Jasmin A. Tiro

Reported drop in mammography : is this cause for concern?

Timely screening with mammography can prevent a substantial number of deaths from breast cancer. The objective of this brief was to ascertain whether recent use of mammography has dropped nationally.

What do women in the U.S. know about human papillomavirus and cervical cancer

Background: Women need to understand the link between human papillomavirus (HPV) and cervical cancer in order to make appropriate, evidence-based choices among existing prevention strategies (Pap test, HPV DNA test, and HPV vaccine). Assessment of the publics knowledge in nationally representative samples is a high priority for cervical cancer control. Objectives: To assess factors associated with U.S. womens awareness of HPV and knowledge about its link to cervical cancer. Methods: Analyzed cross-sectional data from women ages 18 to 75 years old responding to the 2005 Health Information National Trends Survey (n = 3,076). Results: Among the 40% of women who had ever heard about HPV, <50% knew it caused cervical cancer; knowledge that HPV was sexually transmitted and caused abnormal Pap tests was higher (64% and 79%, respectively). Factors associated with having heard about HPV included: younger age, being non–Hispanic White, higher educational attainment, exposure to multiple health information sources, trusting health information, regular Pap tests, awareness of changes in cervical cancer screening guidelines, and having tested positive for HPV. Accurate knowledge of the HPV-cervical cancer link was associated with abnormal Pap and positive HPV test results. Conclusions: Awareness about HPV among U.S. women is low. Having heard about HPV did not ensure accurate knowledge. Strategies for communicating accurate information about HPV transmission, prevention, and detection as well as risk and treatment of cervical cancer are needed. (Cancer Epidemiol Biomarkers Prev 2007;16(2):288–94)

Detection of hepatocellular carcinoma at advanced stages among patients in the HALT-C trial: where did surveillance fail?

OBJECTIVES:Only 40% of patients with hepatocellular carcinoma (HCC) are diagnosed at an early stage, suggesting breakdowns in the surveillance process. The aim of our study was to assess the reasons behind surveillance process failures among patients in the Hepatitis C Antiviral Long-Term Treatment against Cirrhosis Trial (HALT-C), which prospectively collected HCC surveillance data on a large cohort of patients.METHODS:Binary regression analysis was used to identify predictors of consistent surveillance, which was defined as having an ultrasound and alpha-fetoprotein every 12 months. Surveillance failures among patients who developed HCC were classified into one of three categories: absence of screening, absence of follow-up, or absence of detection.RESULTS:Over a mean follow-up of 6.1 years, 692 (68.9%) of 1,005 patients had consistent surveillance. Study site was the strongest predictor of consistent surveillance (P<0.001). After adjusting for study site, patient-level predictors of consistent surveillance included platelet count >150,000/mm3 (hazard ratio (HR) 1.28; 95% confidence interval (CI): 1.05–1.56) and complete clinic visit adherence (HR 1.72, 95% CI: 1.11–2.63). Of 83 patients with HCC, 23 (27.7%) were detected beyond Milan criteria. Three (13%) had late-stage HCC due to the absence of screening, 4 (17%) due to the absence of follow-up, and 16 (70%) due to the absence of detection.CONCLUSIONS:Surveillance process failures, including absence of screening or follow-up, are common and potentially contribute to late-stage tumors in one-third of cases. However, the most common reason for finding HCC at a late stage was an absence of detection, suggesting better surveillance strategies are needed.

Failure rates in the hepatocellular carcinoma surveillance process

Hepatocellular carcinoma (HCC) surveillance is underutilized among patients with cirrhosis. Understanding which steps in the surveillance process are not being conducted is essential for designing effective interventions to improve surveillance rates. The aim of our study was to characterize reasons for failure in the HCC surveillance process among a cohort of cirrhotic patients with HCC. We conducted a retrospective cohort study of cirrhotic patients diagnosed with HCC at a large urban safety-net hospital between 2005 and 2011. Patients were characterized by receipt of HCC surveillance over a two-year period before HCC diagnosis. Among patients without HCC surveillance, we classified reasons for failure into four categories: failure to recognize liver disease, failure to recognize cirrhosis, failure to order surveillance, and failure to complete surveillance despite orders. Univariate and multivariate analyses were conducted to identify predictors of failures. We identified 178 patients with HCC, of whom 20% had undergone surveillance. There were multiple points of failure—20% had unrecognized liver disease, 19% had unrecognized cirrhosis, 38% lacked surveillance orders, and 3% failed to complete surveillance despite orders. Surveillance was more likely among patients seen by hepatologists [OR, 6.11; 95% confidence interval (CI), 2.5–14.8] and less likely in those with alcohol abuse (OR, 0.14; 95% CI, 0.03–0.65). Although a retrospective analysis in a safety-net hospital, our data suggest that only one in five patients received surveillance before HCC diagnosis. There are multiple points of failure in the surveillance process, with the most common being failure to order surveillance in patients with known cirrhosis. Future interventions must target multiple failure points in the surveillance process to be highly effective. Cancer Prev Res; 5(9); 1124–30. ©2012 AACR.

