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Racquel E Kohler,1 Clara N Lee,2 Satish Gopal,3 Bryce B Reeve,1 Bryan J Weiner,1 Stephanie B Wheeler11Department of Health Policy and Management, Gillings School of Global Public Health, 2Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; 3UNC Project-Malawi, Tidziwe Center, Lilongwe, MalawiBackground: In Malawi, routine breast cancer screening is not available and little is known about women’s preferences regarding early detection services. Discrete choice experiments are increasingly used to reveal preferences about new health services; however, selecting appropriate attributes that describe a new health service is imperative to ensure validity of the choice experiment.Objective: To identify important factors that are relevant to Malawian women’s preferences for breast cancer detection services and to select attributes and levels for a discrete choice experiment in a setting where both breast cancer early detection and choice experiments are rare.Methods: We reviewed the literature to establish an initial list of potential attributes and levels for a discrete choice experiment and conducted qualitative interviews with health workers and community women to explore relevant local factors affecting decisions to use cancer detection services. We tested the design through cognitive interviews and refined the levels, descriptions, and designs.Results: Themes that emerged from interviews provided critical information about breast cancer detection services, specifically, that breast cancer interventions should be integrated into other health services because asymptomatic screening may not be practical as an individual service. Based on participants’ responses, the final attributes of the choice experiment included travel time, health encounter, health worker type and sex, and breast cancer early detection strategy. Cognitive testing confirmed the acceptability of the final attributes, comprehension of choice tasks, and women’s abilities to make trade-offs.Conclusion: Applying a discrete choice experiment for breast cancer early detection was feasible with appropriate tailoring for a low-income, low-literacy African setting.Keywords: breast cancer, early detection, patient preferences, discrete choice experiment, Malawi, qualitative interviews

HPV-associated cancer disparities disproportionately affect Black/African American and Hispanic individuals in the U.S. HPV vaccination, which can prevent many HPV-associated cancers, should be clearly recommended by pediatricians to parents of adolescents aged 9-12, yet uptake and completion remain lower than other adolescent vaccinations. We used the Structural Influence Model of Health Communication to explore communication inequalities from interviews with 19 Black and Hispanic mothers of adolescents. We identified HPV vaccination information seeking behaviors, media use, and preferred channels to address information needs. This study provides insights into how mothers' nativity and ethno-racial identity influenced how they accessed and processed information from various sources. Preferences for digital and community-based strategies to address information gaps and hesitancy concerns are also presented. Findings suggest future prevention strategies must increase access to accurate information that resonates with NH-Black and Hispanic communities' needs and is disseminated via preferred communication channels to maximize the effects of multi-level interventions promoting HPV vaccination among communities experiencing disparities.

Challenges in ensuring adherence to colposcopy and follow-up recommendations, particularly within underserved communities, hinder the delivery of appropriate care. Informed by our established evidence-based program, we sought to assess the feasibility and acceptability of a novel cognitive-affective intervention delivered through a Chatbot interface, aimed to enhance colposcopy adherence within an urban inner-city population. We developed the evidence-based intervention, CervixChat, to address comprehension of colposcopy's purpose, human papillomavirus (HPV) understanding, cancer-related fatalistic beliefs, procedural concerns, and disease progression, offered in both English and Spanish. Females aged 21-65, with colposcopy appointments at an urban OBGYN clinic, were invited to participate. Enrolled patients experienced real-time counseling messages tailored via a Chatbot-driven barriers assessment, dispatched via text one week before their scheduled colposcopy. Cognitive-affective measures were assessed at baseline and through a 1-month follow-up. Participants also engaged in a brief post-intervention satisfaction survey and interview to capture their acceptance and feedback on the intervention. The primary endpoints encompassed study adherence (CervixChat response rate and follow-up survey rate) and self-evaluated intervention acceptability, with predefined feasibility benchmarks of at least 70% adherence and 80% satisfaction. Among 48 eligible women scheduled for colposcopies, 27 (56.3%) agreed, consented, and completed baseline assessments. Participants had an average age of 34 years, with 14 (52%) identifying as non-Hispanic White. Of these, 21 (77.8%) engaged with the CervixChat intervention via mobile phones. Impressively, 26 participants (96.3%) attended their diagnostic colposcopy within the specified timeframe. Moreover, 22 (81.5%) completed the follow-up survey and a brief interview. Barriers assessment revealed notable encodings in the Affect and Values/Goals domains, highlighting concerns and understanding around HPV, as well as its impact on body image and sexual matters. Persistent and relatively high intrusive thoughts and lowered risk perceptions regarding cervical cancer were reported over time, unaffected by the intervention. Post-intervention evaluations documented high satisfaction and perceived usefulness, with recommendations for incorporating additional practical and educational content. Our findings underscore the robust satisfaction and practicality of the CervixChat intervention among a diverse underserved population. Moving forward, our next step involves evaluating the intervention's efficacy through a Sequential Multiple Assignment Randomized Trial (SMART) design. Enhanced by personalized health coaching, we aim to further bolster women's risk perception, address intrusive thoughts, and streamline resources to effectively improve colposcopy screening attendance., (© Society of Behavioral Medicine 2023. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

HPV vaccination has potential to prevent 90% of HPV-associated cancers. The Advisory Committee on Immunization Practices recommends HPV vaccination for 11- and 12-year-olds, but vaccine initiation can start at age 9. The purpose of this study was to explore perceptions about starting HPV vaccination at a younger age to inform future interventions that promote initiation at ages 9 and 10 years. This was part of a larger study about vaccine hesitancy among racially/ethnically diverse parents of adolescents in the Greater Newark Area of New Jersey. We thematically analyzed transcripts from 16 interviews with English- and Spanish-speaking mothers who had at least one child ≤ 10 years. Analyses focused on perceptions of HPV-related disease risk, attitudes toward HPV vaccination need, and vaccine confidence specifically for 9- and 10-year-olds. Few parents with young adolescents reported receiving vaccination recommendations, and only one reported series initiation before age 11. Mothers' hesitation about younger HPV vaccination initiation revolved around: 1) low perceived necessity among English-speaking mothers due to young adolescents not being sexually active, 2) concerns about potential side effects associated with vaccinating prepubescent adolescents, and 3) a desire for adolescents to be old enough to provide assent. Participants were not opposed to younger initiation but wanted and relied on pediatricians to inform them about vaccination for younger adolescents. These findings suggest mothers are willing to vaccinate at younger ages after clear provider recommendations. Equipping providers with evidence about vaccine safety and cancer prevention communication strategies may promote initiation and timely completion at younger ages.

