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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

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.

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.

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.

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 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 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.

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.

BACKGROUND Patient navigation is a promising intervention to address cancer disparities but requires a multisite controlled trial to assess its effectiveness. METHODS The Patient Navigation Research Program compared patient navigation with usual care on time to diagnosis or treatment for participants with breast, cervical, colorectal, or prostate screening abnormalities and/or cancers between 2007 and 2010. Patient navigators developed individualized strategies to address barriers to care, with the focus on preventing delays in care. To assess timeliness of diagnostic resolution, we conducted a meta-analysis of center- and cancer-specific adjusted hazard ratios (aHRs) comparing patient navigation vs usual care. To assess initiation of cancer therapy, we calculated a single aHR, pooling data across all centers and cancer types. We conducted a metaregression to evaluate variability across centers. All statistical tests were two-sided. RESULTS The 10521 participants with abnormal screening tests and 2105 with a cancer or precancer diagnosis were predominantly from racial/ethnic minority groups (73%) and publically insured (40%) or uninsured (31%). There was no benefit during the first 90 days of care, but a benefit of navigation was seen from 91 to 365 days for both diagnostic resolution (aHR = 1.51; 95% confidence interval [CI] = 1.23 to 1.84; P < .001)) and treatment initiation (aHR = 1.43; 95% CI = 1.10 to 1.86; P < .007). Metaregression revealed that navigation had its greatest benefits within centers with the greatest delays in follow-up under usual care. CONCLUSIONS Patient navigation demonstrated a moderate benefit in improving timely cancer care. These results support adoption of patient navigation in settings that serve populations at risk of being lost to follow-up.

BACKGROUND: Because proximal colorectal cancers have a tendency to present at a more advanced stage and thus have a poorer prognosis, it is important to understand the factors associated with the development of proximal colorectal cancer. We hypothesized that older age, female gender, and the presence of comorbid illness would be associated with proximal cancers. METHODS: Incident cases of colorectal cancer (n=9,550) occurring in 1994 were identified from Florida's population-based statewide cancer registry. We categorized colorectal cancers as either proximal (cecum, ascending colon, and transverse colon) or distal (descending colon, sigmoid colon, rectosigmoid, and rectum). Multiple logistic regression analysis was used to determine the multivariable relationship between clinical characteristics and the odds of a proximal-occurring lesion. RESULTS: Four characteristics emerged as independent predictors of a proximal lesion. Each year of increasing age was associated with a 2.2 percent increase in the odds of a proximal lesion, whereas female gender was associated with a 38 percent increase in the odds of a proximal lesion. The presence of a comorbid condition was associated with a 28 percent greater odds of a proximal lesion, and, finally, black, non-Hispanic race was associated with a 24 percent greater odds of a proximal lesion. CONCLUSIONS: We found that increasing age, female gender, black, non-Hispanic race, and the presence of comorbid illnesses were factors associated with a greater likelihood of developing colorectal cancer in a proximal location. Further studies will be required to confirm these findings and to establish the mechanism by which comorbidity influences the site of colorectal cancer development.

Background. The purpose of this study was to evaluate the knowledge, attitudes, and behaviors of university students regarding the human papillomavirus (HPV). Methods. A random sample of 500 university students was mailed a self-administered questionnaire that elicited their knowledge and awareness about HPV and compared their knowledge and attitudes with those of other sexually transmitted diseases (STDs). Among the 480 deliverable addresses, 289 students responded (response rate 60%). Results. Only 37% of respondents had ever heard of HPV, and the median score on a 13-item knowledge scale was only 3. Of seven STDs assessed, respondents indicated they knew the least about HPV and perceived that this STD has received the least educational effort. In multivariate analyses, predictors of lower knowl edge and awareness about HPV were male gender and sexual behavior (having multiple partners, not using condoms). Conclusions. Despite the high prevalence of HPV among young adults, most students knew very little about this infection. Implementing HPV educational programs and measuring their effectiveness should be a priority.

