Moderators of the effects of perceived racism and discrimination on cancer-related health behaviors among two samples of African Americans

BACKGROUND

Assumptions regarding within-race variation in the associations between measures of discrimination racism and health-related behaviors among African Americans have been largely unexplored.

METHODS

We conducted secondary analyses of two studies to examine support for a model which describes several theoretical moderators of the effects of discrimination and racism on health behaviors. The first study examined the effects of group-based behavioral information and racial identity on the association between perceived racism and requests for at home colorectal cancer screening tests among a sample of 205 geographically diverse African Americans who participated in an online experiment from 2019 to 2020.

RESULTS

Group-based behavioral information attenuated the association between perceived racism and requests for at-home screening kit. In the absence of group-based behavioral information, perceived racism was positively associated with screening kit requests for African Americans with weaker racial identity and negatively associated with requests for African Americans with stronger racial identity. The second study examined the influence of personal and group-based perceived discrimination, and behavior-relevant affective information related to a breast cancer risk notification, on 89 Michigan dwelling African American women's self-reported physician communication from 2015 to 2016. Results showed that perceived group-based discrimination was positively associated with physician communication in the absence of negative affective information, and perceived personal discrimination was negatively associated with physician communication as positive affective information increased.

CONCLUSIONS

Together, these results support our theoretical model highlighting variation in the effects of discrimination and racism on health behaviors among African Americans, and indicates group-relevant behavioral information, racial identity, behavior relevant affective information, and target of discrimination as moderators of the effect. Implications for conceptualizing the effects of racism and discrimination and for examining racially targeted interventions are discussed.

Addressing multilevel barriers to clinical trial participation among Black and White men with prostate cancer through the PACCT study

BACKGROUND

Cancer clinical trial participation is low and inequitable. Partnering Around Cancer Clinical Trials (PACCT) addressed systemic and interpersonal barriers through an observational study of eligibility and an intervention to improve patient-physician communication and trial invitation rates.

METHODS

Physicians at two comprehensive cancer centers and Black and White men with prostate cancer participated. Patients were followed for 2 years to determine whether they became potentially eligible for an available therapeutic trial. Potentially eligible patients were randomized to receive a trials-focused Question Prompt List or usual care. Patient-physician interactions were video-recorded. Outcomes included communication quality and trial invitation rates. Descriptive analyses assessed associations between sociodemographic characteristics and eligibility and effects of the intervention on outcomes.

RESULTS

Only 44 (22.1%) of participating patients (n = 199) became potentially eligible for an available clinical trial. Patients with higher incomes were more often eligible (>$80,000 vs. <$40,000, adjusted OR = 6.06 [SD, 1.97]; $40,000-$79,000 vs. <$40,000, adjusted OR = 4.40 [SD, 1.81]). Among eligible patients randomized to the intervention (n = 19) or usual care (n = 25), Black patients randomized to the intervention reported participating more actively than usual care patients, while White intervention patients reported participating less actively (difference, 0.41 vs. -0.34). Intervention patients received more trial invitations than usual care patients (73.7% vs. 60.0%); this effect was greater for Black (80.0% vs. 30.0%) than White patients (80.0% vs. 66.7%).

CONCLUSIONS

Findings suggest the greatest enrollment barrier is eligibility for an available trial, but a communication intervention can improve communication quality and trial invitation rates, especially for eligible Black patients.

Nonverbal Synchrony: An Indicator of Clinical Communication Quality in Racially-Concordant and Racially-Discordant Oncology Interactions

Objectives

The aim of this cross-sectional study was to apply a novel software to measure and compare levels of nonverbal synchrony, as a potential indicator of communication quality, in video recordings of racially-concordant and racially-discordant oncology interactions. Predictions include that the levels of nonverbal synchrony will be greater during racially-concordant interactions than racially-discordant interactions, and that levels of nonverbal synchrony will be associated with traditional measures of communication quality in both racially-concordant and racially-discordant interactions.

Design

This is a secondary observational analysis of video-recorded oncology treatment discussions collected from 2 previous studies.

Setting

Two National Cancer Institute-designated Comprehensive Cancer Centers and another large urban cancer center.

Participants

Participants from Study 1 include 161 White patients with cancer and 11 White medical oncologists. Participants from Study 2 include 66 Black/African-American patients with cancer and 17 non-Black medical oncologists. In both studies inclusion criteria for patients was a recent cancer diagnosis; in Study 2 inclusion criteria was identifying as Black/African American.

Main outcome measures

Nonverbal synchrony and communication quality.

Results

Greater levels of nonverbal synchrony were observed in racially-discordant interactions than in racially-concordant interactions. Levels of nonverbal synchrony were associated with indicators of communication quality, and these associations were more consistently found in racially-discordant interactions.

Conclusion

This study advances clinical communication and disparities research by successfully applying a novel approach capturing the unconscious nature of communication, and revealing differences in communication in racially-discordant and racially-concordant oncology interactions. This study highlights the need for further exploration of nonverbal aspects relevant to patient-physician interactions.

Development and pilot test of a physician-focused cancer clinical trials communication training intervention

Objective

We describe the development and pilot test of a physician-focused, web-based training module designed to improve physician communication related to clinical trials in a diverse cancer patient population.

Methods

Researchers and stakeholders developed the training module, which included a video explaining patient-centered communication strategies for discussing trials, and re-enactments of actual clinical interactions. For the pilot test, the module was provided to physician participants in the Partnering Around Cancer Clinical Trials (PACCT) trial at two major urban cancer centers. Questionnaires assessed change in beliefs, behavioral attitudes, knowledge and comfort; and perceptions of the module.

Results

Nineteen physicians participated in the pilot test. Most were experienced in discussing trials. Assessments of change were mixed regarding beliefs; they showed marginal improvement in attitudes, and significant improvement in knowledge, but no change in comfort. Feedback on the module was favorable.

Conclusions

This stakeholder-developed physician communication training module was acceptable and effective, albeit in this small and highly-experienced physician sample. Future research should determine its effectiveness on communication in clinical settings.

Innovation

This is the first physician training module to focus on communicating about clinical trials in a diverse patient population. It offers a web-based format and re-enactments of naturally-occurring clinical interactions.

Trial Registration Number: NCT02906241

Examining the dynamic nature of nonverbal communication between Black patients with cancer and their oncologists

BACKGROUND

Although communication quality is associated with patient outcomes, racial disparities in communication exist, disproportionately burdening Black patients. However, most communication research focuses on verbal behaviors in predominantly White patient populations. We used a newly developed and theory-guided network analysis that examines the dynamic interplay and behavioral convergence and divergence between Black patients with cancer and their oncologists during cancer treatment discussions.

METHODS

We applied a nonverbal behavioral coding system to thin slices of video recordings of Black patients and their oncologists discussing treatment. We then estimated 3 networks: 1) a temporal network to determine whether a nonverbal behavior predicts another nonverbal behavior at the next time point in an interaction, and how much each nonverbal behavior influences other nonverbal behaviors and is influenced by other nonverbal behaviors; 2) a contemporaneous network to determine whether a nonverbal behavior co-occurs with other nonverbal behaviors at the same time point in an interaction; and 3) a between-dyads network to examine the covariation between nonverbal behaviors across all dyads.

RESULTS

Black patients (n = 74) and their non-Black physicians (n = 15) showed a mix of convergence and divergence in their nonverbal behaviors at the same points in time, from one time point to the next, and across dyads. Across analyses, convergence was most likely to occur when physicians matched their behaviors to their patients; especially with smiling, gaze, leaning, and laughter behaviors.

CONCLUSION

Our findings reveal patterns of modifiable behaviors that can potentially inform interventions to reduce disparities in clinical communication and, in turn, treatment and mortality disparities.

Willingness to Discuss Clinical Trials Among Black vs White Men With Prostate Cancer

Importance

Black individuals are underrepresented in cancer clinical trials.

Objective

To examine whether Black and White men with prostate cancer differ in their willingness to discuss clinical trials with their physicians and, if so, whether patient-level barriers statistically mediate racial differences.

Design, Setting, and Participants

This cross-sectional survey study used baseline data from Partnering Around Cancer Clinical Trials, a randomized clinical trial to increase Black individuals' enrollment in prostate cancer clinical trials. Data were collected from 2016 through 2019 at 2 National Cancer Institute-designated comprehensive cancer centers; participants were Black and White men with intermediate-risk to high-risk prostate cancer. In mediation analysis, path models regressed willingness onto race and each potential mediator, simultaneously including direct paths from race to each mediator. Significant indirect effect sizes served as evidence for mediation.

Exposures

Race was the primary exposure. Potential mediators included age, education, household income, perceived economic burden, pain/physical limitation, health literacy, general trust in physicians, and group-based medical suspicion.

Main Outcomes and Measures

The primary outcome was the answer to a single question: "If you were offered a cancer clinical trial, would you be willing to hear more information about it?"

Results

A total of 205 participants were included (92 Black men and 113 White men), with a mean (range) age of 65.7 (45-89) years; 32% had a high school education or lower, and 27.5% had a household income of less than $40 000. Most (88.3%) reported being definitely or probably willing to discuss trials, but White participants were more likely to endorse this highest category of willingness than Black participants (82% vs 64%; χ22 = 8.81; P = .01). Compared with White participants, Black participants were younger (F1,182 = 8.67; P < .001), less educated (F1,182 = 22.79; P < .001), with lower income (F1,182 = 79.59; P < .001), greater perceived economic burden (F1,182 = 42.46; P < .001), lower health literacy (F1,184 = 9.84; P = .002), and greater group-based medical suspicion (F1,184 = 21.48; P < .001). Only group-based medical suspicion significantly mediated the association between race and willingness to discuss trials (indirect effect, -0.22; P = .002).

Conclusions and Relevance

In this study of men with prostate cancer, most participants were willing to discuss trials, but Black men were significantly less willing than White men. Black men were more likely to believe that members of their racial group should be suspicious of the health care system, and this belief was associated with lower willingness to discuss trials. Addressing medical mistrust may improve equity in clinical research.

Abstract B032: Which forms of financial hardship predict financial distress among African American and white cancer survivors?

Background: Financial hardship (FH) is common among cancer survivors and prevalence is often higher in non-white survivors. It is not known whether specific forms of FH are stronger predictors of financial distress than others, or if predictors of distress differ by race.

