Post-acute sequelae of COVID-19 and longitudinal antibody levels in a community-based cohort

BACKGROUND

Coronavirus disease 2019 (COVID-19) infection invokes variable immune responses and poses a risk of post-acute sequelae SARS-CoV-2 infection (PASC) symptoms; however, most data on natural history are derived from patients with severe infection. Further data are needed among patients with mild infection, who comprise most cases.

METHODS

The Dallas Fort-Worth (DFW) COVID-19 Prevalence Study included 21,597 community-dwelling adults (ages 18-89) who underwent COVID-19 PCR and anti-nucleocapsid antibody testing between July 2020 and March 2021. We invited participants with positive COVID-19 results (cases) and a subset with negative results (controls), matched on age, sex, race/ethnicity, and ZIP code, to complete a follow-up questionnaire for PASC symptoms and repeat anti-nucleocapsid testing, and anti-spike antibody testing between July and December 2021.

RESULTS

Of 3,917 adults invited to participate, 2260 (57.7%) completed the questionnaire- 1150 cases and 1110 controls. Persistent symptoms were reported in 21.1% of cases, with the most common being shortness of breath, fatigue, and loss of taste or smell. Among 292 cases with asymptomatic infection, >15% reported new fatigue and 8-10% reported new loss of taste/smell, myalgias, or headache. Median anti-nucleocapsid levels in cases decreased from 3.5U to 0.7U over a median follow-up of 8.6 months. Anti-spike antibody levels at 6-7 months post-vaccination in cases were similar to that of controls.

CONCLUSIONS

More than 1 in 5 patients with COVID-19 infection, including those with mild infection, reported persistent symptoms during follow-up. Both nucleocapsid and spike protein antibody levels decreased within six months following a COVID-19 infection and vaccination.

Surviving the COVID-19 pandemic: navigating the recovery of breast imaging services in a safety-net hospital

PURPOSE

The purpose of this study was to determine the impact of COVID-19 on county safety-net breast imaging services and describe the steps taken to actively manage and mitigate delays.

METHODS

This was an IRB exempt retrospective review of our county safety-net breast imaging practice analyzed for 4 distinct time periods: (1) "Shut-down period": March 17, 2020 to May 17, 2020; (2) "Phased re-opening": May 18, 2020 to June 30, 2020; (3) "Ramp-up": July 1, 2020 to September 30, 2020; and (4) "Current state": October 1, 2020 to September 30, 2021. These time periods were compared to identical time periods 1 year prior. For "Current state," given that the 1-year prior comparison encompassed the first 3 periods of the pandemic, the identical time period 2 years prior was also compared.

RESULTS

Our safety-net practice sustained significant volume losses during the first 3 time periods with a 99% reduction in screening mammography in the shut-down period. Cancers diagnosed decreased by 17% in 2020 (n = 229) compared to 2019 (n = 276). By implementing multiple initiatives that targeted improved access to care, including building community-hospital partnerships and engagement through outreach events and a community education roadshow, we were able to recover and significantly exceed our pandemic screening volumes by 48.1% (27,279 vs 18,419) from October 1, 2020 to September 30, 2021 compared to the identical time period 1 year prior, and exceed our pre-pandemic screening volume by 17.4% (27,279 vs 23,234) compared to the identical time period 2 years prior.

CONCLUSION

Through specific community outreach programs and optimized navigation, our safety-net breast imaging practice was able to mitigate the impact of COVID-19 on our patient population by increasing patient engagement and breast imaging services.

