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Context: There have been multiple calls in the United States for public health workforce development approaches that expand practitioner skill sets to respond to profound inequities and improve population health more effectively. However, most workforce models address individual competencies that instead focus on collective approaches to systems change., Program: In response to this opportunity, the HRSA-funded Regional Public Health Training Centers (PHTCs) and the University of Illinois Chicago Policy, Practice, and Prevention Research Center (P3RC) released Creating a Learning Agenda for Systems Change: A Toolkit for Building an Adaptive Public Health Workforce (the Toolkit) in December 2020. We later supplemented the Toolkit with additional learning activities to launch the Learning Agenda Toolkit Pilot Test (Toolkit Pilot)., Implementation: From June to August 2021, 24 diverse teams piloted the Toolkit. Teams completed a multistep process simulating the development of a learning agenda aimed at addressing community health issues and impacting systems change., Evaluation: We conducted an evaluation process to assess the usability and impact of the Toolkit Pilot to inform its improvement and future implementation. An evaluation subcommittee analyzed worksheets completed by the Pilot Teams that are aligned to the Learning Agenda steps and conducted and analyzed 12 key informant interviews using concepts from the Toolkit Pilot Logic Model., Findings and Discussion: Evaluation results suggest that most Pilot Teams found that the Toolkit Pilot offered a step-by-step process toward a clear vision that produced a concrete product on how to address community challenges through learning and systems change. Pilot Teams noted that the Toolkit Pilot provided exposure to and a unique focus on systems thinking; however, prior knowledge of systems thinking and systems change was important. Building readiness for systems change and having more time, resources, and technical assistance would be needed for future versions of the Learning Agenda Toolkit., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Recently, there has been increasing evidence that reducing burnout in healthcare providers requires significant organizational efforts that include the integration of leadership strategies., Methods: Focus groups were conducted across four health systems within the University of Colorado Department of Medicine in four affinity groups (administrative staff, medical trainees, research faculty, and clinical faculty). Authentic leadership theory was used for analysis to advance the understanding of the role of leadership style upon participants' work experiences and preferences, and to identify opportunities for translation of site-specific results to other academic medical settings., Results: Study participants from each affinity group believed their clinical leaders lacked objectivity with decision-making (lacking "balancing processing"), which contributed to their overall feeling of powerlessness. The experience of increasing work demands was salient throughout all twelve focus groups, and participants identified leadership that interacted in a more open and self-disclosing manner ("relational transparency") as alleviating at least some of this burden. Strong preference discernable alignment between their leaders' decision-making and their internal moral compass of values (demonstrating "internalized moral perspective") was described, as was clinical leaders demonstrating "self-awareness" (having a self-reflective process that informs the leader's decision-making). Comparing affinity group experiences within each authentic leadership theory construct identified the relevance of contextual factors, such as work setting and roles, upon employees' perceptions and expectations of their leaders., Conclusions: Use of authentic leadership theory advanced the understanding of the association between leadership traits and experiences of burnout amongst a large group of academic clinicians, researchers, trainees, and administrative staff. Leadership styles that promoted relationship transparency, openness, and support were preferred and fostering these traits may help address the demands in academic medicine, including symptoms of burnout., (© 2022. The Author(s).)

