Abstract PO-262: Achieving health equity in cancer preventive services: NIH Workshop insights on barriers and the effectiveness of evidence-based interventions and strategies

Background: Evidence-based guidelines for preventive services are developed by expert groups such as the U.S. Preventive Services Task Force (USPSTF) to help Americans stay healthy. Despite the proven value of evidence-based preventive services (e.g., screenings, provider counseling, and preventive medications), implementation by providers and uptake by patients vary, contributing to disparities in disease burden and life expectancy. The NIH convened a workshop with multidisciplinary and multisector participants in June 2019 to assess the available scientific evidence on achieving health equity in the use of clinical preventive services for three leading causes of death: diabetes, heart disease, and cancer.

Methods: The workshop was framed around five key questions (KQ) and included a systematic evidence review, speaker presentations, and public discussion. KQ 1-2 considered the effects of barriers on the part of providers and patients to adopting and implementing evidence-based preventive services, and how they contribute to health disparities. KQ 3-5 addressed the effectiveness of health information technology and health care organization interventions to reduce disparities in preventive services use. An unbiased, independent panel of experts considered the scientific evidence in addition to speaker and audience perspectives to develop a report of findings and recommendations for addressing disparities in the use of ten clinical preventive services recommended by the USPSTF. Results: Overall, the need for more research on the effects of barriers was identified. However, compared with heart disease and diabetes, the barriers to adopting preventive services for breast, cervical, and colorectal cancer screening have received greater attention. While patient navigation was shown to be effective in increasing cancer screening rates, strategies for bundling preventive services and implementing health information technologies require more study. The importance of addressing unmet basic needs related to health and enhancing community resources to reduce disparities were recurring themes throughout the workshop. Lastly, there were implications for more research in cancer dissemination and implementation. Conclusion: Chronic diseases, including heart disease, cancer, and diabetes, are responsible for seven of every ten deaths in the U.S. each year. Greater use of proven clinical preventive services could avert the loss of millions of life-years. Achieving health equity in preventive services is feasible, but requires efforts at the patient, provider, healthcare organization, and community levels, and greater attention to addressing social determinants of health.

Citation Format: Antoinette Percy-Laurry, Richard Berzon, Jennifer Croswell, Carrie Klabunde, Melissa Green Parker, LeShawndra Price, Pamela Thornton, Kate Winseck, Xinzhi Zhang. Achieving health equity in cancer preventive services: NIH Workshop insights on barriers and the effectiveness of evidence-based interventions and strategies [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-262.

Overexpression of ALDH1 and EMT marker profile are linked with unfavorable outcome in head and neck cancer

Background

The aim of this research was to assess the expression of aldehyde dehydrogenase 1 (ALDH1) and epithelial-mesenchymal transition (EMT) markers in head and neck squamous cell carcinoma (HNSCC), and to correlate them with the clinical and histopathological parameters of a patient cohort with follow-up over an 8-year period.

Material and Methods

For this, seventeen HNSCC and non-neoplastic adjacent epithelium (AE) samples were subjected to laser microdissection and real-time PCR to evaluate the mRNA expression of ALDH1, E-cadherin (E-CAD), N-cadherin (N-CAD), and vimentin (VIM). Also, immunohistochemistry was performed for ALDH1, E-CAD, N-CAD, and VIM in the tumor center (TC), invasion front (IF), and AE of the seventeen samples. Mann-Whitney, Kruskal-Wallis and Chi-square tests were used to correlate the mRNA and immunohistochemical expression with different variables, considering p<0.05. Kaplan-Meier curves were produced for local recurrence, regional metastasis and treatment.

Results

A mRNA overexpression of ALDH1 in primary tumors was associated with regional metastasis and a high ALDH1 immunostaining was related to metastasis and a worse patient outcome. Additionally, a favorable outcome was associated with the transition phase and an unfavorable outcome was associated with EMT event. An overall 26.9 months was observed with longer survival associated with surgery and radiotherapy.

Conclusions

However, due to the intense variability inherent to the indicator proteins in the EMT process, the complete profile markers related to this biological process should be continuous investigated.

