Advancing Health Equity in Cancer-Related Distress: Lessons Learned From the COVID-19 Pandemic on Leveraging Digital Tools and Future Directions.

espanolLa politica europea de energia lleva varios anos en primera linea de actuacion de la UE. Su incorporacion al Tratado de Lisboa, asi como su relacion estrecha con otras politicas de la UE tales como competencia, mercado interior, tecnologia o medio ambiente, han convertido a la energia en un actor principal en lo que respecta a la accion y legislacion europeas y hay que mencionar las politicas y actuacion en el campo internacional, incluida la ayuda al desarrollo. No debe olvidarse en este contexto el transporte como gran consumidor de energia y uno de los mayores responsables de emision de gases de efecto invernadero. Tampoco hay que dejar de lado la tecnologia como tal. Las tres dimensiones de la politica de energia, competitividad, sostenibilidad y seguridad de abastecimiento, estan al mismo nivel de importancia, pero el equilibrio que se establezca entre las tres necesita decisiones politicas cuidadosas, que no suponen necesariamente alcanzar los optimos individuales de manera separada. La dimension exterior habria de anadirse a las tres anteriores. La UE persigue ejercer un cierto liderazgo mundial en relacion con sus objetivos para los horizontes 2020 y 2050. EnglishEuropean energy policy has been at the forefront of EU action for several years now. Its inclusion in the Lisbon Treaty, as well as its connection with other key EU policies such as competition, internal market, technology or environment, has made energy a major player in terms of EU action and legislation, let alone in its international policies and action including development aid. Transport as a major energy user - and greenhouse gas emitter - should not be forgotten in this context. Neither should technology as such. The three pillars of energy policy, that is to say competitiveness, sustainability, and security of supply are on an equal footing, but the balance to be struck between them requires delicate political set-offs, which means that the optimum objective for each of them separately is unlikely to be attainable. A pillar on external relations should also be added to the former three. The EU pursues exert world leadership in view of its 2020 and 2050 objectives.

Embedding Racial Justice and Advancing Health Equity at the American Medical Association

Cancer-related distress (CRD) is frequently observed in rural settings and may have been exacerbated during the COVID-19 pandemic. We examined pre and post COVID-19 changes in CRD among individuals treated for thoracic cancers at a rural cancer center. Patient demographics, clinical information, and CRD measures derived from the National Comprehensive Cancer Network psychosocial distress problem list were abstracted from electronic medical records for thoracic oncology patients treated at a rural Michigan cancer center before (January 1, 2019-January 1, 2020; n=139) and during (January 20, 2020-January 31, 2021; n=84) the COVID-19 pandemic. CRD scores were calculated by summing theitems on the problem lists, and the prevalenceof CRD was examined bothoverall and by specificsources of distress (practical, emotional, social, and physical concerns). We assessed changes in CRD overall and by type using chi-square tests, Fisher's exact tests, and multivariable logistic regression models. CRD prevalence increased by 9.1% during vs. before the pandemic (97.6% vs. 88.5%; p=0.02), with thelargest increases evident for emotional (82.1% vs. 64.0%; p=0.004) and physical (82.1% vs. 67.6%; p=0.02) concerns. CRD scores were slightly higher during vs. before the pandemic, but the differences were not significant (all p-values≥0.05). Compared to those treated in the year prior, patients treated during the pandemic had higher odds of elevated CRD (OR (95% CI) =1.86 (1.1, 3.2)), and practical concerns (OR (95% CI) =2.19 (1.3, 3.8)). Findings from this preliminary study suggest an increased prevalence of CRD among rural thoracic oncology patients treated during compared to before the COVID-19 pandemic.

National Comprehensive Cancer Network Guidelines: Who Makes Them? What Are They? Why Are They Important?

