Session
Series 2: Innovative Analyses of Cancer Risk and Outcomes in Diverse Populations
APHA 2022 Annual Meeting and Expo
Abstract
Individual and System-Level Factors Affecting Participation in Lung Cancer Genomic Testing
APHA 2022 Annual Meeting and Expo
Polygenic risk scores (PRS) are an emerging precision medicine tool in lung cancer (LC) that can be used to identify individuals who are at a high risk of developing the disease. However, the benefit of PRS may not be equal among non-European populations as they are under-represented in genome-wide association studies (GWAS) that serve as the basis for PRS development. In this study, semi-structured interviews were conducted with 30 African-American and non-Hispanic White smokers to elucidate individual-level differences in barriers/facilitators of genomic testing for LC risk. Guided by the Consolidated Framework for Implementation Research (CFIR) we also interviewed 15 healthcare providers to identify barriers and facilitators to the uptake of LC PRS in clinical care. Interviews were digitally audio-recorded, transcribed, and coded using Rapid Qualitative Analysis. Regardless of race/ethnicity, individuals noted that a lack of familiarity with PRS and medical terminology made it difficult for them to evaluate benefits of testing. They also expressed concern about not knowing if there were any actions they could take after receiving high risk results that could meaningfully decrease their cancer risk. Providers noted several inner-setting barriers to LC PRS uptake including structural characteristics (time constraints), organizational culture (disagreement about who should deliver LC PRS information), and implementation climate (lack of resources, infrastructure). They also wanted more information and training to communicate LC PRS results to patients. Overall, this study is an important first step toward prioritizing greater racial/ethnic diversity in genetic studies and realizing the full and equitable potential of LC PRS.
Abstract
Disproportionate Burden of Survival among Blacks/AA Children with Gliobalstoma: A Large Cohort Evidence
APHA 2022 Annual Meeting and Expo
Background: Pediatric cancer remains the leading cause of disease-related mortality among children, 0-14 years in the United States. While glioblastoma, characterized as glioblastoma multiforme (GBM) or diffuse astrocytoma is a common and aggressive malignant neoplasm among adults, however GBM incidence remains rare among children, implying challenges in the understanding of its morphologic and molecular sequencing as well as specific subtypes in a reliable and meaningful therapeutics. GMB, implying 12-15% of brain/CNS cumulative incidence (CmI) well as 50% to 60% of astrocytoma CmI, abnormal cellular proliferation through proto-oncogene and tumor suppressor genes mutations, adversely impact programmed cell death, apoptosis. The current study aimed to assess the CmI, mortality and survival of children with GBM by race and sex.
Method: A retrospective cohort design was utilized to examine pediatric glioblastoma mortality and survival. The Surveillance Epidemiology and End Result (SEER) data between 2000 and 2018 were utilized. The variables of examined were race, sex, tumor grade, tumor size, median household income, and urbanity. The binomial regression model was used for racial mortality differentials modeling. The univariable and multivariable Cox Proportional Hazard models were used for survival racial differentials modeling.
Results: The CmI varied by race and sex. Females were observed with lower CmI, 42.0% relative to their male counterparts, 58.0%. Similarly, a disproportionate mortality was observed in pediatric GBM, 84.4% v.15.6%, as well as racial differentials, with excess mortality observed among blacks/AA (93.8% v. 6.2%) relative to whites, 83.0% v. 17.0%., X2(3)=10.2, p = 0.02. With respect to GBM mortality risk, compared to Whites, Blacks/AA children were 13% more likely to die, Risk Ratio (RR) = 1.13, 95% CI,1.04-1.22.However, Asian/PI children were 17% less likely to experience mortality relative to their white counterparts, RR=0.83, 95%CI, 0.75-1.15. Regarding pediatric GBM survival, racial variances were observed with Blacks/AA indicative of survival disadvantage relative to their white counterparts, Hazard Ratio (HR) = 1.11, 95%CI, 1.00-1.61. Additionally, Black/AA male children were 44% more likely to experience mortality as a function time (survival), compared to their white male counterparts, HR=1.44, 95%CI, 1.00-2.21. After controlling for the potential confoundings namely age, sex, median income, tumor grade and urbanicity, the survival disadvantage of Blacks/AA slightly marginalized, adjusted HR (aHR)=1.06, 99%CI, 0.72-1.56.
