Conducting Precision Medicine Research with African Americans

Importance Precision medicine is an approach to detecting, treating, and managing disease that is based on individual variation in genetic, environmental, and lifestyle factors. Precision medicine is expected to reduce health disparities, but this will be possible only if studies have adequate representation of racial minorities. Objective It is critical to anticipate the rates at which individuals from diverse populations are likely to participate in precision medicine studies as research initiatives are being developed. We evaluated the likelihood of participating in a clinical study for precision medicine. Design, Setting, Participants Observational study conducted between October 2010 and February 2011 in a national sample of African Americans. Main Outcome Measure Intentions to participate in a government sponsored study that involves providing a biospecimen and generates data that could be shared with other researchers to conduct future studies. Results One third of respondents would participate in a clinical study for precision medicine. Only gender had a significant independent association with participation intentions. Men had a 1.86 (95% CI = 1.11, 3.12, p = 0.02) increased likelihood of participating in a precision medicine study compared to women in the model that included overall barriers and facilitators. In the model with specific participation barriers, distrust was associated with a reduced likelihood of participating in the research described in the vignette (OR = 0.57, 95% CI = 0.34, 0.96, p = 0.04). Conclusion and Relevance African Americans may have low enrollment in PMI research. As PMI research is implemented, extensive efforts will be needed to ensure adequate representation. Additional research is needed to identify optimal ways of ethically describing precision medicine studies to ensure sufficient recruitment of racial minorities

Primary Care Physiciansʼ Adherence to Expert Recommendations for Cervical Cancer Screening and Prevention in the Context of Human Papillomavirus Vaccination

BACKGROUND: Expert recommendations do not recommend using Papanicolaou (Pap) or human papillomavirus (HPV) test results to determine whether unvaccinated women should receive HPV vaccine, nor do they recommend using vaccine receipt to inform cervical cancer screening practices. This study characterizes physicians' HPV vaccine recommendations and practices in the context of HPV and Pap testing. METHODS: We surveyed family physicians and obstetrician-gynecologists randomly selected from the American Medical Association Masterfile in 2011 (n = 574). Physicians used a 5-point scale (never to always) to report the frequency of (1) using HPV testing results to decide whether to recommend HPV vaccine, and (2) recommending HPV vaccination to women (≤26 years) who had an abnormal Pap test. Physicians also reported (3) intention to change Pap screening frequency for vaccinated women. RESULTS: Across both specialties, 80% correctly reported rarely or never using HPV testing results to guide vaccine recommendations; 66% often or always recommended vaccination to patients with an abnormal Pap result; and 77% did not plan to change Pap screening frequency for vaccinated women. About 41% reported recommendation-consistent practices with all 3 measures. In multivariable analysis, obstetrician-gynecologist specialty and private practice type were associated with higher average overall adherence to recommendations. CONCLUSIONS: Contrary to expert recommendations, a considerable minority of physicians reported recommending HPV vaccination based on HPV and Pap test results. If these clinical practices persist, many young adult women will not realize the benefits of HPV vaccination. Additional efforts are needed to ensure all young women are screened and vaccinated appropriately

Adoption and cancer survivors: Findings from a learning activity for oncology nurses

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/113172/1/cncr29322.pd

Lessons Learned: Feasibility of a Discussion Prompting Tool to Increase Fertility Risk Discussion Among Adolescent Oncology Families

The purpose of this study was to explore the feasibility of distributing a prompting tool (stress egg) in order to increase discussions about fertility risk and preservation (FP) among female adolescent oncology patients, parents, and healthcare providers (HCP). 200 eggs were distributed to four pediatric oncology centers. Qualitative interviews were completed with healthcare staff (N=7) after 6 months of distribution to newly diagnosed female oncology patients ages 12-18. Interviews showed that the main barriers to distribution of the prompt were: forgetting to distribute the eggs; uncertainty about the significance of fertility; and uncertainty about fertility issues in general for female adolescent cancer patients. The scientific community must continually explore effective avenues of communication to ensure such information is received. The stress egg has potential to impact a cancer survivor’s outlook on future partnering, family life, and self-concept when used in conjunction with policy

