Modifiable patient-reported factors associated with cancer-screening knowledge and participation in a community-based health assessment

BACKGROUND

We sought to identify modifiable factors associated with cancer screening in a community-based health assessment.

METHODS

24 organizations at 47 community events in central North Carolina distributed a 91-item survey from April-December 2017. Responses about (1) interest in disease prevention, (2) lifestyle choices (e.g., diet, tobacco), and (3) perceptions of primary care access/quality were abstracted to examine their association with self-reported screening participation and knowledge about breast, prostate, and colorectal cancer.

RESULTS

2135/2315 participants (92%; 38.5% White, 38% Black, 9.9% Asian) completed screening questions. >70% of screen-eligible respondents reported guideline-concordant screening. Healthy dietary habits were associated with greater knowledge about breast and colorectal cancer screening; reporting negative attitudes about and barriers to healthcare were associated with less breast, prostate, and colorectal cancer screening. Having a place to seek medical care (a proxy for primary care access) was independently associated with being ∼5 times as likely to undergo colorectal screening (OR 4.66, 95% CI 1.58-13.79, all p < 0.05).

CONCLUSIONS

In this diverse, community-based sample, modifiable factors were associated with screening engagement, highlighting opportunities for behavioral intervention.

An Assessment of the Feasibility and Utility of an ACCC-ASCO Implicit Bias Training Program to Enhance Racial and Ethnic Diversity in Cancer Clinical Trials

PURPOSE

Cancer trial participants do not reflect the racial and ethnic diversity in the population of people with cancer in the United States. As a result of multiple system-, patient-, and provider-level factors, including implicit bias, cancer clinical trials are not consistently offered to all potentially eligible patients.

MATERIALS AND METHODS

ASCO and ACCC evaluated the utility (pre- and post-test knowledge changes) and feasibility (completion rates, curriculum satisfaction metrics, survey questions, and interviews) of a customized online training program combined with facilitated peer-to-peer discussion designed to help research teams identify their own implicit biases and develop strategies to mitigate them. Discussion focused on (1) specific elements of the training modules; (2) how to apply lessons learned; and (3) key considerations for developing a facilitation guide to support peer-to-peer discussions in cancer clinical research settings. We evaluated discussion via a qualitative assessment.

RESULTS

Participant completion rate was high: 49 of 50 participating cancer programs completed training; 126 of 129 participating individuals completed the training (98% response rate); and 119 completed the training and evaluations (92% response rate). Training increased the mean percentage change in knowledge scores by 19%-45% across key concepts (eg, causes of health disparities) and increased the mean percentage change in knowledge scores by 10%-31% about strategies/actions to address implicit bias and diversity concerns in cancer clinical trials. Knowledge increases were sustained at 6 weeks. Qualitative evaluation validated the utility and feasibility of facilitated peer-to-peer discussion.

CONCLUSION

The pilot implementation of the training program demonstrated excellent utility and feasibility. Our evaluation affirms that an online training designed to raise awareness about implicit bias and develop strategies to mitigate biases among cancer research teams is feasible and can be readily implemented in cancer research settings.

The 5Ws of Racial Equity in Research: A Framework for Applying a Racial Equity Lens Throughout the Research Process

Ensuring equity in research is a critical step in advancing health equity. In this perspective, the authors introduce a guiding framework for advancing racial equity in research processes, environments, and among the research workforce, the 5Ws of Racial Equity in Research. Centering their discussion on the 5Ws: Who, What, When, Where, and Why, they use historical and contemporary examples of research inequities to demonstrate how these five simple questions can encourage open discussion and proactive planning for equity in research. They close with an acknowledgment of the framework's broad utility and a researcher-directed call to action.

A Review of Race and Ethnicity in Hospice and Palliative Medicine Research: Representation Matters

CONTEXT

Despite documented racial and ethnic disparities in care, there is significant variability in representation, reporting, and analysis of race and ethnic groups in the hospice and palliative medicine (HPM) literature.

OBJECTIVES

To evaluate the race and ethnic diversity of study participants and the reporting of race and ethnicity data in HPM research.

METHODS

Adult patient and/or caregiver-centered research conducted in the U.S. and published as JPSM Original Articles from January 1, 2015, through December 31, 2019, were identified. Descriptive analyses were used to summarize the frequency of variables related to reporting of race and ethnicity.

RESULTS

Of 1253 studies screened, 218 were eligible and reviewed. There were 78 unique race and ethnic group labels. Over 85% of studies included ≥ one non-standard label based on Office of Management and Budget designations. One-quarter of studies lacked an explanation of how race and ethnicity data were collected, and 83% lacked a rationale. Over half did not include race and/or ethnicity in the analysis, and only 14 studies focused on race and/or ethnic health or health disparities. White, Black, Hispanic, Asian, American Indian or Alaska Native, and Native Hawaiian or Other Pacific Islander persons were included in 95%, 71%, 43% 37%,10%, and 4% of studies. In 92% of studies the proportion of White individuals exceeded 57.8%, which is their proportion in the U.S.

CONCLUSION

Our findings suggest there are important opportunities to standardize reporting of race and ethnicity, strive for diversity, equity, and inclusion among research participants, and prioritize the study of racial and ethnic disparities in HPM research.

Health Misinformation Exposure and Health Disparities: Observations and Opportunities

The concepts of health misinformation and health disparities have been prominent in public health literature in recent years, in part because of the threat that each notion poses to public health. How exactly are misinformation proliferation and health disparities related, however? What roles might misinformation play in explaining the health disparities that we have documented in the United States and elsewhere? How might we mitigate the effects of misinformation exposure among people facing relatively poor health outcomes? In this review, we address such questions by first defining health disparities and misinformation as concepts and then considering how misinformation exposure might theoretically affect health decision-making and account for disparate health behavior and health outcomes. We also assess the potential for misinformation-focused interventions to address health disparities based on available literature and call for future research to address gaps in our current evidence base. Expected final online publication date for the Annual Review of Public Health, Volume 44 is April 2023. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Initial Longitudinal Outcomes of Risk-Stratified Men in Their Forties Screened for Prostate Cancer Following Implementation of a Baseline Prostate-Specific Antigen

PURPOSE

Prostate cancer (PCa) screening can lead to potential over-diagnosis/over-treatment of indolent cancers. There is a need to optimize practices to better risk-stratify patients. We examined initial longitudinal outcomes of mid-life men with an elevated baseline prostate-specific antigen (PSA) following initiation of a novel screening program within a system-wide network.

MATERIALS AND METHODS

We assessed our primary care network patients ages 40 to 49 years with a PSA measured following implementation of an electronic health record screening algorithm from 2/2/2017-2/21/2018. The multidisciplinary algorithm was developed taking factors including age, race, family history, and PSA into consideration to provide a personalized approach to urology referral to be used with shared decision-making. Outcomes of men with PSA ≥1.5 ng/mL were evaluated through 7/2021. Statistical analyses identified factors associated with PCa detection. Clinically significant PCa (csPCa) was defined as Gleason Grade Group (GGG) ≥2 or GGG1 with PSA ≥10 ng/mL.

RESULTS

The study cohort contained 564 patients, with 330 (58.5%) referred to urology for elevated PSA. Forty-nine (8.7%) underwent biopsy; of these, 20 (40.8%) returned with PCa. Eleven (2.0% of total cohort and 55% of PCa diagnoses) had csPCa. Early referral timing (odds ratio [OR], 4.58) and higher PSA (OR, 1.07) were significantly associated with PCa at biopsy on multivariable analysis (both p<0.05), while other risk factors were not. Referred patients had higher mean PSAs (2.97 vs. 1.98, p=0.001).

