Preventive Services Task Force Guidelines Research Articles

Abstract A146: Racial/ethnic differences in the relationship between human papillomavirus vaccination status and up-to-date Papanicolaou tests

Abstract Background: Human papillomavirus (HPV) vaccination and routine Papanicolaou (Pap) testing can prevent morbidity and mortality associated with cervical cancer (CC). Research suggests women who have initiated and completed the HPV vaccine are more likely to have an up-to-date Pap test than women who are unvaccinated against HPV. Limited research has focused on whether the association between HPV vaccination and Pap testing varies based on the number of HPV vaccine doses received across racial/ethnic groups. Methods: We conducted a cross-sectional analysis of 2018 – 2022 Behavioral Risk Factor Surveillance System data to investigate the relationship between HPV vaccination status and having an up-to-date Pap test by race/ethnicity. Based on the Advisory Committee on Immunization Practices’ (ACIP) guidelines, women who received 0 doses of the HPV vaccine were unvaccinated, women who received 1 or 2 doses initiated the vaccine series, and women who received 3 doses completed the HPV vaccine series. Based on the United States Preventive Services Task Force guidelines, women were considered to have an up-to-date Pap test if they reported having one within the past 3 years. We used weighted multivariable logistic regression models to examine the association. Results: Most women (n = 14,615) were unvaccinated (82.9%) and had an up-to- date Pap test (75.5%). Non-Hispanic White (NHW) women had the highest rate of HPV vaccine series completion (11.8%), followed by non-Hispanic Other (NHO) women (11.2%), non- Hispanic Black (NHB) women (8.6%), and Hispanic women (8.3%). NHW women also had the highest rate of up-to-date Pap test (78.8%). NHB women had the second highest rate (77.6%), followed by Hispanic women (67.8%), and NHO women (66.4%). In adjusted analyses, NHO women were 34% less likely to have an up-to-date Pap test than NHW women (OR, 0.66; 95% CI: 0.51-0.86). Compared to unvaccinated women, those who completed and initiated the HPV vaccine series were more likely to have an up-to-date Pap test (initiated: OR: 1.40, 95% CI: 1.04-1.87; completed: OR:1.77, 95% CI: 1.35-2.34). NHB and NHO women who initiated the HPV vaccine series were more likely to have an up-to-date Pap test (NHB: OR: 3.37, 95% CI: 1.65-6.85; NHO: OR: 3.21, 95% CI: 1.73-5.95). NHW women who completed the HPV vaccine series were more likely to have an up-to-date Pap test (OR: 2.19, 95% CI: 1.55-3.08). Conclusion: NHB and NHO women who initiated the HPV vaccine series were three times as likely to have an up-to-date Pap test; NHW women who have completed the HPV vaccine series were twice as likely to receive an up-to-date Pap test. Women who do not receive Pap tests or the HPV vaccine miss important CC prevention opportunities. Thus, relevant stakeholders should aim to improve HPV vaccination rates; doing so could potentially enhance Pap test adherence simultaneously. This may be especially important for NHB and NHO women as they have lower rates of Pap test adherence and HPV vaccine series completion. Citation Format: Elinita Pollard, Meng-Han Tsai, Minjee Lee, Alice W. Lee, Mary A. Gerend. Racial/ethnic differences in the relationship between human papillomavirus vaccination status and up-to-date Papanicolaou tests [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr A146.

Through the Looking Glass Darkly: How May AI Models Influence Future Underwriting?

Applications of Artificial Intelligence (AI) deep-learning models to screening for clinical conditions continue to evolve. Instances provided in this treatise include using a simple one-view PA chest radiograph to screen for Type 2 Diabetes Mellitus (T2DM), congestive heart failure, valvular heart disease, and to assess mortality in asymptomatic persons with respiratory diseases. This technology incorporates hundreds of thousands of CXRs into a convoluted neural network and is generally named AI CXR. As an example, the AUROC (Area Under Receiving Operator Characteristic) of screening for T2DM was 0.84, with sensitivity and specificities that exceed those of the United States Preventative Services Task Force (USPSTF) guidelines for screening with HBA1c or blood glucose studies. The AUROC's for diagnosing ejection fractions less than 40% was 0.92, and for detecting valvular heart diseases was 0.87. The potential implications for underwriting life and disability policies may be significant. A companion article in the Journal of Insurance Medicine addresses this same technology using a simple 12-lead ECG, generally named AI ECGs.

Culturally Competent Education and Human Papillomavirus Self-Sampling Achieves Healthy People 2030 Cervical Screening Target Among Low-Income Non-Hispanic Black and Hispanic Women.

