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Purpose: To describe policy and system-level interventions with potential to improve cancer care at six sites., Methods: In 2016, six institutions received foundation support to develop unique multi-component interventions aimed at improving cancer care for underserved populations. These organizations, located across the United States, participated in a cross-site evaluation to assess the overall initiative impact and to identify potentially promising policy and system-level solutions for dissemination and broader implementation. A health system and policy tracking tool was developed to collect data from each site and included a description of their efforts, strategies employed, and changes achieved (e.g., new policies, clinical protocols). Tracking tool data were analyzed using rapid qualitative analyses and a matrix approach. Semi-structured interviews were conducted with site leaders (N = 65) and were analyzed by thematic analysis., Results: Sites reported 20 system and policy efforts, which resulted in improvements to electronic health records and telehealth strategies, changes to hospital/health system policies, and standardized clinical protocols/guidelines, among others. Efforts were aimed at: (1) coordinating care across multiple providers, supported by patient navigators; (2) expanding psychosocial and supportive care; (3) improving patient-provider communication; and (4) addressing barriers to accessing care. Interview analyses provided insights into successful strategies, challenges, and implications of the COVID-19 pandemic on cancer care., Conclusions and Implications for Cancer Survivors: Despite advances in diagnosis and treatment, cancer care remains inequitable. System-level improvements aimed at eliminating common barriers faced by underserved populations offer opportunities to improve the delivery of equitable, effective, and efficient care., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

The NCCN Guidelines for Ovarian Cancer/Fallopian Tube Cancer/Primary Peritoneal Cancer provide multidisciplinary diagnostic workup, staging, and treatment recommendations for this disease. These NCCN Guidelines Insights detail how the evolution of the use of PARP inhibitors as maintenance and single-agent regimens for the treatment of ovarian cancer informed panel recommendations in the guidelines.

Importance: People experiencing homelessness die of lung cancer at rates more than double those in the general population. Lung cancer screening (LCS) with low-dose computed tomography (LDCT) reduces lung cancer mortality, but the circumstances of homelessness create barriers to LCS participation., Objective: To determine whether patient navigation, added to usual care, improved LCS LDCT receipt at a large Health Care for the Homeless (HCH) program., Design, Setting, and Participants: This parallel group, pragmatic, mixed-methods randomized clinical trial was conducted at Boston Health Care for the Homeless Program (BHCHP), a federally qualified HCH program that provides tailored, multidisciplinary care to nearly 10 000 homeless-experienced patients annually. Eligible individuals had a lifetime history of homelessness, had a BHCHP primary care practitioner (PCP), were proficient in English, and met the pre-2022 Medicare coverage criteria for LCS (aged 55-77 years, ≥30 pack-year history of smoking, and smoking within the past 15 years). The study was conducted between November 20, 2020, and March 29, 2023., Intervention: Participants were randomized 2:1 to usual BHCHP care either with or without patient navigation. Following a theory-based, patient-centered protocol, the navigator provided lung cancer education, facilitated LCS shared decision-making visits with PCPs, assisted participants in making and attending LCS LDCT appointments, arranged follow-up when needed, and offered tobacco cessation support for current smokers., Main Outcomes and Measures: The primary outcome was receipt of a 1-time LCS LDCT within 6 months after randomization, with between-group differences assessed by χ2 analysis. Qualitative interviews assessed the perceptions of participants and PCPs about the navigation intervention., Results: In all, 260 participants (mean [SD] age, 60.5 [4.7] years; 184 males [70.8%]; 96 non-Hispanic Black participants [36.9%] and 96 non-Hispanic White participants [36.9%]) were randomly assigned to usual care with (n = 173) or without (n = 87) patient navigation. At 6 months after randomization, 75 participants in the patient navigation arm (43.4%) and 8 of those in the usual care-only arm (9.2%) had completed LCS LDCT (P < .001), representing a 4.7-fold difference. Interviews with participants in the patient navigation arm and PCPs identified key elements of the intervention: multidimensional social support provision, care coordination activities, and interpersonal skills of the navigator., Conclusions and Relevance: In this randomized clinical trial, patient navigation support produced a 4.7-fold increase in 1-time LCS LDCT completion among HCH patients in Boston. Future work should focus on longer-term screening participation and outcomes., Trial Registration: ClinicalTrials.gov Identifier: NCT04308226.

Background: Bundling is combining individual interventions to meet quality metrics. Bundling offers of cancer screening with screening for social determinants of health (SDOH) may enable health centers to assist patients with social risks and yield efficiencies., Objective: To measure effects of bundling fecal immunochemical testing (FIT) and SDOH screening in federally qualified health centers (FQHCs)., Design: Clustered stepped-wedge trial., Participants: Four Massachusetts FQHCs randomized to implement bundled FIT-SDOH over 8-week "steps.", Intervention: Outreach to 50-75-year-olds overdue for CRC screening to offer FIT with SDOH screening. The implementation strategy used facilitation and training for data monitoring and reporting., Main Measures: Implementation process descriptions, data from facilitation meetings, and CRC and SDOH screening rates. Rates were compared between implementation and control FQHCs in each "step" by fitting generalized linear mixed-effects models with random intercepts for FQHCs, patients, and "step" by FQHC., Key Results: FQHCs tailored implementation processes to their infrastructure, workflows, and staffing and prioritized different groups for outreach. Two FQHCs used population health outreach, and two integrated FIT-SDOH within established programs, such as pre-visit planning. Of 34,588 patients overdue for CRC screening, 54% were female; 20% Black, 11% Latino, 10% Asian, and 47% white; 32% had Medicaid, 16% Medicare, 32% private insurance, and 11% uninsured. Odds of CRC screening completion in implementation "steps" compared to controls were higher overall and among groups prioritized for outreach (overall: adjusted odds ratio (aOR) 2.41, p = 0.005; prioritized: aOR 2.88, p = 0.002). Odds of SDOH screening did not differ across "steps.", Conclusions: As healthcare systems are required to conduct more screenings, it is notable that outreach for a long-standing cancer screening requirement increased screening, even when bundled with a newer screening requirement. This outreach was feasible in a real-world safety-net clinical population and may conserve resources, especially compared to more complex or intensive outreach strategies., Clinical Trials Registration: NCT04585919., (© 2024. The Author(s).)

Introduction: A smoking-cessation program was implemented as a randomized non-inferiority trial in primary care practices in Croatia and Slovenia to investigate whether a standard 4-week treatment with cytisine was at least as effective and feasible as a standard 12-week treatment with varenicline in helping smokers quit., Aims and Methods: Out of 982 surveyed smokers, 377 were recruited to the non-inferiority trial: 186 were randomly assigned to cytisine and 191 to varenicline treatment. The primary cessation outcome was 7-day abstinence after 24 weeks, while the primary feasibility outcome was defined by adherence to the treatment plan. We also compared the rates of adverse events between the two treatment groups., Results: The cessation rate after 24 weeks was 32.46% (62/191) in the varenicline group and 23.12% (43/186) in the cytisine group (odds ratio [OR]: 95%, credible interval [CI]: 0.39 to 0.98). Of 191 participants assigned to varenicline treatment 59.16% (113) were adherent, while 70.43% (131 of 186) were adherent in the cytisine group (OR: 1.65, 95% CI: 1.07 to 2.56). Participants assigned to cytisine experienced fewer total (incidence rate ratio [IRR]: 0.59, 95% CI: 0.43 to 0.81) and fewer severe or more extreme adverse events (IRR: 0.72, 95% CI: 0.35 to 1.47)., Conclusions: This randomized non-inferiority trial (n = 377) found the standard 4-week cytisine treatment to be less effective than the standard 12-week varenicline treatment for smoking cessation. However, adherence to the treatment plan, ie, feasibility, was higher, and the rate of adverse events was lower among participants assigned to cytisine treatment., Implications: The present study found the standard 12 weeks of varenicline treatment to be more effective than the standard 4 weeks of cytisine treatment for smoking cessation in a primary care setting in Croatia and Slovenia. Participants assigned to cytisine, however, had a higher adherence to the treatment plan and a lower rate of adverse events. Estimates from the present study may be especially suitable for generalizations to high-smoking prevalence populations in Europe. Given the much lower cost of cytisine treatment, its lower rate of adverse events, and higher feasibility (but its likely lower effectiveness with the standard dosage regimen), future analyses should assess the cost-effectiveness of the two treatments for health policy considerations., (© The Author(s) 2023. 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.)