CONCLUSIONS

Preliminary outcomes following implementation of a multidisciplinary screening algorithm identified PCa in a small, important percentage of men in their forties. These results provide insight into baseline PSA measurement to provide early risk stratification and detection of csPCa in patients with otherwise extended life expectancy. Further follow-up is needed to possibly determine the prognostic significance of such mid-life screening and optimize primary care physician-urologist coordination.

Racial/Ethnic Disparities in Healthcare Worker Experiences During the COVID-19 Pandemic: An Analysis of the HERO Registry

BACKGROUND

The extent to which healthcare worker (HCWs) experiences during the COVID-19 pandemic vary by race or ethnicity after adjustment for confounding factors is not currently known.

METHODS

We performed an observational prospective cohort study of 24,769 healthcare workers from 50 U.S. states and the District of Columbia, enrolled between April 10, 2020 and June 30, 2021, and evaluated participant experiences during the COVID-19 pandemic, including testing, diagnosis with COVID-19, emotional experiences, burnout, and interest in vaccines and vaccine clinical trials.

FINDINGS

After adjustment for professional role, medical history, and community characteristics, Black and Asian participants were less likely to receive SARS-CoV-2 viral testing (adjusted odds ratio (aOR) 0·82 [0·70, 0·96], p=0·012 and aOR 0·77 [0·67, 0·89], p<0·001 respectively) than White participants. Hispanic participants were more likely to have evidence of COVID-19 infection (aOR 1·23 (1·00, 1·50, p=0·048). Black and Asian participants were less likely to report interest in a COVID-19 vaccine (aOR 0·11 [0·05, 0·25], p<0·001 and aOR 0·48 [0·27, 0·85] p=0·012). Black participants were less likely to report interest in participating in a COVID-19 vaccine trial (aOR = 0·39 [0·28, 0·54], p<0·001). Black participants were also less likely to report 3 or more daily emotional impacts of COVID-19 (aOR = 0·66 [0·53, 0·82], p=<0·001). Black participants were additionally less likely to report burnout (aOR = 0·66 ([0·49, 0·95], p=0·025).

INTERPRETATION

In a large, national study of healthcare workers, after adjustment for individual and community characteristics, race/ethnicity disparities in COVID-19 outcomes persist. Future work is urgently needed to understand precise mechanisms behind these disparities and to develop and implement targeted interventions to improve health equity for healthcare workers.

FUNDING

This work was funded by the Patient-Centered Outcomes Research Institute (PCORI), Contract # COVID-19-2020-001.

Association of Smartphone Ownership and Internet Use With Markers of Health Literacy and Access: Cross-sectional Survey Study of Perspectives From Project PLACE (Population Level Approaches to Cancer Elimination)

Background

Telehealth is an increasingly important component of health care delivery in response to the COVID-19 pandemic. However, well-documented disparities persist in the use of digital technologies.

Objective

This study aims to describe smartphone and internet use within a diverse sample, to assess the association of smartphone and internet use with markers of health literacy and health access, and to identify the mediating factors in these relationships.

Methods

Surveys were distributed to a targeted sample designed to oversample historically underserved communities from April 2017 to December 2017. Multivariate logistic regression was used to estimate the association of internet and smartphone use with outcomes describing health care access and markers of health literacy for the total cohort and after stratifying by personal history of cancer. Health care access was captured using multiple variables, including the ability to obtain medical care when needed. Markers of health literacy included self-reported confidence in obtaining health information.

Results

Of the 2149 participants, 1319 (61.38%) were women, 655 (30.48%) were non-Hispanic White, and 666 (30.99%) were non-Hispanic Black. The median age was 51 years (IQR 38-65). Most respondents reported using the internet (1921/2149, 89.39%) and owning a smartphone (1800/2149, 83.76%). Compared with the respondents with smartphone or internet access, those without smartphone or internet access were more likely to report that a doctor was their most recent source of health information (344/1800, 19.11% vs 116/349, 33.2% for smartphone and 380/1921, 19.78% vs 80/228, 35.1% for internet, respectively; both P<.001). Internet use was associated with having looked for information on health topics from any source (odds ratio [OR] 3.81, 95% CI 2.53-5.75) and confidence in obtaining health information when needed (OR 1.83, 95% CI 1.00-3.34) compared with noninternet users. Smartphone owners had lower odds of being unable to obtain needed medical care (OR 0.62, 95% CI 0.40-0.95) than nonsmartphone owners. Among participants with a prior history of cancer, smartphone ownership was significantly associated with higher odds of confidence in ability to obtain needed health information (OR 5.63, 95% CI 1.05-30.23) and lower odds of inability to obtain needed medical care (OR 0.17, 95% CI 0.06-0.47), although these associations were not significant among participants without a prior history of cancer.

Conclusions

We describe widespread use of digital technologies in a community-based cohort, although disparities persist. In this cohort, smartphone ownership was significantly associated with ability to obtain needed medical care, suggesting that the use of smartphone technology may play a role in increasing health care access. Similarly, major illnesses such as cancer have the potential to amplify health engagement. Finally, special emphasis must be placed on reaching patient populations with limited digital access, so these patients are not further disadvantaged in the new age of telehealth.

Implementation and Impact of a Risk-Stratified Prostate Cancer Screening Algorithm as a Clinical Decision Support Tool in a Primary Care Network

BACKGROUND

Implementation methods of risk-stratified cancer screening guidance throughout a health care system remains understudied.

OBJECTIVE

Conduct a preliminary analysis of the implementation of a risk-stratified prostate cancer screening algorithm in a single health care system.

DESIGN

Comparison of men seen pre-implementation (2/1/2016-2/1/2017) vs. post-implementation (2/2/2017-2/21/2018).

PARTICIPANTS

Men, aged 40-75 years, without a history of prostate cancer, who were seen by a primary care provider.

INTERVENTIONS

The algorithm was integrated into two components in the electronic health record (EHR): in Health Maintenance as a personalized screening reminder and in tailored messages to providers that accompanied prostate-specific antigen (PSA) results.

MAIN MEASURES

Primary outcomes: percent of men who met screening algorithm criteria; percent of men with a PSA result. Logistic repeated measures mixed models were used to test for differences in the proportion of individuals that met screening criteria in the pre- and post-implementation periods with age, race, family history, and PSA level included as covariates.

KEY RESULTS

During the pre- and post-implementation periods, 49,053 and 49,980 men, respectively, were seen across 26 clinics (20.6% African American). The proportion of men who met screening algorithm criteria increased from 49.3% (pre-implementation) to 68.0% (post-implementation) (p < 0.001); this increase was observed across all races, age groups, and primary care clinics. Importantly, the percent of men who had a PSA did not change: 55.3% pre-implementation, 55.0% post-implementation. The adjusted odds of meeting algorithm-based screening was 6.5-times higher in the post-implementation period than in the pre-implementation period (95% confidence interval, 5.97 to 7.05).

CONCLUSIONS

In this preliminary analysis, following implementation of an EHR-based algorithm, we observed a rapid change in practice with an increase in screening in higher-risk groups balanced with a decrease in screening in low-risk groups. Future efforts will evaluate costs and downstream outcomes of this strategy.

