Underserved Cancer Survivors Research Articles

Abstract C043: Exploring underserved cancer survivors' perspectives on survivorship care at community health centers

Abstract Background: Community Health Centers (CHCs) serve as critical healthcare centers for vulnerable and underserved populations, including those living with cancer (also referred to as cancer survivors), offering essential services and care to survivors who often face numerous barriers to care. Despite the vital role CHCs play, cancer survivors who rely on these centers frequently encounter unique challenges, including managing chronic conditions, accessing specialized care, and addressing social determinants of health (SDOH). Understanding cancer survivors' experiences at CHCs is crucial to enhancing care delivery and improving their overall quality of life. Methods: We conducted semi-structured interviews with adult patients with a history of cancer and other chronic conditions at two Texas-based CHCs. Data analysis employed an adapted version of Crabtree and Miller's immersion and crystallization approach. One researcher and a second coder led the immersion phase, followed by a collaborative crystallization process with a team to identify and refine the emergent themes. Results: Seven female cancer survivors, with a mean age of 70 years and at least two chronic conditions, were interviewed. Three themes emerged: (1) complexity in chronic care management, (2) satisfaction and trust in care, and (3) the role of faith and reminders. In theme 1, cancer survivors discussed their challenges of managing multiple doctor's appointments and the number of medications they need to take while encountering SDOH barriers. Meanwhile, in theme 1, they expressed extreme satisfaction with the care they received at CHC. Finally, in theme 3, spiritual prayers and the use of written reminders helped with coping and managing their medications and multiple doctor’s visits. Additionally, during the interviews, survivors were not prompted by the research team about their past cancer history and did not voluntarily mention it to the interviewer. Conclusion: Cancer survivors’ at CHCs did not perceive the need for well-coordinated survivorship care. This could be due to survivors not being informed about the necessity of survivorship care and having an insufficient understanding of cancer-related risks. The absence of recognition of their cancer history highlights the importance of shared care between primary care clinicians and specialists, as well as the integration of survivorship care in primary care settings to ensure optimal, high-quality care. Citation Format: Bijal A. Balasubramanian, Maram Museitif, Hilary Ma, Simon Lee, Gretchen H. Walton, Aubree Laura Shay. Exploring underserved cancer survivors' perspectives on survivorship care at community health centers [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 C043.

A scoping review of the evidence on survivorship care plans among minority, rural, and low-income populations.

Despite recent advances in cancer control and the number of cancer survivors increasing substantially over the past years, some cancer survivors continue to experience disparities due to barriers to recommended survivorship care. The use of survivorship care plans (SCPs) may be a way to help care for these individuals and their respective issues after they complete their primary treatment. The purpose of this scoping review is to understand the evidence on SCPs among minority, rural, and low-income populations: groups that experience disproportionately poorer cancer health outcomes. Computer-based searches were conducted in four academic databases. We included peer-reviewed studies published in the English language and conducted in the USA. We systematically extracted information from each paper meeting our inclusion criteria. Our search identified 45 articles. The 4 major themes identified were (1) disparities in the receipt of SCPs where populations experience unmet needs; (2) benefits of SCPs, including improved care coordination and self-management of cancer; (3) needs and preferences for survivorship care; and (4) barriers and facilitators to using SCPs. Despite the potential benefits, underserved cancer survivors experience disparities in the receipt of SCPs and continue to have unmet needs in their survivorship care. Survivorship care may benefit from a risk-stratified approach where SCPs are prioritized to survivors belonging to high-risk groups. SCPs are a tool to deliver quality care for cancer survivors. While evidence is mixed on SCPs' benefits among the general population, SCPs show promise for underserved populations when it comes to proximal outcomes that contribute to disparities.

Outcomes for breast cancer survivors with metastatic disease in a physical activity program for medically underserved cancer survivors.

This study examined the effectiveness and feasibility of the Active Living After Cancer (ALAC) program for metastatic breast cancer (MBC) survivors. ALAC is a 12-session community-based program to help cancer survivors improve their physical functioning and quality of life through increased physical activity. ALAC participants with MBC (stage IV) were compared to survivors with early-stage breast cancer (stages I and II). The International Physical Activity Questionnaire, Godin Leisure-Time Physical Activity, 30-second sit-to-stand test, and PROMIS Global Health were administered at baseline and follow-up. Program satisfaction and retention were assessed at week 12. Repeated-measures mixed models were used to compare changes in outcomes between survivors with early-stage breast cancer and MBC. A total of 585 women (59.3 y ± 10.6), most of whom were Hispanic (54%) or non-Hispanic Black (22%), were included (early stage, n = 538; MBC, n = 47). After the ALAC program, a significant increase in physical activity (P < 0.001), improved physical and mental health T-scores (P < 0.001), and more sit-to-stand repetitions (P < 0.001) were observed for both survivors with early-stage breast cancer and MBC. Women with MBC showed significantly lower physical health (P = 0.037) and physical function (P = 0.010) compared to early-stage at baseline. The ALAC program increased physical activity and improved health-related quality of life and physical function among breast cancer survivors with both early-stage and metastatic disease. This study emphasizes the importance of incorporating physical activity interventions like the ALAC program into the comprehensive care of cancer survivors, including those with metastatic disease.