Key words:Aldehyde dehydrogenase 1, epithelial mesenchymal transition, head and neck cancer, squamous cell carcinoma, follow-up study.

Risks and rewards of using prepaid vs. postpaid incentive checks on a survey of physicians

BACKGROUND

Survey researchers use monetary incentives as a strategy to motivate physicians' survey participation. Experiments from general population surveys demonstrate that prepaid incentives increase response rates and lower survey administration costs relative to postpaid incentives. Experiments comparing these two incentive strategies have rarely been attempted with physician samples.

METHODS

A nationally representative sample of oncologists was recruited to participate in the National Survey of Precision Medicine in Cancer Treatment. To determine the optimal strategy for survey incentives, sample members were randomly assigned to receive a $50 prepaid incentive check or a $50 promised (postpaid) incentive check. Outcome measures for this incentives experiment include cooperation rates, speed of response, check-cashing behavior, and comparison of hypothetical costs for different incentive strategies.

RESULTS

Cooperation rates were considerably higher for sample members in the prepaid condition (41%) than in the postpaid condition (29%). Similar differences in cooperation rates were seen for physicians when stratified by region, size of the physician's metropolitan statistical area, specialty, and gender by age. Survey responders in the prepaid condition responded earlier in the field period than those in the postpaid condition, thus requiring fewer contacts. In the prepaid group, 84% of sample members who responded with a completed survey cashed the incentive check and only 6% of nonresponders cashed the check. In the postpaid condition, 72% of survey responders cashed the check; nonresponders were not given a check. The relatively higher cooperation rates and earlier response of the responders in the prepaid condition was associated with a 30% cost savings for the prepaid condition compared to the postpaid incentive condition.

CONCLUSIONS

The results of this study suggest that the rewards of offering physicians a prepaid incentive check outweigh the possible risks of nonresponders cashing the check. The relative cost benefit of this strategy is likely to vary depending on the amount of the incentive relative to the costs of additional contact attempts to nonresponders.

Variations in Oncologist Recommendations for Chemotherapy for Stage IV Lung Cancer: What Is the Role of Performance Status?

PURPOSE

Chemotherapy prolongs survival in patients with advanced non-small-cell lung cancer. However, few studies have included patients with poor performance status. This study examined rates of oncologists' recommendations for chemotherapy by patient performance status and symptoms and how physician characteristics influence chemotherapy recommendations.

METHODS

We surveyed medical oncologists involved in the care of a population-based cohort of patients with lung cancer from the CanCORS (Cancer Care Outcomes Research and Surveillance) study. Physicians were queried about their likelihood to recommend chemotherapy to patients with stage IV lung cancer with varying performance status (Eastern Cooperative Oncology Group performance status 0 [good] v 3 [poor]) and presence or absence of tumor-related pain. Repeated measures logistic regression was used to estimate the independent associations of patients' performance status and symptoms and physicians' demographic and practice characteristics with chemotherapy recommendations.

RESULTS

Nearly all physicians (adjusted rate, 97% to 99%) recommended chemotherapy for patients with good performance status, and approximately half (adjusted rate, 38% to 53%) recommended chemotherapy for patients with poor performance status (P < .001). Compared with patient factors, physician and practice characteristics were less strongly associated with chemotherapy recommendations in adjusted analyses.

CONCLUSION

Strong consensus among oncologists exists for chemotherapy in patients with advanced non-small-cell lung cancer and good performance status. However, the relatively high rate of chemotherapy recommendations for patients with poor performance status despite the unfavorable risk-benefit profile highlights the need for ongoing work to define high-value care in oncology and to implement and evaluate strategies to align incentives for such care.

Participation rates for organized colorectal cancer screening programmes: an international comparison

OBJECTIVE

Participation, an indicator of screening programme acceptance and effectiveness, varies widely in clinical trials and population-based colorectal cancer (CRC) screening programmes. We aimed to assess whether CRC screening participation rates can be compared across organized guaiac fecal occult blood test (G-FOBT)/fecal immunochemical test (FIT)-based programmes, and what factors influence these rates.

METHODS

Programme representatives from countries participating in the International Cancer Screening Network were surveyed to describe their G-FOBT/FIT-based CRC screening programmes, how screening participation is defined and measured, and to provide participation data for their most recent completed screening round.

