cancer screening (control group) or printed educational materials + patient navigation services designed to help participants overcome barriers to cancer screening (intervention group).

MAIN MEASURE

Self-reported receipt of mammography screening within 2 years of the end of the study.

KEY RESULTS

The median follow-up period for participants in this analysis was 17.8 months. In weighted multivariable logistic regression analyses, women in the intervention group had significantly higher odds of being up to date on mammography screening at the end of the follow-up period compared to women in the control group (odds ratio [OR] 2.26, 95 % confidence interval [CI]1.59-3.22). The effect of the intervention was stronger among women who were not up to date with mammography screening at enrollment (OR 3.63, 95 % CI 2.09-6.38).

CONCLUSION

Patient navigation among urban African American Medicare beneficiaries increased self-reported mammography utilization. The results suggest that patient navigation for mammography screening should focus on women who are not up to date on their screening.

Mobilizing social support networks to improve cancer screening: the COACH randomized controlled trial study design

BACKGROUND

Disadvantaged populations face many barriers to cancer care, including limited support in navigating through the complexities of the healthcare system. Family members play an integral role in caring for patients and provide valuable care coordination; however, the effect of family navigators on adherence to cancer screening has not previously been evaluated. Training and evaluating trusted family members and other support persons may improve cancer outcomes for vulnerable patients.

METHODS

Guided by principles of community based participatory research (CBPR), "Evaluating Coaches of Older Adults for Cancer Care and Healthy Behaviors (COACH)" is a community-based randomized controlled trial to assess the effectiveness of a trained participant-designated coach (support person or care giver) in navigating cancer-screening for older African American adults, 50-74 years old. Participants are randomly assigned as dyads (participant+coach pair) to receiving either printed educational materials only (PEM--control group) or educational materials plus coach training (COACH--intervention group). We defined a coach as family member, friend, or other lay support person designated by the older adult. The coach training is designed as a one-time, 35- to 40-minute training consisting of: 1) a didactic session that covers the role of the coach, basic facts about colorectal, breast and cervical cancers (including risk factors, signs and symptoms and screening modalities), engaging the healthcare provider in cancer screening, insurance coverage for screening, and related healthcare issues, 2) three video skits addressing misconceptions about and planning for cancer screening, and 3) an interactive role-play session with the trainer to reinforce and practice strategies for encouraging the participant to get screened. The primary study outcome is the difference in the proportion of participants completing at least one of the recommended screenings (for breast, cervix or colorectal cancer) between the control and intervention groups.

DISCUSSION

Building on trusted patient contacts to encourage cancer screening, COACH is a highly sustainable intervention in a high-risk population. It has the potential to minimize the effect of mistrust of the medical establishment on screening behaviors by mobilizing participants' existing support networks. If effective, the intervention could have a high impact on health care disparities research across multiple diseases.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT01613430 ). Registered June 5, 2012.

Effect of Adjuvant FOLFOX Chemotherapy Duration on Outcomes of Patients With Stage III Colon Cancer

BACKGROUND

Studies have demonstrated that patients with stage III colon cancer who receive adjuvant FOLFOX (5-fluorouracil and oxaliplatin) chemotherapy experience an improved disease-free (DFS) and overall survival (OS). However, the magnitude of benefit among patients who discontinue FOLFOX early is not well known. We sought to examine the rate of FOLFOX treatment completion, determine the factors associated with adherence, and explore the relationship between duration of FOLFOX treatment and survival.

PATIENTS AND METHODS

We analyzed patients diagnosed with stage III colon cancer from 2006 to 2010 and initiated at least 1 cycle of adjuvant FOLFOX at any 1 of 5 regional cancer centers in British Columbia. Logistic regression models were constructed to determine the clinical factors associated with treatment completion, which was defined as receipt of ≥ 10 cycles of FOLFOX. Kaplan-Meier methods and Cox regression that accounted for known prognostic factors were used to evaluate the relationship between early FOLFOX discontinuation and DFS and OS.