Background: Large segments of the US population do not receive quality cancer care due to pervasive and systemic inequities, which can increase morbidity and mortality. Multicomponent, multilevel interventions can address inequities and improve care, but only if they reach communities with suboptimal access. Intervention studies often underenroll individuals from historically excluded groups., Methods: The Alliance to Advance Patient-Centered Cancer Care includes 6 grantees across the United States who implemented unique multicomponent, multilevel intervention programs with common goals of reducing disparities, increasing engagement, and improving the quality of care for targeted populations. The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework informed the evaluation efforts across sites. Each Alliance site identified their intended populations, which included underrepresented minorities (eg, Black and Latinx persons), individuals who prefer a language other than English, and rural residents. We evaluated the demographic characteristics of participants to determine program reach., Results: Between 2018 and 2020, a total of 2,390 of 5,309 potentially eligible participants were enrolled across the 6 sites. The proportion of enrolled individuals with selected characteristics included 38% (n=908) Black adults, 24% (n=574) Latinx adults, 19% (n=454) preferring a language other than English, and 30% (n=717) rural residents. The proportion of those enrolled who were the intended population was commensurate to the proportion with desired characteristics in those identified as potentially eligible., Conclusions: The grantees met or exceeded enrollments from their intended populations who have been underserved by quality cancer care into patient-centered intervention programs. Intentional application of recruitment/engagement strategies is needed to reach individuals from historically underserved communities.

Thousands of colonoscopies were canceled during the initial surge of the COVID-19 pandemic. As facilities resumed services, some patients were hesitant to reschedule. The purpose of this study was to determine whether a decision aid plus telephone coaching would increase colorectal cancer (CRC) screening and improve patient reports of shared decision making (SDM). A randomized controlled trial assigned adults aged 45-75 without prior history of CRC who had a colonoscopy canceled from March to May 2020 to intervention (n = 400) or usual care control (n = 400) arms. The intervention arm received three-page decision aid and call from decision coach from September 2020 through November 2020. Screening rates were collected at 6 months. A subset (n = 250) in each arm was surveyed 8 weeks after randomization to assess SDM (scores range 0-4, higher scores indicating more SDM), decisional conflict, and screening preference. The sample was on average, 60 years old, 53% female, 74% White, non-Hispanic, and 11% Spanish speaking. More intervention arm patients were screened within 6 months (35% intervention vs 23% control, p < 0.001). The intervention respondents reported higher SDM scores (mean difference 0.7 [0.4, 0.9], p < 0.001) and less decisional conflict than controls (-21% [-35%, -7%], p = 0.003). The majority in both arms preferred screening versus delaying (68% intervention vs. 65% control, p = 0.75). An SDM approach that offered alternatives and incorporated patients' preferences resulted in higher screening rates. Patients who are overdue for CRC screening may benefit from proactive outreach with SDM support., (© 2022 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Background: For adults aged 76-85, guidelines recommend individualizing decision-making about whether to continue colorectal cancer (CRC) testing. These conversations can be challenging as they need to consider a patient's CRC risk, life expectancy, and preferences., Objective: To promote shared decision-making (SDM) for CRC testing decisions for older adults., Design: Two-arm, multi-site cluster randomized trial, assigning physicians to Intervention and Comparator arms. Patients were surveyed shortly after the visit to assess outcomes. Analyses were intention-to-treat., Participants and Setting: Primary care physicians affiliated with 5 academic and community hospital networks and their patients aged 76-85 who were due for CRC testing and had a visit during the study period., Interventions: Intervention arm physicians completed a 2-h online course in SDM communication skills and received an electronic reminder of patients eligible for CRC testing shortly before the visit. Comparator arm received reminders only., Main Measures: The primary outcome was patient-reported SDM Process score (range 0-4 with higher scores indicating more SDM); secondary outcomes included patient-reported discussion of CRC screening, knowledge, intention, and satisfaction with the visit., Key Results: Sixty-seven physicians (Intervention n=34 and Comparator n=33) enrolled. Patient participants (n=466) were on average 79 years old, 50% with excellent or very good self-rated overall health, and 66% had one or more prior colonoscopies. Patients in the Intervention arm had higher SDM Process scores (adjusted mean difference 0.36 (95%CI (0.08, 0.64), p=0.01) than in the Comparator arm. More patients in the Intervention arm reported discussing CRC screening during the visit (72% vs. 60%, p=0.03) and had higher intention to follow through with their preferred approach (58.0% vs. 47.1, p=0.03). Knowledge scores and visit satisfaction did not differ significantly between arms., Conclusion: Physician training plus reminders were effective in increasing SDM and frequency of CRC testing discussions in an age group where SDM is essential., Trial Registration: The trial is registered on clinicaltrials.gov (NCT03959696)., (© 2022. The Author(s).)

Background. Early in the COVID-19 pandemic colonoscopies for colorectal cancer (CRC) screening were canceled. Patient perceptions of the benefits and risks of routine screening relative to health concerns associated with the COVID-19 pandemic were unknown. Purpose. Assess patient anxiety, worry, and interest in CRC screening during the COVID-19 pandemic. Methods. A random sample of 200 patients aged 45 to 75 y with colonoscopy cancellation due to COVID-19 in March to May 2020 were surveyed. Anxiety, COVID-19 and CRC risk perceptions, COVID-19 and CRC worry, likelihood of following through with colonoscopy in the next month, and interest in alternatives to colonoscopy were assessed. Subsequent screening was tracked for 12 mo. Results. Respondents ( N  = 127/200, 63.5%) were on average 60 y old, female (59%), college educated (62% college degree or more), and White (91%). A substantial portion of patients (46%) stated they may not follow through with a colonoscopy in the next month. There was greater interest in stool-based testing than in delaying screening (48% v. 26%). Women, older patients, and patients indicating tolerance of uncertainty due to complexity reported they were less likely to follow through with colonoscopy in the next month. Greater interest in stool-based testing was related to lower perceptions of CRC risk. Greater interest in delaying screening was related to less worry about CRC and less tolerance of risk. Over 12 mo, 60% of participants completed screening. Patients who stated they were more likely to screen in the next month were more likely to complete CRC screening ( P  = 0.01). Conclusions. Respondents who had a colonoscopy canceled during the COVID-19 pandemic varied in interest in rescheduling the procedure. A shared decision-making approach may help patients address varying concerns and select the best approach to screening for them., Highlights: In the wake of the first wave of the COVID-19 pandemic, almost half of patients stated they were not likely to follow through with a colonoscopy in the short term, about half were interested in screening with a stool-based test, and only one-quarter were interested in delaying screening until next year.Patients who perceived themselves at higher risk of colorectal cancer were less interested in stool-based testing, and patients who were more worried about colorectal cancer were less interested in delaying screening.A shared decision-making approach may be necessary to tailor screening discussions for patients during subsequent waves of the pandemic, other occasions where resources are limited and patient preferences vary, or where patients hold conflicting views of screening., Competing Interests: With regard to potential conflicts of interest for this study, Dr. Atlas reports a grant from the National Cancer Institute, and Dr. Richter reports approximately 25% income derived from performing colonoscopy. All other authors report no conflicts outside receiving grant funding through their institution from PCORI for this study., (© The Author(s) 2022.)

