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Purpose: Unmet social needs pose barriers to cancer care, contributing to adverse outcomes and health inequities. A better understanding of how social needs change after cancer diagnosis can inform more effective, equity-focused interventions., Methods: In this study, we examined self-reported social needs at 0, 3, and 6 months after a breast cancer diagnosis in a racially diverse, multilingual sample (n = 222) enrolled in patient navigation intervention at an urban safety-net hospital. At each timepoint, respondents completed surveys about social needs related to employment, disability benefits, housing and utilities, and personal and family stability., Results: Over three-quarters (78%, n = 175) reported ≥ 1 social need, and 46% (n = 102) reported ≥ 3 social needs. The most frequently reported need was housing and utilities (64%, n = 142), followed by employment (40%, n = 90). Individuals from minoritized groups more frequently reported an increased number of social needs over time, compared with their White counterparts (p = 0.02)., Conclusion: Our findings suggest that despite navigation, many cancer patients from historically underrepresented populations continue to experience social concerns over the first 6 months of treatment. Further research, conducted with historically underrepresented populations in research, is needed to better understand the social needs of breast cancer patients to inform effective and equitable interventions., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Women who engage in sex work and use drugs (WSWUD) experience disproportionate HIV risks. Substance use treatment bridge clinics offer an opportunity to increase HIV pre-exposure prophylaxis (PrEP) delivery to WSWUD, but research on best practices is lacking. Therefore, we explored facilitators and barriers to PrEP across the PrEP care continuum in these settings., Methods: Bridge clinic and affiliated harm reduction health service providers and WSWUD from Boston were recruited using passive and active outreach between December 2021 and August 2022. Participants were invited to take part in semi-structured phone or in-person interviews to explore HIV prevention and PrEP care experiences overall and within bridge clinic settings. Deductive codes were developed based on HIV risk environment frameworks and the Information-Motivation-Behavioral Skills model and inductive codes were added based on transcript review. Grounded content analysis was used to generate themes organized around the PrEP care continuum., Results: The sample included 14 providers and 25 WSWUD. Most WSWUD were aware of PrEP and more than half had initiated PrEP at some point. However, most who initiated PrEP did not report success with daily oral adherence. Providers and WSWUD described facilitators and barriers to PrEP across the steps of the care continuum: Awareness, uptake, adherence, and retention. Facilitators for WSWUD included non-stigmatizing communication with providers, rapid wraparound substance use treatment and HIV services, having a PrEP routine, and service structures to support PrEP adherence. Barriers included low HIV risk perceptions and competing drug use and survival priorities. Provider facilitators included clinical note templates prompting HIV risk assessments and training. Barriers included discomfort discussing sex work risks, competing clinical priorities, and a lack of PrEP adherence infrastructure., Conclusion: WSWUD and bridge clinic providers favored integrated HIV prevention and substance use services in harm reduction and bridge clinic settings. Harm reduction and bridge clinic programs played a key role in HIV prevention and PrEP education for WSWUD. Effective behavioral and structural interventions are still needed to improve PrEP adherence for WSWUD., (© 2024. The Author(s).)

Background: Suboptimal communication between clinicians remains a frequent driver of preventable adverse health care-related events, increased costs, and patient and physician dissatisfaction., Methods: Cross-sectional surveys on preoperative interspecialty communication, tailored by stakeholder type, were administered to (1) primary care providers in northern New England, (2) anesthesia providers working in the perioperative clinic of a tertiary rural academic medical center, (3) surgeons from the same center, and (4) older surgical patients who underwent preoperative assessment at the same center., Results: In total, 107/249 (43.0%) providers and 103/265 (39.9%) patients completed the survey. Preoperative communication was perceived as logistically challenging (59.8%), particularly across health systems. More than 77% of anesthesia and surgery providers indicated that they communicate frequently or sometimes, but 92.5% of primary care providers indicated that they rarely or never communicate with anesthesia providers. Some of the most common reasons for preoperative communication were discussion of complex patients, perioperative medication management, and optimization of comorbidities. Although 96.1% of older surgical patients reported that preoperative communication between providers is important, only 40.4% felt that their providers communicate very or extremely well. Many patients emphasized the importance of preoperative communication between providers to ensure transfer of critical clinical information., Conclusion: Surgeons and anesthesiologists infrequently communicate with primary care providers in one rural tertiary center, in contrast to patient expectations and values. These study results will help identify priorities and potentially resolvable barriers to bridging the gap between the inpatient perioperative and outpatient primary care teams. Future studies should focus on strategies to improve communication between hospital and community providers to prevent complications and readmission., (Copyright © 2024 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Background: Significant disparities in substance use severity and treatment persist among women who use drugs compared to men. Thus, we explored how identifying as a woman was related to drug use and treatment experiences., Methods: The study recruited participants for a qualitative interview study in Boston and San Francisco from January-November 2020. Self-identified women, age ≥ 18 years, with nonprescribed opioid use in the past 14 days were eligible for inclusion. The study team developed deductive codes based on intersectionality theory and inductive codes generated from transcript review, and identified themes using grounded content analysis., Results: The study enrolled thirty-six participants. The median age was 46; 58 % were White, 16 % were Black, 14 % were Hispanic, and 39 % were unstably housed. Other drug use was common with 81 % reporting benzodiazepine, 50 % cocaine, and 31 % meth/amphetamine use respectively. We found that gender (i.e., identifying as a woman) intersected with drug use and sex work practices and exacerbated experiences of marginalization. Violence was ubiquitous in drug use environments. Some women reported experiences of gender-based violence in substance use service settings that perpetuated cycles of trauma and reinforced barriers to care. Substance use services that were women-led, safe, and responsive to women's needs were valued and sought after., Conclusion: Women reported a cycle of trauma and drug use exacerbated by oppression in substance use services settings. In addition to increasing access to gender-responsive care, our study highlights the need for greater research and examination of practices within substance use service settings that may be contributing to gender-based violence., Competing Interests: Declaration of competing interest None declared., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objectives: Little research exists on how risk scores are used in counselling. We examined (a) how Breast Cancer Risk Assessment Tool (BCRAT) scores are presented during counselling; (b) how women react and (c) discuss them afterwards., Design: Consultations were video-recorded and participants were interviewed after the consultation as part of the NRG Oncology/National Surgical Adjuvant Breast and Bowel Project Decision-Making Project 1 (NSABP DMP-1)., Setting: Two NSABP DMP-1 breast cancer care centres in the USA: one large comprehensive cancer centre serving a high-risk population and an academic safety-net medical centre in an urban setting., Participants: Thirty women evaluated for breast cancer risk and their counselling providers were included., Methods: Participants who were identified as at increased risk of breast cancer were recruited to participate in qualitative study with a video-recorded consultation and subsequent semi-structured interview that included giving feedback and input after viewing their own consultation. Consultation videos were summarised jointly and inductively as a team.tThe interview material was searched deductively for text segments that contained the inductively derived themes related to risk assessment. Subgroup analysis according to demographic variables such as age and Gail score were conducted, investigating reactions to risk scores and contrasting and comparing them with the pertinent video analysis data. From this, four descriptive categories of reactions to risk scores emerged. The descriptive categories were clearly defined after 19 interviews; all 30 interviews fit principally into one of the four descriptive categories., Results: Risk scores were individualised and given meaning by providers through: (a) presenting thresholds, (b) making comparisons and (c) emphasising or minimising the calculated risk. The risk score information elicited little reaction from participants during consultations, though some added to, agreed with or qualified the provider's information. During interviews, participants reacted to the numbers in four primary ways: (a) engaging easily with numbers; (b) expressing greater anxiety after discussing the risk score; (c) accepting the risk score and (d) not talking about the risk score., Conclusions: Our study highlights the necessity that patients' experiences must be understood and put into relation to risk assessment information to become a meaningful treatment decision-making tool, for instance by categorising patients' information engagement into types., Trial Registration Number: NCT01399359., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: Breast density notifications advise women to discuss breast density with their clinicians, yet little is known about such discussions., Objectives: To examine the content of women's reports of breast density discussions with clinicians and identify variations by women's sociodemographic characteristics (age, income, state legislation status, race and ethnicity, and literacy level)., Design, Setting, and Participants: This US nationwide, population-based, random-digit dial telephone survey study was conducted from July 1, 2019, to April 30, 2020, among 2306 women aged 40 to 76 years with no history of breast cancer who underwent mammography in the prior 2 years and had heard the term dense breasts or breast density. Results were analyzed from a subsample of 770 women reporting a conversation about breast density with their clinician after their last mammographic screening. Statistical analysis was conducted in April and July 2023., Main Outcomes and Measures: Survey questions inquired whether women's clinicians had asked about breast cancer risk or their worries or concerns about breast density, had discussed mammography results or other options for breast cancer screening or their future risk of breast cancer, as well as the extent to which the clinician answered questions about breast density., Results: Of the 770 women (358 [47%] aged 50-64 years; 47 Asian [6%], 125 Hispanic [16%], 204 non-Hispanic Black [27%], 317 non-Hispanic White [41%], and 77 other race and ethnicity [10%]) whose results were analyzed, most reported that their clinicians asked questions about breast cancer risk (88% [670 of 766]), discussed mammography results (94% [724 of 768]), and answered patient questions about breast density (81% [614 of 761]); fewer women reported that clinicians had asked about worries or concerns about breast density (69% [524 of 764]), future risk of breast cancer (64% [489 of 764]), or other options for breast cancer screening (61% [459 of 756]). Women's reports of conversations varied significantly by race and ethnicity; non-Hispanic Black women reported being asked questions about breast cancer risk more often than non-Hispanic White women (odds ratio [OR], 2.08 [95% CI, 1.05-4.10]; P = .04). Asian women less often reported being asked about their worries or concerns (OR, 0.42 [95% CI, 0.20-0.86]; P = .02), and Hispanic and Asian women less often reported having their questions about breast density answered completely or mostly (Asian: OR, 0.28 [95% CI, 0.13-0.62]; P = .002; Hispanic: OR, 0.48 [95% CI, 0.27-0.87]; P = .02). Women with low literacy were less likely than women with high literacy to report being asked about worries or concerns about breast density (OR, 0.64 [95% CI, 0.43-0.96]; P = .03), that mammography results were discussed with them (OR, 0.32 [95% CI, 0.16-0.63]; P = .001), or that their questions about breast density were answered completely or mostly (OR, 0.51 [95% CI, 0.32-0.81]; P = .004)., Conclusions and Relevance: In this survey study, although most women reported that their clinicians counselled them about breast density, the unaddressed worries or concerns and unanswered questions, especially among Hispanic and Asian women and those with low literacy, highlighted areas where discussions could be improved.