Some methodologic lessons learned from cancer screening research

Credible and useful methodologic evaluations are essential for increasing the uptake of effective cancer screening tests. In the current article, the authors discuss selected issues that are related to conducting behavior change interventions in cancer screening research and that may assist researchers in better designing future evaluations to increase the credibility and usefulness of such interventions. Selection and measurement of the primary outcome variable (i.e., cancer screening behavior) are discussed in detail. The report also addresses other aspects of study design and execution, including alternatives to the randomized controlled trial, indicators of study quality, and external validity. The authors conclude that the uptake of screening should be the main outcome when evaluating cancer screening strategies; that researchers should agree on definitions and measures of cancer screening behaviors and assess the reliability and validity of these definitions and measures in different populations and settings; and that the development of methods for increasing the external validity of randomized designs and reducing bias in nonrandomized studies is needed. Cancer 2004.

Reliability and Validity of a Questionnaire to Measure Colorectal Cancer Screening Behaviors: Does Mode of Survey Administration Matter?

Valid and reliable self-report measures of cancer screening behaviors are important for evaluating efforts to improve adherence to guidelines. We evaluated test-retest reliability and validity of self-report of the fecal occult blood test (FOBT), sigmoidoscopy (SIG), colonoscopy (COL), and barium enema (BE) using the National Cancer Institute colorectal cancer screening (CRCS) questionnaire. A secondary objective was to evaluate reliability and validity by mail, telephone, and face-to-face survey administration modes. Consenting men and women, 51 to 74 years old, receiving care at a multispecialty clinic for at least 5 years who had not been diagnosed with colorectal cancer were stratified by prior CRCS status and randomized to survey mode (n = 857). Within survey mode, respondents were randomized to complete a second survey at 2 weeks, 3 months, or 6 months. Comparing self-report with administrative and medical records, concordance estimates were 0.91 for COL, 0.85 for FOBT, 0.85 for SIG, and 0.92 for BE. Overall sensitivity estimates were 0.91 for COL, 0.82 for FOBT, 0.76 for SIG, and 0.56 for BE. Specificity estimates were 0.91 for COL, 0.86 for FOBT, 0.89 for SIG, and 0.97 for BE. Sensitivity and specificity varied little by survey mode for any test. Report-to-records ratio showed overreporting for SIG (1.1), COL (1.15), and FOBT (1.57), and underreporting for BE (0.82). Reliability at all time intervals was highest for COL; there was no consistent pattern according to survey mode. This study provides evidence to support the use of the National Cancer Institute CRCS questionnaire to assess self-report with any of the three survey modes. (Cancer Epidemiol Biomarkers Prev 2008;17(4):758–67)

Factorial Validity and Invariance of a Survey Measuring Psychosocial Correlates of Colorectal Cancer Screening among African Americans and Caucasians

Background: Psychosocial constructs are widely used to predict colorectal cancer screening and are targeted as intermediate outcomes in behavioral intervention studies. Reliable and valid instruments for measuring general colorectal cancer screening psychosocial constructs are needed; yet, few studies have conducted psychometric analyses. This study replicated a five-factor structure for 16 theory-based, general colorectal cancer screening items measuring salience and coherence, cancer worries, perceived susceptibility, response efficacy, and social influence. In addition, we examined factorial invariance across race and sex. Methods: African American and Caucasian patients (n = 1,413) attending an urban, primary care clinic were included in this study. These individuals completed a baseline survey as part of a colorectal cancer screening intervention trial. Single and multigroup confirmatory factor analyses using maximum-likelihood estimation were done. Results: The five-factor general colorectal cancer screening model provided excellent fit and was invariant across race-sex subgroups. Conclusions: The findings of invariance across sex and race subgroups support the use of these scales to measure group differences. (Cancer Epidemiol Biomarkers Prev 2005;14(12):2855-61)

Too much of a good thing? Physician practices and patient willingness for less frequent pap test screening intervals

