The US President's Cancer Panel: A Model For Gathering Country-Level Input to Inform Cancer Control Policy and Program Initiatives.

PURPOSE: The President's Cancer Panel (Panel) is a federal advisory committee charged with monitoring the US National Cancer Program and reporting directly to the US President. Since its creation a half century ago, the Panel has gathered input from individuals and organizations across the US cancer community and beyond and recommended actions to accelerate progress against cancer. The Panel is unique in its structure and function, and merits examination for its potential applicability in other settings worldwide. METHODS: We present an overview of the general President's Cancer Panel model and describe the noteworthy and unique characteristics of the Panel that help achieve its charge. We also detail the specific processes, outputs, and achievements of the Panel appointed by President Barack Obama, which served between 2012 and 2018. RESULTS: From 2012 to 2018, the Panel focused on three topics that addressed timely issues in cancer prevention and control: (1) HPV vaccination for cancer prevention, (2) connected health and cancer, and (3) value and affordability of cancer drug treatment. The Panel held 11 meetings with 165 participants who provided diverse perspectives on these issues. Four reports were delivered to the president, which were cited about 270 times in the literature. Over 20 collaborator activities, including commitments of funding, can be linked to the recommendations published in these reports. CONCLUSION: The US President's Cancer Panel highlights the importance of independent advisory bodies within a national cancer control program and of national leadership support for the cancer community. The structure and function of the Panel could be applicable in other settings worldwide.

A tribute to Robert Croyle, PhD, Director, Division of Cancer Control and Population Sciences.

At the beginning of Dr. Robert Croyle's 18th and final year as director of the National Cancer Institute's (NCI) Division of Cancer Control and Population Sciences (DCCPS), before his retirement in December 2021, it is fitting to review some of his and the division's many accomplishments and pay tribute to him as one of the government's most effective leaders. The focus of this article is on Dr. Croyle's contributions in the behavioral and related domains and his and the division's impact on the landscape of cancer control and population sciences. Dr. Croyle joined DCCPS in 1998 as associate director for behavioral research. He became acting director of DCCPS in 2001 and then director in 2003. DCCPS is a formidable NCI division, with broad mandates and responsibilities and many partners from multiple sectors. The division conducts and supports an integrated program of the highest-quality genetic, epidemiological, behavioral, social, applied, survivorship, surveillance, and health care delivery cancer research. The division's notable successes in implementation science and the dissemination of evidence-based findings and products, use of cancer research consortia, and partnerships across National Institutes of Health and with external federal and nongovernmental organizations are among many that reflect Dr. Croyle's visionary leadership.

Improving Physician Recommendations for Human Papillomavirus Vaccination: The Role of Professional Organizations.

BACKGROUND: To address low human papillomavirus (HPV) vaccination coverage, the American Academy of Family Physicians (AAFP) and the American Academy of Pediatrics (AAP) have launched national campaigns encouraging physicians to deliver strong HPV vaccine recommendations. We surveyed family physicians and pediatricians to examine the impact of these efforts on physicians' recommendation practices. METHODS: A national sample of family physicians and pediatricians (n = 776) completed our online survey in 2014. The survey assessed reach, content, and influence of AAFP and AAP communications about HPV vaccination. The survey also assessed quality of physicians' communication practices for recommending HPV vaccination. RESULTS: Forty-seven percent of family physicians reported receiving information on HPV vaccination from AAFP, whereas 62% of pediatricians reported receiving information from AAP. Among physicians reached by AAFP or AAP, most reported receiving the message to give strong recommendations to adolescent boys (71%) and girls (78%). Although receiving information was not associated with HPV vaccine recommendation quality, receiving the message to give strong recommendations correlated with delivering higher-quality recommendations for boys (odds ratio, 4.19, 95% confidence interval, 2.64-6.64) and girls (odds ratio, 3.15, 95% confidence interval, 1.91-5.18). Over half of physicians reported improving their HPV vaccine communication after receiving information from AAFP (69%) or AAP (53%). CONCLUSIONS: Our findings suggest that it is important for AAFP and AAP to communicate the need for strong HPV vaccine recommendations. Given that many physicians reported improving their recommendation practices, professional organizations stand to contribute to increasing HPV vaccination coverage, but they will likely need to increase the intensity of quality improvement efforts to do so.

School Entry Requirements and Coverage of Nontargeted Adolescent Vaccines.