Purpose: Little is known about the uptake of germline genetic testing for patients with prostate cancer after 2018 guideline changes. This study characterizes genetic service referral patterns and predictors of referrals among patients with prostate cancer., Methods: A retrospective cohort study using electronic health record data was conducted at an urban safety-net hospital. Individuals diagnosed with prostate cancer between January 2011 and March 2020 were eligible. The primary outcome was referral to genetic services after diagnosis. Using multivariable logistic regression, we identified patient characteristics associated with referrals. Interrupted time series analysis using a segmented Poisson regression examined whether guideline changes resulted in higher rates of referral after implementation., Results: The cohort included 1,877 patients. Mean age was 65 years; 44% identified as Black, 32% White; and 17% Hispanic or Latino. The predominant insurance type was Medicaid (34%) followed by Medicare or private insurance (25% each). Most were diagnosed with local disease (65%), while 3% had regional and 9% had metastatic disease. Of the 1,877 patients, 163 (9%) had at least one referral to genetics. In multivariable models, higher age was negatively associated with referral (odds ratio [OR], 0.96; 95% CI, 0.94 to 0.98), while having regional (OR, 4.51; 95% CI, 2.44 to 8.34) or metastatic disease (OR, 4.64; 95% CI, 2.98 to 7.24) versus local only disease at diagnosis was significantly associated with referral. The time series analysis demonstrated a 138% rise in referrals 1 year after guideline implementation (relative risk, 3.992; 97.5% CI, 2.20 to 7.24; P < .001)., Conclusion: Referrals to genetic services increased after guideline implementation. The strongest predictor of referral was clinical stage, suggesting opportunities to raise awareness about guideline eligibility for patients with advanced local or regional disease who may benefit from genetic services.

The early COVID-19 pandemic was associated with cessation of screening services, but the prevalence of ongoing delays in cancer screening into the third year of the pandemic are not well-characterized. In February/March 2022, a population-based survey assessed cancer needs in New Hampshire and Vermont. The associations between cancer screening delays (breast, cervical, colorectal or lung cancer) and social determinants of health, health care access, and cancer attitudes and beliefs were tested. Distributions and Rao-Scott chi-square tests were used for hypothesis testing and weighted to represent state populations. Of 1717 participants, 55% resided in rural areas, 96% identified as White race, 50% were women, 36% had high school or less education. Screening delays were reported for breast cancer (28%), cervical cancer (30%), colorectal cancer (24%), and lung cancer (30%). Delays were associated with having higher educational attainment (lung), urban living (colorectal), and having Medicaid insurance (breast, cervical). Low confidence in ability to obtain information about cancer was associated with screening delays across screening types. The most common reason for delay was the perception that the screening test was not urgent (31% breast, 30% cervical, 28% colorectal). Cost was the most common reason for delayed lung cancer screening (36%). COVID-19 was indicated as a delay reason in 15-29% of respondents; 12-20% reported health system capacity during the pandemic as a reason for delay, depending on screening type. Interventions that address sub-populations and reasons for screening delays are needed to mitigate the impact of the COVID-19 pandemic on cancer burden and mortality., Competing Interests: Declaration of Competing Interest No authors have conflicts of interest to report., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Compared with urban areas, rural areas have higher cancer mortality and have experienced substantially smaller declines in cancer incidence in recent years. In a New Hampshire (NH) and Vermont (VT) survey, we explored the roles of rurality and educational attainment on cancer risk behaviors, beliefs, and other social drivers of health. In February-March 2022, two survey panels in NH and VT were sent an online questionnaire. Responses were analyzed by rurality and educational attainment. Respondents ( N = 1,717, 22%) mostly lived in rural areas (55%); 45% of rural and 25% of urban residents had high school education or less and this difference was statistically significant. After adjustment for rurality, lower educational attainment was associated with smoking, difficulty paying for basic necessities, greater financial difficulty during the COVID-19 pandemic, struggling to pay for gas ( P < 0.01), fatalistic attitudes toward cancer prevention, and susceptibility to information overload about cancer prevention. Among the 33% of respondents who delayed getting medical care in the past year, this was more often due to lack of transportation in those with lower educational attainment (21% vs. 3%, P = 0.02 adjusted for rurality) and more often due to concerns about catching COVID-19 among urban than rural residents (52% vs. 21%; P < 0.001 adjusted for education). In conclusion, in NH/VT, smoking, financial hardship, and beliefs about cancer prevention are independently associated with lower educational attainment but not rural residence. These findings have implications for the design of interventions to address cancer risk in rural areas., Significance: In NH and VT, the finding that some associations between cancer risk factors and rural residence are more closely tied to educational attainment than rurality suggest that the design of interventions to address cancer risk should take educational attainment into account., (© 2023 The Authors; Published by the American Association for Cancer Research.)

We tested the hypotheses that adult cancer incidence and mortality in the Northeast region and in Northern New England (NNE) were different than the rest of the United States, and described other related cancer metrics and risk factor prevalence. Using national, publicly available cancer registry data, we compared cancer incidence and mortality in the Northeast region with the United States and NNE with the United States overall and by race/ethnicity, using age-standardized cancer incidence and rate ratios (RR). Compared with the United States, age-adjusted cancer incidence in adults of all races combined was higher in the Northeast (RR, 1.07; 95% confidence interval [CI] 1.07-1.08) and in NNE (RR 1.06; CI 1.05-1.07). However compared with the United States, mortality was lower in the Northeast (RR, 0.98; CI 0.98-0.98) but higher in NNE (RR, 1.05; CI 1.03-1.06). Mortality in NNE was higher than the United States for cancers of the brain (RR, 1.16; CI 1.07-1.26), uterus (RR, 1.32; CI 1.14-1.52), esophagus (RR, 1.36; CI 1.26-1.47), lung (RR, 1.12; CI 1.09-1.15), bladder (RR, 1.23; CI 1.14-1.33), and melanoma (RR, 1.13; CI 1.01-1.27). Significantly higher overall cancer incidence was seen in the Northeast than the United States in all race/ethnicity subgroups except Native American/Alaska Natives (RR, 0.68; CI 0.64-0.72). In conclusion, NNE has higher cancer incidence and mortality than the United States, a pattern that contrasts with the Northeast region, which has lower cancer mortality overall than the United States despite higher incidence., Significance: These findings highlight the need to identify the causes of higher cancer incidence in the Northeast and the excess cancer mortality in NNE., (© 2023 The Authors; Published by the American Association for Cancer Research.)

