Caitlin C. Murphy

Taking the next step: a systematic review and meta-analysis of physical activity and behavior change interventions in recent post-treatment breast cancer survivors

Research has shown that recent post-treatment breast cancer survivors face significant challenges around physical activity as they transition to recovery. This review examined randomized controlled trials targeting physical activity behavior change in breast cancer survivors <5xa0years post-treatment and described (1) characteristics of interventions for breast cancer survivors as well as (2) effect size estimates for these studies. A systematic search was conducted following PRISMA guidelines with Medline, PubMed, PsycINFO, CINAHL, and Scopus databases. Data were abstracted for primary intervention strategies and other details (e.g., setting, duration, theory use). A subgroup analysis was conducted to assess intensity of exercise supervision/monitoring and intervention effectiveness. The search produced 14 unique behavior intervention trials from the US and abroad published 2005–2013. The mean sample size was 153 participants per study. All interventions included moderate-intensity activities plus various behavioral change strategies. Most interventions were partially or entirely home based. The overall standardized mean difference was 0.47 (0.23, 0.67) with pxa0<xa00.001. Most interventions were effective in producing short-term behavior changes in physical activity, but varied greatly relative to intervention strategies and intensity of supervision/monitoring. Highly structured interventions tended to produce larger behavior change effects overall, but many larger effect sizes came from interventions supported by phone counseling or e-mail. We observed that ‘more’ may not be better in terms of direct supervision/monitoring in physical activity behavior interventions. This may be important in exploring less resource-intensive options for effective behavior change strategies for recent post-treatment survivors.

An assessment of benefits and harms of hepatocellular carcinoma surveillance in patients with cirrhosis

Although surveillance ultrasound and alpha fetoprotein (AFP) tests have minimal direct harm, downstream harms from follow‐up tests must be weighed against surveillance benefits when determining the value of hepatocellular carcinoma (HCC) screening programs. Our studys aims were to characterize prevalence and correlates of surveillance benefits and harms in cirrhosis patients undergoing HCC surveillance. We conducted a retrospective cohort study among patients with cirrhosis followed at a safety‐net health system between July 2010 and July 2013. We recorded surveillance‐related benefits, defined as early tumor detection and curative treatment, and surveillance‐related physical harms, defined as computed tomography or magnetic resonance imaging scans, biopsies, or other procedures performed for false‐positive or indeterminate surveillance results. Sociodemographic and clinical correlates of surveillance harms were evaluated using multivariable logistic regression. We identified 680 patients with cirrhosis, of whom 78 (11.5%) developed HCC during the 3‐year study period. Of the 48 (61.5%) HCCs identified by surveillance, 43.8% were detected by ultrasound, 31.2% by AFP, and 25.0% by both surveillance tests. Surveillance‐detected patients had a higher proportion of early HCC (70.2% vs. 40.0%; P = 0.009), with no difference in tumor stage between ultrasound‐ and AFP‐detected tumors (P = 0.53). Surveillance‐related physical harms were observed in 187 (27.5%) patients, with a higher proportion of ultrasound‐related harm than AFP‐related harm (22.8% vs. 11.4%; P < 0.001). Surveillance‐related harms were associated with elevated ALT (odds ratio [OR], 1.87; 95% confidence interval [CI], 1.26‐2.76), thrombocytopenia (OR, 2.06; 95% CI, 1.26‐3.38), and hepatology subspecialty care (OR, 1.63; 95% CI, 1.09‐2.42). Conclusion: Over one fourth of patients with cirrhosis experience physical harm for false‐positive or indeterminate surveillance tests—more often related to ultrasound than AFP. Interventions are needed to reduce surveillance‐related harm to increase the value of HCC screening programs in clinical practice. (Hepatology 2017;65:1196‐1205).