Expanding active living after cancer to underserved cancer survivors and their caregivers.

Physical activity improves physical and psychological health in cancer survivors. This study evaluated Active Living After Cancer (ALAC), a community-based program to improve physical activity, physical function, and quality of life (QOL) in minority and medically underserved cancer survivors and their caregivers. Participants completed 12 weekly ALAC sessions and assessments of physical activity, physical functioning, and QOL at baseline and follow-up (week 12). Paired samples t tests were used to assess changes in outcomes over time. A total of 540 cancer survivors (mean age = 61.1 [SD = 11.3] years) and 87 caregivers (mean age = 62.3 [SD = 13.1] years) were enrolled. Most were women (91.4%), Hispanic (61.1%) or non-Hispanic Black (19.3%), and medically underserved (86.4%). The percent of cancer survivors meeting physical activity recommendations increased from 28.9% to 60.2% (d = 0.75), and the number of sit-to-stand repetitions in a 30-second period increased from 12.3 to 14.3 (d = 0.39) from 0-12 weeks. Cancer survivors reported statistically significant improvements in physical (t score Δ = 1.7, d = 0.06) and mental (t score Δ = 2.3, d = 0.31) health-related QOL. Caregivers also improved their physical activity, physical function, and QOL, and there were no statistically significant differences between breast and other cancer survivors and between cancer survivors and caregivers. The ALAC program demonstrated increased physical activity, physical function, and QOL in medically underserved cancer survivors and their caregivers. Furthermore, ALAC was successfully implemented by community partners and serves as a good model for reaching medically underserved cancer survivors and improving survivorship. Additional efforts are warranted to further extend reach, improve cancer survivorship, and reduce cancer health disparities among underserved cancer survivors.

Factors influencing implementation of a care coordination intervention for cancer survivors with multiple comorbidities in a safety-net system: an application of the Implementation Research Logic Model

BackgroundUnder- and uninsured cancer survivors have significant medical, social, and economic complexity. For these survivors, effective care coordination between oncology and primary care teams is critical for high-quality, comprehensive care. While evidence-based interventions exist to improve coordination between healthcare teams, testing implementation of these interventions for cancer survivors seen in real-world safety-net settings has been limited. This study aimed to (1) identify factors influencing implementation of a multicomponent care coordination intervention (nurse coordinator plus patient registry) focused on cancer survivors with multiple comorbidities in an integrated safety-net system and (2) identify mechanisms through which the factors impacted implementation outcomes.MethodsWe conducted semi-structured interviews (patients, providers, and system leaders), structured observations of primary care and oncology operations, and document analysis during intervention implementation between 2016 and 2020. The practice change model (PCM) guided data collection to identify barriers and facilitators of implementation; the PCM, Consolidated Framework for Implementation Research, and Implementation Research Logic Model guided four immersion/crystallization data analysis and synthesis cycles to identify mechanisms and assess outcomes. Implementation outcomes included appropriateness, acceptability, adoption, and penetration.ResultsThe intervention was appropriate and acceptable to primary care and oncology teams based on reported patient needs and resources and the strength of the evidence supporting intervention components. Active and sustained partnership with system leaders facilitated these outcomes. There was limited adoption and penetration early in implementation because the study was narrowly focused on just breast and colorectal cancer patients. This created barriers to real-world practice where patients with all cancer types receive care. Over time, flexibility intentionally designed into intervention implementation facilitated adoption and penetration. Regular feedback from system partners and rapid cycles of implementation and evaluation led to real-time adaptations increasing adoption and penetration.DiscussionEvidence-based interventions to coordinate care for underserved cancer survivors across oncology and primary care teams can be implemented successfully when system leaders are actively engaged and with flexibility in implementation embedded intentionally to continuously facilitate adoption and penetration across the health system.