Epithelial ovarian cancer is the leading cause of death from gynecologic cancer in the United States, with less than half of patients living >5 years following diagnosis. The NCCN Guidelines for Ovarian Cancer provide recommendations for the diagnosis, evaluation, treatment, and follow-up for patients with ovarian, fallopian tube, and primary peritoneal cancers. These NCCN Guidelines Insights summarize the panel discussion behind recent important updates to the guidelines, including revised guidance on alternative chemotherapy regimens for patients with advanced age and/or comorbidities, a new algorithm for recurrent low-grade serous carcinoma based on developing research and novel therapeutic agents, and updated language regarding tumor molecular analysis applications in ovarian cancer.

Background: Six multidisciplinary cancer centers were selected and funded by the Merck Foundation (2017-2021) to collaborate in the Alliance to Advance Patient-Centered Cancer Care ("Alliance"), an initiative to improve patient access, minimize health disparities, and enhance the quality of patient-centered cancer care. These sites share their insights on implementation and expansion of their patient navigation efforts., Methods: Patient navigation represents an evidence-based health care intervention designed to enhance patient-centered care and care coordination. Investigators at 6 National Cancer Institute-designated cancer centers outline their approaches to reducing health care disparities and synthesize their efforts to ensure sustainability and successful transferability in the management of patients with cancer and their families in real-world health care settings., Results: Insights are outlined within the context of patient navigation program effectiveness and supported by examples from Alliance cancer center sites: 1) understand the patient populations, particularly underserved and high-risk patients; 2) capitalize on the existing infrastructure and institutional commitment to support and sustain patient navigation; and 3) build capacity by mobilizing community support outside of the cancer center., Conclusions: This process-level article reflects the importance of collaboration and the usefulness of partnering with other cancer centers to share interdisciplinary insights while undergoing intervention development, implementation, and expansion. These collective insights may be useful to staff at other cancer centers that look to implement, enhance, or evaluate the effectiveness of their patient navigation interventions., (© 2022 American Cancer Society.)

Background: Lung cancer is a major cause of death among people experiencing homelessness, with mortality rates more than double those in the general population. Lung cancer screening (LCS) with low-dose computed tomography (LDCT) could reduce lung cancer deaths in this population, although the circumstances of homelessness present multiple barriers to LCS LDCT completion. Patient navigation is a promising strategy for overcoming these barriers., Methods: The Investigating Navigation to Help Advance Lung Equity (INHALE) Study is a pragmatic randomized controlled trial of patient navigation for LCS among individuals receiving primary care at Boston Health Care for the Homeless Program (BHCHP). Three hundred BHCHP patients who meet Medicare/Medicaid criteria for LCS will be randomized 2:1 to usual care with (n = 200) or without (n = 100) LCS navigation. Following a structured, theory-based protocol, the patient navigator assists with each step in the LCS process, providing lung cancer education, facilitating shared decision-making visits with primary care providers (PCPs), assisting in making and attending LCS LDCT appointments, arranging follow-up when needed, and offering tobacco cessation support for smokers. The primary outcome is receipt of LCS LDCT at 6 months. Using a sequential explanatory mixed methods approach, qualitative interviews with participants and PCPs will aid in interpreting and contextualizing the trial results., Discussion: This trial will produce the first experimental evidence on patient navigation for cancer screening in a homeless health care setting. Results could inform cancer health equity efforts at the 299 Health Care for the Homeless programs that serve over 900,000 patients annually in the US., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: While substantial attention is focused on the delivery of routine preventive cancer screening, less attention has been paid to systematically ensuring that there is timely follow-up of abnormal screening test results. Barriers to completion of timely follow-up occur at the patient, provider, care team and system levels., Methods: In this pragmatic cluster randomized controlled trial, primary care sites in three networks are randomized to one of four arms: (1) standard care, (2) "visit-based" reminders that appear in a patient's electronic health record (EHR) when it is accessed by either patient or providers (3) visit based reminders with population health outreach, and (4) visit based reminders, population health outreach, and patient navigation with systematic screening and referral to address social barriers to care. Eligible patients in participating practices are those overdue for follow-up of an abnormal results on breast, cervical, colorectal and lung cancer screening tests., Results: The primary outcome is whether an individual receives follow-up, specific to the organ type and screening abnormality, within 120 days of becoming eligible for the trial. Secondary outcomes assess the effect of intervention components on the patient and provider experience of obtaining follow-up care and the delivery of the intervention components., Conclusions: This trial will provide evidence for the role of a multilevel intervention on improving the follow-up of abnormal cancer screening test results. We will also specifically assess the relative impact of the components of the intervention, compared to standard care., Trial Registration: ClinicalTrials.gov NCT03979495., (Copyright © 2021. Published by Elsevier Inc.)

Background: Conversation aids can facilitate shared decision-making and improve patient-centered outcomes. However, few examples exist of sustained use of conversation aids in routine care due to numerous barriers at clinical and organizational levels. We explored factors that will promote the sustained use of two early-stage breast cancer conversation aids. We examined differences in opinions between the two conversation aids and across socioeconomic strata., Methods: We nested this study within a randomized controlled trial that demonstrated the effectiveness of two early-stage breast cancer surgery conversation aids, one text-based and one picture-based. These conversation aids facilitated more shared decision-making and improved the decision process, among other outcomes, across four health systems with socioeconomically diverse patient populations. We conducted semi-structured interviews with a purposive sample of patient participants across conversation aid assignment and socioeconomic status (SES) and collected observations and field notes. We interviewed trial surgeons and other stakeholders. Two independent coders conducted framework analysis using the NOrmalization MeAsure Development through Normalization Process Theory. We also conducted an inductive analysis. We conducted additional sub-analyses based on conversation aid assignment and patient SES., Results: We conducted 73 semi-structured interviews with 43 patients, 16 surgeons, and 14 stakeholders like nurses, cancer center directors, and electronic health record (EHR) experts. Patients and surgeons felt the conversation aids should be used in breast cancer care in the future and were open to various methods of giving and receiving the conversation aid (EHR, email, patient portal, before consultation). Patients of higher SES were more likely to note the conversation aids influenced their treatment discussion, while patients of lower SES noted more influence on their decision-making. Intervention surgeons reported using the conversation aids did not lengthen their typical consultation time. Most intervention surgeons felt using the conversation aids enhanced their usual care after using it a few times, and most patients felt it appeared part of their normal routine., Conclusions: Key factors that will guide the future sustained implementation of the conversation aids include adapting to existing clinical workflows, flexibility of use, patient characteristics, and communication preferences., Trial Registration: ClinicalTrials.gov Identifier: NCT03136367 , registered on May 2, 2017.

