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Rationale and Objectives Limited exposure to radiology by medical students can perpetuate negative stereotypes and hamper recruitment efforts. The purpose of this study is to understand medical students’ perceptions of radiology and how they change based on medical education and exposure. Materials and Methods A single-institution mixed-methods study included four groups of medical students with different levels of radiology exposure. All participants completed a 16-item survey regarding demographics, opinions of radiology, and perception of radiology stereotypes. Ten focus groups were administered to probe perceptions of radiology. Focus groups were coded to identify specific themes in conjunction with the survey results. Results Forty-nine participants were included. Forty-two percent of participants had positive opinions of radiology. Multiple radiology stereotypes were identified, and false stereotypes were diminished with increased radiology exposure. Opinions of the impact of artificial intelligence on radiology closely aligned with positive or negative views of the field overall. Multiple barriers to applying for a radiology residency position were identified including board scores and lack of mentorship. COVID-19 did not affect perceptions of radiology. There was broad agreement that students do not enter medical school with many preconceived notions of radiology, but that subsequent exposure was generally positive. Exposure both solidified and eliminated various stereotypes. Finally, there was general agreement that radiology is integral to the health system with broad exposure on all services. Conclusion Medical student perceptions of radiology are notably influenced by exposure and radiology programs should take active steps to engage in medical student education.

PURPOSE: Patients diagnosed with ductal carcinoma in situ (DCIS) face trade-offs when deciding among different treatments, including surgery, radiation, and endocrine therapy. A less chosen option is active monitoring. While evidence from clinical trials is not yet available, observational studies show comparable results for active monitoring and immediate treatment on cancer outcomes in select subgroups of patients. We developed and tested a web-based decision support tool (DST) to help patients explore current knowledge about DCIS and make an informed choice. METHODS: The DST, an interactive web application, was informed by literature reviews and formative work with patients, breast surgeons, and health communication experts. We conducted iterative interviews to evaluate the DST content among women with and without a history of breast cancer, as well as breast cancer experts. For usability testing, we conducted an online survey among women with and without a history of breast cancer. RESULTS: For content evaluation, 5 women with and 10 women without a history of DCIS were interviewed. The sample included 11 White and 4 non-White women, with a mean age of 64 years. The expert sample consisted of 5 attendings and a physician assistant. The feedback was used to add, clarify, or reorganize information in the DST. For usability testing, 22 participants with a mean age of 61 years were recruited including 15 White and 7 Black women and 6 women with a history of DCIS. The mean usability score was 3.7 out of 5. Most participants (86%) found that the DST provided unbiased information about treatments. To improve usability, we reduced the per-page content and added navigation cues. CONCLUSION: Content and usability evaluation showed that the DST helps patients explore trade-offs of active monitoring and immediate treatment. By adopting a personalized approach, the tool will enable informed decisions aligned with patients’ values and expectations.

This prospective study was designed to compare quality of life (QoL) among patients who underwent open (O-PD) vs minimally invasive pancreaticoduodenectomy (MI-PD), using a combination of validated qualitative and quantitative methodologies.From 2017 to 2019, patients scheduled for pancreaticoduodenectomy (PD) were enrolled and presented with Functional Assessment of Cancer Therapy-Hepatobiliary surveys preoperatively, before discharge, at first postoperative visit and approximately 3 to 4 months after operation ("3 months"). Longitudinal plots of median QoL scores were used to illustrate change in each score over time. In a subset of patients, content analysis of semistructured interviews at postoperative time points (1.5 to 6 months after operation) was conducted.Among 56 patients who underwent PD, 33 had an O-PD (58.9%). Physical and functional scores decreased in the postoperative period but returned to baseline by 3 months. No significant differences were found in any domains of QoL at baseline and in the postoperative period between patients who underwent O-PD and MI-PD. Qualitative findings were concordant with quantitative data (n = 14). Patients with O-PD and MI-PD reported similar experiences with complications, pain, and wound healing in the postoperative period. Approximately half the patients in both groups reported "returning to normal" in the 6-month postoperative period. A total of 4 patients reported significant long-term issues with physical and functional well-being.Using a novel combination of qualitative and quantitative analyses in patients undergoing PD, we found no association between operative approach and QoL in patients who underwent O-PD vs MI-PD. Given the increasing use of minimally invasive techniques for PD and the steep learning curve associated with these techniques, continued assessment of patient benefit is critical.

PURPOSE: Among cancer survivors who have completed curative-intent treatment, the high prevalence and adverse consequences of chronic pain are well documented. Yet, research on clinicians' experiences with and perspectives on managing chronic pain among cancer survivors is critically lacking. METHODS: We conducted semistructured interviews with 17 clinicians (six oncology, three palliative care, and eight primary care) affiliated with an academic medical center. Interview questions addressed clinicians' experiences with and perspectives on managing chronic pain (with or without opioid therapy) during the transition from active treatment to survivorship. A multidisciplinary team conducted content analysis of interview transcripts to identify and refine themes related to current practices and challenges in managing chronic pain in this context. RESULTS: Overall, clinicians perceived chronic pain to be relatively uncommon among cancer survivors. Identified challenges included a lack of clarity about which clinician (or clinicians) are best positioned to manage chronic pain among cancer survivors, and (relatedly) complexities introduced by long-term opioid management, with many clinicians describing this practice as outside their skill set. Additionally, although most clinicians recognized chronic pain as a biopsychosocial phenomenon, they described challenges with effectively managing psychosocial stressors, including difficulty accessing mental or behavioral health services for cancer survivors. CONCLUSION: Discovered challenges highlight unmet needs related to cancer survivor-clinician communication about chronic pain and the absence of a chronic pain management home for cancer survivors, including those requiring long-term opioid therapy. Research evaluating routine pain monitoring and accessible, tailored models of multimodal pain care in survivorship may help to address these challenges.