Disparities in cervical cancer screening, incidence, and mortality exist in the United States. Cervical cancer incidence and mortality rates in Texas are 20% and 32% higher, respectively, than national averages. Within Texas, these rates are significantly higher among non-Hispanic (NH) Black and Hispanic women. Cervical cancer screening uptake is lower among NH Black and Hispanic women (72.9% and 75.9%, respectively) compared with White women (85.5%) in Texas. During March-August 2023, we conducted a pilot study that offered culturally competent education and human papillomavirus (HPV) self-sampling kits to women in two public housing projects in Houston, TX, that have predominantly NH Black or Hispanic residents. Among those eligible for cervical cancer screening, 35% (n = 24) of the NH Black and 34% (n = 16) of the Hispanic women were found to be underscreened per the US Preventive Services Task Force Guideline. We recruited 40 (24 NH Black and 16 Hispanic) eligible women for our study. The study was approved by the MD Anderson institutional review board and registered with ClinicalTrials.gov (NCT04614155-March 11, 2020). Seventy-five percent of the NH Black and 87% of the Hispanic participants completed the HPV self-sampling procedures per protocol. Samples of 17% NH Black and 12% Hispanic participants showed a performance error. Overall, cervical cancer screening uptake improved from 65% to 91% among NH Black and from 66% to 96% among Hispanic participants. Culturally competent education and HPV self-sampling resulted in remarkable improvement in cervical cancer screening uptake among underscreened NH Black and Hispanic women residents of Houston public housing projects. Implementing this strategy could significantly reduce cervical cancer incidence and mortality among similar populations in the United States and globally.

Non-use and inadequate use of cervical cancer screening among a representative sample of women in the United States.

Women's adherence to the United States (U.S.) Preventive Services Task Force guidelines for cervical cancer screening was determined by examining predisposing, enabling, and needs factors from Andersen's Behavioral Model of Health Services Use conceptual framework. The outcome was operationalized as cervical cancer screening use, non-use, and inadequate-use. Multinomial logistic regression was conducted on data from the 2019 National Health Interview Survey of 7,331 eligible women aged 21-65. Compared with women who used cervical cancer screening services, women aged 30-65 were less likely to be Non-Users than those aged 21-29. Hispanic, Asian, and American Indian/Alaska Native (AIAN) women were more likely to be Non-Users than White women. More educated women were less likely to be Non-Users. Foreign-born women <10 years in the U.S. were more likely to be Non-Users than U.S.-born women. Women with financial hardship were less likely to be Non-Users. Poorer women and uninsured women were more likely to be Non-Users. Women with children in their household were less likely to be Non-Users than those without children. Women who had a well-visit in the past year were less likely to be Non-Users. Women with a history of human papillomavirus (HPV) vaccination were less likely to be Non-Users. Compared with women who used cervical cancer screening services, women aged 30-65 were less likely to be Inadequate-Users. AIAN women were more likely to be Inadequate-Users. Women of other races were less likely to be Inadequate-Users. Employed women were less likely to be Inadequate-Users. Uninsured women were more likely to be Inadequate-Users. Women who had a well-visit within a year were less likely to be Inadequate-Users. Women with past HPV vaccination were more likely to be Inadequate-Users. Smokers were less likely to be Inadequate-Users. Predisposing, enabling, and needs factors are differently associated with non-use and inadequate use of cervical cancer screening. Understanding factors associated with the use, non-use, and inadequate use of cervical cancer screening is crucial to avoid or curb unnecessary tests, increased costs to both society and individuals, and the ill-allocation of limited resources.

A multi-cancer early detection blood test using machine learning detects early-stage cancers lacking USPSTF-recommended screening.

US Preventive Services Task Force (USPSTF) guidelines recommend single-cancer screening for select cancers (e.g., breast, cervical, colorectal, lung). Advances in genome sequencing and machine learning have facilitated the development of blood-based multi-cancer early detection (MCED) tests intended to complement single-cancer screening. MCED tests can interrogate circulating cell-free DNA to detect a shared cancer signal across multiple tumor types. We report real-world experience with an MCED test that detected cancer signals in three individuals subsequently diagnosed with cancers of the ovary, kidney, and head/neck that lack USPSTF-recommended screening. These cases illustrate the potential of MCED tests to detect early-stage cancers amenable to cure.

Pack-Year Smoking History: An Inadequate and Biased Measure to Determine Lung Cancer Screening Eligibility.

Pack-year smoking history is an imperfect and biased measure of cumulative tobacco exposure. The use of pack-year smoking history to determine lung cancer screening eligibility in the current US Preventive Services Task Force (USPSTF) guideline may unintentionally exclude many high-risk individuals, especially those from racial and ethnic minority groups. It is unclear whether using a smoking duration cutoff instead of a smoking pack-year cutoff would improve the selection of individuals for screening. We analyzed 49,703 individuals with a smoking history from the Southern Community Cohort Study (SCCS) and 22,126 individuals with a smoking history from the Black Women's Health Study (BWHS) to assess eligibility for screening under the USPSTF guideline versus a proposed guideline that replaces the ≥20-pack-year criterion with a ≥20-year smoking duration criterion. Under the USPSTF guideline, only 57.6% of Black patients with lung cancer in the SCCS would have qualified for screening, whereas a significantly higher percentage of White patients with lung cancer (74.0%) would have qualified (P < .001). Under the proposed guideline, the percentage of Black and White patients with lung cancer who would have qualified for screening increased to 85.3% and 82.0%, respectively, eradicating the disparity in screening eligibility between the groups. In the BWHS, using a 20-year smoking duration cutoff instead of a 20-pack-year cutoff increased the percentage of Black women with lung cancer who would have qualified for screening from 42.5% to 63.8%. Use of a 20-year smoking duration cutoff instead of a 20-pack-year cutoff greatly increases the proportion of patients with lung cancer who would qualify for screening and eliminates the racial disparity in screening eligibility between Black versus White individuals; smoking duration has the added benefit of being easier to calculate and being a more precise assessment of smoking exposure compared with pack-year smoking history.