BACKGROUND Little is known about the actual frequency with which men have prostate screening in primary care settings, nor are the determinants of screening understood. METHODS We examined the records of 50 consecutive primary care office visits by men aged 50 or older. Men were asked to complete a brief questionnaire outlining their previous use of prostate screening services and the factors that influenced screening. RESULTS Screening in the previous year with digital rectal examination (DRE) and prostate specific antigen (PSA) was reported by 46% and 30% of respondents, respectively. Most respondents (86%) had heard of prostate screening and most (78%) believed it was effective. The only factor predictive of screening with DRE in multivariate analysis was a doctor's discussion of screening (odds ratio, 4.8). Two factors were predictive of PSA screening--knowing someone who had prostate cancer (odds ratio, 12.8) and advancing age (odds ratio [per year], 1.1). CONCLUSIONS Many men are not having annual prostate screening. Men who were older, who reported knowing someone with prostate cancer, and whose doctors discussed screening, were more likely to have been screened in the past year.

Background . Few studies have examined timeliness of diagnostic evaluation of abnormal cancer screening tests in community health centers. Methods . Using medical record review, timeliness of diagnosis was assessed among 317 people having either breast or colorectal-related abnormalities. Results . For 241 subjects (76.0%) who reached clinical resolution, the median time to diagnostic resolution was 37 days. People with breast abnormalities had more than twice the odds (adjusted odds ratio: 2.84) of reaching diagnostic resolution within 180 days compared with patients with colorectal abnormalities. We found, however, no evidence of disparate outcomes according to patient race/ethnicity, insurance status, or spoken language. Conclusions . Diagnostic evaluations are often either not completed or are delayed after a cancer-related abnormality is discovered. Further research is needed to understand the patient, provider, and health care system factors that contribute to these delays. There was no evidence of cancer disparities in the community health centers studied.

In the United States, colorectal cancer (CRC) is the source of much morbidity and mortality and increased health care costs. In 2013, there will be an estimated 142 820 new cases and 50 830 deaths from CRC (1). Five-year costs to Medicare for care of persons diagnosed with CRC in a single year exceed $3 billion (2). Colorectal cancer may be prevented through screening tests and polypectomy (3). Yet, only 59% of U.S. adults aged 50 years or older have ever received CRC screening (4), and merely 39% of CRC cases are diagnosed at a localized stage (5). Primary care plays an important role in increasing CRC screening rates because the recommendation of a primary care physician (PCP) is one of the strongest predictors of adherence to CRC screening (6, 7). Areas with more PCPs have been previously found to have lower CRC incidence (8, 9) and mortality (10). However, those studies were limited by the ecologic fallacy that whether persons with better outcomes are the same ones who visited primary care cannot be determined. Our previous cohort study of Medicare beneficiaries with CRC, which described the association between PCP visits with early-stage diagnosis and reduced CRC mortality (11), was subject to lead-time bias because it did not have a comparison group. Therefore, the improved survival observed with primary care visits could have been due to earlier diagnosis without actual changes in mortality. In addition, that study could not examine CRC incidence. The anticipated shortage of PCPs over the next decade in the United States (12, 13), coupled with the lack of PCP use by some Medicare beneficiaries (11, 14), may create barriers to achieving national goals of reducing CRC incidence and mortality. (15). In this study, we extend our prior work by examining the association of utilization of PCPs with CRC incidence and actual mortality within a population-based sample. We hypothesized that Medicare beneficiaries with few or no visits to a PCP would have higher CRC incidence and mortality, mediated by ever receipt of previous CRC screening and polypectomy.

Colorectal cancer screening (CRCS) rates are low among men and women who seek health care at federally qualified health centers (FQHCs). This study explores health care providers’ perspectives about their patient’s motivators and impediments to CRCS and receptivity to preparatory education. A mixed methods design consisting of in-depth interviews, focus groups, and a short survey is used in this study. The participants of this study are 17 health care providers practicing in FQHCs in the Tampa Bay area. Test-specific patient impediments and motivations were identified including fear of abnormal findings, importance of offering less invasive fecal occult blood tests, and need for patient-centered test-specific educational materials in clinics. Opportunities to improve provider practices were identified including providers’ reliance on patients’ report of symptoms as a cue to recommend CRCS and overemphasis of clinic-based guaiac stool tests. This study adds to the literature on CRCS test-specific motivators and impediments. Providers offered unique approaches for motivating patients to follow through with recommended CRCS and were receptive to in-clinic patient education. Findings readily inform the design of educational materials and interventions to increase CRCS in FQHCs.