OBJECTIVE The purpose of this paper was to examine changes in situational temptations to smoke among women in early to late pregnancy enrolled in a texting trial to help them quit smoking. We compared changes between (1) intervention arms, (2) those who quit, (3) those who reduced by 50% or more, and (4) those who reduced by less than 50%. We also examined cravings overtime in the intervention arm and the relationship between real-time cravings assessed via text message and situational temptations. METHODS This was a secondary analysis of the Baby Steps trial, a randomized controlled trial testing the efficacy of a text-based scheduled gradual reduction (SGR) intervention on cessation. We used t-tests to examine changes across intervention arms and repeated measured proc mixed to explore changes in situational temptations and cravings. RESULTS Among all women, situational temptations decreased from early to late pregnancy for the positive, negative, and habitual subscales, (ps

Background and objectives Despite a high burden of human papillomavirus (HPV)-attributable cancers, the southern US lags other regions in HPV vaccination coverage. This study sought to characterize and contextualize predictors of HPV vaccination in the southern US. Methods From December 2019 – January 2020, parents of adolescents (ages 9–17 years) living in thirteen southern US states were recruited from a nationally-representative online survey panel and completed a cross-sectional survey. The primary study outcome was initiation of HPV vaccination. Results Of 1105 parents who responded to the survey, most were ≥35 years of age and of female gender. HPV vaccination initiation was reported only among 37.3% of adolescents and was highest at age 12. Cumulative HPV vaccination coverage was highest at age 15 (52%) but lower than coverage for tetanus-diphtheria-acellular pertussis (Tdap, 79.3%) and Meningococcal vaccines (MenACWY, 67.3%). Provider recommendation was strongly associated with higher odds of HPV vaccination (aOR: 49.9, 95 %CI: 23.1–107.5). In alternative predictive models, home/online (vs. public) schooling and parents’ working status were associated with lower odds of vaccination; health care visits in the past 12 months and shorter travel times to adolescents’ usual health care provider were associated with greater odds of vaccination. Conclusions Our findings suggest missed opportunities for HPV vaccination in the southern US and support strengthening provider recommendation for on-time initiation of HPV vaccination among adolescents. Other strategies to increase HPV vaccinations may include encouraging co-administration with other adolescent vaccines, increasing vaccine access, and promoting vaccinations for home/online-school students.

Breast reconstruction is associated with improved patient well-being after mastectomy; however, factors that contribute to post-surgical dissatisfaction remain poorly characterized. Adult women who underwent post-mastectomy implant-based or autologous breast reconstruction between 2015 and 2019 were recruited to participate in semi-structured interviews regarding their lived experiences with reconstructive care. Participants completed the BREAST-Q, and tabulated scores were used to dichotomize patient-reported outcomes as satisfied or dissatisfied (high or low) for each BREAST-Q domain. A convergent mixed-methods analysis was used to evaluate interviews for content related to satisfaction or dissatisfaction with breast reconstruction. Overall, we interviewed 21 women and identified 17 subcodes that corresponded with the five BREAST-Q domains. Sources of dissatisfaction were found to be related to the following domains: (a) low breast satisfaction due to asymmetry, cup size, and lack of sensation and physical feeling (n = 8, 38%); (b) poor sexual well-being due to shape, look and feel (n = 7, 78% [of 9 who discussed sexual well-being]); (c) reduced physical well-being of the chest due to persistent pain and weakness (n = 11, 52%); (d) reduced abdominal well-being due to changes in abdominal strength, numbness, and posture (n = 6, 38% [of 16 who underwent abdominally based reconstruction]); and (e) low psychosocial well-being impacted by an unexpected appearance that negatively influenced self-confidence and self-identity (n = 13, 62%). Patients may be unprepared for the physical, sexual, and psychosocial outcomes of breast reconstruction. Targeted strategies to improve preoperative education and shared decision making are needed to mitigate unexpectedness associated with breast reconstruction and related outcomes.

We sought to identify modifiable factors associated with cancer screening in a community-based health assessment.24 organizations at 47 community events in central North Carolina distributed a 91-item survey from April-December 2017. Responses about (1) interest in disease prevention, (2) lifestyle choices (e.g., diet, tobacco), and (3) perceptions of primary care access/quality were abstracted to examine their association with self-reported screening participation and knowledge about breast, prostate, and colorectal cancer.2135/2315 participants (92%; 38.5% White, 38% Black, 9.9% Asian) completed screening questions.70% of screen-eligible respondents reported guideline-concordant screening. Healthy dietary habits were associated with greater knowledge about breast and colorectal cancer screening; reporting negative attitudes about and barriers to healthcare were associated with less breast, prostate, and colorectal cancer screening. Having a place to seek medical care (a proxy for primary care access) was independently associated with being ∼5 times as likely to undergo colorectal screening (OR 4.66, 95% CI 1.58-13.79, all p 0.05).In this diverse, community-based sample, modifiable factors were associated with screening engagement, highlighting opportunities for behavioral intervention.

We sought to examine patient and provider perspectives regarding modifiable contributors to breast cancer treatment and to assess perceptual alignment between these two groups.Participants were women≥18 y with stage 0-IV breast cancer who received all oncologic care in a single health system and physicians and advanced practice providers who provided medical, radiation, or surgical oncology care for breast cancer. All completed ∼45-min semistructured interviews that were recorded and transcribed verbatim. A 5-stage approach to thematic analysis was conducted, with emergent themes and exemplar quotes placed into clinical, psychological, social/logistical, financial, and lifestyle categories using a multilevel conceptual framework.Eighteen patients (9 Black, 9 White, and median age 60 y) and 10 providers (6 physicians and 4 advanced practice providers) were interviewed from May to November 2018. Both patients and providers perceived suboptimal communication, parking and transportation, and competing family-caregiving responsibilities as modifiable barriers to care. Treatment costs were cited by patients as barriers that were inadequately addressed even with referrals to financial counselors, but providers did not raise the issue of cost unless prompted by patients and did not feel prepared to discuss the topic when it arose. Providers cited obesity as a barrier to treatment, a view not shared by patients.Several modifiable factors were recognized by both patients and providers as either promoting or detracting from treatment receipt, but there was also significant incongruence and asymmetry. Alignment of provider and patient perceptions regarding contributors to guideline-concordant care receipt could mitigate disparities in breast cancer treatment and outcomes.