Background: Breast density information aims to increase awareness of breast density and its risks and to foster more informed future breast screening decisions among women with dense breasts. We explored associations between such information and outcomes including anxiety, confusion, or feeling informed, and whether they varied by race/ethnicity or literacy, or differentially affected future mammography plans., Methods: A national telephone survey of a diverse sample of women previously informed of personal breast density (N = 1,322) assessed reactions to receipt of breast density information and future mammography plans., Results: Most women (86%) felt informed after receiving personal breast density information; however, some felt anxious (15%) or confused (11%). Reactions varied significantly by sociodemographics; non-Hispanic Black, Asian, and Hispanic women and women with low literacy were nearly two to three times more likely to report anxiety than non-Hispanic White women (all ps < .05). Asian women and those with low literacy less often felt informed and more often felt confused. Non-Hispanic Black and Asian women were nearly twice as likely to report that knowing their breast density made them more likely to have future mammograms. Women with low literacy were more likely to change mammography plans, with some being more likely and others less likely to plan to have future mammograms. Greater anxiety and confusion were associated with higher likelihood of planning future mammograms; those feeling informed were less likely to plan future mammography., Conclusions: Differential reactions to breast density information are concerning if associated with disparate future screening plans. Future breast density education efforts should ensure that such information is readily accessible and understandable to all women in order to lead to desired effects., (Copyright © 2023 Jacobs Institute of Women's Health, George Washington University. Published by Elsevier Inc. All rights reserved.)

Importance: Breast density is an independent risk factor for breast cancer. Despite the proliferation of mandated written notifications about breast density following mammography, there is little understanding of how women perceive the relative breast cancer risk associated with breast density., Objective: To assess women's perception of breast density compared with other breast cancer risks and explore their understanding of risk reduction., Design, Setting, and Participants: This mixed-methods qualitative study used telephone surveys and semistructured interviews to investigate perceptions about breast cancer risk among a nationally representative, population-based sample of women. Eligible study participants were aged 40 to 76 years, reported having recently undergone mammography, had no history of prior breast cancer, and had heard of breast density. Survey participants who had been informed of their personal breast density were invited for a qualitative interview. Survey administration spanned July 1, 2019, to April 30, 2020, with 2306 women completing the survey. Qualitative interviews were conducted from February 1 to May 30, 2020., Main Outcomes and Measures: Respondents compared the breast cancer risk associated with breast density with 5 other risk factors. Participants qualitatively described what they thought contributed to breast cancer risk and ways to reduce risk., Results: Of the 2306 women who completed the survey, 1858 (166 [9%] Asian, 503 [27%] Black, 268 [14%] Hispanic, 792 [43%] White, and 128 [7%] other race or ethnicity; 358 [19%] aged 40-49 years, 906 [49%] aged 50-64 years, and 594 [32%] aged ≥65 years) completed the revised risk perception questions and were included in the analysis. Half of respondents thought breast density to be a greater risk than not having children (957 [52%]), having more than 1 alcoholic drink per day (975 [53%]), or having a prior breast biopsy (867 [48%]). Most respondents felt breast density was a lesser risk than having a first-degree relative with breast cancer (1706 [93%]) or being overweight or obese (1188 [65%]). Of the 61 women who were interviewed, 6 (10%) described breast density as contributing to breast cancer risk, and 43 (70%) emphasized family history as a breast cancer risk factor. Of the interviewed women, 17 (28%) stated they did not know whether it was possible to reduce their breast cancer risk., Conclusions and Relevance: In this qualitative study of women of breast cancer screening age, family history was perceived as the primary breast cancer risk factor. Most interviewees did not identify breast density as a risk factor and did not feel confident about actions to mitigate breast cancer risk. Comprehensive education about breast cancer risks and prevention strategies is needed.

Introduction: The 2018 National Comprehensive Cancer Network guidelines for prostate cancer genetic testing expanded access to genetic services. Few studies have examined how this change has affected provider practice outside of large cancer centers., Methods: We conducted a qualitative study of multi-disciplinary health care providers treating patients with prostate cancer at a safety-net hospital. Participants completed an interview that addressed knowledge, practices, and contextual factors related to providing genetic services to patients with prostate cancer. A thematic analysis using both inductive and deductive coding was undertaken., Results: Seventeen providers completed interviews. Challenges in identifying eligible patients for genetic testing stemmed from a lack of a) systems that facilitate routine patient identification, and b) readily available family history data for eligibility determination. Providers identified non-medical patient characteristics that influenced their referral process, including health literacy, language, cultural beliefs, patient distress, and cost. Providers who see patients at different times along the cancer care continuum viewed benefits of testing differently., Conclusion: The use of digital technologies that systematically identify those eligible for genetic testing referrals may mitigate some but not all challenges identified in this study. Further research should determine how individual provider perceptions influence referral practices and patient access to genetics both within and across cancer specialties.

Background and Aims: Women have historically been under-represented in clinical research, but the extent to which this is true for substance use disorder (SUD) trials is unknown. We aimed to determine the ratio of female:male participation in clinical trials for SUDs and describe the reporting of sex-specific outcomes from 2010 to 2019., Design: A retrospective cohort review of clinical trials involving people with SUD., Setting: United States., Participants: Clinical trials including people with SUD registered in clinicaltrials.gov and completed between 1 January 2010 and 31 December 2019 were reviewed. Trials were excluded if they had < 30 participants, focused on SUD prevention, were conducted outside the United States and/or did not report data on participant sex or gender., Measurements: The following were extracted for each trial: primary outcome, number of participants enrolled, analytical sample size, percentage of participants who were female, inclusion of transgender participants, whether sex-based analyses were performed, funding source, type of SUD and type of intervention. Relative representation in trials was examined using the female:male ratio, reported using median ratios and by year of trial completion. The proportion of females participating was adjusted using the underlying disease prevalence among females using National Survey on Drug Use and Health data., Findings: A total of 316 trials met inclusion criteria: 274 were mixed-sex, 12 enrolled only males and 30 only females. In 274 mixed-sex trials, 40% of 57 544 participants were female. Only 22 trials (8%) reported any sex-specific analyses; four studies (1.5%) reported inclusion of transgender participants. Females represented 35% of participants in trials targeting illicit drug use disorder, 52% in nicotine use disorder and 29% in alcohol use disorder. Accounting for underlying disease prevalence revealed that women had the lowest relative enrollment in alcohol use disorder trials (median participation to prevalence ratio in 2017: 0.58; 95% confidence interval: 0.13, 0.91)., Conclusions: A review of 316 US clinical trials for alcohol, nicotine and illicit substance use disorders completed between 2010 and 2019 showed that females were enrolled at lower rates than males overall. Only 8% of the trials reviewed reported sex-specific analyses and 1.5% reported transgender participants., (© 2022 Society for the Study of Addiction.)

This special communication provides an approach for applying implementation science frameworks to a Clinical and Translational Science Institutes (CTSIs) community engagement (CE) program that measures the use of implementation strategies and outcomes that promote the uptake of CE in research. Using an iterative multi-disciplinary group process, we executed a four-phased approach to developing an evaluation plan: 1) creating an evaluation model adapted from Proctor's conceptual model of implementation research; 2) mapping implementation strategies to CTSI CE program interventions that support change in research practice; 3) identifying and operationalizing measures for each strategy; and 4) conducting an evaluation. Phase 2 employed 73 implementation strategies across 9 domains generated by the Expert Recommendations for Implementing Change project. The nine domains were used to classify each CE program implementation strategy. In Phase 3, the group used the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework to define measures for each individual strategy. Phase 4 demonstrates the application of this framework and measures Year 1 outcomes for the strategy providing interactive assistance , which we implemented using a centralized consultation model. This approach can support the CTSA program in operationalizing CE program measurement to demonstrate which activities and strategies may lead to benefits derived by the program, institution, and community., (© The Author(s) 2022.)