Background. The incidence of pertussis in the United States has been increasing. Adult vaccination is important to reduce disease burden and prevent transmission to infants at high risk of complications. The tetanus–diphtheria–acellular pertussis (Tdap) vaccine has been available in the United States since 2005 and is indicated as a one-time replacement for the routine tetanus–diphtheria (Td) booster. However, among adults receiving tetanus vaccination, only about half receive Tdap. Purpose. To identify predictors of adult Tdap vaccination among individuals who receive tetanus vaccine. Methods. National Health Interview Survey data from 2008 were analyzed in 2011. Respondents were 18 to 64 years old, received tetanus vaccination during 2005-2008, and were aware if it contained pertussis. Predictors of Tdap vaccination were identified with multivariate logistic regression using procedures for complex survey methods. Results. Overall, 51.1% of respondents received Tdap. Vaccination was less likely for those 50 to 64 years old compared with those 18 to 24 years old (odds ratio [OR] = 0.61, 95% confidence interval [CI] = 0.38-0.96). Some college education was associated with higher odds of vaccination compared with lower education levels (OR = 1.55, 95% CI = 1.16-2.07). Having 2 to 3 office visits (OR = 2.01, 95% CI = 1.32-3.06) or 4 to 9 office visits (OR = 1.60, 95% CI = 1.06-2.42) in the previous year increased the odds of vaccination compared with no visits. Individuals with functional limitation due to illness had lower odds compared with no limitation (OR = 0.70, 95% CI = 0.54-0.91). Conclusions. In 2008, 51.1% of adult Td vaccinations included pertussis, suggesting continued efforts to remove barriers are needed. Interventions should target older, functionally impaired, and educationally disadvantaged populations.

OBJECTIVE: Despite having markedly higher breast cancer risk, compliance of older women with screening mammography has been poor. This study was undertaken to determine which physician and patient practice characteristics were associated with high self-reported mammography referral rates for older women. METHODS: Primary care physicians (n = 129) from three socioeconomically diverse communities in Los Angeles were surveyed. Agreement with annual screening and self-reported referral rates were assessed for two groups of women, those 65 to 74 years of age and those 75 years and older. Screening outcomes were compared with physician and patient practice characteristics using bivariate and multivariate techniques. RESULTS: Although 73% of physicians agreed with annual screening of women aged 65 to 74 years, only 24% of physicians reported actually screening most women seen in this age group. Similarly, 57% of physicians agreed that women age 75 years and older should be screened annually, but only 21% reported recommending mammograms for most women seen in this age group. In multivariate analysis, white physicians (adjusted OR = 9.1), younger physicians (adjusted OR = 3.85), and those who used the American Cancer Society's low cost mammography projects (adjusted OR = 5.01) were more likely to report screening the majority of women seen. DISCUSSION: This study suggests that although physicians' intentions to screen older women may be relatively high, a gap exists between intentions and what is reported to be accomplished in practice. Race/ethnicity and physician specialty were the two strongest predictors of high self-reported referral rates, suggesting that targeted interventions may be useful.

