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Objectives In 2012, onetime hepatitis C virus (HCV) screening was recommended for all baby boomers (people born during 1945-1965) in the United States, but only 4.0%-12.9% of baby boomers have ever had a screening ordered by a health care provider. This study examined the HCV screening prevalence among adult patients in a large academic health care system and assessed factors associated with the completion of screening when ordered for baby boomers. Methods We defined HCV screening completion as the completion of an HCV antibody test when it was ordered. We used electronic health records to examine HCV screening completion rates among adults (N = 106 630) from August 1, 2015, through July 31, 2020, by birth cohort. Among baby boomers whose health care provider ordered HCV screening, we examined frequency and percentages of HCV screening completion by sociodemographic and clinical characteristics. We conducted univariate and multivariable logistic regression analyses to assess factors associated with HCV screening completion among baby boomers. Results During the study period, 73.0% of baby boomers completed HCV screening when it was ordered. HCV completion did not differ by sex or race and ethnicity among baby boomers. Baby boomers with Medicare supplemental health insurance compared with commercial health insurance (adjusted odds ratio [aOR] = 1.87) and those seeing only advanced practice professionals compared with specialty care physicians (aOR = 2.24) were more likely to complete HCV screening when it was ordered. Conclusions Noncompletion of HCV screening is one of many barriers along the HCV treatment continuum. Our findings suggest a need for interventions targeting systems, health care providers, and patients to increase HCV screening rates in the United States.

To assess Hispanic participants' ratings of intervention materials and examine differences by language preference.Participants on a skin cancer prevention trial were randomized to receive generic (n = 457) or precision prevention materials conveying average (n = 195) or higher genetic risk (n = 268) based on MC1R genotype. Three months after receiving either English or Spanish language prevention materials, participants reported amount read, believability and clarity of materials, and intention to change preventive behavior.Participants reported high levels on all four outcomes, but the precision prevention groups noted lower clarity than the generic group (p = 3.2 ×10Skin cancer prevention materials were well-received by Hispanic participants. Higher scores among participants preferring Spanish may indicate acquiescence bias, or that translated prevention materials met their linguistic needs. Participants in the precision prevention groups with English language preference may have challenges in the uptake of genetic risk results.Availability of Spanish materials may have facilitated higher scores. Additional strategies should be explored to optimize participants' believability and clarity of precision prevention materials.

Objectives Chronic hepatitis C virus (HCV) infection is one of the main causes of hepatocellular carcinoma. Before initiating a multilevel HCV screening intervention, we sought to (1) describe concordance between the electronic health record (EHR) data warehouse and manual medical record review in recording aspects of HCV testing and treatment and (2) estimate the percentage of patients with chronic HCV infection who initiated and completed HCV treatment using manual medical record review. Methods We examined the medical records for 177 patients (100 randomly selected patients born during 1945-1965 without evidence of HCV testing and 77 adult patients of any birth cohort who had completed HCV testing) with a primary care or relevant specialist visit at an academic health care system in Tampa, Florida, from 2015 through 2018. We used the Cohen κ coefficient to examine the degree of concordance between the searchable data warehouse and the medical record review abstractions. Descriptive statistics characterized referral to and receipt of treatment among patients with chronic HCV infection from medical record review. Results We found generally good concordance between the data warehouse abstraction and medical record review for HCV testing data (κ ranged from 0.66 to 0.87). However, the data warehouse failed to capture data on HCV treatment variables. According to medical record review, 28 patients had chronic HCV infection; 16 patients were prescribed treatment, 14 initiated treatment, and 9 achieved and had a reported posttreatment undetected HCV viral load. Conclusions Using data warehouse data provides generally reliable HCV testing information. However, without the use of natural language processing and purposeful EHR design, manual medical record reviews will likely be required to characterize treatment initiation and completion.

A randomized trial was conducted to examine whether providing precision prevention materials incorporating melanocortin-1 receptor genetic risk information would increase intention to practice melanoma preventive behaviors. Here, we determine retention/evaluation of prevention materials for adolescent and young adults (AYA) 18 to 39 years old versus adults aged 40+ at 6 and 12 months as an a priori adjunct analysis to the primary research question. Using qualitative methodology, open-ended questions probing most important information from prevention materials and additional comments were collected at 6 and 12 months after baseline. Descriptive statistics were performed on demographic/self-reported characteristics. Two independent researchers applied qualitative thematic content analysis to identify major themes in open-ended questions. Of the 1,134 participants randomized, 906 completed at least one of the follow-up surveys and contributed to analyses of intervention efficacy. Five major thematic categories emerged from the open-ended response data: (i) tips and tricks for sun protection; (ii) cancer prevention; (iii) risk factors and genetics; (iv) general information; and (v) intervention comments. Across all ages, the most important information retained were sun protection techniques in the generic prevention materials group and identifying the importance of genetic risk factors/implementing lifestyle behavior changes in the precision prevention materials group. For additional comments, AYA participants in the generic prevention materials group preferred more scientific information including statistics and citations for references while adults were more likely to state they already knew cancer prevention techniques. Results provide unique qualitative evaluation of AYA versus adult retention of prevention materials for melanoma that enhance quantitative findings. Prevention Relevance: It is important to evaluate information within groups defined by periods of the life trajectory, e.g., AYA and adults, to best inform preferences, knowledge, and motivation for behavior change. By assessing retention, evidence-based interventions can be designed to better support public health messaging and encourage positive health behaviors.

Few studies have examined cognitive responses to mailed precision prevention materials. MC1R is a robust, well-described melanoma susceptibility marker. The purpose was to assess cognitive responses to generic or precision prevention materials incorporating MC1R genetic risk. Non-Hispanic White participants (n = 1134) enrolled in a randomized controlled trial received either precision prevention materials incorporating MC1R genetic risk (higher/average) or generic prevention (standard) materials. Six months after baseline, 808 (71.3%) participants reported on the amount of prevention materials read (5-point scale); believability and clarity of materials; intention to change preventive behaviors (7-point Likert scale); and recall of their MC1R genetic risk. Comparisons were conducted using Kruskal-Wallis and chi-squared tests. Overall, participants read most to all (Mdn = 4, IQR = 2) of the prevention materials, reported high believability (Mdn = 7, IQR = 1) and clarity (Mdn = 7, IQR = 1), and moderate intention to change preventive behaviors (Mdn = 5, IQR = 2). Higher-risk participants reported slightly less clarity (Mdn = 6, IQR = 2) than either average-risk (Mdn = 6, IQR = 1, p = 2.50 × 10-3) or standard participants (Mdn = 7, IQR = 1, p = 2.30 × 10-5); and slightly less believability (Mdn = 6, IQR = 1) than standard participants (Mdn = 7, IQR = 1, p = .005). Higher-risk participants were 2.21 times as likely (95% CI = 1.43-3.43) to misremember or forget their risk compared to average-risk participants; misremembering was observed only among higher-risk participants (14%). Mailed precision prevention information were mostly read, highly believable and clear, and resulted in moderate levels of intention to change sun protection behaviors, bolstering the feasibility of population-level precision prevention. Defensive reactions may explain lower clarity, believability, and higher incorrect risk recall among higher-risk participants.Precision prevention uses an individual’s genetics, environment, and/or lifestyle to promote prevention behaviors. However, if materials incorporating precision prevention information are not easily accessible, individuals may misinterpret or distrust findings. Few studies have examined participant-reported believability and clarity of mailed precision prevention materials, how much they read, and whether they intend to change preventive behaviors. We assessed genetic risk for melanoma by determining DNA variation at the MC1R gene, a known melanoma risk marker. Participants were mailed either precision prevention materials conveying their MC1R genetic risk or generic (without genetic risk information) prevention materials. Overall, participants read most of the materials, gave high believability and clarity scores, and reported moderate levels of intention to change preventive behavior. However, participants at higher genetic risk had slightly lower believability and clarity scores than the generic group and were more likely to forget or misremember their genetic risk than participants at average genetic risk. Among participants who correctly recalled their genetic risk, differences in believability diminished, while differences in clarity remained. We conclude that precision prevention materials are highly believable and clear, but additional strategies may be necessary to maximize believability, clarity, and risk recall for individuals at a higher genetic risk.

