Erica S. Breslau

Introduction: Understanding and Influencing Multilevel Factors Across the Cancer Care Continuum

Health care in the United States is notoriously expensive while often failing to deliver the care recommended in published guidelines. There is, therefore, a need to consider our approach to health-care delivery. Cancer care is a good example for consideration because it spans the continuum of health-care issues from primary prevention through long-term survival and end-of-life care. In this monograph, we emphasize that health-care delivery occurs in a multilevel system that includes organizations, teams, and individuals. To achieve health-care delivery consistent with the Institute of Medicines six quality aims (safety, effectiveness, timeliness, efficiency, patient-centeredness, and equity), we must influence multiple levels of that multilevel system. The notion that multiple levels of contextual influence affect behaviors through interdependent interactions is a well-established ecological view. This view has been used to analyze health-care delivery and health disparities. However, experience considering multilevel interventions in health care is much less robust. This monograph includes 13 chapters relevant to expanding the foundation of research for multilevel interventions in health-care delivery. Subjects include clinical cases of multilevel thinking in health-care delivery, the state of knowledge regarding multilevel interventions, study design and measurement considerations, methods for combining interventions, time as a consideration in the evaluation of effects, measurement of effects, simulations, application of multilevel thinking to health-care systems and disparities, and implementation of the Affordable Care Act of 2010. Our goal is to outline an agenda to proceed with multilevel intervention research, not because it guarantees improvement in our current approach to health care, but because ignoring the complexity of the multilevel environment in which care occurs has not achieved the desired improvements in care quality outlined by the Institute of Medicine at the turn of the millennium.

Improving Colorectal Cancer Screening in Primary Care Practice: Innovative Strategies and Future Directions

Colorectal cancer (CRC) screening has been supported by strong research evidence and recommended in clinical practice guidelines for more than a decade. Yet screening rates in the United States remain low, especially relative to other preventable diseases such as breast and cervical cancer. To understand the reasons, the National Cancer Institute and Agency for Healthcare Research and Quality sponsored a review of CRC screening implementation in primary care and a program of research funded by these organizations. The evidence base for improving CRC screening supports the value of a New Model of Primary Care Delivery: 1. a team approach, in which responsibility for screening tasks is shared among other members of the practice, would help address physicians’ lack of time for preventive care; 2. information systems can identify eligible patients and remind them when screening is due; 3. involving patients in decisions about their own care may enhance screening participation; 4. monitoring practice performance, supported by information systems, can help target patients at increased risk because of family history or social disadvantage; 5. reimbursement for services outside the traditional provider—patient encounter, such as telephone and e-mail contacts, may foster enhanced screening delivery; 6. training opportunities in communication, cultural competence, and use of information technologies would improve provider competence in core elements of screening programs. Improvement in CRC screening rates largely depends on the efforts of primary care practices to implement effective systems and procedures for screening delivery. Active engagement and support of practices are essential for the enormous potential of CRC screening to be realized.

Prevalence of Cancer Screening in Older, Racially Diverse Adults: Still Screening After All These Years

BACKGROUND While a great deal is known about cancer screening behaviors and trends in young and middle-aged adults, little is known about screening behaviors in older adults from different racial backgrounds. Our goal was to establish prevalence estimates and correlates of cancer screening, including physician recommendation in older (≥75 years), racially diverse adults. METHODS Data were analyzed from the National Health Interview Survey--an annual, in-person, nationwide survey used to track health trends in US civilians. The analytic sample included 49,575 individuals, of whom 1697 were 75 to 79 years old and 2376 were 80 years or older. Screening behaviors were examined according to the US Preventive Services Task Force recommendations for breast, cervical, colorectal, and prostate cancer screening. RESULTS Among adults aged 75 to 79 years, the percentage screened for cancer was as follows: colorectal, 57%; breast, 62%; cervical, 53%; and prostate, 56%. Among those 80 years or older, rates of screening ranged from a low of 38% for cervical cancer to a high of 50% for breast cancer. Although unadjusted screening prevalence rates differed by race/ethnicity, these differences were accounted for by low education attainment in the multivariate logistic regression model. Physician recommendation for a specific test was the largest predictor of screening. Over 50% of men and women older than 75 years report that their physicians continue to recommend screening. CONCLUSION A high percentage of older adults continue to be screened in the face of ambiguity of recommendations for this group.

Targeting of Mammography Screening According to Life Expectancy in Women Aged 75 and Older

To examine receipt of mammography screening according to life expectancy in women aged 75 and older.

Perspectives on behavioral and social science research on cancer screening

The first section in the current article offered several themes that characterize behavioral and social science cancer screening research to date and are likely to be relevant for studying the adoption and utilization of future screening technologies. The themes discussed included the link between epidemiologic surveillance and the priorities of intervention, the “at‐risk” perspective that often guides research on screening and initiatives to redress disparities, the need to monitor the diversification of personal screening histories, the range of intervention groups and study designs that can be tested, the importance of including key questions in population‐level surveys and national health objectives, and the desirability of clarifying the characteristics of cancer screening that make it an attractive field of study in its own right. The second section commented on emerging areas in which more research will allow additional lessons to be learned. The other articles in the current supplement presented many more lessons in a variety of areas, and other authors are encouraged to write similar articles that help to identify general themes characterizing cancer screening research. Cancer 2004. Published 2004 by the American Cancer Society.

Cancer screening practices among racially and ethnically diverse breast cancer survivors: results from the 2001 and 2003 California Health Interview Survey

IntroductionWomen treated for breast cancer are at increased risk for developing second or new cancers. This study examined behavioral and health care utilization practices associated with screening behaviors for mammography, Papanicolaou (Pap), home fecal occult blood test (FOBT) and endoscopy (flexible sigmoidoscopy, colonoscopy, proctoscopy) among racially and ethnically diverse female breast cancer survivors (BCS) and women without a cancer history.MethodsData from the 2001 and 2003 California Health Interview Survey (CHIS), a random-digit dial population-based survey of adult respondents was used to examine self-reported screening practices of BCS (n = 1,502) and women without a cancer history (n = 31,911).ResultsCompared to women without a cancer history, BCS reported more recent screening for all tests. Among BCS, Hispanics reported lowest screening for routine mammography (84.2% versus 68.9%; P < 0.05) but highest screening for Pap test (95.4% versus 85.4%; P > 0.01). White and Asian BCS reported more endoscopic examinations (58.9% versus 46.5%; P < 0.001; 61.2% versus 38.4%; P < 0.05) than the comparison population. After adjustment for demographic, socioeconomic, and health status differences, screening rates for BCS showed higher mammography use (odds ratio [OR] 1.97; 95% confidence interval [95% CI] 1.58–2.46), Pap test (OR 1.44; 95% CI 1.22–1.70), and endoscopic use (OR 1.35; 95% CI 1.16–1.58), but not higher for FOBT.ConclusionsEven though BCS generally had higher cancer screening rates than women without a cancer history, racial/ethnic differences exist among the type of test received. Narrowing these differences is essential to lessen disparities.Implications for cancer survivorsThe need for screening guidelines for BCS remains a high priority. Survivors would benefit from the frequency of screening for all cancers post-treatment.

Colon Cancer Screening in U.S. Adults Aged 65 and Older According to Life Expectancy and Age

To examine receipt of colorectal cancer (CRC) screening according to age and life expectancy (LE) in adults aged 65 and older.

Improving colorectal cancer screening through research in primary care settings.

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The Implementation Road Engaging Community Partnerships in Evidence-Based Cancer Control Interventions

445 Individual,

Changes in newspaper coverage about hormone therapy with the release of new medical evidence.

940 Institution,