Background: This study examines efficacy of a lay patient navigation (PN) program aimed to reduce time between a cancer abnormality and definitive diagnosis among racially/ethnically diverse and medically underserved populations of Tampa Bay, Florida. Methods: Using a cluster randomized design, the study consisted of 11 clinics (six navigated; five control). Patients were navigated from time of a breast or colorectal abnormality to diagnostic resolution, and to completion of cancer treatment. Using a generalized mixed-effects model to assess intervention effects, we examined: (i) length of time between abnormality and definitive diagnosis, and (ii) receipt of definitive diagnosis within the 6-month minimum follow-up period. Results: A total of 1,267 patients participated (588 navigated; 679 control). We also included data from an additional 309 chart abstractions (139 navigated arm; 170 control arm) that assessed outcomes at baseline. PN did not have a significant effect on time to diagnostic resolution in multivariable analysis that adjusted for race-ethnicity, language, insurance status, marital status, and cancer site (P = 0.16). Although more navigated patients achieved diagnostic resolution by 180 days, results were not statistically significant (74.5% navigated vs. 68.5% control, P = 0.07). Conclusions: PN did not impact the overall time to completion of diagnostic care or the number of patients who reached diagnostic resolution of a cancer abnormality. Further evaluation of PN programs applied to other patient populations across the cancer continuum is necessary to gain a better perspective on its effectiveness. Impact: PN programs may not impact timely resolution of an abnormality suspicious of breast or colorectal cancer. Cancer Epidemiol Biomarkers Prev; 21(10); 1664–72. ©2012 AACR.

Background. Ultraviolet radiation exposure may interact synergistically with cutaneous human papillomavirus (HPV) infection in the development of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) of the skin. Methods. To investigate differences in the risk of sunlight-associated BCC and SCC by cutaneous genusspecific HPV serostatus, a case-control study was conducted among 204 BCC and 156 SCC cases who were recruited from a university dermatology clinic and 297 controls who had no history of cancer and screened negative for current skin cancer. Logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for the associations between measures of sunlight exposure and BCC/SCC, stratified by genus-specific HPV serostatus, with adjustment for age and sex. Results. Sunburn due to cutaneous sensitivity to sunlight exposure (P= .006) and poor tanning ability (P = .003) were associated with a higher seroprevalence for genus beta HPV types. Poor or no tanning ability was more strongly associated with SCC among individuals who were seropositive for antibodies to cutaneous HPV types in genera alpha (OR, 15.60; 95% CI, 5.40–45.1; P= .01 for interaction) and beta (OR, 6.86; 95% CI, 3.68–12.80; P= .001 for interaction), compared with individuals who were seronegative for these HPV types. Conclusions. Seropositivity for HPV types in genera alpha or beta increased the risk of SCC associated with poor tanning ability.

The Moffitt Cancer Center Patient Navigation Research Program (Moffitt PNRP) is evaluating the efficacy of patient navigation in reducing delays from screening abnormality to diagnostic resolution of a breast or colorectal abnormality. The Moffitt PNRP was conducted in three phases: (1) developing an acceptable, appealing, and culturally appropriate patient navigation program; (2) conducting a group randomized controlled trial to evaluate the patient navigation program; and (3) disseminating research findings and Moffitt PNRP intervention model. The patient navigation program was developed through significant formative research, input from the Moffitt PNRP Community Advisory Board, and through a close collaboration with the Tampa Bay Community Cancer Network. 1367 patients are enrolled in the Phase 2 group randomized trial of the Moffitt PNRP. Most Moffitt PNRP group randomized trial participants are Hispanic, female, and Spanish speaking, with minimal education and income. The intervention is being disseminated in primary care clinics in west central Florida.

Background: Merkel cell polyomavirus (MCV) DNA has been reported in 0% to 25% of squamous cell carcinomas (SCC) occurring in immunocompetent individuals. We conducted the first serologic case–control study of MCV and SCC. Methods: Patients with histologically confirmed cutaneous SCC (n = 173) were recruited from a university dermatology clinic. Controls were individuals who screened negative for and had no history of skin or other cancers (n = 300). Levels of antibodies against capsid antigens for MCV and another polyomavirus, JC virus (JCV), were determined by fluorescent bead-based multiplex serology. Fresh-frozen tumor tissues were obtained from 145 SCC cases and tested for MCV DNA by multiplexed PCR. Associations between MCV seroreactivity and SCC were estimated by ORs and 95% CIs calculated using logistic regression with adjustment for age and sex. Results: MCV DNA was detected in SCC tumor tissues from 55 (38%) of 145 cases. A statistically significant association was observed between MCV seropositivity and MCV DNA-positive SCC (OR = 2.49, 95% CI = 1.03–6.04), with an almost four-fold association observed when comparing those with MCV antibodies in the fourth versus first quartiles (OR = 3.93, 95% CI = 1.43–10.76, Ptrend = 0.01). No significant associations were observed between MCV seropositivity and MCV DNA-negative SCC (OR = 1.38, 95% CI = 0.76–2.48) or between JCV seropositivity and MCV DNA-positive or DNA-negative SCC. Conclusion: Past exposure to MCV may be a risk factor for SCC. Impact: Understanding the role of viral infections in the development of nonmelanoma skin cancer could lead to novel prevention strategies. Cancer Epidemiol Biomarkers Prev; 21(1); 74–81. ©2011 AACR.