Background: South Asians are a rapidly growing population in the United States. Breast cancer is a major concern among South Asian American women, who are an understudied population. We established the South Asian Breast Cancer (SABCa) study in New Jersey during early 2020 to gain insights into their breast cancer-related health attitudes. Shortly after we started planning for the study, the COVID-19 disease spread throughout the world. In this paper, we describe our experiences and lessons learned from recruiting study participants by partnering with New Jersey's community organizations during the COVID-19 pandemic., Methods: We used a cross-sectional design. We contacted 12 community organizations and 7 (58%) disseminated our study information. However, these organizations became considerably busy with pandemic-related needs. Therefore, we had to pivot to alternative recruitment strategies through community radio, Rutgers Cancer Institute of New Jersey's Community Outreach and Engagement Program, and Rutgers Cooperative Extension's community health programs. We recruited participants through these alternative strategies, obtained written informed consent, and collected demographic information using a structured survey., Results: Twenty five women expressed interest in the study, of which 22 (88%) participated. Nine (41%) participants learned about the study through the radio, 5 (23%) through these participants, 1 (4.5%) through a non-radio community organization, and 7 (32%) through community health programs. Two (9%) participants heard about the study from their spouse. All participants were born outside the US, their average age was 52.4 years (range: 39-72 years), and they have lived in the US for an average of 26 years (range: 5-51 years)., Conclusion: Pivoting to alternative strategies were crucial for successful recruitment. Findings suggest the significant potential of broadcast media for community-based recruitment. Family dynamics and the community's trust in our partners also encouraged participation. Such strategies must be considered when working with understudied populations., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Satagopan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Black and African American adults exhibited higher levels of mistrust and vaccine hesitancy and lower levels of vaccination throughout the COVID-19 pandemic. Vaccination and booster uptake remains disproportionately low among Black adults. We conducted a systematic review of empirical research published between February 2021 and July 2022 from five electronic databases and the grey literature. We screened studies that assessed COVID-19 vaccination information needs and preferences as well as communication strategies among Black adults in the USA. We extracted data, then analyzed and synthesized results narratively. Twenty-two articles were included: 2 interventions, 3 experimental surveys, 7 observational surveys, 8 qualitative inquiries, and 2 mixed methods studies. Studies reported credible and preferred COVID-19 vaccination information sources/messengers, channels, and content. Commonly trusted messengers included personal health care providers, social network connections, and church/faith leaders. Electronic outreach (e.g., email, text messages), community events (e.g., forums, canvassing), and social media were popular. Black communities wanted hopeful, fact-based messages that address racism and mistrust; persuasive messages using collective appeals about protecting others may be more influential in changing behavior. Future communication strategies aiming to increase vaccine confidence and encourage COVID-19 booster vaccination among Black communities should be developed in partnership with community leaders and local health care providers to disseminate trauma-informed messages with transparent facts and collective action appeals across multiple in-person and electronic channels., (© 2023. The Author(s).)

Objective: Attendance to colposcopy after abnormal cervical cancer screening is essential to cervical cancer prevention. This qualitative study explored patients' understanding of screening results, their experiences of the time leading up to the colposcopy appointment, and colposcopy., Methods: We recruited women referred for colposcopy from two urban practices in an academic health system. Individual interviews (N = 15) with participants were conducted after colposcopy appointments about their cervical cancer screening histories, current results, and colposcopy experiences. A team analyzed and summarized interviews and coded transcripts in Atlas.ti., Results: We found that most women were confused about their screening results, did not know what a colposcopy was before being referred for one, and experienced anxiety in the interval between receiving their results and having their colposcopy. Most women searched for information online, but found "misinformation," "worst-case scenarios" and generic information that did not resolve their confusion., Conclusion: Women had little understanding of their cervical cancer risk and experienced anxiety looking for information and waiting for the colposcopy. Educating patients about cervical precancer and colposcopy, providing tailored information about their abnormal screening test results and potential next steps, and helping women manage distress may alleviate uncertainty while waiting for follow-up appointments., Practice Implications: Interventions to manage uncertainty and distress in the interval between receiving an abnormal screening test result and attending colposcopy are needed, even among highly adherent patients., Competing Interests: Declaration of Competing Interest The authors have no competing interests to disclose., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Purpose: Belize has among the highest cervical cancer incidence and mortality rates of Latin American and Caribbean countries. This study evaluates the perspectives of key stakeholders for cervical cancer screening in Belize and identifies the barriers and facilitators for providing equitable access to prevention services., Methods: Semi-structured interviews discussing cervical cancer screening were conducted with key stakeholders across the six districts of Belize in 2018. Interviews were transcribed, coded, and analyzed thematically; themes were organized by levels of the social-ecological model., Results: We conducted 47 interviews with health care providers (45%), administrators (17%), government officials (25%), and other stakeholders (13%). Majority (78%) of interviews were from the public sector. Perceived barriers to cervical cancer screening were identified across multiple levels: (1) Individual Patient: potential delays in Pap smear results and fear of a cancer diagnosis; (2) Provider: competing clinician responsibilities; (3) Organizational: insufficient space and training; (4) Community: reduced accessibility in rural areas; and (5) Policy: equipment and staffing budget limitations. The main facilitators we identified included the following: (1) at the Community level: resource-sharing between public and private sectors and dedicated rural outreach personnel; (2) at the Policy level: free public screening services and the establishment of population-based screening., Conclusion: Despite free, publicly available cervical cancer screening in Belize, complex barriers affect access and completion of management when abnormal screening tests are identified. Provider workload, education outreach, and additional funding for training and facilities are potential areas for strengthening this program and increasing detection and management for cervical cancer control., (© 2023. The Author(s).)

Background: Low adherence to triage after positive screening is a widespread problem for cervical cancer screening programs in Low- and Middle-income Countries. Adherence to cytology-based triage can be challenging, especially among women with self-collected tests. SMS-based interventions are accepted by women and can increase screening uptake. The ATICA study was an effectiveness-implementation hybrid type I trial, combining a cluster randomized controlled trial (RCT) with a mixed-methods implementation evaluation involving quantitative and qualitative methods. Although the RCT provided evidence regarding the effectiveness of the SMS-based intervention, less is known about its acceptability, relevance, and usefulness from the women´s perspective., Methods: We carried out a cross-sectional study based on a structured questionnaire among HPV-positive women who were enrolled in ATICA's intervention group. We measured acceptability, appropriateness, and message content comprehension. Also, we evaluated if the SMS message was considered a cue to encourage women to pick up their HPV test results and promote the triage., Results: We interviewed 370 HPV-positive women. Acceptability of SMS messages among women who had received at least one message was high (97%). We found high levels of agreement in all appropriateness dimensions. More than 77% of women showed high comprehension of the content. Among women who received at least one SMS message, 76% went to the health center to pick up their results. Among those who got their results, 90% reported that the SMS message had influenced them to go. We found no significant differences in acceptability, appropriateness or message comprehension between women who adhered to triage and those who did not adhere after receiving the SMS messages., Conclusion: The intervention was highly acceptable, and women reported SMS was an appropriate channel to be informed about HPV test results availability. SMS was also a useful cue to go to the health center to pick up results. The implementation did not encounter barriers associated with the SMS message itself, suggesting the existence of other obstacles to triage adherence. Our results support the RCT findings that scaling up SMS is a highly acceptable intervention to promote cervical screening triage adherence., (© 2023. The Author(s).)

Background: In 2019, the World Health Organization identified vaccine hesitancy as a top ten global health threat, which has been exacerbated by the COVID-19 pandemic. Despite local and nationwide public health efforts, adolescent COVID-19 vaccination uptake in the US remains low. This study explored parents' perceptions of the COVID-19 vaccine and factors influencing hesitancy to inform future outreach and education campaigns., Methods: We conducted two rounds of individual interviews via Zoom in May-September 2021 and January-February 2022, with parents of adolescents from the Greater Newark Area of New Jersey, a densely populated area with historically marginalized groups that had low COVID-19 vaccination uptake. Data collection and analysis was guided by the Increasing Vaccination Model and WHO Vaccine Hesitancy Matrix. Interview transcripts were double-coded and thematically analyzed in NVivo., Results: We interviewed 22 parents (17 in English, 5 in Spanish). Nearly half (45%) were Black and 41% were Hispanic. Over half (54%) were born outside of the US. Most of the parents described that their adolescents had received at least one dose of a COVID-19 vaccine. All but one parent had received the COVID-19 vaccine. Despite strong vaccination acceptance for themselves, parents remained hesitant about vaccinating their adolescents. They were mostly concerned about the safety and potential side effects due to the novelty of the vaccine. Parents sought information about the vaccines online, through healthcare providers and authorities, and at community spaces. Interpersonal communication exposed parents to misinformation, though some personal connections to severe COVID-19 illness motivated vaccination. Historical mistreatment by the healthcare system and politicization of the vaccine contributed to parents' mixed feelings about the trustworthiness of those involved with developing, promoting, and distributing COVID-19 vaccines., Conclusions: We identified multilevel influences on COVID-19 vaccine-specific hesitancy among a racially/ethnically diverse sample of parents with adolescents that can inform future vaccination interventions. To increase vaccine confidence, future COVID booster campaigns and other vaccination efforts should disseminate information through trusted healthcare providers in clinical and also utilize community settings by addressing specific safety concerns and promoting vaccine effectiveness.