Methods: We utilized data from 500 (196 white, 304 African American) participants in the Detroit Research on Cancer Survivors pilot cohort. Adults ages 20-79 were eligible if they were diagnosed with a first primary breast, colorectal, lung, or prostate cancer since January 1, 2013; identified through the Metropolitan Detroit Cancer Surveillance System; and diagnosed/treated at the Karmanos Cancer Institute. Measures of financial hardship included decreased income, cancer-related debt, utilizing assets or borrowing money to pay for cancer care, refusing treatment or not seeing a doctor when needed due to cost, and skipping doses of prescribed medication to save money. Financial distress was measured using the validated Comprehensive Score for Financial Toxicity (COST), coded so that lower scores indicate higher distress (lower financial quality of life). We used backward selection models including demographic and socioeconomic factors to identify predictors of financial distress overall and separately for white and African American survivors.

Results: COST scores were 27.3 on average (SD: 10.9; 95% CI: 26.2, 28.3; range: 0-44), and were lower (more financial distress) in African American (24.5, 95% CI: 23.1, 25.8) than white survivors (31.0, 95% CI: 29.4, 32.5; p&lt;0.001). Younger age, being unmarried, lower income, not being employed, and having Medicaid coverage were all associated with higher financial distress. Debt, decreased income, utilizing assets, skipping doses of prescribed medication, and needing a doctor but not going were each independently associated with more financial distress overall (all p=0.013). Debt was associated with distress among both white and African American survivors in race-specific models (p=0.005) and decreased income was associated with distress in white (p=0.013) and marginally associated (p=0.06) in African American survivors. Not going to the doctor when needed and utilizing assets (both p&lt;0.001) predicted distress among white survivors, while refusing treatment due to cost (p=0.007) and skipping doses of prescribed medication to save money (p=0.007) predicted distress in African American survivors. Not going to a doctor when needed was more common in African American survivors, but more strongly associated with distress in white survivors (p-interaction=0.024). A similar pattern was observed for utilizing assets but was only marginally significant (p=0.08).

Conclusions: Several forms of financial hardship were strongly associated with financial distress after cancer, but their association with distress differed by race. Some forms of financial hardship that are more common in African American survivors are more strongly associated with financial distress among white survivors.

Citation Format: Theresa A. Hastert, Amanda R. Reed, Jennifer L. Beebe-Dimmer, Terrance L. Albrecht, Julia Mantey, Tara Baird, Ann G. Schwartz. Which forms of financial hardship predict financial distress among African American and white cancer survivors? [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 B032.

Understanding differences in the long-term psychosocial adjustment of pediatric cancer patients and their parents: an individual differences resources model

The experience of childhood cancer is a major life stressor for children and their parents. There is substantial variability among pediatric cancer patients and their parents in their ability to cope with the cancer. Although other models typically focus on the psychological resources families use to broadly cope with a diagnosis of pediatric cancer, we present a model that focuses specifically how parents and children cope with the stress of invasive and often painful treatment episodes. Our resources model is further distinct with its focus on individual differences in personal (e.g., personality traits) and social (e.g., social support) resources and the role these differences may play in psychosocial adjustment of families confronting pediatric cancer. We use findings from the broader pediatric cancer research literature and our own 15-year program of research on individual differences in psychological resources and parents and children's responses to treatment episodes to provide empirical support for our model. Support was found for the six premises of the model: (a) parent resources influence their longer-term psychosocial adjustment, (b) parent resources influence children's responses to treatment episodes, (c) parent resources indirectly influence their longer-term psychosocial adjustment through their responses to treatment episodes, (d) children's personal resources influence how parent responses to treatment episodes, (e) children's resources influence their longer-term psychosocial adjustment, and (f) children's resources indirectly influence their longer-term psychosocial adjustment through their responses to treatment episodes. Understanding how the availability of resources influences parents and children confronting cancer provides a foundation for future research on individual differences in resources and offers other avenues through which clinicians can assess and treat families at risk for poor psychosocial adjustment during treatment and in their life beyond cancer treatments.

Unpacking Trial Offers and Low Accrual Rates: A Qualitative Analysis of Clinic Visits With Physicians and Patients Potentially Eligible for a Prostate Cancer Clinical Trial

PURPOSE

Cancer clinical trial accrual rates are low, and information about contributing factors is needed. We examined video-recorded clinical interactions to identify circumstances under which patients potentially eligible for a trial at a major cancer center were offered a trial.

METHODS

We conducted a qualitative directed content analysis of 62 recorded interactions with physicians (n = 13) and patients with intermediate- or high-risk prostate cancer (n = 43). Patients were screened and potentially eligible for a trial. We observed and coded the interactions in 3 steps: (1) classification of all interactions as explicit offer, offer pending, trial discussed/not offered, or trial not discussed; (2) in interactions with no explicit offer, classification of whether the cancer had progressed; (3) in interactions classified as progression but no trial offered, identification of factors discussed that may explain the lack of an offer.

RESULTS

Of the 62 interactions, 29% were classified as explicit offer, 12% as offer pending, 18% as trial discussed/not offered, and 39% as trial not discussed. Of those with no offer, 57% included information that the cancer had not progressed. In 68% of the remaining interactions with patients whose cancer had progressed but did not receive an offer, reasons for the lack of offer were identified, but in 32%, no explanation was provided.

CONCLUSION

Even in optimal circumstances, few patients were offered a trial, often because their cancer had not progressed. Findings support professional recommendations to broaden trial inclusion criteria. Findings suggest accrual rates should reflect the proportion of eligible patients who enroll.

Between-Race Differences in Processes Predicting Physician Communication for African American and European American Recipients of Breast Density Notifications

BACKGROUND

Breast density notification laws mandate reporting of dense breast to applicable women. The same psychological and systemic barriers that yield between-race differences in mammography use will probably yield between-race differences in women's psychological and behavioral responses to breast density notifications.

PURPOSE

We used the theory of planned behavior as a framework to examine between-race differences in the likelihood of following-up with physicians after receiving breast density notifications and to examine differences in African American and Caucasian American women's behavioral decision-making processes.

METHODS

A subset of 212 African American and Caucasian American women who participated in an initial and follow-up survey examining responses to breast density notifications were examined for this study. Participants reported background and demographic measures, psychological responses to receiving notifications, and planned behavior measures related to following up with physicians approximately 2 weeks after receiving their mammogram reports. Participants self-reported their behaviors 3 months later.

RESULTS

There were no between-race differences in self-reported physician communication; however, there were differences in processes that predicted behavior. For Caucasian American women, behavioral intentions, education, and income predicted behaviors. Instead of intentions, group-based medical suspicion, confusion, breast cancer worry, and breast density anxiety predicted behaviors for African American women.

CONCLUSIONS

Behavioral decision-making processes for Caucasian American women were in line with well-validated theoretical predictions. For African American women, race-related medical suspicion, prior breast density awareness, and emotional responses to breast density notifications predicted behavior. The results highlight the need to focus on racially distinct psychological targets when designing interventions to support guideline concordant behavioral decisions among women who receive breast density notifications.

Decoding the Role of Companions in Supporting the Health Communication of Older African-American Men With Cancer

The objective of this study was to systematically characterize the content and patterning of companion’s communicative behavior during oncology consultations for older African-American male patients. Companions and family members often play an important role in patient-centered communication for patients with cancer. Despite their disproportionate cancer burden, little is known about how companions facilitate patient-provider communication for older African-American men with cancer. This study represents a secondary qualitative analysis of 14 video-recorded doctor patient-companion medical visits for African-American male patients with cancer. Videos were captured with consent and institutional review board approval at a Midwest comprehensive cancer center between 2002 and 2006. These medical visits were transcribed, deidentified, and analyzed for the content, frequency, co-occurrence, and thematic clustering of companions’ active participation behaviors during the interaction. Results were well aligned with existing studies on accompanied oncology visits. Patients were on average, 60.14 years old and all but one of the 16 companions was a woman. A total 782 companion behaviors were coded across 14 medical interactions. While companions communicated directly with providers (eg, asking questions, providing medical history) and directly with patients (eg, clarifying information, giving advice), there was a lack of triadic communication. This study clarifies the role of mainly spousal companions as important intermediaries in the patient-provider communication dynamic for older African-American men with cancer.

Designing and Testing Apps to Support Patients With Cancer: Looking to Behavioral Science to Lead the Way

Background

Behavioral science has a long and strong tradition of rigorous experimental and applied methodologies, which have produced several influential and far-reaching theoretical frameworks and have guided countless inquiries of human behavior in various contexts. In cancer care, behavioral scientists have established a firm foundation of research focused on understanding the experience of cancer and using that understanding to design and implement theory- and evidenced-based interventions to help patients cope with the cancer experience. Given the rich behavioral research base in oncology, behavioral scientists are ideally positioned to lead the integration of evidence-based science on behavior and behavior change into the development of smartphone apps supporting patients with cancer. Smartphone apps are being disseminated to patients with cancer with claims of being able to help them negotiate areas of vulnerability in their cancer experience. However, the vast majority of these apps are developed without the rigor and expertise of behavioral scientists.

Objective

In this article, we have illustrated the importance of behavioral science leading the development and evaluation of apps to support patients with cancer by providing an illustrative scientific process that our team of behavioral scientists, patient stakeholders, medical oncologists, and software developers used to empirically design and evaluate 2 patient-focused apps: the Discussion of Cost App (DISCO App) and MyPatientPal.

Methods

Using a focused literature review and a descriptive roadmap of our team’s process for designing and evaluating patient-focused behavioral apps for patients with cancer, we have demonstrated how behavioral scientists are integral to the development of empirically sound apps to help support patients with cancer. Specifically, we have illustrated the process by which our multidisciplinary team combined the established user-centered design principles and behavioral science theory and scientific rigor to design and evaluate 2 patient-focused apps.

Results

On the basis of initial acceptability and feasibility testing among patients and providers, our team has demonstrated how critical behavioral science is for designing and evaluating app-based interventions for patients with cancer.

Conclusions

Behavioral science can and should be coupled with user-centered design principles to provide theoretical guidance and the rigor of the scientific method, thereby adding the much-needed and critical evidence for these types of app-based interventions for patients with cancer.