Black patients with endometrial cancer are less likely to express distress and receive referrals for support services compared to White patients. We aim to characterize patient perceptions of the National Comprehensive Cancer Network Distress Thermometer and Problem List (NCCN DTPL), a common distress screening tool, among Black and White patients with endometrial cancer and determine strategies to improve equity in referral to appropriate support services.We conducted semi-structured interviews with 15 Black and 15 White patients with endometrial cancer who reported varying levels of distress on the NCCN DTPL. Interviews were audio-recorded, transcribed, evaluated through staged content analysis, and salient themes were compared by patient race.The NCCN DTPL was generally considered understandable, however the word "distress" could be alienating to participants who considered their stress to be less "drastic." Black participants mentioned fewer negative emotions such as worry and sadness in describing distress and spoke more often of a positive outlook. Additionally, Black participants emphasized the importance of relationship-building with clinicians for open communication on the NCCN DTPL and clinical encounter. Finally, participants were divided on whether they would alter the way they completed the NCCN DTPL given more information on cut off scores for referrals, but generally expressed a desire for more direct offers of support services.Relationship-building, open communication around emotion, and longitudinal direct offers of support emerged as avenues to reduce inequities in referral to supportive services for patients with endometrial cancer.

OBJECTIVE: To understand how women and historically underrepresented minority medical students perceive radiology as a potential career choice. METHODS: Medical students representing a broad spectrum of radiology exposure from a single institution were invited to participate in a mixed-methods study. Participants completed a 16-item survey about demographics and perceptions of radiology. Ten focus groups were administered to probe decision making regarding career selection. The themes influencing women and historically underrepresented minority students are presented. RESULTS: Forty-nine medical students, including 29 (59%) women and 17 (35%) underrepresented minorities, participated. Most participants (28/48, 58%) reported men outnumbered women in radiology. Female participants reported a lack of mentorship and role models as major concerns. Outreach efforts focused on the family friendly nature of radiology were viewed as patronizing. Demographic improvements in the field were viewed as very slow. Forty-six percent (22/48) of participants indicated that radiology had a less underrepresented racial/ethnic workforce than other medical specialties. Minority participants especially noted a lack of radiology presence in mainstream media so students have few preconceived biases. A failure to organically connect with the mostly white male radiologists due to a lack of shared background was a major barrier. Finally, participants described a hidden curriculum which pushes minority medical students away from specialty fields like radiology and towards primary care fields to address underserved communities and healthcare disparities. DISCUSSION: Women and historically underrepresented minority medical students perceive major barriers to choosing a career in radiology. Radiology departments must develop sophisticated multilevel approaches to improve diversity.

The connection between health and housing is well-established. People who are precariously housed have worse health than those who have stable housing arrangements.- Persons moving into public housing have a higher illness burden than the general population, and public housing residents engage in less healthy behaviors, which contribute to public housing residents having poorer health than persons living in other housing situations. Public housing authorities and residents can benefit from authentic and constructive relationships with academic partners; academicians and students can benefit from engaging in partnerships with housing authorities and residents to better understand the connection between housing and health. This article describes the well-established relationship between the Duke University School of Nursing (DUSON) and the Durham Housing Authority (DHA), the evolution of that relationship, our collaborative work in improving the health of DHA residents while advancing nursing education and science, and lessons learned.

Background: Although recognized as the most lethal breast cancer, inflammatory breast cancer (IBC), a NCI designated rare cancer and a cancer health disparity, is severely understudied. Given the unique presentation of diffuse tumor spread without a solid mass, not easily detected by self-breast exams or mammograms, IBC patients often face delays in diagnosis and treatment leading to poor outcomes. Moreover, reproductive risk factors in IBC and high incidence in younger women, minoritized and marginalized populations highlight the significance of primary care providers (PCP) who are often the first point of contact when patients begin to notice symptoms. Methods: In this study, we evaluated the knowledge gaps and barriers amongst PCP (physicians, physician assistants, nurse practitioners) in their ability to recognize the signs and coordinate care effectively for IBC. To assess PCP experiences with IBC in their practices and overall breast cancer care during COVID, we first conducted semi-structured interviews (n=11) with providers selected from a convenience sample at Duke University and in the local clinics. Based on data from these interviews and additional cognitive interviews, we developed and disseminated a comprehensive online survey (n=78). Results: In this study, access to care was identified as the single most important barrier to treating rare cancers. Furthermore, majority of the PCPs in this cohort identified only a moderate ability to recognize IBC in patients (mean = 3.3, range 1-7), thereby limiting early diagnosis. From the semi-structured interviews, PCPs recognized that IBC is not likely to be part of typical differential diagnosis when patients present with mastitis or breast changes, and most had not seen IBC in their practice. Only 31% (n=78) reported ever suspecting IBC in a patient. Delays in referrals to specialized large clinical centers were also reported as a major barrier. In particular, 62.8% (n=49) reported some delay in referrals for diagnostic imaging. In addition, since the COVID-19 pandemic started, 33% reported diagnosing less breast cancer cases and 63% reported that they experienced breast cancer referral delays. When asked what methods providers would find most helpful to learn more about diagnosing and caring for patients with IBC, the top three modes of preferred education were online CME options (53%); lunchtime, or other in-service training (33%); and website for patients and providers (32%). Conclusions: We succeeded in developing a survey instrument and to our knowledge first mixed methods study to assess PCP knowledge gaps and barriers to timely diagnosis and care of IBC patients. Results underscore need to develop PCP training modules and care coordination tools to improve guideline-concordant care. This survey instrument also has the potential to serve as a blueprint to design, implement, and evaluate interventions for other rare cancers. Support: Duke Behavioral Health and Survey Research Core Award (GRD, ANT); Dept of Surgery (GRD); Duke Undergraduate Nakiyama Public Service Scholar (AB). Citation Format: Gayathri R. Devi, Laura J. Fish, Alexandra Bennion, Sarah Weaver, Gregory Sawin, Anh N. Tran. Assessing knowledge and barriers at the primary care provider level that contribute to disparities in inflammatory breast cancer diagnosis and treatment [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr B045.