RESULTS

Information was obtained from 15 programmes in 12 countries. Programmes varied in size, reach, maturity, target age groups, exclusions, type of test kit, method of providing test kits and use, and frequency of reminders. Coverage by invitation ranged from 30-100%, coverage by the screening programme from 7-67.7%, overall uptake/participation rate from 7-67.7%, and first invitation participation from 7-64.3%. Participation rates generally increased with age and were higher among women than men and for subsequent compared with first invitation participation.

CONCLUSION

Comparisons among CRC screening programmes should be made cautiously, given differences in organization, target populations, and interpretation of indicators. More meaningful comparisons are possible if rates are calculated across a uniform age range, by gender, and separately for people invited for the first time vs. previously.

The colorectal cancer screening process in community settings: a conceptual model for the population-based research optimizing screening through personalized regimens consortium

Reducing colorectal cancer mortality by promoting screening has been a national goal for two decades. The NCI's Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium is the first federal initiative to foster coordinated, transdisciplinary research evaluating the entire cancer screening process in community settings. PROSPR is creating a central data repository to facilitate research evaluating the breast, cervical, and colorectal cancer screening process across different patient populations, provider types, and delivery systems. Data are being collected and organized at the multiple levels in which individuals are nested (e.g., healthcare systems, facilities, providers, and patients). Here, we describe a conceptual model of the colorectal cancer screening process guiding data collection and highlight critical research questions that will be addressed through pooled data. We also describe the three research centers focused on colorectal cancer screening with respect to study populations, practice settings, and screening policies. PROSPR comprehensively elucidates the complex screening process through observational study, and has potential to improve care delivery beyond the healthcare systems studied. Findings will inform intervention designs and policies to optimize colorectal cancer screening delivery and advance the Institute of Medicine's goals of effective, efficient, coordinated, timely, and safe health care with respect to evidence-based cancer screening.

Abstract 3565: Colorectal cancer screening among US adults with and without doctor's specific recommendation regarding choice of screening modality

Background: Absence of a physician's recommendation is among the most commonly reported barriers to undergoing colorectal cancer (CRC) screening. It is unknown whether a physician's specific recommendation of a particular screening modality, rather than a patient's choice from a menu of screening options, improves CRC screening uptake. Aim: To assess whether healthcare providers’ discussion of CRC screening options and recommending a specific screening modality improve uptake of screening. Methods: We used the 2007 Health Information National Trends Survey (HINTS) to evaluate how respondents who were 50 years and older (n = 4,342) were informed of CRC screening. We used logistic regression analyses to examine the association of recommendations and being current with CRC screening (Fecal occult blood testing (FOBT) within 1 year, sigmoidoscopy within 5 years, or colonoscopy within 10 years). Results: The mean age of responders was 64.9 years, 60.3% female, 81.5% white, 8.6% black, and 92.7% had health insurance. CRC screening discussions occurred with 3,320 (77.5%) respondents; 94.7% of which occurred with a doctor as opposed to a nurse or other health care professional. Colonoscopy was the most recommended test. Overall, 2,824 (65.0%) respondents were up to date with CRC screening regardless of the screening modality. After adjusting for age, sex, race, highest education, income, marital status and health insurance, having a discussion about screening and receiving a specific test recommendation were associated with being up to date with CRC screening (Table). Conclusion: Uptake of CRC screening is better when providers discuss CRC screening and make specific CRC screening test recommendations. Table: Association of the patterns of CRC screening recommendations with being up to date with CRC screening

U.S. primary care physicians' diet-, physical activity-, and weight-related care of adult patients

BACKGROUND

Overweight and obesity are substantial problems in the U.S., but few national studies exist on primary care physicians' (PCPs') clinical practices regarding overweight and obesity.

PURPOSE

To profile diet, physical activity, and weight control practice patterns of PCPs who treat adults.

METHODS

A nationally representative survey of 1211 PCPs sampled from the American Medical Association's Masterfile was conducted in 2008 and analyzed in 2010. Outcomes included PCPs' assessment, counseling, referral, and follow-up of diet, physical activity, and weight control in adult patients with and without chronic disease and PCPs' use of pharmacologic treatments and surgical referrals for overweight and obesity.