Nonverbal synchrony as a behavioural marker of patient and physician race-related attitudes and a predictor of outcomes in oncology interactions: protocol for a secondary analysis of video-recorded cancer treatment discussions

INTRODUCTION

Racial disparities in cancer treatment contribute to racial disparities in mortality rates. The quality of patient-physician communication during clinical interactions with black patients and non-black physicians (racially discordant) is poorer than communication quality with white patients (racially concordant). Patient and physician race-related attitudes affect the quality of this communication. These attitudes are likely expressed through subtle non-verbal behaviours, but prior research has not examined these behaviours. Nonverbal synchrony, the coordination of physical movement, reflects the preinteraction attitudes of participants in interactions and predicts their postinteraction perceptions of and affect towards one another. In this study, peer reviewed and funded by the National Institute of Minority Health and Health Disparities (R21MD011766), we will investigate non-verbal synchrony in racially concordant and discordant interactions to better understand racial disparities in clinical communication.

METHODS AND ANALYSIS

This secondary analysis includes racially concordant (n=163) and racially discordant (n=68) video-recorded oncology interactions, patient and oncologist self-reported race-related attitudes, perceptions of the interaction and observer ratings of physician patient-centred communication and patient and physician affect and rapport. In aim 1, we will assess and compare non-verbal synchrony between physicians and patients in racially concordant and discordant interactions. In aim 2, we will determine the influence of non-verbal synchrony on patient and physician affect and communication. In aim 3, we will examine possible causes (ie, race-related attitudes) and consequences (ie, negative perceptions) of non-verbal synchrony in racially discordant interactions. In aim 4, we will develop and test a mediational model linking physician and patient race-related attitudes to non-verbal synchrony and, in turn, interaction outcomes.

ETHICS AND DISSEMINATION

The parent and current studies were approved by the Wayne State University Institutional Review Board. Since only archival data will be used, ethical or safety risks are low. We will disseminate our findings to relevant conferences and journals.

The Detroit Research on Cancer Survivors (ROCS) Pilot Study: A Focus on Outcomes after Cancer in a Racially Diverse Patient Population

BACKGROUND

African Americans are often diagnosed with advanced stage cancer and experience higher mortality compared with whites in the United States. Contributing factors, like differences in access to medical care and the prevalence of comorbidities, do not entirely explain racial differences in outcomes.

METHODS

The Detroit Research on Cancer Survivors (ROCS) pilot study was conducted to investigate factors related to short- and long-term outcomes among patients with cancer. Participants completed web-based surveys, and mailed saliva specimens were collected for future genetic studies.

RESULTS

We recruited 1,000 participants with an overall response rate of 68%. Thirty-one percent completed the survey without any interviewer support and the remaining participated in an interviewer-administered survey. Seventy-four percent provided a saliva specimen and 64% consented for tumor tissue retrieval. African American survivors required more interviewer support (P < 0.001); however, their response rate (69.6%) was higher than non-Hispanic whites (65.4%). African Americans reported poorer overall cancer-related quality of life compared with non-Hispanic whites, measured by FACT-G score (P < 0.001), however, this relationship was reversed after controlling for socioeconomic factors, marital status, and the presence of comorbidities.

CONCLUSIONS

In this pilot study, we demonstrated that a web-based survey supplemented with telephone interviews and mailed saliva kits are cost-effective methods to collect patient-reported data and DNA for large studies of cancer survivors with a high proportion of minority patients. The preliminary data collected reinforces differences by race in factors affecting cancer outcomes. Our efforts continue as we expand this unique cohort to include more than 5,000 African American cancer survivors.

IMPACT

Formal investigation of factors influencing adverse outcomes among African American cancer survivors will be critical in closing the racial gap in morbidity and mortality.

Risk of incident claims for chemotherapy-induced peripheral neuropathy among women with breast cancer in a Medicare population

BACKGROUND

Chemotherapy-induced peripheral neuropathy (CIPN) is a common and disabling consequence of neurotoxic therapies, yet factors that modulate the development and clinical impact of CIPN are poorly understood. This epidemiological analysis identifies risk factors for the incidence of CIPN.

METHODS

This retrospective analysis of Surveillance, Epidemiology, and End Results-Medicare data examined predictors of incident CIPN claims among 11,149 women aged 66 years or older with American Joint Commission on Cancer (AJCC) stage II to IV breast cancer (and no secondary cancer diagnosis or preexisting neuropathy) who received chemotherapy.

RESULTS

Overall, new CIPN claims occurred for 8.3% of patients within 1 year of starting chemotherapy. Risk emerged approximately 3 months after the start of chemotherapy and increased throughout 1 year. Paclitaxel as part of first-line therapy increased CIPN risk 2.7-fold in comparison with nonneurotoxic agents (15.9% vs 5.0%), with lower incidence rates for carboplatin and paclitaxel (11.9%), carboplatin and docetaxel (9.3%), carboplatin alone (7.7%), and docetaxel alone (6.6%). The CIPN incidence rate was higher for women who at the time of their breast cancer diagnosis were relatively young (within this Medicare sample), were at AJCC stage II or III, were married or had an equivalent status, and had fewer comorbidities, but it did not differ by race/ethnicity or poverty level.

CONCLUSIONS

These Medicare claims database findings indicate that women aged 66 years or older with breast cancer are susceptible to CIPN from taxane and/or platinum compounds, with risk emerging approximately 3 months into treatment. Prospective studies of symptom emergence and clinical response (eg, stopping chemotherapy and adjunctive treatments) are indicated to determine how best to inform patients of this risk and to manage CIPN in this population.

Between-Race Differences in Supplemental Breast Cancer Screening Before and After Breast Density Notification Law

Guidelines recommend supplemental breast cancer screening for women at increased breast cancer risk; however, the passage of breast density notification laws may lead to supplemental screening that is incongruent with women's risk. We examined supplemental screening (ie, MRI, ultrasound, or tomosynthesis within 6 months of screening mammogram) among a sample of 2,764 African American (AA) and 691 European American (EA) women with negative or benign screening mammograms for whom we had data from both before and after implementation of breast density notification laws in the state of Michigan. Results indicated a 5-fold increase (from 0.14% to 0.7% of women) in supplemental screening among screen-negative women after passage of the law, driven in large part by an increase in supplemental screening among AA women. Breast density was more predictive of supplemental screening and had a marginally greater explanatory role in between-race differences in supplemental screening after passage of the law. Subgroup analyses (n = 250) indicated that whereas 5-year breast cancer risk was positively associated with supplemental screening before the law and negatively associated after the law for EA women, 5-year risk was not associated with supplemental screening either before or after passage of the law for AA women. Our findings suggest that whereas passage of the breast density notification laws may have motivated supplemental screening among AA women in particular, it lessened the consideration of breast cancer risk in supplemental screening decision making.

Abstract B09: Partnering around cancer clinical trials: Preliminary report of an intervention to improve patient-physician communication and clinical trial enrollment of Black and White men with prostate cancer

Background: Few patients, especially racial/ethnic minorities, enroll in clinical trials (CTs) in the United States, in part due to factors related to patient-physician interactions. We describe a theory-based patient intervention to improve communication and enrollment of Black and White men in prostate cancer CTs. We also report on preliminary baseline data comparing Black and White participants' demographic and social characteristics and their willingness to discuss a CT with a physician.

Method: A team of communication scientists, psychologists, and clinicians collaborated to create a theory-based, patient-focused intervention. Theories included the common ingroup identity model, which suggests people from different social groups can better achieve goals when they see themselves as members of the same team, and patient-centered communication, which suggests that patient active participation improves clinical communication. The intervention is in the form of a booklet given to patients prior to meeting with their oncologist. The booklet includes a) encouragement to view the patient and physician as a team and participate actively in clinical interactions, and b) 33 questions about participating in a CT. Preliminary data from one data collection site (Detroit, Michigan) include 72 Black (n=40) and White (n=32) men with prostate cancer who completed baseline measures assessing age; education; income; breadwinner status; marital status; health literacy; perceived economic burden (e.g., how difficult is it for you to live on your total household income right now?); general trust in physicians; group-based medical mistrust (including three subscales--suspicion, perceived racial health care disparities, and perceived health care provider support); and willingness to discuss a CT with a physician. Chi-square and independent samples t-tests were conducted to determine racial differences.

Results: Black patients were younger (p=.04), had less education (p=.006) and lower annual incomes (p&lt;.001) than White patients, but were equally likely to be the breadwinner. Blacks were more likely to be single than Whites (p&lt;.001). Blacks reported significantly higher economic burden (p=.02), greater group-based medical mistrust (p=.001), greater suspicion of health care (p=.003), greater perceived racial disparities in health care (p=.001), and less perceived support from health care providers (p=.002). Blacks and Whites did not differ in health literacy or general trust in physicians. Regarding willingness to discuss CTs with their physician, high means for both Blacks and Whites (4.2 and 4.7, respectively, on a 5-point scale) indicated that both groups were very willing to discuss a CT with their physician, but Whites were significantly more willing (p=.03).

Discussion: Black and White patients differed in many demographic and social characteristics. Both groups indicated they were very willing to discuss a CT with their physician, although Whites were significantly more willing. This finding suggests the intervention may be especially beneficial for Black patients, who are disproportionately under-represented in CTs. Next steps involve analysis of the effect of the intervention and addition of a physician-focused intervention.

Citation Format: Lauren M. Hamel, Louis A. Penner, Elisabeth Heath, Dina Lansey, Michael Carducci, Terrance L. Albrecht, Ellen Barton, Mark Manning, Tanina Foster, Mark Wojda, Susan Eggly. Partnering around cancer clinical trials: Preliminary report of an intervention to improve patient-physician communication and clinical trial enrollment of Black and White men with prostate cancer [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 B09.

The influence of affective behavior on impression formation in interactions between black cancer patients and their oncologists

OBJECTIVE

Black patients and their physicians tend to form relatively negative impressions of each other, and these may contribute to racial disparities in health outcomes. The current research tested the hypothesis that the interaction between positive and negative affective behavior predicts the most positive impressions in clinic visits between Black patients and their oncologists.