Abstract IA02: The Compelling Imperative to Diversify Participation in Clinical Trials and Research

COVID 19 has brought race disparities to the forefront as part of a national dialogue and upset. Those of us that are people of color or do research in this space are not surprised. The reality is that despite the numerous reports and efforts that have so keenly highlighted race disparities and recommendations to address them, we have yet to truly move the needle to improve the health of black and brown people. Interestingly, COVID 19 has caused a national pivot among funding agencies to add research around COVID-19 to their current funding portfolios as enhancement awards or RFAs specific to the pandemic, quickly emerged requiring a rapid response. The value and need for this pivot given this monumental time in global health history is necessary. Yet to what extent are we thinking carefully and deliberately about the importance of diversity in our clinical research and trials to ensure our findings positively impact the populations who are hardest hit and carry the greatest burden of the disease, namely African Americans and other people of color. This a fundamental question and poses an opportunity for us to do something different than what has been our historical pattern. It is well documented that a lack of diverse participation in clinical research and trials is a national problem, where in most studies disproportionally engage white men and women more than any other race and ethnic group. For example, in a recent publication the authors found that 96% of prostate cancer research study participants are white men, in a disease in which black men have the highest incidence and mortality than any other race and ethnic group. National studies engage thousands of patients in clinical research, trials, registries and biobanks but on average have less than 20% of participants from underrepresented race and ethnic groups. This is a far cry from national representation of race and ethnic groups of color and has clear implications that in essence perpetuates the disparities we seek to reduce or eliminate. Lack of diversity in research participation limits our ability to accelerate research and improve population health more broadly. For example, it limits generalizability of findings from the development of effective therapeutics to dissemination and implementation of evidence-based methods to increase screening, treatment, and quality of care are critical, all critical points care points highlighted by COVID-19. It excludes or limits access to cutting edge and potentially life-saving therapies that may have the potential to ease the burden of disease and death for people of color. Essentially, access to clinical research and trials is a social justice and an equity issue and without deliberate and intentional diversity strategies being initiated as we develop and design studies, we are adding to the ongoing sickness and death or preventable diseases among people who are black and brown, this particularly true in the case of COVID 19, cancer and other chronic diseases. While diversity in clinical trials to improve population health and advance racial equity is critical, COVID 19 has presented added challenges and opportunities to address the lack of diversity in oncology clinical research, trials, and biobanking. The very nature of a pandemic requires rapid response, action with a heightened sense of urgency, and some would argue, fear of the unknown. Add these key factors to the well-known points that influence lack of diversity in clinical trials including race and ethnic minorities not being asked or informed about clinical trials, assumptions made by research teams that suggest implicit biases, lack of an overarching diversity strategy embedded in recruitment strategies, lack of accountability -despite the requirement to complete the minority enrollment table, and a paucity of authentic community and stakeholder partnerships that have the ability to build trust and bolster diversity in clinical research before, during and post the pandemic and across an array of diseases, the outcomes could seem dismal. However, addressing these key elements can yield invaluable outcomes, namely improved health and quality of life, preventing avoidable deaths, and equity. This presentation provides key recommendations to advance equity and move the needle in increasing diversity in oncology clinical research and trials, a national imperative.

Citation Format: Nadine J. Barrett. The Compelling Imperative to Diversify Participation in Clinical Trials and Research [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 IA02.

The Durham Initiative for Stomach Health (DISH): a pilot community-based Helicobacter pylori education and screening study

Background

Approximately 15% of all cancers are due to infection. The bacteria Helicobacter pylori is the single leading carcinogenic infectious agent and the main cause of stomach cancer. Prevalence of H. pylori, and, correspondingly, stomach cancer incidence and mortality, is significantly greater among African Americans than whites in the United States. In the present study, we conducted a pilot community-engaged H. pylori education and screening study in partnership with a predominantly African American church in Durham, North Carolina.

Methods

Initially, we consulted with community advisory boards and convened stakeholder meetings with local community members and primary care physicians. We then developed this pilot study through an iterative collaboration with church partners. Our main outcomes were feasibility and acceptability as measured by participation in a one-day H. pylori screening initiative, and participation in follow-up for those who tested positive. We also sought to determine prevalence and determinants of active H. pylori infection in this population.

Results

Community engagement informed the event logistics, messaging, educational materials provided, and follow-up plans. A total of 92 individuals participated in the primary study event, 25% of whom had a current H. pylori infection. Of those, 87% returned for the follow-up events, among whom 70% had successfully cleared their infection.

Conclusions

Through community engagement, community-based H. pylori screening and stomach cancer prevention is feasible and acceptable. This is a necessary step in order to move stomach cancer prevention forward to population-based precision H. pylori screening and eradication.

The Fierce Urgency of Now: Addressing Racial and Ethnic Disparities in Serious Illness Care

Racial and ethnic disparities in serious illness care are profound and require an urgent response. We present actionable recommendations for health care organizations, providers, and policymakers to address disparities and advance equity.

Abstract A080: Rates of Invitation, participation, and willingness to engage in medical and clinical research: Findings from attendees at two gender-specific community-based screening programs

Introduction: Community-based screening programs are associated with increased access to care, particularly for traditionally underserved people of color, the poor, and those who face barriers to health care and resources. The utility of health fairs to increase access to care by providing screenings and services that include accountable and clearly articulated follow-up plans can, in part, address health disparities. Interestingly, the same populations that community-based screening programs typically serve are grossly under-represented in medical and clinical research, including biospecimen donation. Lack of diversity in medical and clinical research, including clinical trials and biobanking, has significant consequences, including lack of generalizability to broader diverse communities and limiting access to potentially life-saving and risk-reducing research.

Methodology: Funded by the NCI (P30CA014236), the Duke Cancer Institute Office of Health Equity engaged community partners to conduct a population health assessment entitled Project PLACE (Population Level Approaches to Cancer Elimination). We collected 2,315 surveys of which 232 were respondents attending two gender-specific, community-based screening programs held in April 2017 and September 2017. We assessed access and participation in clinical research and biobanking, and likelihood to participate in medical research in the future among program attendees who completed the survey. We asked the following questions via self-administered pen and paper surveys: 1. Have you ever been asked to participate in a clinical trial or medical research? 2. Did you decide to participate in the clinical trial or medical research? 3. Have you ever been asked to donate bio specimens (blood, saliva, or other tissue) for the purpose of medical research? 4. Did you decide to donate the bio specimen? 5. How likely would you be to participate in medical research in the future?

Results: Two-hundred and thirty-two (232) respondents completed the survey questions related to research participation. Thirty percent of respondents have been asked to participate in clinical research in the past, of whom 22% did participate. Twenty percent (22%) of respondents have been asked to donate bio specimens for research, of whom 16% have donated. Fifty percent (50%) of respondents report that they would or are likely to participate in medical research in the future.

Conclusions: This study highlights community-based screening programs as a viable outlet to reach and engage participants in medical and clinical research. Of note, 50% of respondents who were primarily African American/Black are likely to participate in medical research in the future. Multiple factors including the longevity of the screening programs, and the quality of partnerships and engagement between the DCI and collaborating community organizations may also influence these outcomes.

Citation Format: Kearston L. Ingraham, Joan Packenham, Demetrius Harvey, Steven Patierno, Nadine J. Barrett. Rates of Invitation, participation, and willingness to engage in medical and clinical research: Findings from attendees at two gender-specific community-based screening programs [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr A080.