In resource-limited settings, augmenting primary care provider (PCP)-based referrals with data-derived algorithms could direct scarce resources towards those patients most likely to have a cancer diagnosis and benefit from early treatment. Using data from Botswana, we compared accuracy of predictions of probable cancer using different approaches for identifying symptomatic cancer at primary clinics. We followed cancer suspects until they entered specialized care for cancer treatment (following pathologically confirmed diagnosis), exited from the study following noncancer diagnosis, or died. Routine symptom and demographic data included baseline cancer probability assessed by the primary care provider (low, intermediate, high), age, sex, performance status, baseline cancer probability by study physician, predominant symptom (lump, bleeding, pain or other) and HIV status. Logistic regression with 10-fold cross-validation was used to evaluate classification by different sets of predictors: (1) PCPs, (2) Algorithm-only, (3) External specialist physician review and (4) Primary clinician augmented by algorithm. Classification accuracy was assessed using c-statistics, sensitivity and specificity. Six hundred and twenty-three adult cancer suspects with complete data were retained, of whom 166 (27%) were diagnosed with cancer. Models using PCP augmented by algorithm (c-statistic: 77.2%, 95% CI: 73.4%, 81.0%) and external study physician assessment (77.6%, 95% CI: 73.6%, 81.7%) performed better than algorithm-only (74.9%, 95% CI: 71.0%, 78.9%) and PCP initial assessment (62.8%, 95% CI: 57.9%, 67.7%) in correctly classifying suspected cancer patients. Sensitivity and specificity statistics from models combining PCP classifications and routine data were comparable to physicians, suggesting that incorporating data-driven algorithms into referral systems could improve efficiency., (© 2022 The Authors. International Journal of Cancer published by John Wiley & Sons Ltd on behalf of UICC.)

Purpose: Underserved Black and Hispanic/Latinx women show low rates of follow-up care after an abnormal Pap test, despite the fact that cervical cancer is one of the few preventable cancers if detected early. However, extant literature falls short on efficacious interventions to increase follow-up for this population. A concurrent mixed methods study was completed to evaluate the acceptability of a text message-based intervention and identify perceived barriers and facilitators to follow-up after an abnormal Pap test among underserved predominantly Black and Hispanic/Latinx women., Methods: Patients who completed follow-up for an abnormal Pap test were recruited to complete a cross-sectional survey, qualitative interview assessing barriers and facilitators to follow-up, and text message content evaluation (N = 28). Descriptive statistics were performed to describe background variables and to evaluate the acceptability of text messages. A directed content analysis was completed for the qualitative interviews., Results: Participants expressed interest in a text message-based intervention to increase abnormal Pap test follow-up. In the qualitative interviews, low knowledge about cervical risk and negative affect toward colposcopy/test results were identified as barriers to follow-up. Facilitators of follow-up included feeling relieved after the colposcopy and adequate social support. Participants rated the text messages as understandable, personally relevant, and culturally appropriate., Conclusion: The findings suggest that underserved Black and Hispanic/Latinx women experience cognitive and emotional barriers that undermine their ability to obtain follow-up care and a text message-based intervention may help women overcome these barriers. Future research should develop and evaluate text message-based interventions to enhance follow-up after an abnormal Pap test., (© 2022. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Background: Human Papillomavirus (HPV) self-collection offered by community health workers (CHWs) during home visits has been hampered by low levels of triage Pap among HPV-positive women. We investigated effectiveness of a mHealth intervention to increase adherence to triage Pap., Methods: We conducted a hybrid type I cluster randomised effectiveness-implementation trial in Jujuy, Argentina. CHWs (clusters) were eligible if actively offering HPV self-collection and served at least 26 women aged 30 years and over. Women were eligible if they conducted self-collection and provided a mobile phone number. 260 CHWs were randomly allocated (3:2 ratio) to a multi-component intervention (Up to four SMS messages sent to HPV-positive women, and one SMS message to CHWs to prompt a visit of women with no triage Pap 60 days after a positive-test), or control group (Usual care: Women instructed to attend their health centre 30 days after HPV self-collection to pick-up results). The primary effectiveness outcome was percentage of HPV-positive women with triage 120 days after the HPV-test result. We evaluated implementation of the intervention using the RE-AIM framework., Findings: 221 CHWs (132 intervention, 89 control group) contacted 5389 women; and 5351 agreed to participate (3241 intervention, 2110 control group). In total 314/445 (70·5%) HPV-positive women of the intervention group had triage at 120 days after the HPV result, compared to 163/292 (55·1%) in the control group: 15·5% point improvement; 95%CI: 6·8-24·1; relative risk: 1·28; 95%CI: 1·11-1·48. 97·2% of women accepted the intervention and 86·9% of CHWs agreed to its adoption., Interpretation: The multicomponent mHealth intervention was effective in increasing the percentage of HPV-positive women who had triage Pap, allowing for many more women at risk of cervical cancer to receive timely follow-up., Funding: National Cancer Institute of the National Institutes of Health (USA) under Award Number R01CA218306.

Background: Suboptimal human papillomavirus (HPV) vaccination rates persist among adolescents in the United States (U.S.). New Jersey (NJ), among the top, most racially/ethnically diverse states in the U.S., had among the lowest HPV vaccine initiation rates, prior to 2018. This study examined parental HPV vaccine knowledge and adolescent HPV vaccine initiation among multiethnic parents in NJ, where access to language concordant HPV vaccine information and vaccination services may differ, for immigrant parents., Methods: We surveyed parents of adolescents (ages 11-18) at community events in NJ to examine parental HPV vaccine knowledge and adolescent HPV vaccine uptake. Vaccine knowledge was assessed using an 11-item question stem that covered vaccine efficacy, gender recommendation, vaccine protection, and myths. Multivariable models assessed the association of parent nativity on HPV vaccine knowledge scores and adolescent HPV vaccine initiation, controlling for sociodemographic factors., Results: Of the 77 parents, most parents (84%) were aware of the HPV vaccine. However, knowledge scores were low and differed by parent nativity. Non-U.S. born parents had significantly lower knowledge scores - 1.7 [- 3.1, - 0.4] and lower odds of adolescent children initiating the HPV vaccine 0.3 [0.1, 0.9] compared to U.S.-born parents after adjusting demographic characteristics., Conclusions: Our findings reveal that parental HPV vaccine knowledge remains low among suburban dwelling, immigrant parents, even though they have higher education and access to health care. Multilevel strategies to reduce missed opportunities for HPV vaccine education among parents and HPV vaccination for adolescents are needed, including for suburban, immigrant communities., (© 2022. The Author(s).)