PURPOSE: Breast cancer survivors (BrCS) experience many psychosocial difficulties following treatment, leading to an increased risk of psychological distress compared to the general population. This is especially true for underserved BrCS whose unmet supportive care needs can result in worse physical and mental health outcomes. This qualitative study compared health care and support providers’ perceptions of BrCS’ needs to survivors’ perceptions of their own needs. METHODS: Semi-structured in-depth interviews were conducted with 25 underserved BrCS and 20 cancer survivorship stakeholders identified using purposeful sampling. Using the constant comparison method and content analysis, data were analyzed via an iterative process of coding and discussion. Data were summarized according to three intermediate and proximal themes mentioned by both stakeholders and survivors: 1) psychosocial needs of cancer survivors; 2) support; and 3) benefit finding/positive feelings about cancer. Demographic data were analyzed by calculating descriptive statistics. RESULTS: There was consistency in providers’ and survivors’ perceptions of post-treatment mood changes, financial burden, familial stress, and physical changes. Providers and survivors differed in perceptions of BrCS’ preferred sources of care and support, effects of cancer treatment on body image, the effects of fear of cancer recurrence on follow-up care, and benefit finding. CONCLUSIONS: This study provides valuable insight into areas in which health care and support providers’ perceptions may differ from underserved BrCS’ lived experiences. Results from this study can be used to develop interventions and inform health care and support providers on how to provide high quality care to underserved BrCS.

Background Breast cancer (BC) risk assessment models are statistical estimates based on patient characteristics. We developed a gene expression assay to assess BC risk using benign breast biopsy tissue. Methods A NanoString-based malignancy risk (MR) gene signature was validated for formalin-fixed paraffin-embedded (FFPE) tissue. It was applied to FFPE benign and BC specimens obtained from women who underwent breast biopsy, some of whom developed BC during follow-up to evaluate diagnostic capability of the MR signature. BC risk was calculated with MR score, Gail risk score, and both tests combined. Logistic regression and receiver operating characteristic curves were used to evaluate these 3 models. Results NanoString MR demonstrated concordance between fresh frozen and FFPE malignant samples (r = 0.99). Within the validation set, 563 women with benign breast biopsies from 2007 to 2011 were identified and followed for at least 5 y; 50 women developed BC (affected) within 5 y from biopsy. Three groups were compared: benign tissue from unaffected and affected patients and malignant tissue from affected patients. Kruskal–Wallis test suggested difference between the groups (P = 0.09) with trend in higher predicted MR score for benign tissue from affected patients before development of BC. Neither the MR signature nor Gail risk score were statistically different between affected and unaffected patients; combining both tests demonstrated best predictive value (AUC = 0.71). Conclusions FFPE gene expression assays can be used to develop a predictive test for BC. Further investigation of the combined MR signature and Gail Model is required. Our assay was limited by scant cellularity of archived breast tissue.

Women who lack health insurance have much lower rates of cervical cancer screening and higher rates of cervical cancer than insured women. The current screening rate for insured patients is 86.9%, while the rate for uninsured women is 68.2%. Student-run free clinics may help increase the rates of cervical cancer screening in uninsured women. As screening rates in this setting are uncertain, this study was performed to determine rates of cervical cancer screening at a student-run free clinic, and therefore determine its effectiveness in increasing screening rates in uninsured women. A retrospective chart review was conducted among female patients ages 21-64 at a student-run free clinic to determine how many patients were up-to-date with cervical cancer screening per American Cancer Society (ACS) guidelines. A total of 239 women were included in the retrospective chart review. At their most recent visit, 87.9% of clinic patients were up-to-date on cervical cancer screening. This screening rate is higher than both the reported uninsured (68.2%) and insured (86.9%) national screening rates in the United States. Although there are multiple barriers that prevent uninsured patients from undergoing cervical cancer screenings, screening rates at our student-run free clinic are higher than national screening rates. This higher screening rate can be attributed to a standardized screening system, access to resources including Pap tests provided by community partners, and the clinic's ability to longitudinally follow patients. However, there remain areas for improvement, such as reducing no-show rates and ensuring that staff screen for cervical cancer at each visit.

Background Baby boomers are at increased risk for hepatitis C virus (HCV) infection and related cancer; therefore, one‐time HCV screening is recommended. Methods To assess prevalence of, and factors associated with providers ordering HCV screening, we examined a retrospective cohort of electronic medical records for patient visits from 01 August 2015 until 31 July 2017 in a large health system. HCV screening ordered was examined by patient age, gender, race/ethnicity, provider specialty, and number of clinical visits, stratified by birth cohort: born ≤1945, 1945‐1965 (baby boomers), 1966‐1985, and ≥1985. Multivariable regression identified factors independently associated with HCV screening ordered among average risk baby boomers. Results A total of 65 114 patients ages ≥18 years were evaluated. Among baby boomers HCV screening test order increased threefold between the two study years (4.0%‐12.9%). Odds of screening test ordered were significantly higher for non‐Hispanic Blacks (multivariable adjusted odds ratio [aOR]=1.36; 95% CI = 1.19‐1.55), males (aOR = 1.44; 95% CI = 1.33‐1.57), and having a clinic visit with a primary care provider alone or with specialty care (aOR = 3.25‐4.16). Medicare (aOR = 0.89; 95% CI = 0.80‐0.99), Medicaid (aOR 0.89; 95% CI 0.80‐0.99), and an unknown provider type (aOR = 0.16; 95% CI = 0.08‐0.33), were associated with lower odds of screening tests ordered. Conclusions While the proportion of baby boomers with an HCV screening test ordered increased during the study, the rate of screening remains far below national goals. Data from this study indicate that providers are not ordering HCV screening universally for all of their baby boomer patients. Continued efforts to increase HCV screening are needed to reduce the incidence of HCV‐related morbidity and mortality.

BACKGROUND: 50% of liver cancer is caused by hepatitis C virus (HCV). Baby boomers are at increased risk and are recommended for one-time HCV screening. However

Background Team-based care practice models have been shown to improve diabetes-related therapeutic inertia, yet the method and type of antidiabetic treatment intensification (TI) leading to improvements in glycemic control are not well understood. Objective To evaluate time to TI in a pharmacist-physician practice model (PPM) as compared with usual medical care (UMC), explore the method and type of antidiabetic TI, and evaluate achievement of hemoglobin A1C (A1C) goal among each cohort. Methods This was a retrospective cohort study conducted between January 1, 2017, and December 31, 2018. Median time to TI was calculated and compared between patients in the PPM and UMC groups using the log rank test. Descriptive statistics were used to evaluate the method and type of TI and A1C goal achievement. Results A total of 56 patients were included. The median (interquartile range) time to antidiabetic TI among the PPM cohort was 37.5 days (8, 216.5), as compared with 142 days (16, 465) in the UMC cohort ( P = 0.19). At 1 year post–index date, 25% of patients in the PPM cohort reached their A1C goal compared with 18.8% of patients in the UMC cohort. This effect was maintained in the subgroup (n = 49) of patients receiving TI (23.1% vs 17.8%). Conclusion and Relevance A shorter time to TI and improvement in A1C goal achievement was observed with pharmacist-physician care compared with UMC. These findings suggest that pharmacist-physician care may be one of several interventions necessary to overcome therapeutic inertia in diabetes care.

OBJECTIVE. Supplemental screening breast MRI is recommended for women with an estimated lifetime risk of breast cancer of greater than 20-25%. The performance of risk prediction models varies for each individual and across groups of women. The present study investigates the concordance of three breast cancer risk prediction models among women presenting for screening mammography. SUBJECTS AND METHODS. In this prospective study, we calculated the estimated lifetime risk of breast cancer using the modified Gail, Tyrer-Cuzick version 7, and BRCAPRO models for each woman who presented for screening mammography. Per American Cancer Society guidelines, for each woman the risk was categorized as less than 20% or 20% or greater as well as less than 25% or 25% or greater with use of each model. Venn diagrams were constructed to evaluate concordance across models. The McNemar test was used to test differences in risk group allocations between models, with p ≤ .05 considered to denote statistical significance. RESULTS. Of 3503 screening mammography patients who underwent risk stratification, 3219 (91.9%) were eligible for risk estimation using all three models. Using at least one model, 440 (13.7%) women had a lifetime risk of 20% or greater, including 390 women (12.1%) according to the Tyrer-Cuzick version 7 model, 18 (0.6%) according to the BRCAPRO model, and 141 (4.4%) according to the modified Gail model. Six women (0.2%) had a risk of 20% or greater according to all three models. Women were significantly more likely to be classified as having a high lifetime breast cancer risk by the Tyrer-Cuzick version 7 model compared with the modified Gail model, with thresholds of 20% or greater (odds ratio, 6.4; 95% CI, 4.7-8.7) or 25% or greater (odds ratio, 7.4; 95% CI, 4.7-11.9) used for both models. CONCLUSION. To identify women with a high lifetime breast cancer risk, practices should use estimates of lifetime breast cancer risk derived from multiple risk prediction models.