Abstract A023: Outcomes for breast cancer survivors with metastatic disease in a physical activity program for medically underserved cancer survivors

Abstract Background: Physical activity (PA) improves cancer survivors’ health outcomes including physical functioning, fatigue, and health-related quality of life (HRQOL), but the feasibility and effectiveness of PA programs for survivors with metastatic breast cancer (MBC) are still unclear. The purpose of this study was to examine the effects of the Active Living After Cancer (ALAC) program on breast cancer survivors with metastatic disease. ALAC is an evidence-based community program for underrepresented and medically underserved cancer survivors that aims to improve HRQOL and physical functioning through increasing PA. This presentation will analyze program effects on HRQOL and physical functioning as well as program satisfaction and retention among survivors with MBC compared to those with early stage breast cancer. Methods: This study is a secondary analysis of data from the ALAC program. ALAC is offered in the community in both English and Spanish and consists of 12 group sessions provided weekly. Among ALAC participants, we identified those with MBC (stage IV and with metastasis) and compared them to survivors with early stage breast cancer (stage I and II). The International Physical Activity Questionnaire (IPAQ), 30-second sit to stand test, and PROMIS Global Short Form-Physical and Mental Health T-scores were measured at baseline and follow-up. Program satisfaction and retention were assessed at the end of program. Repeated measure mixed models were used to compare changes in outcomes between patients with early stage breast cancer and MBC and Pearson’s chi-squared tests were used to examine differences in program satisfaction and attendance. Results: A total of 248 women (60 yr ±10.4), mostly Hispanic (50.6%) or non-Hispanic Black (19.7%), were included in the analyses (early stage: n=226; MBC: n=22). After the ALAC program, there were significant increases in PA (p&amp;lt;.001) and improvement of physical HRQOL (p=.011) and 30-second sit-to-stand (p&amp;lt;.001), but no significant between-group differences in these outcomes. Although session attendance was similar between groups, women with early stage breast cancer showed significantly higher program satisfaction compared to those with MBC (χ2=4.24, p=.039). Conclusions: The ALAC program effectively increases PA and improves physical HRQOL and physical functioning among breast cancer survivors with both metastatic and early stage disease. More research is needed to identify program changes needed to improve mental HRQOL and program satisfaction among women with MBC. Citation Format: Che Young Lee, Scherezade M. Mama, Yue Liao, Abenaa Brewster, Meagan Whisenant, Kylee Laffoon, Stacy J. Mitchell, Patricia V. Tracy, Giselle M Garza, Karen M. Basen-Engquist. Outcomes for breast cancer survivors with metastatic disease in a physical activity program for medically underserved cancer survivors [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 A023.

Effectiveness of Active Living After Cancer (ALAC), a community-based physical activity program for underserved cancer survivors and their caregivers.

12013 Background: Physical activity (PA) improves physical functioning and quality of life in cancer survivors, yet few cancer survivors meet recommendations of ≥150 minutes/week of moderate intensity PA. Active Living After Cancer (ALAC) is a community-based program to improve the quality of life of cancer survivors by promoting PA and providing navigation services for survivorship issues. This study evaluates the impact of ALAC on PA, physical functioning, and quality of life in underserved cancer survivors who participated with and without a caregiver. Methods: Cancer survivors were recruited through community organizations to participate in ALAC, which consists of 12 weekly sessions, with or without a caregiver. Participants completed assessments of PA (Godin Leisure Time Exercise Questionnaire), physical functioning (30-sec sit-to-stand test), and quality of life (PROMIS physical and mental health) at baseline and follow-up. Paired samples t-tests were used to assess changes in physical activity, physical functioning and quality of life in cancer survivors and general linear models were used to compare changes between cancer survivors who participated with vs. without a caregiver. Results: Cancer survivors (N = 539; M age = 61.0±11.3 years) were mostly women (92.4%), Hispanic (57.3%) or non-Hispanic Black (21.5%), and medically underserved (85.3%). Most were breast cancer survivors (69.4%), diagnosed with Stage 0-III cancer (91.5%), and participated in ALAC without a caregiver (N = 463, 85.9%). From baseline to follow-up, the percent of cancer survivors meeting PA recommendations increased from 30.3% to 59.6% (Δ = 27.8 score, t= 16.4, p&lt;.001), and the number of sit-to-stand repetitions in a 30-second period increased from 12.4 to 14.3 (Δ = 2.1, t= 8.6, p&lt;.001). Cancer survivors also reported significant improvements in physical (Δ = 0.6, t= 2.4, p=.015) and mental (Δ = 1.0, t= 3.7, p&lt;.001) health-related quality of life. Cancer survivors who participated with a caregiver reported improvements in physical (Δ = 0.7) and mental (Δ = 1.2) health-related quality of life, whereas those who participated without a caregiver reported slight decreases in physical (Δ = -0.2) and mental (Δ = -0.2) health-related quality of life. However, group x time interactions were not statistically significant [physical F(1,412) = 1.9, p=.168; mental F(1,412) = 49.2, p=.061]. Conclusions: Results confirm the effectiveness of ALAC among medically underserved cancer survivors for increasing PA and physical function and suggest that quality of life improvements may be enhanced by participating with a caregiver. Thus, community-based programs should encourage participation with a caregiver when possible to further increase PA, improve cancer survivorship, and reduce cancer health disparities among underserved cancer survivors.