The Dietary Approaches to Stop Hypertension (DASH) eating plan improves hypertension in Black individuals and is associated with favorable chronic kidney disease (CKD) outcomes. Yet, adherence to DASH is low among US adults in general, particularly among Black Americans. We assessed perceptions about DASH, its cultural compatibility, and barriers and facilitators to DASH adherence in Black adults with CKD.We conducted focus groups and semistructured individual interviews involving 22 Black men and women with CKD Stages 3-4 from outpatient clinics at a US academic medical center. Transcripts of audio-recorded interviews were analyzed using thematic analysis.Among participants (2 focus groups [N = 8 and 5] and 9 individual interviews), 13 (59%) had CKD Stage 3, 13 (59%) were female, the median age was 61 years, and 19 (90%) had hypertension. After receiving information about DASH, participants perceived it as culturally compatible based on 3 emergent themes: (1) Black individuals already eat DASH-recommended foods ("Blacks eat pretty much like this"), (2) traditional recipes (e.g., southern or soul food) can be modified into healthy versions ("you can come up with decent substitutes to make it just as good"), and ( 3) diet is not uniform among Black individuals ("I can't say that I eat traditional"). Perceived barriers to DASH adherence included unfamiliarity with serving sizes, poor cooking skills, unsupportive household members, and high cost of healthy food. Eleven (52%) reported after paying monthly bills that they "rarely" or "never" had leftover money to purchase healthy food. Perceived facilitators included having local access to healthy food, living alone or with supportive household members, and having willpower and internal/external motivation for change.Black adults with CKD viewed DASH as a healthy, culturally compatible diet. Recognizing that diet in Black adults is not uniform, interventions should emphasize person-centered, rather than stereotypically culture-centered, approaches to DASH adherence.

Objectives: Understanding the relationship between human papillomavirus (HPV) knowledge and vaccination behavior is important to inform public health interventions, yet few validated HPV knowledge scales exist. This study describes development of the Human Papillomavirus Knowledge Questionnaire (HPV-KQ) and its validation with parents residing in the southern United States (US). Methods: Drawing on previously published measures, we developed the 13-item HPV-KQ and administered the scale via Web-based survey to parents (N=1105) of adolescents ages 9 to 17 years. Dimensionality, internal consistency, model fit, and predictive validity were assessed. Results: The scale was bidimensional. One factor captured general HPV knowledge, and the second factor captured perceptions of gender differences in HPV infection and vaccine recommendations. The 13-item scale and 2-factor solution displayed strong internal consistency and good model fit. Parents of vaccinated adolescents scored higher on the 13-item HPV-KQ (Mean = 8.56) than parents of unvaccinated adolescents (Mean = 6.43) (p < .001). In regression models, controlling for key covariates, parents' performance on the HPV-KQ predicted adolescent HPV vaccination (p < .001). Conclusions: Evaluation indicates the HPV-KQ is a reliable and valid tool for measuring knowledge of HPV and the HPV vaccine among parents residing in the southern US. We recommend further efforts to validate the scale with other populations.

IntroductionLight and intermittent smokers (LITS) represent almost 50% of all current smokers. Research is needed to understand smoking motives among adult light smokers.AimsTo explore smoking cues and motivators among a racially diverse sample of adult LITS (≤10 CPD). In addition, we explored differences between native (always smoked ≤10), and converted (former heavier) LITS.MethodsWe used purposive sampling to recruit participants who were native and converted LITS and to include equal numbers of African Americans, Whites and Latinos. We coded and analyzed transcripts using a stage approach to identify themes.ResultsFour main themes emerged that may be unique to light smokers and suggests potential strategies for intervention: (1) smoking in response to cues and control, (2) identifying as a smoker, (3) concern about health consequences, and (4) other priorities influencing smoking. There were some differences among smoking cues and motivators by race and ethnicity, and differences between native and converted LITS.ConclusionsOverall, LITS reported drivers of smoking that were unrelated to symptoms of nicotine withdrawal. Even when experiencing salient cues, our LITS cohort expressed the ability to assert control over smoking by abstaining when situational contexts made smoking inconvenient.

Introduction Smoking during pregnancy poses serious risks to baby and mother. Few disseminable programs exist to help pregnant women quit or reduce their smoking. We hypothesized that an SMS text-delivered scheduled gradual reduction (SGR) program plus support texts would outperform SMS support messages alone. Methods We recruited 314 pregnant women from 14 prenatal clinics. Half of the women received theory-based support messages throughout their pregnancy to promote cessation and prevent relapse. The other half received the support messages plus alert texts that gradually reduced their smoking more than 3–5 weeks. We conducted surveys at baseline, end of pregnancy, and 3 months postpartum. Our primary outcome was biochemically validated 7-day point prevalence abstinence at late pregnancy. Our secondary outcome was reduction in cigarettes per day. Results Adherence to the SGR was adequate with 70% responding to alert texts to smoke within 60 minutes. Women in both arms quit smoking at the same rate (9%–12%). Women also significantly reduced their smoking from baseline to the end of pregnancy from nine cigarettes to four; we found no arm differences in reduction. Conclusions Support text messages alone produced significant quit rates above naturally occurring quitting. SGR did not add significantly to helping women quit or reduce. Sending support messages can reach many women and is low-cost. More obstetric providers might consider having patients who smoke sign up for free texting programs to help them quit. Implications A disseminable texting program helped some pregnant women quit smoking. Clinical Trial Registration number: NCT01995097.

Cancer treatment costs are not routinely addressed in shared decisions for breast cancer surgery. Thus, we sought to characterize cost awareness and communication among surgeons treating breast cancer. We conducted a self-administered, confidential electronic survey among members of the American Society of Breast Surgeons from 1 July to 15 September 2018. Questions were based on previously published or validated survey items, and assessed surgeon demographics, cost sensitivity, and communication. Descriptive summaries and cross-tabulations with Chi-square statistics were used, with exact tests where warranted, to assess findings. Of those surveyed (N = 2293), 598 (25%) responded. Surgeons reported that ‘risk of recurrence’ (70%), ‘appearance of the breast’ (50%), and ‘risks of surgery’ (47%) were the most influential on patients’ decisions for breast cancer surgery; 6% cited out-of-pocket costs as significant. Over half (53%) of the surgeons agreed that doctors should consider patient costs when choosing cancer treatment, yet the majority of surgeons (58%) reported ‘infrequently’ (43%) or ‘never’ (15%) considering patient costs in medical recommendations. The overwhelming majority (87%) of surgeons believed that patients should have access to the costs of their treatment before making medical decisions. Surgeons treating a higher percentage of Medicaid or uninsured patients were more likely to consistently consider costs (p