Abstract 1973: A geo inelegant approach to cancer disparity

UCRShiny is an intelligent user interface application that utilizes R and R-Shiny tools and statistical intelligence to allow users to visualize geospatial cancer data and perform advanced analyses and predictive modeling. UCRShiny's focus is the catchment area (in Illinois and Indiana) near UCCC and utilizes various metadata. This includes fitting univariate and multivariate models to make statistically sound inferences from the data. It also allows the user to plot specific data on a map of the catchment area as layers for descriptive analysis and visual geospatial assessment. As well as assessing the significance of the relation between these factors. These statistical tools should have a level of intelligence that can determine the correctness of the model's assumptions. An advantage of our tool is that it provides an overall diagnosis of the model to the user without the need for the intervention of an expert statistician. The data selected for analysis are assessed to ensure they meet the assumptions of the statistical model being used, and proper data transformations are applied. The presence of confounding factors is assessed using linear models in sequence. Initially, a single variable linear model is fit using the primary variable of interest (i.e., Cancer mortality) as the response variable and the second variable in the univariate analysis as the covariate. The second model adds the internal metadata columns as potential confounders to the model. In the third step, the percent change in the coefficient of the second variable in the first and second linear models is calculated. Multivariate analysis using ML is used to simultaneously assess the effect of multiple variables on the outcome variable. Here, we use various ML algorithms based on the problem and data at hand, report the significant features, and quantify their impact on the response of interest. The tool allows users to utilize the in-app data, load their dataset, or combine both datasets. It helps to visualize geospatial health data on a map, perform statistical analysis and build ML/AI models without being concerned about the validity of the statistical models. After uploading data and selecting the appropriate statistical test/analysis, results will be visualized as a plot on a map with the specified layers collared by the layer variable values. The layers can be turned on or off using specific buttons on the map. GIS maps may be easily shared and included in apps and are available to almost everyone, anywhere. The user can study the effect of multiple variables and rank their importance in predicting the response variable using multivariate ML/AI models. The UI allows the user to select an appropriate ML algorithm for the model or the application's intelligent backend algorithms to choose the proper ML model (This will be implemented in phase II). The outcome feature and the covariates to use in the model can be selected using searchable textboxes in the UI, and the model is run using the Run model button.

Citation Format: Ahmed Fadiel Metwaly, Adam Thomas Koster, Mohammad Abbasi, Aya Hassouneh, Jasmin Tiro, Nita Lee, Adekunle Odunsi. A geo inelegant approach to cancer disparity [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 1973.

Population-based correlates of COVID-19 infection: An analysis from the DFW COVID-19 prevalence study

BACKGROUND

COVID-19 has resulted in over 1 million deaths in the U.S. as of June 2022, with continued surges after vaccine availability. Information on related attitudes and behaviors are needed to inform public health strategies. We aimed to estimate the prevalence of COVID-19, risk factors of infection, and related attitudes and behaviors in a racially, ethnically, and socioeconomically diverse urban population.

METHODS

The DFW COVID-19 Prevalence Study Protocol 1 was conducted from July 2020 to March 2021 on a randomly selected sample of adults aged 18-89 years, living in Dallas or Tarrant Counties, Texas. Participants were asked to complete a 15-minute questionnaire and COVID-19 PCR and antibody testing. COVID-19 prevalence estimates were calculated with survey-weighted data.

RESULTS

Of 2969 adults who completed the questionnaire (7.4% weighted response), 1772 (53.9% weighted) completed COVID-19 testing. Overall, 11.5% of adults had evidence of COVID-19 infection, with a higher prevalence among Hispanic and non-Hispanic Black persons, essential workers, those in low-income neighborhoods, and those with lower education attainment compared to their counterparts. We observed differences in attitudes and behaviors by race and ethnicity, with non-Hispanic White persons being less likely to believe in the importance of mask wearing, and racial and ethnic minorities more likely to attend social gatherings.

CONCLUSION

Over 10% of an urban population was infected with COVID-19 early during the pandemic. Differences in attitudes and behaviors likely contribute to sociodemographic disparities in COVID-19 prevalence.

Novel Application of Predictive Modeling: A Tailored Approach to Promoting HCC Surveillance in Patients With Cirrhosis

OBJECTIVE

There has been increased interest in interventions to promote hepatocellular carcinoma (HCC) surveillance given low utilization and high proportions of late stage detection. Accurate prediction of patients likely versus unlikely to respond to interventions could allow a cost-effective approach to outreach and facilitate targeting more intensive interventions to likely non-responders.

DESIGN

We conducted a secondary analysis of a randomized clinical trial evaluating a mailed outreach strategy to promote HCC surveillance among 1200 cirrhosis patients at a safety-net health system between December 2014 and March 2017. We developed regularized logistic regression (RLR) and gradient boosting machine (GBM) algorithm models to predict surveillance completion during each of the 3 screening rounds in a training set (n = 960). Model performance was assessed using multiple performance metrics in an independent test set (n = 240).

RESULTS

Among 1200 patients, surveillance was completed in 41-47% of patients over the three rounds. The RLR and GBM models demonstrated good discriminatory accuracy, with area under receiver operating characteristic (AUROC) curves of 0.67 and 0.66 respectively in the first surveillance round and improved to 0.77 by the third surveillance round after incorporating prior screening behavior as a feature. Additional performance characteristics including the Brier score, Hosmer-Lemeshow test and reliability diagrams were also evaluated. The most important variables for the predictive model were prior screening completion status and past primary care contact.

CONCLUSIONS

Predictive models can help stratify patients' likelihood to respond to surveillance outreach invitations, facilitating tailored strategies to maximize effectiveness and cost-effectiveness of HCC surveillance population health programs.