Objective: Women experiencing homelessness are at increased risk of cervical cancer and have disproportionately low Pap screening behaviors compared to the general population. Prevalence of Pap refusals and multiple kinds of trauma, specifically sexual trauma, are high among homeless women. This qualitative study explored how trauma affects Pap screening experiences, behaviors, and provider practices in the context of homelessness., Methods: We conducted 29 in-depth interviews with patients and providers from multiple sites of a Federally Qualified Health Center as part of a study on barriers and facilitators to cervical cancer screening among urban women experiencing homelessness. The Health Belief Model and trauma-informed frameworks guided the analysis., Results: Trauma histories were common among the 18 patients we interviewed. Many women also had strong physical and psychological reactions to screening, which influenced current behaviors and future intentions. Although most women had screened at least once in their lifetime, many patients experienced anticipated anxiety and retraumatization which pushed them to delay or refuse Paps. We recruited 11 providers who identified strategies they used to encourage screening, including emphasizing safety and shared decision-making before and during the exam, building strong patient-provider trust and communication, and individually tailoring education and counseling to patients' needs. We outlined suggestions and implications from these findings as trauma-informed cervical cancer screening., Conclusion: Discomfort with Pap screening was common among women experiencing homelessness, especially those with histories of sexual trauma. Applying a trauma-informed approach to cervical cancer screening may help address complex barriers among women experiencing homelessness, with histories of sexual trauma, or others who avoid, delay, or refuse the exam.

Female sex workers (FSW) in Malawi have among the highest HIV prevalence estimates worldwide. Daily oral pre-exposure prophylaxis (PrEP) is an effective HIV prevention method, yet preferences for PrEP delivery among FSW are lacking. Eight focus group discussions, a literature review, and cognitive interviews were conducted to identify modifiable PrEP delivery attributes and inform discrete-choice experiment (DCE) development for FSW in Lilongwe. Enrolled FSW received an interviewer-assisted DCE. Data were analyzed using mixed logit regression. Dispensing location was most preferred, followed by the provision of additional services. Women preferred receiving PrEP at family planning clinics or non-governmental organization run drop-in centers. Cervical cancer screening was the most preferred additional service, while pregnancy testing and partner risk reduction counseling were less valued. This study was the first study to examine PrEP delivery preferences in Malawi using DCE-a powerful elicitation tool to apply to other key populations at risk for HIV.

Background: SMS interventions are effective in promoting a variety of health behaviors; however, there is limited information regarding the use of SMS for cervical cancer screening and follow-up care. The Application of Communication and Information Technologies to Self-Collection study aims to evaluate a multicomponent mobile health intervention to increase triage adherence among women with human papillomavirus (HPV)-positive self-collected tests in Jujuy, Argentina. Here, we describe the formative results used to design the content of the SMS to be tested in the trial., Objective: This study aimed to understand the cultural and contextual elements, women's beliefs, and perceptions regarding the use of SMS by the health care system and women's preferences about the message content., Methods: We conducted five focus groups (FGs), stratified by rural or urban residence and age. All participants were aged 30 years or older and had performed HPV self-collection. Participatory techniques, including brainstorming, card-based classification, and discussions were used to debate the advantages and disadvantages of messages. We openly coded the discussions for agreements and preferences regarding the SMS content. Messages for both HPV-negative and HPV-positive women were validated through interviews with health authorities and 14 HPV-tested women. The final versions of the messages were pilot-tested., Results: A total of 48 women participated in the FGs. Participants rejected receiving both negative and positive HPV results by SMS because, for them, the delivery of results should be done in a face-to-face interaction with health professionals. They stressed the importance of the SMS content informing them that results were available for pick up and reflecting the kind of relationship that they have with the community health workers and the nearest health center. Women considered that a personalized SMS was important, as was the use of a formal yet warm tone. Owing to confidentiality issues, not using the word "HPV" was also a key component of the desired SMS content; therefore, the final message included the term "self-collection" without the mention of HPV infection. Results from the validation stage and pilot test showed high acceptability of the final version of the message., Conclusions: The results suggest that SMS is accepted when notifying women about the availability of the HPV test result, but it should not replace the delivery of results in face-to-face, doctor-patient encounters. In addition, messages must be tailored and must have a persuasive tone to motivate women to adhere to the triage., (©Victoria Sanchez Antelo, Racquel E Kohler, Mariana Curotto, Kasisomayajula "Vish" Viswanath, Melisa Paolino, Silvina Arrossi. Originally published in JMIR Formative Research (http://formative.jmir.org), 06.03.2020.)

Objective: To assess the acceptability and preferences of HPV screening with self-sampling and mobile phone results delivery among women living with HIV (WLWH) in Botswana, as an alternative to traditional speculum screening., Methods: WLWH aged 25 years or older attending an infectious disease clinic in Gaborone were enrolled in a cross-sectional study between March and April 2017. Women self-sampled with a flocked swab, had a speculum exam, and completed an interviewer-administered questionnaire about screening acceptability, experiences, and preferences., Results: Of the 104 WLWH recruited, 98 (94%) had a history of traditional screening. Over 90% agreed self-sampling was easy and comfortable. Ninety-five percent were willing to self-sample again; however, only 19% preferred self-sampling over speculum exam for future screening. Preferences differed by education and residence with self-sampling being considered more convenient, easier, less embarrassing, and less painful. Speculum exams were preferred because of trust in providers' skills and women's low self-efficacy to sample correctly. Almost half (47%) preferred to receive results via mobile phone call. Knowledge of cervical cancer did not affect preferences., Conclusion: HPV self-sampling is acceptable among WLWH in Botswana; however, preferences vary. Although self-sampling is an important alternative to traditional speculum screening, education and support will be critical to address women's low self-efficacy to self-sample correctly., (© 2019 International Federation of Gynecology and Obstetrics.)

Purpose: To describe the cost of treating diffuse large B-cell lymphoma (DLBCL) in Malawi under the following circumstances: (1) palliation only, (2) first-line cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP), (3) salvage etoposide, ifosfamide, and cisplatin (EPIC), and (4) salvage gemcitabine and oxaliplatin (GEMOX)., Methods: We conducted a microcosting analysis from the health system perspective in the context of a prospective cohort study at a national teaching hospital in Lilongwe, Malawi. Clinical outcomes data were derived from previously published literature from the cohort. Cost data were collected for treatment and 2-year follow-up, reflecting costs incurred by the research institution or referral hospital for goods and services. Costs were collected in Malawian kwacha, inflated and converted to 2017 US dollars., Results: On a per-patient basis, palliative care alone cost $728 per person. Total costs for first-line treatment with CHOP chemotherapy was $1,844, of which chemotherapy drugs made up 15%. Separate salvage EPIC and GEMOX cost $2,597 and $3,176, respectively. Chemotherapy drugs accounted for 30% of EPIC and 47% of GEMOX., Conclusion: To our knowledge, this is among the first published efforts to characterize detailed costs of cancer treatment in sub-Saharan Africa. The per-patient cost of first-line treatment of DLBCL in Malawi is low relative to high-income countries, suggesting that investments in fixed-duration, curative-intent DLBCL treatment may be attractive in sub-Saharan Africa. Salvage treatment of relapsed/refractory DLBCL costs much more than first-line therapy. Formal cost-effectiveness modeling for CHOP and salvage treatment in the Malawian and other low-resource settings is needed to inform decision makers about optimal use of resources for cancer treatment.