METHOD

Naïve coders rated patients' and oncologists' positive and negative affective behavior in thin slices from 74 video recorded clinic visits. We examined whether (a) physician positive affect, negative affect, or their interaction predicted patients' perceptions of patient-centeredness, trustworthiness, and confidence in recommended treatments and (b) patient positive affect, negative affect, or their interaction predicted physicians' perceptions of patient cognitive ability, likelihood of treatment adherence, and likelihood of treatment tolerance. We also tested whether affective behavior mediated relationships between race-related attitudes and post-visit impressions or influenced post-visit impressions independently of attitudes.

RESULTS

When oncologists displayed relatively high levels of both positive and negative affect, patients were more confident in recommended treatments but did not rate physicians higher in patient centeredness or trustworthiness. When patients expressed relatively high levels of positive and negative affect, oncologists perceived patients to be higher in cognitive ability and more likely to adhere to treatment recommendations, but no more likely to tolerate treatments. Affective behavior influenced impressions independently of race-related attitudes.

CONCLUSIONS

Positive and negative affective behaviors jointly contribute to impression formation in clinic visits between Black patients and oncologists, and may have implications for patient treatment and outcomes in this underserved patient population.

An Analysis of Race-related Attitudes and Beliefs in Black Cancer Patients: Implications for Health Care Disparities

This research concerned relationships among Black cancer patients' health care attitudes and behaviors (e.g., adherence, decisional control preferences,) and their race-related attitudes and beliefs shaped by (a) general life experiences (i.e., perceived discrimination, racial identity) and (b) experiences interacting with health care systems (i.e., physician mistrust, suspicion about medical care). Perceived discrimination, racial identity, and medical suspicion correlated weakly with one another; mistrust and suspicion correlated only moderately. Race-related attitudes and beliefs were associated with health care attitudes and behavior, but patterns of association varied. Physician mistrust and medical suspicion each independently correlated with adherence and decisional control preferences, but discrimination only correlated with control preferences. Associations among patients' different racial attitudes/beliefs are more complex than previously assumed. Interventions that target patient attitudes/beliefs and health care disparities might be more productive if they focus on mistrust or suspicion specific to health care providers/systems and their correlates identified in this study.

Partnering around cancer clinical trials (PACCT): study protocol for a randomized trial of a patient and physician communication intervention to increase minority accrual to prostate cancer clinical trials

Background

Cancer clinical trials are essential for testing new treatments and represent state-of-the-art cancer treatment, but only a small percentage of patients ever enroll in a trial. Under-enrollment is an even greater problem among minorities, particularly African Americans, representing a racial/ethnic disparity in cancer care. One understudied cause is patient-physician communication, which is often of poor quality during clinical interactions between African-American patients and non-African-American physicians. Partnering Around Cancer Clinical Trials (PACCT) involves a transdisciplinary theoretical model proposing that patient and physician individual attitudes and beliefs and their interpersonal communication during racially discordant clinical interactions influence outcomes related to patients’ decisions to participate in a trial. The overall goal of the study is to test a multilevel intervention designed to increase rates at which African-American and White men with prostate cancer make an informed decision to participate in a clinical trial.

Methods/design

Data collection will occur at two NCI-designated comprehensive cancer centers. Participants include physicians who treat men with prostate cancer and their African-American and White patients who are potentially eligible for a clinical trial. The study uses two distinct research designs to evaluate the effects of two behavioral interventions, one focused on patients and the other on physicians. The primary goal is to increase the number of patients who decide to enroll in a trial; secondary goals include increasing rates of physician trial offers, improving the quality of patient-physician communication during video recorded clinical interactions in which trials may be discussed, improving patients’ understanding of trials offered, and increasing the number of patients who actually enroll. Aims are to 1) determine the independent and combined effects of the two interventions on outcomes; 2) compare the effects of the interventions on African-American versus White men; and 3) examine the extent to which patient-physician communication mediates the effect of the interventions on the outcomes.

Discussion

PACCT has the potential to identify ways to increase clinical trial rates in a diverse patient population. The research can also improve access to high quality clinical care for African American men bearing the disproportionate burden of disparities in prostate and other cancers.

Trial registration

Clinical Trials.gov registration number: NCT02906241 (September 8, 2016).

Explaining between-race differences in African-American and European-American women's responses to breast density notification

BACKGROUND

Prior research shows between-race differences in women's knowledge and emotions related to having dense breasts, thus suggesting that between-race differences in behavioral decision-making following receipt of breast density (BD) notifications are likely. Guided by the theory of planned behavior, this study examined differences in emotion-related responses (i.e., anxiety, worry, confusion) and behavioral cognition (e.g., intentions, behavioral attitudes) following receipt of BD notifications among African American (AA) and European American (EA) women. This study also examined whether race-related perceptions (i.e., discrimination, group-based medical mistrust), relevant knowledge and socioeconomic status (SES) explained the between race differences.

METHOD

Michigan women (N = 457) who presented for routine screening mammogram and had dense breasts, no prior breast cancer diagnoses, and had screen-negative mammograms were recruited from July, 2015 to March 2016. MANOVA was used to examine between race differences in psychological responses (i.e., emotional responses and behavioral cognition), and a multi-group structural regression model was used to examine whether race-related constructs, knowledge and SES mediated the effect of race on emotional responses and behavioral cognition. Prior awareness of BD was accounted for in all analyses.

RESULTS

AA women generally reported more negative psychological responses to receiving BD notifications regardless of prior BD awareness. AA women had more favorable perceptions related to talking to their physicians about the BD notifications. Generally, race-related perceptions, SES, and related knowledge partially accounted for the effect of race on psychological response. Race-related perceptions and SES partially accounted for the differences in behavioral intentions. Between-race differences in emotional responses to BD notifications did not explain differences in women's intentions to discuss BD notifications with their physicians.

CONCLUSIONS

Future examinations are warranted to examine whether there are between-race differences in actual post-BD notification behaviors and whether similar race-related variables account for differences.

Building Motivation in African American Caregivers of Adolescents With Obesity: Application of Sequential Analysis

Objective

We sought to examine communication between counselors and caregivers of adolescents with obesity to determine what types of counselor behaviors increased caregivers' motivational statements regarding supporting their child's weight loss.

Methods

We coded 20-min Motivational Interviewing sessions with 37 caregivers of African American 12-16-year-olds using the Minority Youth Sequential Coding for Observing Process Exchanges. We used sequential analysis to determine which counselor communication codes predicted caregiver motivational statements.

Results

Counselors' questions to elicit motivational statements and emphasis on autonomy increased the likelihood of both caregiver change talk and commitment language statements. Counselors' reflections of change talk predicted further change talk, and reflections of commitment language predicted more commitment language.

Conclusions

When working to increase motivation among caregivers of adolescents with overweight or obesity, providers should strive to reflect motivational statements, ask questions to elicit motivational statements, and emphasize caregivers' autonomy.

Discussing prognosis and treatment goals with patients with advanced cancer: A qualitative analysis of oncologists' language

BACKGROUND

The National Academy of Medicine recommends that cancer patients be knowledgeable of their prognosis to enable them to make informed treatment decisions, but research suggests few patients receive this information.

OBJECTIVE

This qualitative study describes oncologists' language during discussions of prognosis and treatment goals in clinical interactions with African American patients diagnosed with cancer.

DESIGN

We analysed transcripts from video recordings of clinical interactions between patients with Stage III or IV cancer (n=26) and their oncologists (n=9). In-depth discourse analysis was conducted to describe and interpret oncologists' communication behaviours and common linguistic features in the interactions.

SETTING AND PARTICIPANTS

Data were from a larger study of patient-provider communication between African Americans and oncologists at two cancer hospitals in Detroit.

RESULTS

Prognosis was discussed in 73.1% (n=19) of the interactions; treatment goals were discussed in 92.3% (n=24). However, analysis revealed that oncologists' description of prognosis was vague (e.g. "prognosis is a bit worse in your case") and rarely included a survival estimate. Oncologists often used ambiguous terminology, including euphemisms and jargon, and emphasized uncertainty (e.g. "lesions are suspicious for the disease"). Conversation about prognosis was frequently brief, moving quickly to the urgency and details of treatment.

DISCUSSION

This study demonstrates how oncologists' language may obscure discussion of prognosis and treatment goals. The identified behaviours may lead to missed opportunities in eliciting and discussing patients' knowledge about and preferences for their care. Patient-, provider- and system-oriented interventions are needed to improve clinical communication, especially among minority patients with advanced cancer.

The impact of Black cancer patients' race-related beliefs and attitudes on racially-discordant oncology interactions: A field study

OBJECTIVE

Both physician and patient race-related beliefs and attitudes are contributors to racial healthcare disparities, but only the former have received substantial research attention. Using data from a study conducted in the Midwestern US from 2012 to 2014, we investigated whether 114 Black cancer patients' existing race-related beliefs and attitudes would predict how they and 18 non-Black physicians (medical oncologists) would respond in subsequent clinical interactions.

METHOD

At least two days before interacting with an oncologist for initial discussions of treatment options, patients completed measures of perceived past discrimination, general mistrust of physicians, and suspicion of healthcare systems; interactions were video-recorded. Measures from each interaction included patients' verbal behavior (e.g., level of verbal activity), patients' evaluations of physicians (e.g., trustworthiness), patients' perceptions of recommended treatments (e.g., confidence in treatment), physicians' evaluations of patient personal attributes (e.g., intelligence) and physicians' expectations for patient treatment success (e.g., adherence).

RESULTS

As predicted, patients' race-related beliefs and attitudes differed in their associations with patient and physician responses to the interactions. Higher levels of perceived past discrimination predicted more patient verbal activity. Higher levels of mistrust also predicted less patient positive affect and more negative evaluations of physicians. Higher levels of suspicion predicted more negative evaluations of physicians and recommended treatments. Stronger patient race-related attitudes were directly or indirectly associated with lower physician perceptions of patient attributes and treatment expectations.

CONCLUSION

Results provide new evidence for the role of Black patients' race-related beliefs and attitudes in racial healthcare disparities and suggest the need to measure multiple beliefs and attitudes to identify these effects.

Randomized trial of a question prompt list to increase patient active participation during interactions with black patients and their oncologists

OBJECTIVE

Communication during racially-discordant interactions is often of poor quality and may contribute to racial treatment disparities. We evaluated an intervention designed to increase patient active participation and other communication-related outcomes during interactions between Black patients and non-Black oncologists.

