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Background: New York State law mandates that women with dense breasts receive a written notification of their breast density (BD) and its implications, but data on the impact of dense breast notification (DBN) on BD awareness and knowledge in diverse populations remain limited. Methods: Between 2016 and 2018, we collected survey and mammographic data from 666 women undergoing screening mammography in New York City (ages 40–60, 80% Hispanic, 69% Spanish-speaking) to examine the impact of prior DBN on BD awareness by sociodemographic and breast cancer risk factors, and describe BD knowledge by sources of information. Results: Only 24.8% of the overall sample and 34.9% of women receiving DBN had BD awareness. In multivariable models adjusting for DBN, awareness was significantly lower in women who were Spanish-speaking [OR, 0.16; 95% confidence interval (CI), 0.09–0.30 vs. English speakers], were foreign-born (OR, 0.31; 95% CI, 0.16–0.58 vs. U.S.-born), and had lower educational attainment (e.g., high school degree or less; OR, 0.14; 95% CI, 0.08–0.26 vs. college or higher degree). Women receiving DBN were more likely to be aware of BD (OR, 2.61; 95% CI, 1.59–4.27) but not more knowledgeable about the impact of BD on breast cancer risk and detection. However, women reporting additional communication about their BD showed greater knowledge in these areas. Conclusions: DBN increases BD awareness disproportionately across sociodemographic groups. Impact: Efforts to improve communication of DBN must focus on addressing barriers in lower socioeconomic and racially and ethnically diverse women, including educational and language barriers.

IntroductionTreatment delays are significantly associated with increased mortality risk among adult cancer patients; however, factors associated with these delays have not been robustly evaluated. This review and meta-analysis will evaluate factors associated with treatment delays among patients with five common cancers.Methods and analysisScientific databases including Ovid MEDLINE, Elsevier Embase, EBSCOhost CINAHL Plus Full Text, Elsevier Scopus and ProQuest Dissertations and Theses Global will be searched to identify relevant articles published between January 2000 and October 2021. Research articles published in the USA evaluating factors associated with treatment delay among breast, lung, prostate, cervical or colorectal adult cancer patients will be included. The primary outcome of the meta-analysis will be the pooled adjusted and unadjusted odds of treatment delay for patient, disease, provider and system-level factors defined according to specified time intervals. The secondary outcomes will be mean or median treatment delay for each cancer site according to first treatment and the influence of factors on the pooled mean treatment delay for each cancer site (via meta-regression analyses). Results from qualitative and mixed-methods studies will be narratively synthesised. Three reviewers will independently screen records generated from the search and two reviewers will independently extract data following a consensus agreement. Statistical heterogeneity will be assessed with a standard I2 test and funnel plots will be conducted to evaluate publication bias. Risk of bias will be assessed independently by two authors using validated tools according to the article’s study design.Ethics and disseminationFormal ethical approval is not required because the work is being carried out on publicly accessible studies. The findings of this review will be disseminated through a peer-reviewed scientific journal, academic conferences, social media, and key stakeholders.PROSPERO registration numberCRD42021293131.

Coronavirus disease of 2019 (COVD-19) continues to disrupt cancer care delivery efforts and exacerbate existing health inequities. Here we describe the impact of COVID-19 on community outreach organizations partnering with a National Cancer Institute—designated Community Outreach and Engagement (COE) office in New York City (NYC) and lessons learned from these experiences. Between July and September of 2020, we conducted 16 semi-structured interviews with community key-informants to validate and inform efforts to support community organizations in response to COVID-19. Key-informants represented organizations performing a broad range of health and cancer care activities serving historically underserved, low-income, marginalized communities of color in NYC. All interviews were recorded, transcribed, and analyzed using rapid qualitative approaches. We summarize our response to challenges raised by partnering organizations. Themes included the impact of COVID-19 on communities served, challenges faced by organizations, and solutions to address COVID-19 related challenges. The COE and community organizations had to shift priorities and adapt engagement efforts to address the more urgent needs of the community (e.g., emotional distress, food insecurity). COVID-19 disrupted traditional community engagement activities for cancer outreach—calling for creativity and innovation in the community engagement process and shift in priorities. The COE responded by maintaining ongoing dialogue with community partners, by being flexible in scope/priorities beyond cancer prevention and control, and by providing education, outreach, fundraising and other resources, and developing new partnerships to meet needs of community organizations and the populations they serve.

