Barriers and facilitators to cancer clinical trial enrollment and participation among rural populations: a scoping review protocol.

OBJECTIVE: The objective of this scoping review is to identify barriers and facilitators related to cancer clinical trial enrollment and participation among rural populations. INTRODUCTION: Advancing the effectiveness of cancer treatment and increasing early detection of cancer relies on enrollment and participation of individuals in cancer clinical trials. Lack of enrollment and participation in trials is a concern, and there is evidence that individuals living in rural areas are unlikely to participate in such trials. Information on barriers to, and facilitators of, enrollment and participation in cancer clinical trials is needed for the development of evidence-based interventions to increase the enrollment and participation of rural populations. INCLUSION CRITERIA: The review will consider studies on adults aged 18 years or older living in rural areas. Studies that report on barriers and facilitators to enrollment and participation in cancer clinical trials, including both cancer therapeutic and cancer early detection trials, will be included in the review. The review will consider quantitative, qualitative, and text and opinion papers for inclusion. METHODS: The search strategy will aim to locate published primary studies, reviews, and opinion papers, the latter including those by professional oncology organizations. The databases to be searched include MEDLINE, CINAHL, Embase, Web of Science, and Cochrane Library. Gray literature databases will also be searched. Two independent reviewers will retrieve full-text studies and extract data. The results will be presented in diagrammatic format with a narrative summary.

Barriers and facilitators for low-dose computed tomography lung cancer screening in rural populations in the United States: a scoping review protocol.

OBJECTIVE: The objective of this scoping review is to identify barriers and facilitators for low-dose computed tomography lung cancer screening uptake and adherence among rural populations in the United States. INTRODUCTION: Lung cancer is the leading cause of cancer-related death in the United States, and cancer patients from rural areas have poorer outcomes than those from metropolitan areas. Evidence exists that lung cancer screening by low-dose computed tomography significantly increases survival time but is also significantly underutilized. INCLUSION CRITERIA: Studies completed in the United States with adults who fit United States Preventive Services Task Force guidelines for lung cancer screening and who live in rural areas will be included. Studies published in English since 2013 that report on barriers and facilitators for low-dose computed tomography lung cancer screening uptake and adherence will be included in this review. Quantitative, qualitative, or mixed-methods studies will be included, along with opinion pieces published by government agencies or professional cancer-related organizations. METHODS: The search strategy will locate published primary studies, reviews, and opinion papers, including those by government and nonprofit agencies focused on cancer. The databases to be searched include MEDLINE, CINAHL Complete, Embase, Web of Science, and Cochrane Library. Gray literature databases and sources of unpublished studies will also be searched. Independent reviewers will be used throughout the search and selection process.

Racial/ethnic differences in the association of childhood adversities with depression and the role of resilience.

BACKGROUND: Adverse childhood experiences (ACE) including childhood abuse and trauma increase depressive symptoms. The role of resilience and how it interacts with both ACEs and the potential development of depressive symptoms, including how race and ethnicity moderate these effects, are much less studied. The aims of this study were to examine: 1) whether there is a dose-response relationship between trauma and depressive symptoms; 2) whether early trauma affected European Americans (EA) and African Americans (AA) in a similar fashion; and 3) whether resilience mitigates the effect of trauma. METHODS: The present study comprised a cross-sectional study of subjects from a longitudinal cohort. All subjects were 19 years or older with traumatic experiences prior to age 18. Subjects were assessed for depressive symptoms as well as resilience. RESULTS: In 413 subjects enrolled, ACEs were significantly associated with depression severity in a dose-response fashion (p<0.001). Notably, AAs had lower depression scores at low to moderate levels of ACEs than EAs, but reported comparable levels of depression with severe exposure to ACEs (pInteraction=0.05). In both EAs and AAs, young adults with high and medium levels of resilience showed less depressive symptoms compared to those with low resilience (p<0.05). LIMITATIONS: to consider are the cross-sectional design, possibility of other confounders, and potential for recall bias of this study. CONCLUSION: While ACEs were significantly associated with severity of depression in a dose-response fashion, higher resilience mitigated the impact of childhood adversities on depressive symptoms in young adults. The results are encouraging, and guides research for therapeutics to boost resilience.