Objective: Despite evidence of disparate uptake of breast density (BD) information, little is known about diverse women's preferences for and experiences learning about BD., Methods: Telephone survey among 2306 racially/ethnically and literacy diverse women; qualitative interviews with 61 survey respondents. Responses by participant race/ethnicity and literacy were examined using bivariate, then multivariable analyses. Interviews were content-analyzed for themes., Results: Most women (80%) preferred learning of personal BD from providers, with higher rates among Non-Hispanic Black (85%) than Non-Hispanic White women (80%); and among Non-Hispanic White than Asian women (72%, all ps<0.05). Women with low literacy less often preferred receiving BD information from providers (76% v. 81%), more often preferring written notification (21% vs. 10%); women with high literacy more often preferred learning through an online portal (9% vs 3%). Most women (93%) received BD information from providers (no between group differences). Qualitative findings detailed women's desires for obtaining BD information from providers, written information, and visual depictions of BD., Conclusions: When educating women about BD, one size does not fit all., Practice Implications: Additional educational methods are needed beyond written BD notifications to sufficiently address the varying informational needs and preferences of all USA women., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: Sociolegal barriers to cancer care are defined as health-related social needs like affordable healthy housing, stable utility service, and food security that may be remedied by public policy, law, regulation, or programming. Legal support has not been studied in cancer care., Methods: The authors conducted a randomized controlled trial of patients who had newly diagnosed cancer at a safety-net medical center in Boston from 2014 through 2017, comparing standard patient navigation versus enhanced navigation partnered with legal advocates to identify and address sociolegal barriers. English-speaking, Spanish-speaking, or Haitian Creole-speaking patients with breast and lung cancer were eligible within 30 days of diagnosis. The primary outcome was timely treatment within 90 days of diagnosis. Secondary outcomes included patient-reported outcomes (distress, cancer-related needs, and satisfaction with navigation) at baseline and at 6 months., Results: In total, 201 patients with breast cancer and 19 with lung cancer enrolled (response rate, 78%). The mean patient age was 55 years, 51% of patients were Black and 22% were Hispanic, 20% spoke Spanish and 8% spoke Haitian Creole, 73% had public health insurance, 77% reported 1 or more perceived sociolegal barrier, and the most common were barriers to housing and employment. Ninety-six percent of participants with breast cancer and 73% of those with lung cancer initiated treatment within 90 days. No significant effect of enhanced navigation was observed on the receipt of timely treatment among participants with breast cancer (odds ratio, 0.88; 95% CI, 0.17-4.52) or among those with lung cancer (odds ratio, 4.00; 95% CI, 0.35-45.4). No differences in patient-reported outcomes were observed between treatment groups., Conclusions: Navigation enhanced by access to legal consultation and support had no impact on timely treatment, patient distress, or patient needs. Although most patients reported sociolegal barriers, few required intensive legal services that could not be addressed by navigators., Lay Summary: In patients with cancer, the experience of sociolegal barriers to care, such as unstable housing, utility services, or food insecurity, is discussed. Addressing these barriers through legal information and assistance may improve care. This study compares standard patient navigation versus enhanced navigation partnered with legal advocates for patients with breast and lung cancers. Almost all patients in both navigation groups received timely care and also reported the same levels of distress, needs, and satisfaction with navigation. Although 75% of patients in the study had at least 1 sociolegal barrier identified, few required legal advocacy beyond what a navigator who received legal information and coaching could provide., (© 2022 American Cancer Society.)

Background: Most U.S. states require written notification of breast density after mammograms, yet effects of notifications on knowledge are mixed. Little is known about potential misunderstandings. Methods: We used a sequential mixed-methods study design to assess women's knowledge about breast density, after receiving a notification. We conducted a telephone survey among a racially/ethnically and health-literacy level diverse sample ( N  = 754) and qualitative interviews with 61 survey respondents. Results: In survey results, 58% of women correctly indicated that breast density is not related to touch, with higher accuracy among non-Hispanic White women and those with greater health literacy. Next, 87% of women recognized that breast density is identified visually via mammogram, with no significant differences in responses by race/ethnicity or health literacy. Most (81%) women recognized that a relationship exists between breast tissue types and density; Non-Hispanic White women were less likely to respond correctly. Only 47% of women correctly indicated that having dense breasts increases one's risk of breast cancer; women with low health literacy were more often correct. Qualitative results revealed additional dimensions of understanding: Some women incorrectly reported that density could be felt, or dense breasts were lumpier, thicker, or more compacted; others identified "dense" tissue as fatty. Interpretations of risk included that breast density was an early form of breast cancer. Conclusion: We found areas of consistent knowledge and identified misperceptions surrounding breast density across race/ethnicity and health literacy levels. Further education to address disparities and correct misunderstandings is essential to promote better knowledge, to foster informed decisions.

Background: Socioeconomic and health-related factors, including comorbid illness, may affect mammography screening rates and subsequently contribute to breast cancer outcomes. We explored the association between diabetes and mammography screening, and whether this association varied between racial, ethnic, and geographic groups. Methods: Cross-sectional data from the 2012, 2014, 2016, and 2018 Behavioral Risk Factor Surveillance System were used to fit logistic regression models assessing the association between diabetes and up-to-date mammography screening in 497,600 women, aged 50-74 years. Participants were considered exposed if they responded "yes" to "(Ever told) you have diabetes?" and up to date on screening if they responded "yes" to having a mammogram within the past 2 years. Models were adjusted for age, health status, socioeconomic, and access variables. Results: The majority of participants were White (79.6%), non-Hispanic (88.9%), and up to date on screening (78.8%). Overall, 16.8% reported having diabetes. In fully adjusted models, White women with diabetes were 12% more likely to be up to date on screening (odds ratio [OR]: 1.12, 95% confidence interval [CI]: 1.06-1.19) than those without diabetes. Black/African American women and those of Hispanic ethnicity with diabetes were more likely to report being up to date with mammography (OR Black : 1.28, 95% CI: 1.12-1.45; OR Hispanic : 1.19, 95% CI: 1.13-1.24) than those without. Patterns were similar across geographic regions. Conclusions: Women of ages 50-74 years with diabetes were more likely to be up to date on screening than women without diabetes. Chronic disease management may represent an opportunity to address cancer screening.

Background: Limited English proficiency (LEP) is common among hospitalized patients and may impact care. We synthesized the literature comparing clinical outcomes after in-hospital care for English-proficient(EP) versus LEP patients., Methods: This systematic review searched PubMed, Embase, and Web of Science from database inception through June 7, 2020, to identify research investigating clinical outcomes in patients receiving hospital-based care (in the emergency department, inpatient ward, surgical/procedural suite, or intensive care unit) that compared patients with LEP to an EP group. We assessed mortality, length of stay (LOS), readmissions/revisits, and complications. Study quality was evaluated using the Newcastle-Ottawa Scale., Results: Twenty-six studies met eligibility criteria. Study settings and populations were heterogeneous. Determination of primary language varied; a majority of studies (16/26) used patient self-report directly or via hospital records. Of 16 studies examining LEP and all-cause mortality, 13 found no significant association. Of 17 studies measuring LOS, 9 found no difference, 4 found longer LOS, 3 found shorter LOS, and 1 had mixed LOS results among patients with LEP. Several investigations suggested that LOS differences may be mediated at the hospital level. Nine studies evaluated inpatient readmissions. Among patients with LEP, there was evidence for increased readmissions in the setting of chronic medical conditions such as heart failure, but no evidence for increased readmissions among cohorts undergoing surgeries/procedures or with acute medical conditions. Five studies evaluated complications or harm related to a hospitalization, and no differences were found between language groups., Discussion: The research community lacks a standardized definition of LEP. Most studies did not find an association between English proficiency and mortality or complications. LOS findings were mixed and may be influenced at the hospital level. Differences in readmissions by language were concentrated in chronic medical conditions. Given the paucity of studies examining LEP populations, additional research is imperative., Prospero Registration Number: CRD42020143477., (© 2022. The Author(s) under exclusive licence to Society of General Internal Medicine.)