Conclusion: In a large cohort of children with pediatric glioblastoma, Black/AA children and male children experienced survival disadvantage relative to their White and female counterparts. These findings are suggestive of the need to examine epigenomic modulations in GBM.
Abstract
Trends in cancer mortality among Black individuals in the United States, 1999-2019
APHA 2022 Annual Meeting and Expo
Background: Cancer is the second leading cause of mortality in the United States (U.S.). Despite national declines in cancer mortality, Black individuals continue to have the highest cancer death rates.
Objective: We examined national trends in cancer mortality from 1999-2019 among Black individuals by demographic characteristics and then compared cancer death rates in 2019 with other racial/ethnic groups.
Method: This serial cross-sectional study used U.S. national death certificate data obtained from the National Center for Health Statistics and included all cancer deaths among individuals aged ≥20 from January 1999 to December 2019. Trends in age-standardized mortality rates and average annual percent change (AAPC) in rates were estimated by cancer type, age, sex, and race/ethnicity.
Results: During 1999-2019, over one million cancer deaths occurred among Black individuals. The overall cancer death rate significantly declined among Black men (AAPC: -2.6%/year) and women (-1.5%/year). Death rates declined for most cancer types, with the most rapid declines observed for lung cancer (-3.8%/year) among men and stomach cancer (-3.4%/year) among women. We observed a significant increase in liver cancer deaths among men and women aged 65-79 (AAPC: 3.8%, men; 1.8%, women). Additionally, there were increasing trends in uterus cancer mortality among women aged 35-49 (2.9%/year), 50-64 (2.3%/year), and 65-79 (1.6%/year). In 2019, Black men and women had the highest cancer mortality rates when compared to their White, Asian and Pacific Islander, American Indian and Alaska Native, and Hispanic/Latino counterparts.
Discussion: Though there were substantial declines in cancer death rates among Black individuals during 1999-2019, higher cancer death rates among Black men and women compared to other racial/ethnic groups persisted in 2019. Targeted interventions are needed to eliminate social inequalities that contribute to Black individuals having higher cancer mortality.
Abstract
Analysis of the Hispanic/Latinx community in Southern Arizona for willingness to participate in cancer-related clinical research
APHA 2022 Annual Meeting and Expo
Background: The University of Arizona Cancer Center (UACC), the only NIH-designated Comprehensive Cancer Center in Arizona, has a catchment area consisting of Arizona’s five southern counties: Cochise, Pima, Pinal, Santa Cruz, and Yuma. Four of these counties fall along the U.S.-Mexico border and 40% of residents are of Hispanic/Latinx background; an under-resourced and underrepresented population in cancer research experiencing structural barriers. To promote cancer health equity, increasing the community’s participation in clinical cancer research is crucial.
Objective: To describe and evaluate Southern AZ’s Hispanic/Latinx community’s interest and potential involvement in cancer research considering their previous research experience.
Methods: A bilingual community-based survey was collaboratively developed to assess community health priorities, knowledge of basic science, and experience with and willingness to participate in clinical cancer research. Aiming to enroll 300 participants by the end of 2022, current recruitment strategies include in-person events and the use of physical and virtual flyers posted at local businesses, clinics, and media. The survey is administered over the phone and responses are recorded by research personnel.
Results: Preliminary data (n=23) from this ongoing study shows that most (n=16) participants have neither experience with medical research nor cancer research (n=19). In contrast, a majority (n=14) are willing to participate in cancer research while all are willing to provide some type of bio-sample. At least 50% of participants would provide a blood, urine, fecal, tumor, and/or tissue sample while 100% are willing to provide saliva samples.