METHODS

Participants were 18 non-Black medical oncologists and 114 Black patients at two cancer hospitals in Detroit, Michigan, USA. Before a clinic visit to discuss treatment, patients were randomly assigned to usual care or to one of two question prompt list (QPL) formats: booklet (QPL-Only), or booklet and communication coach (QPL-plus-Coach). Patient-oncologist interactions were video recorded. Patients reported perceptions of the intervention, oncologist communication, role in treatment decisions, and trust in the oncologist. Observers assessed interaction length, patient active participation, and oncologist communication.

RESULTS

The intervention was viewed positively and did not increase interaction length. The QPL-only format increased patient active participation; the QPL-plus-Coach format decreased patient perceptions of oncologist communication. No other significant effects were found.

CONCLUSION

This QPL booklet is acceptable and increases patient active participation in racially-discordant oncology interactions. Future research should investigate whether adding physician-focused interventions might improve other outcomes.

PRACTICE IMPLICATIONS

This QPL booklet is acceptable and can improve patient active participation in racially-discordant oncology interactions.

Abstract A13: Randomized trial of a Question Prompt List to increase patient active participation during racially discordant oncology interactions

Purpose: Communication during racially discordant oncology interactions (i.e., Black patient, non-Black physician) is often of poorer quality than during similar interactions with White patients, and may contribute to racial disparities in cancer treatment. Question Prompt Lists (QPL) have been shown to increase patient active participation in clinical interactions and to influence related outcomes, but have never been tested in racially discordant oncology interactions. This study evaluated the acceptability and effectiveness of a QPL designed to increase patient active participation and related outcomes during clinical interactions in which Black patients discussed medical treatment for breast, colon, or lung cancer with non-Black oncologists.

Participants and Methods: Eighteen non-Black medical oncologists and 114 Black patients at two cancer hospitals in Detroit, MI completed baseline measures. Patients were then randomly assigned to one of three arms: 1) usual care; 2) receiving a QPL specifically designed for this study in the form of a booklet (QPL-only); 3) receiving the QPL booklet plus the assistance of a communication coach (QPL-plus-Coach). Patient-oncologist interactions were video recorded. Trained observers assessed patient active participation using two measures: a frequency count of active participation communication behaviors (i.e., questions, assertions, and statements of concern) and a global rating scale of seven items indicating active participation (e.g., “The patient asked the doctor a lot of questions”). Observers also rated oncologist patient-centered communication using a 14-item global scale with three subscales (i.e., informativeness, supportiveness, relationship-building). Following interactions, patients rated oncologist patient-centeredness; shared decision-making; trust in their oncologist; and difficulty understanding and remembering what was discussed during the conversation with their oncologist. Intervention arm patients also used a 3-point scale to provide their perceptions of the intervention. Analyses included multi-level regression models, with patients nested within oncologists.

Results: Patients in both intervention arms viewed the QPL booklet favorably (M=2.80; SD=.23). Patients in the QPL-plus-Coach arm also viewed the coaching favorably (M=2.83; SD=.29). Interaction length did not significantly differ across arms. Patients in the QPL-only arm participated more actively than patients in the usual care or QPL-plus-coach arm (frequency count: p=.02; global scale p=.06). The intervention had no significant effect on other outcomes.

Conclusion: Findings suggest a QPL in the form of a booklet may be an acceptable and effective intervention to increase active participation in oncology interactions among Black patients. Future research should investigate whether the addition of a physician-focused intervention might produce additional benefits, such as better oncologist communication and increased patient trust. Research examining the influence of patient and oncologist characteristics, including race-related attitudes, on patient active participation and related outcomes in racially discordant oncology interactions may inform future interventions to improve the quality of communication and care for Black patients with cancer.

Citation Format: Susan Eggly, Lauren Hamel, Terrance L. Albrecht, Tanina Foster, Robert Chapman, Louis A. Penner. Randomized trial of a Question Prompt List to increase patient active participation during racially discordant oncology interactions. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr A13.

Abstract A84: Perceived Social Support Moderates the Associations between Race-Based Medical Suspicion and Perceptions of Cancer Treatment

Background: Decades of research have demonstrated the salutary effects of higher perceived social support on thoughts and feelings about one's health. Separate work has shown that Black patients with higher race-based medical suspicion have more negative perceptions of their healthcare. Prior studies have not systematically investigated the extent to which perceived social support is related to medical suspicion in Black cancer populations. Purpose: We specifically explored whether larger social network size and higher social support satisfaction moderated negative perceptions and feelings typically experienced by Black patients scoring high on suspicion. Methods: 114 Black cancer patients reported their social support and suspicion at a baseline session. One week later, they interacted with their oncologist about initial treatment options during a clinic visit. Following the interaction, patients reported their uncertainty regarding the recommended treatment, perceived difficulty completing treatment, and distress. Results: Moderation results showed that larger social network size was related to less uncertainty and less perceived difficulty completing treatment for Black patients low in suspicion. However, larger social network size failed to reduce uncertainty and perceived difficulty and exacerbated distress for Black patients high in suspicion. Social support satisfaction moderated only the relation between medical suspicion and perceived difficulty. Conclusions: Social support is associated with distinct cancer treatment perceptions for Black cancer patients as a function of patients' suspicion, which may be explained by entrenchment in a social network that reinforces negative personal biases.

Citation Format: Sarah C. E. Stanton, Louis A. Penner, Susan Eggly, Felicity W. K. Harper, Lauren M. Hamel, Tanina Foster, Michael S. Simon, Ellen Barton, Robert A. Chapman, Terrance L. Albrecht. Perceived Social Support Moderates the Associations between Race-Based Medical Suspicion and Perceptions of Cancer Treatment. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr A84.

Abstract C13: How does the financial impact of cancer differ by race? Results from the Cancer Survivorship in Metropolitan Detroit cohort study

Background: Previous research suggests that financial burdens due to cancer are more common in African-American than white survivors, but it is not known whether or how the types of burdens experienced differ by race.

Methods: This study utilizes preliminary data from the Cancer Survivorship in Metropolitan Detroit (CSMD) cohort. African-American and white adults ages 20-79 are eligible to join the cohort if they were identified through the Metropolitan Detroit Cancer Surveillance System as having been diagnosed with a first primary breast, colorectal, lung, or prostate cancer since January 1, 2013 and were diagnosed and/or treated at the Karmanos Cancer Institute. To date, 695 (281 white, 414 African-American) of the targeted 1000 survivors have completed the baseline questionnaire online or over the phone. Data collected include demographic and socioeconomic characteristics, medical history, and financial burden measures including indicators of whether participants sold assets or borrowed money to pay for cancer care; limited care due to cost; experienced a decrease in income since diagnosis; and whether they are currently in debt due to cancer expenses. This abstract presents results of bivariate analyses and odds ratios (OR) and 95% confidence intervals (CI) from logistic regressions controlling for age, sex, treatment, and insurance.

Results: Overall, 52.4% of survivors experienced some form of financial burden related to cancer, and prevalence was higher in African-American (56.6%) than in white survivors (46.3%; p=0.011). A marginally higher proportion of white (24.7%) than African-American survivors (19.2%; p=0.08) used existing assets to pay for cancer care, including higher proportions who withdrew money from savings (14.6% vs. 9.2%; p=0.027) or retirement accounts (7.8% vs. 3.4%; p=0.009). Although an identical proportion (9.8%) of white and African-American survivors borrowed money from family or friends, more African-American (31.2%) than white (18.1%; p&lt;0.001) survivors were still in debt due to expenses related to cancer treatment. More African-American (21.3%) than white (14.6%; p=0.027) survivors also limited care due to cost concerns, including reporting that they needed to see a doctor in the past year but could not due to cost (15.1% vs. 9.1%; p=0.022) and that they skipped doses of prescribed medication to save money (8.8% vs. 5.4%; p=0.094). No differences were observed in the proportion of African-American and white survivors who sold stocks or other investments (1.2% vs. 2.1%), refused treatment due to cost (4.6% vs. 5.0%), or experienced a decrease in income due to cancer (30.2% vs. 27.3%). In adjusted analyses, African-American race remained associated with higher odds of being in debt due to cancer (OR: 2.09; 95% CI: 1.39, 2.14) and experiencing any form of economic burden (OR: 1.49, 95% CI: 1.04, 2.12) and marginally associated with skipping doses of prescribed medication (OR: 1.77 95% CI: 0.92, 3.42) and limiting care due to cost (OR: 1.46, 95% CI; 0.93, 2.28).

Implications: These findings suggest that although large proportions of both white and African-American survivors experience some form of financial burden related to cancer, a larger proportion of white survivors may be able to utilize existing resources to pay for cancer treatment, while a larger proportion of African-American survivors experience lasting debt or forego necessary care due to cost concerns. As research into the economic consequences of cancer survivorship continues and expands into the development of interventions to reduce their impacts, it is important to identify not only disparities in the overall prevalence of economic burden, but also in the forms those burdens take for distinct groups.

Citation Format: Theresa A. Hastert, Lauren M. Hamel, Tara Baird, Terrance L. Albrecht, Ann G. Schwartz, Michael S. Simon, Fawn Vigneau, Jennifer L. Beebe-Dimmer. How does the financial impact of cancer differ by race? Results from the Cancer Survivorship in Metropolitan Detroit cohort study. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr C13.

Do Patients and Oncologists Discuss the Cost of Cancer Treatment? An Observational Study of Clinical Interactions Between African American Patients and Their Oncologists

PURPOSE

Financial toxicity negatively affects patients with cancer, especially racial/ethnic minorities. Patient-oncologist discussions about treatment-related costs may reduce financial toxicity by factoring costs into treatment decisions. This study investigated the frequency and nature of cost discussions during clinical interactions between African American patients and oncologists and examined whether cost discussions were affected by patient sociodemographic characteristics and social support, a known buffer to perceived financial stress. Methods Video recorded patient-oncologist clinical interactions (n = 103) from outpatient clinics of two urban cancer hospitals (including a National Cancer Institute-designated comprehensive cancer center) were analyzed. Coders studied the videos for the presence and duration of cost discussions and then determined the initiator, topic, oncologist response to the patient's concerns, and the patient's reaction to the oncologist's response.

RESULTS

Cost discussions occurred in 45% of clinical interactions. Patients initiated 63% of discussions; oncologists initiated 36%. The most frequent topics were concern about time off from work for treatment (initiated by patients) and insurance (initiated by oncologists). Younger patients and patients with more perceived social support satisfaction were more likely to discuss cost. Patient age interacted with amount of social support to affect frequency of cost discussions within interactions. Younger patients with more social support had more cost discussions; older patients with more social support had fewer cost discussions.