Race and Insurance Differences in the Receipt of Adjuvant Chemotherapy Among Patients With Stage III Colon Cancer

PURPOSEnAlthough the incidence and mortality of colon cancer in the United States has declined over the past two decades, blacks have worse outcomes than whites. Variations in treatment may contribute to mortality differentials.nnnMETHODSnPatients diagnosed with stage III colon cancer were randomly sampled from the SEER program from the years 1990, 1991, 1995, 2000, 2005, and 2010. Patients were categorized as non-Hispanic white (n = 835) or black (n = 384). Treatment data were obtained from a review of the medical records, and these data were verified through contact with the original treating physicians. Log-binomial regression models were used to estimate the association between race and receipt of adjuvant chemotherapy. Effect modification by insurance was assessed with use of single referent models.nnnRESULTSnReceipt of adjuvant chemotherapy among both white and black patients increased from the period encompassing the years 1990 and 1991 (white, 58%; black, 45%) to the year 2005 (white, 72%; black, 71%) and then decreased in the year 2010 (white, 66%; black, 57%). There were marked racial disparities in the time period of 1990 to 1991 and again in 2010, with black patients less likely to receive adjuvant chemotherapy as compared with white patients (risk ratio [RR], .82; 95% CI, .72 to .93). For black patients, receipt of adjuvant chemotherapy did not differ across insurance categories (RR for private insurance, .80; 95% CI, .69 to .93; RR for Medicare, .84; 95% CI, .69 to 1.02; and RR for Medicaid, .84; 95% CI, .69 to 1.02), although a larger proportion had Medicaid in all years of the study as compared with white patients.nnnCONCLUSIONnThe chemotherapy differential narrowed after the time period of 1990 to 1991, but our findings suggest that the disparity reemerged in 2010. Recent decreases in chemotherapy use may be due, in part, to the economic downturn and an increase in Medicaid coverage.

Patterns of Colorectal Cancer Care in the United States: 1990–2010

BACKGROUNDnColorectal cancer (CRC) mortality has declined in the United States, in part because of advances in treatment. Few studies have evaluated the adoption of therapies and temporal changes in patterns of care.nnnMETHODSnPatients age 20 years and older diagnosed with stages II/III CRC were randomly sampled from the population-based Surveillance, Epidemiology, and End Results (SEER) program in 1990-1991, 1995, 2000, 2005, and 2010 (n = 7057). Therapy was obtained from medical records and physician verification. We described the receipt of chemotherapy and radiation therapy. Log-binomial regression was used to examine factors associated with therapy. All statistical tests were two-sided.nnnRESULTSnChemotherapy receipt among colon cancer patients increased from 1990 (stage II: 22.5%; stage III: 56.3%) to 2005 (stage II: 32.1%; stage III: 72.4%) and declined slightly in 2010 (stage II: 29.3%; stage III: 66.4%). Stage III colon cancer patients who were older (vs <55 years, 75-79 years: risk ratio [RR] 0.81, 95% confidence interval [CI] = 0.71 to 0.91; ≥80 years: RR = 0.37, 95% CI = 0.28 to 0.47) or had a comorbidity score of 2 or higher (vs 0, RR = 0.56, 95% CI = 0.35 to 0.87) received chemotherapy less often. Receipt of radiation therapy by rectal cancer patients increased across all years from 45.5% to 66.1%. Increasing age (vs <55 years, 75-79 years: RR = 0.59, 95% CI = 0.47 to 0.74; ≥80 years: RR = 0.33, 95% CI = 0.25 to 0.45) was associated with lower chemoradiation use among stage II/III rectal cancer patients.nnnCONCLUSIONnOur findings demonstrate increased adoption of chemotherapy and radiation therapy for colon and rectal cancer patients and differences in therapy by age, comorbidity, and diagnosis year. Increased receipt of these therapies in the community may further reduce CRC mortality.

Underuse and Overuse of Colonoscopy for Repeat Screening and Surveillance in the Veterans Health Administration