The content and context of physicians' communication with males about human papillomavirus vaccination

A physician's recommendation for human papillomavirus (HPV) vaccine is a key predictor of vaccine uptake; however, little is known about how physicians communicate about HPV vaccine with male patients. We sought to describe physicians' HPV vaccine communication practices with males who are of vaccine-eligible age (9-26 years). We surveyed representative samples of pediatric and family medicine physicians in Florida, and assessed whether physicians present HPV vaccine as optional or routine, and as a vaccine that prevents cancer. We also assessed the type of visit during which physicians discuss HPV vaccine with adolescent males and whether other healthcare providers in the practice discuss HPV vaccine or make the initial recommendation. We received 367 completed surveys (50.7% response rate). Few physicians (29.9%) reported they typically present HPV vaccine as routine to males ages 11-12 years, who constitute the target group for routine vaccination. When discussing HPV vaccination, many physicians reported somewhat or strongly emphasizing cancer prevention (80.0%). Physicians most often discussed HPV vaccine when they saw patients for well-child visits (93.0%) and least often at acute care visits (15.3%). Over half reported that at least one other healthcare professional in their practice discusses (56.1%) or makes the initial recommendation for (54.9%) HPV vaccination. Many physicians in our sample are presenting HPV vaccine as optional rather than routine and are missing opportunities to communicate with males about the vaccine. Our findings identify areas for future interventions to improve physicians' HPV vaccine communication and, ultimately, increase the use of this cancer-preventing vaccine

Do Breast Cancer Patients Tested in the Oncology Care Setting Share BRCA

BRCA genetic test results provide important information to manage cancer risk for patients and their families. Little is known on the communication of genetic test results by mutation status with family members and physicians in the oncology care setting. As part of a longitudinal study evaluating the impact of genetic counseling and testing among recently diagnosed breast cancer patients, we collected patients' self-reported patterns of disclosure. Descriptive statistics characterized the sample and determined the prevalence of disclosure of BRCA test results to family members and physicians. Of 100 patients who completed the baseline and the 6-month followup survey, 77 reported pursuing testing. The majority shared test results with female first-degree relatives; fewer did with males. Participants were more likely to share results with oncologists compared to surgeons, primary care physicians, or other specialty physicians. These findings suggest that while breast cancer patients may communicate results to at-risk female family members and their medical oncologist, they may need education and support to facilitate communication to other first-degree relatives and providers

Physicians' human papillomavirus vaccine recommendations in the context of permissive guidelines for male patients: a national study

BACKGROUND: Little is known about physicians' human papillomavirus (HPV) vaccine recommendations for males while the Advisory Committee on Immunization Practices' (ACIP) permissive guidelines for male vaccination were in effect. The purpose of this study was to examine and explore factors associated with U.S. physicians' HPV vaccine recommendations to early (ages 11-12), middle (13-17), and late adolescent/young adult (18-26) males. METHODS: Nationally representative samples of family physicians and pediatricians were selected in 2011 (n = 1,219). Physicians reported the frequency with which they recommended HPV vaccine to male patients ["always" (>75% of the time) vs. other] for each age group. Statistically significant predictors of vaccine recommendation were identified using multivariable logistic regression. RESULTS: The prevalence of physicians reporting they "always" recommended HPV vaccination for males was 10.8% for ages 11 to 12, 12.9% for ages 13 to 17, and 13.2% for ages 18 to 26. Pediatrician specialty and self-reported early adoption of new vaccines were significantly associated with recommendation for all patient age groups. In addition, physician race and patient payment method were associated with physician recommendations to patients ages 11 to 12, and patient race was associated with recommendations to ages 13 to 17 and 18 to 26. CONCLUSIONS: Less than 15% of physicians surveyed reported "always" recommending HPV vaccine to male patients following national guidelines for permissive vaccination. Vaccine financing may have affected physicians' vaccine recommendations. IMPACT: If these recommendation practices continue following the ACIP's routine recommendation for males in October 2011, then interventions designed to increase recommendations should target family physicians and possibly use early adopters to encourage support of HPV vaccination guidelines