CONCLUSION

Cost discussions occurred in fewer than one half of the interactions and most commonly focused on the impact of the diagnosis on patients' opportunity costs rather than treatment costs. Implications for ASCO's Value Framework and design of interventions to improve cost discussions are discussed.

Influences of race and breast density on related cognitive and emotion outcomes before mandated breast density notification

RATIONALE

Many states have adopted laws mandating breast density (BD) notification for applicable women; however, very little is known about what women knew or felt about BD and related breast cancer (BC) risk before implementation of BD notification laws.

OBJECTIVE

We examined between-race differences in the extent to which having dense breasts was associated with women's related BD cognition and emotion, and with health care providers' communication about BD.

METHODS

We received surveys between May and October of 2015 assessing health care provider (HCP) communication about BD, BD-related knowledge, BD-related anxiety and BC worry from 182 African American (AA) and 113 European American (EA) women in the state of Michigan for whom we had radiologists' assessments of BD.

RESULTS

Whereas having dense breasts was not associated with any BD-related cognition or emotion, there were robust effects of race as follows: EA women were more likely to have been told about BD by a HCP, more likely to know their BD status, had greater knowledge of BD and of BC risk, and had greater perceptions of BC risk and worry; AA women had greater BD-related anxieties. EA women's greater knowledge of their own BD status was directly related to the increased likelihood of HCP communication about BD. However, HCP communication about BD attenuated anxiety for AA women only.

CONCLUSION

We present the only data of which we are aware that examines between-race differences in the associations between actual BD, HCP communication and BD related cognition and emotion before the implementation of BD notification laws. Our findings suggest that the BD notification laws could yield positive benefits for disparities in BD-related knowledge and anxiety when the notifications are followed by discussions with health care providers.

Barriers to Clinical Trial Enrollment in Racial and Ethnic Minority Patients With Cancer

BACKGROUND

Clinical trials that study cancer are essential for testing the safety and effectiveness of promising treatments, but most people with cancer never enroll in a clinical trial - a challenge exemplified in racial and ethnic minorities. Underenrollment of racial and ethnic minorities reduces the generalizability of research findings and represents a disparity in access to high-quality health care.

METHODS

Using a multilevel model as a framework, potential barriers to trial enrollment of racial and ethnic minorities were identified at system, individual, and interpersonal levels. Exactly how each level directly or indirectly contributes to doctor-patient communication was also reviewed. Selected examples of implemented interventions are included to help address these barriers. We then propose our own evidence-based intervention addressing barriers at the individual and interpersonal levels.

RESULTS

Barriers to enrolling a diverse population of patients in clinical trials are complex and multilevel. Interventions focused at each level have been relatively successful, but multilevel interventions have the greatest potential for success.

CONCLUSION

To increase the enrollment of racial and ethnic minorities in clinical trials, future interventions should address barriers at multiple levels.

The Effects of Oncologist Implicit Racial Bias in Racially Discordant Oncology Interactions

PURPOSE

Health providers' implicit racial bias negatively affects communication and patient reactions to many medical interactions. However, its effects on racially discordant oncology interactions are largely unknown. Thus, we examined whether oncologist implicit racial bias has similar effects in oncology interactions. We further investigated whether oncologist implicit bias negatively affects patients' perceptions of recommended treatments (i.e., degree of confidence, expected difficulty). We predicted oncologist implicit bias would negatively affect communication, patient reactions to interactions, and, indirectly, patient perceptions of recommended treatments.

METHODS

Participants were 18 non-black medical oncologists and 112 black patients. Oncologists completed an implicit racial bias measure several weeks before video-recorded treatment discussions with new patients. Observers rated oncologist communication and recorded interaction length of time and amount of time oncologists and patients spoke. Following interactions, patients answered questions about oncologists' patient-centeredness and difficulty remembering contents of the interaction, distress, trust, and treatment perceptions.

RESULTS

As predicted, oncologists higher in implicit racial bias had shorter interactions, and patients and observers rated these oncologists' communication as less patient-centered and supportive. Higher implicit bias also was associated with more patient difficulty remembering contents of the interaction. In addition, oncologist implicit bias indirectly predicted less patient confidence in recommended treatments, and greater perceived difficulty completing them, through its impact on oncologists' communication (as rated by both patients and observers).

CONCLUSION

Oncologist implicit racial bias is negatively associated with oncologist communication, patients' reactions to racially discordant oncology interactions, and patient perceptions of recommended treatments. These perceptions could subsequently directly affect patient-treatment decisions. Thus, implicit racial bias is a likely source of racial treatment disparities and must be addressed in oncology training and practice.

Between-race differences in the effects of breast density information and information about new imaging technology on breast-health decision-making

OBJECTIVES

Some US states have mandated that women be informed when they have dense breasts; however, little is known about how general knowledge about breast density (BD) affects related health decision-making. We examined the effects of BD information and imaging technology information on 138 African-American (AA) and European-American (EA) women's intentions to discuss breast cancer screening with their physicians.

METHODS

Women were randomly assigned to receive BD information and/or imaging technology information via 2 by 2 factorial design, and completed planned behavior measures (e.g., attitudes, intentions) related to BC screening.

RESULTS

Attitudes mediated the effects of BD information, and the mediation was stronger for AA women compared to EA women. Effects were more robust for BD information compared to imaging technology information. Results of moderator analyses revealed suppressor effects of injunctive norms that were moderated by imaging technology information.

CONCLUSION

Information about BD favorably influences women's intentions to engage in relevant breast health behaviors. Stronger attitude mediated-effects for AA women suggest greater scrutiny of BD information.

PRACTICE IMPLICATIONS

Since BD information may influence women's intentions to discuss BC screening, strategies to effectively present BD information to AA women should be investigated given the likelihood of their increased scrutiny of BD information.

Barriers to cancer screening among Orthodox Jewish women

The increased risk of genetic cancer mutations for Ashkenazi Jews is well known. However, little is known about the cancer-related health behaviors of a subset of Ashkenazi Jews, Orthodox Jews, who are a very religious and insular group. This study partnered with Rabbinical leadership and community members in an Orthodox Jewish community to investigate barriers to cancer screening in this community. Orthodox Jewish women were recruited to participate in focus groups designed to elicit their perspectives on barriers to cancer screening. A total of five focus groups were conducted, consisting of 3-5 members per group, stratified by age and family history of cancer. Focus groups were audio recorded and transcribed. Transcripts were coded using conventional content analysis. The resulting themes identified as barriers to cancer screening were: preservation of hidden miracles, fate, cost, competing priorities, lack of culturally relevant programming, lack of information, and fear. These results provide a unique perspective on barriers to cancer screening in a high risk but understudied population. Findings from this study may serve to inform culturally appropriate cancer education programs to overcome barriers to screening in this and other similar communities.

Abstract IA14: Multilevel sources of bias as determinants of treatment disparities

Race disparities in cancer incidence and mortality continue to persist. Unequal treatment (IOM, 2003) for Blacks compared to Whites, is a key factor driving disparities in survivorship and mortality. Research documenting disparities in cancer treatment has shown, for example, that when compared to Whites, Black patients have less access and/or information about clinical trials, are more likely to be under dosed when receiving chemotherapy for breast cancer, are less likely to receive chemotherapy for leukemia, are given less information about hospice care, are less likely to receive adequate levels of pain medication, among others. Social psychological theories of intergroup relations have been helpful for understanding unequal treatment as an outcome of individual level factors associated with physician and patient race related thoughts and feelings, (e.g., White physicians' prejudice or explicit/implicit bias regarding Black patients and Black patients' mistrust or suspicion of White physicians and the healthcare system.) These individual level factors may be expressed in the treatment setting because most Black cancer patients are treated by non-Black oncologists and experience race-discordant clinical interactions. The interaction occurs at the relational level, which, thus, presents a second set of factors related to poor communication and errors in understanding that also potentially contribute to treatment disparities.

This presentation will include research showing how social psychological theories of intergroup relations are helping to explain how individual level race-related thoughts and feelings and relational level communication factors that arise in race-discordant clinical interactions result in treatment disparities. The discussion will include initial results from a current study at two comprehensive cancer centers in an urban Midwestern city that included Black cancer patients (n=112) and non-Black oncologists (n=18). Baseline information collected before the initial clinic visit to discuss treatment options included measures of physicians' explicit and implicit racial bias and patients' perceived past discrimination, and group-based suspicion of healthcare. The clinic visit was then video recorded and digitally coded for verbal and nonverbal behavior, information exchange, physician/patient talk time, interaction length, patient centeredness, behavioral synchronicity, etc. Measures administered to patients after the visit included perceived patient centeredness, trust, distress, difficulty in remembering the content of the interaction, and expectations about recommended treatments. Physician measures included perceptions of patient involvement in treatment decisions, and the patients' personal attributes, and expectations about patient responses to treatments. Appropriateness of actual treatment received was later abstracted from the patient's medical record. Early findings show that higher oncologist implicit bias is associated with less reported patient involvement in treatment decisions, less time spent with the patient, lower blind observers' ratings of physician supportiveness, and less smiling and shorter gaze towards patient. Patients interacting with higher implicit oncologists reported less patient centeredness, less trust in the oncologist (one week later), and more difficulty remembering and understanding the conversation (one week later). Indirect effects show that higher implicit physician bias results in lower patient perceived patient centeredness (during the interaction), which subsequently causes patients to be more distressed following the interaction and to expect the recommended treatment to be more difficult to complete.

Interventions to reduce the negative impacts of individual level race related thoughts and feelings and race-discordant interactions will be described during the talk. Unfortunately, race-discordant clinical interactions are unlikely to change in the near-term given the major shortage of Black oncologists (e.g., only about 172 Black medical oncologists practice in the U.S.) and low percentage of Black medical trainees. However, other multilevel approaches are being tested, including patient activation techniques, such as the use of question prompt lists to improve communication patterns in the visit, which may enhance the quality of the interaction and the treatment decision making process. In addition, physician-focused interventions are being created to increase relational communication skills and alliance building. One unique strategy is to increase mindfulness and behavior modeling. The study authors are testing this by using direct observations of video recorded oncology interactions. The project involves having professional actors re-enact the actual clinical interactions that we have video recorded of high-implicit bias physicians and low implicit bias physicians. Fidelity studies comparing our re-enacted (but de-identified) clinical interactions with the original video recordings show strong concordance. Using re-enactments to show physicians, especially less experienced physicians, how such verbal and nonverbal behavioral patterns differ may provide effective training.