T Cell Receptor Repertoires Acquired via Routine Pap Testing May Help Refine Cervical Cancer and Precancer Risk Estimates

Cervical cancer is the fourth most common cancer and fourth leading cause of cancer death among women worldwide. In low Human Development Index settings, it ranks second. Screening and surveillance involve the cytology-based Papanicolaou (Pap) test and testing for high-risk human papillomavirus (hrHPV). The Pap test has low sensitivity to detect precursor lesions, while a single hrHPV test cannot distinguish a persistent infection from one that the immune system will naturally clear. Furthermore, among women who are hrHPV-positive and progress to high-grade cervical lesions, testing cannot identify the ~20% who would progress to cancer if not treated. Thus, reliable detection and treatment of cancers and precancers requires routine screening followed by frequent surveillance among those with past abnormal or positive results. The consequence is overtreatment, with its associated risks and complications, in screened populations and an increased risk of cancer in under-screened populations. Methods to improve cervical cancer risk assessment, particularly assays to predict regression of precursor lesions or clearance of hrHPV infection, would benefit both populations. Here we show that women who have lower risk results on follow-up testing relative to index testing have evidence of enhanced T cell clonal expansion in the index cervical cytology sample compared to women who persist with higher risk results from index to follow-up. We further show that a machine learning classifier based on the index sample T cells predicts this transition to lower risk with 95% accuracy (19/20) by leave-one-out cross-validation. Using T cell receptor deep sequencing and machine learning, we identified a biophysicochemical motif in the complementarity-determining region 3 of T cell receptor β chains whose presence predicts this transition. While these results must still be tested on an independent cohort in a prospective study, they suggest that this approach could improve cervical cancer screening by helping distinguish women likely to spontaneously regress from those at elevated risk of progression to cancer. The advancement of such a strategy could reduce surveillance frequency and overtreatment in screened populations and improve the delivery of screening to under-screened populations.

Out of reach? Correlates of cervical cancer underscreening in women with varying levels of healthcare interactions in a United States integrated delivery system

One in five U.S. women with health insurance are underscreened for cervical cancer. We sought to identify whether underscreening correlates differed among women with different levels of health care interaction. Among women age 30-64 years who were members of an integrated U.S. health system, we used 2014-2015 electronic health record data to identify underscreened cases (≥3.4 years since last Papanicolaou (Pap) test, n=3352) and screening-adherent controls (<3.4 years since last Pap test, n=45,359) and extracted data on potential underscreening correlates (demographics, health history, and healthcare utilization). We calculated the odds of underscreening in the total population and by subgroups defined by healthcare visits and online health portal usage in the prior 12 months. Underscreening was associated with older age (50-64 vs. 30-39; odds ratio (OR)=1.6; 95%CI=1.4-1.8), current tobacco use (vs. never use; OR=2.1; 95%CI=1.8-2.2), higher BMI (≥35 kg/m² vs <25 kg/m², OR=2.0; 95%CI=1.8-2.3), screening non-adherence for colorectal cancer (OR=5.1; 95%CI=4.6-5.7) and breast cancer (OR=8.1, 95%CI=7.2-9.0), and having no recent visit with their primary care provider (PCP) nor recent health portal use (vs. recent PCP visit and portal use; OR=8.4, 95%CI=7.6-9.4). Underscreening correlates were similar between the total study population and within all healthcare interaction groups. Interaction with the healthcare system is associated with lower odds of underscreening, but sociodemographic and health status correlates are similar regardless of primary care visits or online portal use. These data support the need for additional interventions to reach insured women who remain underscreened for cervical cancer.

Sex disparities in presentation and prognosis of 1110 patients with hepatocellular carcinoma

BACKGROUND

Although sex disparities in hepatocellular carcinoma (HCC) incidence have been well described, there are limited data examining sex disparities in HCC prognosis.

AIM

To characterise sex differences in HCC presentation and prognosis.

METHODS

We performed a retrospective study of consecutive patients (n = 1110, 23.5% women) diagnosed with HCC between 2008 and 2017 at two US health systems. We used Cox proportional hazard and multivariable logistic regression models to identify factors associated with overall survival, early tumour detection and response to HCC treatment (per the modified Response Evaluation Criteria in Solid Tumors [mRECIST] criteria).

