Accuracy of Cancer Registry Primary Payer Information and Implications for Policy Research

BACKGROUND

Cancer registry-based "primary payer at diagnosis" (PPDx) data are commonly used to evaluate the effect of insurance on cancer care outcomes, yet little is known about how well they capture Medicaid or Medicare enrollment.

METHODS

We linked the National Cancer Institute's Surveillance, Epidemiology, and End Results registry data to monthly Centers for Medicare and Medicaid Services (CMS) Medicaid and Medicare enrollment records, state-year Medicaid policy, and managed care enrollment. We selected adults aged 19-64 years diagnosed between 2007 and 2011. We used bivariate analyses to compare PPDx to CMS enrollment at diagnosis month and assessed underreporting rates by patient characteristics and state-year policy.

RESULTS

PPDx reported 7.8% Medicare and 10.1% Medicaid, whereas CMS enrollment indicated 5.5% Medicare, 10.4% Medicaid, and 3.4% dual Medicare-Medicaid (N = 896,031). Positive predictive values for PPDx assignment to Medicaid and Medicare were 65.3% and 75.4%, with false negative rates of 52.0% and 33.8%, respectively. Medicaid underreporting was higher in low (56.5%) versus high (50.8%) poverty areas, for males (56.1%) versus females (48.9%), for Medicaid poverty expansion or waiver enrolled (63.8%) versus cash assistance-related eligibility (47.3%), and in states with large managed care enrollment (all P < 0.001). If Medicaid and Medicare enrollment data were used to edit PPDx, 12.0% of persons would switch primary payer assignment.

CONCLUSIONS

Registry-reported PPDx fails to fully capture Medicaid and Medicare enrollment, which may result in biased estimates of insurance-related policy impacts. Enhancement with objective enrollment data could reduce measurement error and bias in estimates necessary to support policy assessment.

Clinical Multiteam System Composition and Complexity Among Newly Diagnosed Early-Stage Breast, Colorectal, and Lung Cancer Patients With Multiple Chronic Conditions: A SEER-Medicare Analysis

PURPOSE

Sixty percent of adults have multiple chronic conditions at cancer diagnosis. These patients may require a multidisciplinary clinical team-of-teams, or a multiteam system (MTS), of high-complexity involving multiple specialists and primary care, who, ideally, coordinate clinical responsibilities, share information, and align clinical decisions to ensure comprehensive care needs are managed. However, insights examining MTS composition and complexity among individuals with cancer and comorbidities at diagnosis using US population-level data are limited.

METHODS

Using SEER-Medicare data (2006-2016), we identified newly diagnosed patients with breast, colorectal, or lung cancer who had a codiagnosis of cardiopulmonary disease and/or diabetes (n = 75,201). Zaccaro's theory-based classification of MTSs was used to categorize clinical MTS complexity in the 4 months following cancer diagnosis: high-complexity (≥ 4 clinicians from ≥ 2 specialties) and low-complexity (1-3 clinicians from 1-2 specialties). We describe the proportions of patients with different MTS compositions and quantify the incidence of high-complexity MTS care by patient groups.

RESULTS

The most common MTS composition was oncology with primary care (37%). Half (50.3%) received high-complexity MTS care. The incidence of high-complexity MTS care for non-Hispanic Black and Hispanic patients with cancer was 6.7% (95% CI, -8.0 to -5.3) and 4.7% (95% CI, -6.3 to -3.0) lower than non-Hispanic White patients with cancer; 13.1% (95% CI, -14.1 to -12.2) lower for rural residents compared with urban; 10.4% (95% CI, -11.2 to -9.5) lower for dual Medicaid-Medicare beneficiaries compared with Medicare-only; and 16.6% (95% CI, -17.5 to -15.8) lower for colorectal compared with breast cancer.

CONCLUSION

Incidence differences of high-complexity MTS care were observed among cancer patients with multiple chronic conditions from underserved populations. The results highlight the need to further understand the effects of and mechanisms through which care team composition, complexity, and functioning affect care quality and outcomes.

Multilevel factors associated with inequities in multidisciplinary cancer consultation

OBJECTIVE

To assess changes in the prevalence of multidisciplinary cancer consultations (MDCc) over the last decade and examine patient, surgeon, hospital, and neighborhood factors associated with receipt of MDCc among individuals diagnosed with cancer.

DATA SOURCE

Surveillance, Epidemiology and End Results (SEER)-Medicare data from 2006 to 2016.

STUDY DESIGN

We used time-series analysis to assess change in MDCc prevalence from 2007 to 2015. We also conducted multilevel logistic regression with random surgeon- and hospital-level effects to assess associations between patient, surgeon, neighborhood, and health care organization-level factors and receipt of MDCc during the cancer treatment planning phase, defined as the 2 months following cancer diagnosis.

DATA COLLECTION/EXTRACTION METHODS

We identified Medicare beneficiaries >65 years of age with surgically resected breast, colorectal (CRC), or non-small cell lung cancer (NSCLC) stages I-III (n = 103,250).