BACKGROUND: Low human papillomavirus (HPV) vaccination coverage is an urgent public health problem requiring action. To identify policy remedies to suboptimal HPV vaccination, we assessed the relationship between states' school entry requirements and adolescent vaccination. METHODS: We gathered data on states' school entry requirements for adolescent vaccination (tetanus, diphtheria, and pertussis [Tdap] booster; meningococcal; and HPV) from 2007 to 2012 from Immunization Action Coalition. The National Immunization Survey-Teen provided medical record-verified vaccination data for 99 921 adolescents. We calculated coverage (among 13- to 17-year-olds) for individual vaccinations and concomitant vaccination. HPV vaccination outcomes were among female adolescents. Analyses used weighted longitudinal multivariable models. RESULTS: States with requirements for Tdap booster and meningococcal vaccination had 22 and 24 percentage point increases in coverage for these vaccines, respectively, compared with other states (both P < .05). States with HPV vaccination requirements had <1 percentage point increase in coverage for this vaccine (P < .05). Tdap booster and meningococcal vaccination requirements, respectively, were associated with 8 and 4 percentage point spillover increases for HPV vaccination coverage (both P < .05) and with increases for concomitant vaccination (all P < .05). CONCLUSIONS: Ensuring all states have meningococcal vaccination requirements could improve the nation's HPV vaccination coverage, given that many states already require Tdap booster but not meningococcal vaccination for school entry. Vaccination programs and clinicians should capitalize on changes in adolescent vaccination, including concomitant vaccination, that may arise after states adopt vaccination requirements. Additional studies are needed on the effects of HPV vaccination requirements and opt-out provisions.

Government Service as a Public and Personal Good.

The concerted, strategic efforts of government leaders can create rapid accelerations in knowledge and the application of that knowledge for the public good. Government service can represent part or all of one's career. Working at the National Institutes of Health (NIH) early in my career helped me develop a macro-level understanding of how the NIH operates, what forces propel change, how priorities are set, and how programs are developed. While leading a large division at the National Cancer Institute later in my career, after many years in a research institution and academia, we created new models for collaboration, including transdisciplinary centers, the first NIH unit focused on dissemination (now implementation science), and tools that enabled citizens, scientists, and others to access and use effective interventions, new data sets, and ways to aggregate data to show local cancer profiles. In this article, I provide my own career as an example of the opportunities afforded by federal service-for both individuals in government service and the public good.

Collaborative patient-provider communication and uptake of adolescent vaccines.

RATIONALE: Recommendations from healthcare providers are one of the most consistent correlates of adolescent vaccination, but few studies have investigated other elements of patient-provider communication and their relevance to uptake. OBJECTIVE: We examined competing hypotheses about the relationship of patient-driven versus provider-driven communication styles with vaccination. METHODS: We gathered information about vaccine uptake from healthcare provider-verified data in the 2010 National Immunization Survey-Teen for tetanus, diphtheria, and pertussis (Tdap) booster, meningococcal vaccine, and human papillomavirus (HPV) vaccine (initiation among females) for adolescents ages 13-17. We categorized communication style in parents' conversations with healthcare providers about vaccines, based on parents' reports (of whether a provider recommended a vaccine and, if so, if conversations were informed, shared, or efficient) (N = 9021). RESULTS: Most parents reported either no provider recommendation (Tdap booster: 35%; meningococcal vaccine: 46%; and HPV vaccine: 31%) or reported a provider recommendation and shared patient-provider communication (43%, 38%, and 49%, respectively). Provider recommendations were associated with increased odds of vaccination (all ps < 0.001). In addition, more provider-driven communication styles were associated with higher rates of uptake for meningococcal vaccine (efficient style: 82% vs. shared style: 77% vs. informed style: 68%; p < 0.001 for shared vs. informed) and HPV vaccine (efficient style: 90% vs. shared style: 70% vs. informed style: 33%; p < 0.05 for all comparisons). CONCLUSION: Efficient communication styles were used rarely (≤2% across vaccines) but were highly effective for encouraging meningococcal and HPV vaccination. Intervention studies are needed to confirm that efficient communication approaches increase HPV vaccination among adolescents.

Disparities in collaborative patient-provider communication about human papillomavirus (HPV) vaccination.