Background Liver cancer rates are rising and hepatitis C virus (HCV) is the primary cause. The CDC recommends a one-time HCV screening for all persons born 1945–1965 (baby boomers). However, 14% of baby boomers have been screened. Few studies have examined primary care providers’ (PCP) perspectives on barriers to HCV screening. This study examines current HCV screening practices, knowledge, barriers, and facilitators to HCV screening recommendation for baby boomers among PCPs. Methods We conducted a mixed methods pilot study of PCPs. Quantitative: We surveyed PCPs from 3 large academic health systems assessing screening practices, knowledge (range:0–9), self-efficacy to identify and treat HCV (range:0–32), and barriers (range:0–10). Qualitative: We conducted interviews assessing patient, provider, and clinic-level barriers to HCV screening for baby boomers in primary care. Interviews were audio recorded, transcribed, and analyzed with content analysis. Results The study sample consisted of 31 PCPs (22 survey participants and nine interview participants). All PCPs were aware of the birth cohort screening recommendation and survey participants reported high HCV testing recommendation, but qualitative interviews indicated other priorities may supersede recommending HCV testing. Provider knowledge of viral transmission was high, but lower for infection prevalence. While survey participants reported very few barriers to HCV screening in primary care, interview participants provided a more nuanced description of barriers such as lack of time. Conclusions There is a need for provider education on both HCV treatment as well as how to effectively recommend HCV screening for their patients. As HCV screening guidelines continue to expand to a larger segment of the primary care population, it is important to understand ways to improve HCV screening in primary care.

Lower vaccination rates in uninsured adults may be related to prohibitive costs of and limited access to vaccines. To compare Tdap and pneumococcal vaccination rates of a student-run free clinic to national averages. A retrospective chart review of 236 adult patients from 05/2017 to 06/2019 was conducted. Vaccine eligibility was determined according to CDC guidelines at the time of the patient visit and according vaccination history by review of medical records. Percent up-to-date was determined by dividing the number of up-to-date individuals by the total number of patients eligible for the vaccine. BRIDGE Healthcare Clinic vaccination rates were near or surpassed national averages. The percent of up-to-date individuals was 63.1% for Tdap, 90% for pneumococcal vaccines in adults 65 or older, and 86.5% for pneumococcal vaccines in high-risk adults 18–64 years. This compares with 2017 national averages of 63.4%, 69%, and 24.5%, respectively (Center for Disease Control and Prevention (CDC) Vaccination coverage among adults in the United States, National Health Interview Survey. Retrieved February 8, 2018 from https://www.cdc.gov/vaccines/imz-managers/coverage/adultvaxview/pubs-resources/NHIS-2017.html#pneumo , 2017). Of the 197 vaccines provided during the course of this study, 184 were provided by the BRIDGE Healthcare Clinic. In conclusion, with the appropriate funding and stewardship, student-run free clinics play a resourceful role in increasing access to preventative health care for uninsured patients.

HPV vaccination rates in Florida are low. To increase rates, the CDC recommends clinics adhere to components of their evidence-based quality improvement program, AFIX (Assessment, Feedback, Incentives, and eXchange of information). We explored factors associated with engaging in HPV-specific AFIX-related activities. In 2016, we conducted a cross-sectional survey of a representative sample of 770 pediatric and family medicine physicians in Florida and assessed vaccination practices, clinic characteristics, and HPV-related knowledge. Data were analyzed in 2017. The primary outcome was whether physicians' clinics engaged in ≥1 AFIX activity. We stratified by physician specialty and developed multivariable models using a backward selection approach. Of the participants in the analytic sample (n = 340), 52% were male, 60% were White of any ethnicity, and 55% were non-Hispanic. Pediatricians and family medicine physicians differed on: years practicing medicine (p 0.001), HPV-related knowledge (p 0.001), and VFC provider status (p 0.001), among others. Only 39% of physicians reported engaging in ≥1 AFIX activity. In the stratified multivariable model for pediatricians, AFIX activity was significantly associated with HPV-related knowledge (aOR = 1.33;95%CI = 1.08-1.63) and provider use of vaccine reminder prompts (aOR = 3.61;95%CI = 1.02-12.77). For family medicine physicians, HPV-related knowledge was significant (aOR = 1.57;95%CI = 1.20-2.05) as was majority race of patient population (non-Hispanic White vs. Other: aOR = 3.02;95%CI = 1.08-8.43), daily patient load (20 vs. 20-24: aOR = 9.05;95%CI = 2.72-30.10), and vaccine administration to male patients (aOR = 2.98;95%CI = 1.11-8.02). Fewer than half of Florida pediatric and family medicine physicians engaged in any AFIX activities. Future interventions to increase AFIX engagement should focus on implementing and evaluating AFIX activities in groups identified as having low engagement in AFIX activities.

The Pearlin Mastery (PM) Scale is frequently used in health research to assess individuals’ personal mastery or the extent to which they believe they are in control of their own lives. It has been adapted from English into multiple languages including Spanish. However, no studies have assessed the psychometric properties of Spanish translations of the scale. This analysis evaluated structural validity and measurement invariance of the original Spanish translation of the PM Scale in two groups of Spanish-speaking individuals receiving primary care at community clinics in Florida. Confirmatory factor analysis (CFA) indicated that the 5-item version used in the literature yields a unidimensional factor structure as expected; however, multiple-group CFA revealed that the PM Scale items did not load equivalently on the factor across samples. This indicates that the Spanish version of the PM Scale may not measure mastery consistently across groups, possibly due to differences in respondents’ semantic understanding of items or differences in the meaning of the construct itself. Findings suggest that researchers seeking to measure personal mastery in Spanish-speaking participants from diverse cultural backgrounds should consider alternative approaches including the development of new instruments.

Background Recruiting ethnically diverse Black participants to an innovative, community-based research study to reduce colorectal cancer screening disparities requires multipronged recruitment techniques. Objectives This article describes active, passive, and snowball recruitment techniques, and challenges and lessons learned in recruiting a diverse sample of Black participants. Methods For each of the three recruitment techniques, data were collected on strategies, enrollment efficiency (participants enrolled/participants evaluated), and reasons for ineligibility. Results Five hundred sixty individuals were evaluated, and 330 individuals were enrolled. Active recruitment yielded the highest number of enrolled participants, followed by passive and snowball. Snowball recruitment was the most efficient technique, with enrollment efficiency of 72.4%, followed by passive (58.1%) and active (55.7%) techniques. There were significant differences in gender, education, country of origin, health insurance, and having a regular physician by recruitment technique (p < .05). Discussion Multipronged recruitment techniques should be employed to increase reach, diversity, and study participation rates among Blacks. Although each recruitment technique had a variable enrollment efficiency, the use of multipronged recruitment techniques can lead to successful enrollment of diverse Blacks into cancer prevention and control interventions.

The current study examines changes in awareness and health beliefs from baseline to 12 months post-intervention following receipt of one of two colorectal cancer (CRC) educational interventions that aimed to promote CRC screening among a racially and ethnically diverse and medically underserved population. Participants (N = 270) were enrolled in a randomized controlled trial to increase CRC screening and completed both baseline and 12-month follow-up assessments. Participants were aged 50–75, at average CRC risk, not up-to-date with CRC screening guidelines, and receiving care at one of three community-based clinics. Participants were randomized to receive either a targeted, low-literacy intervention informed by the Preventive Health Model [PHM] (photonovella and DVD plus fecal immunochemical test [FIT]) or a non-targeted intervention (standard educational brochure plus FIT). Changes in CRC awareness and health beliefs from baseline to 12 months were examined both within and between intervention groups using Student’s t tests. Participants in both intervention conditions demonstrated an increase in CRC awareness, PHM social influence, and trust in the healthcare system (all p’s

The current study examined the sociodemographic and psychosocial variables that predicted being at risk for low health literacy among a population of racially and ethnically diverse patients accessing primary care services at community-based clinics. Participants (N = 416) were aged 50-75 years, currently not up-to-date with colorectal cancer (CRC) screening, at average CRC risk, and enrolled in a randomized controlled trial (RCT) aimed at promoting CRC screening. Participants completed a baseline interview that assessed health literacy as measured by Rapid Estimate of Adult Literacy in Medicine-Revised, sociodemographic factors, and psychosocial variables (e.g., health beliefs) prior to randomization and receipt of an intervention. Thirty-six percent of the participants were found to be at risk for low health literacy. Sociodemographic and psychosocial variables were assessed as predictors of being at risk for low health literacy using logistic regression. In the final model, predictors were male gender, being from a racial/ethnic minority group, being unable to work, having higher social influence scores, and having higher religious belief scores. These findings suggest several patient characteristics that may be associated with low health literacy, and highlight the importance of supporting all patients through simplified and clear communications and information to improve understanding of CRC screening information.