PRINCIPAL FINDINGS

From 2007 to 2015, the prevalence of MDCc increased from 35.0% to 61.2%. Overall, MDCc was most common among patients with breast cancer compared to CRC and NSCLC. Cancer patients who were Black, had comorbidities, had dual Medicare-Medicaid coverage, were residing in rural areas or in areas with higher Black and Hispanic neighborhood composition were significantly less likely to have received MDCc. Patients receiving surgery at disproportionate payment-sharing or rural-designated hospitals had 2% (95% CI: -3.55, 0.58) and 17.6% (95% CI: -21.45, 13.70), respectively, less probability of receiving MDCc. Surgeon- and hospital-level effects accounted for 15% of the variance in receipt of MDCc.

CONCLUSIONS

The practice of MDCc has increased over the last decade, but significant geographical and health care organizational barriers continue to impede equitable access to and delivery of quality care across cancer patient populations. Multilevel and multicomponent interventions that target care coordination, health system, and policy changes may enhance equitable access to and receipt of MDCc.

National Cancer Institute-Funded Social Risk Research in Cancer Care Delivery: Opportunities for Future Research

BACKGROUND

Cancer patients and survivors with food insecurity, housing instability, and transportation-related barriers face challenges in access and utilization of quality cancer care thereby adversely impacting their health outcomes. This portfolio analysis synthesized and described National Cancer Institute (NCI)-supported social risk research focused on assessing food insecurity, housing instability, and transportation-related barriers among individuals diagnosed with cancer.

METHODS

We conducted a query using the National Institutes of Health iSearch tool to identify NCI-awarded extramural research and training grants (2010-2022). Grant abstracts, specific aims, and research strategies were coded for research characteristics, study population, and outcomes.

RESULTS

Of the 30 grants included in this analysis, most assessed transportation-related barriers as patient-level social needs. Grants focused on community-level social risks, food insecurity, and housing instability were largely absent. Most grants included activities that identified the presence of social risks and/or needs (n = 24), connected patients to social care resources (n = 10), and engaged community members or organizations to inform the research study (n = 9). Of the grants, 18 focused on a single type of cancer, primarily breast cancer, and more than half focused on the treatment and survivorship phases.

CONCLUSIONS

In the last decade, there has been limited NCI-funded social risk research grants focused on food insecurity and housing instability. Findings highlight opportunities for future cancer care delivery research, including community and health system-level approaches that integrate social and clinical care to address social risks and social needs. Such efforts can help improve outcomes of populations that experience cancer health and health-care disparities.

Team-Based Care for Cancer Survivors With Comorbidities: A Systematic Review

Coordination of quality care for the growing population of cancer survivors with comorbidities remains poorly understood, especially among health disparity populations who are more likely to have comorbidities at the time of cancer diagnosis. This systematic review synthesized the literature from 2000 to 2022 on team-based care for cancer survivors with comorbidities and assessed team-based care conceptualization, teamwork processes, and outcomes. Six databases were searched for original articles on adults with cancer and comorbidity, which defined care team composition and comparison group, and assessed clinical or teamwork processes or outcomes. We identified 1,821 articles of which 13 met the inclusion criteria. Most studies occurred during active cancer treatment and nine focused on depression management. Four studies focused on Hispanic or Black cancer survivors and one recruited rural residents. The conceptualization of team-based care varied across articles. Teamwork processes were not explicitly measured, but teamwork concepts such as communication and mental models were mentioned. Despite team-based care being a cornerstone of quality cancer care, studies that simultaneously assessed care delivery and outcomes for cancer and comorbidities were largely absent. Improving care coordination will be key to addressing disparities and promoting health equity for cancer survivors with comorbidities.

Disparities in post-operative surveillance testing for metastatic recurrence among colorectal cancer survivors

PURPOSE

Among colorectal cancer (CRC) survivors, treatment for metastatic recurrence is most effective when malignancies are detected early through surveillance with carcinoembryonic antigen (CEA) level test and computer tomography (CT) imaging. However, utilization of these tests is low, and many survivors fail to meet the recommended guidelines. This population-based study assesses individual- and neighborhood-level factors associated with receipt of CEA and CT surveillance testing.

METHODS

We used the Surveillance, Epidemiology and End Results (SEER)-Medicare data to identify Medicare beneficiaries diagnosed with CRC stages II-III between 2010 and 2013. We conducted multivariate logistic regression to estimate the effect of individual and neighborhood factors on receipt of CEA and CT tests within 18 months post-surgery.

RESULTS

Overall, 78% and 58% of CRC survivors received CEA and CT testing, respectively. We found significant within racial/ethnic differences in receipt of these surveillance tests. Medicare-Medicaid dual coverage was associated with 39% lower odds of receipt of CEA tests among non-Hispanic Whites, and Blacks with dual coverage had almost two times the odds of receiving CEA tests compared to Blacks without dual coverage.