Purpose: Men in Botswana present with more advanced cancer than women, leading to poorer outcomes. We sought to explain sex-specific differences in time to and stage at treatment initiation., Methods: Cancer patients who initiated oncology treatment between October 2010 and June 2017 were recruited at four oncology centers in Botswana. Primary outcomes were time from first visit with cancer symptom to treatment initiation, and advanced cancer (stage III/IV). Sociodemographic and clinical covariates were obtained retrospectively through interviews and medical record review. We used accelerated failure time and logistic models to estimate standardized sex differences in treatment initiation time and risk differences for presentation with advanced stage. Results were stratified by cancer type (breast, cervix, non-Hodgkin's lymphoma, anogenital, head and neck, esophageal, other)., Results: 1886 participants (70% female) were included. After covariate adjustment, men experienced longer excess time from first presentation to treatment initiation (8.4 months) than women (7.0 months) for all cancers combined (1.4 months, 95% CI: 0.30, 2.5). In analysis stratified by cancer type, we only found evidence of a sex disparity (Men: 8.2; Women: 6.8 months) among patients with other, non-common cancers (1.4 months, 95% CI: 0.01, 2.8). Men experienced an increased risk of advanced stage (Men: 67%; Women: 60%; aRD: 6.7%, 95% CI: -1.7%, 15.1%) for all cancers combined, but this disparity was only statistically significant among patients with anogenital cancers (Men: 72%; Women: 50%; aRD: 22.0%, 95% CI: 0.5%, 43.5%)., Conclusions: Accounting for the types of cancers experienced by men and women strongly attenuated disparities in time to treatment initiation and stage. Higher incidence of rarer cancers among men could explain these disparities., Competing Interests: The authors have declared that no competing interests exist.

Background: Cervical cancer is one of the leading causes of cancer death among women worldwide, with more than 85% of cases occurring in low- and middle-income countries. Human papillomavirus (HPV) screening allows for self-collection with the potential to increase coverage, but still requires triage to identify which HPV+ women need diagnostic and treatment procedures. However, achieving high levels of triage adherence can be challenging, especially among socially vulnerable women. This paper describes the ATICA protocol (Application of Communication and Information Technologies to Self-Collection, for its initials in Spanish), aimed at evaluating the implementation strategy and the effectiveness of a multi-component mobile health (mHealth) intervention to increase adherence to triage among women with HPV+ self-collected tests., Methods: We will use an effectiveness-implementation hybrid type I trial with a mixed-methods evaluation approach. A cluster randomized trial design including 200 community health workers (CHWs) will evaluate whether the mHealth intervention increases adherence to triage among HPV+ women who self-collected at home during a CHW visit within 120 days after a positive result. The intervention includes an initial mobile phone text message (SMS) alert and subsequent reminders sent to HPV+ women. For those who do not adhere to triage within 60 days of a positive HPV test, an email and SMS will be sent to the CHWs to promote contact with these women during home visits. We will use the Consolidated Framework for Implementation Research (CFIR) as an organizing and analytic framework to evaluate the implementation of the intervention while also drawing on Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM). We will conduct a self-administered, semi-structured survey of CHWs, semi-structured interviews with local health authorities, and a survey of HPV+ women. Combining both qualitative and quantitative data will provide rich insights into local implementation challenges and successes., Discussion: Findings from the implementation evaluation will be applicable to programs that use or are planning to incorporate HPV self-collection and/or mHealth interventions in different settings and countries. This innovative study will also serve as a model for using implementation science in the region., Trial Registration: ClinicalTrials.gov, NCT03478397 . Registered on 20 March 2018.

Background: Cancer incidence is increasing in Africa, and the majority of patients are diagnosed with advanced disease, limiting treatment options and survival. We sought to understand care patterns and factors contributing to delayed diagnosis and treatment initiation among patients with cancer in Botswana., Patients and Methods: We recruited 20 patients who were enrolled in a prospective cancer cohort in Botswana to a qualitative substudy that explored cancer care pathways and factors affecting cancer care access and quality. We conducted an in-depth interview with each participant between October 2014 and January 2015, using a a structured interview guide with questions about initial cancer symptoms, previous consultations, diagnosis, and care pathways. Medical records were used to confirm dates or treatment details when needed., Results: Individual and interpersonal factors such as cancer awareness and social support facilitated care-seeking behaviors. However, patients experienced multiple delays in diagnosis and treatment because of provider and health system barriers. Health system factors, such as misdiagnosis, understaffed facilities, poor referral communication and scheduling, and inadequate laboratory reporting systems, affected access to and quality of cancer care., Conclusion: These findings highlight the need for interventions at the patient, provider, and health system levels to improve cancer care quality and outcomes in Botswana. Results also suggest that widespread cancer education has potential to promote early diagnosis through family and community networks. Identified barriers and facilitators suggest that interventions to improve community education and access to diagnostic technologies could help improve cancer outcomes in this setting., Implications for Practice: The majority (54%) of patients with cancer in Botswana present with advanced-stage cancer despite universal access to free health care, limiting the options for treatment and decreasing the likelihood of positive treatment outcomes. To reduce time from symptom onset to cancer treatment initiation, causes of delay in cancer care trajectories must be identified. The narratives of the patients interviewed for this study give insight into psychosocial factors, outlooks on disease, lower-level provider delays, and health system barriers that contribute to substantial delays for patients with cancer in Botswana. Identification of problems and barriers is essential for development of effective interventions to mitigate these factors, in order to improve cancer outcomes in this population., Competing Interests: Disclosures of potential conflicts of interest may be found at the end of this article., (© AlphaMed Press 2018.)

Introduction: Health system delays in diagnosis of cancer contribute to the glaring disparities in cancer mortality between high-income countries and low- and middle-income countries. In Botswana, approximately 70% of cancers are diagnosed at late stage and median time from first health facility visit for cancer-related symptoms to specialty cancer care was 160 days (IQR 59-653). We describe the implementation and early outcomes of training targeting primary care providers, which is a part of a multi-component implementation study in Kweneng-East district aiming to enhance timely diagnosis of cancers., Methods: Health-care providers from all public facilities within the district were invited to participate in an 8-h intensive short-course program developed by a multidisciplinary team and adapted to the Botswana health system context. Participants' performance was assessed using a 25-multiple choice question tool, with pre- and post-assessments paired by anonymous identifier. Statistical analysis with Wilcoxon signed-rank test to compare performance at the two time points across eight sub-domains (pathophysiology, epidemiology, social context, symptoms, evaluation, treatment, documentation, follow-up). Linear regression and negative binomial modeling were used to determine change in performance. Participants' satisfaction with the program was measured on a separate survey using a 5-point Likert scale., Results: 176 participants attended the training over 5 days in April 2016. Pooled linear regression controlling for test version showed an overall performance increase of 16.8% after participation (95% CI 15.2-18.4). Statistically significant improvement was observed for seven out of eight subdomains on test A and all eight subdomains on test B. Overall, 71 (40.3%) trainees achieved a score greater than 70% on the pretest, and 161 (91.5%) did so on the posttest. Participants reported a high degree of satisfaction with the training program's content and its relevance to their daily work., Conclusion: We describe a successfully implemented primary health care provider-focused training component of an innovative intervention aiming to reduce health systems delays in cancer diagnosis in sub-Saharan Africa. The training achieved district-wide participation, and improvement in the knowledge of primary health-care providers in this setting., Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT02752061.