Objective: Clinical trials are vital in the context of ovarian cancer and may offer further treatment options during disease recurrence, yet enrollment remains low. Understanding patient and family member experiences with identifying trials can inform engagement and education efforts., Methods: Interviews were conducted with 33 patients who had experience with clinical trial conversations and 39 nominated family members. Thematic analysis examined experiences and generated findings for clinical practice., Results: Trial conversations with providers at diagnosis were uncommon and often overwhelming. Most participants delayed engagement until later in the disease course. With hindsight, though, some wished they considered trials earlier. Difficulty identifying appropriate trials led some to defer searching to providers, but then they worried about missed opportunities. Most family members felt unqualified to search., Conclusion: Trial conversations during clinical encounters should start early and include specifying search responsibilities of providers, patients, and family. Patients and family members can be engaged in searches but need guidance., Practice Implications: Trials should be discussed throughout the disease course, even if patients are not ready to participate or are not making a treatment decision. Education should focus on identifying trials that meet search criteria. Transparency regarding each individual's role in identifying trials is critical., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background/aims: Some of the most promising avenues of cancer clinical investigation center on immunotherapeutic approaches. These approaches have provided notable gains in cancer therapeutics with recent Food and Drug Administration approvals of agents of this class in several types of cancers, although gains for ovarian cancer lag behind. This study examined perceptions of therapeutic trials including immunotherapy and virotherapy among ovarian cancer patients and their family members., Methods: A total of 72 semi-structured qualitative interviews were conducted with 33 patients and 39 family members at two National Cancer Institute-designated comprehensive cancer centers. Eligible patients were diagnosed with epithelial ovarian, primary peritoneal, or fallopian tube carcinoma and had experience with clinical trial conversations; family members were nominated by patients and interviewed separately. Applied thematic analysis was used to understand and interpret the data., Results: More participants were aware of vaccine trials than virus trials, although more than half had heard of at least one of them. Initial reactions to vaccine trials were generally favorable. For many, childhood experience with vaccines lent a familiar frame of reference. Virus trials elicited more negative initial reactions, including the use of adjectives such as "scary" and "dreadful." Viruses seemed contagious or difficult to control. Increased receptivity to these trials occurred in the context of limited therapeutic options and cancer recurrence. Most participants, including those not immediately drawn to these types of trials, indicated openness to learning more., Conclusion: Although vaccine and viral trials are both immunologically based therapeutic approaches, patients who are offered these trials may perceive their potential benefit and safety quite differently. There is a need to consider terminology, solicit and address "gut reactions," and provide information that enables patients and their family members to better understand the science behind these trials., Competing Interests: Declaration of conflicting interests The authors have disclosed the federal funding sources of the work. The authors declare that there is no conflict of interest. The corresponding author had full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis., (© The Author(s) 2016.)