CONCLUSIONS

Although this study did not find significant differences in receipt of initial CEA and CT surveillance testing across racial/ethnic groups, the assessment of the factors that measure access to care suggests differences in access to these procedures within racial/ethnic groups.

IMPLICATIONS FOR CANCER SURVIVORS

Our findings have implications for developing targeted interventions focused on promoting surveillance for the early detection of metastatic recurrence among colorectal cancer survivors and improve their health outcomes.

Reliability of cancer registry primary payer information and implications for policy research

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Background: Researchers commonly use “Primary Payer at Diagnosis” measured in cancer registry data to assess the impact of health policy, such as the Affordable Care Act, on insurance, and the impact of insurance on cancer care and outcomes. Measurement error may bias estimated effect size and significance. Little is known about patterns of Medicaid or Medicare misreporting in registry databases commonly used for policy analysis. Methods: We used the National Cancer Institute’s Surveillance, Epidemiology and End Results registry data for adults aged 19-64 years at diagnosis with known cancer stage, linked to most recently available (2007-2011) CMS records on Medicaid and Medicare enrollment at diagnosis month. We recoded the registry Primary Payer variable into 6 categories: private/managed care, Medicare, Medicaid, other government, status unknown, uninsured. State-year policy data regarding Medicaid eligibility and managed care enrollment were also linked. We compared the registry data to Medicaid and/or Medicare enrollment data, and calculated underreporting rates by patient characteristics and state policy. Results: The linked sample (N = 896,031) was 68% non-Hispanic white, 49% male. Overall, the registry data reported 7.8% Medicare and 10.1% Medicaid, while enrollment was 5.5% Medicare, 10.4% Medicaid, and 3.4% dual Medicare-Medicaid. The registry data concordantly identified 61.4% and 57.7% of persons identified per enrollment data to be Medicaid-only and Medicare-only, respectively (Table). Most Medicaid-only enrollees without concordant registry information were reported to have private insurance or be uninsured. Medicaid underreporting (39% overall), was higher for males (43%) vs females (37%), in low (46%) vs high (38%) poverty areas, for Medicaid poverty expansion or waiver enrolled (50%) vs cash assistance related eligibility (33%), and in states with large managed care enrollment, all at p<.001. If Medicaid and Medicare enrollment data were used to edit the registry data, 8% of persons would switch insurance assignment. Conclusions: Primary Payer data reported by cancer registries are subject to measurement error and may result in biased estimates of insurance-related policy impacts. Enhancement with objective Medicaid and Medicare enrollment data will reduce measurement error and may result in unbiased estimates necessary to support policy assessment. [Table: see text]

Abstract PO-072: Care coordination for older cancer patients with multi-morbidities: Implications for addressing cancer health disparities

Purpose: Newly diagnosed cancer patients with multi-morbidities require a clinical care team of higher complexity due to greater care coordination demands to simultaneously coordinate cancer care and chronic disease management. Whereas teams of lower complexity may streamline care needs by using one clinician or discipline type to manage all care needs. However, this requires clinicians to understand that they are assuming other clinical roles and responsibilities or else care needs go unmanaged leading to poor health outcomes. Given that chronic disease management drops off following the cancer diagnosis, we examined whether cancer patients identifying as non-Hispanic Black, with dual Medicaid coverage, more chronic diseases, and later cancer stage were more likely to have a clinical care team of higher complexity in the 4-months post cancer diagnosis. Methods: Surveillance, Epidemiology and End Results (SEER)-Medicare data were used to identify patients with invasive breast, colorectal, or non-small cell lung cancer with a co-diagnosis of cardiopulmonary disease or diabetes (n=85,876). The data were linked with American Medical Association files to identify clinician's discipline (e.g., oncology, primary care, cardiology) from encounter claims. Using Zaccaro's classification of multi-team systems, we categorized the degree of complexity of the clinical care team: lower (1-2 disciplines and 1-3 clinicians) versus higher (2+ disciplines and 4+ clinicians). We used multivariable logistic regression to examine patient factors associated with having a clinical care team of higher complexity (compared with lower). Results: Among older cancer patients with multi-morbidities, the most common clinical care team composition was oncology with primary care (37%) followed by oncology, primary care, and medical subspecialty (34%). In the adjusted model, cancer patients were less likely to have a clinical care team of higher complexity if they were non-Hispanic Black compared to non-Hispanic White (OR: 0.88; 95% CI: 0.83, 0.93), dual Medicaid-Medicare covered compared with Medicare only (OR: 0.63; 95% CI: 0.61, 0.65), and diagnosed with stage III cancer compared to stage I (OR: 0.87; 95% CI: 0.84, 0.90). Cancer patients were more likely to have a clinical care team of higher complexity if they had cardiopulmonary disease (OR: 1.74; 95% CI: 1.68, 1.81) or diabetes (OR: 1.69; 95% CI: 1.63,1.75) compared with hypertension only. Conclusion: Clinical care teams of lower complexity were associated with identifying as Black, Medicaid coverage, and later stage, which are known factors associated with poorer care outcomes. This warrants further investigation to examine whether clinicians are assuming other clinicians' roles and responsibilities for patient care or if cancer care is taking precedence over other chronic diseases. Future research to address cancer care disparities need to focus on clinical care teams and the healthcare organizational context that provide and optimize care coordination for newly diagnosed cancer patients with multi-morbidities.