Background:Recent guidelines recommend longer Pap test intervals. However, physicians and patients may not be adopting these recommendations. Objectives:Identify (1) physician and practice characteristics associated with recommending a less frequent interval, and (2) characteristics associated with womens willingness to adhere to a 3-year interval. Research Design:We used 2 national surveys: (1) a 2006/2007 National Survey of Primary Care Physicians for physician cervical cancer screening practices (N = 1114), and (2) the 2005 Health Information Trends Survey for womens acceptance of longer Pap intervals (N = 2206). Measures and Methods:Physician recommendation regarding Pap intervals was measured using a clinical vignette involving a 35-year-old with no new sexual partners and 3 consecutive negative Pap tests; associations with independent variables were evaluated with logistic regression. In parallel models, we evaluated womens willingness to follow a 3-year Pap test interval. Results:A minority of physicians (32%) have adopted—but more than half of women are willing to adopt—3-year Pap test intervals. In adjusted models, physician factors associated with less frequent screening were: serving a higher proportion of Medicaid patients, white, non-Hispanic race, fewer years since medical school graduation, and US Preventive Services Task Force being very influential in physician clinical practice. Women were more willing to follow a 3-year interval if they were older, but less willing if they had personal or family experiences with cancer or followed an annual Pap test schedule. Conclusions:Many women are accepting of a 3-year interval for Pap tests, although most primary care physicians continue to recommend shorter intervals.

Racial, Social, and Clinical Determinants of Hepatocellular Carcinoma Surveillance

OBJECTIVES Less than 1 in 5 patients receive hepatocellular carcinoma surveillance; however, most studies were performed in racially and socioeconomically homogenous populations, and few used guideline-based definitions for surveillance. The study objective was to characterize guideline-consistent hepatocellular carcinoma surveillance rates and identify determinants of hepatocellular carcinoma surveillance among a racially and socioeconomically diverse cohort of cirrhotic patients. METHODS We retrospectively characterized hepatocellular carcinoma surveillance among cirrhotic patients followed between July 2008 and July 2011 at an urban safety-net hospital. Inconsistent surveillance was defined as at least 1 screening ultrasound during the 3-year period, annual surveillance was defined as screening ultrasounds every 12 months, and biannual surveillance was defined as screening ultrasounds every 6 months. Univariate and multivariate analyses were conducted to identify predictors of surveillance. RESULTS Of 904 cirrhotic patients, 603 (67%) underwent inconsistent surveillance. Failure to recognize cirrhosis was a significant barrier to surveillance use (P < .001). Inconsistent surveillance was associated with insurance status (odds ratio [OR], 1.43; 95% confidence interval [CI], 1.03-1.98), multiple primary care visits per year (OR, 2.63; 95% CI, 1.86-3.71), multiple hepatology visits per year (OR, 3.75; 95% CI, 2.64-5.33), African American race (OR, 0.61; 95% CI, 0.42-0.99), nonalcoholic steatohepatitis cause (OR, 0.60; 95% CI, 0.37-0.98), and extrahepatic cancer (OR, 0.43; 95% CI, 0.24-0.77). Only 98 (13.4%) of 730 patients underwent annual surveillance, and only 13 (1.7%) of 786 had biannual surveillance. CONCLUSIONS Only 13% of patients with cirrhosis receive annual surveillance, and less than 2% of patients receive biannual surveillance. There are racial and socioeconomic disparities, with lower rates of hepatocellular carcinoma surveillance among African Americans and underinsured patients.

Practice Patterns and Attitudes of Primary Care Providers and Barriers to Surveillance of Hepatocellular Carcinoma in Patients with Cirrhosis

BACKGROUND & AIMS Fewer than 20% of patients with cirrhosis undergo surveillance for hepatocellular carcinoma (HCC), therefore these tumors often are detected at late stages. Although primary care providers (PCPs) care for 60% of patients with cirrhosis in the United States, little is known about their practice patterns for HCC surveillance. We investigated factors associated with adherence to guidelines for HCC surveillance by PCPs. METHODS We conducted a web-based survey of all 131 PCPs at a large urban hospital. The survey was derived from validated surveys and pretested among providers; it included questions about provider and practice characteristics, self-reported rates of surveillance, surveillance test and frequency preference, and attitudes and barriers to HCC surveillance. RESULTS We obtained a clinic-level response rate of 100% and a provider-level response rate of 60%. Only 65% of respondents reported annual surveillance and 15% reported biannual surveillance of patients for HCC. Barriers to HCC surveillance included not being up-to-date with HCC guidelines (68% of PCPs), difficulties in communicating effectively with patients about HCC surveillance (56%), and more important issues to manage in the clinic (52%). Approximately half of PCPs (52%) reported using ultrasound or measurements of α-fetoprotein in surveillance; 96% said that this combination was effective in reducing HCC-related mortality. However, many providers incorrectly believed that clinical examination (45%) or levels of liver enzymes (59%) or α-fetoprotein alone (89%) were effective surveillance tools. CONCLUSIONS PCPs have misconceptions about tests to detect HCC that contribute to ineffective surveillance. Reported barriers to surveillance include suboptimal knowledge about guidelines, indicating a need for interventions, including provider education, to increase HCC surveillance effectiveness.