BACKGROUND: Healthcare providers may vary their communications with different patients, which could give rise to differences in vaccination coverage. We examined demographic disparities in parental report of collaborative provider communication and implications for human papillomavirus (HPV) vaccination. METHODS: Participants were 4,124 parents who completed the National Immunization Survey-Teen about daughters ages 13-17. We analyzed disparities in collaborative communication (mutual information exchange, deliberation, and decision) and whether they mediated the relationship between demographic characteristics and HPV vaccine initiation. RESULTS: Half of parents (53%) in the survey reported collaborative communication. Poor, less educated, Spanish-speaking, Southern, and rural parents, and parents of non-privately insured and Hispanic adolescents, were least likely to report collaborative communication (all p<.05). These disparities in communication accounted for geographic variation in HPV vaccination, specifically, the higher rates of uptake in the Northeast versus the South (mediation z=2.31, p<.01) and in urban/suburban vs. rural areas (mediation z=2.87, p<.01). These disparities were also associated with vaccination among subgroups with relatively high coverage, minimizing what could have been even higher uptake among Hispanic compared to non-Hispanic white adolescents (mediation z=-3.04, p<.01) and non-privately versus privately insured adolescents (mediation z=-3.67, p<.001). Controlling for provider recommendation attenuated some of these associations (but all p<.10). CONCLUSIONS: Collaborative communication showed widespread disparities, being least common among underserved groups. Collaborative communication helped account for differences-and lack of differences-in HPV vaccination among some subgroups of adolescent girls. Leveraging patient-provider communication, especially for underserved demographic groups, could improve HPV vaccination coverage.

Summer Peaks in Uptake of Human Papillomavirus and Other Adolescent Vaccines in the United States.

BACKGROUND: Seasonality in human papillomavirus (HPV) vaccination could have a large impact on national cancer prevention efforts. We hypothesized that uptake of HPV vaccine and other adolescent vaccines in the United States would be highest in the summer. METHODS: Data came from health care provider-verified vaccination records for 70,144 adolescents (ages 13-17 years) from the 2008 to 2012 versions of the National Immunization Survey-Teen. Using the Edwards method for testing annual trends, we examined seasonal patterns in the uptake of HPV and other recommended adolescent vaccines [tetanus, diphtheria, and pertussis (Tdap) booster and meningococcal vaccine]. HPV vaccine initiation (receipt of the first of the three-dose series) data were for female adolescents. RESULTS: Uptake for HPV and other adolescent vaccines peaked in the summer across years and states (all P < 0.001). Uptake was five times as frequent at the peak as at the trough for HPV vaccine, and HPV vaccine initiation was highest in June, July, and August (percent of doses delivered in these months: 38.7%). The same pattern existed for Tdap booster and meningococcal vaccine. Concomitant (same-day) vaccination of HPV vaccine with other adolescent vaccines also demonstrated summer peaks each year nationally (all P < 0.001). CONCLUSION: Uptake of adolescent vaccines increased dramatically in summer months. These summer peaks are an important opportunity for interventions focused on concomitant vaccination. IMPACT: The potential cancer prevention impact of HPV vaccination programs could be increased, for example, by delivering messages about concomitant vaccination during the summer, when adolescents and their parents might be most open to them.

Implementation science in cancer prevention and control: a framework for research and programs in low- and middle-income countries.

Implementation science is a set of tools, principles, and methodologies that can be used to bring scientific evidence into action, improve health care quality and delivery, and improve public health. As the burden of cancer increases in low- and middle-income countries, it is important to plan cancer control programs that are both evidence based and delivered in ways that are feasible, cost-effective, contextually appropriate, and sustainable. This review presents a framework for using implementation science for cancer control planning and implementation and discusses potential areas of focus for research and programs in low- and middle-income countries interested in integrating research into practice and policy.

Mass media health communication campaigns combined with health-related product distribution: a community guide systematic review.