Citation Format: Michelle Doose, Dana Verhoeven, Janeth I. Sanchez, Veronica Chollette, Sallie J. Weaver. Care coordination for older cancer patients with multi-morbidities: Implications for addressing cancer health disparities [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-072.

Abstract IA-36: Fragmentation of care among Black women who have breast cancer and multiple comorbidities

Purpose: Black women newly diagnosed with breast cancer and who have multiple comorbidities at the time of cancer diagnosis require greater care coordination to simultaneously manage cancer care and other chronic conditions. Care coordination may be complicated when multiple clinicians from diverse disciplines are involved in managing care and are located in different health systems, defined as care fragmentation. Given that Black women are disproportionately burdened by comorbidities and breast cancer, we examined the degree of care fragmentation and care coordination experienced by this group from a health system and care team perspective using two population-based cohorts. Methods: We analyzed data from two separate cohorts of Black women diagnosed with breast cancer who had diabetes and/or cardiovascular disease. In the first study we used the Women's Circle of Health Follow-Up Study (n=228) to examine types of practice setting for first primary care visit and primary breast surgery, and, through medical chart abstraction, identified whether care visit was within or outside the same health system. In a separate study, we identified women from the SEER-Medicare database (n=3,420) diagnosed with breast cancer and used encounter claims to examine the complexity and composition of the clinical care team. Results: Care fragmentation was experienced by 79% of Black women in the Women's Circle of Health Follow-Up Study, and individual-level factors (age, health insurance, cancer stage, and comorbidity count) were not associated with care fragmentation (p&gt;.05). In the SEER-Medicare cohort, the most common clinical care team composition was oncology with primary care (45%) followed by oncology, primary care, and medical subspecialty (26%). In the adjusted model, Black women were more likely to have a clinical care team of higher complexity if they had cardiopulmonary disease (OR: 1.74; 95% CI: 1.68, 1.81) or diabetes (OR: 1.69; 95% CI: 1.63,1.75) compared with hypertension only. Women were also less likely to have a complex care team if they were dual Medicaid-Medicare covered (OR: 0.56; 95% CI: 0.48, 0.65) compared with Medicare only, rural residents (OR: 0.54; 95% CI: 0.42, 0.65) compared with urban, or diagnosed with stage III cancer (OR: 0.59; 95% CI: 0.47, 0.75) compared with stage I. Conclusion: The majority of Black breast cancer survivors with comorbidities see multiple clinicians from diverse disciplines and in different health systems, illustrating high care coordination demands and care fragmentation. However, the impact of the health system and care team on care outcomes still need to be assessed, and this includes care transitions into survivorship. To address cancer care disparities experienced by Black women, future research should consider examining clinician's perspectives regarding roles and responsibilities for chronic disease management and cancer care, as well as address care fragmentation across diverse healthcare delivery settings.

Citation Format: Michelle Doose, Janeth I. Sanchez, Dana Verhoeven, Veronica Chollette, Joel C. Cantor, Jesse J Plascak, Michael Steinberg, Chi-Chen Hong, Kitaw Demissie, Elisa Bandera, Jennifer Tsui, Sallie J. Weaver. Fragmentation of care among Black women who have breast cancer and multiple comorbidities [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr IA-36.

Fragmentation of Care Among Black Women With Breast Cancer and Comorbidities: The Role of Health Systems

PURPOSE

Black women are disproportionately burdened by comorbidities and breast cancer. The complexities of coordinating care for multiple health conditions can lead to adverse consequences. Care coordination may be exacerbated when care is received outside the same health system, defined as care fragmentation. We examine types of practice setting for primary and breast cancer care to assess care fragmentation.

MATERIALS AND METHODS

We analyzed data from a prospective cohort of Black women diagnosed with breast cancer in New Jersey who also had a prior diagnosis of diabetes and/or hypertension (N = 228). Following breast cancer diagnosis, we examined types of practice setting for first primary care visit and primary breast surgery, through medical chart abstraction, and identified whether care was used within or outside the same health system. We used multivariable logistic regression to explore sociodemographic and clinical factors associated with care fragmentation.

RESULTS

Diverse primary care settings were used: medical groups (32.0%), health systems (29.4%), solo practices (23.7%), Federally Qualified Health Centers (8.3%), and independent hospitals (6.1%). Surgical care predominately occurred in health systems (79.8%), with most hospitals being Commission on Cancer-accredited. Care fragmentation was experienced by 78.5% of Black women, and individual-level factors (age, health insurance, cancer stage, and comorbidity count) were not associated with care fragmentation (P > .05).

