Abraham Aragones

A Randomized Controlled Trial of a Multilevel Intervention to Increase Colorectal Cancer Screening among Latino Immigrants in a Primary Care Facility

BACKGROUNDLatino immigrants face a higher burden of colorectal cancer (CRC) and screening rates are low.OBJECTIVETo assess the effectiveness of a multilevel intervention in increasing the rate of CRC screening among Latino immigrants.DESIGNA randomized controlled trial, with randomization at the physician level.PARTICIPANTSPairs of 65 primary care physicians and 65 Latino immigrant patients participated, 31 in the intervention and 34 in the control group.INTERVENTIONCRC educational video in Spanish on a portable personal digital video display device accompanied by a brochure with key information for the patient, and a patient-delivered paper-based reminder for their physician.MEASUREMENTSCompleted CRC screening, physician recommendation for CRC screening, and patient adherence to physician recommended CRC screening.RESULTSThe overall rate of completed screening for CRC was 55% for the intervention and 18% for the control group (p = 0.002). Physicians recommended CRC screening for 61% of patients in the intervention group versus 41% in the control group (p = 0.08). Of those that received a recommendation, 90% in the intervention group adhered to it versus 26% in the control group (p = 0.007).CONCLUSIONSThe intervention was successful in increasing rates of completed CRC screening primarily through increasing adherence after screening was recommended. Additional efforts should focus on developing new strategies to increase physician recommendation for CRC screening, while employing effective patient adherence interventions.

Parental education and text messaging reminders as effective community based tools to increase HPV vaccination rates among Mexican American children.

Objective Latino populations, particularly Mexican-Americans who comprise 65% of the Latinos in the U.S., are disproportionately affected by HPV-related diseases. The HPV vaccination completion rates remain low, well below the Healthy People 2020 goal. In this study we assessed the effect of parental education and a text messaging reminder service on HPV vaccine completion rates among eligible children of Mexican American parents. Study design Nonequivalent group study of Mexican parents of HPV vaccine eligible children attended the Health Window program at the Mexican Consulate in New York City, a non-clinical, trusted community setting, during 2012–2013. 69 parents received HPV education onsite, 45 of whom also received a series of text message vaccination reminders. We measured HPV vaccination completion of the youngest eligible children of Mexican parents as the main outcome. Results 98% of those in the education plus text messaging group reported getting the first dose of the vaccine for their child and 87% among those in the educational group only (p = 0.11). 88% of those receiving the 1st dose in the text messaging group reported completing the three doses versus 40% in the educational group only (p = 0.004). Conclusions Parental text messaging plus education, implemented in a community based setting, was strongly associated with vaccine completion rates among vaccine-eligible Mexican American children. Although pilot in nature, the study achieved an 88% series completion rate in the children of those who received the text messages, significantly higher than current vaccination levels.

Association of socioeconomic and practical unmet needs with self-reported nonadherence to cancer treatment appointments in low-income Latino and Black cancer patients

Objective. Treatment adherence, with minimal numbers of missed appointments, is an important determinant of survival among cancer patients. This study aims to determine if unmet financial, logistic, and supportive care needs predict self-reported adherence to cancer treatment appointments of chemotherapy and/or radiation among low-income ethnic minority patients. Design. The sample included 1098 underserved Latino and Black patients recruited from cancer clinics in New York City through the Cancer Portal Project. Participants completed a survey which included sociodemographic, health-related questions and a needs assessment, in their preferred language. Patients’ adherence to chemotherapy and/or radiation treatment appointments was assessed using a self-report. Results. A sample of 1098 patients (581 Latino and 517 Black cancer patients) was recruited. Forty-two Latino cancer patients (7.4%) and 78 Black cancer patients (15.5%) reported missing treatment appointments. Patients, who experienced four or more unmet needs (odds ratios [OR] = 2.02–3.36), and those with unmet housing needs (OR = 3.10–3.31), were more likely to report missing cancer treatment appointments, regardless of their ethnicity/race. Black patients with unmet supportive care (OR = 2.27) and health insurance needs (OR = 3.80) were more likely to miss appointments. Amongst Latinos, legal health-related issues (OR = 2.51) was a significant predictor of missed appointments. Conclusions. Among ethnic minority cancer patients, unmet socioeconomic and supportive care needs, housing needs in particular, predicted patient-reported missed radiation, and/or chemotherapy appointments. Future research should focus on exploring the impact of practical and supportive unmet needs on adherence and development of interventions aiming to improve cancer treatment adherence.