Introduction: We conducted a qualitative study to explore the impact of the COVID-19 pandemic on experiences with addiction treatment and harm reduction services., Methods: The study recruited participants from Boston, Massachusetts, aged 18-65 who had a history of opioid use disorder and overdose, from a parent study (REpeated dose Behavioral intervention to reduce Opioid Overdose, REBOOT) to participate between August and October 2020. In-depth individual interviews explored the impact of the COVID-19 pandemic on addiction service experiences. We conducted a grounded content analysis that examined codes related to addiction service access and engagement during the pandemic to compare and categorize participants according to their experiences., Results: The study enrolled twenty participants. The mean age was 42 years; most identified as white (n = 16); ten participants identified as men, nine as cis-gender women, and one as a trans-gender woman. Participants described their experiences with COVID-19-driven changes to addiction care (methadone take homes, televisits for either buprenorphine or behavioral health services, and syringe service outreach) access and engagement as: 1) liberating (n = 7), 2) destabilizing (n = 8), or 3) unjust (n = 5). Participants in the liberating group found adaptations allowed for increased flexibility, freedom, and safety from COVID-19. This group was mostly housed and had strong social supports that facilitated participation in adapted treatment programs. COVID-19-related changes to addiction treatment disrupted routine and community supports among those in the destabilizing group. Participants in the unjust group felt that adaptations exacerbated inequities as a lack of housing and other social supports prohibited them from benefiting from the relaxed restrictions to methadone or buprenorphine. This group was mostly unhoused and found that adaptations did not adequately mitigate other inequities worsened by public health mandates for unhoused people who use drugs., Conclusion: Relaxed restrictions on medications for opioid use disorder created opportunities for improved patient-centered care. Concrete measures that address service barriers, such as phone or transportation access, may have reduced destabilizing and unjust experiences reported by our participants. However, addiction care inequities will persist if drivers of marginalization, specifically a lack of housing, remain unaddressed., (Copyright © 2021. Published by Elsevier Inc.)

Objective: We aimed to describe opioid prescribing practices after obstetric delivery and to evaluate how these practices compare with national opioid prescribing guidelines., Methods: A closed survey was developed, evaluated for validity and reliability, and distributed by email to obstetrician members of the Society of Obstetricians and Gynaecologists of Canada (SOGC) in December 2018. Descriptive statistics were used to summarize respondent demographics, pharmaceutical pain management strategies, and opioid prescribing practices. Logistic regression was used to measure associations between respondent characteristics and high-risk opioid prescribing practices (e.g., prescribing >50 mg morphine equivalent dose per day, prescribing >5 days, not screening for substance/opioid use disorder before prescribing)., Results: Our survey had high content validity (content validity index 0.89; 95% CI 0.78-1.00) and adequate reliability (Kappa 0.70; 95% CI 0.63-0.84 and intraclass correlation coefficient 0.70; 95% CI 0.67-0.81). Of the 1019 SOGC members reached, 243 initiated the survey (response rate, 24%). Among respondents, 235 (92%) completed the survey. Among opioid prescribers, 47% reported at least 1 high-risk opioid prescribing practice, the most frequent being a lack of substance/opioid use disorder screening. In the adjusted logistic regression model, being in practice more than 20 years (adjusted odds ratio [aOR] 0.53; 95% CI 0.29-0.93) and practising in a non-central area of Canada (aOR 0.49; 95% CI 0.28-0.84) reduced the odds of high-risk prescribing., Conclusion: Further research on barriers to screening are needed to support and enhance safer opioid prescribing practices among Canadian obstetricians., (Copyright © 2021. Published by Elsevier Inc.)

Background. When stakeholders offer divergent input, it can be unclear how to prioritize information for decision aids (DAs) on mammography screening. Objectives. This analysis triangulates perspectives (breast cancer screening experts, primary care providers [PCPs], and patients with limited health literacy [LHL]) to understand areas of divergent and convergent input across stakeholder groups in developing a breast cancer screening DA for younger women with LHL. Design. A modified online Delphi panel of 8 experts rated 57 statements for inclusion in a breast cancer screening DA over three rounds. Individual interviews with 25 patients with LHL and 20 PCPs from a large safety net hospital explored informational needs about mammography decision making. Codes from the qualitative interviews and open-ended responses from the Delphi process were mapped across stakeholders to ascertain areas where stakeholder preferences converged or diverged. Results. Four themes regarding informational needs were identified regarding 1) the benefits and harms of screening, 2) different screening modalities, 3) the experience of mammography, and 4) communication about breast cancer risk. Patients viewed pain as the primary harm, while PCPs and experts emphasized the harm of false positives. Patients, but not PCPs or experts, felt that information about the process of getting a mammogram was important. PCPs believed that mammography was the only evidence-based screening modality, while patients believed breast self-exam was also important for screening. All stakeholders described incorporating personal risk information as important. Limitations. As participants came from one hospital, perceptions may reflect local practices. The Delphi sample size was small. Conclusions. Patients, experts, and PCPs had divergent views on the most important information needed for screening decisions. More evidence is needed to guide integration of multiple stakeholder perspectives into the content of DAs., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

Aims: To explore how people who use fentanyl and health-care providers engaged in and responded to overdose risk communication interactions, and how these engagements and responses might vary by age., Design: A single-site qualitative in-depth interview study., Setting: Boston, MA, United States., Participants: The sample included 21 people (10 women, 11 men) who were either 18-25 or 35+, English-speaking, and reported illicit fentanyl use in the last year and 10 health-care providers who worked directly with people who use fentanyl (PWUF) in clinical and community settings., Measurements: Open-ended, flexible interview questions guided by a risk communication framework were used in all interviews. Codes used for thematic analysis included deductive codes related to the risk communication framework and inductive, emergent codes from interview content., Findings: We identified potential age-based differences in perceptions of fentanyl overdose, including that younger participants appeared to display more perceptions of an immunity to fentanyl's lethality, while older people seemed to express a stronger aversion to fentanyl due to its heightened risk of fatal overdose, shorter effects and potential for long-term health consequences. Providers perceived greater challenges relaying risk information to young PWUF and believed them to be less open to risk communication. Compassionate harm reduction communication was preferred by all participants and perceived to be delivered most effectively by community health workers and peers. PWUF and providers identified structural barriers that limited compassionate harm reduction, including misalignment of available treatment with preferred options and clinical structures that impeded the delivery of risk communication messages., Conclusions: Among people who engage in illicit fentanyl use, fentanyl-related risk communication experiences and preferences may vary by age, but some foundational elements including compassionate, trust-building approaches seem to be preferred across the age spectrum. Structural barriers in the clinical setting such as provider-prescribing power and infrequent encounters may impede the providers' ability to provide compassionate harm reduction communication., (© 2020 Society for the Study of Addiction.)