Cancer-related psychosocial distress is defined by the National Comprehensive Cancer Network (NCCN) as a multifactorial unpleasant experience of a psychological, social, spiritual, and/or physical nature that may interfere with the ability to cope effectively with cancer, its physical symptoms, and its treatment. Cancer-related psychological distress is common in patients, and it has been implicated in increasing mortality risk. Findings from prior studies suggest that individuals undergoing cancer treatment in rural areas experience greater psychosocial distress than their urban counterparts. Given healthcare access barriers in rural areas, the COVID-19 pandemic may present an even greater strain on these patients. However, the impact of COVID-19 on psychosocial distress among rural cancer patients is unclear. Thus, the objective of this study was to examine changes in psychosocial distress among rural thoracic oncology patients before and after the onset of COVID-19. We also examined whether demographic, geographic, or clinical factors were associated with overall distress within this population. All thoracic oncology patients treated at Cowell Family Cancer Center (CFCC) in rural Michigan from January 1, 2019 through January 1, 2020 (pre-COVID-19, n=139) and from January 1, 2020 through January 31, 2021 (during COVID-19, n=84) were included in this study. Data on patient demographics, degree of rurality, cancer site, and NCCN psychosocial distress measures were abstracted from the electronic medical records. We assessed differences in participant characteristics and psychosocial distress measures between the pre-COVID and during COVID groups using Chi-square, Fisher’s exact, and t-tests. Using multivariable logistic regression models, we estimated odds ratios and 95% CI for associations between participant characteristics and psychosocial distress. Overall psychosocial distress scores were higher during COVID-19 versus before the pandemic (6.5 vs. 5.8, p=0.045). Differences in specific problems contributing to psychosocial distress were also observed. For example, participants were more likely to report being worried about needing help with daily tasks (25.0% vs. 8.6%, p=.001), fear and worry about the future (60.7% vs. 40.3%, p=.003), feeling more dependent on others (45.2% vs. 33.1%, p=.07), and changes in urination (14.3% vs. 5.0%, p=0.02) during vs. before the pandemic. Being single was associated with higher psychosocial distress compared to married individuals (OR=5.29, 95% CI=1.12, 24.7), while age, distance to hospital, rurality, sex, and occupational status were not significant predictors. Findings from this study suggest increases in psychosocial distress among rural thoracic oncology patients during the COVID-19 pandemic. Further research is needed to characterize the impact of COVID-19 on overall distress and quality of life among cancer patients. Citation Format: Sierra Silverwood, Kelly Hirko. Exploring the impact that COVID-19 had on patient distress in a rural cancer center [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 442.

The Future of Nursing 2020–2030: Charting a path to achieve health equity

1577 Background: Cancer related distress can be seen in as many as one in two patients. Many organizations such as the Commission on Cancer require distress screening. National Comprehensive Cancer Network (NCCN) distress thermometer is a common tool used for screening. We studied feasibility of embedding the NCCN thermometer into oncology electronic health record (EHR) for routine patient care. We concurrently studied feasibility of using a mobile health tool for serial evaluation of cancer related distress. Methods: A flowsheet containing NCCN distress thermometer questions was created in Epic EHR (Epic Systems, Verona, WI). Oncology nurses used the flowsheet for routine patient assessment. Patients with distress level ≥ 4 answered additional questions. Ancillary care providers such as palliative care nurses or social workers addressed the identified needs by providing appropriate ‘services’. A field to capture these interventions was created. We also adapted our previously reported web based mobile tool [1] for monitoring cancer distress. Patients rated their distress on a 1-10 scale and highlighted the distress domain (physical, emotional, practical, family). Distress level ≥ 4 generated a color-coded flag for provider review and intervention. Data from both electronic tools was periodically analyzed to inform patient care and quality improvement. Results: Between January and December 2021, Epic EHR based distress flowsheet collected 28,594 distinct responses in 911 patients. 57.4%, 14.9%, 14.1%, 9.4% and 2.3% of the responses were in the physical, emotional, practical, familial and spiritual domains respectively. ‘Other’ responses were 1.4%. Cumulative frequency of non-physical problems was 42.5%. 1819 ‘services’ were provided with 357 emotional, 351 work, 351 housing, 350 transportation and 350 financial need-based interventions. Of 1231 patients who used the distress scale and provided additional comments, 315 (25.5%) had distress levels ≥ 4. The mobile tool captured 849 unique patient responses to the distress question between April 2020 and February 2022. Distress level ≥ 4 was flagged by 281 unique patients (33.09%). Average distress level was 2.7. Emotional domain problems generated the greatest distress level followed by family, physical and practical problems in decreasing order. Conclusions: We demonstrate feasibility of electronic capture of cancer related distress to facilitate holistic patient care in a community-based oncology program. EHR based and mobile tool distress evaluations generated concordant results. Distress caused by emotional, practical and familial domain problems was nearly as frequent and often more severe than distress caused by physical problems, underscoring the need for comprehensive cancer care.