Many U.S. residents infected with hepatitis C virus (HCV) are baby boomers (born 1945-1965), who remain undiagnosed. Past CDC and USPSTF guidelines recommended one-time HCV testing for all baby boomers, with newer guidelines recommending universal screening for all adults. This retrospective cohort study examined electronic medical records for patient visits from 2015 to 2017 within the OneFlorida Data Trust and University of South Florida Health system. We assessed percentages of HCV tests ordered and completed across four age groups (those born before 1945, 1945-1965, 1966-1985, and after 1985). In 2019, we used logistic regression to examine factors associated with HCV test ordering and completion among baby boomers, including age, race, sex, number of primary care visits, HIV status, hepatitis diagnosis, and liver cancer history. All age groups had low rates of HCV test orders. 4.4% of baby boomers had a test ordered in 2015, and 6.7% in 2016. Of those, 94.5% and 89.7% completed testing, respectively. All other races/ethnicities had lower likelihood of testing completion than Whites (Blacks (aOR 0.82, 95%, CI 0.75-0.91); Asians (0.69, 0.52-0.92); Hispanics (0.29, 0.26-0.32)), although test orders were higher for Asians (1.48, 1.37-1.61) and Blacks (1.78, 1.73-1.82). Tests ordered (11.42, 10.94-11.92) and completed (2.25, 1.94-2.60) were more likely among those with hepatitis history. Test orders were more likely for HIV-positive patients (3.68, 3.45-3.93), but completion was less likely (0.67, 0.57-0.78). Interventions are needed to increase testing rates so that HCV infections are treated early, mitigating HCV-related morbidity and mortality, especially related to liver cancer.

Background: Rates of routine human papillomavirus (HPV) vaccination of adolescent males in the United States are low. Leading health organizations advocate consistent and strong physician recommendations to improve HPV vaccine dissemination. This study describes the prevalence and correlates of consistent and strong physician recommendations for HPV vaccination of adolescent males. Methods: We surveyed pediatric and family medicine physicians in Florida about their HPV vaccine recommendations for male vaccine-eligible age groups (11–12, 13–17, 18–21 years). Descriptive statistics compared consistency and strength of HPV recommendations across age groups. Multivariable logistic regression examined factors associated with consistent and strong recommendations for 11- to 12-year-olds. Results: We received 367 completed surveys (51% response rate). Physicians most often consistently and strongly recommended HPV vaccine to males ages 13 to 17 (39%) compared with ages 11 to 12 (31%) and 18 to 21 (31%). Consistent and strong recommendation for 11- to 12-year-old males was more likely to be delivered by Vaccine for Children providers and less likely among physicians who reported more personal barriers to vaccination, particularly concerns about vaccine safety, concerns about adding vaccines to the vaccine schedule, and difficulty in remembering to discuss HPV vaccination. Conclusions: Physicians' current consistency and strength of HPV vaccine recommendations do not align with national recommendations. Interventions to improve HPV vaccine recommendations must also consider the influence of physicians' personal barriers to HPV vaccine delivery. Impact: As one of the first studies to examine both consistency and strength of physicians' HPV vaccine recommendations for males, our findings can inform future interventions focused on facilitating physicians' recommendations. Cancer Epidemiol Biomarkers Prev; 25(10); 1435–46. ©2016 AACR.

To evaluate the barriers and facilitators to taking anti-hormonal medications among medically and historically underserved breast cancer survivors within the first 5 years post chemotherapy, radiation, and/or surgery.The current study was framed within the National Institutes of Health Centers for Population Health and Health Disparities Model (NIHCPHHD Model). Twenty-five historically or medically underserved breast cancer survivors participated in an in-depth interview, in either English or Spanish. Interviews were audio recorded and transcribed verbatim. Interview data were analyzed using content analysis.Anti-hormonal medication adherence was facilitated in several ways, including establishing a routine of medication taking, leaving the medicine in a visible or easily accessible place, taking the medication with other medications, reducing the cost of medicine, using a pillbox, understanding the negative consequences of lack of adherence, and having positive interactions with physicians. Side effects were the most commonly mentioned barrier to medication adherence.Similar to other research, this qualitative study of medically and historically underserved breast cancer survivors in the USA found that side effects are the most frequently endorsed barrier to anti-hormonal medication adherence. Conversely, there were a number of facilitators of correct and consistent anti-hormonal medication use. The management of side effects is critically important to increase adherence to anti-hormonal medications. Health care providers, support providers, and caregivers can encourage breast cancer survivors to better adhere to anti-hormonal medications using a number of approaches that have been successful for other women.

Cancer patients can be well-connected to resources during treatment but become lost to follow-up and subsequently may receive treatment in free clinics for chronic morbidities. Few studies have examined outcomes for uninsured patients with cancer histories in free clinics, but research examining socioeconomic determinants emphasizes poor cancer outcomes for patients with lower socioeconomic statuses (SES). Demographic data and chronic disease measures were extracted from medical charts of patients treated in 8 free clinics in 2016 in Tampa Bay. Descriptive statistics and Pearson correlation coefficients were used to demonstrate relationships between socioeconomic factors, cancer diagnoses, and comorbidities. Charlson Comorbidity Index (CCI) was used to assess mortality risk and severity of disease burden. The histories of 4804 uninsured patients were evaluated, identifying 86 (1.7%) as having had cancer. They were predominantly female (65.1%) and significantly older than those without cancer histories. Average duration from initial diagnosis was approximately 8.53 years (standard deviation [SD] 7.55). Overall, cancer patients had higher CCI scores (3.04 [1.928 SD] versus 0.90 [1.209 SD]; P

BACKGROUND: To reduce colorectal cancer (CRC) screening disparities, it is important to understand correlates of different types of cancer worry among ethnically-diverse individuals. OBJECTIVES: The current study examined the prevalence of three types of cancer worry (i.e., general cancer worry, CRC-specific worry, and worry about CRC test results) as well as sociodemographic and health-related predictors for each type of cancer worry. METHODS: Participants (N = 416) were aged 50–75, at average CRC risk, non-adherent to CRC screening guidelines, and enrolled in a randomized controlled trial to increase CRC screening. Participants completed a baseline questionnaire assessing sociodemographics, health beliefs, healthcare experiences, and three cancer worry measures. Associations between study variables were examined with separate univariate and multivariable logistic regression models. RESULTS: Forty-seven percent of participants reported experiencing moderate-to-high levels of general cancer worry. Predictors of general cancer worry included salience and coherence (OR = 1.14, 95% CI: 1.01-1.28), perceived susceptibility (OR = 1.18, 95% CI: 1.09-1.27), and social influence (OR = 1.07, 95% CI: 1.01-1.13). Twenty-three percent reported moderate-to-high levels of CRC-specific worry which was predicted by perceived susceptibility (OR = 1.40, 95% CI: 1.26-1.56) and social influence (OR = 1.10, 95% CI: 1.02-1.19). Thirty-five percent reported moderate-to-high levels of worry about CRC test results which was predicted by perceived susceptibility (OR = 1.23, 95% CI: 1.13-1.33) and marital status (OR = 2.00, 95% CI: 1.07-3.73 for married/partnered vs. single and OR = 2.26, 95% CI: 1.26-4.05 for divorced/widowed vs. single). DISCUSSION: Perceived susceptibility consistently predicted the three types of cancer worry, whereas other predictors varied between cancer worry types and in magnitude of association. The three types of cancer worry were generally predicted by health beliefs, suggesting potential malleability. Future research should include multiple measures of cancer worry and clear definitions of how cancer worry is measured.