Abstract 4803: Cancer screening, knowledge, and fatalism among Chinese, Korean, and South Asian residents of New York City

Abstract Background: Asian New York City (NYC) residents have the lowest screening rates by race across cancer type. Past studies indicate heterogeneity within the Asian American population, yet few have examined differences in screening uptake and related factors among Asian ethnic subgroups in NYC. Further, cancer screening knowledge and cancer fatalism have been found to impact cancer screening uptake, and effects vary by race, ethnicity, immigration status, and cancer type. Objective: Our study aimed to examine differences in cancer screening uptake, knowledge, and fatalism among Chinese, Korean, and South Asian NYC adults and to examine the effects of cancer screening knowledge and cancer fatalism on cancer screening uptake. Methods: We used data from NYU Langone Perlmutter Cancer Center’s Cancer Community Health Resources and Needs Assessment survey. The survey was developed and distributed in 10 languages in collaboration with 23 community partners. Data were collected from NYC adults with recruitment strategies focused on immigrant and non-English language preference communities from Oct. 2021 - Dec. 2022. Multivariable logistic and multinomial regression analyses were used to examine differences in breast, cervical, and colorectal cancer (CRC) screening uptake; breast and CRC screening knowledge; and cancer fatalism between Chinese, Korean, and South Asian (Bangladeshi, Pakistani, Asian Indian, and Nepali) adults; and to examine the effects of breast and CRC screening knowledge on breast and CRC screening uptake and cancer fatalism on breast, cervical, and CRC screening uptake (n=1,045). Analyses were restricted by age and sex using United States (U.S.) Preventive Services Task Force guidelines. Results: The sample was 60.0% female with a mean age of 45.7 years; 83.1% of participants were born outside of the U.S., 49.9% of participants were Chinese, 22.8% were Korean, and 27.3% were South Asian. Korean women had 0.52 (95%CI: 0.31, 0.88) times lower odds of Pap test uptake than Chinese women; South Asian adults had 0.44 (95%CI: 0.24, 0.80) times lower odds of CRC screening uptake than Chinese adults. Korean adults had 1.68 (95%CI: 1.17, 2.41) times higher odds of knowing the correct age to begin having mammograms compared to Chinese adults; South Asian adults had 0.66 (95%CI: 0.46, 0.94) times lower odds of knowing the correct age to begin CRC screening compared to Chinese adults. Korean adults had a 0.39 (95%CI: 0.25, 0.63) and 0.22 (95%CI: 0.13, 0.37) times lower odds of some and high cancer fatalism, respectively, compared to Chinese adults. No associations were found between cancer screening knowledge or cancer fatalism and cancer screening uptake. Conclusions: Our study adds to the current literature on the diversity of cancer needs, beliefs, and behaviors among Asian Americans. The findings indicate the need for ethnic-specific cultural tailoring for future cancer screening interventions. Citation Format: Isabel I. Curro, Chloe A. Teasdale, Laura Wyatt, Yousra Yusuf, Victoria Foster, Sonia Sifuentes, Perla Chebli, Julie A. Kranick, Simona C. Kwon, Chau Trinh-Shevrin, Madison N. LeCroy. Cancer screening, knowledge, and fatalism among Chinese, Korean, and South Asian residents of New York City [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4803.

Abstract 4786: Colorectal cancer screening rates among deaf, deafblind, and hard of hearing adults aged 45 to 75 years old

Abstract Background: Deaf, deafblind, and hard of hearing (DDBHH) individuals who use American Sign Language (ASL), a subpopulation of the disability, experience disparities concerning cancer screening and cancer-related health outcomes. For this study, we explored colorectal cancer screening rates among DDBHH survey respondents in comparison to rates found in the hearing population. Materials and Methods: Using the National Cancer Institute Health Information National Trends Survey in ASL (Kushalnagar et al., 2015), we surveyed participants 18+ years old using the Center for Deaf Health Equity at Gallaudet University’s database of over 2,500 DDBHH participants from all over the USA, including Hawaii and Puerto Rico. We used the U.S. Preventive Services Task Force (USPSTF) guidelines’ age cutoffs to assess adherence to colorectal cancer screenings. Results: Survey response rate within three weeks of mail out in July 2023 was 12%. A total of 405 DDBHH adult participants answered screening questions for colorectal cancer in ASL and English. Overall, 43.7% self-reported screening adherence for age-eligible (45-75 years) colorectal cancer screening; 54.7% reported never having a colorectal cancer screening. Similarly-aged hearing adults reported 58.7% adherence in the English version of the National Health Interview Survey (NHIS). Discussion: With the 43.7% adherence rate, the DDBHH community is lagging behind colorectal cancer screenings compared to the general population of hearing adults. Estimating the colorectal cancer screening rates among the DBHH community and understanding the reasons for these existing disparities is important to achieve screening adherence of 68.3%, the target set by the Healthy People 2030. Such research will aid the Center for Deaf Health Equity to actively work with the community to improve strategies to increase colorectal cancer screening. Citation Format: Regina M. Wang, Sowmya R. Rao, Erika J. Bergeron, Emmanuel C. Perrodin-Njoku, Poorna Kushalnagar. Colorectal cancer screening rates among deaf, deafblind, and hard of hearing adults aged 45 to 75 years old [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4786.