BACKGROUND & AIMSnRegular screening with colonoscopy lowers colorectal cancer incidence and mortality. We aimed to determine patterns of repeat and surveillance colonoscopy and identify factors associated with overuse and underuse of colonoscopy.nnnMETHODSnWe analyzed data from participants in a previous Veterans Health Administration (VHA) study who underwent outpatient colonoscopy at 25 VHA facilities between October 2007 and September 2008 (nxa0= 1455). The proportion of patients who received a follow-up colonoscopy was calculated for 3 risk groups, which were defined on the basis of the index colonoscopy: no adenoma, low-risk adenoma, or high-risk adenoma.nnnRESULTSnColonoscopy was overused (used more frequently than intervals recommended by guidelines) by 16% of patients with no adenomas, 26% with low-risk adenomas, and 29% with high-risk adenomas. Most patients with high-risk adenomas (54%) underwent colonoscopy after the recommended interval or did not undergo colonoscopy. Patients who received a follow-up recommendation that was discordant with guidelines were more likely to undergo colonoscopy too early (no adenoma odds ratio [OR], 3.80; 95% confidence interval [CI], 2.31-6.25 and low-risk adenoma OR, 5.28; 95% CI, 1.88-14.83). Receipt of colonoscopy at nonacademic facilities was associated with overuse among patients without adenomas (OR, 5.26; 95% CI, 1.96-14.29) or with low-risk adenomas (OR, 3.45; 95% CI, 1.52-7.69). Performance of colonoscopies by general surgeons vs gastroenterologists (OR, 2.08; 95% CI, 1.02-4.23) and female sex of the patient (OR, 3.28; 95% CI, 1.06-10.16) were associated with overuse of colonoscopy for patients with low-risk adenomas. No factors examined were associated with underuse of colonoscopy among patients with high-risk adenomas.nnnCONCLUSIONSnIn an analysis of patients in the VHA system, more than one fourth of patients with low-risk adenomas received follow-up colonoscopies too early, whereas more than one half of those with high-risk adenomas did not undergo surveillance colonoscopy as recommended. Our findings highlight the need for system-level improvements to facilitate the appropriate delivery of colonoscopy that is based on individual risk.

Decrease in Incidence of Colorectal Cancer Among Individuals 50 Years or Older After Recommendations for Population-based Screening

Background & Aims The incidence of colorectal cancer (CRC) in the United States is increasing among adults younger than 50 years, but incidence has decreased among older populations after population‐based screening was recommended in the late 1980s. Blacks have higher incidence than whites. These patterns have prompted suggestions to lower the screening age for average‐risk populations or in blacks. At the same time, there has been controversy over whether reductions in CRC incidence can be attributed to screening. We examined age‐related and race‐related differences in CRC incidence during a 40‐year time period. Methods We determined the age‐standardized incidence of CRC from 1975 through 2013 by using the population‐based Surveillance, Epidemiology, and End Results (SEER) program of cancer registries. We calculated incidence for 5‐year age categories (20–24 years through 80–84 years and 85 years or older) for different time periods (1975–1979, 1980–1984, 1985–1989, 1990–1994, 1995–1999, 2000–2004, 2005–2009, and 2010–2013), tumor subsite (proximal colon, descending colon, and rectum), and stages at diagnosis (localized, regional, and distant). Analyses were stratified by race (white vs black). Results There were 450,682 incident cases of CRC reported to the SEER registries during the entire period (1975–2013). Overall incidence was 75.5/100,000 white persons and 83.6/100,000 black persons. CRC incidence peaked during 1980 through 1989 and began to decrease in 1990. In whites and blacks, the decreases in incidence between the time periods of 1980–1984 and 2010–2013 were limited to the screening‐age population (ages 50 years or older). Between these time periods, there was 40% decrease in incidence among whites compared with 26% decrease in incidence among blacks. Decreases in incidence were greater for cancers of the distal colon and rectum, and reductions in these cancers were greater among whites than blacks. CRC incidence among persons younger than 50 years decreased slightly between 1975–1979 and 1990. However, among persons 20–49 years old, CRC incidence increased from 8.3/100,000 persons in 1990–1994 to 11.4/100,000 persons in 2010–2013; incidence rates in younger adults were similar for whites and blacks. Conclusions On the basis of an analysis of the SEER cancer registries from 1975 through 2013, CRC incidence decreased only among individuals 50 years or older between the time periods of 1980–1984 and 2010–2013. Incidence increased modestly among individuals 20–49 years old between the time periods of 1990–1994 and 2010–2013. The decision of whether to recommend screening for younger populations requires a formal analysis of risks and benefits. Our observed trends provide compelling evidence that screening has had an important role in reducing CRC incidence.