RESULTS

The survey response rate was 64.5%. Half of PCPs (49%) reported recording BMI regularly. Fewer than 50% reported always providing specific guidance on diet, physical activity, or weight control. Regardless of patients' chronic disease status, <10% of PCPs always referred patients for further evaluation/management and <22% reported always systematically tracking patients over time concerning weight or weight-related behaviors. Overall, PCPs were more likely to counsel on physical activity than on diet or weight control (p's<0.05). More than 70% of PCPs reported ever using pharmacologic treatments to treat overweight and 86% had referred for obesity-related surgery.

CONCLUSIONS

PCPs' assessment and behavioral management of overweight and obesity in adults is at a low level relative to the magnitude of the problem in the U.S. Further research is needed to understand barriers to providing care and to improve physician engagement in tracking and managing healthy lifestyles in U.S. adults.

Breast and cervical cancer screening programme implementation in 16 countries

Objective

There is a continuing need to monitor and evaluate the impact of organized screening programmes on cancer incidence and mortality. We report results from a programme assessment conducted within the International Cancer Screening Network (ICSN) to understand the characteristics of cervical screening programmes within countries that have established population-based breast cancer screening programmes.

Methods

In 2007-2008, we asked 26 ICSN country representatives to complete a web-based survey that included questions on breast and cervical cancer screening programmes. We summarized information from 16 countries with both types of organized programmes.

Results

In 63% of these countries, the organization of the cervical cancer screening programme was similar to that of the breast cancer screening programme in the same country. There were differences in programme characteristics, including year established (1962-2003 cervical; 1986-2002 breast) and ages covered (15-70+ cervical; 40-75+ breast). Adoption of new screening technologies was evident (44% liquid-based Pap tests; 13% human papillomavirus (HPV)-triage tests cervical; 56% digital mammography breast). There was wide variation in participation rates for both programme types (<4-80% cervical; 12-88% breast), and participation rates tended to be higher for cervical (70-80%) than for breast (60-70%) cancer screening programmes. Eleven ICSN member countries had approved the HPV vaccine and five more were considering its use in their organized programmes.

Conclusion

Overall, there were similarities and differences in the organization of breast and cervical cancer screening programmes among ICSN countries. This assessment can assist established and new screening programmes in understanding the organization and structure of cancer screening programmes.

Methodological issues in international comparison of interval breast cancers

International comparisons of interval cancers (IC) are important to better understand the relationship between programmes' performance and screening practices. In this respect, differences in (i) definition, (ii) identification and (iii) quantification of IC have received little attention. To examine these 3 comparability issues and activities involving IC, an assessment was conducted among member countries of the International Breast Cancer Screening Network, and the impact of accuracy of identification and quantification practices was estimated using 1996-98 data from the Dutch breast cancer screening programme. Information was obtained from 19 screening programmes in 18 countries, 16 of which acknowledged the coexistence of opportunistic screening. IC data were collected to evaluate performance of the screening programme (100% of programmes) and the radiologists (89%); 53% of programmes had a designated review process for IC. Most programmes (84%) agreed with the European Guidelines definition of IC, but a case situation exercise evidenced substantial discrepancy in classification of cancers that occurred after a positive screen. Completeness of identification of IC appears to contribute most to international variation, and cannot be easily controlled for in methodologically rigorous comparisons. Statistically significant differences of about 4% were measured between quantification methods for IC. An operational definition of IC is proposed to enhance international comparability. Valid comparisons of IC are possible with careful attention to the definition but true differences in IC frequency across screening programmes should exceed 10% to be possibly indicative of real differences between programmes.