To investigate the association between cigarette smoking and basal and squamous cell carcinomas (BCC and SCC) of the skin, a clinic-based case-control study was conducted in Tampa, FL.Patients with histologically confirmed BCC/SCC were recruited from a university dermatology clinic (n = 215 BCC, 165 SCC). Controls were comprised of individuals with no history of skin cancer who screened negative for skin cancer upon physical examination at the affiliated cancer screening or primary care clinics (n = 315). Information on smoking and other risk factors was obtained from self-administered questionnaires.After adjustment for age, sex, and other skin cancer-risk factors, ever smoking was not associated with BCC (odds ratio (OR) = 1.26, 95% confidence interval (CI) = 0.83-1.92), but was statistically significantly associated with SCC (OR = 1.97, 95% CI = 1.19-3.26), with significant trends observed for SCC associated with increasing cigarettes per day (p = 0.01) and pack-years smoked (p = 0.01). Among men, smoking ≥20 pack-years was associated with non-significant increased risks of BCC (OR = 1.90, 95% CI = 0.88-4.12) and SCC (OR = 1.97, 95% CI = 0.84-4.66), whereas among women, no association was observed with BCC (OR = 0.98, 95% CI = 0.39-2.46) while a statistically significant three-fold risk was observed with SCC (OR = 3.00, 95% CI = 1.02-8.80).Cigarette smoking is more strongly associated with SCC than BCC, particularly among women.

Background/Objectives: Studies suggest that excessive sun exposure in childhood contributes to the development of skin cancer later in life. Methods: This study explores 4th grade student assessment of their sun protection behaviors. This study used baseline data collected in the Fall of 2006 for the Sun Protection for Florida’s Children (SPF) project. In brief, the SPF project is a group randomized trial to test the effectiveness of a school based intervention promoting sun protection in general, and hat use in particular, in Hillsborough County Schools, Florida. The data reported in this study were collected at baseline before any intervention activities was initiated. Results: The self-reported use of various methods of sun protection was low. Only a small percentage of students wore long sleeves or a hat with a brim before leaving for school. In addition, few students wore a hat with a wide brim when outside but not at school. Students spent an average of 59.1 minutes per week outdoors while attending school and 35.5 minutes during peak sun exposure. Conclusion: Sun exposure at school poses a significant risk to student health and more needs to be carried out to promote the use of a wide-brimmed hat and limiting student sun exposure.

Introduction Physical activity is believed to prevent cognitive decline and may enhance frontal lobe activity. Methods Subjects were 91 healthy adults enrolled in a wellness center. Over a 10 week intervention, controls were aerobically active 0–2 days per week. Half the intervention group was active 3–4 days/week and half 5–7 days/week. Outcome measures included memory, mental speed, reaction time, attention, and cognitive flexibility. Results Neurocognitive data were analyzed by repeated measures comparing minimal aerobic exercise (the control group) to moderate aerobic exercise (3–4 days/week), and to high aerobic exercise (5–7 days/week). Initial analyses noted significant improvements in mental speed (p = .03), attention (p = .047), and cognitive flexibility (p = .002). After controlling for age, gender, education, and changes in psychomotor speed, only cognitive flexibility still showed significant improvements (p = .02). Conclusion Over a 10 week period, increasing frequency of aerobic activity was shown to be associated with enhanced cognitive performance, in particular cognitive flexibility, a measure of executive function.