RESULTS

We identified 616 patients: median age of 62 years (range, 26-80), 321 (52%) men, 536 (87%) with T3/4 tumors, and 245 (40%) with N2 disease. Among them, 183 (30%) received < 10 and 433 (70%) received ≥ 10 cycles. Adjusting for covariates, female sex and the absence of obstruction or perforation were each associated with receiving ≥ 10 cycles of FOLFOX (odds ratio [OR], 1.61; 95% confidence interval [CI], 1.12-2.32; P = .01 and OR, 1.82; 95% CI, 1.08-3.05; P = .02, respectively). In multivariate analyses, early discontinuation of FOLFOX did not affect DFS or OS (hazard ratio [HR], 1.16; 95% CI, 0.82-1.63; P = .40 and HR, 1.07; 95% CI, 0.70-1.61; P = .76, respectively).

CONCLUSION

Early discontinuation of FOLFOX was not associated with differences in survival outcomes, lending support to clinical trials that are under way to evaluate the efficacy of shorter durations of therapy.

Effect of patient navigation on colorectal cancer screening in a community-based randomized controlled trial of urban African American adults

PURPOSE

In recent years, colorectal cancer (CRC) screening rates have increased steadily in the USA, though racial and ethnic disparities persist. In a community-based randomized controlled trial, we investigated the effect of patient navigation on increasing CRC screening adherence among older African Americans.

METHODS

Participants in the Cancer Prevention and Treatment Demonstration were randomized to either the control group, receiving only printed educational materials (PEM), or the intervention arm where they were assigned a patient navigator in addition to PEM. Navigators assisted participants with identifying and overcoming screening barriers. Logistic regression analyses were used to assess the effect of patient navigation on CRC screening adherence. Up-to-date with screening was defined as self-reported receipt of colonoscopy/sigmoidoscopy in the previous 10 years or fecal occult blood testing (FOBT) in the year prior to the exit interview.

RESULTS

Compared with controls, the intervention group was more likely to report being up-to-date with CRC screening at the exit interview (OR 1.55, 95 % CI 1.07-2.23), after adjusting for select demographics. When examining the screening modalities separately, the patient navigator increased screening for colonoscopy/sigmoidoscopy (OR 1.53, 95 % CI 1.07-2.19), but not FOBT screening. Analyses of moderation revealed stronger effects of navigation among participants 65-69 years and those with an adequate health literacy level.

CONCLUSIONS

In a population of older African Americans adults, patient navigation was effective in increasing the likelihood of CRC screening. However, more intensive navigation may be necessary for adults over 70 years and individuals with low literacy levels.

Monitoring style of coping with cancer related threats: a review of the literature

Building on the Cognitive-Social Health Information-Processing model, this paper provides a theoretically guided review of monitoring (i.e., attend to and amplify) cancer-related threats. Specifically, the goals of the review are to examine whether individuals high on monitoring are characterized by specific cognitive, affective, and behavioral responses to cancer-related health threats than individuals low on monitoring and the implications of these cognitive-affective responses for patient-centered outcomes, including patient-physician communication, decision-making and the development of interventions to promote adherence and adjustment. A total of 74 reports were found, based on 63 studies, 13 of which were intervention studies. The results suggest that although individuals high on monitoring are more knowledgeable about health threats, they are less satisfied with the information provided. Further, they tend to be characterized by greater perceived risk, more negative beliefs, and greater value of health-related information and experience more negative affective outcomes. Finally, individuals high on monitoring tend to be more demanding of the health providers in terms of desire for more information and emotional support, are more assertive during decision-making discussions, and subsequently experience more decisional regret. Psychoeducational interventions improve outcomes when the level and type of information provided is consistent with the individual's monitoring style and the demands of the specific health threat. Implications for patient-centered outcomes, in terms of tailoring of interventions, patient-provider communication, and decision-making, are discussed.