Telehealth Availability and Use of Related Technologies Among Medicare-Enrolled Cancer Survivors: Cross-sectional Findings From the Onset of the COVID-19 Pandemic.

BackgroundThere has been rapid integration of telehealth into care delivery during the COVID-19 pandemic. However, little is known about technology ownership, internet access and use for communication, and telehealth availability among cancer survivors, particularly those enrolled in Medicare.ObjectiveThis study aims to identify sociodemographic associations with technology ownership, internet access and use for communication, and telehealth availability in a population-based sample of Medicare-enrolled cancer survivors.MethodsData are from the Medicare Current Beneficiary Survey COVID-19 Summer 2020 Supplement administered between June 10 and July 15, 2020. Analyses were restricted to beneficiaries who reported a prior (nonskin) cancer diagnosis and a usual source of care (N=2044). Dichotomous outcomes included technology ownership, internet access, internet use for communication, and telehealth availability from providers. Sociodemographic correlates included sex, age, race/ethnicity, Medicare/Medicaid dual enrollment, rurality, census region, and self-reported comorbidities.ResultsOver half (957/2044, 53%) of cancer survivors reported using the internet for communication purposes, and 62% (1218/2044) reported that their usual provider had telehealth services available. Using the internet for communication purposes was reported less frequently for rural compared to urban survivors (adjusted probability of 28% vs 46%; P<.001) and for Hispanic and Black survivors compared to non-Hispanic White survivors (29%, 31%, and 44%, respectively; all P<.01). Rural survivors reported lower telehealth availability (53% vs 63%; P<.001); no significant differences in telehealth availability were identified by race/ethnicity.ConclusionsDuring the COVID-19 pandemic, study findings highlight a complex digital divide among Medicare beneficiaries with a history of cancer related to device ownership necessary for telehealth, internet access and use for communication, and reports of providers having telehealth available. Multilevel approaches are needed to increase equitable telehealth availability and use for cancer survivors. Suggested strategies include increasing broadband internet access to providers and patients in at-risk communities, supporting telehealth implementation among providers that serve populations with known health disparities, raising awareness of providers’ available telehealth services among patients, and screening for technology use and provision of telehealth-related technical assistance among older and historically underserved cancer survivors.

Abstract A028: Perceptions of the nursing role in cancer survivorship among aging African American cancer survivors and caregivers

Abstract Introduction: Oncology nurses are recognized globally for enhancing health outcomes, improving care coordination, and providing quality care. However, few studies have addressed the role expectations of a nurse among underserved cancer survivors and caregivers (CSCs), especially those who belong to a minority group. The purpose of this study was to explore the role expectations of nurses among aging African American cancer survivors and caregivers. Methods: A qualitative approach was utilized, using purposeful and theoretical sampling. Semi-structured qualitative interviews were conducted with 40 aging and community-dwelling African American cancer survivors and caregivers. Data was analyzed using a descriptive approach and thematic content analysis. Results: The results suggest that nurses should have a greater awareness of life events and challenges that can affect cancer survivorship, such as body image issues, financial hardship, and low social support. The following three themes that emerged that describe the perception of the nursing role and minority CSCs include: (1) adequate health education and nursing skill demonstration related to CSC, (2) increased advocacy for the underserved cancer survivors and caregivers, including resource identification and sharing, and (3) assessment and management of the biopsychosocial needs of CSCs. Implications: The role of nurses in these communities managing cancer survivorship among both survivors and caregivers is critical as these specific populations may have unique care needs. The results can be used to inform the development of culturally relevant and nursing-led interventions targeted towards CSCs to improve the cancer survivorship experience for aging minority populations. Citation Format: Sharon Cobb, Ebere Ume. Perceptions of the nursing role in cancer survivorship among aging African American cancer survivors and caregivers [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr A028.

Abstract B013: Associations between psychosocial distress and physical inactivity and poor health in medically underserved cancer survivors in central Pennsylvania