RESULTS

Women were older at HCC diagnosis (mean 62.5 vs 59.2 years, P < 0.001) and had a higher proportion of early-stage tumours (53.1% vs 43.7% Barcelona Clinic Liver Cancer [BCLC] stage 0/A, P = 0.04), but similar liver function compared to men (49.2% vs 47.1% Child Pugh A, P = 0.27). In univariable analysis, women had significantly better overall survival than men (median 17.1 vs 12.0 months, P = 0.02). When stratified by age, younger (<65 years) women had better overall survival than men (18.3 vs 11.2 months, P = 0.02); however, older (≥65 years) women and men had similar overall survival (15.5 vs 15.7 months, P = 0.45). In multivariable analysis, female sex was independently associated with lower mortality after adjusting for age, race/ethnicity, alpha-fetoprotein, BCLC stage, Albumin-Bilirubin grade and Child Pugh score (hazard ratio [HR] 0.82, 95% confidence interval [CI] 0.68-0.98). In secondary analyses, female sex was independently associated with early tumour detection (odds ratio [OR] 1.46, 95% CI 1.05-2.02) and response to first HCC treatment (OR 1.72, 95% CI 1.18-2.53) after adjusting for the same covariates.

CONCLUSION

In a large cohort of patients with HCC, women had significantly better prognosis than men.

Biophysicochemical motifs in T cell receptor sequences as a potential biomarker for high-grade serous ovarian carcinoma

We previously showed, in a pilot study with publicly available data, that T cell receptor (TCR) repertoires from tumor infiltrating lymphocytes (TILs) could be distinguished from adjacent healthy tissue repertoires by the presence of TCRs bearing specific, biophysicochemical motifs in their antigen binding regions. We hypothesized that such motifs might allow development of a novel approach to cancer detection. The motifs were cancer specific and achieved high classification accuracy: we found distinct motifs for breast versus colorectal cancer-associated repertoires, and the colorectal cancer motif achieved 93% accuracy, while the breast cancer motif achieved 94% accuracy. In the current study, we sought to determine whether such motifs exist for ovarian cancer, a cancer type for which detection methods are urgently needed. We made two significant advances over the prior work. First, the prior study used patient-matched TILs and healthy repertoires, collecting healthy tissue adjacent to the tumors. The current study collected TILs from patients with high-grade serous ovarian carcinoma (HGSOC) and healthy ovary repertoires from cancer-free women undergoing hysterectomy/salpingo-oophorectomy for benign disease. Thus, the classification task is distinguishing women with cancer from women without cancer. Second, in the prior study, classification accuracy was measured by patient-hold-out cross-validation on the training data. In the current study, classification accuracy was additionally assessed on an independent cohort not used during model development to establish the generalizability of the motif to unseen data. Classification accuracy was 95% by patient-hold-out cross-validation on the training set and 80% when the model was applied to the blinded test set. The results on the blinded test set demonstrate a biophysicochemical TCR motif found overwhelmingly in women with HGSOC but rarely in women with healthy ovaries, strengthening the proposal that cancer detection approaches might benefit from incorporation of TCR motif-based biomarkers. Furthermore, these results call for studies on large cohorts to establish higher classification accuracies, as well as for studies in other cancer types.

Evaluating the Validity of the Risk Perception Survey for Developing Diabetes Scale in a Safety-Net Clinic Population of English and Spanish Speakers

PURPOSE

The purpose of this study is to examine the factor structure of the Risk Perception Survey for Developing Diabetes (RPS-DD) and test for factorial invariance by language (English, Spanish) and gender (males, females) in a clinically engaged, racially diverse, low-education population.

METHODS

Adult patients seen in a safety-net health system (N = 641) answered an interviewer-administered survey via telephone in their preferred language (English: 42%, Spanish: 58%). Three constructs in the RPS-DD were assessed-personal control (2 items for internal control and 2 for external control), optimistic bias (2 items), and worry (2 items). Single and multigroup confirmatory factor analyses (CFAs) were performed using maximum-likelihood estimation to determine the factor structure and test for invariance.

RESULTS

Contrary to previous psychometric analyses in white, educated populations, CFAs supported a 4-factor measurement model with internal and external control items loading onto separate factors. The 4-factor structure was equivalent between males and females. However, the structure varied by language, with the worry subscale items loading more strongly for English than Spanish speakers.

CONCLUSIONS

The RPS-DD can be used to investigate group differences across gender and language and to help understand if interventions have differential effects for subgroups at high risk for diabetes. Given the increasing prevalence of diabetes among Spanish speakers, researchers should continue to examine the psychometric properties of the RPS-DD, particularly the worry subscale, to improve its validity and clinical utility.