Adverse childhood experiences and blood pressure trajectories from childhood to young adulthood: the Georgia stress and Heart study.

BACKGROUND: The purposes of this study were to assess the long-term effect of adverse childhood experiences (ACEs) on blood pressure (BP) trajectories from childhood to young adulthood and to examine whether this relation is explained by childhood socioeconomic status (SES) or risk behaviors that are associated with ACEs. METHODS AND RESULTS: Systolic and diastolic BPs were measured up to 16 times (13 times on average) over a 23-year period in 213 African Americans and 181 European Americans 5 to 38 years of age. Retrospective data on traumatic experiences before 18 years of age were collected, including abuse, neglect, and household dysfunction. Individual growth curve modeling within a multilevel framework was used to examine the relation between exposure to ACEs and BP development. No main effect of ACEs on average BP levels was found. However, a significant interaction of ACE score with age(3) was observed (systolic BP, P=0.033; diastolic BP, P=0.017). Subjects who experienced multiple traumatic events during childhood showed a faster rise in BP levels after 30 years of age than those without ACEs. As expected, a graded association of ACEs with childhood socioeconomic status and negative health behaviors was observed (P<0.001). The ACE-systolic BP relation was not explained by these factors, whereas the ACE-diastolic BP relation was partially mediated by illicit drug use. CONCLUSION: In this novel longitudinal study, we observed that participants who were exposed to multiple ACEs displayed a greater increase in BP levels in young adulthood compared with their counterparts without ACEs.

Inflammation-induced activation of the indoleamine 2,3-dioxygenase pathway: Relevance to cancer-related fatigue.

Cancer-related fatigue (CRF) is a common complication of cancer and its treatment that can significantly impair quality of life. Although the specific mechanisms remain poorly understood, inflammation is now considered to be a distinct component of CRF in addition to effects of depression, anxiety, insomnia, and other factors. One key biological pathway that may link inflammation and CRF is indoleamine 2,3-dioxygenase (IDO). Induced by inflammatory stimuli, IDO catabolizes tryptophan to kynurenine (KYN), which is subsequently converted into neuroactive metabolites. Here we summarize current knowledge concerning the relevance of the IDO pathway to CRF, including activation of the IDO pathway in cancer patients and, as a consequence, accumulation of neurotoxic KYN metabolites and depletion of serotonin in the brain. Because IDO inhibitors are already being evaluated as therapeutic agents in cancer, the elucidation of the relationship between IDO activation and CRF in cancer patients may lead to novel diagnostic and clinical approaches to managing CRF and its debilitating consequences.

Effects of screening for psychological distress on patient outcomes in cancer: a systematic review.

OBJECTIVE: Several practice guidelines recommend routine screening for psychological distress in cancer care. The objective was to evaluate the effect of screening cancer patients for psychological distress by assessing the (1) effectiveness of interventions to reduce distress among patients identified as distressed; and (2) effects of screening for distress on distress outcomes. METHODS: CINAHL, Cochrane, EMBASE, ISI, MEDLINE, PsycINFO, and SCOPUS databases were searched through April 6, 2011 with manual searches of 45 relevant journals, reference list review, citation tracking of included articles, and trial registry reviews through June 30, 2012. Articles in any language on cancer patients were included if they (1) compared treatment for patients with psychological distress to placebo or usual care in a randomized controlled trial (RCT); or (2) assessed the effect of screening on psychological distress in a RCT. RESULTS: There were 14 eligible RCTs for treatment of distress, and 1 RCT on the effects of screening on patient distress. Pharmacological, psychotherapy and collaborative care interventions generally reduced distress with small to moderate effects. One study investigated effects of screening for distress on psychological outcomes, and it found no improvement. CONCLUSION: Treatment studies reported modest improvement in distress symptoms, but only a single eligible study was found on the effects of screening cancer patients for distress, and distress did not improve in screened patients versus those receiving usual care. Because of the lack of evidence of beneficial effects of screening cancer patients for distress, it is premature to recommend or mandate implementation of routine screening.