NCCN Highlights Best Practices for Challenges in Oncology

11070 Background: Financial conflict of interest (FCOI) among authors of clinical practice guidelines is a potential concern for the independence and integrity of guideline recommendations. The National Comprehensive Cancer Network (NCCN) Guidelines policy stipulates limits on physician-industry FCOI among its panelists (<$50,000 overall and <$20,000 from each individual company, annually). Those in violation will be asked to resign. However, COI policies reliant on physician self-report may be difficult to enforce. The increased transparency of FCOI resulting from Open Payments – and the ensuing attention in 2016 on high levels of FCOI among guideline-writing bodies including the NCCN – may have enabled and motivated increased enforcement of existing FCOI policy. We describe trends in FCOI among NCCN Guidelines panelists and in enforcement when violations occur. Methods: We manually extracted NCCN Guidelines panelist names and terms of service for the 20 most prevalent cancers, 2013-22. We manually linked each physician to their Open Payments records, a federal archive of financial transactions from industry to physicians. For each panelist, we included only the categories of industry payments deemed relevant by the NCCN COI policy: ownership payments and some General Payments categories (eg., speaking fees, consulting) but not others (eg., free meals). We measured payments during each full calendar year of service. If a panelist received payments above NCCN limits (“violation”), we assessed whether their term of service continued for at least 1 additional full calendar year (“retained"), inferring that panelists who were retained had not been asked to resign as stipulated. We assessed whether retention post-violation was less likely after 2016. Results: There were 978 eligible physician-guideline pairs. Mean industry payments increased from $6175 in 2014 to $9169 in 2019, then declined to $6492 in 2021 following the COVID-19 pandemic. There were 143 panelist-years in violation of NCCN FCOI limits. Violations occurred among 99 unique panelists; 32 panelists had multiple observed violations. Across the full study period, panelists with a violation were less likely to be retained versus those without a violation (OR 0.21, 95% CI 0.15-0.31). However, likelihood of post-violation retention was lower after 2016 compared to before. 81% were retained during 2014-15 (versus 89% for those without violation, OR 0.55, 95% CI 0.26-1.31) compared to 47% during 2017-20 (versus 89% without violation, OR 0.10, 95% CI 0.06-0.17). Conclusions: Lower retention among panelists receiving excessive industry payments is consistent with NCCN enforcement of its COI policy. Lower post-violation retention after 2016 is consistent with stricter enforcement following that year. However, even in 2017-20, in 47% of violations, the panelist continued to serve, suggesting that enforcement remains incomplete.

Precision Adjuvant Therapy Based on Detailed Pathologic Risk Factors for Resected Oral Cavity Squamous Cell Carcinoma: Long-Term Outcome Comparison of CGMH and NCCN Guidelines

Veterans who live with cancer need comprehensive care. The National Comprehensive Cancer Network and the American College of Surgeons Commission on Cancer guidelines recommend evaluating distress and providing appropriate follow-up to all patients with cancer. We created patient-centered, collaborative clinics to screen for and address cancer-related distress. Medical oncologists received education about available supportive services and instructions on how to make referrals. Participants completed the Coleman Supportive Oncology Collaborative screening questions. Patients in this outpatient US Department of Veterans Affairs medical oncology clinic were primarily older, African American men. Most veterans screened positive for ≥ 1 type of cancer-related distress. Patients screened for high levels of distress received in-person clinical follow-up for further evaluation and to make immediate referrals to supportive care services. We evaluated patients' needs, made referrals as needed, and helped bring care directly into the oncology clinic. Using a screening tool for cancer-related distress and managing distress with integrated psychosocial providers could improve care coordination and enhance patient-centered supportive oncology care, especially for high-risk patients. A full-time social worker was integrated into the medical oncology clinics based on our program's success.

To describe the solutions community health nurses (CHNs) identify to address health inequities during the COVID-19 pandemic and to explore what leadership competencies enable CHNs to enact these solutions. Online survey, distributed to all members of the Community Health Nurses of Canada and associated provincial and territorial networks. Inclusion criteria included all nurses who were working during the COVID-19 pandemic in Canada. A total of 245 responses were included in the analysis. The survey included 25 open ended and fixed response questions. Descriptive statistics were used to describe the quantitative data. Framework Analysis was used to analyze the qualitative data. Solutions focused on advancing health equity and expanding community relationships and partnerships were identified as priorities. To enact these solutions system transformation, engaging others, and developing coalitions were identified as the main leadership competencies required by CHNs. Participants in this study clearly articulated structural and process solutions to address health inequities among priority populations during the pandemic. CHNs described with practice knowledge and confidence that solutions enacted in system transformation with community partners are necessary to advance health equity.