Abstract Purpose: Cancer survivors (CS) residing in nonmetro, medically underserved areas (MUA) are less likely to do physical activity (PA) and more likely to report poor health and psychosocial distress than those residing in urban areas with low need. The purpose of this study was to explore the association between psychosocial distress and PA and self-rated health in CS residing in MUA in central Pennsylvania. Method: CS were recruited to the Partnering to Prevent and Control Cancer (PPCC) study, a cross-sectional study to explore factors related to PA in CS living in central Pennsylvania. PPCC participants completed mailed or Internet-based questionnaires assessing sociodemographics, psychosocial distress (perceived stress, depressive symptoms, and anxiety), Godin weekly leisure-time PA (WLPA), and self-rated health. Independent samples t-tests and analysis of variance were used to explore associations between psychosocial distress and PA and self-rated health. Results: Nearly 600 (N=572) CS were contacted to participate; 262 were screened for eligibility. Eligible participants (96.9%, n=254) completed a brief demographic questionnaire, and 211 participants opted to complete a more in-depth questionnaire assessing psychosocial distress and PA. Nearly half of participants were prostate (22.5%) or breast (22.1%) CS, followed by gynecologic (15.7%), colorectal (8.8%), and lung (7.2%) CS, and 21.7% of participants reported multiple cancer diagnoses. Participants were mostly women (58.4%), in their mid-60s (M age=64.9±11.8 years), and overweight (M BMI=29.6±6.8 kg/m2). Only 28.3% of CS reported being active, and 16.0% of CS self-rated their health as poor or fair. Nearly 20% of participants reported an elevated number of depressive symptoms, 41.1% reported moderate-to-high perceived stress, and 4.3% reported moderate-to-high anxiety. MUA CS who reported fewer depressive symptoms engaged in more WLPA (M=26.9 vs. 16.1, t=2.023, p=.045) and self-reported better health (M=3.5 vs. 2.7, t=4.8, p&amp;lt;.001) than those who reported elevated depressive symptoms. Similarly, MUA CS who reported low perceived stress (F=15.6, p&amp;lt;.001) and very low anxiety (F=6.1, p=.003) self-reported their health as better than those who reported moderate-to-high perceived stress and anxiety. Conclusions: CS in PPCC report higher psychosocial distress and engage in less PA than CS in urban, non-MUA areas in the U.S., contributing to cancer health disparities. Strong associations between high psychosocial distress and physical inactivity and poor self-rated health point to the urgent need for psychosocial interventions designed to meet the unique physical and psychological needs of this population in an effort to improve cancer survivorship outcomes, reduce health disparities, and promote health equity in CS residing in MUA in central Pennsylvania. Citation Format: Scherezade K. Mama, Nishat Bhuiyan, Kathryn H. Schmitz, Eugene J. Lengerich. Associations between psychosocial distress and physical inactivity and poor health in medically underserved cancer survivors in central Pennsylvania [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr B013.

Trends of online patient-provider communication among cancer survivors from 2008 to 2017: a digital divide perspective.

In the past decade, online patient-provider communication (OPPC) has emerged as a viable avenue for cancer survivors to communicate with their providers. However, little is known about the patterns of OPPC among cancer survivors. Thus, the current study aims to explore the trend of OPPC used by cancer survivors, and the influence of digital divide on OPPC in the past decade. Data from the 2008, 2011, 2013, and 2017 iterations of the nationally representative survey of Health Information National Trends Survey (HINTS) were analyzed. Only cancer survivors were included in the analyses. Descriptive analyses and multivariate regressions were performed. Email has been the most typical means of OPPC; its adoption rate has increased from 9.7 to 36.6% in the past 10years. More options for OPPC (e.g., mobile app, social medial, video conferencing, electronic health records) have been adopted since 2013. Physical Internet access was a significant predictor of OPPC over the four iterations, while cognitive access failed to predict OPPC in all the four waves. The effect of socio-demographic access varied vastly across iterations, with greater influences in 2017. This study illustrates an increasing trend in OPPC use among cancer survivors. Significant digital divide barriers also exist in the adoption and diffusion of OPPC. OPPC is an important communication channel for cancer survivors and will become more important in the digital era. Targeted interventions to address the digital divide barriers affecting OPPC could be developed to benefit underserved cancer survivors and to bridge health disparities.

Cancer survivorship care in the rural community: A mobile model.

38 Background: As survival rates continue to improve, many forms of cancer are now regarded as chronic diseases requiring long-term follow-up. This survivorship phase of care represents a distinct opportunity to improve the health and quality of life for cancer survivors, addressing the lingering medical and psychosocial effects of illness, recurrent or new cancers, and promoting health behavior changes. Evidence-based cancer survivorship programs are typically limited in scope and only found in large cancer centers because they are costly and poorly reimbursed. As a result, UT Southwestern Moncrief Cancer Institute (UTSW-MCI) mobilized its clinic to provide essential survivorship services to the estimated 15,000 underserved cancer survivors in geographically remote areas of North Texas. Methods: UTSW-MCI provides survivorship care to Medicaid-enrolled and uninsured patients within a nine county service area using a custom-built mobile health unit. Staffed with an experienced team of nurses, social workers, dietitians, exercise specialists and physician assistant, services on the mobile clinic include: cancer screening and surveillance; medical management of long-term side effects of treatment; treatment summary and care plans; dietary evaluations and healthy lifestyle education; psychosocial evaluations, care coordination and navigation to financial assistance; and assessments for balance, immobility, range of motion, and safe physical activity. In-house providers with the ambulatory clinic are also able to see patients on the mobile unit using telemedicine. These services include genetic counseling, physician assistant evaluations, and psychological counseling. Results: After six months, mobile clinic enrollments represent more than 10% (N = 28) of the survivorship program patient population and nearly 15% (N = 130) of completed encounters, including 28 RN assessments, 26 Social Work evaluations, 21 Dietitian assessments, 53 Exercise sessions, and 3 PA consultations. Conclusions: This innovative survivorship care model addresses barriers that impede access to care to improve both the health of medically underserved cancer survivors and the experience of care while reducing the cost of care without compromising quality.