Mammographic breast density (MBD) has been shown to be a strong, independent risk factor for breast cancer (BC) irrespective of race/ethnicity. Given the risk association of MBD and its potential to mask tumors on a mammogram, state and federal laws have mandated that women receive information regarding their personal MBD in their mammography reports. However, concerns have been raised regarding the impact of MBD notification on patient anxiety, especially written information for women who experience health disparities such as racial/ethnic minorities, lower health literacy, limited English proficiency and lower socioeconomic status. We performed a randomized controlled clinical trial to examine the impact of three different written and interpersonal approaches to MBD notification on patient anxiety, BC worry, and self-perceived BC risk, among Latinas receiving routine mammography screening at a federally qualified medical center (FQHC). We hypothesized that interpersonal education would reduce anxiety and worry, relative to the written notifications alone. The study was performed at the Baseline Clinic of Mountain Park Health Center, a FQHC in Phoenix, AZ. Women between ages 40 and 74 years presenting for screening mammogram were eligible. After providing signed informed consent, participants were randomized equally to usual care (UC- mailed notification letter); enhanced care (notification letter and MBD educational brochure designed for this study): interpersonal care (notification letter, brochure, promotora education via telephone). A stratified block randomization procedure was used with age > 50 years (yes vs no), ethnicity (Hispanic vs non-Hispanic), and language preference (Spanish vs. English) as strata. Study participants completed surveys at the time of enrollment/pre-intervention (T0), at two weeks to six months after intervention was delivered (T1), and about one year after randomization (T2). Anxiety state was measured using the state anxiety subscale of the State-Trait Anxiety Inventory scale (STAI-S) (range from 20-80). BC worry was probed using the question: “How frequently do you worry about getting breast cancer someday”. The self-perceived lifetime risk of BC was rated between 0% (no chance of BC) to 100% (definitely will get BC). The proportion of participants with an increase or persistence of higher level for each outcome between time points was compared between the three study groups. The study was approved by the Mayo Clinic Institutional Review Board. 1332 Latina women were enrolled and randomized between October 2016 and October 2019. All completed the baseline (T0) survey, 928 completed T1, 632 completed T2, and 516 completed both T1 and T2 surveys. At study entry, majority of the participants were young (64.1% between age 40-49 years), had no family history of breast cancer (81.0%), had less than high school education (68.8%), and were married or partnered (67.8%). At T0, the mean (SD) anxiety STAI score was 32.5 (11.1); 51.8% with moderate or severe anxiety (score > 30). With regard to BC worry, 41.3% reported worrying “sometimes”, “often”, or “almost all the time”. Further, 25.4% reported a self-perceived lifetime risk of developing BC of >10% while only 6.6% had a Gail model estimated lifetime risk score of >10%. There was no significant difference in changes in anxiety, BC worry or self-perceived risk from T0 to either T1 or T2 surveys between the intervention groups. In summary, this study found high levels of baseline anxiety and BC worry (despite the majority being 40-49 years old and having no family history of BC) which persisted regardless of how notification and education were delivered. Future work is needed to improve the understanding of factors that could lower anxiety and BC worry and improve risk perception in this population. Citation Format: Karthik Ghosh, Sarah Jenkins, Jennifer Ridgeway, Jessica D. Austin, Bijan Borah, Bhavika K. Patel, Deborah Rhodes, Aaron Norman, Edna P. Ramos, Matt Jewett, Crystal Gonzalez, Valentina Hernandez, Davinder Singh, Vera Suman, Celine Vachon. Breast Density Notification: Impact on anxiety, breast cancer worry, and self-perceived risk among Latinas at a federally qualified medical center. [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-05-38.

