Cynthia M. Mojica

What influences diagnostic delay in low-income women with breast cancer?

BACKGROUND Delayed diagnosis of breast cancer (BC) may contribute to adverse outcomes, such as reduced survival. The purpose of this study was to identify correlates of elapsed time between recognition of breast abnormalities and receipt of definitive diagnosis of BC among low-income women. METHODS Data were obtained from a cross-sectional study among a statewide sample of 921 low-income women with a new diagnosis of BC. Patients were grouped by whether their breast abnormalities were self-detected or healthcare system detected. Multivariate logistic regression analyses were used to examine associations between diagnostic delay and patient characteristics, patient communication, and system characteristics. RESULTS The self-detected group experienced much greater delay than the system-detected group (median intervals 80.5 vs. 31.5 days). African Americans had the longest intervals between symptom detection and diagnostic resolution; median delays in the self-detected and system-detected subgroups were 115 and 70 days, respectively, compared to 64 and 22 days for Caucasians. In multivariate analyses, African Americans had considerably greater odds of >60-day delay than Caucasians in both the self-detected (odds ratio [OR] 3.51) and system-detected (OR 5.36) groups. Greater perceived self-efficacy in interacting with healthcare providers was significantly associated with shorter delay among the self-detected group (OR 0.86). CONCLUSIONS Disparities in timely BC diagnosis between African Americans and Caucasians were pronounced in this uniformly low-income population of women. Women with self-detected abnormalities had markedly greater delays than those with healthcare system-detected abnormalities. Among this vulnerable group, increasing self-efficacy in interacting with healthcare providers may reduce diagnostic delays.

Validation of Self-reported Colorectal Cancer (CRC) Screening in a Study of Ethnically Diverse First-Degree Relatives of CRC Cases

Background: Evidence about the accuracy of self-reports of colorectal cancer (CRC) screening is lacking. We conducted a validation protocol in a randomized trial to increase CRC screening among high-risk individuals. Methods: First-degree relatives (n = 1,280) of CRC cases who were due for CRC screening were included in the parent trial. All subjects who completed the follow-up interview (n = 948) were asked to participate in validation activities. Self-reports of receipt of CRC screening during the 12-month study period were verified via physicians. Results: Although 60% (n = 567) verbally agreed, only 171 subjects (18% of original sample) returned the signed validation form with the physician name and contact information and a medical information release statement. The signed forms were mailed to physicians with a

Low-Income Women with Abnormal Breast Findings: Results of a Randomized Trial to Increase Rates of Diagnostic Resolution

10 incentive and the request to list the dates of recent CRC screening tests. One hundred twenty-three physicians (72% of physicians contacted, 13% of original sample) returned completed validation forms. Rates of agreement were low across all three screening types with physicians verifying self-reported screening for 29% of fecal occult blood testing, 56% of sigmoidoscopy, 55% of colonoscopy, and 57% of any screening test. Conclusion: Validation of self-report using the type of protocol we used for subjects receiving medical care in many community settings may be unfeasible and cost inefficient. Given the overall low participation rate in validation activities and considerable challenges in collecting high quality data, conclusions about the accuracy of self-reported CRC screening are difficult to make based on the results of this study. (Cancer Epidemiol Biomarkers Prev 2008;17(4):791–8)

Changes in risk perceptions in relation to self-reported colorectal cancer screening among first-degree relatives of colorectal cancer cases enrolled in a randomized trial.

Background: Timely diagnostic resolution of abnormal breast findings represents a critical step in efforts to reduce breast cancer morbidity and mortality. Yet, follow-up rates among resource poor populations are not optimal. Efforts to mitigate this disparity are needed. We report results of a randomized trial assessing the effectiveness of a patient support and navigation intervention in increasing timely diagnostic resolution of abnormal breast findings among indigent women. Methods: Women (n = 1,708) diagnosed with a breast abnormality at two public hospitals were randomized to an intervention or control group. The intervention, delivered through telephone, involved one call from a professional health worker and multiple calls from a lay health worker. The outcome, timely diagnostic resolution, defined as receipt of a definitive diagnosis (malignant or benign) within 6 months of the index referral, was assessed through medical chart audit. Results: Intent-to-treat analyses revealed no significant effect of the intervention on timely diagnostic resolution. Diagnostic resolution rates were 55% and 56%, respectively, in the intervention and control arms. The significant predictors were method of abnormality identification (odds ratio = 1.50) and location of first scheduled appointment (odds ratio = 0.62). Conclusions: The intervention was not effective in creating change within the County health system. Achieving optimum diagnostic follow-up may require more intensive interventions than the one tested. In addition, system-level rather than patient-level interventions may hold more promise. Impact: There are no randomized trials reported in the literature testing interventions to increase diagnostic follow-up of breast abnormalities. Future research might test patient and system-level interventions that can be sustained beyond the study period. Cancer Epidemiol Biomarkers Prev; 19(8); 1927–36. ©2010 AACR.