Use of Theory in Behavior Change Interventions: An Analysis of Programs to Increase Physical Activity in Posttreatment Breast Cancer Survivors.

Objective. Theory use may enhance effectiveness of behavioral interventions, yet critics question whether theory-based interventions have been sufficiently scrutinized. This study applied a framework to evaluate theory use in physical activity interventions for breast cancer survivors. The aims were to (1) evaluate theory application intensity and (2) assess the association between extensiveness of theory use and intervention effectiveness. Methods. Studies were previously identified through a systematic search, including only randomized controlled trials published from 2005 to 2013, that addressed physical activity behavior change and studied survivors who were <5 years posttreatment. Eight theory items from Michie and Prestwich’s coding framework were selected to calculate theory intensity scores. Studies were classified into three subgroups based on extensiveness of theory use (Level 1 = sparse; Level 2 = moderate; and Level 3 = extensive). Results. Fourteen randomized controlled trials met search criteria. Most trials used the transtheoretical model (n = 5) or social cognitive theory (n = 3). For extensiveness of theory use, 5 studies were classified as Level 1, 4 as Level 2, and 5 as Level 3. Studies in the extensive group (Level 3) had the largest overall effect size (g = 0.76). Effects were more modest in Level 1 and 2 groups with overall effect sizes of g = 0.28 and g = 0.36, respectively. Conclusions. Theory use is often viewed as essential to behavior change, but theory application varies widely. In this study, there was some evidence to suggest that extensiveness of theory use enhanced intervention effectiveness. However, there is more to learn about how theory can improve interventions for breast cancer survivors.

Effect of Colonoscopy Outreach vs Fecal Immunochemical Test Outreach on Colorectal Cancer Screening Completion: A Randomized Clinical Trial

Importance Mailed fecal immunochemical test (FIT) outreach is more effective than colonoscopy outreach for increasing 1-time colorectal cancer (CRC) screening, but long-term effectiveness may need repeat testing and timely follow-up for abnormal results. Objective Compare the effectiveness of FIT outreach and colonoscopy outreach to increase completion of the CRC screening process (screening initiation and follow-up) within 3 years. Design, Setting, and Participants Pragmatic randomized clinical trial from March 2013 to July 2016 among 5999 participants aged 50 to 64 years who were receiving primary care in Parkland Health and Hospital System and were not up to date with CRC screenings. Interventions Random assignment to mailed FIT outreach (nu2009=u20092400), mailed colonoscopy outreach (nu2009=u20092400), or usual care with clinic-based screening (nu2009=u20091199). Outreach included processes to promote repeat annual testing for individuals in the FIT outreach group with normal results and completion of diagnostic and screening colonoscopy for those with an abnormal FIT result or assigned to colonoscopy outreach. Main Outcomes and Measures Primary outcome was screening process completion, defined as adherence to colonoscopy completion, annual testing for a normal FIT result, diagnostic colonoscopy for an abnormal FIT result, or treatment evaluation if CRC was detected. Secondary outcomes included detection of any adenoma or advanced neoplasia (including CRC) and screening-related harms (including bleeding or perforation). Results All 5999 participants (median age, 56 years; women, 61.9%) were included in the intention-to-screen analyses. Screening process completion was 38.4% in the colonoscopy outreach group, 28.0% in the FIT outreach group, and 10.7% in the usual care group. Compared with the usual care group, between-group differences for completion were higher for both outreach groups (27.7% [95% CI, 25.1% to 30.4%] for the colonoscopy outreach group; 17.3% [95% CI, 14.8% to 19.8%] for FIT outreach group), and highest in the colonoscopy outreach group (10.4% [95% CI, 7.8% to 13.1%] for the colonoscopy outreach group vs FIT outreach group; Pu2009<u2009.001 for all comparisons). Compared with usual care, the between-group differences in adenoma and advanced neoplasia detection rates were higher for both outreach groups (colonoscopy outreach group: 10.3% [95% CI, 9.5% to 12.1%] for adenoma and 3.1% [95% CI, 2.0% to 4.1%] for advanced neoplasia, Pu2009<u2009.001 for both comparisons; FIT outreach group: 1.3% [95% CI, −0.1% to 2.8%] for adenoma and 0.7% [95% CI, −0.2% to 1.6%] for advanced neoplasia, Pu2009<u2009.08 and Pu2009<u2009.13, respectively), and highest in the colonoscopy outreach group (colonoscopy outreach group vs FIT outreach group: 9.0% [95% CI, 7.3% to 10.7%] for adenoma and 2.4% [95% CI, 1.3% to 3.3%] for advanced neoplasia, Pu2009<u2009.001 for both comparisons). There were no screening-related harms in any groups. Conclusions and Relevance Among persons aged 50 to 64 years receiving primary care at a safety-net institution, mailed outreach invitations offering FIT or colonoscopy compared with usual care increased the proportion completing CRC screening process within 3 years. The rate of screening process completion was higher with colonoscopy than FIT outreach. Trial Registration clinicaltrials.gov Identifier: NCT01710215