Epithelial ovarian cancer is the leading cause of death from gynecologic cancer in the United States and is the country's fifth most common cause of cancer mortality in women. A major challenge in treating ovarian cancer is that most patients have advanced disease at initial diagnosis. These NCCN Guidelines discuss cancers originating in the ovary, fallopian tube, or peritoneum, as these are all managed in a similar manner. Most of the recommendations are based on data from patients with the most common subtypes─high-grade serous and grade 2/3 endometrioid. The NCCN Guidelines also include recommendations specifically for patients with less common ovarian cancers, which in the guidelines include the following: carcinosarcoma, clear cell carcinoma, mucinous carcinoma, low-grade serous, grade 1 endometrioid, borderline epithelial, malignant sex cord-stromal, and malignant germ cell tumors. This manuscript focuses on certain aspects of primary treatment, including primary surgery, adjuvant therapy, and maintenance therapy options (including PARP inhibitors) after completion of first-line chemotherapy.

Background: Women of lower socioeconomic status (SES) with early-stage breast cancer are more likely to report poorer physician-patient communication, lower satisfaction with surgery, lower involvement in decision making, and higher decision regret compared to women of higher SES. The objective of this study was to understand how to support women across socioeconomic strata in making breast cancer surgery choices., Methods: We conducted a 3-arm (Option Grid, Picture Option Grid, and usual care), multisite, randomized controlled superiority trial with surgeon-level randomization. The Option Grid (text only) and Picture Option Grid (pictures plus text) conversation aids were evidence-based summaries of available breast cancer surgery options on paper. Decision quality (primary outcome), treatment choice, treatment intention, shared decision making (SDM), anxiety, quality of life, decision regret, and coordination of care were measured from T0 (pre-consultation) to T5 (1-year after surgery., Results: Sixteen surgeons saw 571 of 622 consented patients. Patients in the Picture Option Grid arm (n = 248) had higher knowledge (immediately after the visit [T2] and 1 week after surgery or within 2 weeks of the first postoperative visit [T3]), an improved decision process (T2 and T3), lower decision regret (T3), and more SDM (observed and self-reported) compared to usual care (n = 257). Patients in the Option Grid arm (n = 66) had higher decision process scores (T2 and T3), better coordination of care (12 weeks after surgery or within 2 weeks of the second postoperative visit [T4]), and more observed SDM (during the surgical visit [T1]) compared to usual care arm. Subgroup analyses suggested that the Picture Option Grid had more impact among women of lower SES and health literacy. Neither intervention affected concordance, treatment choice, or anxiety., Conclusions: Paper-based conversation aids improved key outcomes over usual care. The Picture Option Grid had more impact among disadvantaged patients., Lay Summary: The objective of this study was to understand how to help women with lower incomes or less formal education to make breast cancer surgery choices. Compared with usual care, a conversation aid with pictures and text led to higher knowledge. It improved the decision process and shared decision making (SDM) and lowered decision regret. A text-only conversation aid led to an improved decision process, more coordinated care, and higher SDM compared to usual care. The conversation aid with pictures was more helpful for women with lower income or less formal education. Conversation aids with pictures and text helped women make better breast cancer surgery choices., (© 2020 The Authors. Cancer published by Wiley Periodicals LLC on behalf of American Cancer Society.)

Patient navigation (PN) improves initial colorectal cancer (CRC) screening in underserved populations. Whether the impact persists and improves the timeliness of follow-up screening colonoscopy (FSC) is not known. Patients receiving PN at initial colonoscopy between 2010-2011 with findings requiring FSC were matched to unnavigated patients requiring FSC. The primary outcome was proportion of patients with timely FSC, defined as colonoscopy within six months of recommendation. Of 216 patients in the study 103 (48%) completed FSC: 33 of 62 (53%) who received PN compared with 70 of 154 (45%) in the control group (p=.30). After adjusting for insurance, education, language and visits, navigated patients had higher odds (AOR=1.53, 95% CI 0.80-2.92) of timely FSC completion compared with unnavigated patients. Timely FSC completion in underserved patients is low. Patients navigated for initial colonoscopy or not had similar rates of FSC completion. Future studies should investigate navigation for FSC to improve equity in CRC.

Objective: Colorectal cancer (CRC) is the second leading cause of cancer death in the US. Screening has decreased CRC mortality. However, disadvantaged patients, particularly those with mental illness or substance use disorder (SUD), are less likely to be screened. The aim of this trial was to evaluate the impact of a patient navigation program on CRC screening in patients with mental illness and/or SUD., Methods: A pilot randomized nonblinded controlled trial was conducted from January to June 2017 in an urban community health center serving a low-income population. We randomized 251 patients aged 50-74 years with mental illness and/or SUD diagnosis overdue for CRC screening to intervention ( n  = 126) or usual care ( n  = 125) stratified by mental illness, SUD, or dual diagnosis. Intervention group patients received a letter followed by a phone call from patient navigators. Navigators helped patients overcome their individual barriers to CRC screening including: education, scheduling, explanation of bowel preparation, lack of transportation or accompaniment to appointments. If patient refused colonoscopy, navigators offered fecal occult blood testing. The main measure was proportion of patients completing CRC screening in intervention and usual care groups., Results: Navigators contacted 85 patients (67%) in the intervention group and 26 declined to participate. In intention-to treat analysis, more patients in the intervention group received CRC screening than in the usual care group, 19% versus 10.4% ( p = .04). Among 56 intervention patients who received navigation, 19 completed screening (33.9% versus 10.4% in the control group, p = .001). In the subgroup of patients with SUD, 20% in the intervention group were screened compared to none in the usual care group ( p = .05)., Conclusions: A patient navigation program improved CRC screening rates in patients with mental illness and/or SUD. Larger studies in diverse care settings are needed to demonstrate generalizability and explore which modality of CRC screening is most acceptable and which navigator activities are most effective for this vulnerable population., Trials Registration Number: 2016P001322.

Lung cancer is a leading cause of cancer death in Latinos. In a telephone survey, we assessed perceptions about lung cancer and awareness of, interest in, and barriers to lung screening among older current and former smokers. We compared Latino and non-Latino responses adjusting for age, sex, education, and smoking status using logistic regression models. Of the 460 patients who completed the survey (51.5% response rate), 58.0% were women, 49.3% former smokers, 15.7% Latino, with mean age 63.6 years. More Latinos believed that lung cancer could be prevented compared to non-Latinos (74.6% vs. 48.2%, OR 3.07, CI 1.89-5.01), and less worried about developing lung cancer (34.8% vs. 50.3%, OR 0.44, CI 0.27-0.72). Most participants were not aware of lung screening (44.1% Latinos vs. 34.3% Non-Latinos, OR 1.24, CI 0.79-1.94), but when informed, more Latinos wanted to be screened (90.7% vs. 67%, OR 4.58, CI 2.31-9.05). Latinos reported fewer barriers to lung screening.

Epithelial ovarian cancer is the leading cause of death from gynecologic cancer in the United States, with less than half of patients living >5 years from diagnosis. A major challenge in treating ovarian cancer is that most patients have advanced disease at initial diagnosis. The best outcomes are observed in patients whose primary treatment includes complete resection of all visible disease plus combination platinum-based chemotherapy. Research efforts are focused on primary neoadjuvant treatments that may improve resectability, as well as systemic therapies providing improved long-term survival. These NCCN Guidelines Insights focus on recent updates to neoadjuvant chemotherapy recommendations, including the addition of hyperthermic intraperitoneal chemotherapy, and the role of PARP inhibitors and bevacizumab as maintenance therapy options in select patients who have completed primary chemotherapy.