Highlights • PCPs believe evidence for screening mammography in older women is insufficient. • PCPs make decisions regarding screening mammography on a patient-by-patient basis. • Factors like patient goals of care and functional status influence decisions. • A strong patient-provider relationship facilitates shared decision-making. • Time constraints prevent providers from engaging in shared decision-making., Objective Guidelines informing screening mammography for older women are lacking. This study sought to characterize PCP perspectives on screening mammography for patients aged 75 and older. Methods This was an exploratory, qualitative study based on semi-structured, one-on-one interviews with PCPs from six clinics affiliated with a tertiary medical center. Two independent coders analyzed interview transcripts and identified themes, subthemes, and representative quotes using inductive analysis methodology. Results Ten providers completed interviews. The majority (90%) of providers reported insufficient evidence to suggest a best practice for screening in this population. Providers relied on shared decision-making with patients, a process facilitated by strong provider-patient relationships. Providers took into consideration factors such as functional status, personal risk of breast cancer, and patient preference. Time constraints disincentivized providers to engage in discussions. Conclusions PCPs make decisions about screening mammography for older patients on an individualized basis, taking into account patient overall health status and desire for aggressive intervention. They often rely on shared decision-making given unclear clinical guidelines. Practice implications These findings suggest that fostering strong provider-patient relationships, addressing patient knowledge gaps, and compensating providers for time spent on counseling may facilitate cost-efficient and patient-centered utilization of screening mammography.

Breast reconstruction is associated with improved patient well-being after mastectomy; however, factors that contribute to post-surgical dissatisfaction remain poorly characterized.Adult women who underwent post-mastectomy implant-based or autologous breast reconstruction between 2015 and 2019 were recruited to participate in semi-structured interviews regarding their lived experiences with reconstructive care. Participants completed the BREAST-Q, and tabulated scores were used to dichotomize patient-reported outcomes as satisfied or dissatisfied (high or low) for each BREAST-Q domain. A convergent mixed-methods analysis was used to evaluate interviews for content related to satisfaction or dissatisfaction with breast reconstruction.Overall, we interviewed 21 women and identified 17 subcodes that corresponded with the five BREAST-Q domains. Sources of dissatisfaction were found to be related to the following domains: (a) low breast satisfaction due to asymmetry, cup size, and lack of sensation and physical feeling (n = 8, 38%); (b) poor sexual well-being due to shape, look and feel (n = 7, 78% [of 9 who discussed sexual well-being]); (c) reduced physical well-being of the chest due to persistent pain and weakness (n = 11, 52%); (d) reduced abdominal well-being due to changes in abdominal strength, numbness, and posture (n = 6, 38% [of 16 who underwent abdominally based reconstruction]); and (e) low psychosocial well-being impacted by an unexpected appearance that negatively influenced self-confidence and self-identity (n = 13, 62%).Patients may be unprepared for the physical, sexual, and psychosocial outcomes of breast reconstruction. Targeted strategies to improve preoperative education and shared decision making are needed to mitigate unexpectedness associated with breast reconstruction and related outcomes.

Background Understanding the factors that influence hospital mobility, especially in the context of a heightened focus on falls prevention, is needed to improve care. Objective This qualitative study uses a socioecological framework to explore factors that influence hospital mobility in older adults. Design Qualitative research PARTICIPANTS: Semi-structured interviews and focus groups were conducted with medically-ill hospitalized older adults (n = 19) and providers (hospitalists, nurses, and physical and occupational therapists (n = 48) at two hospitals associated with an academic health system. Approach Interview and focus group guides included questions on perceived need for mobility, communication about mobility, hospital mobility culture, and awareness of patients' walking activity. Data were analyzed thematically and mapped onto the constructs of the socioecological model. Key results A consistent theme among patients and providers was that "mobility is medicine." Categories of factors reported to influence hospital walking activity included intrapersonal factors (patients' health status, fear of falls), interpersonal factors (patient-provider communication about mobility), organizational factors (clarity about provider roles and responsibilities, knowledge of safe patient handling, reliance on physical therapy for mobility), and environmental factors (falls as a never event, patient geographical locations on hospital units). Several of these factors were identified as potentially modifiable targets for intervention. Patients and providers offered recommendations for improving awareness of patient's ambulatory activity, assigning roles and responsibility for mobility, and enhancing education and communication between patients and providers across disciplines. Conclusion Patients and providers identified salient factors for future early mobility initiatives targeting hospitalized older adults. Consideration of these factors across all stages of intervention development and implementation will enhance impact and sustainability.

PURPOSE: Although financial toxicity is a well-documented aspect of cancer care, little is known about how patients narratively characterize financial experiences related to breast cancer treatment. We sought to examine these patient experiences through mixed methods analysis. METHODS: Women (≥ 18 years old) with a history of breast cancer were recruited from the Love Research Army and Sisters Network to complete an 88-item electronic survey including an open-ended response. Quantitative data were used to sort and stratify responses to the open-ended question, which comprised the qualitative data evaluated here. Descriptive statistics and qualitative content analysis were used to evaluate the financial costs and other burdens resulting from breast cancer surgery. RESULTS: In total, 511 respondents completed the survey in its entirety and wrote an open-ended response. Participants reported significant financial burden in different categories including direct payments for medical care and indirect costs such as lost wages and travel expenses. Treatment-related costs burdened participants for years after diagnosis, forming a financial arc for many participants. Discrepancies existed between the degree of financial burden reported on multiple-choice questions and participants’ corresponding open-ended descriptions of financial burden. Participants described a lack of communication surrounding costs with their providers and difficulty negotiating payments with insurance. CONCLUSION: Breast cancer care can result in ongoing financial burden years after diagnosis among all patients, even those with adequate insurance patient populations.