Purpose of Review Examining what older women know and perceive about mammography screening is critical for understanding patterns of under- and overuse, and concordance with screening mammography guidelines in the USA. This narrative review synthesizes qualitative and quantitative evidence around older women’s perspectives toward mammography screening. Recent Findings The majority of 43 identified studies focused on promoting mammography screening in women of different ages, with only four studies focusing on the overuse of mammography in women ≥ 70 years old. Older women hold positive attitudes around screening, perceive breast cancer as serious, believe the benefits outweigh the barriers, and are worried about undergoing treatment if diagnosed. Older women have limited knowledge of screening guidelines and potential harms of screening. Summary Efforts to address inequities in mammography access and underuse need to be supplemented by epidemiologic and interventional studies using mixed-methods approaches to improve awareness of benefits and harms of mammography screening in older racially and ethnically diverse women. As uncertainty around how best to approach mammography screening in older women remains, understanding women’s perspectives along with healthcare provider and system-level factors is critical for ensuring appropriate and equitable mammography screening use in older women.

Background There is growing concern that routine mammography screening is overused among older women. Successful and equitable de-implementation of mammography will require a multi-level understanding of the factors contributing to mammography overuse. Methods This explanatory, sequential, mixed-methods study collected survey data (n= 52, 73.1% Hispanic, 73.1% Spanish-speaking) from women ≥70 years of age at the time of screening mammography, followed by semi-structured interviews with a subset of older women completing the survey (n=19, 63.2% Hispanic, 63.2% Spanish-speaking) and providers (n=5, 4 primary care, 1 obstetrics and gynecology) to better understand multi-level factors influencing mammography overuse and inform potential de-implementation strategies. We conducted a descriptive analysis of survey data and content analysis of qualitative interview data. Survey and interview data were examined separately, compared, integrated, and organized according to Norton and Chambers Continuum of Factors Influencing De-Implementation Process. Results Survey findings show that 87.2% of older women believe it is important to plan for an annual mammogram, 80.8% received a provider recommendation, and 78.9% received a reminder in the last 12 months to schedule a mammogram. Per interviews with older women, the majority were unaware of or did not perceive to have experienced overuse and intended to continue mammography screening. Findings from interviews with older women and providers suggest that there are multiple opportunities for older women to obtain a mammogram. Per provider interviews, almost all reported that reducing overuse was not viewed as a priority by the system or other providers. Providers also discussed that variation in mammography screening practices across providers, fear of malpractice, and monetary incentives may contribute to overscreening. Providers identified potential strategies to reduce overscreening including patient and provider education around harms of screening, leveraging the electronic health record to identify women who may receive less health benefit from screening, customizing system-generated reminder letters, and organizing workgroups to develop standard processes of care around mammography screening. Conclusions Multi-level factors contributing to mammography overuse are dynamic, interconnected, and reinforced. To ensure equitable de-implementation, there is a need for more refined and empirical testing of theories, models, and frameworks for de-implementation with a strong patient-level component that considers the interplay between multilevel factors and the larger care delivery process.