Patterns and predictors of repeat fecal immunochemical and occult blood test screening in four large health care systems in the United States

OBJECTIVES

Effectiveness of fecal occult blood test (FOBT) for colorectal cancer (CRC) screening depends on annual testing, but little is known about patterns of repeat stool-based screening within different settings. Our study's objective was to characterize screening patterns and identify factors associated with repeat screening among patients who completed an index guaiac FOBT (gFOBT) or fecal immunochemical test (FIT).

METHODS

We performed a multi-center retrospective cohort study among people who completed a FOBT between January 2010 and December 2011 to characterize repeat screening patterns over the subsequent 3 years. We studied at 4 large health care delivery systems in the United States. Logistic regression analyses were used to identify factors associated with repeat screening patterns. We included individuals aged 50-71 years who completed an index FOBT and had at least 3 years of follow-up. We excluded people with a history of CRC, colonoscopy within 10 years or flexible sigmoidoscopy within 5 years before the index test, or positive index stool test. Consistent screening was defined as repeat FOBT within every 15 months and inconsistent screening as repeat testing at least once during follow-up but less than consistent screening.

RESULTS

Among 959,857 eligible patients who completed an index FIT or gFOBT, 344,103 had three years of follow-up and met inclusion criteria. Of these, 46.6% had consistent screening, 43.4% inconsistent screening, and 10% had no repeat screening during follow-up. Screening patterns varied substantially across healthcare systems, with consistent screening proportions ranging from 1 to 54.3% and no repeat screening proportions ranging from 6.9 to 42.8%. Higher consistent screening proportions were observed in health systems with screening outreach and in-reach programs, whereas the safety-net health system, which uses opportunistic clinic-based screening, had the lowest consistent screening. Consistent screening increased with older age but was less common among racial/ethnic minorities and patients with more comorbidities.

CONCLUSIONS

Adherence with annual FOBT screening is highly variable across healthcare delivery systems. Settings with more organized screening programs performed better than those with opportunistic screening, but evidence-based interventions are needed to improve CRC screening adherence in all settings.

An assessment of benefits and harms of hepatocellular carcinoma surveillance in patients with cirrhosis

Although surveillance ultrasound and alpha fetoprotein (AFP) tests have minimal direct harm, downstream harms from follow-up tests must be weighed against surveillance benefits when determining the value of hepatocellular carcinoma (HCC) screening programs. Our study's aims were to characterize prevalence and correlates of surveillance benefits and harms in cirrhosis patients undergoing HCC surveillance. We conducted a retrospective cohort study among patients with cirrhosis followed at a safety-net health system between July 2010 and July 2013. We recorded surveillance-related benefits, defined as early tumor detection and curative treatment, and surveillance-related physical harms, defined as computed tomography or magnetic resonance imaging scans, biopsies, or other procedures performed for false-positive or indeterminate surveillance results. Sociodemographic and clinical correlates of surveillance harms were evaluated using multivariable logistic regression. We identified 680 patients with cirrhosis, of whom 78 (11.5%) developed HCC during the 3-year study period. Of the 48 (61.5%) HCCs identified by surveillance, 43.8% were detected by ultrasound, 31.2% by AFP, and 25.0% by both surveillance tests. Surveillance-detected patients had a higher proportion of early HCC (70.2% vs. 40.0%; P = 0.009), with no difference in tumor stage between ultrasound- and AFP-detected tumors (P = 0.53). Surveillance-related physical harms were observed in 187 (27.5%) patients, with a higher proportion of ultrasound-related harm than AFP-related harm (22.8% vs. 11.4%; P < 0.001). Surveillance-related harms were associated with elevated ALT (odds ratio [OR], 1.87; 95% confidence interval [CI], 1.26-2.76), thrombocytopenia (OR, 2.06; 95% CI, 1.26-3.38), and hepatology subspecialty care (OR, 1.63; 95% CI, 1.09-2.42).

CONCLUSION

Over one fourth of patients with cirrhosis experience physical harm for false-positive or indeterminate surveillance tests-more often related to ultrasound than AFP. Interventions are needed to reduce surveillance-related harm to increase the value of HCC screening programs in clinical practice. (Hepatology 2017;65:1196-1205).

Role functioning is associated with survival in patients with hepatocellular carcinoma

BACKGROUND

Prior studies assessing quality of life (QOL) in patients with hepatocellular carcinoma (HCC) primarily included patients with preserved liver function and/or early HCC, leading to overestimation of QOL. Our study's aim was to evaluate the association of QOL with survival among a cohort of cirrhotic patients with HCC that was diverse with respect to liver function and tumor stage.