Impact of genomic testing and patient-reported outcomes on receipt of adjuvant chemotherapy

Practice guidelines incorporate genomic tumor profiling, using results such as the Oncotype DX Recurrence Score (RS), to refine recurrence risk estimates for the large proportion of breast cancer patients with early-stage, estrogen receptor-positive disease. We sought to understand the impact of receiving genomic recurrence risk estimates on breast cancer patients’ well-being and the impact of these patient-reported outcomes on receipt of adjuvant chemotherapy. Participants were 193 women (mean age 57) newly diagnosed with early-stage breast cancer. Women were interviewed before and 2–3 weeks after receiving the RS result between 2011 and 2015. We assessed subsequent receipt of chemotherapy from chart review. After receiving their RS, perceived pros (t = 4.27, P < .001) and cons (t = 8.54, P <.001) of chemotherapy increased from pre-test to post-test, while perceived risk of breast cancer recurrence decreased (t = 2.90, P = .004). Women with high RS tumors were more likely to receive chemotherapy than women with low RS tumors (88 vs. 5 %, OR 0.01, 0.00–0.02, P < .001). Higher distress (OR 2.19, 95 % CI 1.05–4.57, P < .05) and lower perceived cons of chemotherapy (OR 0.50, 95 % CI 0.26–0.97, P < .05) also predicted receipt of chemotherapy. Distressed patients who saw few downsides of chemotherapy received this treatment. Clinicians should consider these factors when discussing chemotherapy with breast cancer patients

Treatment Choices Based on Onco type

Introduction. This study aimed to evaluate whether OncotypeDx test results predict receipt of adjuvant chemotherapy in breast cancer patients who received an OncotypeDx recurrence score (RS). Materials and Methods. Pathology records were used to identify breast cancer patients who had OncotypeDx testing between December 2004 and January 2009 (n=118). Patient sociodemographic information, tumor characteristics, RS, and treatment-specific data were collected via chart review. RS was classified as follows: low (RS≤17), intermediate (RS = 18–30), or high (RS≥31). Bivariate analyses were conducted to investigate the relationship between adjuvant chemotherapy receipt and each sociodemographic and clinical characteristic; significant sociodemographic and clinical variables were included in a multivariable logistic regression model. Results. In multivariable analysis controlling for tumor size, histologic grade, and nuclear grade, only RS remained significantly associated with chemotherapy uptake. Relative to low RS, an intermediate (adjusted odds ratio [AOR], 21.24; 95% confidence interval [CI], 3.62–237.52) or high (AOR, 15.07; 95% CI, 1.28–288.21) RS was associated with a greater odds of chemotherapy uptake. Discussion. Results indicate that RS was significantly associated with adjuvant chemotherapy uptake, suggesting that OncotypeDx results were used to inform treatment decision making, although it is unclear if and how the information was conveyed to patients

Self-efficacy and HPV Vaccine Attitudes Mediate the Relationship Between Social Norms and Intentions to Receive the HPV Vaccine Among College Students

Human papillomavirus (HPV) has been linked to genital warts and multiple cancers affecting both men and women. Despite college students’ high risk for HPV, their vaccination rates remain suboptimal. The current observational study examined the relationship between social norms and human papillomavirus (HPV) vaccine intentions and potential mechanisms underlying this relationship among undergraduates. Participants (N=190; 66.8% female) completed a survey assessing HPV vaccine social norms, attitudes, self-efficacy, and intentions. Three mediation analyses were conducted to examine whether self-efficacy and attitudes mediated the relationship between social norms (i.e., parents, friends, doctor) and intentions, controlling for demographic and health care covariates. Social norms were indirectly related to intentions through self-efficacy and attitudes in multiple models (ps<.05). Specifically, perceiving greater support for HPV vaccination from one’s friends, parents, and doctor was related to greater HPV vaccine self-efficacy, which, in turn, was related to increased vaccine intentions. In addition, perceiving greater parental and doctor support for HPV vaccination was related to more favorable attitudes towards the vaccine, which, in turn, were related to increased vaccine intentions. Findings suggest potential targets for future interventions to promote HPV vaccination among young adults