The decision to use adjuvant chemotherapy (ACT) after surgical resection for stage II colon cancer remains an area of clinical uncertainty. Many patients diagnosed with stage II colon cancer receive ACT, despite inconclusive evidence of long-term clinical benefit. This study investigates patient experiences and perceptions of treatment decision-making and shared decision making (SDM) for ACT among patients diagnosed with stage II colon cancer. Stage II colon cancer patients engaged in treatment or follow-up care aged >18 years were recruited from two large NYC health systems. Patients participated in 30–60-min semi-structured interviews. All interviews were transcribed, translated, coded, and analyzed using a thematic analysis approach. We interviewed 31 patients, of which 42% received ACT. Overall, patient perspectives indicate provider inconsistency in communicating ACT harms, benefits, and uncertainties, and poor elicitation of patient preferences and values. Patients reported varying perceptions and understanding of personal risk and clinical benefits of ACT. For many patients, receiving a clear treatment recommendation from the provider limited their participation in the decision-making process, whether it aligned with their decisional support preferences or not. Findings advance understanding of perceived roles and preferences of patients in SDM processes for cancer treatment under heightened clinical uncertainty, and indicate a notable gap in understanding for decisions made using SDM models in the context of clinical uncertainty. Educational and communication strategies and training are needed to support providers in communicating uncertainty, risk, treatment options, and implementing clinical guidelines to support patient awareness and informed decisions.

Background There is growing concern that routine mammography screening is overused among older women. Successful and equitable de-implementation of mammography will require a multi-level understanding of the factors contributing to mammography overuse. Methods This explanatory, sequential, mixed-methods study collected survey data (n = 52, 73.1% Hispanic, 73.1% Spanish-speaking) from women ≥ 70 years of age at the time of screening mammography, followed by semi-structured interviews with a subset of older women completing the survey (n = 19, 63.2% Hispanic, 63.2% Spanish-speaking) and providers (n = 5, 4 primary care, 1 obstetrics and gynecology) to better understand multi-level factors influencing mammography overuse and inform potential de-implementation strategies. We conducted descriptive analysis of survey data and content analysis of qualitative interview data. Survey and interview data were examined separately, compared, integrated, and organized according to Norton and Chambers Continuum of Factors Influencing De-Implementation Process. Results Survey findings show that 87.2% of older women believe it is important to plan for an annual mammogram, 80.8% received a provider recommendation, and 78.9% received a reminder in the last 12 months to schedule a mammogram. Per interviews with older women, the majority were unaware of or did not experience overuse and intended to continue mammography screening. Findings from interviews with older women and providers suggest that there are multiple opportunities for older women to obtain a mammogram. Per provider interviews, almost all reported that overuse was not viewed as a priority by the system or other providers. Providers also discussed that variation in mammography screening practices across providers, fear of malpractice, and monetary incentives may be reasons for overuse. Providers identified potential strategies including patient and provider education around harms of screening, leveraging the electronic health record to identify women who may no longer benefit from screening, customizing system-generated reminder letters, and organizing workgroups to develop a standard process of care around mammography screening. Conclusions Multi-level factors contributing to mammography overuse are dynamic and reinforced. To ensure equitable de-implementation, there is a need for more refined theories, models, and frameworks for de-implementation with a strong patient-level component that considers the interplay between multilevel factors and the larger care delivery process.

Introduction: A healthcare provider's ability to give a strong recommendation for the HPV vaccine is of utmost importance in increasing HPV vaccination. To reduce the burden of HPV-related cancers, there is a critical need to develop and implement theory-based interventions aimed at strengthening healthcare providers' communication about the HPV vaccine.Methods: We used Intervention Mapping (IM) steps 1–5 to develop and implement a provider-level intervention that aligns with the priorities and needs of a large, urban Federally Qualified Health Center (FQHC).Results: In step 1, a diverse planning group identified barriers to HPV vaccination in clinical settings and generated process maps and a logic model of the problem. Step 2 outlined outcomes and provider performance objectives of the intervention and identified knowledge, skills, self-efficacy, outcome expectations, and normative beliefs as modifiable targets that need to change for providers to deliver strong recommendations for the HPV vaccine to parents and patients. In step 3, the planning group mapped the methods of persuasive communication, information, and modeling and skills training to behavioral targets and outlined the program practical applications (strategies) components, scope, and sequence. In steps 4 and 5, the planning group produced the intervention and planned for program implementation. The iterative and participatory process of IM resulted in modifications to the initial intervention that aligned with the needs of the FQHC.Discussion: IM provided a systematic, participatory, and iterative approach for developing a theory-based provider-level intervention aimed at strengthening healthcare providers' ability to provide a strong recommendation for the HPV vaccine to eligible patients and parents served by a large FQHC. IM assisted with the identification of behavioral targets and methods that move beyond HPV knowledge and reminders to create behavior change. IM can help researchers and planners describe the processes and rational behind developing interventions and may help to facilitate implementation in real-world clinical settings by tailoring intervention components to the needs of the population.