Discussion: Based on the preliminary analysis, participants are willing to be involved in cancer research and have an overall interest in participating. However, many still have no experience with medical research, indicating a gap in awareness and accessibility of clinical studies. As this study continues, survey findings will be used as community feedback to advise cancer researchers on their clinical study design.
Abstract
Neighborhood and Racial Disparities in Triple Negative Breast Cancer
APHA 2022 Annual Meeting and Expo
Substantial racial disparities in breast cancer outcomes have been previously described, with the most severe among individuals with triple negative breast cancer (TNBC). Other studies have shown that TNBC has a high propensity to recur rapidly, be diagnosed at younger ages, and shows inferior response to standard-of-care chemotherapies and poorer prognosis than other subtypes of breast cancer. Nationally, TNBC incidence is more than double in non-Hispanic Black, compared to non-Hispanic white women. Studies of multiple health conditions and care processes have found that neighborhood socioeconomic position is a key driver of health disparities. We examined (1) the extent to which neighborhood socioeconomic position (measured by the area deprivation index or ADI) is associated with TNBC and (2) the distribution of ADI across racial/ethnic groups among women with TNBC and other subtypes of breast cancer.
We combined tumor registry data on all breast cancer cases at the MetroHealth System from 2007-2020 (N=2,282) with electronic health record data and geocoded area-based measures from the American Community Survey. Using the R sociome package, we extracted the ADI for the year nearest to patient diagnosis year. We performed cross-tabulation and group comparisons.
Of the 2,284 breast cancer cases, 193 (8.5%) were TNBC. TNBC was most common (p<0.001) among Non-Hispanic Black patients (n=103, 53.7%) vs Non-Hispanic White (n=89, 46.4%), and Hispanic patients (n=16, 8.3%). TNBC patients had a lower median age at diagnosis of 58.5 vs. 60.5 for other breast cancer patients (p<0.05). TNBC cases were more than twice as likely to have died of breast cancer (11.9% vs. 4.2% p<0.001). Higher ADI was associated with having TNBC (Mean ADI=110.2) vs. other forms of breast cancer (Mean ADI=105.4, p<0.01, comparative distribution is presented in Figure 1). A far higher proportion of non-Hispanic Black women with TNBC (43.7%) vs Non-Hispanic White women with TNBC (12.8%) resided in the most disadvantaged (highest quartile of ADI) neighborhoods (p<0.001). To our knowledge, this is the first study to examine prevalence of TNBC vs. other breast cancer subtypes across distributions of neighborhood socioeconomic position. Our findings suggest that both neighborhood socioeconomic position and race are powerfully associated with having TNBC vs. other breast cancer subtypes. The burden of TNBC appears to be highest among African American women in the most socioeconomically disadvantaged neighborhoods. These findings suggest that a complex interplay of social conditions and biological disease characteristics contribute to racial disparities in breast cancer outcomes.
Abstract
Results of Training on Digital Health Literacy for Genetic Counseling Training Programs
APHA 2022 Annual Meeting and Expo
Background
The authors developed a pilot training for genetic counseling students outlining factors that affect patients’ digital health literacy, including personal context, social determinants of health and the digital health landscape. The training included activities, small group discussions, and described tools to improve students’ communication skills and help their future patients improve their individual health literacy. Additionally, the training highlighted a FORCE program designed to help patients understand media reports about cancer research.
Methods
Ten certified genetic counselor training programs hosted pilot training session, which ranged between 80 to 120 minutes depending on the program’s schedule. Students completed evaluation surveys. Instructors participated in interviews about their perceptions of the training.
Results and Conclusions
Students’ and instructors’ responses indicated that the training presented new and relevant information in an engaging manner. Students reported that the training would help them communicate with patients about their healthcare needs and help patients evaluate online health information. Additionally, some instructors reported that their faculty did not have expertise on digital health literacy, and that the training would be a useful addition to their curricula. Students and directors recommended retaining the content, flow and presentation approach, activities and discussions, appealing graphics, and emphasis on the practical implications of material presented. Suggestions for improving the training included: dividing the training into modules, minimizing potential for self-consciousness about making mistakes, providing clear explanations about how implementing recommended practices could improve health communication, and offering descriptions of how students could apply the information in their future practice.