Abstract D010: Developing an inflammatory breast cancer campaign: Results from focus groups led by Komen scholars

Introduction: Breast cancer (BC) remains the second leading cause of cancer deaths amongst women worldwide. In the United States, African American and Latino women are disproportionately burdened by the incidence and mortality of BC compared with Caucasian women. Inflammatory breast cancer (IBC) is a rare and aggressive form of BC. African American women are more likely to be diagnosed with IBC and at earlier age compared to whites. IBC frequently lacks a breast lump and hence is difficult to detect. IBC is often diagnosed late at stage III or IV and has worse prognosis than non-IBC BC. Critically, awareness of IBC continues to lag education on other breast cancers. Lifesaving information and resources to reduce cancer risks are not widespread amongst minority populations. Community engagement is a valuable asset that enhances the traditional biomedical scientist’s knowledge in understanding the connection between biological and social factors affecting a particular disease, with the goal of addressing, and ultimately diminishing, BC health disparities. Methods: The purpose of the focus groups were to determine the best methods and messages for community outreach to raise awareness about IBC. To follow up on our initial listening session at the 4th Annual Women’s Health Awareness Day at NCCU, several focus groups were engaged, each with 10-12 participants from various gender, racial, and economic demographics, recruited from the Raleigh and Durham communities. Participants were provided informed consent forms and demographic surveys to complete. With guidance and training from the Komen mentoring team, trainees crafted a marketing plan and focus group session guide. Trainees served as session moderators and note-takers and developed summary reports which highlighted themes from the sessions which included the following topics: knowledge of IBC, best methods for sharing health information, types of messages to raise awareness and promote action, and perceived barriers to breast cancer screening. Results: Information gathered from the focus group sessions provides a unique perspective to strategize and develop marketing campaigns to bring awareness to the community and minority populations in the community. Many participants were unfamiliar with IBC, how it is diagnosed, and treatment options. To better raise awareness about IBC, participants recommended the use of various social media platforms, promoting more one-on-one education, patient self-advocacy sessions, and changing the perception of the presence of lumps as an indicator of BC. Conclusion: Cancer incidence and mortality overall are declining in all groups in the United States; however, minority groups continue to suffer with increased risk of developing or dying from BC. Furthermore, there is a significant need to raise awareness and understanding of IBC in diverse communities. Partnerships between the community and researchers will facilitate the development of relevant and accessible information about IBC.

Citation Format: Portia L Andrews, Alanna Burwell, Maria S Dixon, Hamzah Kharabsheh, Dana M Gant, Tia A Tate, Hassan Shehata, Jodie M Fleming, Kearston L Ingraham, Seronda A Robinson, Nadine J Barrett, Kevin P Williams. Developing an inflammatory breast cancer campaign: Results from focus groups led by Komen scholars [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 D010.

Abstract B071: Genomic differences between non-small cell lung cancer (NSCLC) in African American and white patients

Background: Racial disparities in lung cancer exist, as African Americans (AAs) have the highest incidence of lung cancer and rate of lung cancer-related death and develop lung cancer at an earlier age compared with other racial groups. Multiple structural determinants of health affect poorer survival in AAs. In addition, evidence suggests that differences in tumor biology also contribute to disparities in clinical outcomes. This work addresses the urgent need to define further the molecular landscape of non-small cell lung cancer (NSCLC) in the AA population in order to drive novel biomarker and therapeutic development and ultimately improve clinical outcomes.

Methods: We have analyzed differentially expressed genes (DEGs) and differentially spliced genes (DSGs) between resected formalin-fixed, paraffin-embedded lung squamous cell carcinoma specimens from 20 AA and 20 white patients (self-reported race) using Affymetrix Clariom D Assay, human and Transcriptome Analysis Console Software. To obtain genetically estimated indicators of race, we performed ancestral genotyping. After excluding specimens from biracial patients and those with positive versus negative area under the curve less than 0.6, we used a cohort of 14 specimens from AA patients and 13 specimens from white patients for analysis.

Results: Transcriptome analysis revealed 450 DEGs and 7,089 DSGs, in which we identified 13,763 unique splicing events, between NSCLC in AA and white patients. The nuclear receptors meta pathway and the olfactory receptor pathway are over-represented with such DEGs. Seven of the DEGs also exhibit differential expression between lung squamous cell carcinoma in AA and white patients in The Cancer Genome Atlas (TCGA). Twenty-eight of the DEGs also exhibit differential expression between prostate cancer in AA and white patients. Among the 7,089 DSGs between NSCLC in AA and white patients, 599 also exhibit differential splicing between prostate cancer in AA and white patients, 33 also exhibit differential splicing in breast and liver cancer, and 6 also exhibit differential splicing in breast, liver and prostate cancer. Validation of prioritized genomic differences using polymerase chain reaction and investigation of the functional significance of prioritized genomic differences to lung cancer cell biology using CRISPR-Cas9 technology is currently under way.

Conclusions: This study identifies novel aggregate gene expression and splicing differences between NSCLC in AA and white patients. Interestingly, the number of DSGs far exceeds the number of DEGs in the same tissues and a number of DEGs and DSGs exhibit differential aggregate gene expression and splicing, respectively, in additional solid tumor types. Upon further study, these mechanisms have the potential to serve as novel targets for the development of biomarkers or therapeutic agents for lung cancer, and to reduce the mortality burden from lung cancer among AAs.

Citation Format: April E. Deveaux, Dadong Zhang, Muthana Al Abo, Nadine J. Barrett, Rick A. Kittles, Kouros Owzar, Shannon J. McCall, Jeffrey Crawford, Steven R. Patierno, Jeffrey M. Clarke, Jennifer A. Freedman. Genomic differences between non-small cell lung cancer (NSCLC) in African American and white patients [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr B071.

Abstract A038: Current unmet needs in inflammatory breast cancer/IBC patient care: Analysis of open-ended responses from a community engagement session of clinicians, researchers, advocates, and patients at the Duke Consortium for IBC conference

Introduction: Inflammatory breast cancer (IBC) is an understudied and aggressive breast cancer subtype, accounting for 7-10% of all breast cancer-related deaths in the United States. IBC is more common among African American (AA) women, who also develop higher rates of treatment resistance when compared to other races and survival rates are lower after adjusting for nonbiologic and socioeconomic factors. IBC typically lacks a clinically apparent tumor mass, leading to misdiagnoses and treatment delays. There is little research on the IBC patient perspective regarding quality of care, cost, or side effects of therapy.

Methodology: In order to address critical needs in IBC clinical care and outreach across North Carolina and nationally, the Duke Consortium for IBC organized an interactive community engagement session. Attendees (n=174) at the local and national level included patients, advocates, NC government representatives and stakeholders (28%), health care providers (15%), staff (15%), academic research and clinical faculty from local universities and national IBC centers/laboratories (13%), trainees (9%), and other (16%). Facilitated small groups (3-8) discussed open-ended questions related to 1) gaps preventing timely diagnosis and treatment, 2) advocacy and grassroot programs, and 3) integrating research and outreach. Representative patients and facilitators/community partners were also contacted post-meeting for in-depth responses. All notes were recorded and thematic analysis using NVivo 12 Pro qualitative software was performed by three independent researchers. Grounded theory shaped both design and analysis.

Results: A total of 506 unique responses were recorded and six major themes were identified: barriers to care (57.7%), education (16.4%), outreach/awareness (43.3%), fundraising (6.3%), legislative process/priorities (1.4%), and “other” (3.0%). Within those themes, three topics emerged: a) provider education, b) barriers to diagnostic and/or treatment delays, and c) raising awareness of IBC and late disease breast cancer in communities.