Physician preferences and attitudes regarding different models of cancer survivorship care: a comparison of primary care providers and oncologists.

PURPOSE: New strategies for delivering cancer follow-up care are needed. We surveyed primary care providers (PCPs) and oncologists to assess how physician attitudes toward and self-efficacy with cancer follow-up affect preferences for different cancer survivorship models. METHODS: The survey of physician attitudes regarding the care of cancer survivors was mailed to a randomly selected national sample of PCPs and oncologists to evaluate their perspectives regarding physician roles, knowledge about survivorship care processes, and views on cancer surveillance. Multinomial logistic regression models were constructed to examine how physician attitudes towards, and self-efficacy with, their own skills affected preferences for different cancer survivorship care models. RESULTS: Of 3,434 physicians identified, a total of 2,026 participants provided eligible responses: 938 PCPs and 1,088 oncologists. Most PCPs (51 %) supported a PCP/shared care model; whereas, the majority of specialists (59 %) strongly endorsed an oncologist-based model (p < 0.001). Less than a quarter of PCPs and oncologists preferred specialized survivor clinics. A significant proportion of oncologists (87 %) did not feel that PCPs should take on the primary role of cancer follow-up. Most PCPs believed that they were better able to perform breast and colorectal cancer follow-up (57 %), detect recurrent cancers (74 %), and offer psychosocial support (50 %), but only a minority (32 %) was willing to assume primary responsibility. PCPs already involved with cancer surveillance (43 %) were more likely to prefer a PCP/shared care than oncologist-based survivorship model (OR, 2.08; 95 % CI, 1.34-3.23). CONCLUSIONS AND IMPLICATIONS FOR CANCER SURVIVORS: PCPs and oncologists have different preferences for models of cancer survivorship care. Prior involvement with cancer surveillance was one of the strongest predictors of PCPs' willingness to assume this responsibility.

Who provides psychosocial follow-up care for post-treatment cancer survivors? A survey of medical oncologists and primary care physicians.

PURPOSE: Addressing psychosocial needs, including key components of psychologic distress, physical symptoms, and health promotion, is vital to cancer follow-up care. Yet little is known about who provides psychosocial care. This study examined physician-reported practices regarding care of post-treatment cancer survivors. We sought to characterize physicians who reported broad involvement in (ie, across key components of care) and shared responsibility for psychosocial care. METHODS: A nationally representative sample of medical oncologists (n = 1,130) and primary care physicians (PCPs; n = 1,021) were surveyed regarding follow-up care of breast and colon cancer survivors. RESULTS: Approximately half of oncologists and PCPs (52%) reported broad involvement in psychosocial care. Oncologist and PCP confidence, beliefs about who is able to provide psychosocial support, and preferences for shared responsibility for care predicted broad involvement. However, oncologists' and PCPs' perceptions of who provides specific aspects of psychosocial care differed (P < .001); both groups saw themselves as the main providers. Oncologists' confidence, PCPs' beliefs about who is able to provide psychosocial support, and oncologist and PCP preference for models other than shared care were inversely associated with a shared approach to care. CONCLUSION: Findings that some providers are not broadly involved in psychosocial care and that oncologists and PCPs differ in their beliefs regarding who provides specific aspects of care underscore the need for better care coordination, informed by the respective skills and desires of physicians, to ensure needs are met. Interventions targeting physician confidence, beliefs about who is able to provide psychosocial support, and preferred models for survivorship care may improve psychosocial care delivery.

