Rationale and Methodologic Approach for Assessing Ovarian Cancer Treatment and Gynecologic Oncologist Involvement in the Midwest Region of the United States.

Introduction: A study was conducted to examine treatment patterns and outcomes among women with a primary ovarian cancer diagnosis in the Midwest region of the United States, an area that has relatively fewer gynecologic oncologists (GOs) and diverse geography with respect to urban and rural areas. In this paper, we examine the methodology of working with central cancer registries (CCRs) to collect additional data items, including those related to GO involvement and detailed treatment. Methods: Westat recruited 3 state CCRs from the Midwest to participate in the study. Cases were randomly selected from 2010-2012 ovarian, fallopian tube, or primary peritoneal cancer diagnoses in participating registry databases that met the selection criteria. CCRs abstracted additional information for selected cases, including study-specific data items regarding surgery and chemotherapy, GO involvement, and recurrence, where applicable. Results: Abstracts with study-specific data items were collected among a total of 1,003 incidence ovarian cancer cases, with 432 additional abstracts for those cases identified as having recurrence. Variables with the highest frequency of unknowns were mostly for patients who had chemotherapy. While data were available for whether the patient received chemotherapy, the specifics about that chemotherapy were not always available, with dosing and unit being unknown in 27% of cases. There were several challenges with initiating and completing this study associated with recruitment, the data collection timeline, and the collection of study-specific data items. Conclusion: This paper outlines the methodologic approach and experience of collecting additional surgical and chemotherapy treatment variables and data on GO involvement in care from medical records. Experiences from this study provide critical lessons that can be applied to future data collection in this area. Ultimately, the accurate collection of these elements enables researchers to identify groups of women who are not receiving the benefit of optimal surgery or GO care and provides critical data on interventions for improved outcomes and survival in ovarian cancer patients.

Collaborating with the Centers for Disease Control and Prevention's National Comprehensive Cancer Control Program to Increase Receipt of Ovarian Cancer Care from a Gynecologic Oncologist.

Background: Treatment by a gynecologic oncologist is an important part of ovarian cancer care; however, implementation strategies are needed to increase care by these specialists. We partnered with National Comprehensive Cancer Control Programs in Iowa, Michigan, and Rhode Island in a demonstration project to deepen the evidence base for promising strategies that would facilitate care for ovarian cancer by gynecologic oncologists. Methods: Five main implementation strategies (increase knowledge/awareness; improve models of care; improve payment structures; increase insurance coverage; enhance workforce) were identified in the literature and used to develop initiatives. Specific activities were chosen by state programs according to feasibility and needs. Results: Activities included: (1) qualitative interviews with patients to determine barriers to receipt of specialized care; (2) development of patient/provider educational materials; (3) creation of patient/provider checklists to facilitate appropriate referrals; (4) expansion of a toll-free patient navigation hotline for ovarian cancer patients; (5) training of the health care workforce. The programs developed resources (educational handouts, toolkits, 2 webinars, 2 podcasts); trained 167 medical and nursing students during 8 Survivors Teaching Students® workshops; and conducted 3 provider education sessions reaching 362 providers in 45 states. Evaluations showed increases in providers' knowledge, awareness, abilities, and intentions to refer ovarian cancer patients to a gynecologic oncologist. Conclusion: The state program resources we discussed are available for other cancer control programs interested in initiating or expanding activities to improve access/referrals to gynecologic oncologists for ovarian cancer care. They serve as a valuable repository for public health professionals seeking to implement similar interventions.

Potential Strategies to Increase Gynecologic Oncologist Treatment for Ovarian Cancer.