Cardiovascular disease (CVD) remains the number one cause of mortality in the Western world. This study aims to determine which lifestyle factors are associated with mean carotid intima media thickness (IMT), a safe and reliable predictor of future CVD risk.A prospective cross-sectional analysis of 592 subjects. Measures were made of body composition, anthropometric measures, fitness, diet (measured with a 3-day food diary), laboratory results, and mean carotid IMT. Multivariate analyses show that higher mean IMT values are associated with increasing age (p0.0001), male gender (p = 0.0002), higher systolic blood pressure (BP; p = 0.0008), higher body mass index (BMI; p = 0.0005), and lower intake of zinc (p = 0.0001). Bivariate analyses controlling for age and gender, with and without statin use, showed that higher mean IMT scores were statistically associated with higher diastolic BP (p = 0.007), higher total cholesterol/high-density lipoprotein (HDL) ratio (p0.0001), higher triglyceride/HDL ratio (p = 0.0001), lower aerobic capacity measures (p = 0.0007), higher body fat percentage and waist circumference (p0.0001), higher fasting glucose level (p = 0.028), and lower intake of magnesium (p = 0.019), fish (p = 0.007), and fiber (p = 0.02). Other factors that were not associated with mean IMT include total cholesterol, low-density lipoprotein cholesterol (LDL-C), and high-sensitivity C-reactive protein (hs-CRP); intake of saturated fat, potassium, calcium, sodium, or vitamin K; percentage of calories from protein, fat, or carbohydrate; measures of strength (assessed with push-up and sit-up testing); and reported exercise.Aerobic fitness and dietary intake of fiber, fish, magnesium, and zinc are inversely associated with carotid IMT scores. Of the traditional CVD risk factors, only systolic BP, fasting glucose, body composition, and total cholesterol/HDL ratio have a direct relationship with mean carotid IMT.

Residency training is a pivotal time to establish skills for career-long practices, particularly for challenging skills such as human papillomavirus (HPV) vaccine recommendation. Training experience and preferences related to delivering HPV vaccine recommendations were examined for family medicine (FM) residents and faculty.Residents (n=28) and faculty (n=19) were identified through a national FM residency directory and recruited from training programs in Florida. Participants completed a phone interview assessing key aspects of HPV vaccine recommendation training. Interviews were audio recorded, transcribed verbatim, and analyzed using content analysis. A brief follow-up survey assessing training, practices, and demographics was emailed after the interview.Residents' training experience with HPV vaccine recommendation varied from none to extensive, and was often self-directed. Variation in training was seen between and within programs. Faculty often noted HPV vaccination training was not standardized and residents lacked instruction about effective communication. Most programs relied on preceptors for training residents but training from preceptors varied widely and was often not standardized within the program.This study identified a lack of consistent and standardized training for delivering HPV vaccine recommendations. A training curriculum that uses multiple modalities and reflects resident and faculty preferences is needed.

Background: Rates of hepatitis C virus (HCV) infection are markedly higher for baby boomers compared with other birth cohorts, and they are now recommended for universal one-time screening. This study examines HCV screening rates and predictors for four birth cohorts [born 1985] of a nationally representative sample over time. Methods: We used data from the 2013–2015 National Health Interview Surveys, an annual weighted survey of the U.S. civilian noninstitutionalized population. We assessed HCV screening prevalence stratified birth cohort with bivariate and multivariable logistic regression analyses. Results: There were 15,100 participants born 1985 in the final analytic sample. Screening was 11.5%–12.8% for baby boomers. The second youngest birth cohort was similar to baby boomers (13.7%–14.9%), whereas the older birth cohort was screened less. After excluding participants who typically have higher rates of HCV screening than the general population, we developed a multivariable model of the general population. In the final model for baby boomers the odds of HCV screening increased significantly with each subsequent year (OR=1.20; 95% CI=1.05–1.38 and OR=1.31; 95% CI=1.13–1.52). HCV screening was also significantly associated with age, gender, and race/ethnicity in baby boomers. Conclusions: While HCV screening is increasing over time, these increases are minimal and there is substantial room for improvement. Impact: Future research should develop interventions to increase HCV screening with special focus on groups demonstrating significantly lower screening rates, such as Hispanics and females. Cancer Epidemiol Biomarkers Prev; 27(4); 503–13. ©2018 AACR.

Rates of mild cognitive impairment and Alzheimer's disease are increasing rapidly. None of the current treatment regimens for Alzheimer's disease are effective in arresting progression. Lifestyle choices may prevent cognitive decline. This study aims to clarify which factors best predict cognitive function.This was a prospective cross-sectional analysis of 799 men and women undergoing health and cognitive testing every 1 to 3 years at an outpatient center. This study utilizes data collected from the first patient visit. Participant ages were 18 to 88 (mean = 50.7) years and the sample was 26.6% female and 73.4% male.Measurements were made of body composition, fasting laboratory and anthropometric measures, strength and aerobic fitness, nutrient and dietary intake, and carotid intimal media thickness (IMT). Each participant was tested with a computerized neurocognitive test battery. Cognitive outcomes were assessed in bivariate analyses using t-tests and correlation coefficients and in multivariable analysis (controlling for age) using multiple linear regression.The initial bivariate analyses showed better Neurocognitive Index (NCI) scores with lower age, greater fitness scores (push-up strength, VOModifiable biomarkers that impact cognitive performance favorably include greater aerobic fitness and strength, lower blood sugar levels, greater alcohol intake, lower body fat, and avoidance of tobacco. Further studies are warranted to study whether modifying these lifestyle factors improves cognitive function and slows cognitive decline.

Introduction Varenicline reduces smoking satisfaction during the pre-cessation run-in period, which may contribute to extinction of cravings and smoking behavior. Research indicates that efficacy is enhanced when the run-in period is increased from 1 to 4 weeks, providing a longer extinction opportunity. We hypothesized that efficacy could be further enhanced by harnessing basic and applied research on extinction. We developed a pre-cessation extinction-facilitating intervention and tested its feasibility in a pilot trial. Methods The facilitated extinction (FE) intervention comprised brief counseling and workbook-recommending strategies to maximize extinction processes during the run-in, including instructions to smoke at a normal rate across contexts and cues, and use of an extinction cue to enhance generalization. Participants were randomly assigned to one of three varenicline interventions: standard (1-week run-in), extended (4-week run-in), and extended + FE. Interventions were delivered prior to the target quit date (TQD). Assessments were conducted in weeks 1 and 4 pre-TQD and 1 and 3 months post-TQD, with focus on feasibility indices. Results Recruitment and retention goals were met (N = 58). Treatment satisfaction was high across groups. The majority of FE participants adhered to instructions and maintained their usual smoking rate during the run-in period. Greater decreases in craving and smoking satisfaction were observed among participants in both extended groups versus the standard group (p < .005). Conclusions Feasibility was demonstrated. Participants adhered to the FE intervention, thereby optimizing the number and variety of extinction trials. Findings support testing the novel FE smoking cessation intervention in a fully powered trial. Implications This study expands the research on the clinical benefits of extending the pre-cessation run-in period of varenicline. It introduces the hypothesis that further benefit might be achieved by translating basic behavioral research, as well as cue-exposure research and therapy for other disorders, to improve the extinction and generalization processes thought to underlie much of varenicline’s effect. A FE intervention was developed and found acceptable to smokers and feasible to implement in a research setting. The study sets the stage for a subsequent randomized controlled trial.

This paper recounts experiences, challenges, and lessons learned when implementing a lay patient navigator program to improve cancer care among medically underserved patients who presented in a primary care clinic with a breast or colorectal cancer abnormality. The program employed five lay navigators to navigate 588 patients. Central programmatic elements were the following: (1) use of bilingual lay navigators with familiarity of communities they served; (2) provision of training, education, and supportive activities; (3) multidisciplinary clinical oversight that factored in caseload intensity; and (4) well-developed partnerships with community clinics and social service entities. Deconstruction of healthcare system information was fundamental to navigation processes. We conclude that a lay model of navigation is well suited to assist patients through complex healthcare systems; however, a stepped care model that includes both lay and professional navigation may be optimal to help patients across the entire continuum.