Conclusions: This is the first report, to our knowledge, of a community engagement session and focused interviews that included clinicians, researchers, and patients/community stakeholders to address the unique needs and challenges for IBC patients. The study highlights the critical need to address lack of education around IBC at the provider and hospital level, and the need for better interaction with academic medical centers. Because treatment can be lengthy, social determinants, such as low socioeconomic status, may play an even larger role in patients with IBC. There is also a need for observational data on where knowledge gaps exist among providers and how missed diagnoses impact the patient in order to design improved interventions.

Funding in part to GRD from Duke (SOM-Interdisciplinary-Colloquium, Surgery, Pathology, Medicine, Cancer Institute); IBC Network Foundation; 1P20-CA202925-01A12- Projects (GRD, NB).

Citation Format: Gayathri R. Devi, Whitney Lane, Holly J. Hough, Kearston L. Ingraham, Larisa Gearhart, Nadine J. Barrett. Current unmet needs in inflammatory breast cancer/IBC patient care: Analysis of open-ended responses from a community engagement session of clinicians, researchers, advocates, and patients at the Duke Consortium for IBC conference [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr A038.

Abstract A023: Results from a town hall meeting: Inflammatory breast cancer listening session led by KOMEN scholars

Introduction: Cancer is the leading cause of death in North Carolina. While the incidence rate of breast cancer (BC) is higher in White women, African American and Latino women are more likely to die from BC than White women. Moreover, inflammatory breast cancer (IBC) is a rare and aggressive form of BC, and African Americans are more likely to be diagnosed with IBC compared to whites, have poor BC outcomes, and generally are less likely to get life-saving information and resources to reduce cancer risks. Additionally, work is needed to improve diagnosis rates and decrease time to treatment for IBC patients. Translational research scientists do not get exposure to community engagement opportunities that can add to their knowledge of the research spectrum around a particular disease. Engaging new researchers in this arena can add to addressing cancer disparities research.

Methods: An IBC listening session was conducted during the annual Women's Health Awareness Day conference sponsored by the National Institute of Environmental Health Sciences and North Carolina Central University. The session was developed by KOMEN translational health disparities researchers as part of their enhanced community engagement training program. Scholars created the marketing plan and listening session guide for the program with guidance and training from staff experts. Scholars were note takers, facilitators, and created summary reports that highlighted guiding questions for the session, which included the following questions: 1)What do you know about BC? 2) Are you aware of different types of breast cancers? 3) Have you heard of IBC? 4) How aware do you think people in your community are about BC and IBC? 5) Where do you get your information about BC and IBC? 6) What are ways we should educate the community with getting information on how to become aware about the signs and symptoms of IBC?

Results: There were 49 African American and Latina participants. Only 15 of 49 attendees had heard of IBC. Most women were aware of causes and symptoms of breast cancer; however, there was a lack of awareness around IBC. Those aware of IBC learned about it from their coworkers, doctors, or had family members die from the disease. Participants recommended more one-on-one education, patient self-advocacy sessions, making education and awareness available online, changing breast cancer communication to include IBC symptoms, and letting people know that you can have breast cancer without the presence of lumps.

Conclusion: Poor awareness, communication, and education around inflammatory breast cancer risk factors were substantial. There is significant need to raise awareness in diverse communities about inflammatory breast cancer risks, screening guidelines, diagnosis, and treatment options. Community-engaged research lead by under-represented researcher scholars in training can add to the translational research training experience.

Citation Format: Maria Dixion, Kearston L. Ingraham, Seronda A. Robinson, Jodie M. Fleming, Gayathri R. Devi, Holly Hough, Hamzah Kharabsheh, Dana M. Austin, Tia A. Tate, Artis Woodard, Joshua Alexander, Joan P. Packenham, Nadine J. Barrett, Kevin P. Williams. Results from a town hall meeting: Inflammatory breast cancer listening session led by KOMEN scholars [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr A023.

Abstract IA18: North Carolina Central University and Duke Cancer Institute's collaborative cancer research and education program: Connecting cancer disparities translational research, clinical trials operations, and community engagement

Three interrelated contributors to cancer disparities include the lack of diversity among investigators contributing to cancer research, the deficiency of minority participation in clinical trials and bio-banking, and the need to advance community engagement as a vital component of the translational research spectrum. The North Carolina Central University and Duke Cancer Institute's Cancer Disparities Translational Research Partnership (NCCU-DCI CDTRP) (P20 PACHE), through its Cancer Research and Education Program (C-REP), provides a Translational Immersion Experience (TIE) that spans the full translational research spectrum, for traditionally under-represented PhD students, postdoctoral fellows, and early-stage investigators. The goals of TIE are to (1) provide cancer disparities research training with an emphasis on translational laboratory science including high-throughput screening/drug discovery, (2) equip trainees with unique training and education in the operational infrastructure that supports clinical research and trials, (3) highlight strategies to increase diverse participation in clinical trials and bio banking, and (4) learn and apply principles of community engagement through community-based programs and outreach. Using multimodal training techniques, the TIE program provides training and education in real-life settings that expose trainees to the full translational research spectrum across two diseases that disproportionality affect African Americans at significantly higher rates, prostate cancer and inflammatory breast cancer. The overarching goal is to bolster our trainees' experiences and training to contribute to innovative technologies and discoveries and provide access to training that spans beyond the traditional curriculum in areas of high need in translational cancer disparities research such as minority accrual and clinical trials operations. The program includes evidence-based workshops in healthy mentor-mentee relationships, building and sustaining resilience, and sharpening grantwriting skills coupled with ongoing external evaluation to provide real-time feedback on the program. We present the preliminary evaluation data based on the first cohort of the C-REP TIE program.

Citation Format: Kevin P. Williams, Nadine J. Barrett, Carla E. Oldham, Holly Hough, Artis Woodard, Jennifer Freedman, Gayathri R. Devi, Steven R. Patierno. North Carolina Central University and Duke Cancer Institute's collaborative cancer research and education program: Connecting cancer disparities translational research, clinical trials operations, and community engagement [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr IA18.

Project PLACE: Enhancing community and academic partnerships to describe and address health disparities

Achieving cancer health equity is a national imperative. Cancer is the second leading cause of death in the United States and in North Carolina (NC), where the disease disproportionately impacts traditionally underrepresented race and ethnic groups, those who live in rural communities, the impoverished, and medically disenfranchised and/or health-disparate populations at high-risk for cancer. These populations have worse cancer outcomes and are less likely to be participants in clinical research and trials. It is critical for cancer centers and other academic health centers to understand the factors that contribute to poor cancer outcomes, the extent to which they impact the cancer burden, and develop effective interventions to address them. Key to this process is engaging diverse stakeholders in the development and execution of community and population health assessments, and the subsequent programs and interventions designed to address the need across the catchment area. This chapter describes the processes and lessons learned of the Duke Cancer Institute's (DCI) long standing community partnerships that led to Project PLACE (Population Level Approaches to Cancer Elimination), a National Cancer Institute (NCI)-funded community health assessment reaching 2315 respondents in 7 months, resulting in a community partnered research agenda to advance cancer equity within the DCI catchment area. We illustrate the application of a community partnered health assessment and offer examples of strategic opportunities, successes, lessons learned, and implications for practice.