Revisiting the lung cancer screening eligibility criteria to promote equity for Black individuals

BackgroundEarly detection using low-dose computed tomography reduces lung-cancer-specific mortality by 20% among high-risk individuals. Blacks are less likely than Whites to meet lung cancer screening (LCS) criteria under both the former and the updated United States Preventive Services Task Force (USPSTF) guidelines. The purpose of this study was to assess racial disparities in LCS eligibility and to propose tailored eligibility criteria for Blacks to enable equitable screening rate between Whites and Blacks. MethodsData for this study were obtained from the Behavioral Risk Factor Surveillance System (2017–2021). 101,552 subjects were included in the final analysis. By employing a systematic approach, we sought cut-off points at which Blacks were equally likely as Whites to be eligible for LCS. We evaluated the minimum age and smoking pack-years for Blacks while we retained the 2021 USPSTF criteria for Whites. The final decision was based on the minimum Wald’s Chi-square statistics. ResultsThe model we employed identified cut-off points at which Blacks were equally likely as Whites to be eligible for LCS. Retaining the 2021 USPSTF criteria for Whites, the model discovered a new pair of points for Blacks by reducing the minimum age to 43 years and decreasing the cumulative number of cigarettes smoked to 15 pack-years. Based on these cut-off points, we created tailored criteria for Blacks. Under the tailored criteria, Blacks (OR: 1.00; 95 %CI: 0.88–1.14) had the same odds of eligibility for LCS as Whites. The odds of eligibility for LCS by sex under the tailored criteria did not differ significantly for Black men (OR: 1.02; 95 %CI: 0.85–1.24) and Black women (OR: 0.95; 95 %CI: 0.81–1.12) compared to their respective White counterparts. ConclusionsThese tailored criteria for Blacks eliminate the disparities between Blacks and Whites in LCS eligibility. Future studies should test the sensitivity and specificity of these tailored criteria.

Changes in Health Care Access and Preventive Health Screenings by Race and Ethnicity

The COVID-19 pandemic led to unprecedented disruptions in health care. Little is known about whether health care access and preventive health screenings among US adults have recovered to prepandemic levels, and how patterns varied by race and ethnicity. To evaluate health care access and preventive health screenings among eligible US adults in 2021 and 2022 compared with prepandemic year 2019, overall and by race and ethnicity. This cross-sectional study used data from US adults aged 18 years or older who participated in the National Health Interview Survey in 2021 and 2022. Survey weights provided by the National Health Interview Survey were used to generate nationally representative estimates. Data were analyzed from May 23 to November 13, 2023. Measures of health care access included the proportion of adults with a usual place for care, those with a wellness visit, and those who delayed or did not receive medical care due to cost within the past year. Preventive health screening measures included eligible adults who received blood pressure, cholesterol, or blood glucose screening within the past year (2021), as well as colorectal, cervical, breast, and prostate cancer screenings based on US Preventive Services Task Force guidelines. The unweighted study population included 89 130 US adults. The weighted population included 51.6% females; 16.8% Hispanic, 5.9% non-Hispanic Asian (hereafter, Asian), 11.8% non-Hispanic Black (hereafter, Black), 62.8% non-Hispanic White (hereafter, White) individuals; and 2.9% individuals of other races and ethnicities (including American Indian, Alaska Native, Native Hawaiian or other Pacific Islander, or multiracial). After adjusting for age and sex, having a usual place for health care did not differ among adults in 2021 or 2022 vs 2019 (adjusted rate ratio [ARR] for each year, 1.00; 95% CI, 0.99-1.01). However, fewer participants had wellness visits in 2022 compared with 2019 (ARR, 0.98; 95% CI, 0.97-0.99), with the most pronounced decline among Asian adults (ARR, 0.95; 95% CI, 0.92-0.98). In addition, adults were less likely to delay medical care (ARR, 0.79; 95% CI, 0.73-0.87) or to not receive care (ARR, 0.76; 95% CI, 0.69-0.83) due to cost in 2022 vs 2019. Preventive health screenings in 2021 remained below 2019 levels (blood pressure: ARR, 0.95 [95% CI, 0.94-0.96]; blood glucose: ARR, 0.95 [95% CI, 0.93-0.96]; and cholesterol: ARR, 0.93 [95% CI, 0.92-0.94]). Eligible adults were also significantly less likely to receive colorectal cancer screening (ARR, 0.88; 95% CI, 0.81-0.94), cervical cancer screening (ARR, 0.86; 95% CI, 0.83-0.89), breast cancer screening (ARR, 0.93; 95% CI, 0.90-0.97), and prostate cancer screening (ARR, 0.86 [0.78-0.94]) in 2021 vs 2019. Asian adults experienced the largest relative decreases across most preventive screenings, while Black and Hispanic adults experienced large declines in colorectal cancer screening (ARR, 0.78; 95% CI, 0.67-0.91) and breast cancer screening (ARR, 0.83; 95% CI, 0.75-0.91), respectively. Differences in preventive screening rates across years persisted after additional adjustment for socioeconomic factors (income, employment status, and insurance coverage). Results of this cohort study suggest that, in the US, wellness visits and preventive health screenings have not returned to prepandemic levels. These findings support the need for public health efforts to increase the use of preventive health screenings among eligible US adults.