Expectancies regarding treatment assignment may influence outcomes in placebo-controlled trials above and beyond actual treatment assignment. For smoking pharmacotherapies, guessing enrollment in the active medication treatment is associated with higher abstinence rates. However, placebo-controlled trials of smoking pharmacotherapies rarely assess perceived treatment assignment and those that do only collect this information after reaching full dosage. To determine the temporal relationship between treatment expectancies and smoking-related variables, we assessed the impact of treatment guess during a placebo-controlled laboratory study of varenicline on measures of craving, smoking reward, and smoking reinforcement. We hypothesized that treatment guess at mid-titration would influence smoking-related measures at full dosage, above and beyond actual medication effects. We also explored factors related to guess stability and differences in blind fidelity between mid-drug titration and full dosage. Eighty-eight participants completed laboratory assessments at baseline, mid-titration, and full dosage that involved self-report and behavioral measures of tonic craving, cue-provoked craving, smoking reward, and smoking reinforcement. Participants guessed treatment assignment at mid-titration and full dosage. Generalized linear models confirmed that, beyond actual treatment assignment, treatment guess improved model fit for both self-report and behavioral smoking-related measures. Further, accuracy of treatment guess improved from titration to full dosage, and specific demographic factors (e.g., gender, race) were associated with type of treatment guess and guess stability across time. These results reinforce the importance of assessing perceived treatment assignment repeatedly during placebo-controlled trials and suggest that treatment expectancies during titration can affect outcomes once full dosage has been reached.

The objective of this study is to evaluate whether a patient navigation (PN) program is effective in reducing delay in diagnostic resolution among medically underserved patients with colorectal cancer (CRC)-related abnormalities in Tampa Bay, Florida. This study involved ten primary care clinics randomized either to receive navigation or to serve as controls (five clinics per arm). Each clinic identified all subjects with CRC-related abnormalities in the year prior to the clinic beginning participation in the Moffitt Patient Navigator Research Program. Patients with CRC-related abnormalities were navigated from the time of a colorectal abnormality to diagnostic resolution. Control patients received usual care, and outcome information was obtained from medical record abstraction. Using a frailty Cox proportional hazard model, we examined the length of time between colorectal abnormality and definitive diagnosis. One hundred ninety-three patients were eligible for the study because of a CRC-related abnormality (75 navigated and 118 controls). Analysis of PN effect by two time periods of resolution (0–4 and >4 months) showed a lagged effect of PN. The adjusted time-varying PN effect on diagnostic resolution compared to the controls was marginally significant (adjusted hazard ratio [aHR] = 1.15, 95 % confidence interval = 1.02–1.29) after controlling for insurance status. The predicted aHR at 4 months was 1.2, but showed no significant effect until 12 months. For patients having an abnormal symptom of CRC, PN appeared to have a positive effect over time and sped diagnostic resolution after 4 months. However, the small sample size limits drawing a definitive conclusion regarding the positive PN effect.

Genus-β human papillomavirus (HPV) DNA has been detected in basal cell carcinoma (BCC) tumors, but most epidemiologic studies have not observed associations between genus-β HPV seropositivity and BCC. A clinic-based case–control study was conducted to investigate cutaneous HPV infection in BCC. BCC cases (n = 224) were recruited from a dermatology clinic, and controls (n = 300) were patients who were screened negative for skin cancer. Antibodies against cutaneous HPV types in genera α, β, γ, mu, and nu were measured, and tumors from a subset of BCC cases (n = 195) were tested for HPV DNA. Overall associations were observed between BCC and seropositivity for HPV types in genus-α (odds ratio (OR) = 1.61; 95% confidence interval (CI) = 1.11–2.35), γ (OR = 1.78; 95% CI = 1.22–2.60), and mu (OR = 1.56; 95% CI = 1.06–2.30). BCC cases with β-HPV DNA in their tumors were more likely to be β-HPV seropositive than controls (OR = 1.76; 95% CI = 1.03–3.01), with type-specific associations observed for HPV8 and HPV23, whereas no association was observed between β-HPV seropositivity and β-HPV DNA–negative BCC. No concordance between seropositivity and tumor DNA status was observed for HPV types in genera α and γ. In conclusion, the combined serology and tumor DNA results suggest that β HPV types may have a role in BCC. Additional studies of BCC that assess HPV types in multiple genera are needed.

In Tampa, Florida, researchers have partnered with community- and faith-based organizations to create the Comparative Effectiveness Research for Eliminating Disparities (CERED) infrastructure. Grounded in community-based participatory research, CERED acts on multiple levels of society to enhance informed decision making (IDM) of prostate cancer screening among Black men. CERED investigators combined both comparative effectiveness research and community-based participatory research to design a trial examining the effectiveness of community health workers and a digitally enhanced patient decision aid to support IDM in community settings as compared with “usual care” for prostate cancer screening. In addition, CERED researchers synthesized evidence through the development of systematic literature reviews analyzing the effectiveness of community health workers in changing knowledge, attitudes and behaviors of African American adults toward cancer prevention and education. An additional systematic review analyzed chemoprevention agents for prostate cancer as an emerging technique. Both of these reviews, and the comparative effectiveness trial supporting the IDM process, add to CERED’s goal of providing evidence to eliminate cancer health disparities.

Although they are critical to models of coordinated care, the relationship and communication between primary care providers (PCPs) and cancer specialists throughout the cancer continuum are poorly understood. By using predefined search terms, the authors conducted a systematic review of the literature in 3 databases to examine the relationship and communication between PCPs and cancer specialists. Among 301 articles identified, 35 met all inclusion criteria and were reviewed in-depth. Findings from qualitative, quantitative, and disaggregated mixed-methods studies were integrated using meta-synthesis. Six themes were identified and incorporated into a preliminary conceptual model of the PCP-cancer specialist relationship: 1) poor and delayed communication between PCPs and cancer specialists, 2) cancer specialists' endorsement of a specialist-based model of care, 3) PCPs' belief that they play an important role in the cancer continuum, 4) PCPs' willingness to participate in the cancer continuum, 5) cancer specialists' and PCPs' uncertainty regarding the PCP's oncology knowledge/experience, and 6) discrepancies between PCPs and cancer specialists regarding roles. These data indicate a pervasive need for improved communication, delineation, and coordination of responsibilities between PCPs and cancer specialists. Future interventions aimed at these deficiencies may improve patient and physician satisfaction and cancer care coordination. CA Cancer J Clin 2017;67:156-169. © 2016 American Cancer Society.

Research investigating facilitators of survivorship care among underserved breast cancer survivors (BCS) is sparse. This study aimed to explore facilitators of survivorship care among underserved BCS within the first 5 years following chemotherapy, radiation, or surgery for breast cancer. In-depth interviews were conducted, using a semi-structured interview guide, with underserved BCS exploring survivorship care experiences. Content analysis of the verbatim transcripts was applied, and results were summarized according to themes related to facilitators of breast cancer survivorship care. Interviews were conducted with 25 BCS. Eight main themes were identified: coordination of care; positive perceptions of health care providers; communication between patient and health care providers; financial and insurance facilitators; information, classes, and programs provided; assistance provided by organizations and health care professionals; transportation facilitators; and job flexibility. This study provides a comprehensive look at facilitators of survivorship care among underserved BCS. BCS endorsed several facilitators of their survivorship care, mainly at the interpersonal, organizational, and societal level. This study adds to the research literature on catalysts of care among underserved BCS. Results from this study are currently being used to inform a patient navigation intervention to facilitate care among this population.

BACKGROUND The objective of the current study was to improve colorectal cancer (CRC) screening uptake with the fecal immunochemical test (FIT). The current study investigated the differential impact of a multicomponent, targeted, low-literacy educational intervention compared with a standard, nontargeted educational intervention. METHODS Patients aged 50 to 75 years who were of average CRC risk and not up-to-date with CRC screening were recruited from either a federally qualified health center or a primary care community health clinic. Patients were randomized to the intervention condition (targeted photonovella booklet/DVD plus FIT kit) or comparison condition (standard Centers for Disease Control and Prevention brochure plus FIT kit). The main outcome was screening with FIT within 180 days of delivery of the intervention. RESULTS Of the 416 participants, 54% were female; the participants were racially and ethnically diverse (66% white, 10% Hispanic, and 28% African American), predominantly of low income, and insured (the majority had county health insurance). Overall, the FIT completion rate was 81%, with 78.1% of participants in the intervention versus 83.5% of those in the comparison condition completing FIT (P = .17). In multivariate analysis, having health insurance was found to be the primary factor predicting a lack of FIT screening (adjusted odds ratio, 2.10; 95% confidence interval, 1.04-4.26 [P = .04]). CONCLUSIONS The multicomponent, targeted, low-literacy materials were not found to be significantly different or more effective in increasing FIT uptake compared with the nontargeted materials. Provision of a FIT test plus education may provide a key impetus to improve the completion of CRC screening. The type of educational material (targeted vs nontargeted) may matter less. The findings of the current study provide a unique opportunity for clinics to adopt FIT and to choose the type of patient education materials based on clinic, provider, and patient preferences. Cancer 2016. © 2016 American Cancer Society.