Evidence shows that treatment by gynecologic oncologists (GOs) increases overall survival among women with ovarian cancer. However, specific strategies for institutions and community-based public health programs to promote treatment by GOs are lacking. To address this, we conducted a literature review to identify evidence-based and promising system- and environmental-change strategies for increasing treatment by GOs, in effort to ensure that all women with ovarian cancer receive the standard of care. We searched for English-language literature published from 2008 to 2018. We used PubMed, PubMed Central, OVID, and EBSCO for peer-reviewed literature and Google and Google Scholar for gray literature related to increasing receipt of care by GOs among ovarian cancer patients. Numerous suggested and proposed strategies that have potential to increase treatment by GOs were discussed in several articles. We grouped these approaches into five strategic categories: increasing knowledge/awareness of role and importance of GOs, improving models of care, improving payment structures, improving/increasing insurance coverage for GO care, and expanding or enhancing the GO workforce. We identified several strategies with the potential for increasing GO care among ovarian cancer patients, although currently there is little evidence regarding their effectiveness across US populations. Public health programs and entities that measure delivery of quality health care may pilot the strategies in their populations. Certain strategies may work better in certain environments and a combination of strategies may be necessary for any one entity to increase GO ovarian cancer care. Findings, lessons learned, and recommendations from implementation projects would inform community and public health practice.

Capacity Building for and Implementation of Policy, Systems, and Environmental Change: Results from a Survey of the National Comprehensive Cancer Control Program.

Policy, systems, and environmental (PSE) approaches are commonly used to improve population health. Cancer-related examples include providing data and education to stakeholders about policies that support healthy living, or health systems changes such as universal reminders about recommended cancer screening. The National Comprehensive Cancer Control Program (NCCCP) funds health departments to form cancer coalitions that develop and implement cancer plans. NCCCP initiated a demonstration program in 13 of 65 funded grantees to determine whether skilled, dedicated staffing and using a strategic process to examine data, form a workgroup, and develop an agenda would enhance their capacity to implement PSE approaches, recruit new partners, and provide data and education to stakeholders. The objective of this study was to compare demonstration program grantees to other NCCCP grantees on their ability to develop and implement PSE strategies, and the short-term results that were achieved. Program directors (PDs) from each NCCCP-funded jurisdiction completed web surveys at 2 time points during implementation to assess changes in their capacity for PSE approaches, identify implementation activities, and document short-term outcomes. Responses from demonstration program PDs and other PDs at both time points were compared in a descriptive analysis. Demonstration program grantees experienced greater increases in skills and capacity to address PSE approaches, engaged in necessary implementation activities more often, and achieved greater improvements in stakeholder and decision maker awareness and support for PSE strategies, compared to nonparticipating NCCCP grantees. These findings support continued implementation of PSE approaches for sustainable cancer prevention and control.

Prioritizing Population Approaches in Cancer Prevention and Control: Results of a Case Study Evaluation of Policy, Systems, and Environmental Change.

Development and implementation of policy, systems, and environmental (PSE) change is a commonly used public health approach to reduce disease burden. The Centers for Disease Control and Prevention's National Comprehensive Cancer Control Program conducted a demonstration with 13 programs to determine whether and to what extent dedicated resources would enhance the adoption of PSE strategies. This paper describes results of the qualitative portion of a longitudinal, mixed-methods evaluation of this demonstration. Case studies were conducted with a diverse subset of the 13 programs, and 106 in-depth interviews were completed with state/tribal program staff, community partners, and decision makers. Interviews addressed PSE change planning and capacity building, partnerships, local context, and how programs achieved PSE change. Dedicated PSE resources, including a policy analyst, helped increase PSE change capacity, intensify focus on PSE change overall, and accomplish specific PSE changes within individual jurisdictions. Stakeholders described PSE change as a gradual process requiring preparation and prioritization, strategic collaboration, and navigation of local context. Findings suggest that the demonstration program, including PSE-dedicated funds and a policy analyst, was successful in both increasing PSE change capacity and achieving PSE change itself. These results may be useful to other state, tribal, territorial, and public health organizations planning or implementing PSE change strategies.

Examining comprehensive cancer control partnerships, plans, and program interventions: successes and lessons learned from a utilization-focused evaluation.

The National Comprehensive Cancer Control Program has experienced exponential growth over the past 20 years due to the coordination and collaboration of many stakeholders to sustain multisector coalitions, develop and execute data-driven plans, and successfully implement evidenced-based interventions across the United States. These stakeholders have worked tirelessly to address the burden of cancer by employing strategies that promote healthy behaviors to reduce cancer risk, facilitate screening, and address the needs of cancer survivors. The interaction between the comprehensive cancer control program and the coalitions to engage in this work has been coined the 3Ps: the partnership, the CCC plan, and CCC program interventions. This article describes the efforts to evaluate the growth of the comprehensive cancer control movement, especially as it pertains to coalition contribution, plan priority development and implementation, and intervention implementation. It describes successes and lessons learned from an evaluation whose findings can be used to bolster and sustain comprehensive cancer control programs and coalitions across the U.S.