Citation Format: Terrance L. Albrecht. Multilevel sources of bias as determinants of treatment disparities. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr IA14.

Abstract C20: Understanding disparities in cancer survivorship: Introducing the Cancer Survivorship in Metropolitan Detroit Cohort Study

Background: Recent successes in cancer diagnosis and treatment have led to improved survival overall; however, African-Americans (AA) continue to experience worse survival outcomes than whites for many cancers, and AA survivors in Detroit often experience poorer outcomes than those in other parts of the country. The reasons underlying these differing survivorship outcomes and disparities relative to white survivors are not clear. We have established the Cancer Survivorship in Metropolitan Detroit cohort study to evaluate potential contributors to disparities in outcomes including socioeconomic factors, health behaviors, social support, and comorbidities.

Methods: AA and white adults (ages 20-79) seen at the Karmanos Cancer Institute and identified through the Metropolitan Detroit Cancer Surveillance System as having been diagnosed with a first primary breast, colorectal, lung, or prostate cancer since January 1, 2013 are eligible to join the cohort. To date, 232 of the targeted 1,000 survivors have completed the self-administered online survey which collects information on demographic and socioeconomic characteristics, medical history, health behaviors, and social support. An interviewer-administered option is available to participants in need of assistance or without access to the Internet. Participants are also asked to consent to provide a saliva sample and access to medical records, and to participate in annual follow-up for up to four years. Data are available on both short-term outcomes such as quality of life and treatment, and long-term outcomes including cancer progression and recurrence and total and cancer-specific survival.

Results: Of the first wave of participants contacted, 60% have completed the baseline questionnaire. The average age of participants is 62, 61% of initial respondents are AA and 66% are women. Overall, 30% of initial questionnaires have been completed online without assistance, including 46% completed by white survivors and 18% by AA survivors. Selected preliminary data suggest several differences between AA and white survivors in the cohort. The majority (62%) of white survivors reported household incomes of at least $40,000 compared with 18% of AA survivors (p&lt;0.001). Relative to whites,fewer AA cancer survivors were married (21% vs 65%, p&lt;0.001), or employed full time (11% vs. 24%, p=0.006) at baseline, and fewer owned or leased a vehicle (55% vs. 89%, p&lt;0.001). A lower proportion of AA survivors (56%) had any form of private health insurance compared with whites (83%, p&lt;0.001). AA survivors reported suffering from 3.3 comorbid conditions on average, compared with 2.7 among whites (p=0.014). A higher proportion of AA survivors reported that pain interfered with day-to-day activities (26% vs. 16%, p=0.06), while a higher proportion of whites reported high levels of fatigue (33% vs. 22%, p=0.06). A greater proportion of AA survivors reported current smoking (33% vs. 14%, p=0.005) and eating fast food regularly (46% vs. 25%, p=0.001), while a lower proportion participated in regular physical activity (24% vs. 42%, p=0.006). Alcohol and fruit and vegetable consumption were similar in white and AA survivors. Social support was also similar among the two groups, with a majority (75-80%) reporting usually or always having someone to help with chores, errands, or if they were confined to bed.

Implications: These preliminary data suggest that AA and white cancer survivors in Detroit vary with regard to a number of health-related factors that may impact outcomes. These data can be used to further understand and address survival disparities and improve outcomes among AA cancer survivors, and may be instructive to other investigators implementing cohort studies among cancer survivors, particularly those wishing to incorporate online data collection.

Citation Format: Theresa A. Hastert, Tara Baird, Julie J. Ruterbusch, Terrance L. Albrecht, Ann G. Schwartz, Jennifer L. Beebe-Dimmer. Understanding disparities in cancer survivorship: Introducing the Cancer Survivorship in Metropolitan Detroit Cohort Study. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr C20.

Financial Concerns About Participation in Clinical Trials Among Patients With Cancer

PURPOSE

The decision to enroll in a clinical trial is complex given the uncertain risks and benefits of new approaches. Many patients also have financial concerns. We sought to characterize the association between financial concerns and the quality of decision making about clinical trials.

METHODS

We conducted a secondary data analysis of a randomized trial of a Web-based educational tool (Preparatory Education About Clinical Trials) designed to improve the preparation of patients with cancer for making decisions about clinical trial enrollment. Patients completed a baseline questionnaire that included three questions related to financial concerns (five-point Likert scales): "How much of a burden on you is the cost of your medical care?," "I'm afraid that my health insurance won't pay for a clinical trial," and "I'm worried that I wouldn't be able to afford the costs of treatment on a clinical trial." Results were summed, with higher scores indicating greater concerns. We used multiple linear regressions to measure the association between concerns and self-reported measures of self-efficacy, preparation for decision making, distress, and decisional conflict in separate models, controlling for sociodemographic characteristics.

RESULTS

One thousand two hundred eleven patients completed at least one financial concern question. Of these, 27% were 65 years or older, 58% were female, and 24% had a high school education or less. Greater financial concern was associated with lower self-efficacy and preparation for decision making, as well as with greater decisional conflict and distress, even after adjustment for age, race, sex, education, employment, and hospital location (P < .001 for all models).

CONCLUSION

Financial concerns are associated with several psychological constructs that may negatively influence decision quality regarding clinical trials. Greater attention to patients' financial needs and concerns may reduce distress and improve patient decision making.

Self-distancing Buffers High Trait Anxious Pediatric Cancer Caregivers against Short- and Longer-term Distress

Pediatric cancer caregivers are typically present at their child's frequent, invasive treatments, and such treatments elicit substantial distress. Yet, variability exists in how even the most anxious caregivers cope. Here we examined one potential source of this variability: caregivers' tendencies to self-distance when reflecting on their feelings surrounding their child's treatments. We measured caregivers' self-distancing and trait anxiety at baseline, anticipatory anxiety during their child's treatment procedures, and psychological distress and avoidance three months later. Self-distancing buffered high (but not low) trait anxious caregivers against short- and long-term distress without promoting avoidance. These findings held when controlling for other buffers, highlighting the unique benefits of self-distancing. These results identify a coping process that buffers vulnerable caregivers against a chronic life stressor while also demonstrating the ecological validly of laboratory research on self-distancing. Future research is needed to explicate causality and the cognitive and physiological processes that mediate these results.

Strategies of persuasion in offers to participate in cancer clinical trials I: Topic placement and topic framing

Clinical trials are the gold standard in medical research evaluating new treatments in cancer care; however, in the United States, too few patients enroll in trials, especially patients from minority groups. Offering patients the option of a clinical trial is an ethically-charged communicative event for oncologists. One particularly vexed ethical issue is the use of persuasion in trial offers. Based on a corpus of 22 oncology encounters with Caucasian-American (n = 11) and African-American (n = 11) patients, this discourse analysis describes oncologists' use of two persuasive strategies related to the linguistic structure of trial offers: topic placement and topic framing. Findings are presented in total and by patient race, and discussed in terms of whether these strategies may constitute ethical or unethical persuasion, particularly with respect to the ethical issue of undue influence and the social issue of underrepresentation of minorities in cancer clinical trials.

Abstract B43: Disparities in mortality and five-year survival by race and socioeconomic status in white and African American women diagnosed with breast cancer in metropolitan Detroit

Background: Racial and, to a lesser extent, socioeconomic disparities in breast cancer incidence and mortality have been well documented; however, little is known about whether observed racial disparities differ by socioeconomic status.

Methods: We used data from the population-based Metropolitan Detroit Cancer Surveillance System to estimate hazard ratios of death for non-Hispanic white (N = 31,102, including 8,174 deaths) and African-American women (N = 9,257, including 3,133 deaths) ages 18 and older diagnosed with incident, invasive breast cancer with recorded stage between 2000 and 2013 in Oakland, Wayne, and Macomb counties in Michigan and to estimate 5-year survival percentages for women diagnosed between 2000 and 2008 (N = 18,922). Neighborhood poverty was measured using the proportion of households with incomes below the federal poverty level in 2000 in the women's census tracts of residence at diagnosis. We used Cox proportional hazards models controlling for age at diagnosis, year of diagnosis, and cancer stage at diagnosis to estimate hazard ratios (HR) and 95% confidence intervals (CI) associated with mortality. Standard errors were adjusted to account for unobserved correlation between residents of the same census tracts.

Results: Risk of death in African-American women diagnosed with breast cancer was 57% higher than for white women (HR: 1.57, 95% CI: 1.48, 1.67), and this association attenuated when also controlling for neighborhood poverty (HR: 1.31, 95% CI: 1.20, 1.42). Living in high-poverty neighborhoods was associated with a 77% higher risk of death (HR: 1.77, 95% CI: 1.64, 1.91), and this association also attenuated when controlling for race (HR: 1.46, 95% CI: 1.33, 1.62). Risk of death was higher for African-American women than for white women at every level of neighborhood poverty, although the associations were stronger in the lowest poverty areas (HR associated with being African-American: 1.68, 95% CI: 1.33, 2.12) than in the highest-poverty areas (HR: 1.23, 95% CI 1.08, 1.40). Among white women, higher neighborhood poverty was associated with higher risk of death (HR for high- vs. low-poverty areas: 1.57, 95% CI: 1.37, 1.79), but living in higher-poverty areas was not associated with mortality among African-American women with breast cancer (HR for high- vs. low-poverty areas: 1.21, 95% CI: 0.96, 1.51). Five-year survival was higher in white women (77.6%) than in African-American women (65.3%) overall. This difference in 5-year survival was largest for women living in the lowest-poverty areas (81.5% for whites vs. 70.1% for African-Americans), but was much smaller for women in the highest-poverty areas (66.2% for whites vs. 62.3% for African Americans).

Conclusions: Although important disparities in mortality exist for African-American women compared with white women with breast cancer, disparities also exist by socioeconomic status, particularly for white women. The extent to which these disparities could be due to treatment differences, age at diagnosis, and type of breast cancer is being examined. It is important to consider socioeconomic status in addition to race when identifying and addressing disparities in breast cancer outcomes.