Introduction To gain a better understanding of gynecologic oncology patient adherence to oral anticancer agents through both a cross-sectional survey of adherence and qualitative interviews with patients and clinicians regarding their experience with these medications. Methods Eligible participants completed a survey for this cross-sectional study that included an assessment of adherence, distress, quality of life, and health literacy. Any woman taking an oral anticancer agent for a gynecologic malignancy at a tertiary academic medical center for 30 days or more was eligible. Semi-structured qualitative interviews (n=14) were then conducted to explore experiences with oral anticancer agents. We also conducted a qualitative group interview with physicians and nurse practitioners. Results One hundred women taking oral anticancer agents were enrolled. Fifty-four percent reported perfect adherence to their medication, 21% reported equivocal adherence (demonstrating at least one nonadherent behavior in the previous 7 days), and 25% reported nonadherence (demonstrating more than one nonadherent behavior in the previous 7 days). Qualitative analysis identified five major themes: ease of use compared with traditional therapy; the mental burden of self-administrated medication; perceived importance of the medication; management of side effects; and the desire for consistent physician communication. Common misperceptions expressed in the health care professional interviews included high adherence to oral medications and a belief that cost was the biggest barrier to adherence. Conclusion Almost half of the patients surveyed reported equivocal or nonadherence to their oral anticancer agent. The qualitative interviews identified several important themes, many of which were not recognized by physicians and nurse practitioners. These findings highlight the need for patient and health care professional interventions to improve patient adherence.

Cardiac arrest is the leading cause of death among patients receiving hemodialysis, and major deficiencies exist in hemodialysis staff-provided cardiopulmonary resuscitation (CPR). Our study aimed to identify factors influencing CPR delivery in the outpatient hemodialysis clinic. Through content analysis of in-depth interviews with 10 staff members of a hemodialysis clinic, we identified three broad themes regarding barriers and facilitators to performing CPR in the hemodialysis clinic: 1) physical and environmental challenges regarding the layout of the clinic; 2) uncertainty about optimal in-clinic CPR procedures, particularly concerning patient positioning and dealing with the hemodialysis machine; and 3) benefit of continuous improvement programs, including hemodialysis-specific protocols, hands-on training, and pre-defined team roles. Our findings call for further investigation of optimal in-clinic resuscitation procedures to inform hemodialysis clinic CPR protocols and hemodialysis staff training.

Hematopoietic stem cell transplantation (HCT) is a curative treatment option for patients with hematologic conditions but presents many complications that must be managed as a complex, chronic condition. Mobile health applications (mHealth apps) may permit tracking of symptoms in HCT. In seeking strategies to manage the complexities of HCT, our team collaborated with Sicklesoft, Inc., to develop an mHealth app specifically for HCT patients to allow for daily evaluation of patient health, Technology Recordings to better Understand Bone Marrow Transplantation (TRU-BMT). The primary value of this application is that of potentially enhancing the monitoring of symptoms and general health of patients undergoing HCT, with the ultimate goal of allowing earlier detection of adverse events, earlier intervention, and improving outcomes. To first evaluate patient interest in mHealth apps, we designed and administered an interest survey to patients at the 2017 BMT-InfoNet reunion. As a follow-up to the positive feedback received, we began testing the TRU-BMT app in a Phase 1 pilot study. Thirty patients were enrolled in this single-arm study and were given the TRU-BMT mHealth app on a smartphone device in addition to a wearable activity tracker. Patients were followed for up to 180 days, all the while receiving daily app monitoring. Adherence to TRU-BMT was approximately 30% daily and 44% weekly, and greater adherence was associated with increased meal completion, decreased heart rate, and shorter hospital stay. TRU-BMT assessments of symptom severity were significantly associated with duration of hospital stay and development of chronic graft-versus-host disease. Our findings suggest that using TRU-BMT throughout HCT is feasible for patients and established a proof-of-concept for a future randomized control trial of the TRU-BMT application in HCT. © 2021 American Society for Blood and Marrow Transplantation. Published by Elsevier Inc. All rights reserved.

Introduction Light smoking (smoking ≤ 10 cigarettes per day or on some days) has become increasingly prevalent in the US and increases morbidity and mortality. Many light smokers do not experience significant nicotine withdrawal but instead smoke in response to cues. Minimal evidence exists supporting interventions to help light smokers quit smoking. Methods We present results from a proof-of-concept pilot study designed to evaluate the feasibility and acceptability of a cue-based smoking cessation intervention targeted to light daily and intermittent smokers. Participants were randomized to one of two arms: Arm 1) standard smoking cessation treatment or Arm 2) standard smoking cessation treatment + enhanced cue-based treatment that included interactive texting to extend cue exposure treatment to real-world settings and cue management counseling. Outcomes included feasibility (number of participants who were recruited and who completed the intervention), acceptability (intervention ratings), and preliminary efficacy (7-day point prevalence abstinence). Results We randomized 24 English and Spanish-speaking light smokers, 13 to the treatment arm and 11 to the control arm. Across both arms, 77% attended all counseling sessions, 90% rated these sessions as very useful and 100% said that they would recommend the intervention to a friend. 15% in the treatment arm had biochemically-validated smoking abstinence compared to 0% in the standard counseling arm. Conclusions Results from this proof-of-concept study demonstrated that a cue-based intervention is feasible and acceptable among light smokers and suggests the need for a fully powered study to assess this approach. Trial registration This study is registered at www.clinicaltrials.gov NCT03416621.

Most pregnant women know that smoking poses serious risks to baby and mother, yet many still smoke. We conducted a large randomized controlled trial and found that an SMS text-delivered program helped about 10% of these women quit smoking. In this paper, we describe the feasibility of disseminating a text-based intervention to pregnant women who smoke. We tested dissemination in two ways from prenatal clinics and compared recruitment rates to those found in our large randomized controlled trial. The first method involved “direct texting” where study staff identified women who smoked and sent them a text asking them to text back if they wanted to receive texts to help them quit. The second involved “nurse screening” where clinic staff from county health departments screened women for smoking and asked them to send a text to the system if they wanted to learn more about the program. Our primary outcome was feasibility assessed by the number of women who texted back their baby’s due date, which served as “enrolling” in the texting program, which we compared to the recruitment rate we found in our large trial. Over 4 months, we texted 91 women from the academic health system. Of those, 17 texted back and were counted as “enrolled.” In the health departments, across the 4 months, 12 women texted the system initially. Of those, 10 were enrolled. This rate was similar to the rate enrolled in the randomized controlled trial. Two different methods connected pregnant women who smoke to a texting program. One of these methods can be automated further and have the potential of helping many women quit smoking with minimal effort. Clinical Trial # NCT01995097