CONCLUSION

The majority of Black breast cancer survivors with comorbidities received primary care and surgical care in different health systems, illustrating care fragmentation. Strategies for care coordination and health care delivery across health systems and practice settings are needed for health equity.

Distribution of Genomic Testing Resources by Oncology Practice and Rurality: A Nationally Representative Study

PURPOSE

Oncologists are increasingly using molecular profiling to inform personalized patient treatment decisions. Despite its promising utility, the integration of genomic testing into diverse clinical health care settings across geographic settings has been understudied.

METHODS

We used data from the National Survey of Precision Medicine in Cancer Treatment, a nationally representative sample of practicing US oncologists, to assess the availability of six genomic testing resources, including on-site pathology, contracts with outside laboratories, on-site genetic counselors, internal policies or protocols for using genomic and biomarker testing, electronic medical record alerts, and genomic or molecular tumor boards. We used multivariate logistic regression models to examine differences in the availability of each genomic testing resource by practice type and rurality while adjusting for payer mix and patient volume.

RESULTS

A larger proportion of multispecialty group and academic practices had genomic testing resources available compared with solo and nonacademic practices. Electronic medical record alerts were the least available resource, whereas contracts with outside laboratories were the most available resource. Compared with urban practices, there were significantly fewer practices located in rural areas that had on-site pathology, on-site genetic counselors, protocols for genomic tests, and molecular tumor boards.

CONCLUSION

Genomic testing resources varied by practice type and geography among a nationally representative sample of practicing oncologists. This variation has important implications for the development of interventions and policies to support the more equitable delivery of precision oncology to patients with cancer.

Eat Healthy, Be Active Community Workshops implemented with rural Hispanic women

Background

In the U.S., obesity disproportionately affects some racial/ethnic groups more than others; 42.5% of Hispanic adults are obese, compared to 32.6% of non-Hispanic whites (NHW). Research also shows that Mexican American women are 40% more likely to be overweight, as compared to NHW women. With high obesity rates among Hispanics, improving healthier lifestyle practices is an important step for reducing health disparities. The Eat Healthy, Be Active (EHBA) community workshops were developed to assist individuals in translating national nutrition and physical activity recommendations into action. Promotora-led EHBA workshops could be used to promote obesity-related health behavior lifestyle changes among Hispanics.

Methods

Hispanic women from rural communities in Washington state were recruited to participate in a six-week Promotora-led workshop series. This pilot study used a pre- and post-test study design to examine differences in healthy lifestyle knowledge and practices.

Results

A total of 49 Hispanic women participated in the workshops, of whom 45% were obese. Six-weeks after implementation of EHBA, women had improvements in healthy lifestyle practices, including an increase in nutrition label literacy, decrease in consumption of food eaten in restaurants, and an increase in the number of times a woman performed physical activity long enough to make them sweat.

Conclusion

The findings from this pilot study indicate that delivering EHBA workshops through promotoras is a feasible culturally relevant approach to promoting healthier lifestyle practices among Hispanic women. Further, focusing on females, who do the food shopping and preparation in their homes, may help increase awareness among whole families.

Inequitable access to surveillance colonoscopy among Medicare beneficiaries with surgically resected colorectal cancer

BACKGROUND

After colorectal cancer (CRC) surgery, surveillance with colonoscopy is an important step for the early detection of local recurrence. Unfortunately, surveillance colonoscopy is underused, especially among racial/ethnic minorities. This study assesses the association between patient and neighborhood factors and receipt of surveillance colonoscopy.

METHODS

This retrospective, population-based cohort study used Surveillance, Epidemiology, and End Results-Medicare linked data (2009-2014). Beneficiaries with surgically resected stage II or III CRC between the ages of 66 and 85 years were identified, and multivariable logistic regression was used to assess the effect of factors on receipt of colonoscopy.

RESULTS

Overall, 57.5% of the patients received initial surveillance colonoscopy. After adjustments for all factors, Blacks and Hispanics had lower odds of receiving colonoscopy than non-Hispanic Whites (NHWs; 29.6% for Blacks; P = .002; 12.9% for Hispanics; P > .05). NHWs with Medicaid coverage had 35% lower odds of surveillance colonoscopy than NHWs without Medicaid coverage. Minority patients with Medicaid were more likely to receive colonoscopy than their racial/ethnic counterparts without Medicaid coverage (P > .05). Hispanics residing in neighborhoods with incomes of ≥$90,000 had significantly lower odds of surveillance colonoscopy than Hispanics residing in neighborhoods with incomes of $0 to $30,000.

CONCLUSIONS

Receipt of initial surveillance colonoscopy remains low, and there are acute disparities between Black and NHW patients. The association between factors that assess a patient's ability to access colonoscopy and actual receipt of colonoscopy suggests inequitable access to surveillance colonoscopy within and across racial/ethnic groups.