Objectives: We sought to analyze the clinicopathologic features, recurrence patterns and survival outcomes of women with high-grade uterine cancer (UC) enrolled on The Gynecologic Oncology Group (GOG) LAP2 trial., Methods: This is a post-hoc analysis of LAP-2 patients with grade 3 endometrioid adenocarcinoma (ENDO), uterine serous (USC), clear cell (CC) and carcinosarcoma (CS). Demographics, clinicopathologic features, and recurrence patterns, were compared by histology and surgical approach. Progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan-Meier method., Results: Of the 2600 patients enrolled in LAP-2, 753 patients had high-grade UC: 350 had ENDO, 289 had USC, 42 had CC and 72 had CS. Compared with the ENDO cohort, those with other high-grade subtypes were older (p<0.001) and were more likely to have positive peritoneal cytology (p<0.001), positive lymph nodes (p=0.05) and higher disease stage on final pathology (p<0.001). With a median follow-up time of 60months, compared to patients with ENDO, those with USC, CCC and CS subtypes had higher recurrence rates (p<0.001), extra-pelvic recurrences (p<0.001) and poorer PFS (p<0.001) and OS (p<0.001). Those diagnosed with USC and CS experienced the worst survival outcomes (p=0.003). Patterns of recurrence and survival were not different in those staged with LSC vs LAP. On multivariable analysis, age, stage, pelvic washings and Type II histology were independently and adversely associated with survival., Conclusions: Women with apparent early-stage, USC and CS histologies have poorer outcomes than women with grade 3 endometrioid adenocarcinoma. Patterns of recurrence and survival were not impacted by surgical approach., Competing Interests: Dr. Nick Spirtos receives per capita reimbursement to the Women's Cancer Center, travel supplement as Gyn Onc Committee Chair, co-operative research funding on a per capita basis from GOG Foundation, Inc., and royalties from Wiley Health Services for Bonney's Gynaecological Surgery. Dr. Michael Pearl receives grant money from the GOG/NRG. He also serves as a consultancy for Ethicon, provided expert testimony for legal expert review, and has grants/grants pending from NIH, small foundations, as well as royalties from VitaTex. Dr. David O'Malley serves as a consultant for Yondelis on the Sarcoma Advisory Board, AstraZeneca on the Ovarian Cancer Advisory Board, Clovis on the Ovarian Cancer Advisory Board, Genentech/Roche on the Ovarian Cancer Advisory Board and Eisai on the Advisory Board. Dr. Robert Mannel receives grant monies from GOG-LAP2 grant. He also serves on the Advisory Board as a consultant for Medimmune, Oxigene, Endocyte, Bayer and Clovis. All other coauthors have no conflicts of interest to declare., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives: To evaluate and compare the ability of DW-MRI and CT to detect sites of peritoneal dissemination in gynecologic malignancies. The reproducibility of DW-MRI and CT interpretation between radiologists was also assessed., Methods: Single institution prospective cohort study of women with suspected advanced gynecologic cancer who underwent surgical staging from 2010 to 2013. Participants underwent both DW-MRI and contrast-enhanced CT prior to surgery. Radiologists and surgeons were blinded, respectively, to surgical and DW-MRI results. The area under the receiver operator characteristic curve (AUC) was calculated for each disease site for CT and DW-MRI and compared to surgical findings. Kappa statistics quantified interobserver agreement between both radiologists., Results: Twenty seven patients were enrolled. Mean age at surgery was 59years. Ninety percent of participants had stage IIIC/IV disease. For right diaphragm disease, the AUC for DW-MRI was 0.95 compared to 0.81 for CT. For left diaphragm disease, the AUC was 0.89 for DW-MRI compared to 0.74 for CT. The AUC was similar for DW-MRI and CT for omental disease (0.79 versus 0.64); the liver surface (0.61 versus 0.67); bowel mesentery (0.73 versus 0.64); and cul de sac (0.75 versus 0.64). Interobserver agreement for DW-MRI was greater than CT for omental, Morrison's pouch, liver surface, and right diaphragm disease., Conclusions: DW-MRI detects right diaphragmatic disease found at surgery with greater accuracy than CT. For other disease sites key to surgical planning, DW-MRI is equivalent to CT. Interobserver agreement was superior for a majority of disease sites evaluated by DW-MRI compared to CT., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Radical prostatectomy (RP) is most commonly performed laparoscopically with a robot (robotic-assisted laparoscopic radical prostatectomy, R/PROST). Hysterectomy, which may be open hysterectomy (O/HYST) or laparoscopic hysterectomy (L/HYST), has been increasingly frequently done via robot (R/HYST). Small case series suggest increased corneal abrasions (CAs) with less invasive techniques., Methods: The authors identified RP (166,942), O/HYST (583,298), or L/HYST (216,890) discharges with CA in the Nationwide Inpatient Sample (2000-2011). For 2009-2011, they determined odds ratios (ORs) and 95% confidence intervals (CIs) for CA, in R/PROST, non-R/PROST, L/HYST, O/HYST, and R/HYST. Uni- and multivariate models studied CA risk depending on surgical procedure, age, race, year, chronic illness, and malignancy., Results: In 2000-2011, 0.18% RP, 0.13% L/HYST, and 0.03% O/HYST sustained CA. Compared with 17,554 non-R/PROSTs (34 abrasions, 0.19%) in 2009-2011, OR was not significantly higher in 28,521 R/PROSTs (99, 0.35%; OR 1.508; CI 0.987 to 2.302; P < 0.057). CA significantly increased in L/HYST (70/51,323; 0.136%) versus O/HYST (70/191,199; 0.037%; OR 3.821; CI 2.594 to 5.630; P < 0.0001), further increasing in R/HYST (63/21, 213; 0.297%; OR 6.505; CI 4.323 to 9.788; P < 0.0001). For hysterectomy, risk of CA increased with age (OR 1.020; CI 1.007 to 1.034; P < 0.003) and number of chronic conditions (OR 1.139; CI 1.065 to 1.219; P < 0.0001). CA risk was likewise elevated in R/HYST with number of chronic conditions. Being African American significantly decreased CA risk in R/PROST and in R/HYST or L/HYST., Conclusions: L/HYST increased CA nearly four-fold, and R/HYST approximately 6.5-fold versus O/HYST. Identifiable preoperative factors are associated with either increased risk (age, chronic conditions) or decreased risk (race).