Background: Standard public health approaches to risk communication do not address the gendered dynamics of drug use. The aim of this study was to explore perceptions of fentanyl-related risks among women and men to inform future risk communication approaches., Methods: We conducted a qualitative study, purposively sampling English-speaking women and men, aged 18-25 or 35+ years, with past 12-month illicitly manufactured fentanyl use. In-depth individual interviews explored experiences of women and men related to overdose and fentanyl use. We conducted a grounded content analysis examining specific codes related to overdose and other health or social risks attributed to drug use. Using a constant comparison technique, we explored commonalities and differences in themes between women and men., Results: The study enrolled twenty-one participants, 10 women and 11 men. All participants had personal overdose experiences. Both women and men described overdosing as a "chronic" condition and expressed de-sensitization to the risk of overdose. Women and men described other risks around health, safety, and state services that often superseded their fear of overdose. Women feared physical and sexual violence and prioritized caring for children and maintaining relations with child protective services, while men feared violence arising from obtaining and using street drugs and incarceration. Only women reported that fear of violence prevented their utilization of harm reduction services., Conclusions: Experiences with overdose and risk communication among people who use fentanyl-containing opioids varied by gender. The development of gender-responsive programs that address targeted concerns may be an avenue to enhance engagement with harm reduction and treatment services and create safe spaces for women not currently accessing available services., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: Understanding whether states' breast density notifications are associated with desired effects, or disparities, can inform federal policy. We examined self-reported receipt of personal breast density information, breast density discussions with providers, knowledge about density's masking effect, and association with increased breast cancer risk by state legislation status and women's sociodemographic characteristics., Methods: Cross-sectional observational population-based telephone survey of women aged >40 years who underwent mammography within prior 2 years, had no history of breast cancer, and had heard the term "breast density.", Results: Among 2,306 women, 57% received personal breast density information. Multivariate regression models adjusted for covariates indicated that women in notification states were 1.5 times more likely to receive density information, and older Black and Asian women of lower income and lower health literacy were less likely. Overall, only 39% of women discussed density with providers; women in notification states were 1.75 times as likely. Older and Asian women were less likely to have spoken with providers; women with high literacy or prior biopsy were more likely. State legislation status was not associated with differences in density knowledge, but Hispanic women and women of lower income or low health literacy had less knowledge regarding density's masking effects; older women were more knowledgeable. Hispanic women and women of lower income or low health literacy were more likely, and middle-aged women less likely, to recognize increased breast cancer risk., Discussion: Some positive effects were observed, but sociodemographic disparities suggest tailoring of future breast density communications for specific populations of women to ensure equitable understanding., (Copyright © 2020 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Background: Limited health literacy is a driver of cancer disparities and associated with less participation in medical decisions. Mammography screening decisions are an exemplar of where health literacy may impact decision-making and outcomes., Objective: To describe informational needs and shared decision-making (SDM) experiences among women ages 40-54 who have limited health literacy and primary care providers (PCPs)., Design: Qualitative, in-depth interviews explored experiences with mammography counseling and SDM., Participants: Women ages 40-54 with limited health literacy and no history of breast cancer or mammogram in the prior 9 months were approached before a primary care visit at a Boston academic, safety-net hospital. PCPs practicing at this site were eligible for PCP interviews., Approach: Interviews were audio-recorded and transcribed verbatim. A set of deductive codes for each stakeholder group was developed based on literature and the interview guide. Inductive codes were generated during codebook development. Codes were compared within and across patient and PCP interviews to create themes relevant to mammography decision-making., Key Results: The average age of 25 interviewed patients was 46.5; 18 identified as black, 3 as Hispanic, 2 as non-Hispanic white, and 2 had no recorded race or ethnicity. Of 20 PCPs, 15 were female; 12 had practiced for >5 years. Patients described a lack of technical (appropriate tests and what they do) and process (what happens during a mammogram visit) knowledge, viewing these as necessary for decision-making. PCPs were reluctant to engage patients with limited health literacy in SDM due to time constraints and feared that increased information might confuse patients or deter them from having mammograms. Both groups felt pre-visit education would facilitate mammography-related SDM during clinical visits., Conclusion: Both patients and PCPs perceived a need for tools to relay technical and process knowledge about mammography prior to clinical encounters to address the scope of information that patients with limited health literacy desired.

Introduction: This study sought to examine whether germline genetic counseling and testing were employed differentially among men with prostate cancer by race and/or ethnicity and other social factors., Methods: In this retrospective analysis, all patients with prostate cancer listed as a visit diagnosis during the study period (April 2011 to August 2020) were identified from electronic health records. Patient characteristics were collected along with genetic counselor visits and germline genetic testing results in electronic health records. Multivariable analyses were performed with the primary outcome defined as the receipt of a genetic counseling visit and receipt of genetic testing., Results: A total of 14,610 patients with a prostate cancer diagnosis code were identified. The majority of patients were White (72%), aged >=65 years (62.7%), English-speaking (95%), married (71.4%), and publicly insured (58.7%). A total of 667 patients completed an appointment with a genetic counselor. A total of 439 patients received germline genetic test result, of whom 403 (91.8%) had also completed an appointment with a genetic counselor. Patients that were 65 years or older (adjusted odds ratio 0.53, 95%CI 0.44-0.65) and non-English proficient (adjusted odds ratio 0.71, 95%CI 0.42-1.21) were less likely to receive genetic counseling. Receiving genetic counseling was the strongest independent predictor of receipt of genetic testing., Conclusions: The results of the current study highlight that the role of social factors in contributing to disparities in genetic counseling and testing among men with prostate cancer. These results underscore the importance of developing novel strategies to tackle contributors of observed disparities including language, age, and insurance status., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Approximately one-third of adults in the United States (U.S.) have limited health literacy. Those with limited health literacy often have difficultly navigating the health care environment, including navigating care across the cancer continuum (e.g., prevention, screening, diagnosis, treatment). Evidence-based interventions to assist adults with limited health literacy improve health outcomes; however, little is known about health literacy interventions in the context of cancer and their impact on cancer-specific health outcomes. The purpose of this review was to identify and characterize the literature on health literacy interventions across the cancer care continuum. Specifically, our aim was to review the strength of evidence, outcomes assessed, and intervention modalities within the existing literature reporting health literacy interventions in cancer. Our search yielded 1036 records (prevention/screening n = 174; diagnosis/treatment n = 862). Following deduplication and review for inclusion criteria, we analyzed 87 records of intervention studies reporting health literacy outcomes, including 45 pilot studies (prevention/screening n = 24; diagnosis/treatment n = 21) and 42 randomized controlled trials or quasi-experimental trials (prevention/screening n = 31; diagnosis/treatment n = 11). This literature included 36 unique interventions (prevention/screening n = 28; diagnosis/treatment n = 8), mostly in the formative stages of intervention development, with few assessments of evidence-based interventions. These gaps in the literature necessitate further research in the development and implementation of evidence-based health literacy interventions to improve cancer outcomes.

Starting breast cancer screening at age 40 versus 50 may increase potential harms frequency with a small mortality benefit. Younger women's screening decisions, therefore, may be complex. Shared decision-making (SDM) is recommended for women under 50 and may support women under 55 for whom guidelines vary. How women with limited health literacy (LHL) approach breast cancer screening decision-making is less understood, and most SDM tools are not designed with their input. This phenomenological study sought to characterize mammography counseling experiences among women with LHL and primary care providers (PCPs). Women ages 40-54 with LHL who had no history of breast cancer or mammogram within 9 months were approached before a primary care visit at a safety-net hospital. PCPs at this site were invited to participate. Qualitative interviews explored mammography counseling experiences. Patients also reviewed sample information materials. A constant comparison technique generated four themes salient to 25 patients and 20 PCPs: addressing family history versus comprehensive risk assessment; potential mammography harms discussions; information delivery preferences; and integrating pre-visit information tools. Findings suggest that current counseling techniques may not be responsive to patient-identified needs. Opportunities exist to improve how mammography information is shared and increase accessibility across the health literacy spectrum.

Purpose: Low health literacy (HL) and language negatively affect cancer screening and prevention behaviors; less is known about how they affect the patient's experience during cancer treatment. This study explores associations among HL, spoken language, and dimensions of cancer-related needs within 6 months of receiving a breast cancer diagnosis., Methods: Women speaking English, Spanish, or Haitian Creole, enrolled in a patient navigation study at diagnosis, completed a survey in their primary spoken language at baseline and 6 months to characterize their cancer-related needs. HL was measured using the Brief Health Literacy Screening Tool. Outcomes included the Cancer Needs Distress Inventory (CaNDI; n = 38 items) and the Communication and Attitudinal Self-Efficacy scale (CASE-Cancer) for cancer (n = 12 items). Linear regressions measured the impact of HL and language on total CaNDI and CASE-Cancer scale for cancer scores and subscales, adjusted for demographics., Results: At baseline, 262 women participated and 228 (87%) followed up at 6 months. Of these, 38% had adequate HL, 33% had marginal HL, and 29% had inadequate HL. Women with inadequate or marginal HL had higher median baseline CaNDI scores ( P = .02) and lower self-efficacy scores ( P = .008), relative to those with adequate HL. Haitian-Creole speakers had significantly lower CANDI scores at baseline ( P = .03). Adjusting for demographics, differences in CaNDI scores at baseline remained significant for those with lower HL and Haitian-Creole speakers. At 6 months, differences in self-efficacy persisted for Haitian-Creole speakers., Conclusion: Findings suggest that interventions oriented to mitigating HL and language barriers might reduce distress at the time of diagnosis and improve self-efficacy over the course of treatment.