Young adulthood represents a time of myriad transitions, which leave young adults (YAs) more susceptible to the influences of cancer risk-promoting information. The tobacco, alcohol, indoor tanning, and food and beverage industries engage in aggressive marketing strategies through both traditional and social media to target this age group to consume their products, which have known links to cancer. Despite this barrage of messaging, detailed data are lacking on the communication behaviors of subgroups of this diverse age group, particularly those from low SES. This paper explores the available data on media usage among YAs and describes the cancer risk-promoting information environment, with a focus on communication inequalities and their implications for cancer research and control. Nationally representative data on media consumption patterns indicate that the majority of YAs access a diverse range of traditional and social media platforms, but these data do not fully describe differences at the intersection of age and important factors such as SES, gender, race/ethnicity, or urban/rural residence. Meanwhile, risk-promoting information is heavily marketed to YAs across media, with an increasing focus on using social media sites to normalize products and evade marketing restrictions. Gaps in the available data on YAs' media consumption behaviors, coupled with aggressive risk-promoting marketing strategies toward YAs, may impede cancer control efforts. Relationships between exposure to various cancer risk-promoting information, concurrent risk behaviors, SES disparities, and communication inequalities should be investigated to develop innovative and effective control programs and policies to promote cancer control in this important group., (Copyright © 2017 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: Breast cancer is the most common female cancer in Africa and leading cause of death resulting from cancer; however, many countries lack early detection services. In Malawi, women are frequently diagnosed with large tumors after long symptomatic periods. Little is known about local cancer knowledge., Methods: We administered a cross-sectional survey with a discrete choice experiment to a random sample in urban and rural areas of Lilongwe district. Bivariable and multivariable analyses determined factors associated with knowledge. Preference utilities for early detection interventions were estimated using a hierarchical Bayesian model in Sawtooth software., Results: Of 213 women recruited, fewer than half were aware of breast cancer. In multivariable analysis, electricity at home and knowing someone with cancer increased the odds of awareness. Women were more knowledgeable about symptoms than treatment or risk factors; more than 60% erroneously believed local misconceptions. Seventeen percent were aware of breast self-examination, and 20% were aware of clinical breast examination (CBE); few reported either behavior. Common barriers included not knowing where to access CBE and transportation difficulties. Discrete choice experiment results indicated the detection strategy (breast health awareness, CBE, or both) was the most important attribute of an intervention, followed by the encounter setting and travel time., Conclusion: Addressing misconceptions in health messages and engaging survivors to promote early detection may help improve breast cancer knowledge in Malawi. Program designs accounting for women's preferences should provide breast health education and CBEs in convenient settings to address transportation barriers, particularly for women with low socioeconomic position., Competing Interests: The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc. Racquel E. KohlerNo relationship to discloseSatish GopalNo relationship to discloseClara N. LeeNo relationship to discloseBryan J. WeinerNo relationship to discloseBryce B. ReeveNo relationship to discloseStephanie B. WheelerResearch Funding: Pfizer

Purpose: Low- and middle-income countries face a disproportionate burden of death and disability from injuries, many of which are due to road traffic accidents or falls. Lower extremity injuries in particular have implications not only for physical disabilities affecting work and school performance, but also for quality of life (QOL) of the individual. This qualitative study explores the psychosocial impact and QOL changes due to lower extremity injuries among trauma patients in central Malawi., Methods: We transcribed and translated interviews with 20 patients who received care for a trauma to the lower extremity at a tertiary hospital in Lilongwe. We used NVivo to organize and thematically analyze the data., Results: Participants reported limitations in physical functioning, activities of daily living, social roles, and vocational and social activities. Limited mobility led to unplanned long-term disruptions in work, personal financial loss, and household economic hardship. As a result, psychological distress, fears and worries about recovery, and poor perceptions of health and QOL were common. Several contextual factors influenced patient outcomes including socioeconomic status, religious beliefs, social networks, local landscape, housing structures, and transportation accessibility., Conclusion: Lower extremity trauma led to physical suffering and ongoing social and economic costs among Malawians. Injuries affecting mobility have broad QOL and economic consequences for patients and affected family members. Interventions are needed to improve post-injury recovery and QOL. Better access to trauma surgery and social and welfare support services for people living with disabling conditions are needed to alleviate the consequences of injuries.

Purpose: Despite the increasing burden, breast cancer control in sub-Saharan Africa is insufficient. Late diagnosis and lack of early detection and screening services contribute to high mortality. Clinical breast exam (CBE) screening can be valuable in low-income countries, including use of community health workers and non-health professionals to conduct exams. We assessed experiences of women who underwent CBE screening by trained laywomen in Lilongwe, Malawi, as part of a pilot program., Methods: The pilot study invited women attending urban health clinics to a breast cancer educational talk followed by CBE screening by trained laywomen. We purposively sampled participants from the pilot study and interviewed them about the screening experience and future cancer education programs and services., Results: Overall participants had positive experiences and were willing to undergo CBE screening by trained laywomen. Participants were motivated by the educational talk, shared newly acquired cancer knowledge with their social networks, and encouraged others to seek screening. Screened women suggested strategies for future interventions including combining breast and cervical cancer screening, using female providers, partnering with community leaders to increase uptake, and expanding services into the community., Conclusions: Asymptomatic Malawian women accepted CBE screening by trained laywomen and considered breast cancer an important health issue. Women appreciated combined education and screening services and proposed further linkage of breast and cervical cancer screening. Based on our results, training laywomen to educate the public on breast cancer and conduct CBE is a feasible breast cancer control strategy in sub-Saharan Africa.

Objective: Many women in Africa are diagnosed with advanced breast cancer. We explored Malawian breast cancer patients' perspectives about their diagnosis and ability to access care to identify help-seeking behaviors and to describe factors influencing delay., Methods: We purposively sampled 20 Malawian breast cancer patients to conduct in-depth interviews. Transcripts were double coded to identify major themes of breast cancer help-seeking behaviors and what delayed or facilitated access to care., Results: We outlined a breast cancer help-seeking pathway describing decisions, behaviors, and interactions from symptom presentation to receipt of cancer care. Patients were largely unaware of breast cancer and did not immediately notice or interpret symptoms. As symptoms progressed, women inferred illness and sought help from social networks, traditional remedies, and medical care. Economic hardship, distance to the facility, provider knowledge, health system factors, and social norms often delayed reaching the facility, referrals, diagnosis, and receipt of care., Conclusions: Social-contextual factors at the individual, interpersonal, health system, and societal levels delay decisions, behaviors, and access to breast cancer detection and appropriate care., Practice Implications: A comprehensive approach to improving breast cancer early detection must address public awareness and misconceptions, provider knowledge and communication, and cancer care delivery., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Cervical cancer is the most common cancer among women in Malawi. National guidelines recommend screening women aged 30-45 years every five years; however, no specific recommendations exist for women with HIV. We aimed to assess the frequency of high-grade dysplasia (CIN 2 or CIN3) and cervical cancer among women in central Malawi and to examine associations with CIN2+ (CIN2/3 or cancer). We extracted cervical Pap smear, biopsy, loop electrosurgical excision procedure and uterine specimen reports from a hospital pathology database from November 2012 to November 2013. We used logistic regression to estimate associations with CIN2+. We reviewed specimens from 824 women; we excluded 194 with unknown HIV status, leaving 630 in the analytic sample. Twelve percent had high-grade dysplasia and 109 women (17%) had cancer. Twenty-five percent of high-grade dysplasia cases and 35% of cancers occurred among women outside recommended screening ages. The odds of having CIN2+ were 6.55 times (95% CI 4.44-9.67) greater for HIV+ women. High-grade dysplasia and cervical cancer are very common among Malawian women, especially HIV+ women. HIV infection was strongly associated with CIN2+. Expanding screening to women not covered by current guidelines could avert a substantial proportion of cervical cancer cases in Malawi., (© The Author(s) 2016.)