Objectives: To describe patterns of response to, and assess sexual function and activity elicited by, a self-administered assessment incorporated into a new patient intake form for gynecologic oncology consultation., Methods: A cross-sectional study of patients presenting to a single urban academic medical center between January 2010 and September 2012. New patients completed a self-administered intake form, including six brief sexual activity and function items. These items, along with abstracted medical record data, were descriptively analyzed. Logistic regression was used to assess the association between sexual activity and function and disease status, adjusting for age., Results: Median age was 50 years (range 18-91, N=499); more than half had a final diagnosis of cancer. Most patients completed all sex-related items on the intake form; 98% answered at least one. Among patients who were sexually active in the prior 12 months (57% with cancer, 64% with benign disease), 52% indicated on the intake form having, during that period, a sexual problem lasting several months or more. Of these, 15% had physician documentation of the sexual problem. Eighteen women were referred for care. Providers reported no patient complaints about the inclusion of sexual items on the intake form., Conclusions: Nearly all new patients presenting for gynecologic oncology consultation answered self-administered items to assess sexual activity and function. Further study is needed to determine the role of pre-treatment identification of sexual function concerns in improving sexual outcomes associated with cancer diagnosis and treatment., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: Women with abnormal cervical cancer screening results are referred to colposcopy and biopsy for diagnosis of cervical cancer precursors (high-grade squamous intraepithelial lesions [HSILs]). Colposcopy with a single biopsy can miss identification of HSILs. No systematic study has quantified the improved detection of HSIL by taking multiple lesion-directed biopsies., Methods: The Biopsy Study was an observational study of 690 women referred to colposcopy after abnormal cervical cancer screening results. Up to four directed biopsies were taken from distinct acetowhite lesions and ranked by colposcopic impression. A nondirected biopsy of a normal-appearing area was added if fewer than four directed biopsies were taken. HSIL identified by any biopsy was the reference standard of disease used to evaluate the incremental yield and sensitivity of multiple biopsies., Results: In the overall population, sensitivities for detecting HSIL increased from 60.6% (95% CI, 54.8% to 66.6%) from a single biopsy to 85.6% (95% CI, 80.3% to 90.2%) after two biopsies and to 95.6% (95% CI, 91.3% to 99.2%) after three biopsies. A significant increase in sensitivity of multiple biopsies was observed in all subgroups. The highest increase in yield of HSIL was observed for women with a high-grade colposcopic impression, HSIL cytology, and human papillomavirus (HPV) type 16 positivity. Only 2% of all HSILs diagnosed in the participants were detected by biopsies of normal-appearing transformation zone., Conclusion: Collection of additional lesion-directed biopsies during colposcopy increased detection of histologic HSIL, regardless of patient characteristics. Taking additional biopsies when multiple lesions are present should become the standard practice of colposcopic biopsy., (© 2014 by American Society of Clinical Oncology.)

Objective: The objective of the current study was to describe outcomes among women with low-grade abnormalities on cervical cytology screening in the setting of previous excisional or ablative treatment for cervical intraepithelial neoplasia (CIN)., Methods: Study participants were recruited into the Study to Understand Cervical Cancer Early Endpoints and Determinants. At enrollment, the patient's previous cytology results, previous colposcopic biopsy results, and previous cervical procedures were recorded. Study procedures included collection of biospecimens followed by colposcopy and biopsy. From clinical records, additional information regarding previous treatment for CIN was collected., Results: Two hundred seventy-four women had an atypical squamous cells of uncertain significance (ASCUS) referral Pap and 532 women had a low-grade squamous intraepithelial lesion (LSIL) referral Pap. For patients with an ASCUS referral Pap, previous treatment was associated with an odds ratio for CIN 2+ (45.0% vs 28.2% of untreated patients) of 2.08 (95% confidence interval = 1.05-4.13, p = .04). For patients with an LSIL referral Pap, 33.3% of those women with previous treatment had CIN 2+ compared with 16.7% of those patients enrolled with no previous treatment (odds ratio = 2.49, 95% confidence interval = 1.12-5.51, p = .03)., Conclusions: Patients with a history of previous treatment for CIN have a 2-fold risk of CIN 2+ at the time of colposcopy referral for ASCUS or LSIL cervical cytology.