Depression screening and patient outcomes in cancer: a systematic review.

BACKGROUND: Several practice guidelines recommend screening for depression in cancer care, but no systematic reviews have examined whether there is evidence that depression screening benefits cancer patients. The objective was to evaluate the potential benefits of depression screening in cancer patients by assessing the (1) accuracy of depression screening tools; (2) effectiveness of depression treatment; and (3) effect of depression screening, either alone or in the context of comprehensive depression care, on depression outcomes. METHODS: Data sources were CINAHL, Cochrane, EMBASE, ISI, MEDLINE, PsycINFO and SCOPUS databases through January 24, 2011; manual journal searches; reference lists; citation tracking; trial registry reviews. Articles on cancer patients were included if they (1) compared a depression screening instrument to a valid criterion for major depressive disorder (MDD); (2) compared depression treatment with placebo or usual care in a randomized controlled trial (RCT); (3) assessed the effect of screening on depression outcomes in a RCT. RESULTS: There were 19 studies of screening accuracy, 1 MDD treatment RCT, but no RCTs that investigated effects of screening on depression outcomes. Screening accuracy studies generally had small sample sizes (median = 17 depression cases) and used exploratory methods to set sample-specific cutoff scores that varied substantially across studies. A nurse-delivered intervention for MDD reduced depressive symptoms moderately (effect size = 0.37). CONCLUSIONS: The one treatment study reviewed reported modest improvement in depressive symptoms, but no evidence was found on whether or not depression screening in cancer patients, either alone or in the context of optimal depression care, improves depression outcomes compared to usual care. Depression screening in cancer should be evaluated in a RCT in which all patients identified as depressed, either through screening or via physician recognition and referral in a control group, have access to comprehensive depression care.

Uninformed compliance or informed choice? A needed shift in our approach to cancer screening.

It has been more than 30 years since the first consensus development meeting was held to deal with guidelines of mammography screening. Although the National Cancer Institute has wisely focused on the science of screening and of screening benefits vs harm, many professional organizations, advocacy groups, and the media have maintained a focus on establishing who should be screened and promoting recommendations for which age groups should be screened. Guidelines have been developed not only for mammography but also for screening at virtually all major cancer sites, especially for prostate cancer, and most recently, with the preliminary results of the National Lung Screening Trial, for lung cancer. It seems clear that we have done an inadequate job of educating screening candidates about the harms and benefits of cancer screening, including the extent to which screening can reduce cancer mortality. We must also question whether our practice of summoning women to have mammograms, while providing men informed choice for prostate cancer screening, is consistent with a scientific analysis of the relative harms and benefits. We have spent a staggering amount of time and energy over the past several decades developing, discussing, and debating guidelines. Professional and advocacy groups have spent much time aggressively advocating the adoption of guidelines supported by their respective groups. It seems that it would be much more productive to devote such energy to educating screening candidates about the harms and benefits of screening and to engaging in shared decision making.

Differences between primary care physicians' and oncologists' knowledge, attitudes and practices regarding the care of cancer survivors.