Background: Cutaneous human papillomavirus (HPV) infection may be a risk factor for squamous cell carcinoma (SCC) of the skin. Methods: To investigate the association between cutaneous HPV and SCC, a case–control study was conducted, including 173 SCC cases from a university dermatology clinic and 300 controls that screened negative for skin cancer. Serum antibodies against cutaneous HPV types in genera alpha, beta, gamma, mu, and nu were measured. Tumor tissue from 159 SCC cases was tested for the presence of DNA for genus-beta HPV types. Using logistic regression ORs and 95% confidence intervals (CI) were estimated for the associations between SCC and cutaneous HPV infection, adjusting for age and sex. The Bonferroni method was used to account for multiple comparisons. Results: SCC was positively associated with seropositivity to any genus-beta HPV type (OR, 1.93; 95% CI, 1.23–3.02), particularly with types in species-1 (OR, 1.86; 95% CI, 1.22–2.85). Type-specific associations with SCC were observed for HPV 8 (OR, 1.80; 95% CI, 1.14–2.84), 17 (OR, 1.59; 95% CI, 1.02–2.49) and HPV 10 from genus-alpha (OR, 2.24; 95% CI, 1.04–4.85). None of the type-specific associations remained statistically significant after correction for multiple comparisons. When DNA-positive SCC cases were compared with controls, strong serologic associations were observed for HPVs 5 (OR, 3.48; 95% CI, 1.27–9.59), 17 (OR, 3.36; 95% CI, 1.29–8.72), and 24 (OR, 3.79; 95% CI, 1.24–11.5). Conclusion: Genus-beta HPV infections were associated with SCC in our study population. Impact: Identifying the role of cutaneous HPV infection in SCC may lead to improved characterization of high-risk individuals and the development of novel prevention strategies. Cancer Epidemiol Biomarkers Prev; 21(8); 1303–13. ©2012 AACR.

The purpose of this study was to determine the prevalence of physician recommendation of human papillomavirus (HPV) vaccination in early (ages 11-12), middle (13-17), and late adolescent/young adult (18-26) female patients by physician specialty, and to identify factors associated with recommendation in early adolescents.A 38-item survey was conducted April 2009 through August 2009 among a nationally representative random sample of 1538 Family Physicians, Pediatricians, and Obstetricians and Gynecologists obtained from the American Medical Association Physician Masterfile. A multivariable model was used to assess factors associated with frequency of physician recommendation of HPV vaccination ("always"=76-100% of the time vs. other=0-75%) within the past 12 months.Completed surveys were received from 1013 physicians, including 500 Family Physicians, 287 Pediatricians, and 226 Obstetricians and Gynecologists (response rate=67.8%). Across the specialties, 34.6% of physicians reported they "always" recommend the HPV vaccine to early adolescents, 52.7% to middle adolescents, and 50.2% to late adolescents/young adults. The likelihood of "always" recommending the HPV vaccine was highest among Pediatricians for all age groups (P0.001). Physician specialty, age, ethnicity, reported barriers, and Vaccines for Children provider status were significantly associated with "always" recommending HPV vaccination for early adolescents.Findings suggest missed clinical opportunities for HPV vaccination, and perceived barriers to vaccination may drive decisions about recommendation. Results suggest the need for age and specialty targeted practice and policy level interventions to increase HPV vaccination among US females.

Background: Community health workers (CHW) are lay individuals who are trained to serve as liaisons between members of their communities and health care providers and services. Methods: A systematic review was conducted to synthesize evidence from all prospective controlled studies on effectiveness of CHW programs in improving screening mammography rates. Studies reported in English and conducted in the United States were included if they: (i) evaluated a CHW intervention designed to increase screening mammography rates in women 40 years of age or older without a history of breast cancer; (ii) were a randomized controlled trial (RCT), case–controlled study, or quasi-experimental study; and (iii) evaluated a CHW intervention outside of a hospital setting. Results: Participation in a CHW intervention was associated with a statistically significant increase in receipt of screening mammography [risk ratio (RR): 1.06 (favoring intervention); 95% CI: 1.02–1.11, P = 0.003]. The effect remained when pooled data from only RCTs were included in meta-analysis (RR: 1.07; 95% CI: 1.03–1.12, P = 0.0005) but was not present using pooled data from only quasi-experimental studies (RR: 1.03; 95% CI: 0.89–1.18, P = 0.71). In RCTs, participants recruited from medical settings (RR: 1.41; 95% CI: 1.09–1.82, P = 0.008), programs conducted in urban settings (RR: 1.23; 95% CI: 1.09, 1.39, P = 0.001), and programs where CHWs were matched to intervention participants on race or ethnicity (RR: 1.58, 95% CI: 1.29–1.93, P = 0.0001) showed stronger effects on increasing mammography screening rates. Conclusions: CHW interventions are effective for increasing screening mammography in certain settings and populations. Impact: CHW interventions are especially associated with improvements in rate of screening mammography in medical settings, urban settings, and in participants who are racially or ethnically concordant with the CHW. Cancer Epidemiol Biomarkers Prev; 20(8); 1580–98. ©2011 AACR.

Background Elementary schools represent both a source of childhood sun exposure and a setting for educational interventions. Methods Sun Protection of Florida's Children was a cluster randomized trial promoting hat use at (primary outcome) and outside of schools among fourth-grade students during August 8, 2006, through May 22, 2007. Twenty-two schools were randomly assigned to the intervention (1115 students) or control group (1376 students). Intervention schools received classroom sessions targeting sun protection attitudes and social norms. Each student attending an intervention school received two free wide-brimmed hats. Hat use at school was measured by direct observation and hat use outside of school was measured by self-report. A subgroup of 378 students (178 in the intervention group and 200 in the control group) underwent serial measurements of skin pigmentation to explore potential physiological effects of the intervention. Generalized linear mixed models were used to evaluate the intervention effect by accounting for the cluster randomized trial design. All P values were two-sided and were claimed as statistically significant at a level of .05. Results The percentage of students observed wearing hats at control schools remained essentially unchanged during the school year (baseline = 2%, fall = 0%, and spring = 1 %) but increased statistically significantly at intervention schools (baseline = 2%, fall = 30%, and spring = 41%) (P < .001 for intervention effect comparing the change in rate of hat use over time at intervention vs control schools). Self-reported use of hats outside of school did not change statistically significantly during the study (control: baseline = 14%, fall = 14%, and spring = 11%; intervention: baseline = 24%, fall = 24%, and spring = 23%) nor did measures of skin pigmentation. Conclusions The intervention increased use of hats among fourth-grade students at school but had no effect on self-reported wide-brimmed hat use outside of school or on measures of skin pigmentation.

Background The recent literature contains numerous reports of disparities in the diagnosis, treatment, and outcomes of lung cancer across a growing list of population subgroups, including disability status. A common assumption is that disparities stem mainly from variations in the level and type of treatment resources available to specific subgroups. Few studies, however, have directly measured resource differentials. Since policy makers identify reducing health disparities as a critical priority, this study examined whether cumulative Medicare costs (resource consumption) for lung cancer treatment differ across eight patient subgroups defined by disability status, sex, and race. Hypothesis Treatment disparities across the eight subgroups will be reflected in variations in the cumulative cost profiles of those subgroups, controlling for other plausible cost drivers. Failure to detect statistically significant differentials in these cost profiles implies that treatment disparities stem from factors other than access to, and utilization of, health care services. Methods Linked SEER-Medicare data were used to construct cost profiles by service type and treatment phase for roughly 80,000 incident lung cancer cases in patients aged 45 to 85 years at diagnosis. Multiple regression models then tested for cost differentials across the eight subgroups, controlling for various patient and disease characteristics. Results Significant cost differentials were detected, some unanticipated. Women tended to have higher treatment costs than men; they also had more favorable survivals. Nonwhites also tended to have higher treatment costs than whites, although they had significantly shorter survivals. On average, men with disabilities consumed the fewest treatment resources and had the shortest survivals. Mixed results were obtained for women with disabilities. Conclusions Among others, the findings suggest that reducing disparities will take more than just improving access to health care. Special attention must be paid to lung cancer patients with disabilities by both policy makers and clinicians.