PURPOSE: Several high-profile organizations have mandated the delivery of survivorship care plans (SCPs) despite mixed evidence regarding the effectiveness of SCPs on key survivor-level outcomes. There is a need to understand the types of survivor-level outcomes the SCPs are likely to change. Informed by existing frameworks and the literature, the objective of this study was to understand the pathways linking the receipt of a SCP to key survivor-level outcomes including patient-centered communication (PCC), health self-efficacy, changes in health behaviors, and improvements in overall health. METHODS: We used structural equation modeling to test the direct and indirect pathways linking the receipt of an SCP to patient-centered communication (PCC), health self-efficacy, and latent measures of health behaviors and physical health in a nationally representative sample of breast and colorectal cancer survivors from the Health Information National Trends Survey. RESULTS: The receipt of an SCP did not have a significant effect on key survivor-level outcomes and was removed from the final structural model. The final structural model fit the data adequately well (Chi-square p value = 0.03, RMSEA = 0.07, CFI = .88, and WRMR = 0.73). PCC had a significant direct effect on physical health but not on health behaviors. Health self-efficacy had a significant direct effect on physical health and health behaviors. CONCLUSION: The receipt of an SCP alone is unlikely to facilitate changes in PCC, health self-efficacy, health behaviors, or physical health. IMPLICATION FOR CANCER SURVIVORS: A SCP is a single component of a larger model of survivorship care and should be accompanied by ongoing efforts that promote PCC, health self-efficacy, and changes in health behaviors resulting in improvements to physical health.

PURPOSE: Cancer survivors with multiple chronic conditions experience significant challenges managing their health. The six core functions of patient-centered communication (PCC)—fostering healing relationships, exchanging information, responding to emotions, managing uncertainty, making decisions, and enabling patient self-management—represent a central component to facilitating a survivor’s confidence to manage their health that has not been investigated in cancer survivors with multiple chronic conditions. METHOD: Nationally representative data across two iterations of the Health Information National Trends Survey (HINTS) were merged with combined replicate weights using the jackknife replication method. Adjusted linear regression examined the association between PCC and health self-efficacy in a sample of breast, colorectal, and prostate cancer survivors and by multiple chronic conditions. RESULTS: 53.9% reported that providers did not always respond to their emotions and 48.9% reported that they could not always rely on their providers to help them manage uncertainty. In the adjusted linear regression models, there was a significant positive association between PCC and health self-efficacy (β = 0.2, p = 0.01) for the entire sample. However, the association between PCC and health self-efficacy was attenuated in cancer survivors with multiple chronic conditions (β = 0.1, p = 0.53). CONCLUSION: PCC alone is not enough to improve a cancer survivor’s confidence in their ability to manage their health in the presence of multiple chronic conditions. IMPLICATIONS FOR CANCER SURVIVORS: Cancer survivors with multiple chronic conditions need ongoing support, in addition to PCC, that render them prepared to manage their health after cancer.