Attitudes Surrounding Implementation of the HPV Vaccine for Males among Primary Care Providers Serving Large Minority Populations

Background. Minority populations are disproportionally affected by human papilloma virus (HPV) infection. We examined the attitudes of primary care providers serving large minority populations towards the implementation of the HPV vaccine for males in their practices. Design. Cross-sectional survey of randomly selected primary care providers in Brooklyn, N.Y. Results. Ninety-three eligible providers were surveyed, of whom 62% were pediatricians. Sixty-two percent of all participants reported that they were very likely or will definitely be offering the vaccine to their male patients. The rate was higher among providers who reported higher numbers of minority patient population and who acknowledged high risk among their patient population. Conclusions. Primary care providers included in the study were likely to report incorporation of the HPV vaccine for males as part of their regular clinical practice. Their adoption and dissemination of the vaccine will be a significant factor in determining whether its full benefits are achieved.

Health-Related Quality of Life of Food-Insecure Ethnic Minority Patients With Cancer

PURPOSE The association between food insecurity and health-related quality of life (QOL) of racial/ethnic minority patients with cancer has not been examined. The purpose of this study is to determine the relationship between food insecurity and health-related QOL reported by racial/ethnic minority patients with cancer. METHODS A consecutive sample of 1,390 underserved ethnic minority patients receiving cancer care in 10 cancer clinics and hospitals in New York City participated in this study. Health-related QOL was measured by the Functional Assessment of Cancer Therapy-General (FACT-G) and food security was assessed by the US Department of Agriculture Core Food Security Module. RESULTS Of the 1,390 patients, 581 (41.8%) were classified as food secure, 571 (41.1%) with low food security, and 238 (17.1%) with very low food security. Health-related QOL decreased with each lower food security level. Patient self-reported physical, functional, social, and emotional well-being subscale scores decrease significantly with increasing food insecurity. After controlling for demographic and medical-related factors, the decreases in QOL, physical, functional, social and emotional well-being scores with increasing food insecurity remained significant. CONCLUSION Food insecurity was associated with lower QOL in this sample of underserved racial/ethnic minority patients with cancer. Underserved ethnic minority patients diagnosed with cancer are a vulnerable patient population, at significant risk for inadequate food access and the related lower QOL.

Cancer Screening Practices among Physicians Serving Chinese Immigrants

Chinese immigrants in the United States are broadly affected by cancer health disparities. We examined the cancer screening attitudes and practices of physicians serving Chinese immigrants in the New York City (NYC) area by mailing a cancer screening survey, based on current guidelines, to a random sample of physicians serving this population. Fifty three physicians (44%) completed the survey. Seventy-two percent reported following the guidelines for breast cancer, 35% for cervical cancer screening, and 45% for all colorectal cancer screening tests. Sixty-eight percent of physicians were satisfied with their current rates of cancer screening with their Chinese immigrant patient population. Physicians serving the Chinese community in NYC follow cancer screening guidelines inadequately. Cancer screening rates in this population could likely be increased by interventions that target physicians and improve awareness of guidelines and recommended best practices.

Psychosocial correlates of appointment keeping in immigrant cancer patients.