Evolution of a longitudinal, multidisciplinary, and scalable patient navigation matrix model

This Longitudinal patient navigation Matrix Model was developed to overcome barriers across the cancer care continuum by offering prepatients, patients, and their families with support services. The extraordinary heterogeneity of patient needs during cancer screening, risk assessment, treatment, and survivorship as well as the vast heterogeneity of oncology care settings make it nearly impossible to follow a static navigation model. Our model of patient cancer navigation is unique as it enhances the traditional model by being highly adaptable based on both patient and family needs and scalable based on institutional needs and resources (eg, clinical volumes, financial resources, and community‐based resources). This relatively new operational model for system‐wide and systematic navigation incorporates a carefully cultivated supportive care program that evolved over the last decade from a bottom up approach that identified patient and family needs and developed appropriate resources. A core component of this model includes shifting away from department‐centric operations. This model does not require a patient to opt in or independently be able to report their needs or ask for services—it is an opt out model. The multidisciplinary “cross‐training” model can also facilitate reimbursement and sustainability by clarifying the differentiating actions that define navigation services: identification of barriers to quality care and specific actions taken to overcome those barriers, across the full continue of cancer care from community engagement to survivorship or end‐of‐life care.

Regulation of iron homeostasis through the erythroferrone-hepcidin axis in sickle cell disease

Sickle cell disease (SCD) has a distinct pattern of transfusional iron overload (IO) when compared to transfusion-dependent β-thalassaemia major (TDT). We conducted a single institution prospective study to evaluate plasma biomarkers of iron regulation and inflammation in patients with SCD with IO (SCD IO cases, n = 22) and without IO (SCD non-IO cases, n = 11), and non-SCD controls (n = 13). Hepcidin was found to be inappropriately low, as evidenced by a significantly higher median hepcidin/ferritin ratio in non-SCD controls compared to SCD IO cases (0·3 vs. 0·02, P < 0·0001) and SCD non-IO cases (0·3 vs. 0·02, P < 0·0001), suggesting that certain inhibitory mechanism (s) work to suppress hepcidin in SCD. As opposed to the SCD non-IO state, where hepcidin shows a strong significant positive correlation with ferritin (Spearman ρ = 0·7, P = 0·02), this correlation was lost when IO occurs (Spearman ρ = -0·2, P = 0·4). Although a direct non-linear correlation between erythroferrone (ERFE) and hepcidin did not reach statistical significance both in the IO (Spearman ρ = -0·4, P = 0·08) and non-IO state (Spearman ρ = -0·6, P = 0·07), patients with highest ERFE had low hepcidin levels, suggesting that ERFE contributes to hepcidin regulation in some patients. Our results suggest a multifactorial mechanism of hepcidin regulation in SCD.

Factors associated with biomedical research participation within community-based samples across 3 National Cancer Institute-designated cancer centers

BACKGROUND

Engaging diverse populations in biomedical research, including biospecimen donation, remains a national challenge. This study examined factors associated with an invitation to participate in biomedical research, intent to participate in biomedical research in the future, and participation in biomedical research and biospecimen donation among a diverse, multilingual, community-based sample across 3 distinct geographic areas.

METHODS

Three National Cancer Institute-designated cancer centers engaged in community partnerships to develop and implement population health assessments, reaching a convenience sample of 4343 participants spanning their respective catchment areas. Data harmonization, multiple imputation, and multivariable logistic modeling were used.

RESULTS

African Americans, Hispanic/Latinos, and other racial minority groups were more likely to be offered opportunities to participate in biomedical research compared to whites. Access to care, history of cancer, educational level, survey language, nativity, and rural residence also influenced opportunity, intent, and actual participation in biomedical research.

CONCLUSIONS

Traditionally underserved racial and ethnic groups reported heightened opportunity and interest in participating in biomedical research. Well-established community partnerships and long-standing community engagement around biomedical research led to a diverse sample being reached at each site and may in part explain the current study findings. However, this study illustrates an ongoing need to establish trust and diversify biomedical research participation through innovative and tailored approaches. National Cancer Institute-designated cancer centers have the potential to increase opportunities for diverse participation in biomedical research through community partnerships and engagement. Additional work remains to identify and address system-level and individual-level barriers to participation in both clinical trials and biospecimen donation for research.

Effect of Cultural, Folk, and Religious Beliefs and Practices on Delays in Diagnosis of Ovarian Cancer in African American Women

BACKGROUND

Certain cultural, folk, and religious beliefs that are more common among African Americans (AAs) have been associated with later-stage breast cancer. It is unknown if these beliefs are similarly associated with delays in diagnosis of ovarian cancer.

METHODS

Data from a multicenter case-control study of ovarian cancer in AA women were used to examine associations between cultural/folk beliefs and religious practices and stage at diagnosis and symptom duration before diagnosis. Associations between cultural/folk beliefs or religious practices and stage at diagnosis were assessed with logistic regression analyses, and associations with symptom duration with linear regression analyses.

RESULTS

Agreement with several of the cultural/folk belief statements was high (e.g., 40% agreed that "if a person prays about cancer, God will heal it without medical treatments"), and ∼90% of women expressed moderate to high levels of religiosity/spirituality. Higher levels of religiosity/spirituality were associated with a twofold increase in the odds of stage III-IV ovarian cancer, whereas agreement with the cultural/folk belief statements was not associated with stage. Symptom duration before diagnosis was not consistently associated with cultural/folk beliefs or religiosity/spirituality.

CONCLUSIONS

Women who reported stronger religious beliefs or practices had increased odds of higher stage ovarian cancer. Inaccurate cultural/folk beliefs about cancer treament were not associated with stage; however, these beliefs were highly prevalent in our population and could impact patient treatment decisions. Our findings suggest opportunities for health education interventions, especially working with churches, and improved doctor-patient communication.

Abstract B18: Attitudes, perceptions, and strategies toward increasing cancer screening, treatment, and participation in research among Latinos

Background: Nationally, cancer disparities negatively impact minority communities at alarming rates. Minorities have low rates of cancer screenings compared to white counterparts, resulting in Latinos having poor cancer outcomes in lung, colon, breast, and prostate cancers. Previous studies have examined race/ethnic cancer disparities, yet improved health outcomes are lagging in the Latino community. We assessed perceptions and recommendations to improving cancer screenings, treatment, research participation, and survivorship within the Latino community as part of the codevelopment of a health-equity agenda around cancer services and research at the Duke Cancer Institute.

Methods: We conducted five 90-minute focus groups reaching a total of 51 members of the Latino community, including clergy, community members, survivors, caregivers, and local leaders, to identify the barriers and facilitators to engaging the Latino community in cancer services and research. Data were recorded and analyzed using Atlas Ti Software.

Results: Barriers to cancer screenings and treatment included affordability of care, lack of health insurance or other financial resources, lack of knowing when to seek screenings, poor patient provider communication, treatment and options seem to be different based on insurance and/or immigration status, language barriers, machismo, stigma and fear of a cancer diagnosis, long wait times, and excessive and unclear paperwork when seeking cancer screening and treatment services. Participation in clinical trials and research was considered limited due to lack of outreach, education, and full engagement with the Latino community around research. Key strategies include engaging families and communities to increase community's knowledge and access to prevention, screenings, and available treatment options, including clinical trials. Develop partnerships with Latino faith-based and serving organizations to extend services and education about cancer screenings and research. Have services more accessible and culturally responsive to promote screening and timely follow-up, and incorporate staff and lay community leaders to promote awareness and participation in research.