To determine if the type of insurance arrangement, specifically health maintenance organization (HMO) vs fee-for-service (FFS), affects cancer outcomes for Medicare beneficiaries with disabilities.Retrospective cohort.We used the Surveillance, Epidemiology, and End Results-Medicare linked dataset to identify beneficiaries older and younger than 65 years entitled to Medicare benefits because of disability (Social Security Disability Insurance) who subsequently were diagnosed as having breast cancer (n = 6839) or non-small cell lung cancer (n = 10,229) from 1988 through 1999. We categorized persons according to Medicare insurance arrangement (continuous FFS, continuous HMO, or mixed FFS/HMO) during the periods 12 months before diagnosis and 6 months after diagnosis. Using a retrospective cohort design, we examined stage at diagnosis, cancer-directed treatments, and survival.Women with continuous HMO insurance had earlier-stage breast cancer diagnosis (adjusted relative risk, 0.77; 95% confidence interval, 0.65-0.91) and were more likely to receive radiation therapy following breast-conserving surgery (adjusted relative risk, 1.11; 95% confidence interval, 1.03-1.19). Women having continuous HMO insurance had better breast cancer survival, primarily resulting from earlier-stage diagnosis. Among persons with non-small cell lung cancer, those having mixed FFS/HMO insurance were more likely to receive definitive surgery for early-stage disease (adjusted odds ratio, 1.23; 95% confidence interval, 1.02-1.49) and to have better overall survival but not significantly better lung cancer survival.When diagnosed as having breast cancer or non-small cell lung cancer, some Medicare beneficiaries with disabilities fare better with managed care compared with FFS insurance plans.

Populations with attributes marking social disadvantage in the United States—such as persons living in poverty and racial and ethnic minorities—often experience worse outcomes than others when diagnosed with cancer. They frequently have later-stage cancer diagnoses, less intensive or appropriate therapies, and shorter survivals than persons with greater social advantages (Haynes and Smedley 1999). In recent years, such observations have prompted nationwide efforts to track and eliminate disparities in health-related experiences of vulnerable populations. To date, much of the public focus on health disparities has targeted racial and ethnic minorities. However,Healthy People 2010, which set national health priorities, warns that persons with disabilities might also receive substandard health care. Noting well-documented disparities in their use of screening and preventive services (Nosek and Howland 1997; Chan et al. 1999; Iezzoni et al. 2000,2001),Healthy People 2010 cautions that “as a potentially underserved group, people with disabilities would be expected to experience disadvantages in health and well-being compared with the general population” (Department of Health and Human Services 2000). In a July 2005 “Call to Action,” the United States Surgeon General states that persons with disabilities sometimes lack equal access to care and encourages the inclusion of persons with disabilities in studies concerning disparities in health care access and outcomes (U.S. Department of Health and Human Services 2005). Exploring whether persons with disabilities do, in fact, experience worse cancer-related outcomes is complicated by the lack of information on disability in data sources typically used to conduct disparities research concerning cancer. Data from the Surveillance, Epidemiology, and End Results (SEER) cancer registries have produced important insights into racial and ethnic disparities (Klabunde et al. 1998; McCarthy et al. 1998; Bach et al. 1999; Ngo-Metzger et al. 2003; Jemal et al. 2004; Zeliadt et al. 2004; Shavers, Brown, Klabunde et al. 2004; Shavers, Brown, Potosky et al. 2004; Steyerberg et al. 2005). SEER data merged with Medicare claims have yielded additional findings about outcomes, treatments, and health care costs for Medicare beneficiaries with cancer (Potosky et al. 1993; Warren et al. 2002). Neither SEER nor Medicare data contain indicators of patients' functional status. However, one potential approach to investigate an important subpopulation of people with disabilities involves focusing on persons receiving Social Security Disability Insurance (SSDI) who eventually become eligible for Medicare. Persons with SSDI are presumably too medically disabled to work (an employability-based definition of disability). To qualify, persons must convince the Social Security Administration (SSA) that they cannot engage in “substantial gainful activity” because of medically proven sensory, physical, cognitive, or emotional impairments (Social Security Administration 2003a). Five months after qualifying for SSDI, they start receiving monthly cash payments, although many find their annual incomes plummet—posing another social disadvantage (Martin and Davies 2003/2004). Twenty-four months after first receiving cash benefits, SSDI beneficiaries become eligible for Medicare. In 2004, Medicare covered 6.4 million SSDI recipients under age 65 among its estimated 41.7 million beneficiaries (Centers for Medicare and Medicaid Services 2003). Prior studies using merged SEER–Medicare data have exclusively considered Medicare beneficiaries age 65 and older. Our study is the first to use these data to examine cancer experiences of Medicare beneficiaries under age 65. We examined stage at diagnosis and survival for disabled Medicare beneficiaries diagnosed with non-small cell lung, colorectal, female breast, or prostate cancers and compared their experiences with those of persons diagnosed in this same age group who do not have SSDI/Medicare. Because in previous studies we found that persons with certain types of disabilities (e.g., physical disabilities) are less likely to receive cancer screening and preventive services (Iezzoni et al. 2000,2001), we hypothesized that disabled Medicare beneficiaries would have delayed cancer diagnosis compared with others diagnosed under age 65.