This study aims to determine the psychosocial correlates of self-reported adherence to cancer treatment appointments and treatment delays and interruptions. The sample included 622 immigrant cancer patients from New York City. Patients completed a survey that included sociodemographic and health-related questions, questions assessing missed appointments and delays/or interruptions, and quality of life and depression scales. After controlling for sociodemographic characteristics, having a positive depression screen and poor physical and emotional well-being were significant predictors of missed appointments and delays and/or interruptions of treatment. Non-adherence to treatment appointments in immigrant cancer patients is a complex outcome related to important modifiable or treatable factors.

Abstract C47: Hispanic/Latino lung cancer patients overcoming barriers for accessing cancer care: A qualitative study

Introduction: Hispanic/Latino lung cancer patients typically present at a more advanced stage and are less likely to undergo surgical resection. Prior studies have identified multiple barriers for seeking diagnostic work-up though few studies have focused on difficulties encountered in navigating the health care system. Our study aim was to identify obstacles experienced by Hispanic/Latino patients in accessing timely lung cancer care, as well as the strategies employed to overcome these obstacles. Methods: We conducted semi-structured individual interviews with Hispanic/Latino patients diagnosed with lung cancer to explore their comfort with health care professionals, perceptions about barriers to care, and the process by which they made treatment-related decisions. We analyzed the data through thematic text analysis. Four coders independently summarized the data for conceptual themes focusing on challenges overcome in accessing care, and solutions to address these barriers. The coders then met to reach consensus on overall themes describing perceived difficulties in access to care and strategies used to surmount such barriers. Results: Participants were 24 Stage I-IV Hispanic/Latino lung cancer patients (79% female, ages 20-87, M=63 years), treated at a tertiary cancer center, equally divided as primary English and Spanish speakers. As expected, they reported experiencing multiple patient-, provider-, and health care system-level barriers to cancer care. Patient-level barriers included difficulties understanding providers9 recommendations, comprehending medical jargon, lack of knowledge about lung cancer treatment options, emotional distress, and being overwhelmed which led to denial of diagnosis and confusion about treatment options. Provider-level barriers included providers overlooking symptoms, and lack of detailed explanation about lung cancer symptoms, disease course, and treatment options. Health care system level-barriers included fragmentation with lack of continuity of care, variable primary care provider (PCP)-patient relationships, use of numerous primary care facilities resulting in gaps in medical history and current health status, disagreement among providers about optimal treatment, and PCPs9 referrals to multiple specialists, all leading to delayed diagnosis and access to treatment. Strategies devised to address barriers to care included: using family members as patient advocates and cultural brokers to help patients access providers, navigate the health care system, schedule appointments, determine the best treatment course, and translate physician discussions; and being assertive to pursue more responsive providers and specialized cancer treating facilities, seeking second opinions, asking providers to clarify treatment options and explain medical jargon, independently researching effective treatments, and finding creative solutions to finance care. Surprisingly, ability to pay for care was rarely perceived as being an obstacle for accessing cancer care. No significant differences were found between primary Spanish and English-speaking participants regarding barriers to care and solution strategies. Conclusions: Hispanic/Latino lung cancer patients identified successful strategies in overcoming barriers to accessing specialized cancer care. Future studies on improving the cultural competence and communication skills of the healthcare workforce, involving family caregivers, and patient navigation are warranted. Citation Format: William Alago, Elyse Shuk, Ana-Motta Moss, George Brandon, Abraham Aragones, Idalid Franco, Roberto Valentin, Mutiat A. Akinsemoyin, Melissa Rodriguez, Hector Velez, Tyler Barretto, Uriel Castaneda, Jamie Ostroff. Hispanic/Latino lung cancer patients overcoming barriers for accessing cancer care: A qualitative study. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr C47. doi:10.1158/1538-7755.DISP13-C47

Abstract A59: Sociodemographic predictors for poor quality of life among urban minority oncology patients