Improving Lung Cancer Screening at an Academic Medical Center.

Lung cancer ranks as the third most prevalent cancer in the United States. The use of low-dose computed tomography (LDCT) screening significantly reduces mortality from this disease. Unfortunately, Texas lags in completing lung cancer screening (LCS) for high-risk patients, ranking 48th among all states. It is crucial to implement quality improvement (QI) initiatives in Texas. In collaboration with the American Cancer Society, the primary care center (PCC) at our institution led a multidisciplinary QI project aimed at enhancing LCS through LDCT for eligible PCC patients. The study included patients eligible for screening and who fall into the following categories: established patients with Medicaid, low-income or uninsured established patients, and established patients with either Medicare or commercial insurance. Enhancements to electronic medical records, education for clinical staff and patients, and a coordinated, multidisciplinary effort were implemented. The study revealed a substantial 40.2% improvement in LCS rates. The US Preventive Services Task Force guidelines rely on an accurate history of patient's tobacco use to identify patients eligible for LCS. This QI project achieved success in improving the thoroughness of tobacco use history documentation and surpassed our target for increasing LCS by more than 10%.

Quantifying the Value of Reduced Health Disparities: Low-Dose Computed Tomography Lung Cancer Screening of High-Risk Individuals Within the United States

ObjectiveThis study aimed to measure the value of increasing lung cancer screening rates for high-risk individuals and its impact on health disparities. MethodsThe model estimated changes in health economic outcomes if low-dose computed tomography screening increased from current to 100% compliance, following clinical guidelines. Current low-dose computed tomography screening rates were estimated by income, education, and race, using 2017-2019 Behavioral Risk Factor Surveillance System data. The model contained a decision tree module to segment the population by screening outcomes and a Markov chain module to estimate cancer progression over time. Model parameters included information on survival, quality of life, and costs related to cancer diagnosis, treatment, and adverse events. Distributional cost-effectiveness analysis estimated the net monetary value from reduced health disparities—measured using quality-adjusted life expectancy—across income, education, and race groups. Outcomes were assessed over 30 years. ResultsLung cancer screening eligibility using US Preventive Services Task Force guidelines was higher for individuals with income <$15 000 (47.2%) and without a high-school education (46.1%) than individuals with income >$50 000 (16.6%) and with a college degree (13.5%), respectively. Increasing lung cancer screening to 100% compliance was cost-effective ($64 654 per quality-adjusted life-year) and produced economic value by up to $560 per person ($182.1 billion for United States overall). Up to 32.2% of the value was due to reductions in health disparities. ConclusionsSignificant value in increasing lung cancer screening rates derived from reducing health disparities. Policy makers and clinicians may not be appropriately prioritizing cancer screening if value from reducing health disparities is unconsidered.

Machine learning-based prediction of abdominal aortic aneurysms for individualized patient care

ObjectiveThe United States Preventative Services Task Force guidelines for screening for abdominal aortic aneurysms (AAA) are broad and exclude many at risk groups. We analyzed a large AAA screening database to examine the utility of a novel machine learning (ML) model for predicting individual risk of AAA. MethodsWe created a ML model to predict the presence of AAAs (>3 cm) from the database of a national nonprofit screening organization (AAAneurysm Outreach). Participants self-reported demographics and comorbidities. The model is a two-layered feed-forward shallow network. The ML model then generated AAA probability based on patient characteristics. We evaluated graphs to determine significant factors, and then compared those graphs with a traditional logistic regression model. ResultsWe analyzed a cohort of 10,033 patients with an AAA prevalence of 2.74%. Consistent with logistic regression analysis, the ML model identified the following predictors of AAA: Caucasian race, male gender, advancing age, and recent or past smoker with recent smoker having a more profound affect (P < .05). Interestingly, the ML model showed body mass index (BMI) was associated with likelihood of AAAs, especially for younger females. The ML model also identified a higher than predicted risk of AAA in several groups, including female nonsmokers with cardiac disease, female diabetics, those with a family history of AAA, and those with hypertension or hyperlipidemia at older ages. An elevated BMI conveyed a higher than expected risk in male smokers and all females. The ML model also identified a complex relationship of both diabetes mellitus and hyperlipidemia with gender. Family history of AAA was a more important risk factor in the ML model for both men and women too. ConclusionsWe successfully developed an ML model based on an AAA screening database that unveils a complex relationship between AAA prevalence and many risk factors, including BMI. The model also highlights the need to expand AAA screening efforts in women. Using ML models in the clinical setting has the potential to deliver precise, individualized screening recommendations.