Objectives: In this pilot study, we developed and assessed acceptability of a brochure for women with dense breasts., Material and Methods: We measured Flesch-Kincaid Readability of 22 existing breast density educational materials. We then developed a brochure and tested it in two populations of women: 44 safety net hospital patients and 13 Breast Cancer Surveillance Consortium stakeholders., Results: Average grade score of existing materials was 10.0 (range: 5.5-12.7). Our brochure had a grade score of 5.9, and patients reported it was easy to understand., Conclusion: Our plain language brochure could improve patient understanding following mandatory dense breast notification., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to report., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Competing Interests: Disclosure: The authors have no relevant financial relationships to disclose.

Background: Literature on decision making about breast cancer prevention focuses on individual perceptions and attitudes that predict chemoprevention use, rather than the process by which women decide whether to take risk-reducing medications. This secondary analysis aimed to understand how women's perceptions of breast cancer risk and locus of control influence their decision making., Methods: Women were accrued as part of the NRG Oncology/National Surgical Adjuvant Breast and Bowel Project Decision-Making Project 1, a study aimed at understanding contributors to chemoprevention uptake. Thirty women participated in qualitative in-depth interviews after being counseled about chemoprevention. Deductive codes grouped women based on dimensions of risk perception and locus of control. We used a constant comparative method to make connections among inductive themes focused on decision making, deductive codes for perceived risk and perceived locus of control, and the influence of explanatory models within and across participants., Results: Participants were predominantly non-Hispanic white (63%), with an average age of 50.9 years. Decision making varied across groups: the high-perceived risk/high-perceived control group used "social evidence" to model the behaviors of others. High-perceived risk/low-perceived control women made decisions based on beliefs about treatment, rooted in the experiences of social contacts. The low-perceived risk/low-perceived control group interpreted signs of risk as part of the normal continuum of bodily changes in comparison to others. Low-perceived risk/high-perceived control women focused on maintaining a current healthy trajectory., Conclusion: "Social evidence" plays an important role in the decision-making process that is distinct from emotional aspects. Attending to patients' perceptions of risk and control in conjunction with social context is key to caring for patients at high risk in a way that is evidence based and sensitive to patient preferences.

Background: Legislation requiring mammography facilities to notify women if they have dense breast tissue found on mammography has been enacted in 34 US states. The impact of dense breast notifications (DBNs) on women with limited English proficiency (LEP) is unknown., Objective: This study sought to understand Spanish-speaking women's experience receiving DBNs in a Massachusetts safety-net hospital., Design: Eligible women completed one audio-recorded, semi-structured interview via telephone with a native Spanish-speaking research assistant trained in qualitative methods. Interviews were professionally transcribed verbatim and translated. The translation was verified by a third reviewer to ensure fidelity with audio recordings., Participants: Nineteen Spanish-speaking women ages 40-74 who received mammography with a normal result and recalled receiving a DBN., Approach: Using the verified English transcripts, we conducted a content analysis to identify women's perceptions and actions related to receiving the notification. A structured codebook was developed. Transcripts were independently coded and assessed for agreement with a modification of Cohen's kappa. Content codes were grouped to build themes related to women's perceptions and actions after receiving a DBN., Key Results: Nineteen Spanish-speaking women completed interviews. Nine reported not receiving the notification in their native language. Four key themes emerged: (1) The novelty of breast density contributed to notification-induced confusion; (2) women misinterpreted key messages in the notification; (3) varied actions were taken to seek further information; and (4) women held unrealized expectations and preferences for follow-up., Conclusions: Not having previous knowledge of breast density and receiving notifications in English contributed to confusion about its meaning and inaccurate interpretations of key messages by Spanish speakers. Tools that promote understanding should be leveraged in seeking equity in risk-based breast cancer screening for women with dense breasts.

Background: Explanatory models represent patient understanding of etiology, pathophysiology, illness, symptoms, and treatments, but little attention has been paid to how they are used by patients "at risk" for future disease., Objective: The aims of this study were to elucidate what constitutes an explanatory model of risk and to describe explanatory models of risk related to developing breast cancer., Methods: Thirty qualitative interviews with women identified as at an increased risk for breast cancer were conducted. Interviews were coded to identify domains of explanatory models of risk using a priori codes derived from the explanatory model of illness framework. Within each domain, a grounded thematic analysis described participants' explanatory models related to breast cancer risk., Results: The domains of treatment and etiology remained similar in a risk context compared with illness, whereas course of illness, symptoms, and pathophysiology differed. We identified a new, integrative concept relative to other domains within explanatory models of risk: social comparisons, which was dominant in risk perhaps due to the lack of physical experiences associated with being "at risk.", Conclusions: Developing inclusive understandings of risk and its treatment is key to developing a framework for the care of high-risk patients that is both evidence based and sensitive to patient preferences., Implications for Practice: The concept of "social comparisons" can assist healthcare providers in understanding women's decision making under conditions of risk. Ensuring that healthcare providers understand patient perceptions of risk is important because it relates to patient decision making, particularly due to an increasing focus on risk assessment in cancer.

The physical controlling factors on coastal plant communities are among the most dynamic of known ecosystems, but climate change alters coastal surface and subsurface hydrologic regimes, which makes rapid measurement of greenhouse gas fluxes critical. Greenhouse gas exchange rates in these terrestrial-aquatic ecosystems are highly variable worldwide with climate, soil type, plant community, and weather. Therefore, increasing data collection and availability should be a priority. Here, we demonstrate and validate physical and analytical modifications to automated soil-flux chamber measurement methods for unattended use in tidally driven wetlands, allowing the high-frequency capture of storm surge and day/night dynamics. Winter CO 2 flux from Sarcocornia perennis marsh to the atmosphere was significantly greater during the day (2.8 mmol m -2  hr -1 ) than the night (2.2 mmol m -2  hr -1 ; p < 0.001), while CH 4 was significantly greater during the night (0.16 μmol m -2  hr -1 ) than the day (-0.13 μmol m -2  hr -1 ; p = 0.04). The magnitude of CO 2 flux during the day and the frequency of CH 4 flux were reduced during a surge (p < 0.001). Surge did not significantly affect N 2 O flux, which without non-detects was normally distributed around -24.2 nmol m -2  hr -1 . Analysis with sustained-flux global potentials and increased storm surge frequency scenarios, 2020 to 2100, suggested that the marsh in winter remains an atmospheric CO 2 source. The modeled results showed an increased flux of CO 2 to the atmosphere, while in soil, the uptake of CH 4 increased and N 2 O uptake decreased. We present analytical routines to correctly capture gas flux curves in dynamic overland flooding conditions and to flag data that are below detection limits or from unobserved chamber-malfunction situations. Storm surge is an important phenomenon globally, but event-driven, episodic factors can be poorly estimated by infrequent sampling. Wider deployment of this system would permit inclusion of surge events in greenhouse gas estimates., (© 2018 John Wiley & Sons Ltd.)

Objective: Currently, 30 US states mandate that radiologists notify women when dense breast tissue is found on mammography. Little is understood about how notifications are perceived by recipients. This qualitative study sought to understand how dense breast notifications (DBNs) impact women's perceptions and their participation in follow-up care., Methods: We assessed rates of DBN recall and conducted semi-structured telephone interviews with 30 English-speaking women ages 40 to 74 after receiving a DBN from a Massachusetts hospital. Content coding characterized women's recall of the notification content, perceptions of breast density, and planned or actual participation in follow-up care., Results: Most women (81%) recalled receiving a DBN, but few could recall specific content. Women described struggling to understand the meaning of breast density and created their own explanatory models of dense breasts that differed from medical explanations. Many women planned to or did talk with their doctors about breast density as a result of receiving the notification., Conclusions: Women receiving DBNs have limited knowledge and many misperceptions about the implications of having dense breasts., Practice Implications: Educational support is needed to promote informed decision- making about breast cancer screening that incorporates personal risk in the setting of dense breast legislation., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Dense breasts on mammography independently increases breast cancer risk and decreases mammography sensitivity. Thirty-two states have adopted notification laws to raise awareness among women with dense breasts about supplemental screening. Little is known about these policies' impact on clinical practice among primary care providers (PCPs)., Materials and Methods: This study explores PCP attitudes, knowledge, and the impact of the Massachusetts dense breast notification legislation on clinical practice after its enactment in 2015. An anonymous, online survey at two urban safety-net hospitals was administered in 2015-2016. Practicing MDs and nurse practitioners in primary care were invited to participate., Results: All 145 PCPs in general internal medicine at the two sites were e-mailed a survey link and 80 (55%) were completed. While 64 of 80 PCPs surveyed (80%) had some familiarity with the legislation, none identified the 8 required components of notifications contained in the Massachusetts legislation. Forty-nine percent (39/80) did not feel prepared to respond to patient questions about dense breasts. Forty-one percent (33/80) correctly identified that no current guidelines recommend the use of supplemental screening tests solely based on breast density and 85% (68/80) indicated interest in further training. Female and less experienced providers were more likely to be in favor of the legislation (49% vs. 11% by gender; 76% <5 years vs. 9%> 20 years). Women practitioners (55%) who were more likely than men (17%, p = 0.01) to agree with the policy changed their discussions of mammography results with patients., Conclusions: PCPs feel underprepared to counsel women about breast density identified on mammography and its implications.