Neighborhood socio-economic disadvantage and race/ethnicity as predictors of breast cancer stage at diagnosis

OBJECTIVE This secondary data analysis was conducted to evaluate the applicability of the Risk Reappraisal Hypothesis, which has been proposed to explain the influence of performing a health behavior on perceived risk. Data were collected in the context of a randomized trial, which found that an individually tailored, multicomponent intervention was successful in increasing colorectal cancer (CRC) screening among first-degree relatives of CRC cases. METHOD The ethnically diverse study sample (N = 841; 29% Latino, 21% African American, 20% Asian) consisted of adult siblings and children (40-80 years) of CRC cases, identified through the California Cancer Registry. Data were collected at baseline and at 6- and 12-month follow-up. Changes in self-reported risk perception (perceived likelihood of developing CRC) were examined over the study period in relation to study condition and screening status. RESULTS Greater increases in perceived risk were observed among intervention versus control-group participants over the study period, but increases were limited to intervention participants who had not been screened. We also examined trajectories of perceived risk in relation to timing of screening receipt (e.g., before 6 months, 6-12 months, never). Continued upward shifts in risk were observed during the study period among intervention participants not screened during the study. In contrast, participants screened by 6 months displayed a reduction or leveling off in perceived risk between 6- and 12-month follow-up. CONCLUSION Results provide support for the applicability of the Risk Reappraisal Hypothesis within a high-risk sample enrolled in a CRC screening promotion trial. Future research is needed to explore the impact of short-term risk reductions on future CRC screening behavior.

Low-Income Women With Breast Abnormalities: System Predictors of Timely Diagnostic Resolution

BackgroundThis study investigated the role of key individual- and community-level determinants to explore persisting racial/ethnic disparities in breast cancer stage at diagnosis in California during 1990 and 2000.MethodsWe examined socio-demographic determinants and changes in breast cancer stage at diagnosis in California during 1990 and 2000. In situ, local, regional, and distant diagnoses were examined by individual (age, race/ethnicity, and marital status) and community (income and education by zip code) characteristics. Community variables were constructed using the California Cancer Registry 1990-2000 and the 1990 and 2000 U.S. Census.ResultsFrom 1990 to 2000, there was an overall increase in the percent of in situ diagnoses and a significant decrease in regional and distant diagnoses. Among white and Asian/Pacific Islander women, a significant percent increase was observed for in situ diagnoses, and significant decreases in regional and distant diagnoses. Black women had a significant decrease in distant -stage diagnoses, and Hispanic women showed no significant changes in any diagnosis during this time period. The percent increase of in situ cases diagnosed between 1990 and 2000 was observed even among zip codes with low income and education levels. We also found a significant percent decrease in distant cases for the quartiles with the most poverty and least education.ConclusionsHispanic women showed the least improvement in breast cancer stage at diagnosis from 1990 to 2000. Breast cancer screening and education programs that target under-served communities, such as the rapidly growing Hispanic population, are needed in California.

An Experimental Test of the Effect of Incentives on Recruitment of Ethnically Diverse Colorectal Cancer Cases and Their First-Degree Relatives into a Research Study

BACKGROUND Incomplete or delayed diagnostic resolution of breast abnormalities suspicious for cancer may contribute to poor breast cancer outcomes. We examine system predictors of timely diagnostic resolution in low-income, mostly Latina women with breast abnormalities at two Los Angeles County public hospitals. METHODS We collected medical record data on 1,671 women. The outcome--timely diagnostic resolution--was defined as receipt of definitive diagnosis (malignant or benign) within six months of the index referral. Predictors of the outcome were examined with bivariate and multivariate logistic regression models. RESULTS Only 56% of women received timely diagnostic resolution; however, the proportion was higher at Hospital B (67%) compared to Hospital A (51%). The effect of predictors differed by hospital. At Hospital B, the odds of timely diagnostic resolution were lower for women with self-identified abnormalities (P <.033) and higher for women referred to Radiology rather than Surgery for their first appointment (P <.005). At Hospital A, the odds of timely diagnostic resolution were higher for women with self-identified abnormalities (P <.043) and lower for women referred to Radiology rather than Surgery for their first appointment (P <.001). CONCLUSIONS Rates and predictors of timely diagnostic resolution differed by hospital. System barriers may be a function of referral processes and patient tracking. Interventions may need to be tailored to a hospitals unique culture.

Breast, Cervical, and Colorectal Cancer Education and Navigation Results of a Community Health Worker Intervention

Background: Optimizing participant response rates is important for obtaining representative samples and the timely completion of studies. It is a common practice to use participant incentives to boost response rates, but few studies have systematically examined their effectiveness, particularly among minority groups. Methods: We experimentally tested three incentive strategies for their effectiveness in improving response rates among colorectal cancer cases (n = 3,816) and their relatives (n = 2,353). A 2 × 2 × 2 factorial design compared (a) registered versus first class mail, (b)

Prostate cancer screening among ethnically diverse first-degree relatives of prostate cancer cases

5 cash with the initial mailing (yes/no), and (c)

Assessing Media Access and Use Among Latina Adolescents to Inform Development of a Physical Activity Promotion Intervention Incorporating Text Messaging

20 promise (yes/no) upon completion of the information form (for cases) or