FACTORS ASSOCIATED WITH LOW-DOSE COMPUTED TOMOGRAPHY LUNG CANCER SCREENING IN THE UNITED STATES

Abstract Low-dose computed tomography (LDCT) screening is recommended for high-risk smokers to decrease lung cancer-related mortality. In the US, the uptake of LDCT screening among eligible smokers is suboptimal. The impacts of social-environmental and individual factors on LDCT screening uptake are not clear. The current study investigated multi-level factors associated with the utilization of LDCT screening using national data. Methods: The 2017-2021 Behavioral Risk Factor Surveillance System (BRFSS) data and other state-level variables (Medicaid expansion status and the number of screening facilities) were applied. Our study outcome is the utilization of LDCT screening among study participants who met the US Preventive Services Task Force guidelines for lung cancer screening. The final study sample consisted of 15640 respondents from 29 states. All analyses were weighted to account for the complex sampling design applied in BRFSS. Results: The overall utilization rate of LDCT screening is only 18.4%. The LDCT utilization rate varied by state (6.2 -31.1%). Among the respondents, individuals who were employed, never married, had good health status, didn’t have personal physician, experienced cost problems, never had routine checkups, and did not experience certain chronic conditions (cancer, asthma, COPD) had a lower utilization rate of LDCT screening compare with their counterpart. Conclusion: Utilization of LDCT screening among eligible smokers remains low. Risk factors associated with LDCT screening identified from this study can be used to guide future lung cancer screening programs or revise the LDCT screening guidelines to meet the needs of high-risk smokers.

Clinician and patient perspectives on screening mammography among women age 75 and older: A pilot study of a novel decision aid

Supporting patient-clinician communication is key to implementing tailored, risk-based screening for older adults. Objectives of this multiphase mixed methods study were to identify factors that primary care clinicians consider influential when making screening mammography recommendations for women ≥ 75 years, develop a patient decision aid that incorporates these factors, and gather feasibility and acceptability from the patients' perspective. Clinicians from a Mid-Atlantic practice network completed online surveys. Women in the same network completed surveys before and after receiving a tailored booklet that included information about the benefits and harms of screening for women ≥ 75 years, a breast cancer risk-estimate, and a question prompt list to support patient-clinician communication. Clinicians (N = 21) were primarily women [57.1%] and practiced family medicine [81.0%]. They cited patients' age ≥ 75 years [95.4%], comorbidity [86.4%], functional status [77.3%], cancer family history [63.6%], U.S. Preventive Services Task Force guidelines [81.8%] and new research [77.3%] as factors influencing their recommendations. Fourteen women completed baseline surveys and received personalized decision aids (Mean age = 79.1 years). Eleven completed the post-intervention survey. All were satisfied with the booklet length, 81.8% found the booklet easy to understand and 72.7% helpful in decision-making Perceived lifetime breast cancer risk decreased significantly from pre- to post-intervention (p = 0.02). Results suggest this decision aid, which incorporates key decisional factors from the clinician's perspective, is feasible and acceptable to patients. A tailored decision aid booklet is innovative as it provides information on personalized risk and potential benefits and harms to older women considering screening.

Abstract B148: Colorectal cancer screening uptake and test use for individuals with diabetes in the U.S.: Implications for health equity