Underuse of surveillance colonoscopy in patients at increased risk of colorectal cancer.

OBJECTIVES:Colorectal cancer incidence and mortality have declined over the past two decades, and much of this improvement is attributed to increased use of screening. Approximately 25% of patients who undergo screening colonoscopy have premalignant adenomas that require removal and follow-up colonoscopy. However, there are few studies of the use of surveillance colonoscopy in increased risk patients with previous adenomas.METHODS:We conducted a cross-sectional study to examine factors associated with underuse of surveillance colonoscopy among patients who are at increased risk for colorectal cancer. The study population consisted of patients with previously identified adenomatous polyps and who were due for follow-up colonoscopy. Patients were categorized as attenders (n=100) or non-attenders (n=104) on the basis of completion of follow-up colonoscopy. Telephone surveys assessed the use of surveillance colonoscopy across domains of predisposing patient characteristics, enabling factors, and patient need. Mutlivariable logistic regression was used to identify factors associated with screening completion.RESULTS:Perceived barriers, perceived benefits, social deprivation, and cancer worry were associated with attendance at colonoscopy. Higher benefits (odds ratio (OR) 2.37, 95% confidence interval (CI) 1.04–5.41) and cancer worry (OR 1.73, 95% CI 1.07–2.79) increased the odds of attendance at follow-up colonoscopy, whereas greater barriers (OR 0.49, 95% CI 0.28–0.88) and high social deprivation (≥2; OR 0.09, 95% CI 0.01–0.76) were associated with lower odds.CONCLUSIONS:Our results suggest that multilevel factors contribute to the use of surveillance colonoscopy in higher risk populations, many of which are amenable to intervention. Interventions, such as patient navigation, may help facilitate appropriate use of surveillance colonoscopy.

Racial Differences in Obesity Measures and Risk of Colorectal Adenomas in a Large Screening Population

Obesity is an important risk factor for colorectal neoplasia; however, little research exists on racial differences in obesity measures [body mass index (BMI), waist circumference (WC), and waist-hip-ratio (WHR)] associated with adenoma. We used data from the Diet and Health Studies, Phases III–V to examine differences in the contribution of obesity measures to adenoma risk by race. The sample consisted of 2184 patients (1806 white, 378 African American) undergoing outpatient colonoscopy for average risk screening. Covariates included demographics, health history, and validated measures of diet and physical activity. Among whites, BMI [overweight: odds ratio (OR) = 1.31, 95% confidence interval (CI), 1.00–1.71; obese: OR = 1.89, 95% CI, 1.41–2.56), WC (OR = 1.47, 95% CI, 1.09–1.99), and WHR (OR = 1.60, 95% CI, 1.24–2.06) were associated with adenomas. BMI was not associated with adenomas in African Americans. Although the CIs were wide, the point estimates for WHR (OR = 1.07, 95% CI, 0.51–2.22) and WC (OR = 1.04, 95% CI, 0.56–1.92) were slightly elevated above the null. BMI was associated with adenomas only among whites, whereas WHR and WC appeared to be important risk factors among both races. Racial differences in adenoma risk may be due to differences in body shape and weight and/or fat distribution.