METHODS

We conducted a prospective cohort study among cirrhotic patients with HCC from a large urban safety-net hospital between April 2011 and September 2013. Patients completed two self-administered surveys, the EORTC QLQ-C30 and QLQ-HCC18, prior to the treatment. We used generalized linear models to identify correlates of QOL. Survival curves were generated using Kaplan-Meier analysis and compared using log rank test to determine whether QOL is associated with survival.

RESULTS

A total of 130 treatment-naïve patients completed both surveys. Patients reported high cognitive and social function (median scores 67) but poor global QOL (median score 50) and poor role function (median score 50). QOL was associated with cirrhosis-related (p = 0.02) and tumor-related (p = 0.02) components of Barcelona Clinic Liver Cancer (BCLC) tumor stage. QOL was associated with survival on univariate analysis (HR 0.37, 95 % CI 0.16-0.85) but became nonsignificant (HR 0.82, 95 % CI 0.37-1.80) after adjusting for BCLC stage and treatment. Role functioning was significantly associated with survival (HR 0.40, 95 % CI 0.20-0.81), after adjusting for Caucasian race (HR 0.31, 95 % CI 0.16-0.59), BCLC stage (HR 1.51, 95 % CI 0.21-1.89), and treatment (HR 0.57, 95 % CI 0.33-0.97).

CONCLUSIONS

Role function has prognostic significance and is important to assess in patients with HCC.

Practice patterns and attitudes of primary care providers and barriers to surveillance of hepatocellular carcinoma in patients with cirrhosis

BACKGROUND & AIMS

Fewer than 20% of patients with cirrhosis undergo surveillance for hepatocellular carcinoma (HCC), therefore these tumors often are detected at late stages. Although primary care providers (PCPs) care for 60% of patients with cirrhosis in the United States, little is known about their practice patterns for HCC surveillance. We investigated factors associated with adherence to guidelines for HCC surveillance by PCPs.

METHODS

We conducted a web-based survey of all 131 PCPs at a large urban hospital. The survey was derived from validated surveys and pretested among providers; it included questions about provider and practice characteristics, self-reported rates of surveillance, surveillance test and frequency preference, and attitudes and barriers to HCC surveillance.

RESULTS

We obtained a clinic-level response rate of 100% and a provider-level response rate of 60%. Only 65% of respondents reported annual surveillance and 15% reported biannual surveillance of patients for HCC. Barriers to HCC surveillance included not being up-to-date with HCC guidelines (68% of PCPs), difficulties in communicating effectively with patients about HCC surveillance (56%), and more important issues to manage in the clinic (52%). Approximately half of PCPs (52%) reported using ultrasound or measurements of α-fetoprotein in surveillance; 96% said that this combination was effective in reducing HCC-related mortality. However, many providers incorrectly believed that clinical examination (45%) or levels of liver enzymes (59%) or α-fetoprotein alone (89%) were effective surveillance tools.

CONCLUSIONS

PCPs have misconceptions about tests to detect HCC that contribute to ineffective surveillance. Reported barriers to surveillance include suboptimal knowledge about guidelines, indicating a need for interventions, including provider education, to increase HCC surveillance effectiveness.

Racial, social, and clinical determinants of hepatocellular carcinoma surveillance

OBJECTIVES

Less than 1 in 5 patients receive hepatocellular carcinoma surveillance; however, most studies were performed in racially and socioeconomically homogenous populations, and few used guideline-based definitions for surveillance. The study objective was to characterize guideline-consistent hepatocellular carcinoma surveillance rates and identify determinants of hepatocellular carcinoma surveillance among a racially and socioeconomically diverse cohort of cirrhotic patients.

METHODS

We retrospectively characterized hepatocellular carcinoma surveillance among cirrhotic patients followed between July 2008 and July 2011 at an urban safety-net hospital. Inconsistent surveillance was defined as at least 1 screening ultrasound during the 3-year period, annual surveillance was defined as screening ultrasounds every 12 months, and biannual surveillance was defined as screening ultrasounds every 6 months. Univariate and multivariate analyses were conducted to identify predictors of surveillance.

RESULTS

Of 904 cirrhotic patients, 603 (67%) underwent inconsistent surveillance. Failure to recognize cirrhosis was a significant barrier to surveillance use (P < .001). Inconsistent surveillance was associated with insurance status (odds ratio [OR], 1.43; 95% confidence interval [CI], 1.03-1.98), multiple primary care visits per year (OR, 2.63; 95% CI, 1.86-3.71), multiple hepatology visits per year (OR, 3.75; 95% CI, 2.64-5.33), African American race (OR, 0.61; 95% CI, 0.42-0.99), nonalcoholic steatohepatitis cause (OR, 0.60; 95% CI, 0.37-0.98), and extrahepatic cancer (OR, 0.43; 95% CI, 0.24-0.77). Only 98 (13.4%) of 730 patients underwent annual surveillance, and only 13 (1.7%) of 786 had biannual surveillance.