Abstract
Racism and Structural Bias Experienced by Black People in Healthcare Utilization
APHA 2022 Annual Meeting and Expo
Background:
Racial disparities in cancer screenings, early diagnosis, clinical trials enrollment, and cancer outcomes are confirmed in the literature, and the disproportionate rates of increased morbidity and mortality in Black populations are further evidence of structural racism and bias in healthcare. This project focused on the experience, access, and reported utilization of healthcare services by members of the Black community. Analysis is needed to identify and evaluate these experiences in order to improve equity, access, and outcomes for Black individuals.
Approach:
Seattle Cancer Care Alliance (SCCA), a National Comprehensive Cancer Network (NCCN)-designated cancer center, and a group of population health nursing students from Seattle University (SU) collaborated on a year-long clinical internship to better understand the healthcare experiences of Black individuals. A literature review was performed on the incidence and outcomes of cancer diagnoses in Black individuals and a semi-structured, open-ended qualitative interview tool was designed. Students conducted a total of seven interviews, with a purposive sample of convenience, for qualitative analysis. Interviews elucidated how Black individuals describe their healthcare experiences and provided insight into the barriers encountered in seeking and receiving care.
Lessons Learned:
Content analysis of seven interviews confirmed three distinct themes:
1.Interviewees’ definitions of health and illness were informed by past and present individual, familial, and cultural experiences.
2.Interviewees consistently reported feeling unheard, unseen, dismissed, and being treated differently than their white peers by healthcare providers.
3.Racism and bias from providers influenced decision-making, often resulting in delays or missed opportunities to access healthcare services.
Implications:
Utilization of primary care services is influenced by structural racism and bias and is reinforced by an absence of race-concordant care providers. To achieve equity in healthcare delivery for Black, Indigenous and people of color (BIPOC) it is paramount that schools of nursing and medicine support and cultivate recruitment and retention of BIPOC students. Additionally, medical and nursing curriculum changes are essential to building capacity in cross-cultural and intersectionality in care delivery for the best health outcomes for BIPOC populations.
Abstract
Feasibility, acceptability, and perceived appropriateness of an audiovisual tool to motivate and educate about stool-based colorectal cancer screening among Black Kentuckians
APHA 2022 Annual Meeting and Expo
Background: Knowledge of colorectal cancer (CRC) screening options beyond colonoscopy is suboptimal in Black populations. Subsequently, utilization of stool-based tests, such as the fecal immunochemical test (FIT), is low. To educate and motivate FIT completion, we adapted a novel audiovisual tool originally developed for Appalachian populations to reflect the values and needs of Black Kentuckians.
Methods: We partnered with five Black churches in Louisville and conducted two rounds of focus groups in each. Initial focus groups presented participants (n = 39) with the Appalachian iteration of the tool to determine necessary adaptations. Using these data, we revised the tool and conducted follow-up focus groups with both returning (n = 27) and new (n = 17) participants to assess the adapted tool’s feasibility, acceptability, and appropriateness.
Results: Suggested revisions from first-round focus groups included changes to the tool’s icons and logos, re-recording of the audio component, and inclusion of vignettes from both CRC survivors and trusted Black medical providers. In follow-up focus groups, the following themes about the tool were most prevalent: (1) increased perceptions of screening simplicity; (2) lack of technical jargon; and (3) vocal clarity of test instructions when recorded by Black voices. Perceived feasibility, acceptability, and appropriateness of the tool were all high (mean scores of 4.76, 4.65, and 4.71 on 5-point scales, respectively).