Background: Inadequate diagnostic evaluations of breast lumps and rectal bleeding in primary care are an important source of medical errors. Delays appear particularly common in evaluation of rectal bleeding. Comparing pursuit and completion of diagnostic testing for these two conditions within the same practice settings could help highlight barriers and inform interventions., Objectives: To examine processes undertaken for diagnostic evaluations of breast lumps and rectal bleeding within the same practices and to compare them with regard to (a) the likelihood that diagnostic tests are ordered according to guidelines and (b) the timeliness of order placement and completion., Design: A retrospective cohort study using explicit chart abstraction methods., Participants: Three hundred women aged 30-80 presenting with breast lumps and 300 men and women aged 40-80 years presenting with rectal bleeding to 15 academically affiliated primary care practices, 2012-2016., Main Measures: Rates and timing of test ordering and completion and patterns of visits and communications., Key Results: At initial presentation, physicians ordered recommended imaging or procedures at higher rates for patients with breast lumps compared to those with rectal bleeding (97% vs. 86% of patients recommended to receive imaging or endoscopy; p < 0.01). Most (90%) patients with breast lumps completed recommended diagnostic testing within 1 month, versus 31% of patients with rectal bleeding (p < 0.01). By 1 year, 7% of patients with breast lumps had not completed indicated imaging, versus 27% of those with rectal bleeding. Patients with breast lumps had fewer subsequent primary care visits related or unrelated to their symptom and had fewer related communications with specialists., Limitations: The study relied on documented care, and findings may be most generalizable to academically affiliated institutions., Conclusions: Diagnostic processes for rectal bleeding were less frequently guideline-concordant and timely than those for breast lumps. The largest discrepancies occurred in initial ordering of indicated tests and the timeliness of test completion.

Background: For limited English-proficient (LEP) patients, the digital divide has narrowed, creating a new population of Internet users. However, language-appropriate health information is difficult to find. Community health center (CHC) websites are health information resources and their homepages are critical access points for patients. CHCs supported by Health Resources and Services Administration (HRSA) care for many LEP patients., Objective: We sought to determine the number of HRSA-supported CHC websites providing translated homepage content., Research Design: In February 2017, we performed a cross-sectional analysis of the language availability of CHC homepages., Measures: The primary outcome was availability of translated content on CHC homepages. Secondary outcomes were method of translation and associations between homepage translation and CHC demographics, including percent LEP population and socioeconomic and Internet access characteristics., Results: Of the 1400 CHC homepages, 480 (34.3%) provided translated information with half using Google Translate. We found higher odds of having a translated homepage as the LEP population by county increased [odds ratio (OR): 1.26, confidence interval (CI): 1.07-1.49, P=0.005], Internet subscription at the state level increased (OR: 1.19, CI: 1.02-1.38, P=0.026), and if health centers were in metropolitan areas (OR: 1.81, CI: 1.31-2.51, P<0.001). There was also higher likelihood of having a homepage translated to Spanish in counties with higher Spanish LEP populations (OR: 1.39, CI: 1.19-1.63, P<0.001), but this did not extend to non-Spanish languages (OR: 0.85, CI: 0.71-1.04, P=0.131)., Conclusions: Despite increased Internet use among LEP patients and linguistic diversity of the CHC populations, there is a lack of language-appropriate content on CHC website homepages.

Purpose: To examine the long-term effects of a patient navigation (PN) program for mammography screening tailored to refugee women and to assess screening utilization among these women after PN ended. Methods: We assessed the proportion of patients completing mammography screening during the prior 2 years during 2012-2016 for refugee women who had previously received PN compared with that of English-speaking women cared for at the same health center during the same period, both overall and stratifying by age. We used logistic regression to compare screening completion between refugees and English speakers, adjusting for age, race, insurance status, number of clinic visits, and clustering by primary care physician and to test trends in screening over time. Results: In 2012, the year when the funding for PN ceased, among 126 refugee women eligible for breast cancer screening, mammography screening rates were significantly higher among refugees (90.5%, 95% confidence interval [CI]: 83.5-94.7%) than among English speakers (81.9%, 95% CI: 76.2-86.5%, p =0.006). By 2016, screening rates decreased among refugee women (76.5%, 95% CI: 61.6-86.9%, p =0.023) but were not statistically significantly different from those among English-speaking women (80.5%, 95% CI: 74.4-85.3%, p =0.460). Screening prevalence for refugee women remained above the pre-PN program screening levels, and considerably so in women <50 years. Conclusion: The culturally and language-tailored PN program for refugee women appeared to have persistent effects, with refugee women maintaining similar levels of mammography screening to English-speaking patients 5 years after the PN program's end., Competing Interests: No competing financial interests exist.

Lung cancer remains the leading cause of cancer mortality in the United States. Lung cancer screening (LCS) with low-dose CT reduces mortality among high-risk current and former smokers and has been covered by public and private insurers without cost sharing since 2015. Patients and referring providers confront numerous barriers to participation in screening. To best serve in multidisciplinary efforts to expand LCS nationwide, radiologists must be knowledgeable of these challenges. A better understanding of the difficulties confronted by other stakeholders will help radiologists continue to collaboratively guide the growth of LCS programs in their communities. This article reviews barriers to participation in LCS for patients and referring providers, as well as possible solutions and interventions currently underway., (© RSNA, 2019.)

Purpose: Health care utilization during Ramadan has not been examined in the United States., Methods: A retrospective review of billing and electronic health record data for Muslims (n = 2,919) and non-Muslims (n = 184,803) in primary care practices in Eastern Massachusetts., Results: Muslim patients were younger, less educated, less often commercially insured, more likely to have Medicare, and less likely to be primary English speakers (p &lt; .0001 for all comparisons). In multivariate models, during Ramadan, Muslims, compared with non-Muslims, had a higher rate of primary care visits (incidence rate ratio [IRR], 1.06; 95% confidence interval [CI], 1.01-1.11), emergency department visits (IRR, 1.60; 95% CI, 1.34-1.91), and hospitalizations (IRR, 1.18; 95% CI, 1.03-1.34)., Conclusions: Important demographic differences exist between Muslim and non-Muslim patients. Muslims, compared with non-Muslims, had higher health care utilization during Ramadan.

Introduction. Breast cancer is the second most common malignancy in women. The Decision Quality Instrument (DQI) measures the extent to which patients are informed and involved in breast surgery decisions and receive treatment that aligns with their preferences. There are limited data on the performance of the DQI in women of lower socioeconomic status (SES). Our aims were to 1) examine (and if necessary adapt) the readability, usability, and acceptability of the DQI and 2) explore whether it captures factors important to breast cancer surgery decisions among women of lower SES (relevance). Methods. We conducted semistructured cognitive interviews with women of lower SES (based on insurance status, income, and education) who had completed early-stage breast cancer treatments at three cancer centers. We used a two-step thematic analysis with dual independent coding. The study team (including Patient Partners and a Community Advisory Board) reviewed and refined suggested changes. The revised DQI was presented in two focus groups of breast cancer survivors. Results. We conducted 39 interviews. Participants found most parts of the DQI to be helpful and easy to understand. We made the following suggested changes: 1) added a glossary of key terms, 2) added two answer choices and an open text question in the goals and concerns subscale, 3) reworded the treatment intention question, and 4) revised the knowledge subscale instructions since several women disliked the wording and were unsure of what was expected. Discussion. The readability, usability, acceptability, and relevance of a measure that was primarily developed and validated in women of higher SES required adaptation for optimal use by women of lower SES. Further research will test these adaptations in lower SES populations., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: GE and M-AD have developed the Option Grid patient decision aids, which are licensed to EBSCO Health. They receive consulting income from EBSCO Health and may receive royalties in the future. M-AD is a consultant for ACCESS Community Health Network. KS receives salary support as a member of the scientific advisory board for Healthwise, a not-for-profit foundation that develops and distributes patient education and decision support materials. MCP received a speaker fee from Merck & Co. and as a research contract from Merck, both unrelated to this study or manuscript. The other authors have no conflicts of interest to disclose.