Competing Interests: The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or jco.ascopubs.org/site/ifc. Lily A. GutnikNo relationship to discloseBeatrice Matanje-MwagombaNo relationship to discloseVanessa MsosaNo relationship to discloseSuzgo MzumaraNo relationship to discloseBlandina KhondoweEmployment: Center for Medical Diagnostics, LilongweAgnes MosesNo relationship to discloseRacquel E. KohlerNo relationship to discloseLisa A. CareyResearch Funding: GlaxoSmithKline, Genentech/RocheClara N. LeeNo relationship to discloseSatish GopalNo relationship to disclose

Background: The patient-centered medical home (PCMH) is increasingly being implemented in an effort to improve and coordinate primary care, but its effect on health care utilization among breast cancer patients remains unclear. The objective of this study was to examine health care utilization and expenditures as a function of PCMH enrollment among breast cancer patients in North Carolina's Medicaid program., Methods: North Carolina Medicaid claims linked to North Carolina Central Cancer Registry records (2003-2007) were used to examine monthly patterns of health care use and expenditures. Controlling for a selection bias for time-invariant characteristics, fixed effects regression models analyzed associations between PCMH enrollment and utilization of outpatient, inpatient, and emergency department (ED) services and Medicaid expenditures during the 15 months after the diagnosis of breast cancer., Results: Among 758 breast cancer patients, 381 (50%) were enrolled in a PCMH at some time in the 15 months after diagnosis. After controlling for individual fixed effects, PCMH enrollment was significantly associated with greater outpatient service use, but there was no difference in the probability of inpatient hospitalizations or ED visits. Enrollment in a PCMH was associated with increased average expenditures of $429 per month during the first 15 months., Conclusions: Greater outpatient care utilization and increased average expenditures among breast cancer patients enrolled in a PCMH may suggest that these women have improved access to primary and specialty care. Expanding PCMHs may change patterns of service utilization for Medicaid breast cancer patients but may not be associated with lower costs., Competing Interests: Potential conflicts of interest: All authors have no relevant conflicts of interest., (© 2015 American Cancer Society.)

Introduction: Smoking prevalence rates in Lebanon are among the highest in the Eastern Mediterranean region. Few smoking cessation programs are offered in Lebanon and little is known about the preferences of Lebanese smokers for cessation treatment programs., Objective: To establish which attributes of smoking cessation programs are most important to Lebanese smokers., Methods: Smokers at the American University of Beirut were surveyed to elicit their preferences for, and tradeoffs between the attributes of a hypothetical university-based smoking cessation program. Preferences for medication type/mechanism, risk of benign side effects, availability of support, distance traveled to obtain medication, and price of complete treatment were assessed using the discrete choice experiment method., Results: The smokers' responses (N = 191) to changes in attributes were statistically significant. Smokers were willing to make trade-offs between attributes. On average, smokers were willing to pay LBP 103,000 (USD 69) for cessation support. Respondents were willing to give up LBP 105,000 (USD 70) to avoid an additional 10% risk of minor side effects and LBP 18,000 (USD 12) to avoid an addition kilometer of travel to the nearest pharmacy. Heavy smokers were the least responsive group and had the lowest demand elasticities., Conclusions: Student smokers were willing to participate in a relatively complex exercise that weighs the advantages and disadvantages of a hypothetical smoking cessation program. Overall they were less interested in the pill form of smoking cessation treatment, but they were willing to make tradeoffs to be smoke-free., (© The Author 2014. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: Hormone receptor-positive (HR+) cancers account for most breast cancer diagnoses and deaths. Among survivors with HR + breast cancers, endocrine therapy (ET) reduces 5-year risk of recurrence by up to 40%. Observational studies in Medicare- and privately-insured survivors suggest underutilization of ET. We sought to characterize ET use in a low-income Medicaid-insured population in North Carolina., Methods: Medicaid claims data were matched to state cancer registry records for survivors aging 18-64 diagnosed with stage 0-II HR + breast cancer from 2003 to 2007, eligible for ET, and enrolled in Medicaid for at least 12 of 15 months post-diagnosis. We used multivariable logistic regression to model receipt of any ET medication during 15 months post-diagnosis controlling for age, race, tumor characteristics, receipt of other treatments, comorbidity, residence, reason for Medicaid eligibility, involvement in the Breast and Cervical Cancer Control Program (BCCCP), and diagnosis year., Results: Of 222 women meeting the inclusion criteria, only 50% filled a prescription for ET. Involvement in the BCCCP and earlier year of diagnoses were associated with significantly higher odds of initiating guideline-recommended ET (adjusted odds ratio [AOR] for the BCCCP 3.76, 95% confidence interval [CI] 1.67-8.48; AOR for 2004 relative to 2007 2.80, 95% CI 1.03-7.62; AOR for 2005 relative to 2007 2.11, 95% CI 0.92-4.85)., Conclusions: Results suggest substantial underutilization of ET in this population. Interventions are needed to improve timely receipt of ET and to better support survivors taking ET., Implications for Cancer Survivors: Low-income survivors should be counseled on the importance of ET and offered support services to promote initiation and long-term adherence.

Objectives: Intensity-modulated radiation therapy (IMRT) has been rapidly adopted for the treatment of head and neck cancer. Limited comparative effectiveness data suggest that IMRT reduces the incidence of xerostomia and improves quality of life. We assess the cost of IMRT versus the older conventional radiation therapy (CRT) relative to other potential drivers of cost in patients with head and neck cancer., Methods: We compared patients treated with definitive radiation with or without chemotherapy for squamous cell carcinoma of the head and neck treated between 2000 and 2009. IMRT-treated patients were matched to CRT-treated patients by site, stage, and smoking status. Itemized billing charges were obtained for each patient and used to estimate cost using the Medicare fee schedule. Multivariate analysis was used to assess the influence of demographic, clinical, and treatment variables on total, pretreatment, during treatment, and follow-up costs., Results: Models indicate that compared with CRT, IMRT was associated with, on average, a $5881 increase in total costs (P=0.043), a $1700 decrease in pretreatment costs (P=0.014), a $4768 increase in costs during treatment (P=0.004), and no significant difference in follow-up costs. Positron emission tomography scans, cancer recurrence, and comorbidity were also associated with higher total costs in this sample., Conclusions: Use of IMRT relative to CRT was strongly correlated with higher total costs, but disease control, patient comorbidity, and use of positron emission tomography also had significant effects on overall costs. Cost-effectiveness models should be developed to assess whether the potential benefits of IMRT are worth the associated investment.

Infusion catheters, when used in combination with balloons, are subjected to pressure created by inflation of the balloon. The compression can reduce the catheter flow area and cause elevated shear stresses in the fluid. A model and experiments were developed with a range of applied balloon pressures to investigate whether such situations may cause cell lysis during stem-cell infusion through single-lumen catheters. It was found that for balloon inflation pressures in excess of ~7 atm, it is possible for cell injury to occur, although the critical pressure depends on the fluid viscosity. The study was then applied to a multi-lumen catheter which was designed to resist compression. That device was able to handle very elevated balloon pressures and flow rates before cell lysis became a concern.

Background: Chemotherapy-related health care utilization by breast cancer patients can be expensive for payers and patients. This study evaluated the patient-centered medical home program Community Care of North Carolina (CCNC) in terms of its potential to reduce health care utilization associated with chemotherapy-related adverse events (AEs)., Methods: Early-stage breast cancer cases diagnosed during the 5-year period 2003-2007 were identified in the North Carolina Central Cancer Registry; these cases were then linked to North Carolina Medicaid claims data. We measured health care utilization associated with chemotherapy-related AEs by setting (inpatient, outpatient, or emergency department) during a 15-month postdiagnosis follow-up period. Descriptive and multivariate analyses were performed to examine associations between CCNC enrollment and health care utilization associated with chemotherapy-related AEs., Results: A large proportion of breast cancer patients had at least 1 health care visit associated with a chemotherapy-related AE (n = 412 [72.3%]). The mean numbers of AE-related visits occurring in inpatient, outpatient, and emergency department settings were 0.30 (standard deviation [SD] = 0.83), 6.92 (SD = 10.94), and 0.46 (SD = 1.26), respectively. CCNC enrollment was associated with significantly fewer inpatient admissions (marginal effect, -0.1421; 95% confidence interval, -0.280 to -0.004)., Limitations: In this observational study, we were unable to draw conclusions about the causality of these associations., Conclusions: Patients enrolled in CCNC had fewer inpatient health care visits associated with chemotherapy-related AEs. Future research should continue to explore the extent to which patient-centered medical homes can monitor and help manage the effects of cancer treatments.