Discussion: To reduce CRC screening disparities, educational materials must be developed collaboratively to ensure they reflect local context. An audiovisual tool to educate and motivate FIT completion was perceived to be more acceptable and appropriate when it represented Black Kentuckians’ values, voices, and needs. Future research will utilize the audiovisual tool as one of multiple strategies in a community-based CRC education and screening intervention.
Abstract
Colorectal cancer self-efficacy in African Americans: preliminary findings at baseline from the Test Up Now Education Program (TUNE-UP) Study
APHA 2022 Annual Meeting and Expo
Background: African Americans experience colorectal cancer (CRC) health disparities as compared to whites. Test Up Now Education Program (TUNE-UP) is a behavioral clinical trial to test the effectiveness of a community health advisor (CHA) intervention to increase stool-based screening in African Americans who are patients of community health centers (CHC) in North Florida. Baseline characteristics of study patients are reported in this preliminary study.
Methods: To be eligible for the TUNE-UP study, participants cannot be up-to-date with CRC screening. Following baseline survey completion, all participants are offered the stool-based screening from their CHC. The baseline survey collects patient information on demographic characteristics, communication with health professionals, as well as CRC-related measures on self-efficacy and cultural constructs using validated measures. A four-item self-efficacy measure for CRC screening using 4-point Likert scale responses is a secondary outcome (Vernon et al., 1997). Descriptive statistics and measures of association were calculated.
Results: From April 2021 to April 2022, 71 participants (44% male and 56% female) were recruited to the trial using CHC messaging. Only 27% of participants reported they had ever received CRC screening. When asked if a doctor had discussed different CRC screening tests, 45% responded “no or “never. More than 65% had never done a stool-based screening at home, and 30% did not know how to do it. The mean value for self-efficacy was 1.9 (SD = 0.56), indicating medium self-efficacy for screening, and many participants listed lack of health insurance as the primary reason for not getting screened in an open-ended question. In addition, men have lower self-efficacy compared to women.
Discussion: Given medium self-efficacy for screening, lack of provider discussions on the screening tests, low insurance coverage, and low rates of previous CRC screening, this behavioral clinical trial aims to improve accessible stool-based screening in this CHC patient population.
Abstract
Enhancing health equity capacity in state comprehensive cancer control: A training curriculum
APHA 2022 Annual Meeting and Expo
The American Cancer Society’s Comprehensive Cancer Control Initiative (ACS CCC) has been funded since 2001 to improve capacity for CDC’s National Comprehensive Cancer Control Program (NCCCP) recipients and their coalitions through technical assistance and training (TAT). In 2021, the ACS CCC developed a workshop curriculum to improve health equity in cancer planning. [METHOD] Curriculum design aligned with the Interactive Systems Framework and highlighted health equity frameworks and resources to inform cancer planning. The evaluation included pre- and post-session surveys. Univariate survey analyses including measures of central tendency and frequencies were conducted using STATA 15. [RESULTS] In partnership with the Centers for Disease Control and Prevention, ACS Health Equity experts, and the County Health Rankings & Roadmaps, the curriculum shared strategies to implement health equity guiding principles, frameworks, evidence-based interventions to address cancer inequities and disparities in communities served by comprehensive cancer control programs and coalitions. 34 program directors attended the two workshop sessions. The Advancing Health Equity in Cancer Control Planning Regional Workshops used similar measures to identify the participants content knowledge gains and satisfaction. Across the four sessions, most participants (87.4%) would recommend the workshop to a colleague. The virtual workshop used multiple modalities including didactic, group breakout to apply strategies, and opportunities to learn promising practices from peers. The average post-session knowledge score was 91.6% with a mean gain of 21.8 percentage points (42%). This represents a strong increase in the content areas covered during the workshop. Session 2, which focused on applying strategies and evaluating with a health equity lens, showed the greatest increases at 30.5 percentage points (45.7-61.0%). [CONCLUSION] This workshop approach enhanced health equity knowledge and capacity in cancer planning and implementation. Results show a strong contribution to capacity building for comprehensive cancer programs and coalitions.