Abstract Purpose: Individuals with diabetes mellitus have an estimated 27% elevated risk of developing colorectal cancer (CRC) and are disproportionately from health disparities populations. This study examined associations of race and ethnicity and CRC screening uptake and CRC test type used among individuals with diabetes to identify factors to consider in targeting CRC screening efforts to promote health equity. Methods: Merged Medical Expenditures Panel Survey Household Component (2012-2018) and National Health Interview Survey data sets were used to identify individuals with diabetes (non-Hispanic White (NHW) n=223,046; Hispanic n=54,791; Non-Hispanic Black (NHB) n=54,791). The main outcomes were self-reported up-to-date CRC screening based on United States Preventive Services Taskforce guidelines and screening test used (i.e., blood-stool test or direct visualization). The main independent variable of interest was race and ethnicity. Logistic regression models included socio-demographic and health-related co-variates. Results: Among individuals with diabetes 62.6% reported being up-to-date (UTD) with CRC screening, among the screened 5.8% used blood stool tests only and 56.8% used direct visualization tests. In the final logistic model comparing relative risk of UTD screening to being unscreened, NHBs were more likely to be UTD for CRC screening [RR: 1.3, 95% CI: 1.13-1.53, p=0.001] compared to NHWs. Individuals with no high school degree [RR: 0.8, 95% CI: 0.65-0.99, p=0.3] were less likely to be UTD compared to college educated individuals. Individuals receiving recommended diabetes care were less likely to be unscreened [RR: 0.84, 95% CI: 0.76-0.94, p=0.002]. Among screened individuals, race and ethnicity were insignificant in final models. Low-income individuals were less likely to be screened with direct visualization [RR: 0.73, 95% CI: 0.55-0.97, p=0.03] compared to high-income individuals. Overweight individuals (BMI 26-29) were less likely to be screened with direct visualization [RR:0.75, 95% CI:0.57-0.99, p=0.41] compared to individuals with BMI ≤25. Individuals with five or more comorbidities were more likely to be screened using direct visualization [RR: 3.45, 95% CI: 1.86, 6.43, p&amp;lt;0.001] compared to individuals with 1-2 comorbidities. Conclusions: Among individuals with diabetes, social determinants and health factors associated with UTD and testing type differed. Race, education, and diabetes care quality were determinants of receipt of any UTD CRC testing. Among those screened, lower income and overweight individuals were more likely to use stool-based testing and those with greater comorbidity burdens were more likely to be screened with direct visualization. Efforts to improve CRC screening for patients with diabetes, specifically those in the primary care safety-net, should consider these factors when tailoring CRC prevention and early detection efforts. Citation Format: Denalee M. O'Malley, Pamela Ohman-Strickland, Tracy Andrews, Cilgy Abraham, Benjamin F. Crabtree, Shawna V. Hudson, Anita Y. Kinney. Colorectal cancer screening uptake and test use for individuals with diabetes in the U.S.: Implications for health equity [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr B148.

Rationale, design, and protocol for a hybrid type 1 effectiveness-implementation trial of a proactive smoking cessation electronic visit for scalable delivery via primary care: the E-STOP trial

BackgroundCigarette smoking remains the leading cause of preventable disease and death in the United States. Primary care offers an ideal setting to reach adults who smoke cigarettes and improve uptake of evidence-based cessation treatment. Although U.S. Preventive Services Task Force Guidelines recommend the 5As model (Ask, Advise, Assess, Assist, Arrange) in primary care, there are many barriers to its implementation. Automated, comprehensive, and proactive tools are needed to overcome barriers. Our team developed and preliminarily evaluated a proactive electronic visit (e-visit) delivered via the Electronic Health Record patient portal to facilitate evidence-based smoking cessation treatment uptake in primary care, with promising initial feasibility and efficacy. This paper describes the rationale, design, and protocol for an ongoing Hybrid Type I effectiveness-implementation trial that will simultaneously assess effectiveness of the e-visit intervention for smoking cessation as well as implementation potential across diverse primary care settings.MethodsThe primary aim of this remote five-year study is to examine the effectiveness of the e-visit intervention vs. treatment as usual (TAU) for smoking cessation via a clinic-randomized clinical trial. Adults who smoke cigarettes are recruited across 18 primary care clinics. Clinics are stratified based on their number of primary care providers and randomized 2:1 to either e-visit or TAU. An initial baseline e-visit gathers information about patient smoking history and motivation to quit, and a clinical decision support algorithm determines the best evidence-based cessation treatment to prescribe. E-visit recommendations are evaluated by a patient’s own provider, and a one-month follow-up e-visit assesses cessation progress. Main outcomes include: (1) cessation treatment utilization (medication, psychosocial cessation counseling), (2) reduction in cigarettes per day, and (3) biochemically verified 7-day point prevalence abstinence (PPA) at six-months. We hypothesize that patients randomized to the e-visit condition will have better cessation outcomes (vs. TAU). A secondary aim evaluates e-visit implementation potential at patient, provider, and organizational levels using a mixed-methods approach. Implementation outcomes include acceptability, adoption, fidelity, implementation cost, penetration, and sustainability.DiscussionThis asynchronous, proactive e-visit intervention could provide substantial benefits for patients, providers, and primary care practices and has potential to widely improve reach of evidence-based cessation treatment.Trial registrationNCT05493254.

Long-Term Impact of Medicaid Expansion on Prostate Cancer Screening.

Prostate cancer is the most common noncutaneous malignancy in men. The updated PSA testing 2018 United States Preventive Services Task Force guidelines recommend shared decision-making for men ages 55 to 69. In 2010, the Affordable Care Act expanded Medicaid coverage to childless adults earning < 138% of the federal poverty level. Thereafter, individual states have chosen to adopt or defer Medicaid expansion at different times. This allows for the opportunity to study the effects of expansion on a population that did not previously qualify for Medicaid. We examine the long-term association of Medicaid expansion on prostate cancer screening. Data from the Behavioral Risk Factor Surveillance System were extracted for childless men earning less than 138% of the federal poverty level in states with different Medicaid expansion statuses from 2012 to 2020. States were classified into 4 expansion categories: very early expansion states, early expansion states, late expansion states, and nonexpansion states. Prevalence of PSA screening was determined for each category of expansion. Difference-in-difference analyses were used to understand variations in very early expansion states, early expansion states, and late expansion states trends with reference to nonexpansion states. PSA screening prevalence decreased in very early expansion states (27.76% vs 18.50%), early expansion states (33.79% vs 18.09%), late expansion states (36.08% vs 19.14%), and nonexpansion states (38.82% vs 24.40%) from 2012 to 2020. However, the difference-in-difference analyses did not show statistically significant results among any of the years and expansion category groups in our study period. PSA screening prevalence decreased in all states, regardless of expansion category. No long-term effect of Medicaid expansion on PSA screening prevalence was observed among states with different expansion statuses.