Introduction: This study investigates sociodemographic predictors of low quality of life among a cohort of predominately underserved, minority oncology patients. Given the positive effects of a higher quality of life on patients’ survival rates, as well as the growing body of data supporting the effectiveness of psychosocial interventions in improving both quality of life and survival rates, the ability to quickly identify patients at risk for lower quality of life is critical. Establishing specific risk factors has the potential to help providers connect patients for whom psychosocial interventions may be especially beneficial to support services early in the course of their treatment. Methods: We analyzed demographic, sociocultural, and quality of life data – measured with the Functional Assessment of Cancer Therapy Scale (General) (FACT-G) – from a consecutive sample of 265 oncology patients participating in an individualized patient-navigation program at the Center for Immigrant Health and Cancer Disparities at Memorial Sloan-Kettering Cancer Center. Data was collected in-person during enrollment interviews by bilingual program staff. Results: The majority of the patients were female (68%); were born in Latin America (47%), the Caribbean (21%), the U.S. (16%), or Asia (9%); and preferred to speak English (43%), Spanish (38%), or Chinese (Mandarin, Cantonese, or Fujianese) (8%) in the healthcare setting. More than a third of patients had less than a high school education (39%) and 22% were unemployed before their diagnosis. The most common cancer diagnoses were breast (32%), colorectal (12%), gynecological (cervical, uterine, ovarian, or vulvar) (12%), lymphoma (6%), lung (5%), and prostate (5%). Patients who were foreign-born and who preferred to speak a language other than English in the healthcare setting were more likely to report lower quality of life (p = .015, p = .002, respectively). Similarly, patients who said they spoke English well, very well, or fluently had a higher quality of life than those who spoke it not well or not at all (p = .004). Patients who were employed at the time of interview and/or reported higher monthly incomes also had a significantly higher quality of life (p = .040, p = Conclusions: These results highlight the fact that low-income immigrant oncology patients are at a higher risk for lower quality of life than their higher-income and U.S.-born peers, which may potentially put them at risk for poorer outcomes. While there has been significant progress in developing psychosocial interventions such as support groups and counseling tailored to oncology patients, much less has been done to target the specific and significant psychosocial needs of immigrant and minority patients. Given the fact that lower-income and minority patients continue to experience both lower quality of life and poorer outcomes than their higher-income and white counterparts, more research and interventions are needed to address the interrelationship between quality of life and outcomes, particularly the effect that targeted improvements in quality of life may have on the survival rates of low-income, immigrant, and minority patients. Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):A59.

Letter to the Editor Regarding Aranguri et al.

To the Editor:—“Patterns of Communication through Interpreters: A Detailed Sociolinguistic Analysis,”1 seemingly addresses the important issue of interpreters and their impact on provider-patient communication. The authors state, “many of the structural difficulties exist regardless of who is interpreting for whom, based more in the nature of interpreter discourse itself and the time constraints of a medical interaction than through the specifics of the interpreter.” This is an alarming, and false, conclusion based on the data. This study only documents the negative impact of untrained interpreters on health communication. Immigrant patient advocates and the health care system are working hard to ensure that Title VI of the Civil Rights Act2 is enforced to decrease immigrant health disparities. Published data, used to help inform such service delivery, need to be scientifically rigorous. This study, with its sweeping conclusions based on untrained interpreters, could be potentially misleading. There are marked differences between trained, professional interpreters and the ad hoc interpreters they studied. Because of this, the Department of Justice “Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition against National Origin Discrimination Affecting Limited English Proficient Persons”3 strongly discourages the use of untrained interpreters. The Center for Immigrant Health has conducted a randomized controlled study of outcomes by various interpreting modalities, as well as in same language encounters. In fact, our audiotape analyses of 214 encounters reveal that in visits using a trained remote simultaneous interpreter, physicians give an equal number of instructions per visit as they do in Spanish language concordant encounters (mean # per encounter 14.29, SD 6.9; 14.33, SD 6.33). Usual and customary interpreting, however, results in significantly fewer instructions (mean # per encounter 11.9, SD 6.17). Trained, professional medical interpreters are key to the elimination of health care disparities.