CONTEXT: Health communication campaigns including mass media and health-related product distribution have been used to reduce mortality and morbidity through behavior change. The intervention is defined as having two core components reflecting two social marketing principles: (1) promoting behavior change through multiple communication channels, one being mass media, and (2) distributing a free or reduced-price product that facilitates adoption and maintenance of healthy behavior change, sustains cessation of harmful behaviors, or protects against behavior-related disease or injury. EVIDENCE ACQUISITION: Using methods previously developed for the Community Guide, a systematic review (search period, January 1980-December 2009) was conducted to evaluate the effectiveness of health communication campaigns that use multiple channels, including mass media, and distribute health-related products. The primary outcome of interest was use of distributed health-related products. EVIDENCE SYNTHESIS: Twenty-two studies that met Community Guide quality criteria were analyzed in 2010. Most studies showed favorable behavior change effects on health-related product use (a median increase of 8.4 percentage points). By product category, median increases in desired behaviors ranged from 4.0 percentage points for condom promotion and distribution campaigns to 10.0 percentage points for smoking-cessation campaigns. CONCLUSIONS: Health communication campaigns that combine mass media and other communication channels with distribution of free or reduced-price health-related products are effective in improving healthy behaviors. This intervention is expected to be applicable across U.S. demographic groups, with appropriate population targeting. The ability to draw more specific conclusions about other important social marketing practices is constrained by limited reporting of intervention components and characteristics.

The effect of a decision aid intervention on decision making about coronary heart disease risk reduction: secondary analyses of a randomized trial.

BACKGROUND: Decision aids offer promise as a practical solution to improve patient decision making about coronary heart disease (CHD) prevention medications and help patients choose medications to which they are likely to adhere. However, little data is available on decision aids designed to promote adherence. METHODS: In this paper, we report on secondary analyses of a randomized trial of a CHD adherence intervention (second generation decision aid plus tailored messages) versus usual care in an effort to understand how the decision aid facilitates adherence. We focus on data collected from the primary study visit, when intervention participants presented 45 minutes early to a previously scheduled provider visit; viewed the decision aid, indicating their intent for CHD risk reduction after each decision aid component (individualized risk assessment and education, values clarification, and coaching); and filled out a post-decision aid survey assessing their knowledge, perceived risk, decisional conflict, and intent for CHD risk reduction. Control participants did not present early and received usual care from their provider. Following the provider visit, participants in both groups completed post-visit surveys assessing the number and quality of CHD discussions with their provider, their intent for CHD risk reduction, and their feelings about the decision aid. RESULTS: We enrolled 160 patients into our study (81 intervention, 79 control). Within the decision aid group, the decision aid significantly increased knowledge of effective CHD prevention strategies (+21 percentage points; adjusted p<.0001) and the accuracy of perceived CHD risk (+33 percentage points; adjusted p<.0001), and significantly decreased decisional conflict (-0.63; adjusted p<.0001). Comparing between study groups, the decision aid also significantly increased CHD prevention discussions with providers (+31 percentage points; adjusted p<.0001) and improved perceptions of some features of patient-provider interactions. Further, it increased participants' intentions for any effective CHD risk reducing strategies (+21 percentage points; 95% CI 5 to 37 percentage points), with a majority of the effect from the educational component of the decision aid. Ninety-nine percent of participants found the decision aid easy to understand and 93% felt it easy to use. CONCLUSIONS: Decision aids can play an important role in improving decisions about CHD prevention and increasing patient-provider discussions and intent to reduce CHD risk.

Women's intentions to receive cervical cancer screening with primary human papillomavirus testing.

We explored the potential impact of human papillomavirus (HPV) testing on women's intentions to be screened for cervical cancer in a cohort of Canadian women. Participants aged 25-65 years from an ongoing trial were sent a questionnaire to assess women's intentions to be screened for cervical cancer with HPV testing instead of Pap smears and to be screened every 4 years or after 25 years of age. We created scales for attitudes about HPV testing, perceived behavioral control, and direct and indirect subjective norms. Demographic data and scales that were significantly different (p < 0.1) between women who intended to be screened with HPV and those who did not intend were included in a stepwise logistic regression model. Of the 2,016 invitations emailed, 1,538 were received, and 981 completed surveys for a response rate of 63% (981/1,538). Eighty-four percent of women (826/981) responded that they intended to attend for HPV-based cervical cancer screening, which decreased to 54.2% when the screening interval was extended, and decreased further to 51.4% when screening start was delayed to age of 25. Predictors of intentions to undergo screening were attitudes (odds ratio [OR]: 1.22; 95% confidence interval [CI]: 1.15, 1.30), indirect subjective norms (OR: 1.02; 95% CI: 1.01, 1.03) and perceived behavioral control (OR: 1.16; 95% CI: 1.10; 1.22). Intentions to be screened for cervical cancer with HPV testing decreased substantially when the screening interval was extended and screening started at age of 25. Use of primary HPV testing may optimize the screening paradigm, but programs should ensure robust planning and education to mitigate any negative impact on screening attendance rates.