Adult leukemia survival trends in the United States by subtype: A population-based registry study of 370,994 patients diagnosed during 1995-2009.

BACKGROUND: The lifetime risk of developing leukemia in the United States is 1.5%. There are challenges in the estimation of population-based survival using registry data because treatments and prognosis vary greatly by subtype. The objective of the current study was to determine leukemia survival estimates in the United States from 1995 to 2009 according to subtype, sex, geographical area, and race. METHODS: Five-year net survival was estimated using data for 370,994 patients from 43 registries in 37 states and in 6 metropolitan areas, covering approximately 81% of the adult (15-99 years) US population. Leukemia was categorized according to principal subtype (chronic lymphocytic leukemia, acute myeloid leukemia, and acute lymphocytic leukemia), and subcategorized in accordance with the HAEMACARE protocol. We analyzed age-standardized 5-year net survival by calendar period (1995-1999, 2000-2004, and 2005-2009), leukemia subtype, sex, race, and US state. RESULTS: The age-standardized 5-year net survival estimates increased from 45.0% for patients diagnosed during 1995-1999 to 49.0% for those diagnosed during 2000-2004 and 52.0% for those diagnosed during 2005-2009. For patients diagnosed during 2005-2009, 5-year survival was 18.2% (95% confidence interval [95% CI], 17.8%-18.6%) for acute myeloid leukemia, 44.0% (95% CI, 43.2%-44.8%) for acute lymphocytic leukemia, and 77.3% (95% CI, 76.9%-77.7%) for chronic lymphocytic leukemia. For nearly all leukemia subtypes, survival declined in successive age groups above 45 to 54 years. Men were found to have slightly lower survival than women; however, this discrepancy was noted to have fallen in successive calendar periods. Net survival was substantially higher in white than black patients in all calendar periods. There were large differences in survival noted between states and metropolitan areas. CONCLUSIONS: Survival from leukemia in US adults improved during 1995-2009. Some geographical differences in survival may be related to access to care. We found disparities in survival by sex and between black and white patients.

Human Papillomavirus Vaccine as an Anticancer Vaccine: Collaborative Efforts to Promote Human Papillomavirus Vaccine in the National Comprehensive Cancer Control Program.

Widespread use of the human papillomavirus (HPV) vaccine has the potential to reduce incidence from HPV-associated cancers. However, vaccine uptake among adolescents remains well below the Healthy People 2020 targets. The Centers for Disease Control and Prevention (CDC) National Comprehensive Cancer Control Program (NCCCP) awardees are well positioned to work with immunization programs to increase vaccine uptake. The CDC chronic disease management information system was queried for objectives and activities associated with HPV vaccine that were reported by NCCCP awardees from 2013 to 2016 as part of program reporting requirements. A content analysis was conducted on the query results to categorize interventions according to strategies outlined in The Guide to Community Preventive Services and the 2014 President's Cancer Panel report. Sixty-two percent of NCCCP awardees had planned or implemented at least one activity since 2013 to address low HPV vaccination coverage in their jurisdictions. Most NCCCP awardees (86%) reported community education activities, while 65% reported activities associated with provider education. Systems-based strategies such as client reminders or provider assessment and feedback were each reported by less than 25% of NCCCP awardees. Many NCCCP awardees report planning or implementing activities to address low HPV vaccination coverage, often in conjunction with state immunization programs. NCCCP awardees can play a role in increasing HPV vaccination coverage through their cancer prevention and control expertise and access to partners in the healthcare community.

Communication Within Hospice Interdisciplinary Teams: A Narrative Review.