Background Engaging diverse populations in biomedical research, including biospecimen donation, remains a national challenge. This study examined factors associated with an invitation to participate in biomedical research, intent to participate in biomedical research in the future, and participation in biomedical research and biospecimen donation among a diverse, multilingual, community-based sample across 3 distinct geographic areas. Methods Three National Cancer Institute-designated cancer centers engaged in community partnerships to develop and implement population health assessments, reaching a convenience sample of 4343 participants spanning their respective catchment areas. Data harmonization, multiple imputation, and multivariable logistic modeling were used. Results African Americans, Hispanic/Latinos, and other racial minority groups were more likely to be offered opportunities to participate in biomedical research compared to whites. Access to care, history of cancer, educational level, survey language, nativity, and rural residence also influenced opportunity, intent, and actual participation in biomedical research. Conclusions Traditionally underserved racial and ethnic groups reported heightened opportunity and interest in participating in biomedical research. Well-established community partnerships and long-standing community engagement around biomedical research led to a diverse sample being reached at each site and may in part explain the current study findings. However, this study illustrates an ongoing need to establish trust and diversify biomedical research participation through innovative and tailored approaches. National Cancer Institute-designated cancer centers have the potential to increase opportunities for diverse participation in biomedical research through community partnerships and engagement. Additional work remains to identify and address system-level and individual-level barriers to participation in both clinical trials and biospecimen donation for research.

Achieving cancer health equity is a national imperative. Cancer is the second leading cause of death in the United States and in North Carolina (NC), where the disease disproportionately impacts traditionally underrepresented race and ethnic groups, those who live in rural communities, the impoverished, and medically disenfranchised and/or health-disparate populations at high-risk for cancer. These populations have worse cancer outcomes and are less likely to be participants in clinical research and trials. It is critical for cancer centers and other academic health centers to understand the factors that contribute to poor cancer outcomes, the extent to which they impact the cancer burden, and develop effective interventions to address them. Key to this process is engaging diverse stakeholders in the development and execution of community and population health assessments, and the subsequent programs and interventions designed to address the need across the catchment area. This chapter describes the processes and lessons learned of the Duke Cancer Institute's (DCI) long standing community partnerships that led to Project PLACE (Population Level Approaches to Cancer Elimination), a National Cancer Institute (NCI)-funded community health assessment reaching 2315 respondents in 7 months, resulting in a community partnered research agenda to advance cancer equity within the DCI catchment area. We illustrate the application of a community partnered health assessment and offer examples of strategic opportunities, successes, lessons learned, and implications for practice.

IntroductionThe Duke Multidisciplinary Education and Research in Translational Sciences Program provides educational resources for faculty and trainees in translational research.MethodsTo aid in program development, we assessed perceptions of translational science through focus groups targeting different career stages.ResultsIn total, 3 essential themes emerged: collaboration, movement toward application, and public health impact. Facilitators and barriers varied among groups.ConclusionTraining programs must provide specific strategies for collaboration and selectively accelerating discoveries to therapies.

Many couples tend to report steadily decreasing relationship quality following the birth of a child. However, little is known about the postpartum period for Latino couples, a rapidly growing ethnic group who are notably underserved by mental and physical health caregivers in the United States. Thus, this study investigated whether a brief couples’ intervention focused on helping couples support each other while increasing healthy behaviors might improve dyadic functioning postpartum. This study presents secondary analyses of data regarding couple functioning from a larger randomized controlled trial with 348 Latino couples to promote smoking cessation. Portions of the intervention taught the couple communication and problem-solving skills to increase healthy behavior. Couples participated in four face-to-face assessments across 1 year starting at the end of the first trimester. Latent growth curve analyses revealed that the treatment group reported an increase in relationship satisfaction and constructive communication after the intervention, which diminished by 1-year follow-up, returning couples to their baseline levels of satisfaction. Results suggest that incorporating a brief couple intervention as part of a larger health intervention for Latinos may prevent postpartum decreases in relationship satisfaction.

IntroductionLess than 40% of patients with ovarian cancer (OC) in the USA receive stage-appropriate guideline-adherent surgery and chemotherapy. Black patients with cancer report greater depression, pain and fatigue than white patients. Lack of access to healthcare likely contributes to low treatment rates and racial differences in outcomes. The Ovarian Cancer Epidemiology, Healthcare Access and Disparities study aims to characterise healthcare access (HCA) across five specific dimensions—Availability, Affordability, Accessibility, Accommodation and Acceptability—among black, Hispanic and white patients with OC, evaluate the impact of HCA on quality of treatment, supportive care and survival, and explore biological mechanisms that may contribute to OC disparities.Methods and analysisWe will use the Surveillance Epidemiology and Ends Results dataset linked with Medicare claims data from 9744 patients with OC ages 65 years and older. We will recruit 1641 patients with OC (413 black, 299 Hispanic and 929 white) from cancer registries in nine US states. We will examine HCA dimensions in relation to three main outcomes: (1) receipt of quality, guideline adherent initial treatment and supportive care, (2) quality of life based on patient-reported outcomes and (3) survival. We will obtain saliva and vaginal microbiome samples to examine prognostic biomarkers. We will use hierarchical regression models to estimate the impact of HCA dimensions across patient, neighbourhood, provider and hospital levels, with random effects to account for clustering. Multilevel structural equation models will estimate the total, direct and indirect effects of race on treatment mediated through HCA dimensions.Ethics and disseminationResult dissemination will occur through presentations at national meetings and in collaboration with collaborators, community partners and colleagues across othercancer centres. We will disclose findings to key stakeholders, including scientists, providers and community members. This study has been approved by the Duke Institutional Review Board (Pro00101872). Safety considerations include protection of patient privacy. All disseminated data will be deidentified and summarised.