Background Increased use of screening mammography is associated with lower death rates from breast cancer in the United States. Despite recommendations that women over 40 years of age should obtain regular screening mammography at least every 2 years, many women do not adhere to these guidelines. Historically, women from underserved and minority populations have been less likely to receive screening mammography. Methods A critical review of recent research literature was conducted to evaluate whether Latinas are less likely to receive screening mammography, determine whether disparities in screening mammography persist when controlling for other variables, and examine what other variables are associated with screening mammography. The articles were obtained from a search of the PubMed database. Results Fifteen published articles met the inclusion criteria and were critically reviewed. The unadjusted odds ratios (ORs) of the association between Hispanic ethnicity and screening mammography ranged from 0.40 to 0.93. For the most part, the ORs adjusted for other variables in multiple logistic regression analyses increased (range: 0.3 to 1.67). Age, education, income, health insurance, having a usual source of care, and having a recent visit to a physician were consistently related to screening mammography in multiple logistic regression analysis. Conclusions Hispanic ethnicity is a risk factor for lack of adherence to screening mammography. However, other demographic, socioeconomic, and health system variables account for some of the disparity related to Hispanic ethnicity.

A large proportion of women with a history of cervical cancer experience sexual problems as a result of treatment. The present study examined whether differences in sexual health between cervical cancer survivors and women with no history of cervical cancer could be explained by selected demographic, clinical, and psychosocial and physical factors.Women treated between 1 and 5 years previously for stage 0 to II cervical cancer and age- and education-matched women with no history of cancer undergoing routine cervical cancer screening were recruited to participate. All participants had a partner with whom they had ever been sexually active. Women completed measures of sexual health, vaginal changes, partner relationship quality, perceived physical appearance, and sexual self-concept.Cervical cancer survivors reported significantly (p.05) less sexual interest, more sexual dysfunction, and lower sexual satisfaction. The most consistent predictors of sexual health after treatment among survivors were time since diagnosis, receipt of radiotherapy, partner relations, and perceived physical appearance, as well as vaginal changes. These variables accounted for about 50% of the variance in sexual health outcomes.The findings suggest that efforts to improve sexual health in women with a history of cervical cancer must move beyond the direct effects of cancer treatment on vaginal anatomy and physiology. Sexual rehabilitation interventions should consider partner relationships, perceived physical appearance, and women's attitudes toward themselves as sexual beings, in addition to vaginal changes. Future research should use prospective longitudinal research designs incorporating appropriate comparison groups to further explore this issue.

Background. The main goal was to conduct a cost-effectiveness analysis of an intervention designed to increase cancer screening rates in primary care settings serving disadvantaged populations. The Cancer Screening Office Systems intervention reminded clinicians whether screening mammography, Pap smears, and/or fecal occult blood tests were up-to-date in eligible patients and then established a division of office responsibilities to ensure that tests were ordered and completed. Methods. The cost-effectiveness analysis was predicated on data generated from a cluster-randomized controlled trial of Cancer Screening Office Systems conducted at eight clinics participating in a county-funded health insurance plan in Florida. Cost numerators were computed from estimated time inputs of both clinical personnel and patients valued at nationally representative wages as well as expenses for Cancer Screening Office Systems-related materials and overhead. Effectiveness denominators were constructed from net changes in screening rates observed experimentally over a 12-month follow-up. Two types of incremental cost-effectiveness ratios were computed: the cost per extra screening test by type and the cost per life-year saved without and with Cancer Screening Office Systems. Results. Cancer Screening Office Systems produced statistically significant increases in screening rates, and these gains more than outweighed the costs of the intervention viewed from either payer or societal perspectives. Conclusions. Cancer Screening Office Systems are a cost-effective means of addressing cancer-related health disparities.

BACKGROUND We assessed the efficacy of the Cancer Screening Office Systems (Cancer SOS), an intervention designed to increase cancer screening in primary care settings serving disadvantaged populations. METHODS Eight primary care clinics participating in a county-funded health insurance plan in Hillsborough County, Fla, agreed to take part in a cluster-randomized experimental trial. The Cancer SOS had 2 components: a cancer-screening checklist with chart stickers that indicated whether specific cancer-screening tests were due, ordered, or completed; and a division of office responsibilities to achieve high screening rates. Established patients were eligible if they were between the ages of 50 and 75 years and had no contraindication for screening. Data abstracted from charts of independent samples collected at baseline (n = 1,196) and at a 12-month follow-up (n = 1,237) was used to assess whether the patient was up-to-date on one or more of the following cancer-screening tests: mammogram, Papanicolaou (Pap) smear, or fecal occult blood testing (FOBT). RESULTS In multivariate analysis that controlled for baseline screening rates, secular trends, and other patient and clinic characteristics, the intervention increased the odds of mammograms (odds ratio [OR] = 1.62, 95% confidence interval [CI], 1.07–9.78, P = .023) and fecal occult blood tests (OR = 2.5, 95% CI, 1.65–4.0, P

Lipid abnormalities are twice as common in patients with type 2 diabetes, and this contributes substantially to their increased risk of cardiac disease. The American Diabetic Association (ADA) has defined treatment goals for high-density lipoprotein (HDL) cholesterol (45 mg/dL), triglyceride (200 mg/dL), and low-density lipoprotein (LDL) cholesterol (100 mg/dL). It is unknown, however, how frequently patients with diabetes managed in primary care settings are able to attain these treatment goals.We randomly selected 239 patients with type 2 diabetes and conducted a chart review to determine whether patients had attained ADA lipid goals. We examined clinical predictors of goal attainment using logistic regression.The number and percentage of patients who had attained ADA lipid goals was as follows: HDL cholesterol, 87 of 207 (42.0%); LDL cholesterol, 93 of 208 (47.0%); and triglyceride, 142 of 206 (70.0%). Only 30 of 206 (14.6%) patients had achieved all 3 lipid goals. Three groups of patients with diabetes had greater odds of achieving the LDL treatment goal: men, patients taking a lipid-lowering drug, and patients with hypertension. Patients with diabetes had greater odds of achieving the HDL goal if they were female, were black, or if they had lower values for body mass index and triglyceride. The odds of achieving the triglyceride goal were greater for men, for patients having Medicare insurance supplemented by private insurance, and for those with increasing values of HDL.We found that the majority of patients with diabetes failed to attain lipid goals set forth by the American Diabetes Association. Further study is needed in larger populations to confirm these findings, and if confirmed, to determine the reasons that patients fail to achieve lipid goals.

Uveitis, or inflammation of the uveal tract (i.e., iris, ciliary body, and choroid), results from a heterogeneous collection of disorders of varying etiologies and pathogenic mechanisms. Uveitis is caused by a systemic disease in 30% to 45% of patients. Primary care physicians may be asked to evaluate patients with uveitis when an underlying systemic diagnosis is suspected but not apparent from eye examination or history. If the history, physical examination, and basic laboratory studies do not suggest an underlying cause, serologic tests for syphilis and chest radiography for sarcoidosis and tuberculosis are recommended. Typing for human leukocyte antigen-B27 is appropriate for patients with recurrent anterior uveitis. Because the prevalence of many rheumatologic and infectious diseases is low among persons with uveitis, Lyme serology, antinuclear antibody tests, serum angiotensin-converting enzyme tests, serum lysozyme tests, and tuberculin skin tests can result in false-positive results and are not routinely recommended. Drug-induced uveitis is rare and can occur from days to months after the time of initial exposure. Primary ocular lymphoma should be considered in persons older than 50 years with persistent intermediate or posterior uveitis that does not respond to anti-inflammatory therapy.

African American men experience a 60% higher incidence of prostate cancer and are more than twice as likely to die from it than White men. Evidence is insufficient to conclude that definitively screening for prostate cancer reduces the likelihood of morbidity or death. Patients are encouraged to discuss screening alternatives with health care providers for informed decision-making (IDM). The extent of IDM in clinical or community setting is not known. This study uses data from a community-based, computer-mediated, IDM intervention that targeted 152 African American aged 40 to 70. Pretest-posttest differences in means for prostate cancer knowledge, screening decisional conflict, and screening decisional self-efficacy were examined by two-tailed t-tests. Overall, the intervention significantly improved respondents' prostate cancer knowledge (plt;.0001), significantly improved decisional self-efficacy (plt;.0001) and significantly reduced decisional conflict (plt;.0001). Specifically, the intervention significantly promoted IDM among men who reported more education, being married, having financial resources, and younger age.