Background: Medicare covers several cancer screening tests not currently recommended by the U.S. Preventive Services Task Force (Task Force). In September 2002, the Task Force relaxed the upper age limit of 70 years for breast cancer screening recommendations, and in March 2003 an upper age limit of 65 years was introduced for cervical cancer screening recommendations. We assessed whether mammogram and Pap test utilization among women with Medicare coverage is influenced by changes in the Task Force's recommendations for screening., Methods: We identified female Medicare beneficiaries aged 66-80 years and used bivariate probit regression to examine the receipt of breast (mammogram) and cervical (Pap test) cancer screening reflecting changes in the Task Force recommendations. We analyzed 9,760 Medicare Current Beneficiary Survey responses from 2001 to 2007., Results: More than two-thirds reported receiving a mammogram and more than one-third a Pap test in the previous 2 years. Lack of recommendation was given as a reason for not getting screened among the majority (51% for mammogram and 75% for Pap). After controlling for beneficiary-level socioeconomic characteristics and access to care factors, we did not observe a significant change in breast and cervical cancer screening patterns following the changes in Task Force recommendations., Conclusions: Although there is evidence that many Medicare beneficiaries adhere to screening guidelines, some women may be receiving non-recommended screening services covered by Medicare.

Purpose: To assess the cost-effectiveness of intensity modulated radiation therapy (IMRT) versus 3-dimensional conformal radiation therapy (3D-CRT) in the treatment of head-and neck-cancer (HNC)., Methods and Materials: We used a Markov model to simulate radiation therapy-induced xerostomia and dysphagia in a hypothetical cohort of 65-year-old HNC patients. Model input parameters were derived from PARSPORT (CRUK/03/005) patient-level trial data and quality-of-life and Medicare cost data from published literature. We calculated average incremental cost-effectiveness ratios (ICERs) from the US health care perspective as cost per quality-adjusted life-year (QALY) gained and compared our ICERs with current cost-effectiveness standards whereby treatment comparators less than $50,000 per QALY gained are considered cost-effective., Results: In the first 2 years after initial treatment, IMRT is not cost-effective compared with 3D-CRT, given an average ICER of $101,100 per QALY gained. However, over 15 years (remaining lifetime on the basis of average life expectancy of a 65-year-old), IMRT is more cost-effective at $34,523 per QALY gained., Conclusion: Although HNC patients receiving IMRT will likely experience reduced xerostomia and dysphagia symptoms, the small quality-of-life benefit associated with IMRT is not cost-effective in the short term but may be cost-effective over a patient's lifetime, assuming benefits persist over time and patients are healthy and likely to live for a sustained period. Additional data quantifying the long-term benefits of IMRT, however, are needed., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Community Care of North Carolina (CCNC) initiated an innovative medical home program in the 1990 s to improve primary care in Medicaid-insured populations. CCNC has been successful in improving asthma, diabetes, and cardiovascular outcomes but has not been evaluated in the context of cancer care. We explored whether CCNC enrollment was associated with guideline-concordant follow-up care among breast cancer survivors., Methods: Using state cancer registry records matched to Medicaid claims, we identified women 18 to 64 years old who were diagnosed with stage 0, I, II, or unstaged breast cancer from 2003 to 2007 and tracked their monthly CCNC enrollment. Using published American Society for Clinical Oncology guidelines to define our outcomes, we employed multivariate logistic regressions to examine, as a function of CCNC enrollment, receipt of mammogram and at least 2 physical examinations/history-taking visits within observational windows consistent with the guidelines., Results: Of the 840 women, approximately half were enrolled into the CCNC for some time during the study period. Between 40% and 85% received follow-up mammogram in accordance with guidelines, with significant variation by CCNC status, and 95% of women received at least 2 physical examinations/history-taking visits. In multivariate models, increasing months of CCNC enrollment was significantly positively associated with receipt of follow-up mammogram but not with physical examinations/history-taking visits., Conclusions: Results suggest that CCNC enrollment is associated with guideline-concordant follow-up care for Medicaid-insured survivors. Given the growing population of cancer survivors and increased emphasis on primary care medical homes, future studies should explore what factors are associated with medical home participation and whether similar findings are observed with extended follow-up.

Via a transcription factor, Foxp3, immunoregulatory CD4(+)CD25(+) T cells (T reg cells) play an important role in suppressing the function of other T cells. Adoptively transferring high numbers of T reg cells can reduce the intensity of the immune response, thereby providing an attractive prospect for inducing tolerance. Extending our previous findings, we describe an in vivo approach for inducing rapid expansion of T reg cells by injecting mice with interleukin (IL)-2 mixed with a particular IL-2 monoclonal antibody (mAb). Injection of these IL-2-IL-2 mAb complexes for a short period of 3 d induces a marked (>10-fold) increase in T reg cell numbers in many organs, including the liver and gut as well as the spleen and lymph nodes, and a modest increase in the thymus. The expanded T reg cells survive for 1-2 wk and are highly activated and display superior suppressive function. Pretreating with the IL-2-IL-2 mAb complexes renders the mice resistant to induction of experimental autoimmune encephalomyelitis; combined with rapamycin, the complexes can also be used to treat ongoing disease. In addition, pretreating mice with the complexes induces tolerance to fully major histocompatibility complex-incompatible pancreatic islets in the absence of immunosuppression. Tolerance is robust and the majority of grafts are accepted indefinitely. The approach described for T reg cell expansion has clinical potential for treating autoimmune disease and promoting organ transplantation.

Chemokines are essential for homeostasis and activation of the immune system. The chemokine ligand/receptor pairing CCL20/CCR6 is interesting because these molecules display characteristics of both homeostatic and activation functions. These dual characteristics suggest a role for CCR6 in the priming and effector phases of the immune response. However, while CCR6 has been implicated in the effector phase in several models, a role in the priming phase is less clear. Herein we analyze the role of CCR6 in these two important arms of the immune response during experimental autoimmune encephalomyelitis (EAE). Both CCR6 and its chemokine ligand CCL20 were up-regulated in the draining lymph nodes and spinal cord during EAE, and CCR6 was up-regulated on CD4(+) T cells that had divided following induction of EAE. The functional role of this expression was demonstrated by impaired development of EAE in gene-targeted CCR6-deficient mice and in mice treated either with a neutralizing anti-CCR6 Ab or with a novel receptor antagonist. Inhibition of EAE was due to reduced priming of autoreactive CD4(+) T cells probably as a result of impaired late-stage influx of dendritic cells into draining lymph nodes. This was accompanied by reduced egress of activated lymphocytes from the lymph nodes. These results demonstrate a novel role for CCR6 in the mechanism of autoreactive lymphocyte priming and emigration to the efferent lymphatics.

Between the 1890s and the 1930s field ecologists in the United States (and elsewhere) looked to classification to make their fledgling science an exacting and respectable one. Taking plant taxonomy as their model, ecologists expected that more comprehensive empirical knowledge of vegetation types would produce robust systems of classifications, as it did with species taxonomy. In the event, however, scaled-up data-gathering in the field led ecologists to conclude that vegetation types were not natural units, as species are. Most ecologists then abandoned classification for agendas borrowed from causal sciences such as chemistry or physiology. This cycle of expectation and despair is examined in the practical fieldwork of four ecologists: Henry Cowles, Frederic Clements, Henry Gleason, and Arthur Vestal. Their experiences reveal how perceptions of categories depend on the density and geographical scope of data. Cycles of optimism and disillusionment probably characterize all the classifying sciences in the modern period: because in the "Age of Progress" all sciences sought to advance by expanding and perfecting their empirical base. Comparative study of collecting and classifying practices across the sciences is in order.