BACKGROUND: The growing number of cancer survivors combined with a looming shortage of oncology specialists will require greater coordination of post-treatment care responsibilities between oncologists and primary care physicians (PCPs). However, data are limited regarding these physicians' views of cancer survivors' care. OBJECTIVE: To compare PCPs and oncologists with regard to their knowledge, attitudes, and practices for follow-up care of breast and colon cancer survivors. DESIGN AND SUBJECTS: Mailed questionnaires were completed by a nationally representative sample of 1,072 PCPs and 1,130 medical oncologists in 2009 (cooperation rate = 65%). Sampling and non-response weights were used to calculate estimates to reflect practicing US PCPs and oncologists. MAIN MEASURES: PCPs and oncologists reported their 1) preferred model for delivering cancer survivors' care; 2) assessment of PCPs' ability to perform follow-up care tasks; 3) confidence in their knowledge; and 4) cancer surveillance practices. KEY RESULTS: Compared with PCPs, oncologists were less likely to believe PCPs had the skills to conduct appropriate testing for breast cancer recurrence (59% vs. 23%, P < 0.001) or to care for late effects of breast cancer (75% vs. 38%, P < 0.001). Only 40% of PCPs were very confident of their own knowledge of testing for recurrence. PCPs were more likely than oncologists to endorse routine use of non-recommended blood and imaging tests for detecting cancer recurrence, with both groups departing substantially from guideline recommendations. CONCLUSION: There are significant differences in PCPs' and oncologists' knowledge, attitudes, and practices with respect to care of cancer survivors. Improving cancer survivors' care may require more effective communication between these two groups to increase PCPs' confidence in their knowledge, and must also address oncologists' attitudes regarding PCPs' ability to care for cancer survivors.

National Institutes of Health State-of-the-Science Conference Statement: Family History and Improving Health.

National Institutes of Health consensus and state-of-the science statements are prepared by independent panels of health professionals and public representatives on the basis of 1) the results of a systematic literature review prepared under contract with the Agency for Healthcare Research and Quality (AHRQ); 2) presentations by investigators working in areas relevant to the conference questions during a 2-day public session; 3) questions and statements from conference attendees during open discussion periods that are part of the public session; and 4) closed deliberations by the panel during the remainder of the second day and morning of the third. This statement is an independent report of the panel and is not a policy statement of the National Institutes of Health or the U.S. government. The statement reflects the panel's assessment of medical knowledge available at the time the statement was written. Thus, it provides a "snapshot in time" of the state of knowledge on the conference topic. When reading the statement, keep in mind that new knowledge is inevitably accumulating through medical research.

Finding what is not there: unwarranted claims of an effect of psychosocial intervention on recurrence and survival.

In a recently published randomized trial, Andersen et al. claimed to observe a reduced risk of recurrence and improved survival among women with early stage breast cancer who were assigned to a psychological intervention versus an assessment-only group. Anderson et al. concluded that "psychological intervention, as delivered and studied here, can improve survival." The current commentary challenges that conclusion on methodological and statistical grounds, noting that the study by Andersen et al. was not designed to assess survival and used methods that capitalized on chance, making it highly unlikely that their claims could be replicated. No other study designed to assess whether psychosocial intervention provides a survival benefit for cancer patients has ever demonstrated such an effect; and, currently, there is no support for the hypothesis that survival benefits can be attributed to psychosocial intervention. The authors of this commentary argue that much needs to be learned at the more basic biobehavioral level about the impact of stress or psychological factors on tumor biology before even considering whether large clinical trials are warranted. In addition, making the claim that psychological interventions improve survival is not evidence-based, is potentially harmful, and detracts from the potential significant benefits of psychological interventions related to quality of life.

Introduction: charting the landscape of cancer survivors' health-related outcomes and care.

The field of cancer survivorship is characterized by a complex and rapidly evolving landscape. This supplement presents a series of data-driven articles selected to highlight the breadth of new knowledge in this area of the cancer control continuum that were presented at the Fourth Biennial Cancer Survivorship Research Conference in Atlanta, Georgia, June 2008. Included in the volume is research on the biobehavioral impact of cancer; studies on quality-of-life and economic outcomes; and work focused on caregivers, understudied populations, and healthcare providers.

Behavioral oncology and the war on cancer: partnering with biomedicine.

The call for interdisciplinary research in the war on cancer has escalated over the past several years. Behavioral science has played a key role in cancer control, and several exciting opportunities exist and will develop with the ongoing significant advances made in biomedical science. The current article briefly reviews the maturity of behavioral science in the areas of prevention, early detection, and survivorship and how the partnership of behavioral and biomedical science can effectively impact cancer incidence, morbidity, and mortality.