¡Cocinar Para Su Salud!: Randomized Controlled Trial of a Culturally Based Dietary Intervention among Hispanic Breast Cancer Survivors

BackgroundThere is a need for culturally relevant nutrition programs targeted to underserved cancer survivors. ObjectiveOur aim was to examine the effect of a culturally based approach to dietary change on increasing fruit/vegetable (F/V) intake and decreasing fat intake among Hispanic breast cancer survivors. DesignParticipants were randomized to Intervention and Control groups. Diet recalls, detailed interviews, fasting blood, and anthropometric measures were collected at baseline, 3, 6, and 12 months. Participants/settingHispanic women (n=70) with stage 0 to III breast cancer who completed adjuvant treatment and lived in New York City were randomized between April 2011 and March 2012. InterventionThe Intervention group (n=34) participated in ¡Cocinar Para Su Salud!, a culturally based nine-session (24 hours over 12 weeks) intervention including nutrition education, cooking classes, and food-shopping field trips. The Control group (n=36) received written dietary recommendations for breast cancer survivors. Main outcome measuresChange at 6 months in daily F/V servings and percent calories from total fat were the main outcome measures. Statistical analysesLinear regression models adjusted for stratification factors and estimated marginal means were used to compare changes in diet from baseline to 3 and 6 months. ResultsBaseline characteristics were the following: mean age 56.6 years (standard deviation 9.7 years), mean time since diagnosis 3.4 years (standard deviation 2.7 years), mean body mass index (calculated as kg/m2) 30.9 (standard deviation 6.0), 62.9% with annual household income ≤$15,000, mean daily servings of all F/V was 5.3 (targeted F/V 3.7 servings excluding legumes/juices/starchy vegetables/fried foods), and 27.7% of daily calories from fat. More than 60% in the Intervention group attended seven or more of nine classes, with overall study retention of 87% retention at 6 months. At month 6, the Intervention group compared with Control group reported an increase in mean servings of F/V from baseline (all F/V: +2.0 vs −0.1; P=0.005; targeted F/V: +2.7 vs +0.5; P=0.002) and a nonsignificant decrease in percent calories from fat (−7.5% vs −4.4%; P=0.23) and weight (−2.5 kg vs +3.8 kg; P=0.22). Conclusions¡Cocinar Para Su Salud! was effective at increasing short-term F/V intake in a diverse population of Hispanic breast cancer survivors.

¡Cocinar Para Su Salud!: Randomized Controlled Trial of a Culturally Based Dietary Intervention among Hispanic Breast Cancer Survivors

BackgroundThere is a need for culturally relevant nutrition programs targeted to underserved cancer survivors. ObjectiveOur aim was to examine the effect of a culturally based approach to dietary change on increasing fruit/vegetable (F/V) intake and decreasing fat intake among Hispanic breast cancer survivors. DesignParticipants were randomized to Intervention and Control groups. Diet recalls, detailed interviews, fasting blood, and anthropometric measures were collected at baseline, 3, 6, and 12 months. Participants/settingHispanic women (n=70) with stage 0 to III breast cancer who completed adjuvant treatment and lived in New York City were randomized between April 2011 and March 2012. InterventionThe Intervention group (n=34) participated in ¡Cocinar Para Su Salud!, a culturally based nine-session (24 hours over 12 weeks) intervention including nutrition education, cooking classes, and food-shopping field trips. The Control group (n=36) received written dietary recommendations for breast cancer survivors. Main outcome measuresChange at 6 months in daily F/V servings and percent calories from total fat were the main outcome measures. Statistical analysesLinear regression models adjusted for stratification factors and estimated marginal means were used to compare changes in diet from baseline to 3 and 6 months. ResultsBaseline characteristics were the following: mean age 56.6 years (standard deviation 9.7 years), mean time since diagnosis 3.4 years (standard deviation 2.7 years), mean body mass index (calculated as kg/m2) 30.9 (standard deviation 6.0), 62.9% with annual household income ≤$15,000, mean daily servings of all F/V was 5.3 (targeted F/V 3.7 servings excluding legumes/juices/starchy vegetables/fried foods), and 27.7% of daily calories from fat. More than 60% in the Intervention group attended seven or more of nine classes, with overall study retention of 87% retention at 6 months. At month 6, the Intervention group compared with Control group reported an increase in mean servings of F/V from baseline (all F/V: +2.0 vs −0.1; P=0.005; targeted F/V: +2.7 vs +0.5; P=0.002) and a nonsignificant decrease in percent calories from fat (−7.5% vs −4.4%; P=0.23) and weight (−2.5 kg vs +3.8 kg; P=0.22). Conclusions¡Cocinar Para Su Salud! was effective at increasing short-term F/V intake in a diverse population of Hispanic breast cancer survivors.