To determine the rate of colorectal cancer screening in patients attending a sample of community health centers, medical records of 1,176 patients from eight community health centers were abstracted. Among the patients studied, 43.8% of patients had undergone at least one of the three colorectal screening tests (fecal occult blood test, colonoscopy, or flexible sigmoidoscopy) in the recommended interval. Colorectal screening in this community health center population was predicted by male gender, being African American, older age, having a greater number of chronic illnesses, a family history of colorectal cancer, and by having engaged in other preventive cancer screenings in the previous year. Although screening rates certainly were not optimal, they compare favorably to rates reported in national surveys for the general population. Our results add to a growing body of evidence that community health centers, despite serving disadvantaged populations, are able to deliver preventive care at rates comparable to health facilities used by the general population.

Background The success with which primary care physicians are able to meet American Diabetes Association (ADA) clinical goals is unknown. Methods Charts of 218 randomly sampled type 2 diabetic patients were abstracted to assess the attainment of six ADA treatment goals and receipt of four ADA-recommended health services. Results The mean number of ADA goals attained was 4.9 (SD, 1.6). Only one patient had attained all 10 goals. Most patients had attained ADA goals for triglycerides, diastolic blood pressure, hemoglobin A1c, low-density lipoprotein cholesterol, and diabetic education. Most patients had not received an annual eye examination or urine microalbuminuria screening, most were not taking daily aspirin, and most had not attained treatment goals for high-density lipoprotein or systolic blood pressure. Conclusion ADA treatment goals may be quite difficult to attain in the primary care setting. Further studies are needed to understand the barriers to diabetes control.

Background: Increasing supplies of dermatologists and family physicians have been associated with earlier detection of malignant melanoma. We investigated whether physician supply was similarly related to incidence and mortality rates of malignant melanoma. Methods: Using the state tumor registry, we determined melanoma incidence and mortality rates for the years 1993 to 1995 for each Florida county. We measured physician supply for each Florida county using data from the 1994 American Medical Association Physician Masterfile. Multiple linear regression analysis was used to determine relationships between physician supply and melanoma incidence and mortality rates, controlling for other county-level characteristics. Results: Among male patients, an increasing supply of family physicians was associated with higher melanoma incidence and lower melanoma mortality. Increasing supplies of dermatologists were associated with lower overall melanoma mortality rates, and increasing supplies of general internists were associated with higher overall melanoma mortality. Conclusion: We found that melanoma incidence and mortality rates varied substantially among Florida's 67 counties, and that differences in physician supply explained some of this variability. Further study is needed to confirm these findings and to elucidate possible mechanisms that would account for these associations.