Minimum surgical treatment for endometrial cancer is removal of the uterus. The operative approach to achieve that goal ranges from vaginal hysterectomy alone to laparotomy with radical hysterectomy, bilateral salpingoophorectomy, bilateral pelvic and para-aortic lymphadenectomy with possible omentectomy, and resection of all metastatic disease. Stratifying the risk factors for predicting presence of metastatic disease has error rates exceeding tolerance for many gynecologic oncologists. Most accept routine laparoscopic surgical staging with hysterectomy, pelvic and para-aortic lymphadenectomy, and removal of adnexa as standard care for patients with endometrial cancer. Modifying the extent of surgical staging for low-risk intrauterine findings or excessive risk for postoperative morbidity is also accepted. Laparoscopic surgery has become the ideal initial surgical approach for this disease, allowing for visual inspection of common metastatic sites, biopsy of abnormal areas, and cytology from peritoneal surfaces. The extent of staging can be altered depending on frozen section findings from the uterus, adnexa, and peritoneal surfaces. Intraoperative medical decision-making can be individualized, encompassing all known risk factors for metastases and balancing comorbidities and potential adverse outcomes. This article documents how laparoscopic surgery satisfies the needs of individual patients and surgeons treating this disease.

Background: American Indian women's historically low breast cancer incidence and mortality rates have gradually increased such that in many parts of the United States they equal "U.S. All Races" rates. Thus, American Indian women need screening to maintain their low rates., Methods: In an outreach program, local American Indian women were trained as lay health advisers, "Native Sisters," to locate and contact American Indian women in the Denver metropolitan area and provide education and encouragement to increase participation in mammography screening. Participation was monitored and interviews collected descriptive information and information about risk factors for breast cancer. An interrupted-time-series design was used to assess changes in mammography participation., Results: The NAWWA program increased recruitment of American Indian women (p < 0.05). Women recruited by the Native Sisters were more likely to be currently on hormone replacement therapy and to be menopausal., Conclusions: The lay health adviser program was effective in recruiting American Indian women to have screening mammography. Barriers to participation were complex and often involved cultural values and beliefs.

Background: Cancer is becoming a significant health problem for American Indians and Alaska Natives. Despite the precipitous increase in cancer rates in these populations, limited data are available regarding the extent of cancer control services available in these communities., Methods: A cross-sectional survey of tribal health directors of all federally recognized tribes was undertaken to discover the breadth of cancer control activities offered and directors' perceptions of and priorities ascribed to cancer., Results: Little more than half (53%) of respondents perceived cancer rates to be increasing. Cancer was found to rank fifth among seven health conditions when directors were asked to rank their tribe's commitment to confronting each. Lower relative levels of awareness of cancer patterns coupled with competing health problems relegated cancer control activities to low-priority issues., Conclusions: Findings from this study underscore the need to elevate the issue of cancer in Indian Country and to educate investigators to become more sensitive and responsive to other tribal health issues.