Our goal is to define patient navigation for an imaging audience, present a focused selection of published experiences with navigation programs for breast and colorectal cancer screening, and expose principal barriers to the success of such programs. Despite numerous advances in the early detection of cancers, many patients still present with advanced disease. A disproportionate number are low-income minority patients who experience worse health outcomes than their white or more financially stable counterparts. Patient navigation, which aims to assist the medically underserved by overcoming specific barriers to care, may represent one solution to narrowing disparities. Related research suggests that in general, patient navigation programs that have addressed breast or colorectal cancer screening have been successful in improving screening rates and timeliness of follow-up care. However, although beneficial, navigation is expensive and may present an unmanageable financial burden for many health care centers. To overcome this challenge, navigation efforts will likely need to target those patients that are most likely to benefit. Further research to identify such patients will be critically important for improving the sustainability of navigation programs, and, in turn, for realizing the benefits of such programs in reducing cancer disparities., (Copyright © 2018. Published by Elsevier Inc.)

Background: Patient navigation (PN) programs can improve cancer screening in underserved populations. PN may advance quality and equity of care by supporting individuals at increased risk of not receiving recommended care., Objective: To evaluate patient satisfaction with medical care and PN for cancer screening., Methods: We conducted a telephone survey of patients enrolled in a randomized control trial evaluating the impact of PN for cancer screening to assess their satisfaction with overall medical care and the PN program. We measured patient satisfaction with medical care using the Patient Satisfaction Questionnaire-18 and evaluated patient satisfaction with PN in the navigated group using the Patient Satisfaction with Interpersonal Relationships with Navigator questionnaire., Key Results: Satisfaction surveys were completed by 114 navigated and 108 non-navigated patients (33% response rate). Patients who received PN had higher satisfaction scores with overall medical care (71.0 vs 66.8; P < .001)., Conclusions: Our findings show that patients at high risk of nonadherence with comprehensive cancer screening were satisfied with PN and suggest that PN could positively influence patient satisfaction with overall medical care., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Rectal bleeding is a common, frequently benign problem that can also be an early sign of colorectal cancer. Diagnostic evaluation for rectal bleeding is complex, and clinical practice may deviate from available guidelines., Objective: To assess the degree to which primary care physicians document risk factors for colorectal cancer among patients with rectal bleeding and order colonoscopies when indicated, and the likelihood of physicians ordering and patients receiving recommended colonoscopies based on demographic characteristics, visit patterns, and clinical presentations., Design: Cross-sectional study using explicit chart abstraction methods., Participants: Three hundred adults, 40-80 years of age, presenting with rectal bleeding to 15 academically affiliated primary care practices between 2012 and 2016., Main Measures: 1) The frequency at which colorectal cancer risk factors were documented in patients' charts, 2) the frequency at which physicians ordered colonoscopies and patients received them, and 3) the odds of ordering and patients receiving recommended colonoscopies based on patient demographic characteristics, visit patterns, and clinical presentations., Key Results: Risk factors for colorectal cancer were documented between 9% and 66% of the time. Most patients (89%) with rectal bleeding needed a colonoscopy according to a clinical guideline. Physicians placed colonoscopy orders for 74% of these patients, and 56% completed the colonoscopy within a year (36% within 60 days). The odds of physicians ordering recommended colonoscopies were significantly higher in patients aged 50-64 years of age than in those aged 40-50 years (OR = 2.23, 95% CI: 1.04, 4.80), and for patients whose most recent colonoscopy was 5 or more years ago (OR = 4.04, 95% CI: 1.50, 10.83). The odds of physicians ordering and patients receiving recommended colonoscopies were significantly lower for each primary care visit unrelated to rectal bleeding (OR = 0.85, 95% CI: 0.75, 0.96)., Conclusions: Diagnostic evaluation of patients presenting to primary care with rectal bleeding may be suboptimal because of inadequate risk factor assessment and prioritization of patients' other concurrent medical problems.

Annual chest computed tomography (CT) can decrease lung cancer mortality in high-risk individuals. Patient navigation improves cancer screening rates in underserved populations. Randomized controlled trial was conducted from February 2016 to January 2017 to evaluate the impact of a patient navigation program on lung cancer screening (LCS) among current smokers in five community health centers (CHCs) affiliated with an academic primary care network. We randomized 1200 smokers aged 55-77 years to intervention (n = 400) or usual care (n = 800). Navigators contacted patients to determine LCS eligibility, introduce shared decision making about screening, schedule appointments with primary care physicians (PCPs), and help overcome barriers to obtaining screening and follow-up. Control patients received usual care. The main outcome was the proportion of patients who had any chest CT. Secondary outcomes were the proportion of patients contacted, proportion receiving LCS CTs, screening results and number of lung cancers diagnosed. Of the 400 intervention patients, 335 were contacted and 76 refused participation. Of the 259 participants, 124 (48%) were ineligible for screening; 119 had smoked <30 pack-years, and five had competing comorbidities. Among the 135 eligible participants in the intervention group, 124 (92%) had any chest CT performed. In intention-to-treat analyses, 124 intervention patients (31%) had any chest CT versus 138 control patients (17.3%, P < 0.001). LCS CTs were performed in 94 intervention patients (23.5%) versus 69 controls (8.6%, P < 0.001). A total of 20% of screened patients required follow-up. Lung cancer was diagnosed in eight intervention (2%) and four control (0.5%) patients. A patient navigation program implemented in CHCs significantly increased LCS among high-risk current smokers., (© 2018 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Background: Breast cancer is the most commonly diagnosed malignancy in women. Mastectomy and breast-conserving surgery (BCS) have equivalent survival for early stage breast cancer. However, each surgery has different benefits and harms that women may value differently. Women of lower socioeconomic status (SES) diagnosed with early stage breast cancer are more likely to experience poorer doctor-patient communication, lower satisfaction with surgery and decision-making, and higher decision regret compared to women of higher SES. They often play a more passive role in decision-making and are less likely to undergo BCS. Our aim is to understand how best to support women of lower SES in making decisions about early stage breast cancer treatments and to reduce disparities in decision quality across socioeconomic strata., Methods: We will conduct a three-arm, multi-site randomized controlled superiority trial with stratification by SES and clinician-level randomization. At four large cancer centers in the United States, 1100 patients (half higher SES and half lower SES) will be randomized to: (1) Option Grid, (2) Picture Option Grid, or (3) usual care. Interviews, field-notes, and observations will be used to explore strategies that promote the interventions' sustained use and dissemination. Community-Based Participatory Research will be used throughout. We will include women aged at least 18 years of age with a confirmed diagnosis of early stage breast cancer (I to IIIA) from both higher and lower SES, provided they speak English, Spanish, or Mandarin Chinese. Our primary outcome measure is the 16-item validated Decision Quality Instrument. We will use a regression framework, mediation analyses, and multiple informants analysis. Heterogeneity of treatment effects analyses for SES, age, ethnicity, race, literacy, language, and study site will be performed., Discussion: Currently, women of lower SES are more likely to make treatment decisions based on incomplete or uninformed preferences, potentially leading to poorer decision quality, quality of life, and decision regret. This study hopes to identify solutions that effectively improve patient-centered care across socioeconomic strata and reduce disparities in decision and care quality., Trial Registration: NCT03136367 at ClinicalTrials.gov Protocol version: Manuscript based on study protocol version 2.2, 7 November 2017.