Hospice care is coordinated through an interdisciplinary team (IDT), which assures that a holistic care plan based on the patient's wishes is implemented. The extent to which an IDT provides quality care may be associated with how effectively they communicate within the team as well as with patients, caregivers, and families. This review seeks to characterize communication strategies among hospice IDT members and to determine how such strategies impact patient care. Although the existing literature sheds some light on communication within hospice IDTs, further research is needed. Inquiry into the communicative process of IDTs in settings other than team meetings, such as during patient visits or informal settings, would provide a more comprehensive representation of how communication influences IDT dynamics and overall team functioning.

Public Health Action Model for Cancer Survivorship.

Long-term objectives associated with cancer survivors have been suggested by Healthy People 2020, including increasing the proportion of survivors living beyond 5 years after diagnosis and improving survivors' mental and physical health-related quality of life. Prior to reaching these objectives, several intermediate steps must be taken to improve the physical, social, emotional, and financial well-being of cancer survivors. Public health has a role in developing strategic, actionable, and measurable approaches to facilitate change at multiple levels to improve the lives of survivors and their families. The social ecological model has been used by the public health community as the foundation of multilevel intervention design and implementation, encouraging researchers and practitioners to explore methods that promote internal and external changes at the individual, interpersonal, organizational, community, and policy levels. The survivorship community, including public health professionals, providers, policymakers, survivors, advocates, and caregivers, must work collaboratively to identify, develop, and implement interventions that benefit cancer survivors. The National Action Plan for Cancer Survivorship highlights public health domains and associated strategies that can be the impetus for collaboration between and among the levels in the social ecological model and are integral to improving survivor outcomes. This paper describes the Public Health Action Model for Cancer Survivorship, an integrative framework that combines the National Action Plan for Cancer Survivorship with the social ecological model to demonstrate how interaction among the various levels may promote better outcomes for survivors.

Evaluation of a Web-Based Program for African American Young Breast Cancer Survivors.

INTRODUCTION: Among women aged <45 years, African Americans have the highest breast cancer incidence rates of any ethnic/racial group and disproportionately higher rates of mortality. Young breast cancer survivors (YBCSs) may require psychosocial and reproductive health support when navigating diagnosis, treatment, and follow-up care. To address these needs, the Young Sisters Initiative: A Guide to a Better You! Program (YSI) was developed, implemented, and evaluated. The purpose of this study was to assess implementation and fidelity; identify barriers and facilitators to implementation; and explore audience access, use, and perceived value of the YSI. METHODS: A mixed-method, process evaluation of the YSI using interviews, an online screener, and post-use survey was conducted with data collected and analyzed from February through August 2013. Thematic analysis of qualitative data was conducted without qualitative data analysis software. Survey data were analyzed using PASW Statistics, version 18. RESULTS: YSI core elements were implemented as intended. A total of 1,442 people visited the YSI website; 93% of breast cancer survivors who visited the site (and consented to be in the study) were African American; 75% of post-use survey YBCS respondents were very or somewhat satisfied with the YSI; and 70% of YBCS respondents said the YSI content was somewhat or very useful. CONCLUSIONS: Findings suggest the value of using the Internet, including social media, to provide African-American YBCSs who are newly diagnosed, in treatment, and post-treatment with reproductive and psychosocial information and support. Further implementation and evaluation of programs addressing the needs of YBCSs are needed.

What Does a Performance Measurement System Tell Us About the National Comprehensive Cancer Control Program?