Background: The results of preconference and postconference surveys, as well as conference evaluation forms, distributed to attendees at the "Native American Cancer Conference III: Risk Factors, Outreach and Intervention Strategies," Seattle, Washington, June 16-19, 1995, are presented., Methods: Conference attendees were requested to complete a multi-item survey designed to assess knowledge and perceptions relating to cancer among native peoples at the beginning and end of the conference. The evaluation instrument solicited qualitative impressions of the conference., Results: Survey respondents were predominantly female (70%), and approximately half were native persons representing 48 different American Indian and Alaska Native communities. Knowledge levels were generally high at baseline for most items relating to cancer, with evidence of significant improvement for several items on the postconference survey. The majority of respondents believed that cancer was of equal importance compared with other health problems and that cancer services for American Indians and Alaska Natives are generally less extensive compared with the majority population; there was no evidence of opinion change noted in the postconference survey. Results from the qualitative evaluation expressed the unique and affirmative experiences among participants in terms of the social, cultural, and informational sharing that occurred., Conclusions: It is hoped that the positive experiences of conference attendees will serve to stimulate the organization of similar programs and the design of research projects that both assess and expand cancer control services among Native peoples.

Background: Based on the lack of published information regarding Native Americans and cancer and the success of previous meetings, the Network for Cancer Control Research among American Indian and Alaska Native Populations (NCCR-AIANP) and the Native Hawaiian and American Samoan Cancer Research Network determined there was sufficient need to have annual national Native American cancer conferences., Methods: The NCCR-AIANP, the Native Hawaiian and American Samoan Cancer Research Network, and the AMC Native American Cancer Research Program collaborated to organize the third national Native American cancer conference, "Native American Cancer Conference III: Risk Factors, Outreach and Intervention Strategies.", Results: The conference was held in Seattle, Washington, June 16-19, 1995. It provided a forum for scientific discussion and dissemination of information related to cancer prevention and control., Conclusions: Conference participants benefited from the topics presented and the diversity of the audience members. There continues to be a need to share what is happening in cancer research with this unique population and to address new issues of concern. A cancer conference seems to be a useful mechanism to provide such an opportunity.

Background: Cancer has become a significant health concern in American Indian communities. Over the past several decades Native peoples have experienced significant increases in life expectancy and, with these gains, significant increases in cancer incidence and mortality. Limited data are available concerning cancer-control activities accessible to American Indian communities. Even less is known about control programs in place for American Indians resident in urban areas, where more that half of all Native peoples reside., Methods: To ascertain the extent of available services and perceptions of health directors, a survey of all Indian-Health-Service-recognized urban clinics was undertaken., Results: Results indicate that the cancer needs of American Indians resident in urban areas are not being adequately addressed. Only one-third of urban health directors reported perceived increases in cancer incidence and mortality rates. The directors ranked cancer fifth among seven health problems in terms of their clinics' commitment to addressing them. Findings from this study are juxtaposed with whose obtained in a separate survey of reservation-based health directors., Conclusions: Results indicate a need to develop more responsive cancer-control programs in Indian country and to sensitize researchers to other health needs of these communities.

Cancer has become a significant health problem in American Indian and Alaskan Native (AI/AN) communities. Despite the precipitous rise in cancer rates, limited data are available concerning cancer control services operative in these communities. To address this issue, a cross-sectional survey of all federally recognized tribes was undertaken to ascertain the breadth of cancer control activities offered and Tribal Health Directors perceptions of and priorities ascribed to cancer. This article presents responses given by AN Health Directors juxtaposed to those proffered by AI Health Directors. Nearly three-quarters (71%) of respondents perceived cancer rates to be increasing. Cancer was found to rank third, fifth among AI Health Directors, among seven health conditions when Directors were asked to rank their Tribe's commitment to confronting each one. Awareness of cancer as a public health concern coupled with competing health problems relegates cancer control activities to a lower priority. Findings underscore the need to elevate the issue of cancer in Indian Country as well as to educate investigators to become more sensitive and responsive to other Tribal health issues.

Recruitment of ethnic or racial minority subjects for health intervention research is a methodologic challenge. A recruitment plan that consisted of a feasibility analysis, recruitment strategies and activities, and evaluation was developed and used for a smoking cessation study of pregnant Latinas. Specific recruitment recommendations for similar research consist of a thorough feasibility analysis, developing partnerships with target groups and community members, using active face-to-face recruitment, and using process evaluation techniques.