Introduction: CollaboRATE is a brief patient survey focused on shared decision making. This paper aims to (i) provide insight on facilitators and challenges to implementing a real-time patient survey and (ii) evaluate CollaboRATE scores and response rates across multiple clinical settings with varied patient populations., Method: All adult patients at three United States primary care practices were eligible to complete CollaboRATE post-visit. To inform key learnings, we aggregated all mentions of unanticipated decisions, problems and administration errors from field notes and email communications. Mixed-effects logistic regression evaluated the impact of site, clinician, patient age and patient gender on the CollaboRATE score., Results: While CollaboRATE score increased only slightly with increasing patient age (OR 1.018, 95% CI 1.014-1.021), female patient gender was associated with significantly higher CollaboRATE scores (OR 1.224, 95% CI 1.073-1.397). Clinician also predicts CollaboRATE score (random effect variance 0.146). Site-specific factors such as clinical workflow and checkout procedures play a key role in successful in-clinic implementation and are significantly related to CollaboRATE scores, with Site 3 scoring significantly higher than Site 1 (OR 1.759, 95% CI 1.216 to 2.545) or Site 2 (z=-2.71, 95% CI -1.114 to -0.178)., Discussion: This study demonstrates that CollaboRATE can be used in diverse primary care settings. A clinic's workflow plays a crucial role in implementation. Patient experience measurement risks becoming a burden to both patients and administrators. Episodic use of short measurement tools could reduce this burden., (© 2017 The Authors Health Expectations Published by John Wiley & Sons Ltd.)

Background: Mobility limitations among older adults increase the risk for disability and healthcare utilization. Rehabilitative care is identified as the most efficacious treatment for maintaining physical function. However, there is insufficient evidence identifying a healthcare model that targets prevention of mobility decline among older adults. The objective of this study is to evaluate the preliminary effectiveness of a physical therapy program, augmented with mobile tele-health technology, on mobility function and healthcare utilization among older adults., Methods: This is a quasi-experimental 12-month clinical trial conducted within a metropolitan-based healthcare system in the northeastern United States. It is in parallel with an existing longitudinal cohort study evaluating mobility decline among community-dwelling older adult primary care patients over one year. Seventy-five older adults (≥ 65-95 years) are being recruited using identical inclusion/exclusion criteria to the cohort study. Three aims will be evaluated: the effect of our program on 1) physical function, 2) healthcare utilization, and 3) healthcare costs. Changes in patient-reported function over 1 year in those receiving the intervention (aim 1) will be compared to propensity score matched controls (N = 150) from the cohort study. For aims 2 and 3, propensity scores, derived from logistic regression model that includes demographic and diagnostic information available through claims and enrollment information, will be used to match treatment and control patients in a ratio of 1:2 or 1:3 from a Medicare Claims Registry derived from the same geographic region. The intervention consists of a one-year physical therapy program that is divided between a combination of outpatient and home visits (6-10 total visits) and is augmented on a computerized tablet using of a commercially available application to deliver a progressive home-based exercise program emphasizing lower-extremity function and a walking program., Discussion: Incorporating mobile health into current healthcare models of rehabilitative care has the potential to decrease hospital visits and provide a longer duration of care. If the hypotheses are supported and demonstrate improved mobility and reduced healthcare utilization, this innovative care model would be applicable for optimizing the maintenance of functional independence among community-dwelling older adults., Trial Registration: ClinicalTrial.gov Identifier: NCT02580409 (Date of registration October 14, 2015).

Objective: Fatigue is a common condition contributing to disability among older patients. We studied self-reported task-specific fatigue and its relation with mobility task performance among community-dwelling primary care patients., Method: Cross-sectional analysis of baseline demographic and health data from a prospective cohort study of 430 primary care patients aged 65 years or older. Fatigue was measured using the Avlund Mobility-Tiredness Scale. Performance tasks included rising from a chair, walking 4 m, and climbing two flights of stairs., Results: Among demographic and health factors, pain was the only attribute consistently predictive of fatigue status. Self-reported chair rise fatigue and walking fatigue were associated with specific task performance. Stair climb fatigue was not associated with stair climb time., Discussion: Pain is strongly associated with fatigue while rising from a chair, walking indoors, and climbing stairs. This study supports the validity of self-reported chair rise fatigue and walking fatigue as individual test items.

Objectives: To validate trajectories of late-life mobility change using a novel approach designed to overcome the constraints of modest sample size and few follow-up time points., Methods: Using clinical reasoning and distribution-based methodology, we identified trajectories of mobility change (Late Life Function and Disability Instrument) across 2 years in 391 participants age ≥65 years from a prospective cohort study designed to identify modifiable impairments predictive of mobility in late-life. We validated our approach using model fit indices and comparing baseline mobility-related factors between trajectories., Results: Model fit indices confirmed that the optimal number of trajectories were between 4 and 6. Mobility-related factors varied across trajectories with the most unfavorable values in poor mobility trajectories and the most favorable in high mobility trajectories. These factors included leg strength, trunk extension endurance, knee flexion range of motion, limb velocity, physical performance measures, and the number and prevalence of medical conditions including osteoarthritis and back pain., Conclusions: Our findings support the validity of this approach and may facilitate the investigation of a broader scope of research questions within aging populations of varied sizes and traits., Competing Interests: AMJ declares stock in CREcare, LLC, a small business that disseminates outcome tools including the Late-Life Function and Disability Instrument. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background/aim: Given the need for access to patient-facing materials in multiple languages, this study aimed to develop and pilot test an accurate and understandable translation of CollaboRATE, a three-item patient-reported measure of shared decision-making, for Spanish-speaking patients in the United States (US)., Method: We followed the Translate, Review, Adjudicate, Pre-test, Document (TRAPD) survey translation protocol. Cognitive interviews were conducted with Spanish-speaking adults within an urban Massachusetts internal medicine clinic. For the pilot test, all patients with weekday appointments between May 1 and May 29, 2015 were invited to complete CollaboRATE in either English or Spanish upon exit. We calculated the proportion of respondents giving the best score possible on CollaboRATE and compared scores across key patient subgroups., Results: Four rounds of cognitive interviews with 26 people were completed between January and April 2015. Extensive, iterative refinements to survey items between interview rounds led to final items that were generally understood by participants with diverse educational backgrounds. Pilot data collection achieved an overall response rate of 73 percent, with 606 (49%) patients completing Spanish CollaboRATE questionnaires and 624 (51%) patients completing English CollaboRATE questionnaires. The proportion of respondents giving the best score possible on CollaboRATE was the same (86%) for both the English and Spanish versions of the instrument., Discussion: Our translation method, guided by emerging best practices in survey and health measurement translation, encompassed multiple levels of review. By conducting four rounds of cognitive interviews with iterative item refinement between each round, we arrived at a Spanish language version of CollaboRATE that was understandable to a majority of cognitive interview participants and was completed by more than 600 pilot questionnaire respondents., Competing Interests: GE reports personal fees from EMMI Solutions LLC, National Quality Forum, Washington State Health Department, and Radcliffe Press outside the submitted work. GE has initiated and led the Option Grid TM patient decisions aids collaborative, which produces and publishes patient knowledge tools, and has been a member of teams that have developed measures of shared decision--making and care integration which are published and available for use. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

To determine the difference in risk of developing diabetes for refugees, immigrants, and American-born participants living in the same communities, and to explore potential mediators of that difference. Retrospective longitudinal cohort from January 1, 2003 and December 31, 2013. Refugees aged ≥18 years were matched in a 1:3 ratio by age, gender, and date of care initiation to (1) Spanish-speaking non-refugee immigrants, and (2) English-speaking controls receiving care in the same community health center. We used proportional hazards regression to estimate the risk of incident diabetes. We tested whether differences in education or baseline obesity mediated diabetes risk using counterfactual mediation analysis. We included 3174 participants. Among refugee participants, the most common countries of origin were Somalia (17.8 %), Iraq (16.7 %) and Bhutan (8.8 %). Diabetes incidence rate was 1.94, 1.91, and 1.22 cases per 100 person-years follow-up for refugees, immigrants, and controls, respectively. In adjusted models, both refugee (HR 2.08 95 % CI 1.32-3.30) and immigrant (HR 1.51 95 % CI 1.01-2.24) statuses were associated with increased diabetes risk compared with controls. Risk between refugees and immigrants did not differ (adjusted HR for refugees 1.37 95 % CI 0.91-2.06). In mediation analyses, educational attainment mediated 36 % (p = 0.007) of the difference in diabetes risk between refugees/immigrants and controls. Baseline obesity did not mediate difference in diabetes risk (proportion mediated 1 %, p = 0.84). Refugees and immigrants had significantly increased risk for diabetes, partially mediated by education. Education-based lifestyle interventions may be a promising strategy to prevent diabetes for these vulnerable patients.