CONTEXT: The National Comprehensive Cancer Control Program (NCCCP) performance measurement system seeks to understand both the processes that funded programs undertake with their respective coalitions to implement the objectives of their cancer plans and the outcomes of those efforts. OBJECTIVE: To identify areas of achievement and technical assistance needs of NCCCP awardees. DESIGN: Program performance was assessed through surveys completed by program directors on performance indicators in 2009 and 2010 and queries from a Web-based management information system in 2011 and 2012. SETTING: Programs funded by the Centers for Disease Control and Prevention's NCCCP. PARTICIPANTS: Sixty-nine programs. MAIN OUTCOME MEASURE(S): The key performance measures assessed were inclusion of diverse partners and key sectors in cancer coalitions, partners' involvement in activities, receiving in-kind resources from partners, using evidence-based interventions and data for setting priorities, conducting program evaluation, using community- or organization-level strategies to address cancer control efforts, and demonstrating progress toward achieving health outcomes. RESULTS: Most programs reported having active coalitions that represent diverse organizational sectors. Nearly all programs routinely assess the burden of cancer. In-kind resources to implement activities peaked at $64 716 in the second year of a 5-year funding cycle and declined in subsequent project years. By year 3, more than 70% of programs reported having an evaluation plan. While programs reported that nearly two-thirds of their interventions were evidence-based, some programs implemented non-evidence-based interventions. A majority of programs successfully used at least 1 community- or organization-level change strategy. However, many programs did not incorporate objectives linked to health outcomes as they reported progress in implementing interventions. CONCLUSIONS: While NCCCP programs were strong at building and maintaining infrastructure, some programs may need additional technical assistance to increase the adoption of evidence-based interventions, develop solid and responsive evaluation plans, and better link efforts to population-based measures that demonstrate impact toward reducing the burden of cancer.

Gynecologic cancer prevention and control in the National Comprehensive Cancer Control Program: progress, current activities, and future directions.

Gynecologic cancer confers a large burden among women in the United States. Several evidence-based interventions are available to reduce the incidence, morbidity, and mortality from these cancers. The National Comprehensive Cancer Control Program (NCCCP) is uniquely positioned to implement these interventions in the US population. This review discusses progress and future directions for the NCCCP in preventing and controlling gynecologic cancer.

Addressing cancer survivorship through public health: an update from the Centers for Disease Control and Prevention.

Currently, there are nearly 12 million cancer survivors living in the United States. They face a myriad of personal and health issues related to their cancer treatment. Increased recognition of cancer survivorship as a distinct and important phase that follows the diagnosis and treatment of cancer has contributed to the development of public health-related strategies and plans to address those strategies. CDC's Division of Cancer Prevention and Control (DCPC) uses an interdisciplinary public health approach to address the needs of cancer survivors through applied research, public health surveillance and data collection, education, and health promotion, especially among underserved populations that may be at risk for health disparities. Our surveillance activities contribute to population-based descriptions of the health and treatment experiences of cancer survivors in the United States. These data inform applied research activities as well as provide baseline data on cancer survivors for local comprehensive cancer control programs. The knowledge gained by our research efforts informs the development of interventions, awareness and education campaigns, and other outreach activities targeting cancer survivors and those who care for and support them. Our partnerships with national organizations, state health agencies, and other key groups are essential in the development, implementation, and promotion of effective cancer control practices related to cancer survivorship. This article provides an overview of the cancer survivorship activities currently being implemented by DCPC. We highlight several public health surveillance, research, and programmatic outreach and partnership activities currently underway.

Ultrasound-guided fine-needle aspiration biopsy remains a valid approach in the evaluation of nonpalpable breast lesions.

The use of ultrasound-guided fine-needle aspiration (FNA) biopsy for nonpalpable breast lesions varies considerably. This retrospective study stresses the role of breast FNA in evaluating sonographically suspicious nonpalpable breast masses using a probabilistic reporting system. One hundred and eight consecutive ultrasound-guided FNA biopsies diagnosed as positive (32), suspicious (8), atypical (11), benign (55), and unsatisfactory (2) were analyzed and correlated with 61 subsequent surgical specimens. All positive cytologies showed carcinoma on histology; suspicious cases were followed by 5 carcinomas, 2 fibroadenomas, and 1 papillary lesion. Follow-up of atypical cases included 4 carcinomas, 3 fibroadenomas, and 2 papillary lesions, while all 10 biopsies following benign cytology showed fibrocystic changes. Two cases with suspicious sonographic findings but unsatisfactory cytology had lobular carcinoma. The remainder of the benign and atypical cases were followed clinically and radiographically for at least 10 months and had no evidence of carcinoma. Positive predictive values were positive, 100%; suspicious, 63%; atypical, 36%; benign, 0%. Most (40/43; 93%) carcinomas were invasive. In conclusion, ultrasound-guided FNA for nonpalpable breast lesions is highly accurate, and probabilistic reporting helps direct patient management.