Results from Lung Cancer Screening Outreach Utilizing a Mobile CT Scanner in an Urban Area

IntroductionLung cancer screening using low-dose (LD) CT reduces lung cancer–specific and all-cause mortality in high-risk individuals, although significant barriers to screening remain. We assessed the outreach of a mobile lung cancer screening program to increase screening accessibility and early detection of lung cancer. MethodsWe placed a mobile CT unit in a high-traffic area in New York City and offered free screening to all eligible patients. Characteristics of the mobile screening cohort were compared with those of our hospital-based screening cohort. ResultsBetween December 9, 2019, and January 30, 2020, a total of 216 patients underwent mobile LDCT screening. Compared with the hospital-based screening cohort, mobile screening participants were significantly more likely to be younger, be uninsured, and have lower smoking intensity and were less likely to meet 2013 US Preventive Services Task Force guidelines (but would meet their 2021 guidelines) and self-identify as White race and Hispanic ethnicity. Asian New Yorkers were substantially underrepresented in both hospital and mobile screening cohorts, compared with their level of representation in New York City. Two patients were diagnosed with lung cancer and were treated. Potentially clinically significant non–lung cancer findings were identified in 28.2%, most commonly moderate-severe coronary artery calcification and emphysema. ConclusionsMobile LDCT screening is useful and effective in detecting lung cancer and other significant findings and may engage a distinct high-risk patient demographic. Disproportionately low screening rates among certain high-risk populations highlight the imperative of implementing strategies aimed at understanding health behaviors and access barriers for diverse populations. Effective care-navigation services, facilitating high-quality care for all patients, are critical.

Patient Preferences for Lung Cancer Interception Therapy

Interception therapy requires individuals to undergo treatment to prevent a future medical event, but little is known about preferences of individuals at high risk for lung cancer and whether they would be interested in this type of treatment. To explore preferences of individuals at high risk for lung cancer for potential interception therapies to reduce this risk. This survey study used a discrete-choice experiment and included hypothetical lung cancer interception treatments with 4 attributes: reduction in lung cancer risk over 3 years, injection site reaction severity, nonfatal serious infection, and death from serious infection. Respondents were assigned to a baseline lung cancer risk of 6%, 10%, or 16% over 3 years. The discrete-choice experiment was administered online (July 13 to September 6, 2022) to US respondents eligible for lung cancer screening according to US Preventive Services Task Force guidelines. Participants included adults aged 50 to 80 years with at least a 20 pack-year smoking history. Statistical analysis was performed from September to December 2022. Attribute-level preference weights were estimated, and conditional relative attribute importance, maximum acceptable risks, and minimum acceptable benefits were calculated. Characteristics of respondents who always selected no treatment were also explored. Of the 803 survey respondents, 495 (61.6%) were female, 138 (17.2%) were African American or Black, 55 (6.8%) were Alaska Native, American Indian, or Native American, 44 (5.5%) were Asian or Native Hawaiian or Other Pacific Islander, 104 (13.0%) were Hispanic, Latin American, or Latinx, and 462 (57.5%) were White, Middle Eastern or North African, or a race or ethnicity not listed; and mean (SD) age was 63.0 (7.5) years. Most respondents were willing to accept interception therapy and viewed reduction in lung cancer risk as the most important attribute. Respondents would accept a greater than or equal to a 12.0 percentage point increase in risk of nonfatal serious infection if lung cancer risk was reduced by at least 20.0 percentage points; and a greater than or equal to 1.2 percentage point increase in risk of fatal serious infection if lung cancer risk was reduced by at least 30.0 percentage points. Respondents would require at least a 15.4 (95% CI, 10.6-20.2) percentage point decrease in lung cancer risk to accept a 12.0 percentage point increase in risk of nonfatal serious infection; and at least a 23.1 (95% CI, 16.4-29.8) percentage point decrease in lung cancer risk to accept a 1.2 percentage point increase in risk of death from serious infection. Respondents who were unwilling to accept interception therapy in any question (129 [16.1%]) were more likely to be older and to currently smoke with no prior cessation attempt, and less likely to have been vaccinated against COVID-19 or examined for skin cancer. In this survey study of individuals at high risk of lung cancer, most respondents were willing to consider interception therapy. These results suggest the importance of benefit-risk assessments for future lung cancer interception treatments.