US physicians' attitudes toward genetic testing for cancer susceptibility

Genetic testing for an inherited susceptibility to cancer is an emerging technology in medical practice. Little information is currently available about physicians' attitudes toward these tests. To assess US physicians' opinions on unresolved issues surrounding genetic testing, a 15-min survey was administered to a stratified random sample of 1,251 physicians from 8 specialties, selected from a file of all licensed physicians in the US (response rate = 71.0%). Dependent measures included physicians' attitudes toward genetic counseling and testing qualifications, availability of guidelines, patient confidentiality and insurance discrimination issues, and clinical utility of genetic tests. More than 89% of physicians reported a need for physician guidelines, 81% thought that patients with positive genetic test results are at risk for insurance discrimination, and more than 53% thought that it was difficult to ensure the confidentiality of test results. Almost 25% indicated that genetic tests for cancer susceptibility have too many inaccurate or ambiguous results; nearly 75% thought that clear guidelines are not available for managing patients with positive test results. Only 29% of physicians reported feeling qualified to provide genetic counseling to their patients. More than 84% of oncologists considered themselves qualified to recommend genetic testing to their patients compared with 40% of primary care physicians (PCPs), and 57% of tertiary care physicians (TCPs). US physicians expressed great uncertainty about issues surrounding genetic testing for cancer susceptibility. Results of this national survey underscore the need to provide physicians with clear guidelines on the use of genetic cancer susceptibility tests and effective medical training on their appropriate implementation.

Cancer screening practices from National Health Interview Surveys: past, present, and future

The National Health Interview Survey (NHIS) has provided data about health behaviors at the national level since 1957. The 1987 and 1992 Cancer Control Supplements to the NHIS, along with other supplemental surveys administered intermittently on self-reported cancer-related behaviors, have contributed to important research and public health purposes. In this article, we reviewed 73 papers published between 1980 and 2001 that used NHIS data, including the first report from the 1998 NHIS, to examine what has been learned from past surveys. Our goal was to facilitate future analyses of recently released data on cancer screening practices from the Cancer Control Supplement to the 2000 NHIS, which is now known as the Cancer Control Module. We categorized the papers according to which of the following three study approaches they used: trends in screening rates, correlates of these rates with factors that may influence screening, and linkages or comparisons of NHIS data with other surveys or sources of information. We summarize knowledge gained in cancer screening for each of these three categories and identify areas that could benefit from more research. We highlight some of the new information available for the first time on the Cancer Control Module of the 2000 NHIS as fresh opportunities for cancer control research. Finally, we describe how the Cancer Control Supplements to the NHIS are integrated with the objectives of and developments in national cancer surveillance research that have emerged from federal planning efforts and collaborations with national partners in cancer surveillance in recent years.

Technical quality control practices in mammography screening programs in 22 countries

OBJECTIVE

To assess current technical quality control (QC) practices within breast cancer screening or surveillance programs internationally.

MATERIALS AND METHODS

The International Breast Cancer Screening Network (IBSN) conducted an extensive survey of quality assurance (QA) activities in developed countries known to have population-based breast cancer screening or surveillance programs in place. Twenty-three countries were sent questionnaires that included items about QA and QC requirements at screening sites, the minimum frequencies of QC test performance, and the personnel responsible for performing QC tests.

RESULTS

All 23 countries in the IBSN completed general information on their QA practices. Twenty-two countries responded with complete details on their technical QC practices. The responses indicated a pattern of consistently high-quality control practices among population-based breast cancer screening and surveillance programs. Most programs performed the great majority of QC tests. Variations were observed in the performance frequencies of QC tests and in the personnel responsible for performing QC tests.

CONCLUSION

QC practices among population-based breast cancer screening and surveillance programs are highly evolved, with the great majority of responding countries following prescribed QC protocols. Further research is needed on appropriate performance frequencies for mammography QC tests.

Quality assurance for screening mammography: an international comparison

STUDY OBJECTIVE

In 1998, the International Breast Cancer Screening Network (IBSN) sponsored an assessment of quality assurance policies and practices to define their scope for population-based screening mammography programmes across IBSN countries.

DESIGN

Analysis of data from a survey designed to assess multiple elements of screening programme quality assurance, including organisation of quality assurance activities, mechanisms for site visits and accreditation, requirements for quality control and data systems, and inclusion of treatment, follow up, and programme evaluation in screening mammography quality assurance activities.

PARTICIPANTS AND SETTING

IBSN representatives in 23 countries completed a comprehensive questionnaire between May and December 1998.