Abstract A058: Patient and neighborhood factors associated with receipt of surveillance colonoscopy among Medicare beneficiaries with surgically resected colorectal cancer

Background: After colorectal cancer (CRC) surgery, surveillance with colonoscopy is an important step for the early detection of local recurrence. Unfortunately, surveillance colonoscopy is underutilized and only about 55% of CRC patients receive a colonoscopy as recommended. Lower rates are observed among racial/ethnic minorities. Identifying the factors that contribute to disparities in receipt of surveillance colonoscopy can assist researchers in developing targeted interventions to promote surveillance colonoscopy for the early detection of recurrence. Purpose: This study assesses the association between patient- and neighborhood-level factors and receipt of surveillance colonoscopy. Methods: This retrospective population-based cohort study uses the National Cancer Institutes’ Surveillance, Epidemiology and End Results (SEER) – Medicare linked data collected from 2009 to 2014. We identified beneficiaries with surgically resected CRC stages II and III between the ages of 66 and 85. We used multivariate logistic regression to assess the effect of factors on receipt of colonoscopy. Results: A total of 6,602 patients were identified. Overall, 57.5% of patients received a colonoscopy within 18-months after surgery. After adjusting for patient- and neighborhood-level factors, Blacks had 29.6% lower odds of receiving a colonoscopy compared to non-Hispanic Whites (NHWs) (p=.002). Hispanics had 12.9% lower odds of receiving a colonoscopy compared to NHWs, however, this association was not significant (p&gt;.05). Among NHWs, older age, male gender, and single status were significantly associated with lower odds of receipt of colonoscopy. Clinical factors, such as higher stage, no comorbidities and receipt of chemotherapy, were significantly associated with higher odds of receipt of colonoscopy, but only among NHWs. The odds of receipt of surveillance colonoscopy was 35% lower among NHWs patients with Medicaid coverage compared to NHWs without coverage. Although not significant, Black and Hispanic patients with Medicaid coverage were more likely to receive a colonoscopy compared to their racial/ethnic counterparts without coverage. Hispanics residing in neighborhoods with median household incomes of $90K+ had significantly lower odds of receipt of colonoscopy compared to Hispanics residing in neighborhoods with incomes of $0-$30K. Conclusion: Receipt of initial surveillance colonoscopy remains low and disparities exist between Blacks and NHW patients. The association between factors that assess a patient’s ability to access colonoscopy and actual receipt of colonoscopy suggest inequitable access to surveillance colonoscopy within and across racial/ethnic groups.

Citation Format: Janeth I Sanchez, Veena Shankaran, Joseph Unger, Beti Thompson. Patient and neighborhood factors associated with receipt of surveillance colonoscopy among Medicare beneficiaries with surgically resected colorectal cancer [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr A058.

Knowledge and social engagement change in intention to be screened for colorectal cancer

OBJECTIVE

Innovative technologies have been used to promote colorectal cancer (CRC) screening among the underserved. However, the impact of these innovative technologies on knowledge and social engagement likelihood as they relate to subsequent intention to be screened across different populations has not been fully explored.

DESIGN

Using a pre-post-test design with an inflatable walk-through colon, we assessed changes in knowledge and social engagement likelihood across populations and their associations with intention to be screened in two community settings. One was a community setting in Washington State (WA); the other, a college campus in New Mexico (NM). Differential effects on knowledge and social engagement likelihood were examined across demographic groups (race/ethnicity, gender, age, education, insurance status, and geographic region). Finally, we assessed if changes in knowledge and social engagement likelihood were associated with CRC screening intention.

RESULTS

NM males had greater gains in CRC knowledge than NM females; in WA, Hispanics, younger, less educated, and uninsured participants had greater gains in knowledge. NM females and younger WA participants were more likely to discuss CRC with their social networks than NM males and older WA participants. In WA, Hispanics and older adults reported greater intention to be screened for CRC. Change in social engagement likelihood, but not knowledge, was associated with intention to be screened.

CONCLUSIONS

The effectiveness of health promotion technologies on knowledge and social engagement may vary across different demographic characteristics. Further, the importance of social engagement likelihood in interacting with intention to be screened was substantiated.

Using a Culturally Tailored Intervention to Increase Colorectal Cancer Knowledge and Screening among Hispanics in a Rural Community

Background: Disparities in colorectal cancer incidence and mortality rates exist among racial/ethnic minorities, especially those living in rural areas. There is an urgent need to implement interventions to improve colorectal cancer screening behaviors among such groups, particularly those living in rural areas in the United States.Methods: From a rural community of Hispanics, we recruited participants to attend home-based promotor(a)-led "home health parties" in which participants were taught about colorectal cancer screening; participants ages 50 and older were given a free fecal occult blood test (FOBT) kit to complete on their own. A pre- and posttest design was used to assess changes in colorectal cancer awareness, knowledge, and screening at baseline and at 1-month follow-up after the intervention.Results: We observed a statistically significant increase in colorectal cancer screening awareness and knowledge among participants. Colorectal cancer screening rates with FOBT increased from 51.0% to 80%. There was also a statistically significant increase in social engagement, that is, the intent to speak to friends and relatives about colorectal cancer screening.Conclusions: Findings indicate that culturally tailored colorectal cancer education facilitated by promotores in a rural environment, coupled with free stool-based test for colorectal cancer screening, is an effective way to increase colorectal cancer screening awareness, knowledge, and screening among Hispanics living in a rural area in Washington State. Impact: Culturally tailored home health interventions have the potential to achieve Healthy People 2020 colorectal cancer screening goals in Hispanic rural communities. Cancer Epidemiol Biomarkers Prev; 27(11); 1283-8. ©2018 AACR.