Purpose: In Tanzania, women are diagnosed at advanced breast cancer stages. The reasons for this are multifactorial and have not been systematically investigated in the Kilimanjaro Region. This study aimed to identify reasons for advanced stage breast cancer at time of diagnosis. Methods: Four focus group discussions and 8 semi- structured in-depth interviews were conducted among health care providers (HCP) and traditional healers from five health care facilities (1 regional and 2 district hospitals) and two urban and rural communities in Kilimanjaro, Tanzania. Thematic coding via grounded theory technique was done by two independent reviewers. Results: Twenty HCP (10 doctors and 10 nurses) and 8 traditional healers participated in the study. The average ages for doctors were 38, nurses 33, and traditional healers 50. Among HCP, the most common reasons for advanced stage breast cancer at time of diagnosis were patients initially seeking care from traditional healers, and patient distrust of conventional medicine. Among traditional healers, the most common reasons were: delayed initiation of biomedical treatment due to long turnaround of pathology results, inability to pay for diagnostic workup and treatment, and transportation issues. Both groups stated lack of patient breast cancer knowledge. Conclusions: There was agreement that lack of adequate breast cancer knowledge and awareness as a very common reason for advanced disease presentation among HCP and traditional healers. Community health education must be designed to adopt socio-cultural and religious doctrines to alleviate the misconceptions and knowledge gap. Health system interventions are also needed to facilitate access to timely, affordable, and quality breast cancer diagnosis and treatment Citation Format: Elizabeth F. Msoka, Lily Gutnik, Agnes M. Cyril, Brenda C. Kitali, Vivian F. Saria, Jackline C. Kwayu, Adellaida A. Kavishe, Perry C. Msoka, Ayesiga Herman, Furaha Serventi, Gilleard G. Masenga, Oluwadamilola Fayanju, Laura Fish, Blandina Th. Mmbaga. Health Care Providers and Traditional Healers Perspectives on Late Diagnosis of Breast Cancer in Tanzania: A Qualitative Study [abstract]. In: Proceedings of the 9th Annual Symposium on Global Cancer Research; Global Cancer Research and Control: Looking Back and Charting a Path Forward; 2021 Mar 10-11. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2021;30(7 Suppl):Abstract nr 77.

PURPOSE: Financial toxicity is a well-recognized adverse effect of cancer care, yet little is known about how women consider treatment costs when facing preference-sensitive decisions for breast cancer surgery or how surgical treatment choice affects financial harm. We sought to determine how financial costs and burden relate to decisions for breast cancer surgery. METHODS: Women (≥ 18 years old) with a history of breast cancer were recruited from the Army of Women and Sisters Network to complete an 88-item electronic survey. Descriptive statistics and regression analysis were used to evaluate the impact of costs on surgical decisions and financial harm after breast cancer surgery. RESULTS: A total of 607 women with stage 0 to III breast cancer were included. Most were white (90%), were insured privately (70%) or by Medicare (25%), were college educated (78%), and reported household incomes of more than $74,000 (56%). Forty-three percent underwent breast-conserving surgery, 25% underwent mastectomy, 32% underwent bilateral mastectomy, and 36% underwent breast reconstruction. Twenty-eight percent reported that costs of treatment influenced their surgical decisions, and at incomes of $45,000 per year, costs were prioritized over breast preservation or appearance. Overall, 35% reported financial burden as a result of their cancer treatment, and 78% never discussed costs with their cancer team. When compared with breast-conserving surgery, bilateral mastectomy with or without reconstruction was significantly associated with higher incurred debt, significant to catastrophic financial burden, treatment-related financial hardship, and altered employment. Among the highest incomes, 65% of women were fiscally unprepared, reporting higher-than-expected (26%) treatment costs. CONCLUSION: Cancer treatment costs influenced decisions for breast cancer surgery, and comparably effective surgical treatments differed significantly in their risk of patient-reported financial burden, debt, and impact on employment. Cost transparency may inform preference-sensitive surgical decisions and improve patient-centered care.

Background Patients with acute myeloid leukemia (AML) face a unique, difficult situation characterized by sudden changes in health, complex information, and pressure to make quick treatment decisions amid sizeable tradeoffs. Yet, little is known about patients' experiences with AML. We used qualitative methods to learn about their experiences with diagnosis and treatment decision-making to identify areas for improvement. Methods We recruited hospitalized patients with AML to participate in semi-structured qualitative interviews about their experiences being diagnosed with AML, receiving information, and making a treatment decision. Interviews were conducted during their hospitalization for induction chemotherapy. We analyzed data by using a constant comparison approach. Results Thirty-two patients completed an interview. Four main themes emerged: (a) shock and suddenness, (b) difficulty processing information, (c) poor communication, and (d) uncertainty. Patients frequently described their diagnosis as shocking. They also felt that the amount of information was too great and too difficult to process, which negatively impacted their understanding. Patients frequently described a lack of emotional support from clinicians and described uncertainty about their prognosis, the number and nature of available treatments, and what to expect from treatment. Conclusions Acute myeloid leukemia poses a sudden, emotionally challenging, information-laden situation, where little time is available to make important decisions. This results in difficulty processing information and is sometimes complicated by a lack of emotive communication from clinicians. Results indicate a need for targeted interventions to improve AML patients' understanding of illness and treatment options and to address their traumatic experiences around diagnosis.

IntroductionSmokeless tobacco (ST) use significantly affects morbidity and mortality and remains disproportionally prevalent in rural and medically underserved communities. Few programs exist for rural smokeless tobacco users. Text-based interventions may increase the reach of cessation interventions; yet, none has tested them in ST users. We evaluated the feasibility, acceptability, and preliminary efficacy of a text-based Scheduled Gradual Reduction (SGR) intervention in rural and underserved ST users.MethodsST users were randomized in 2:1 fashion to the SGR group (N=65), a text-based reduction program plus text-based support counseling messages or text-based support messages only group (N=33). We surveyed participants at 30-days post intervention initiation to assess feasibility and acceptability and examined self-report 7-day point prevalence cessation at 30-days and 6-months post intervention initiation in the two arms.ResultsWe achieved benchmarks for feasibility and acceptability. Among the SGR participants 51% (n=48) reported that intervention was useful in helping them quit, 83% (n=48) indicated that they would recommend the intervention to a friend. Over 95% (n=39) of SGR participants said that they read all alert texts. The SGR participants had a higher quit rate at 30-days compared to support messages alone (SGR=21.5%, Control=9.1%, p=0.1627, Cohen's d equivalent=0.56, medium effect). However, the quit rate at 6-months was 21% (p=0.9703) for both groups.ConclusionsA text-based intervention was feasible and acceptable among underserved ST users. SGR helped promote short-term cessation. The text-based interventions both had long-term efficacy. Given that text-based interventions have the potential to increase reach in underserved ST users, further testing is warranted.