Conclusion: Developing sustainable and equitable collaborations and partnerships between the cancer center and the Latino community to increase access to education, screening, treatment, and research is critical to addressing longstanding cancer disparities. There are key community-derived opportunities to incorporate culturally tailored community programs designed to ensure the Latino community and patients gain access to quality, culturally responsive health care and research. Ongoing outreach and education across the cancer continuum needs to reflect and respond to the values and perspectives of the Latino community. Leveraging the family and the community strengths to address the need and build capacity to fully engage in clinical services and research has the potential to yield better cancer outcomes. Likewise, heightened education and training opportunities are needed to engage the Latino community in oncology research and clinical trials from idea generation to full participation to effectively improve community and population health and decrease cancer disparities.

Citation Format: Nadine J. Barrett, Kearston L. Ingraham, Xiomara Boyce, Rebecca Reyes. Attitudes, perceptions, and strategies toward increasing cancer screening, treatment, and participation in research among Latinos [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr B18.

Engaging African Americans in Research: The Recruiter's Perspective

Purpose

To examine barriers recruiters encounter when enrolling African American study participants, identify motivating factors to increase research participation, and provide recommendations to facilitate successful minority recruitment.

Background

Recruiters are often the first point of contact between the research study and potential African American participants. While challenges in enrolling African Americans into clinical and epidemiologic research has been reported in numerous studies the non-physician recruiter's role as a determinant of overall participation rates has received minimal attention.

Methods

We conducted four 90-minute teleconference focus groups with 18 recruiters experienced in enrolling African Americans for clinical and epidemiologic studies at five academic/medical institutions. Participants represented diverse racial and ethnic backgrounds and were asked to reflect on barriers preventing African Americans from participating in research studies, factors that motivated participation, and recommendations to increase participation of African Americans in research. Multi-coder and thematic data analysis was implemented using the Braun and Clarke method.

Results

Prominent concerns in recruitment of African Americans in research include fear and mistrust and inflexible research protocols. The participants suggest that improved recruitment could be achieved through cross-cultural and skillset building training opportunities for recruiters, greater community engagement among researchers, and better engagement with clinic staff and research teams.

Connecting Mentally Ill Detainees in Large Urban Jails with Community Care

Large urban jails have become a collection point for many persons with severe mental illness. Connections between jail and community mental health services are needed to assure in-jail care and to promote successful community living following release. This paper addresses this issue for 2855 individuals with severe mental illness who received community mental health services prior to jail detention in King County (Seattle), Washington over a 5-year time period using a unique linked administrative data source. Logistic regression was used to determine the probability that a detainee with severe mental illness received mental health services while in jail as a function of demographic and clinical characteristics. Overall, 70 % of persons with severe mental illness did receive in-jail mental health treatment. Small, but statistically significant sex and race differences were observed in who received treatment in the jail psychiatric unit or from the jail infirmary. Findings confirm the jail's central role in mental health treatment and emphasize the need for greater information sharing and collaboration with community mental health agencies to minimize jail use and to facilitate successful community reentry for detainees with severe mental illness.

Abstract A43: Barriers, strategies, and recommendations to engaging African American women in clinical research: The recruiter's perspective

The Purpose: The purpose of this study was to systematically gather information on the barriers interviewers encounter when recruiting African American women (AAW) study participants, identify approaches that increase the likelihood that an individual will agree to participate, and describe the resources and support that interviewers believe is important for them to be successful.

Background: The challenge of recruiting African Americans for clinical and epidemiologic research have been presented in numerous papers, with some focusing on patient/community perceptions (Herring, 2004; Corbie-Smith, 1999; Scharff, 2010) and others focusing on the perspective of the investigator. One viewpoint that has received relatively little attention is the role of the recruiter or interviewer. These individuals are often the first point of contact between the research study and the potential participant, and they may be a prime determinant of overall participation rates. Although some papers have examined the association between participation rates and interviewer characteristics such as race, age and years of experience, (Hansen, 2006; Davis 2010; Moorman, 1999) these papers have not solicited the input and opinions of the interviewers. There is little in the scientific literature about barriers to participation and strategies for improving response rates from the perspective of the interviewer.

Methods: To address this gap in knowledge, we conducted a series of focus groups with interviewers experienced in recruiting African American women for observational epidemiologic studies, including case-control and prospective cohort studies. Focus groups were conducted reaching 18 recruiters from three research intensive academic/medical institutions along the east coast and the Midwest. Sessions were conducted via 90 minute recorded conference calls and a $10 incentive was provided to each participant. Study approval was obtained through the University's IRB.

The following questions guided the focus groups: (1) What barriers do you hear and face when recruiting AAW into research? (2) What strategies have you used to overcome challenges associated with recruiting AAW in research studies? (3) What resources, tools, and skills would you find helpful so as to more effectively recruit AAW in research? Recordings were transcribed and a thematic analysis of the data was implemented using a systematic, multistep, rigorous process outlined by Braun and Clarke (2006).

Summary of Data: Commonly cited barriers to research participation among AAW include “the gatekeeper,” maintaining confidentiality, lack of community engagement among researchers, requesting bio specimens, and lack of buy-in among clinic staff. As with other studies, research participation among AAW included fear of being a guinea pig, historical medical atrocities, fear and distrust of the medical system, and competing priorities. Key strategies often used to address barriers and increase enrollment include being open about the historical relationship between research and minorities, emphasize the voluntary role, treat potential and current enrollees as a “whole” person, address competing needs with resources, be flexible with protocol, specimen requests, and schedules. Unique recommendations include highlighting the importance of system and research team engagement by understanding clinic culture and increasing researcher's engagement within local minority communities. Consistent with the literature, other cited recommendations to improve enrollment include training around building rapport, understanding bias, cultural competence, and role play with significant feedback on the nuances to consider when engaging minorities in clinical research.

Conclusion: The strategies and recommendations gleaned from front line recruiting personnel have significant policy and practice implications. These findings will inform training and interventions designed to more effectively support research teams as they aim to reach, enroll, and retain African American women and other minorities in clinical research.

Citation Format: Nadine J. Barrett, Patricia Moorman, Tracey Vann Hawkins, Chamali Wickramasekara. Barriers, strategies, and recommendations to engaging African American women in clinical research: The recruiter's perspective. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr A43.

Microbiological safety of sandwiches from hospitals and other health care establishments in the United Kingdom with a focus on Listeria monocytogenes and other Listeria species

In the United Kingdom between 1999 and 2004, there were four outbreaks of Listeria monocytogenes infection associated with sandwiches purchased from or provided in hospitals. Elderly or immunocompromised individuals and pregnant women are particularly vulnerable to infection; therefore, the focus of this study was on sandwiches served in health care establishments. Of 3,249 sandwich samples collected between April 2005 and March 2006, 3.3% were of unsatisfactory microbiological quality because of high levels of Enterobacteriaceae (2.0%; > or = 10(4) CFU/g for sandwiches not containing salad), Escherichia coli (0.8%; > or = 10(2) CFU/g), Staphylococcus aureus (0.6%; > or = 10(2) CFU/g), and/or Listeria spp. (0.1%; two samples with L. welshimeri at 1.8 x 10(2) and 7.4 x 10(3) CFU/g and one sample with L. seeligeri at 1.8 x 10(3) CFU/g). Overall, 7.6% of sandwiches were contaminated with Listeria spp. L. monocytogenes was detected in 2.7% (88) of samples: 87 samples at < 10 CFU/g and 1 sample at 20 CFU/g. More frequent contamination with Listeria spp. and L. monocytogenes was found in sandwiches collected from hospital cafeterias, shops, or wards and in sandwiches stored and/or displayed at temperatures higher than 8 degrees C. The presence of Listeria spp. and L. monocytogenes also was associated with sandwiches that (i) were supplied from outside the establishment, (ii) were prepacked, (iii) had a main sandwich filling of poultry meat, or (iv) contained salad ingredients, soft cheese, and/or mayonnaise. Control of L. monocytogenes in sandwich manufacturing and within health care establishments is essential to minimize the potential for consumption of this bacterium at levels hazardous to health. The findings from this study support the proposal that manufacturers supplying sandwiches to health care establishments should follow the British Sandwich Association recommended guidelines of complete absence of L. monocytogenes in sandwiches at the point of production.