Abstract B83: Development of a cancer coalition to promote colorectal cancer screening in rural underserved communities in New Mexico

Introduction: Cancer continues to be one of the leading causes of death in the US; colorectal cancer (CRC) for example, has high incidence and mortality rates, even though much CRC is preventable. The rates of preventable cancers could be reduced through the promotion of early detection and screening. However, providing access to screening services to rural underserved communities, such as those found along the US – Mexico border can be difficult. Developing multidisciplinary collaborative screening efforts may expand the reach of regional healthcare services. Specifically, cancer coalitions have the potential to advance culturally competent health promotion programs because they include locally vested organizations and individuals working together to build a foundation for health promotion and social change. This study established the Southern New Mexico Cancer Coalition (SNMCC) to promote CRC education and increase access to CRC screening in Doña Ana County, New Mexico. Methods: Organizations and individuals from southern NM came together to address low CRC screening rates, a leading health concern in the state. SNMCC was created in October 2014 and included members representing New Mexico State University (NMSU), a local cancer center and endoscopy center, 2 federally qualified health centers (FQHC) who participated in the state CRC Control program, and a local community organization whose mission is to provide financial assistance to cancer patients in the county. Over a period of six months, the SNMCC planned and implemented a multi-component screening program that included the distribution of fecal immunochemical tests (FIT) in two regions of Doña Ana County, NM. The FITs were distributed by the Community Health Educator at NMSU and by promotoras de salud from the two FQHC's throughout February 2015. Individuals who received the FITs were asked to complete the tests and return them at the March Colorectal Cancer Awareness Day event held at a community center in southern Doña Ana County and at a church in northern Doña Ana County. All individuals who completed the test were entered into the FQHC's CRC Control Program and those with positive FITs were navigated to schedule colonoscopies. Results: A total of 100 FITs were distributed in Doña Ana County (50 in the southern sector and 50 in the northern sector) and had a 75% screening rate. In the southern sector of the county, 34 individuals completed and returned FITs at the event and at follow-up at the clinic. Of these, three were positive for blood in the stool; two of these received a follow-up colonoscopy. In the northern sector, a total of 41 individuals completed and returned FITs. Of these, 4 were positive for blood in the stool; three of these individuals received a follow-up colonoscopy, and have follow-up appointments scheduled for the colonoscopy results. Discussion: CRC continues to be a leading cause of cancer-related deaths in NM. Health promotion and prevention programs have the potential to address and reduce CRC incidence and mortality rates by promoting screening in regions where CRC screening is underutilized. Community-research collaborative efforts are crucial in increasing access to such healthcare and screening services and assist in closing the gaps in cancer health disparities found in the region. The development of the SNMCC was a comprehensive public health response to a major cancer issue affecting communities in southern NM. These coordinated efforts to promote colorectal cancer screening and improve access to cancer control programs had high screening rates (75%), identified at risk individuals at a high frequency, ~ 10% and navigated at risk individuals to treatment and further care. This program therefore has the potential to reduce CRC incidence and mortality among minority and underserved populations.

Citation Format: Janeth I. Sanchez, Lynn Arnold, Daniel Armistead, Diana Dorado, Tara Lucero, Cliff Sanders, Frances Scappaticci, Tim Washburn, Yolanda Diaz, Beti Thompson, Mary O'Connell. Development of a cancer coalition to promote colorectal cancer screening in rural underserved communities in New Mexico. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr B83.

Evaluation of the walk-through inflatable colon as a colorectal cancer education tool: results from a pre and post research design

BACKGROUND

Colorectal cancer (CRC) is a disease that can be prevented through early detection. Through the use of effective educational tools, individuals can become better informed about CRC and understand the importance of screening and early detection. The walk through Inflatable Colon is an innovative educational resource developed to engage and educate communities on CRC and the importance of receiving screening at the appropriate ages.

METHODS

The Inflatable Colon Assessment Survey (ICAS) assessed knowledge and behavioral intentions to obtain screening and promote CRC awareness. New Mexico State University faculty, staff, and students completed a consent form, took the pre-ICAS, toured the Inflatable Colon, and completed the post-ICAS. The majority of participants (92%) were young adults, mostly college students, under the age of 30 yrs.