Citation Format: Theresa A. Hastert, Ann G. Schwartz, Terrance L. Albrecht. Disparities in mortality and five-year survival by race and socioeconomic status in white and African American women diagnosed with breast cancer in metropolitan Detroit. [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 B43.

Satisfaction with support versus size of network: differential effects of social support on psychological distress in parents of pediatric cancer patients

OBJECTIVE

This study examined the direct and buffering effects of social support on longer-term global psychological distress among parents coping with pediatric cancer. In both sets of analyses, we examined whether these effects depended on the dimension of social support provided (i.e., satisfaction with support versus size of support network).

METHOD

Participants were 102 parents of pediatric cancer patients. At study entry, parents reported their trait anxiety, depression, and two dimensions of their social support network (satisfaction with support and size of support network). Parents subsequently reported their psychological distress in 3- and 9-month follow-up assessments.

RESULTS

Parents' satisfaction with support had a direct effect on longer-term psychological distress; satisfaction was negatively associated with distress at both follow-ups. In contrast, size of support network buffered (moderated) the impact of trait anxiety and depression on later distress. Parents with smaller support networks and higher levels of trait anxiety and depression at baseline had higher levels of psychological distress at both follow-ups; for parents with larger support networks, there was no relationship.

CONCLUSION

Social support can attenuate psychological distress in parents coping with pediatric cancer; however, the nature of the effect depends on the dimension of support. Whereas interventions that focus on increasing satisfaction with social support may benefit all parents, at-risk parents will likely benefit from interventions that ensure they have an adequate number of support resources.

Patient- and Family-Centered Care as an approach to reducing disparities in asthma outcomes in urban African American children: A review of the literature

We thank Cathy Eames (Director, Library Services, Detroit Medical Center) for valuable input and assistance with the search strategy. Funding for this research was supported by a grant from Children's Hospital of Michigan Research Foundation (Principal Investigator: Terrance L. Albrecht, Ph.D.).

BACKGROUND

Patient- and family-centered care (PFCC) has the potential to address disparities in access and quality of healthcare for African American pediatric asthma patients by accommodating and responding to the individual needs of patients and families.

STUDY OBJECTIVES

To identify and evaluate research on the impact of family-provider interventions that reflect elements of PFCC on reducing disparities in the provision, access, quality, and use of healthcare services for African American pediatric asthma patients.

METHODS

Electronic searches were conducted using PubMed, CINAHL, and Psyclnfo databases. Inclusion criteria were peer-reviewed, English-language articles on family-provider interventions that (a) reflected one or more elements of PFCC and (b) addressed healthcare disparities in urban African American pediatric asthma patients (≤18years).

RESULTS

Thirteen interventions or programs were identified and reviewed. Designs included randomized clinical trials, controlled clinical trials, pre- and post-interventions, and program evaluations.

CONCLUSIONS

Few interventions were identified as explicitly providing PFCC in a pediatric asthma context, possibly because of a lack of consensus on what constitutes PFCC in practice. Some studies have demonstrated that PFCC improves satisfaction and communication during clinical interactions. More empirical research is needed to understand whether PFCC interventions reduce care disparities and improve the provision, access, and quality of asthma healthcare for urban African American children.

ELECTRONIC DATABASES USED

PubMed, CINAHL, and Psyclnfo

ABBREVIATIONS

AA-African American: CCT-Controlled clinical trial; ED-Emergency Department; ETS-Environmental tobacco smoke; FCC- Family Centered Care; PFCC-Patient and Family Centered Care; RCT- Randomized, controlled trial.

Comparing thin slices of verbal communication behavior of varying number and duration

OBJECTIVE

The aim of this study was to assess the accuracy of thin slices to characterize the verbal communication behavior of counselors and patients engaged in Motivational Interviewing sessions relative to fully coded sessions.

METHODS

Four thin slice samples that varied in number (four versus six slices) and duration (one- versus two-minutes) were extracted from a previously coded dataset. In the parent study, an observational code scheme was used to characterize specific counselor and patient verbal communication behaviors. For the current study, we compared the frequency of communication codes and the correlations among the full dataset and each thin slice sample.

RESULTS

Both the proportion of communication codes and strength of the correlation demonstrated the highest degree of accuracy when a greater number (i.e., six versus four) and duration (i.e., two- versus one-minute) of slices were extracted.

CONCLUSION

These results suggest that thin slice sampling may be a useful and accurate strategy to reduce coding burden when coding specific verbal communication behaviors within clinical encounters.

PRACTICE IMPLICATIONS

We suggest researchers interested in using thin slice sampling in their own work conduct preliminary research to determine the number and duration of thin slices required to accurately characterize the behaviors of interest.

Measuring the use of examination room time in oncology clinics: a novel approach to assessing clinic efficiency and patient flow

PURPOSE

The use of time in outpatient cancer clinics is a marker of quality and efficiency. Inefficiencies such as excessive patient wait times can have deleterious effects on clinic flow, functioning, and patient satisfaction. We propose a novel method of objectively measuring patient time in cancer clinic examination rooms and evaluating its impact on overall system efficiency.

METHODS

We video-recorded patient visits (N = 55) taken from a larger study to determine patient occupancy and flow in and out of examination rooms in a busy urban clinic in a National Cancer Institute-designated comprehensive cancer center. Coders observed video recordings and assessed patient occupancy time, patient wait time, and physician-patient interaction time. Patient occupancy time was compared with scheduled occupancy time to determine discrepancy in occupancy time. Descriptive and correlational analyses were conducted.

RESULTS

Mean patient occupancy time was 94.8 minutes (SD = 36.6), mean wait time was 34.9 minutes (SD = 28.8), and mean patient-physician interaction time was 29.0 minutes (SD = 13.5). Mean discrepancy in occupancy time was 40.3 minutes (range, 0.75 to 146.5 minutes). We found no correlation between scheduled occupancy time and patient occupancy time, patient-physician interaction time, and patient wait time, or between discrepancy in occupancy time and patient-physician interaction time.

CONCLUSION

The method is useful for assessing clinic efficiency and patient flow. There was no relationship between scheduled and actual time patients spend in exam rooms. Such data can be used in the design of interventions that reduce patient wait times, increase efficient use of resources, and improve scheduling patterns.

Reducing Racial Health Care Disparities: A Social Psychological Analysis

Large health disparities persist between Black and White Americans. The social psychology of intergroup relations suggests some solutions to health care disparities due to racial bias. Three paths can lead from racial bias to poorer health among Black Americans. First is the already well-documented physical and psychological toll of being a target of persistent discrimination. Second, implicit bias can affect physicians' perceptions and decisions, creating racial disparities in medical treatments, although evidence is mixed. The third path describes a less direct route: Physicians' implicit racial bias negatively affects communication and the patient-provider relationship, resulting in racial disparities in the outcomes of medical interactions. Strong evidence shows that physician implicit bias negatively affects Black patients' reactions to medical interactions, and there is good circumstantial evidence that these reactions affect health outcomes of the interactions. Solutions focused on the physician, the patient, and the health care delivery system; all agree that trying to ignore patients' race or to change physicians' implicit racial attitudes will not be effective and may actually be counterproductive. Instead, solutions can minimize the impact of racial bias on medical decisions and on patient-provider relationships.

Unexpected findings in the exploration of African American underrepresentation in biospecimen collection and biobanks

Racial/ethnic minorities are underrepresented in current biobanking programs. The current study utilized community-based participatory research to identify motivating factors and barriers that affect older African Americans' willingness to donate biospecimens. The standardized phone survey was administered to 78 African Americans who are 55 years old or older and live in the metropolitan Detroit area to assess their overall willingness to donate biospecimens and what factors were associated with it. The majority of the participants were willing to donate biospecimens, along with their personal information, for medical research and indicated that they did donate biospecimens when they were asked. However, African Americans were rarely asked to participate in biobanking programs. Furthermore, African Americans were not as concerned with research exploitation or as mistrusting of medical researchers as previously thought by the medical researchers. Even if African Americans were concerned over potential research exploitation or mistrust of medical researchers, these concerns or mistrust did not translate into an actual unwillingness to participate in biobanking programs. Rather, transparency in medical research and biobanking programs was more important when predicting African Americans' willingness to donate biospecimens for medical research. The findings suggest that underrepresentation of African Americans in current biobanking programs may not be due to their willingness/unwillingness to participate in such programs but rather due to a failure of medical researchers to approach them. Additionally, researchers and clinicians should focus on increasing the transparency of medical research and biobanking programs rather than changing African Americans' potential negative attitudes toward them.

Modeling the sustainability of community health networks: novel approaches for analyzing collaborative organization partnerships across time

Sustainability is important if community health organizations are to be effective in collaborating to achieve long term health goals. We present a multi-method set of longitudinal analyses examining structural markers applied to a group of organizations brought together to reduce cancer disparities among older African American adults. At the overall network level, sustainability was seen in the growth of outgoing connections and multiplexity. Results of hierarchical clustering analyses identified distinct patterns of collaborative activation over time at the relationship level. Growth modeling indicated the effects of continuing network membership and participation in collaborative events on several structural markers of sustainability. Results of these analyses provide longitudinal indicators for how collaborations among partner organizations impacted their likelihood of continuing in the community network program. The strategy presented here introduces novel methods to assist with planning and evaluation of future community based public health endeavors.

Temperament, personality, and quality of life in pediatric cancer patients

OBJECTIVE

The developmental psychology literature shows that children with higher levels of effortful control (EC) and ego-resilience (ER) display greater social competence and better emotional adjustment. This study examined whether these dispositional attributes contribute to positive quality of life (QOL) in pediatric cancer patients.

METHOD

Participants were 103 pediatric cancer patients (and their parents) who were part of a larger parent study. At study entry, parents reported their own anxiety and depression and their children's EC and ER. At 3-month follow-up, parents reported children's QOL.

RESULTS

ER was positively correlated with children's QOL. EC showed a positive indirect effect on QOL through ER. Inclusion of potential correlates of pediatric QOL (e.g., parent neuroticism) did not change these relationships.

CONCLUSIONS

Temperament and personality play significant roles in pediatric cancer patients' QOL. Assessing dispositional attributes early in treatment may help identify children at risk for poor QOL during and after treatment.