Purpose: As part of an ongoing effort to support the equitable delivery of cancer care to historically underserved communities in New York City (NYC), we examined the impact of COVID-19 on community outreach organizations working with an NCI-comprehensive cancer center Methods: We conducted 16 semi-structured interviews (30–90 minutes; July-September 2020) with stakeholders (SH) including patient navigators, patient advocates, faith-based leaders, community health, and non-profit organizations in NYC – the epicenter of the COVID-19 pandemic in the US. Using thematic analysis, we characterized experiences and challenges in supporting cancer care delivery during COVID-19. Results: Per SH, COVID-19 required organizations to shift priorities to address day-to-day needs exacerbated by COVID-19 (food insecurity, financial/housing instability, misinformation, emotional distress). Organizations adapted by leveraging existing partnerships, including the cancer center, and partnering with new local/state organizations to broaden their work scope (e.g., COVID-19 testing centers, food pantries, technology training), and disseminate reliable COVID-19 information to communities. All organizations transitioned to virtual platforms creating challenges for those with limited technical resources and often excluded older or isolated populations; thus, many organizations retained a socially distanced in-person component to remain visible and trustworthy within the community. Importantly, SH emphasized the importance of cancer center support via proactive involvement and communication with community members, providing a supportive infrastructure (funding, technical support, personnel), and incorporating community voices into new programs and projects during and beyond the COVID-19 pandemic. Conclusion: In addition to or in lieu of cancer care delivery efforts, community organizations are compelled to develop innovative approaches that address the more immediate needs of the community resulting from COVID-19. Cancer centers can support their community partners by being responsive and flexible to the community needs, building trust within the community, and strengthening community organizational capacity to reduce the long-term damage of COVID-19 and achieve equity.

Introduction. Vulnerable populations, such as minorities, under-, and uninsured patients receiving care from safety-net settings, are more likely to receive a late-stage cancer diagnosis, resulting in higher mortality rates. Studies have shown that being connected to a primary care provider can play a vital role in timely diagnosis of early-stage cancer. Yet, vulnerable populations often have difficulty accessing primary care services and resources in most safety-net settings where care is fragmented. Receiving care in an integrated health system may help to reduce stage disparities by providing the infrastructure to support continuity and coordination of care. Yet, the degree to which vulnerable patients are connected to a primary care provider within an integrated setting is uncertain. A better understanding of the role of primary care connectedness among vulnerable patient populations receiving care in an integrated, safety-net hospital setting is needed to address the issue of stage disparity. We hypothesize that vulnerable patients connected to a primary care provider prior to their cancer diagnosis will have increased odds of early-stage cancer diagnosis. Methods. As part of an ongoing prospective study, we examined a cross-sectional sample of 66 patients diagnosed with Stage I-III colorectal and breast cancer receiving care within an integrated, safety-net hospital system during the years 2017 and 2018. We analyzed medical records data to generate descriptive statistics to characterized patient demographics, cancer-related demographics, and primary care connectedness - defined as having a primary care provider listed in the medical record prior to diagnosis. Using logistic regression, we calculated the odds of early-stage disease, according to the American Joint Commission on Cancer (AJCC) (stages I and II vs. III) as a function of primary care connectedness. Results. The majority of the sample was non-white (58%) and nearly half reported having no insurance (47%). Females comprised nearly 80% of the sample and one-third of the sample was diagnosed with colorectal cancer. In addition, nearly 60% had a primary care provider listed in the medical record prior to their cancer diagnosis and 60% received an early-stage diagnosis. Preliminary findings from the logistic regression support our hypothesis that vulnerable patients connected to a primary care provider prior to a cancer diagnosis had significantly higher odds of early-stage diagnosis (OR = 3.9, 95% CI 1.2-13.0). Conclusion. Being connected to a primary care provider may help to reduce stage disparities among vulnerable populations receiving care from an integrated safety-net setting. Integrated safety-net settings may facilitate early-stage diagnosis through clear referral pathways that ensure more timely diagnosis after screening abnormalities and prevent diagnostic delay. Citation Format: Jessica D Austin, Matthieu Chansard, Simon C Lee, Bijal A Balasubramanian. Influence of primary care connectedness on early-stage cancer diagnosis among vulnerable patients in an integrated, safety-net setting [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C096.