Development and Evaluation of the Curriculum for BOLD (Bronx Oncology Living Daily) Healthy Living: a Diabetes Prevention and Control Program for Underserved Cancer Survivors.

Underserved minority communities have few resources for addressing comorbidity risk reduction among long-term cancer survivors. To address this community need, we developed and piloted the Bronx Oncology Living Daily (BOLD) Healthy Living program, the first known diabetes prevention and control program to target cancer survivors and co-survivors in Bronx County, NY. The program aimed to facilitate lifestyle change and improve health-related quality of life (HRQoL) through weekly group nutrition education (60-90 min) and exercise (60 min) classes. We examined baseline characteristics of participants using simple descriptive statistics and evaluated program implementation and impact using the Reach, Efficacy, Adoption, Implementation and Maintenance (RE-AIM) framework. The curriculum, which drew from the social-ecological framework and motivational and cognitive behavioral strategies, consisted of 12 culturally and medically tailored modules with options for implementation as a 12- or 4-week program. Seven programs (four 12 weeks and three 4 weeks in length, respectively) were implemented at five community site locations. Sixty-six cancer survivors and 17 cancer co-survivors (mean age 60.5 ± 10.2 years) enrolled in one of the programs. Most participants were female (95.2 %) minority (55.4 % black, 26.5 % Hispanic/Latino) breast cancer survivors (75.7 %). Median program attendance was 62.5 % and did not significantly differ by program length; however, 67.3 % of participants achieved ≥60 % attendance among the 12-week programs, compared to 41.9 % among the 4-week programs, and this difference was statistically significant (p = 0.02). Overall, participants reported significant pre/post improvements in perceived health as good/excellent (66.0 to 75.5 %; p = 0.001) and borderline significant decreases in perceived pain as moderate/severe (45.5 to 38.2 %; p = 0.05). More than 90 % of participants reported that the program helped them to achieve their short-term goals, motivated them to engage in healthier behaviors, and felt that the nutrition and exercise classes were relevant to their needs. These results indicate that a short-term lifestyle intervention program for adult cancer survivors was acceptable in our community and motivated cancer survivors to improve their HRQoL. The curriculum can be used as a tool to facilitate development of similar programs in the future.

Abstract B22: Lesbian, gay, and bisexual cancer survivor's participation in cancer clinical trials: Findings from a national health survey.

Abstract Introduction: Clinical trials are important tools for advancing cancer treatment, prevention, and control. To identify and describe clinical effects relevant to underserved groups, representation of medically underserved cancer survivors in clinical trials is necessary. Medically underserved groups historically have been defined to include racial/ethnic minorities, under-insured or uninsured groups, those with low levels of education, and those with low socioeconomic status. The recent Institute of Medicine report on the Health of Lesbian, Gay, Bisexual, and Transgender People also describes lesbian, gay, and bisexual (i.e., LGB) people as medically underserved. Medically underserved groups are known to be underrepresented in cancer clinical trials, except in the case of LGB cancer survivors. Currently, no published research has examined LGB cancer survivor's participation in cancer trials. Given this paucity in the literature, this study aimed to test the hypothesis that prevalence of clinical trial participation would be lower among LGB cancer survivors than heterosexual cancer survivors. Methods: Data were from the Behavioral Risk Factor Surveillance System (BRFSS), which is a health surveillance program sponsored collaboratively by the Centers for Disease Control and Prevention (CDC) and U.S. states. The BRFSS is administered annually to probability-based samples of non-institutionalized adults over 18 years of age. The Cancer Survivorship module is an optional module that states may elect to use and that assesses cancer survivor participation in cancer clinical trials. Data for this study are from five states' 2010 BRFSS surveys that included both the Cancer Survivorship module and an item asking self-identified LGB status to either their entire survey population (Massachusetts, New Mexico, Wisconsin, and Alaska) or to one or more probability-based sample splits (California) (n=4,339). Results: Participation in cancer clinical trials was higher among LGB cancer survivors (12.5%) than among heterosexual cancer survivors (6.0%) (p = .005). In the multivariate model, adjusted by age, sex, education, race/ethnicity, and survey state, LGB cancer survivors were more than twice as likely, as heterosexual cancer survivors, to report participation in a clinical trial (AOR 2.17, 95% CI 1.21-3.90). Conclusion: LGB cancer survivors had greater likelihood of cancer clinical trial participation than heterosexual cancer survivors, and this association was not explained by education. The finding was not expected given the historic marginalization of this group and previous reports that up to 15% of clinical trials explicitly excluded LGB participants. The finding may be explained by insurance coverage. LGB people are more likely to lack health insurance than heterosexuals. Thus, LGB cancer survivors may be more inclined to seek care through clinical trial participation. Small sample size precluded examining whether denial of insurance coverage was an explanatory factor for trial participation; however this is a logical next step for future research. Citation Format: Jennifer M. Jabson, John R. Blosnich. Lesbian, gay, and bisexual cancer survivor's participation in cancer clinical trials: Findings from a national health survey. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr B22.