Farm visits and zoonoses

Recent reports of outbreaks of gastrointestinal illness, such as cryptosporidiosis, associated with visits to farms have drawn attention to the possible risks of acquiring zoonotic infections through contact with farm animals. These risks seem to be small, but it is important that people who work in urban and rural farms, and such establishments as animal sanctuaries where the general public can come into close contact with farm livestock and other animals, should be alerted to the simple precautions needed to prevent transmission of infections.

Toxoplasmosis in England and Wales 1981 to 1992

We have examined laboratory reports of toxoplasmosis received by the PHLS Communicable Disease Surveillance Centre between January 1981 and December 1992 in order to describe epidemiological trends in the three main clinical manifestations of toxoplasmosis-lymphadenopathy, eye disease, and neurological disease; and the two most important risk groups-fetuses and people whose immunity is impaired. The total numbers of reports each year did not change significantly between 1981 and 1992 and were similar to the numbers between 1976 and 1980, but different trends emerged in each subgroup. Reports of acute lymphadenopathic toxoplasmosis declined in children and young adults and eye disease associated with toxoplasmosis fell markedly in all age groups. Reports of neurological disease and severe toxoplasmosis complicating impaired immunity, due mainly to HIV infection or transplant surgery, rose. Reports of infections diagnosed in pregnancy rose steeply in the late 1980s although reports of congenital toxoplasmosis were no more common than in 1975 to 1980. Reports of acute toxoplasmosis came mainly from southern England. The emergence of these diverse trends from apparently unchanging totals emphasises the importance of surveillance systems capable of discrimination.

Increasing incidence of cryptococcosis in the United Kingdom

The incidence of infection with Cryptococcus neoformans in the United Kingdom during the years between 1953 and 1981 is compared with that between 1982 and 1991. The patients were those from whom samples were submitted to the PHLS Mycological Reference Laboratory (MRL), or those in whom the disease was confirmed elsewhere in the United Kingdom and reported to PHLS Communicable Disease Surveillance Centre (CDSC). In all, 83 cases were identified between 1953 and 1981 and 322 between 1982 and 1991, 201 of which were known to be HIV-associated. The incidence of infection with Cryptococcus neoformans has increased four-fold in the last decade. It is an increasing cause of infection in immunosuppressed patients, most notably those with HIV infection. Currently, 4.0% patients with AIDS in the United Kingdom are known to have developed cryptococcosis.

The resurgence of scabies

The prevalence of scabies infection shows a cyclical pattern with a periodicity of 10-30 years. Various sources indicate that a major increase has been underway since 1991 and CDSC has received several reports of outbreaks in schools, hospitals and nursing homes in recent months. This brief review outlines the clinical features, diagnosis, epidemiology and management of this time-honoured infection.

A case of intracerebral air embolism secondary to the insertion of a Hickman line

Complications following the insertion of intravenous catheters are relatively uncommon. We report a potentially serious, hitherto unrecognized complication of Hickman line insertion, and discuss the condition.

Communicable disease associated with milk and dairy products in England and Wales: 1983-1984

During the period 1983-1984 32 outbreaks of disease (II in 1983 and 21 in 1984) associated with consumption of milk and dairy products and affecting at least 714 people were reported from England and Wales. Twenty-seven of the outbreaks were attributed to raw milk, two to contaminated pasteurised milk and one each to cheese, cream and ice-cream. Twenty-two were due to salmonellas, seven to campylobacters and one each to Staphylococcus aureus, Yersinia enterocolitica and Streptococcus zooepidemicus. Two sporadic cases of Corynebacterium ulcerans infection associated with raw milk were also reported. There were eight deaths, all associated with the S. zooepidemicus outbreak. The continuing occurrence of milk-borne outbreaks, and an increasing number of incidents affecting rural communities, emphasises the urgent need for enforcing pasteurisation of milk and dairy products in England and Wales.

Pasteurisation and the control of milkborne infection in Britain

Infections carried in milk, particularly salmonellosis and campylobacter enteritis, have continued to feature in Great Britain in recent years. Less commonly reported infections included an outbreak in 1984 in England due to Streptococcus zooepidemicus, in which 12 people, eight of whom died, were admitted to hospital. The implementation of legislation in 1983 requiring heat treatment of cows' milk for sale to the public reduced the incidence of milkborne infection in Scotland compared with previous years and compared with England and Wales, where, without legislative control, outbreaks continue to occur. Until compulsory pasteurisation is introduced throughout Britain and dairy farming communities can be persuaded to drink only heat treated milk outbreaks of milkborne infection will continue.

Isolation, fractionation and partial characterization of the tegumental surface from protoscoleces of the hydatid organism, Echinococcus granulosus

Several approaches were adopted for the disruption and removal of the tegumental surface from protoscoleces of the horse strain of the hydatid organism, Echinococcus granulosus. The effectiveness of each method and the purity of subsequent microthrix-enriched fractions obtained by differential centrifugation were evaluated by electron microscopy, by the amount of protein released and by the degree of enrichment of surface plasma membrane marker enzymes. Incubation in saponin for 10 min produced the purest microtriche preparation, but in low yield; freeze/thawing, incubation in Triton X-100 for 10 min or in saponin for 20 min produced fractions containing significant amounts of relatively pure microtriches, but mild homogenization was a poor method for surface disruption and subsequent isolation of microtriches. Phosphodiesterase, adenosine triphosphatase (total and ouabain-inhibited), leucine aminopeptidase and glutamyltransferase were active in the protoscoleces but none were enriched in any of the microthrix fractions. In contrast, alkaline phosphatase, acid phosphatase, 5' nucleotidase and maltase were enriched significantly in all of the isolated microtriche preparations, which suggests that these enzymes are predominantly surface membrane bound. The protein profiles of the microthrix-enriched fractions, following SDS-PAGE, were basically similar, although there were some qualitative and quantitative differences in the proteins released by each isolation procedure. Three major PAS-staining components were present in all the preparations and these probably originated from the glycocalyx. One of these PAS-positive components, with an approximate molecular weight of 110 kDa, may be a glycoprotein specific to the horse strain of E. granulosus.

Procedures for testing the viability of human hydatid cysts following surgical removal, especially after chemotherapy

The basic problems involved in assessing the viability of hydatid material following surgical removal from human cases are outlined and the use of enzyme digestion techniques is shown to provide a rapid and relatively simple diagnostic procedure. The method is described in detail and examples of its practicability are cited. Infection in laboratory animals provides a back-up diagnostic procedure but cyst development in them is too slow to be of value for most clinical work.