MAIN RESULTS

Completed questionnaires were obtained from all 23 countries. Responses indicated that countries vary in their approaches to implementing quality assurance, although all monitor components of structure, process, and outcome. Nearly all have in place laws, surveillance mechanisms, or standards for quality assurance. In all countries, quality assurance activities extend beyond the screening mammography examination.

CONCLUSIONS

The assessment has enhanced understanding of the organisation of screening mammography programmes across countries, as well as the comparability of screening mammography data. All countries have established mechanisms for assuring the quality of screening mammography in population-based programmes, although these mechanisms vary across countries.

Breast cancer screening in 21 countries: delivery of services, notification of results and outcomes ascertainment

Following clinical trial evidence of mammography screening's efficacy and effectiveness, data are needed from organized population-based programmes to determine whether screening in these programmes results in breast cancer mortality reductions comparable to those demonstrated in controlled settings. The International Breast Cancer Screening Network (IBSN) conducted two international programme assessments: in 1990 among nine countries and in 1995 among 22 countries, obtaining information on the organization and process for screening within breast cancer screening programmes. This manuscript describes procedures for recruitment, service delivery, interpretation and communication of results, case ascertainment, and quality assurance. Practices in more established programmes are compared with pilot programmes. Each IBSN country defined a unique programme of population-based breast cancer screening. Some programmes were sub-national rather than national in scope, while others were in pilot stages of development. Screening took place in dedicated centres in established programmes and in both dedicated and general radiology centres in pilot programmes. Although most countries used personal invitation systems to recruit women to screening, other recruitment mechanisms were used. Most countries used two-view mammography in their screening programmes. About half had implemented independent double reading of mammograms, considering it a key component of high-quality mammography screening. In conclusion, diversity exists in the organization and delivery of screening mammography internationally. Quality assurance activities are a priority and are being evaluated in the IBSN.

Physicians' recommendations for colon cancer screening in women. Too much of a good thing?

BACKGROUND

Expert groups support periodic colorectal cancer (CRC) screening for persons aged 50 and older but not for persons younger than 50. We were interested in community primary care physicians' recommendations to women for fecal occult blood tests (FOBT), flexible sigmoidoscopy (SIG), and colonoscopy (COL).

METHODS

In a mailed survey of 1,292 community primary care physicians in North Carolina, we queried physicians regarding their recommendations to women for CRC screening.

RESULTS

Analysis was performed on 508 respondents (39%). Recommendation for FOBT (96%) and SIG (69%) for women > 50 years old was high among all subgroups of physicians. Recommendation for women < 50 years old was high for FOBT (82%) but lower for SIG (28%). Overall, 19% of physicians recommended COL. Recommendation for FOBT, SIG, and COL varied by physician specialty, physician age, perceived patient demand, physician need for additional CRC screening information, practice size, and location.

CONCLUSIONS

Although increasing physician recommendation for CRC screening is important, primary care physicians report recommending earlier and more aggressive screening than that supported by national guidelines.

Community Clinical Oncology Program participation in the Breast Cancer Prevention Trial: factors affecting accrual

Cancer prevention and control involves a diverse spectrum of activities that range from preventing the disease to providing rehabilitation to its survivors. The range of activities included within the definition of cancer prevention and control makes it difficult to determine factors that would predict accrual to specific cancer prevention and control trials. The participation of 36 CCOP organization in the National Cancer Institute-sponsored Breast Cancer PRevention TRial (BCPT) presented the opportunity to assess the ability of Community Clinical Oncology Program (CCOPs) to enroll subjects in one of the nation's first large-scale cancer prevention trials and to compare characteristics of CCOP accrual to the BCPT with factors associated with accrual by CCOPs to cancer treatment and other cancer prevention and control clinical trials. Although representing only 13% of participating health care organizations, CCOPs presently contribute nearly 30% of total BCPT accrual. Comparison of regression models representing accrual to treatment, cancer control, and chemoprevention (i.e., BCPT) protocols shows similar predictors between treatment and chemoprevention models. Cancer control models, however, did not share similar predictors. Thus, accrual to chemoprevention trials is associated, to a greater extent, with the characteristics that facilitate accrual to treatment trials rather than to cancer control trials. Results have implications for the planning and ongoing management of cancer treatment, control, and chemoprevention clinical trials.