A contextual approach to understanding breast cancer survivorship among Latinas

The purpose of this review is to describe the empirical literature on the health-related quality of life (HRQOL) in Latina breast cancer survivors by exploring the social determinants of health. In framing the key domains of survivors' quality of life within a ecological-contextual model that evaluates individual and societal contributions to health outcomes, we provide a comprehensive landscape of the diverse factors constituting Latina survivors' lived experiences and their resultant quality of life outcomes. We retrieved 244 studies via search engines and reference lists, of which 37 studies met the inclusion criteria. Findings document the importance of the social determinants of HRQOL, with studies documenting ecological and contextual factors accounting for significant variance in HRQOL outcomes. Our review identifies a dearth of research examining community-, institutional-, and policy-level factors, such as health care access, legal and immigration factors, physical and built environments, and health care affordability and policies affecting Latina breast cancer survivors' HRQOL. Overall research on Latina breast cancer survivorship is sparse, with even greater underrepresentation within longitudinal and intervention studies. Results highlight a need for clear documentation of the comprehensive care needs of underserved cancer survivors and interventions considering integrated systems of care to address the medical and ecological factors known to impact the HRQOL of breast cancer survivors.

Recruitment and retention results for a population-based cervical cancer biobehavioral clinical trial

Objective . Minority and low-income cancer patients are underrepresented in clinical trials, contributing to diminished access to state-of-the-art care and disparities in cancer outcomes including survivorship issues. In cervical cancer, there is a disproportionate disease burden among minority and underserved women and persistent quality of life disruption. We encountered significant challenges in both recruitment and retention in a randomized biobehavioral clinical trial for cervical cancer survivors, identified through California Cancer Registries, leading to this investigation. Methods. To determine differential rates of accrual and retention, data from our trial are analyzed using descriptive statistics, logistic regression and multivariate analysis of variance. Ethnic differences in associations between covariables and attrition rates were tested by interaction factors. Process evaluation and focus group data were obtained to inform improvement strategies. Results. Of eligible subjects with viable phone numbers, 29% enrolled and 71% actively or passively refused. Enrolled Hispanic women were more likely to have less education ( p < 0.001), lower income ( p = 0.003), and more children ( p = 0.028). The dropout rate was associated with less education ( p = 0.012), foreign-birth ( p = 0.061), speaking Spanish in the home ( p = 0.012). Reported reasons for active refusal were ‘too busy’ for all women, ‘too emotional’ for non-Hispanic women, ‘too ill’ and phlebotomy for Hispanic women. Subsequent focus groups identified specific strategies to improve study materials. Conclusion. Although population-based recruitment of minority and underserved cancer patients continues to be a challenge, specific sociodemographic and disease variables can predict accrual difficulties. The information herein, taken together with disease and culturally relevant strategies, can be useful when recruiting underserved cancer survivors.

Social Workers as Patient Navigators for Breast Cancer Survivors: What Do African-American Medically Underserved Women Think of This Idea?

Patient navigation (PN) is a new initiative in health care aimed at reducing disparities by assisting patients in overcoming barriers within the health care system. As PN programs grow around the country, it is important to consult the key stakeholders in the development of these programs. The purpose of this qualitative study was to discuss the needs of medically underserved cancer patients and allow them the opportunity to provide input on models of care to meet their needs. Four focus groups were conducted in three major cities across Tennessee. Research participants (n = 36) were recruited by the staff in area cancer support programs and treatment programs across the state and through recruitment flyers at various treatment centers and community organizations. Findings revealed four key themes in the development of PN programs: (1) the PN needs to address access to quality care issues; (2) the PN needs to address the emotional and practical concerns of the cancer survivor; (3) the PN needs to address family concerns; (4) the PN needs to be involved across the continuum of care from time of diagnosis into long-term survivorship. Oncology social workers have a unique opportunity to meet the needs of medically underserved cancer patients through the PN movement. Our profession is a key stakeholder in this movement. We need to advocate for trained oncology social workers to actively pursue the role of patient navigators to ensure that the needs of medically underserved cancer survivors and their families are met.