CONCLUSIONS

Only 13% of patients with cirrhosis receive annual surveillance, and less than 2% of patients receive biannual surveillance. There are racial and socioeconomic disparities, with lower rates of hepatocellular carcinoma surveillance among African Americans and underinsured patients.

Early detection, curative treatment, and survival rates for hepatocellular carcinoma surveillance in patients with cirrhosis: a meta-analysis

BACKGROUND

Surveillance for hepatocellular carcinoma (HCC) has level I evidence among patients with hepatitis B but only level II evidence in patients with cirrhosis. This lack of randomized data has spurred questions regarding the utility of HCC surveillance in this patient population; however, lack of randomized data does not equate to a lack of data supporting the efficacy of surveillance. The aim of our study was to determine the effect of HCC surveillance on early stage tumor detection, receipt of curative therapy, and overall survival in patients with cirrhosis.

METHODS AND FINDINGS

We performed a systematic literature review using Medline from January 1990 through January 2014 and a search of national meeting abstracts from 2009-2012. Two investigators identified studies that reported rates of early stage tumor detection, curative treatment receipt, or survival, stratified by HCC surveillance status, among patients with cirrhosis. Both investigators independently extracted data on patient populations, study methods, and results using standardized forms. Pooled odds ratios, according to HCC surveillance status, were calculated for each outcome using the DerSimonian and Laird method for a random effects model. We identified 47 studies with 15,158 patients, of whom 6,284 (41.4%) had HCC detected by surveillance. HCC surveillance was associated with improved early stage detection (odds ratio [OR] 2.08, 95% CI 1.80-2.37) and curative treatment rates (OR 2.24, 95% CI 1.99-2.52). HCC surveillance was associated with significantly prolonged survival (OR 1.90, 95% CI 1.67-2.17), which remained significant in the subset of studies adjusting for lead-time bias. Limitations of current data included many studies having insufficient duration of follow-up to assess survival and the majority not adjusting for liver function or lead-time bias.

CONCLUSIONS

HCC surveillance is associated with significant improvements in early tumor detection, receipt of curative therapy, and overall survival in patients with cirrhosis. Please see later in the article for the Editors' Summary.

Comparative effectiveness of fecal immunochemical test outreach, colonoscopy outreach, and usual care for boosting colorectal cancer screening among the underserved: a randomized clinical trial

IMPORTANCE

Colorectal cancer (CRC) screening saves lives, but participation rates are low among underserved populations. Knowledge on effective approaches for screening the underserved, including best test type to offer, is limited.

OBJECTIVE

To determine (1) if organized mailed outreach boosts CRC screening compared with usual care and (2) if FIT is superior to colonoscopy outreach for CRC screening participation in an underserved population.

DESIGN, SETTING, AND PARTICIPANTS

We identified uninsured patients, not up to date with CRC screening, age 54 to 64 years, served by the John Peter Smith Health Network, Fort Worth and Tarrant County, Texas, a safety net health system.

INTERVENTIONS

Patients were assigned randomly to 1 of 3 groups. One group was assigned to fecal immunochemical test (FIT) outreach, consisting of mailed invitation to use and return an enclosed no-cost FIT (n = 1593). A second was assigned to colonoscopy outreach, consisting of mailed invitation to schedule a no-cost colonoscopy (n = 479). The third group was assigned to usual care, consisting of opportunistic primary care visit–based screening (n = 3898). In addition, FIT and colonoscopy outreach groups received telephone follow-up to promote test completion.

MAIN OUTCOME MEASURES

Screening participation in any CRC test within 1 year after randomization.