Objectives To determine use of recommended maternal healthcare services among refugee and immigrant women in a setting of near-universal insurance coverage. Methods Refugee women age ≥18 years, who arrived in the US from 2001 to 2013 and received care at the same Massachusetts community health center, were matched by age, gender, and date of care initiation to Spanish-speaking immigrants and US-born controls. The primary outcome was initiation of obstetrical care within the first trimester (12 weeks gestation). Secondary outcomes were number of obstetrical visits and attending a postpartum visit. Results We included 375 women with 763 pregnancies (women/pregnancies: 53/116 refugee, 186/368 immigrant, 136/279 control). More refugees (20.6 %) and immigrants (15.0 %) had their first obstetric visit after 12 weeks gestation than controls (6.0 %, p < 0.001). In logistic regression models adjusted for age, education, insurance, BMI, and median census tract household income, both refugee (odds ratio [OR] 4.58, 95 % confidence interval [CI] 1.73-12.13) and immigrant (OR 2.21, 95 % CI 1.00-4.84) women had delayed prenatal care initiation. Refugees had fewer prenatal visits than controls (median 12 vs. 14, p < 0.001). Refugees (73.3 %) and immigrant (78.3 %) women were more likely to have postpartum care (controls 54.8 %, p < 0.001) with differences persisting after adjustment (refugee [OR 2.00, 95 % CI 1.04-3.83] and immigrant [OR 2.79, 95 % CI 1.72-4.53]). Conclusions for Practice Refugee and immigrant women had increased risk for delayed initiation of prenatal care, but greater use of postpartum visits. Targeted outreach may be needed to improve use of beneficial care.

Despite increases in obesity and related diseases in developing nations, initial refugee clinical visits do not address these issues. We explored the development of obesity and related diseases in a longitudinal prospective cohort of African refugees resettling in northeastern US. Using state Department of Health data, refugees were linked to a health system. Body mass index, diabetes, hypertension, and hyperlipidemia status were extracted from charts. US regional controls from NAMCS/NHAMCS data were matched by age, sex, race, and visit year. African refugee BMI increased after resettlement at 1 (1.7 ± 2.9, p < 0.0001) and 5 years (3.1 ± 3.7, p < 0.0001), a different trend than matched regional controls (p = 0.01). Refugees had increased rates of diabetes (1.0 vs. 10.8 %, p < 0.0001), hypertension (16.7 vs. 21.6 %, p < 0.0001) and hyperlipidemia (3.9 vs. 10.8 %, p < 0.0001) at 5 years not observed in regional controls. Our findings emphasize the need for interventions during resettlement to prevent development of obesity and related disease in this vulnerable population.

Background: Women of low socioeconomic status (SES) diagnosed with early stage breast cancer are less likely to be involved in treatment decisions. They tend to report higher decisional regret and poorer communication. Evidence suggests that well-designed encounter decision aids (DAs) could improve outcomes and potentially reduce healthcare disparities. Our goal was to evaluate the acceptability and feasibility of encounter decision aids (Option Grid, Comic Option Grid, and Picture Option Grid) adapted for a low-SES and low-literacy population., Methods: We used a multi-phase, mixed-methods approach. In phase 1, we conducted a focus group with rural community stakeholders. In phase 2, we developed and administered a web-based questionnaire with patients of low and high SES. In phase 3, we interviewed patients of low SES and relevant healthcare professionals., Results: Data from phase 1 (n = 5) highlighted the importance of addressing treatment costs for patients. Data from phase 2 (n = 268) and phase 3 (n = 15) indicated that using both visual displays and numbers are helpful for understanding statistical information. Data from all three phases suggested that using plain language and simple images (Picture Option Grid) was most acceptable and feasible. The Comic Option Grid was deemed least acceptable., Conclusion: Option Grid and Picture Option Grid appeared acceptable and feasible in facilitating patient involvement and improving perceived understanding among patients of high and low SES. Picture Option Grid was considered most acceptable, accessible and feasible in the clinic visit. However, given the small sample sizes used, those findings need to be interpreted with caution. Further research is needed to determine the impact of pictorial and text-based encounter decision aids in underserved patients and across socioeconomic strata.

This selection from the NCCN Guidelines for Ovarian Cancer focuses on the less common ovarian histopathologies (LCOHs), because new algorithms were added for LCOHs and current algorithms were revised for the 2016 update. The new LCOHs algorithms include clear cell carcinomas, mucinous carcinomas, and grade 1 (low-grade) serous carcinomas/endometrioid epithelial carcinomas. The LCOHs also include carcinosarcomas (malignant mixed Müllerian tumors of the ovary), borderline epithelial tumors (also known as low malignant potential tumors), malignant sex cord-stromal tumors, and malignant germ cell tumors., (Copyright © 2016 by the National Comprehensive Cancer Network.)

Objective: To identify neuromuscular impairments most predictive of unfavorable mobility outcomes in late life., Design: Longitudinal cohort study., Setting: Research clinic., Participants: Community-dwelling primary care patients aged ≥65 years (N=391) with self-reported mobility modifications, randomly selected from a research registry., Interventions: Not applicable., Main Outcome Measures: Categories of decline in and persistently poor mobility across baseline, 1 and 2 years of follow-up in the Lower-Extremity Function scales of the Late-Life Function and Disability Instrument. The following categories of impairment were assessed as potential predictors of mobility change: strength (leg strength), speed of movement (leg velocity, reaction time, rapid leg coordination), range of motion (ROM) (knee flexion/knee extension/ankle ROM), asymmetry (asymmetry of leg strength and knee flexion/extension ROM measures), and trunk stability (trunk extensor endurance, kyphosis)., Results: The largest effect sizes were found for baseline weaker leg strength (odds ratio [95% confidence interval]: 3.45 [1.72-6.95]), trunk extensor endurance (2.98 [1.56-5.70]), and slower leg velocity (2.35 [1.21-4.58]) predicting a greater likelihood of persistently poor function over 2 years. Baseline weaker leg strength, trunk extensor endurance, and restricted knee flexion motion also predicted a greater likelihood of decline in function (1.72 [1.10-2.70], 1.83 [1.13-2.95], and 2.03 [1.24-3.35], respectively)., Conclusions: Older adults exhibiting poor mobility may be prime candidates for rehabilitation focused on improving these impairments. These findings lay the groundwork for developing interventions aimed at optimizing rehabilitative care and disability prevention, and highlight the importance of both well-recognized (leg strength) and novel impairments (leg velocity, trunk extensor muscle endurance)., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)