Effectiveness of interventions to increase screening for breast, cervical, and colorectal cancers: nine updated systematic reviews for the guide to community preventive services.

CONTEXT: Screening reduces mortality from breast, cervical, and colorectal cancers. The Guide to Community Preventive Services previously conducted systematic reviews on the effectiveness of 11 interventions to increase screening for these cancers. This article presents results of updated systematic reviews for nine of these interventions. EVIDENCE ACQUISITION: Five databases were searched for studies published during January 2004-October 2008. Studies had to (1) be a primary investigation of one or more intervention category; (2) be conducted in a country with a high-income economy; (3) provide information on at least one cancer screening outcome of interest; and (4) include screening use prior to intervention implementation or a concurrent group unexposed to the intervention category of interest. Forty-five studies were included in the reviews. EVIDENCE SYNTHESIS: Recommendations were added for one-on-one education to increase screening with fecal occult blood testing (FOBT) and group education to increase mammography screening. Strength of evidence for client reminder interventions to increase FOBT screening was upgraded from sufficient to strong. Previous findings and recommendations for reducing out-of-pocket costs (breast cancer screening); provider assessment and feedback (breast, cervical, and FOBT screening); one-on-one education and client reminders (breast and cervical cancer screening); and reducing structural barriers (breast cancer and FOBT screening) were reaffirmed or unchanged. Evidence remains insufficient to determine effectiveness for the remaining screening tests and intervention categories. CONCLUSIONS: Findings indicate new and reaffirmed interventions effective in promoting recommended cancer screening, including colorectal cancer screening. Findings can be used in community and healthcare settings to promote recommended care. Important research gaps also are described.

Influence of false-positive mammography results on subsequent screening: do physician recommendations buffer negative effects?

OBJECTIVE: Cancer screening guidelines often include discussion about the unintended negative consequences of routine screening. This prospective study examined effects of false-positive mammography results on women's adherence to subsequent breast cancer screening and psychological well-being. We also assessed whether barriers to screening exacerbated the effects of false-positive results. METHODS: We conducted secondary analyses of data from telephone interviews and medical claims records for 2406 insured women. The primary outcome was adherence to screening guidelines, defined as adherent (10-14 months), delayed (15-34 months), or no subsequent mammogram on record. RESULTS: About 8% of women reported that their most recent screening mammograms produced false-positive results. In the absence of self-reported advice from their physicians to be screened, women were more likely to have no subsequent mammograms on record if they received false-positive results than if they received normal results (18% vs. 7%, OR = 3.17, 95% CI = 1.30, 7.70). Receipt of false-positive results was not associated with this outcome for women who said their physicians had advised regular screening in the past year (7% vs. 10%, OR = 0.74, 95% CI = 0.38, 1.45). False-positive results were associated with greater breast cancer worry (P < .01), thinking more about the benefits of screening (P < .001), and belief that abnormal test results do not mean women have cancer (P < .01), regardless of physicians' screening recommendations. CONCLUSION: False-positive mammography results, coupled with reports that women's physicians did not advise regular screening, could lead to non-adherence to future screening. Abnormal mammograms that do not result in cancer diagnoses are opportunities for physicians to stress the importance of regular screening.

It's the amount of thought that counts: when ambivalence contributes to mammography screening delay.

PURPOSE: This study examines whether ambivalence toward mammography screening, as moderated by total amount of thought given to the reasons for and against getting mammograms at recommended intervals, predicts greater delay in obtaining subsequent screening mammograms. METHODS: A sample of 3,430 insured women with recent (within the last 8-9 months) screening mammograms completed telephone interviews as part of a 5-year intervention study to achieve sustained adherence to annual-interval mammography. Delay was assessed by the number of days between mammograms. RESULTS: Controlling for demographic factors and perceived screening barriers, days between mammograms increased as ambivalence and thought increased. Thought moderated ambivalence: Among women who were most ambivalent, women obtained mammograms 1 month earlier for each unit increase in thought. CONCLUSION: Future studies should test innovative ways to resolve ambivalence and increase thought about consequences of getting mammograms as a strategy to promote mammography screening adherence.