Objectives: A false-positive mammogram can result in anxiety, distress, and increased perceptions of breast cancer risk, potentially changing how women utilize healthcare. This study examined whether having an abnormal mammogram, considered a proxy for elevated risk perception, was associated with greater future health service use (outpatient visits and referrals)., Study Design: A retrospective cohort study using electronic health record data, spanning 2008 to 2012, from Boston Medical Center, a safety-net hospital., Methods: We grouped 3920 women aged 40 to 75 years receiving primary care and who had a mammogram between 2010 and 2011 into 3 categories: false-positive mammogram at index date; previous false positive, but normal index mammogram; and no history of false-positive mammograms. We contrasted the longitudinal changes in outpatient visits and provider referrals, before versus after the index mammogram, between women with false-positive mammogram and those without using Poisson regression models with a difference-in-differences specification. Clinical, visit, and demographic data were obtained from the institutional clinical data warehouse., Results: Adjusting for baseline differences in sociodemographic characteristics across risk groups and for secular changes between pre- and postindex periods, a current false-positive mammogram was associated with an 18% increase in overall outpatient visits (incidence rate ratio [IRR], 1.18; 95% CI, 1.07-1.51), but no corresponding increase in provider referrals (IRR, 1.15; 95% CI, 0.99‑1.34), relative to never having a false positive. A previous false-positive mammogram had no associated change in outpatient utilization (IRR, 0.99; 95% CI, 0.91-1.07)., Conclusions: Providers should discuss the implications of mammography findings at the time of screening to help mitigate potential detrimental effects and promote appropriate engagement in health services.

Background: Despite individual and institutional awareness of the inequity in retention, promotion and leadership of racially and ethnically underrepresented minority faculty in academic medicine, the number of such faculty remains unacceptably low. The authors explored challenges to the recruitment, retention and promotion of underrepresented faculty among a sample of leaders at academic medical centers., Methods: Semi-structured interviews were conducted from 2011 to 2012 with 44 senior faculty leaders, predominantly members of the Group on Diversity and Inclusion (GDI) and/or the Group on Women in Medical Sciences (GWIMS), at the 24 randomly selected medical schools of the National Faculty Survey of 1995. All institutions were in the continental United States and balanced across public/private status and geographic region. Interviews were audio-taped, transcribed, and organized into content areas before conducting inductive thematic analysis. Themes expressed by multiple informants were studied for patterns of association., Results: The climate for underrepresented minority faculty was described as neutral to positive. Three consistent themes were identified regarding the challenges to recruitment, retention and promotion of underrepresented faculty: 1) the continued lack of a critical mass of minority faculty; 2) the need for coordinated programmatic efforts and resources necessary to address retention and promotion; and 3) the need for a senior leader champion., Conclusion: Despite a generally positive climate, the lack of a critical mass remains a barrier to recruitment of racially and ethnically underrepresented faculty in medicine. Programs and resources committed to retention and promotion of minority faculty and institutional leadership are critical to building a diverse faculty., (Copyright © 2018 National Medical Association. Published by Elsevier Inc. All rights reserved.)

Objectives: The presentation of risks and benefits in clinical practice is common particularly in situations in which treatment recommendations involve trade-offs. The treatment of breast cancer risk with selective estrogen receptor modulators (SERMs) is such a decision. We investigated the influence of health care provider (HCP) counseling on women's decision-making., Methods: Thirty breast cancer risk counseling sessions were recorded from April 2012-August 2013 at a comprehensive cancer center and at a safety-net, community hospital in the US. Participating women and HCPs were interviewed. A cross-case synthesis was used for analysis., Results: Of 30 participants 21 received a SERM-recommendation, 11 decided to take SERMs. Counseling impacted decision-making, but did not determine it. Three categories emerged: 1.) ability to change the decision anytime, 2.) perceptions on medications, and 3.) proximity of cancer., Conclusion: Decision-making under conditions of a risk diagnosis such as increased breast cancer risk is a continuous process in which risk information is transformed into practical and experiential considerations., Practice Implications: Individuals' health care decision-making is only marginally dependent on the interactions in the clinic. Accepting patients' experiences and beliefs in their own right and letting them guide the discussion may be important for a satisfying decision-making process., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Introduction: High breast density is an independent risk factor for breast cancer and can decrease the sensitivity of mammography. However, evidence surrounding recommendations for patient risk stratification and supplemental screening is evolving, and providers receive limited training on breast density counseling., Methods: We implemented an introductory, interactive workshop about breast density including current evidence behind supplemental screening and risk stratification. Designed for providers who counsel women on breast health, this workshop was evaluated with internal medicine providers, primary care residents, and radiology residents. We surveyed participants about knowledge and attitudes at baseline, postintervention (residents and providers), and 3-month follow-up (providers only). We compared baseline and postintervention scores and postintervention and 3-month follow-up scores using paired t tests and McNemar's tests., Results: Internal medicine providers had significant gains in knowledge when comparing baseline to postintervention surveys (6.5-8.5 on a 10-point scale, p < .0001), with knowledge gains maintained when comparing postintervention to 3-month follow-up surveys ( p = .06). Primary care and radiology residents also had significant gains in knowledge when comparing baseline to postintervention surveys ( p < .004 for both). All learner groups reported increases in their confidence regarding counseling women about breast density and referring for supplemental screening., Discussion: Through this breast density session, we showed trends for increased knowledge and change in attitudes for multiple learner groups. Because we aim to prepare providers with the best currently available recommendations, these materials will require frequent updating as breast density evidence and national consensus evolve., Competing Interests: None to report.

Background: Minority women in the U.S. continue to experience inferior breast cancer outcomes compared with white women, in part due to delays in care delivery. Emerging cancer care delivery models like patient navigation focus on social barriers, but evidence demonstrating how these models increase social capital is lacking. This pilot study describes the social networks of newly diagnosed breast cancer patients and explores the contributing role of patient navigators., Materials and Methods: Twenty-five women completed a one hour interview about their social networks related to cancer care support. Network metrics identified important structural attributes and influential individuals. Bivariate associations between network metrics, type of network, and whether the network included a navigator were measured. Secondary analyses explored associations between network structures and clinical outcomes., Results: We identified three types of networks: kin-based, role and/or affect-based, or heterogeneous. Network metrics did not vary significantly by network type. There was a low prevalence of navigators included in the support networks (25%). Network density scores were significantly higher in those networks without a navigator. Network metrics were not predictive of clinical outcomes in multivariate models., Conclusion: Patient navigators were not frequently included in support networks, but provided distinctive types of support. If navigators can identify patients with poorly integrated (less dense) social networks, or who have unmet tangible support needs, the intensity of navigation services could be tailored. Services and systems that address gaps and variations in patient social networks should be explored for their potential to reduce cancer health disparities., Implications for Practice: This study used a new method to identify the breadth and strength of social support following a diagnosis of breast cancer, especially examining the role of patient navigators in providing support. While navigators were only included in one quarter of patient support networks, they did provide essential supports to some individuals. Health care providers and systems need to better understand the contributions of social supports both within and outside of health care to design and tailor interventions that seek to reduce health care disparities and improve cancer outcomes., Competing Interests: Disclosures of potential conflicts of interest may be found at the end of this article., (© AlphaMed Press 2017.)