RESULTS

Overall, participants demonstrated increases in CRC knowledge and awareness after touring the inflatable colon (p-values < 0.001). Interestingly, both males and Hispanics had lower CRC awareness at pre-test, but exhibited maximum awareness gains equal to that of females and non Hispanic Whites after touring the IC. Behavioral intentions to obtain CRC screening in the future and to promote CRC awareness also increased (p-value < 0.001). Gender differences in behavioral intentions to act as advocators for CRC education were found (p < 0.05), with females being more likely to educate others about CRC than males.

CONCLUSION

Educational efforts conducted in early adulthood may serve to promote healthier lifestyles (e.g., physical activity, healthy nutrition, screening). These educated young adults may also serve to disseminate CRC information to high-risk friends and relatives. The walk through Inflatable Colon can increase CRC knowledge and intentions to get screened among a young and diverse population.

Assessing Colorectal Cancer Screening Behaviors and Knowledge among At-Risk Hispanics in Southern New Mexico

Purpose

Colorectal cancer (CRC) mortality rates in New Mexico (NM) continue to be higher than national rates. Hispanic CRC mortality rates in NM surpass those of overall Hispanics in the US. This study was designed to characterize and understand factors contributing to low CRC screening rates in this border region.

Methods

A CRC Knowledge Assessment Survey (KAS) was administered in either English or Spanish to 247 individuals attending community events throughout southern NM. A subset of these individuals completed an online CRC risk assessment survey managed by the National Cancer Institute (NCI). Data analysis tested for significant differences in knowledge, physician-patient CRC interactions, CRC risk level perception, and screening rates across diverse ethnic and age groups.

Results

Both CRC knowledge and physician-patient CRC interactions were positively associated with participant screening history. Significant age and ethnic differences for CRC knowledge, physician-patient CRC interactions, and screening history in the NM border sample were also seen. Age-eligible Hispanics (50+) as well as those less than 50 years of age had lower CRC knowledge and were less likely to engage in physician-patient CRC interactions than non-Hispanic Whites (NHWs). The age-eligible Hispanics also reported lower CRC screening rates than their NHW counterparts.

Conclusions

Low CRC knowledge and limited physician-patient CRC interactions appear to contribute to low screening rates in this NM population. Expanding education and outreach efforts for this border population are essential to promote early CRC detection and thereby decrease overall CRC mortality rates.

Arabinoxylan-oligosaccharides (AXOS) affect the protein/carbohydrate fermentation balance and microbial population dynamics of the Simulator of Human Intestinal Microbial Ecosystem

Arabinoxylan‐oligosaccharides (AXOS) are a recently newly discovered class of candidate prebiotics as – depending on their structure – they are fermented in different regions of gastrointestinal tract. This can have an impact on the protein/carbohydrate fermentation balance in the large intestine and, thus, affect the generation of potentially toxic metabolites in the colon originating from proteolytic activity. In this study, we screened different AXOS preparations for their impact on the in vitro intestinal fermentation activity and microbial community structure. Short‐term fermentation experiments with AXOS with an average degree of polymerization (avDP) of 29 allowed part of the oligosaccharides to reach the distal colon, and decreased the concentration of proteolytic markers, whereas AXOS with lower avDP were primarily fermented in the proximal colon. Additionally, prolonged supplementation of AXOS with avDP 29 to the Simulator of Human Intestinal Microbial Ecosystem (SHIME) reactor decreased levels of the toxic proteolytic markers phenol and p‐cresol in the two distal colon compartments and increased concentrations of beneficial short‐chain fatty acids (SCFA) in all colon vessels (25–48%). Denaturant gradient gel electrophoresis (DGGE) analysis indicated that AXOS supplementation only slightly modified the total microbial community, implying that the observed effects on fermentation markers are mainly caused by changes in fermentation activity. Finally, specific quantitative PCR (qPCR) analysis showed that AXOS supplementation significantly increased the amount of health‐promoting lactobacilli as well as of Bacteroides–Prevotella and Clostridium coccoides–Eubacterium rectale groups. These data allow concluding that AXOS are promising candidates to modulate the microbial metabolism in the distal colon.

Childhood trauma. Now and in the new millennium

Given the magnitude of childhood injuries that occur yearly in the United States, physicians need integrated echelons of care that include regional pediatric trauma centers, trauma centers with pediatric commitment, and EDs appropriate for children. Head injury is the most significant cause of morbidity and mortality among children, but physicians are far from effectively evaluating the dynamics of cerebral metabolism and oxygen delivery in the acute resuscitation of injured children. Critically injured children must be kept normothermic, and attention to the signs of hypovolemic shock must be monitored. Secondary brain ischemia frequently occurs because the details of resuscitation are not carefully monitored. A "leader" must be designated, and this should be someone experienced in childhood trauma. The younger the child and the more severe the injury, the more important is the notion of "experience." The ultimate goal, now and in the new millennium, should not be who, where, or when to administer care to critically ill or injured children but rather the quality of the treatment of these children.