RESULTS

Mean patient age was 59 years; 64% of patients were women. The sample was 41% white, 24% black, 29% Hispanic, and 7% other race/ethnicity. Screening participation was significantly higher for both FIT (40.7%) and colonoscopy outreach (24.6%) than for usual care (12.1%) (P < .001 for both comparisons with usual care). Screening was significantly higher for FIT than for colonoscopy outreach (P < .001). In stratified analyses, screening was higher for FIT and colonoscopy outreach than for usual care, and higher for FIT than for colonoscopy outreach among whites, blacks, and Hispanics (P < .005 for all comparisons). Rates of CRC identification and advanced adenoma detection were 0.4% and 0.8% for FIT outreach, 0.4% and 1.3% for colonoscopy outreach, and 0.2% and 0.4% for usual care, respectively (P < .05 for colonoscopy vs usual care advanced adenoma comparison; P > .05 for all other comparisons). Eleven of 60 patients with abnormal FIT results did not complete colonoscopy. CONCLUSIONS AND REVELANCE: Among underserved patients whose CRC screening was not up to date, mailed outreach invitations resulted in markedly higher CRC screening compared with usual care. Outreach was more effective with FIT than with colonoscopy invitation.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01191411.

Abstract WMP102: Development and Testing of a Web-Based Decision Aid to Improve Decision Making for Asymptomatic Carotid Disease

Introduction: Patients (Pts) with asymptomatic (ASX) carotid stenosis have 3 treatment (Rx) options (surgery[CEA], stenting[CAS], and medical therapy alone[Med],) each with its own risks and benefits (R/Bs). In prior work, many ASX Pts who had CEA did not understand the disease (Dz), their Rx options, and associated R/Bs. Decision aids (DAs) have been shown in other conditions to foster more informed Rx choices.

Objective: To develop and assess the impact of a DA on knowledge of Dz, Rx options, and DA satisfaction.

Methods: We created a multimedia, web-based DA to explain ASX carotid Dz, Rx options, and associated R/Bs. The DA was refined and vetted by experts in neurology, vascular/neuro-surgery, internal medicine, decision making, and patient education. The DA included: text, anatomic graphics, pictographs of short term and long R/Bs of CEA v. Med, and Pt and MD video testimonials. We tested it in an online Pt panel in those: 55+ yrs with ≥ 1 risk factor for carotid Dz (HTN, DM, CHOL, CAD, PVD). Post-viewing knowledge of key educational messages incl. Rx options, associated R/Bs, and DA satisfaction were assessed with validated instruments.

Results: Overall, 1778 of 1843 completed viewing the 40 minute DA (96%). Mean age was 67 yrs, 51% female, 91% White, and 24% ≤high school degree. Pts correctly answered 68% of the 19 knowledge items. The DA was well-liked with mean score of 4.4 (out of 5) on a 10 item DA satisfaction score and 4.3 (out of 5) on a 7 item DA helpfulness score. Pts correctly grasped most gist messages including that: not everyone needed CEA (99%), there was no best Rx it depends on the Pt (92%), they had time to make a decision (86%), CEA can cause stroke (92%), CEA can cause death (91%), and carotid Dz can cause stroke (83%). They had trouble understanding the time trade of CEA v. Med-only 55% correctly said CEA was riskier in the short term, and 50% that Med was riskier in the long term. Overall, 74% said they would choose Med. Pts who were younger, female, White, higher education, or with family/friends with stroke or CAD had higher knowledge scores.

Conclusions: A web-based DA was effective in conveying most gist messages regarding making an informed decision in ASX carotid Dz. The next step is testing the impact of the DA in Pts facing a real decision about revascularization.

Factorial validity and invariance of a survey measuring psychosocial correlates of colorectal cancer screening in Ontario, Canada--a replication study

Psychosocial constructs have been used to predict colorectal cancer screening and are frequently targeted as intermediate outcomes in behavioral intervention studies. Few studies have conducted analyses to adequately test construct validity. The psychometric analyses undertaken with U.S. populations of 16 theory-based, colorectal cancer screening items designed to measure five factors (salience-coherence, cancer worries, perceived susceptibility, response efficacy, and social influence) are an exception. The current investigation replicates previous work by examining factor validity and invariance in a random sample of Ontario, Canada residents. A survey instrument was administered to 1,013 Ontario male (49%) and female (51%) residents randomly selected by the Canada Survey Sample. Single-group confirmatory factor analyses (CFA) assessed data fit to the proposed five-factor model for males and females separately, and then a multigroup CFA evaluated if the factor structure was invariant for men and women. The five-factor model provided good fit for both males and females. Tests for factorial invariance between sexes, however, found mixed results. chi2 difference test was significant (P = 0.025); however, DeltaRMSEA = 0.0001. Factor loadings were similar by sex except for two social influence items, with item frequency distributions suggesting an extreme response style, in females, on these items. Overall, the single-group and multigroup CFA results support factorial validity and partial invariance of the five-factor model first identified in the U.S. populations. The items can be used to evaluate and compare psychosocial correlates across U.S. and Canadian samples. Additional research is needed to show invariance for other ethnocultural and national subgroups.