Health disparities persist, posing significant health, social and economic challenges. Digital health technologies (DHTs) present a promising opportunity to address these inequities and advance health equity. Despite this potential, a comprehensive and structured overview of existing frameworks and guidelines on advancing health equity and a clear understanding of the potential of DHTs in their implementation to systematically close the healthcare gap is yet to be done. To this end, our objectives are twofold: first, to identify frameworks and guidelines that promote health equity and second, to pinpoint the role of DHTs as an avenue for their implementation. We conducted a scoping review informed by Arksey and O'Malley's five-stage framework, methodological guidelines by the Joanna Briggs Institute and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. A comprehensive search was conducted across seven databases on 6 December 2023: PubMed, EMBASE, Cochrane, PsycINFO, Scopus, Web of Science and WISO. We included primary and secondary studies published in English between 2010 and 2023 focusing on advancing health equity for priority populations. For the analysis, we applied multistaged coding approaches to answer our twofold objective. The search identified 6419 studies, of which 38 met our final inclusion criteria and were included in this review. We extracted 559 recommendations on advancing health equity and synthesised these into 82 distinct recommendations across five levels of initiative and 19 areas of initiative. Thereby, 24% of the included studies explicitly mentioned the use of (digital) technology with 10 impact opportunities on advancing health equity. Our synthesis offers key insights into the advancement of health equity across different levels of initiative and the role of DHTs in their implementation. This offers practitioners and researchers alike a comprehensive overview to make health equity advancement more tangible and actionable. https://osf.io/94pht.

Purpose: A strong family history (FH) of CRC is an important risk factor for the disease as well as a potential source of cancer-related stress and distress. Colonoscopy is the recommended screening test in people with a strong FH of CRC. Little is known about adherence to colonscopy screening, perceptions of CRC risk and cancer-related distress in this population. Aims: To determine screening rates, perceived CRC risk and cancer-related stress and distress in members of high risk CRC families and to determine if these parameters vary by demographic factors. Methods: Baseline data was analyzed from the Family Health Promotion Project, a multi-center randomized intervention trial designed to promote colonoscopy in members of families at high risk for CRC. Two National Cancer Institute funded registries (Colorectal Cancer Family Registry and Cancer Genetics Network) were used to recruit unaffected members of families that met the Amsterdam II criteria for HNPCC and high risk (HR) families (one member with CRC under age 60 or >2 FDRs with CRC that do not meet Amsterdam II criteria). 632 participants (166 HNPCC and 466 HR) completed a baseline questionnaire which included questions about demographics, colonoscopy screening rates, perceived CRC risk as well as measures of cancer related stress and distress using the Impact of Events Scale (IES). Results: The overall rate of adherence to current colonoscopy screening recommendations was 52% and 44% in the HNPCC and HR groups respectively. 68% of the HNPCC group thought their risk was much higher and 79% of the HR group thought their risk was either much (24%) or a little (35%) higher than people without a FH of CRC. 18% of the HNPCC group and 44% of the HR group reported moderate to high levels of stress related to their FH of CRC. Higher levels of stress in both groups were more commonly found in women than men (p<.0001) and in participants with a lower income (p=.01). Very high levels of cancer related distress (IES scores >20; a level that usually prompts a counseling referral) were reported by 28% of the HNPCC group and 30% of the HR group. IES scores >20 in both groups were more commonly found in women than men (37 vs. 16%, p<0.0001), in participants with lower income (p=.02), lower levels of education (p=.0003) and in those without health insurance (69 vs. 27%, p=.03). Conclusion: Unaffected members of high risk CRC families generally recognized they are at risk for the disease but had relatively low rates of adherence to colonoscopy screening guidelines. Additionally, high levels of cancer-specific distress and stress are present in this population, particularly in women and lower SES groups.

Rural health departments face unique challenges in advancing health equity, particularly during times of political polarization. These challenges intensified during the COVID-19 pandemic, highlighting the complex interplay between public health authorities, political dynamics, and community trust. To document how a rural local county health department (LCHD) navigated political barriers and systemic inequities to conduct a community health assessment (CHA) during and after the COVID pandemic. This CHA, conducted during 2021-2023, employed mixed methods data collection strategies: a bilingual community survey, listening sessions in English and Spanish, and informal interviews. Utilizing a health equity lens, the analysis focused on identifying power dynamics, systemic barriers, and community perspectives on health. Survey data revealed differences between Hispanic and non-Hispanic respondents' health concerns and perceived barriers. Healthcare access was the only statistically significant barrier for Hispanic respondents. Lessons learned from the CHA process are provided. The strategies employed during the CHA demonstrate how rural health departments can advance health equity while navigating complex political landscapes. Success requires careful attention to language, strategic coalition building, and persistent focus on elevating marginalized voices. The LCHD built community trust despite political resistance by modifying language around equity issues and strategic coalitions.