Review of: The Cancer Crisis in Appalachia: Kentucky Students Take Action

The Journal of Appalachian Health is committed to reviewing published media that relates to contemporary concepts affecting the health of Appalachia. With cancer mortality rates higher in rural and Appalachian communities, a focus on how cancer impacts our families and communities is more important than ever. Dr. Stephenie Kennedy-Rea reviews the book The Cancer Crisis in Appalachia: Kentucky Students Take Action

Cancer Screening Behaviors and Associations with Childhood Trauma, Resiliency, and Patient–Provider Relationships: Findings from an Exploratory Study of Appalachian Cervical Cancer Survivors

Introduction: Adverse childhood experiences (ACEs) are associated with increased cancer risk. ACEs may affect this risk in a variety of ways, including cancer screening compliance. ACEs can contribute to mistrust in the medical profession, inhibit patient­–provider relationships and cause at-risk individuals to miss critical access points to preventive services. Protective factors may play an important role in mitigating ACE-related consequences by supporting resiliency. Purpose: This study assesses the associations between ACEs, protective factors, patient–provider relationships, stage of cancer at diagnosis, and cancer screening behaviors for West Virginia (WV) cervical cancer survivors. Methods: WV cervical cancer survivors diagnosed between 2000 and 2020 were mailed a survey which included questions on demographic information and cancer screening behaviors, alongside three scales to measure depth of patient–provider relationships, ACEs, and protective factors. Results: Ninety participants completed the survey. ACEs were associated with weaker patient–provider relationships (p \u3c .01) and fewer protective factors (p \u3c .01). More protective factors were associated with stronger patient–provider relationships (p \u3c .01), earlier stage of cancer at diagnosis (p \u3c .05) and positive cancer screening behaviors. Positive cancer screening behaviors were associated with deeper patient–provider relationships (p \u3c .05). A statistically significant model (p = .004) using ACE and resilience scores was able to account for 13% of the explained variability in depth of patient–provider relationships. Implications: These findings suggest an important interplay between ACEs, protective factors, and patient–provider relationships on cancer screening behaviors. Future studies should consider these variables in different populations. In addition, interventions focused on enhancing patient–provider relationships and supporting acquisition of protective factors should be considered

Advancing Cancer Prevention Practice Facilitation Work in Rural Primary Care During COVID-19

COVID-19 and the response to slow the virus spread in West Virginia (WV), including a statewide stay-at-home order, presented challenges to rural primary care clinics on the frontlines. These challenges affected critical quality improvement work, including cancer screening services. In this commentary, the authors present the results of a survey of WV primary care practices that highlight potential long-term implications and identifies opportunities for practice facilitators to partner with rural primary care clinics to address them

Case Study of a Comprehensive Team-Based Approach to Increase Colorectal Cancer Screening

Introduction: Colorectal cancer is the second leading cause of cancer deaths among men and women in West Virginia. In addition, 51% of all colorectal cancers diagnosed in West Virginia from 2012 to 2016 were detected at either regional (31%) or distant (20%) stages indicating a need for improved early detection. Methods: West Virginia University Cheat Lake Physicians participated in the West Virginia Program to Increase Colorectal Cancer Screening, a program of Cancer Prevention and Control at the WVU Cancer Institute. As a result, Cheat Lake Physicians assembled a team of health care professionals to implement evidence-based interventions and system changes including provider assessment and feedback, patient reminders, accurate data capture, and tracking of CRC screening tests. Results: These efforts resulted in a 15.8% increase in colorectal cancer screening rates within one year of implementation. Additionally, the clinic achieved a 66% return rate for Fecal Immunochemical Test kits, an inexpensive, stool-based colorectal cancer screening test. Implications: The utilization of a team-based approach to patient care yields positive results that can be carried over to other cancer and disease prevention efforts in primary care clinics

Leveraging Electronic Health Records Data for Enhanced Colorectal Cancer Screening Efforts

Introduction: Colorectal cancer is the third most common type of cancer in the United States for men and women combined. While the current threat of disease nationally is significant, the majority of colorectal cancer cases and deaths could be prevented through established screening tests and guidelines. Within the Appalachian region and West Virginia in particular, colorectal cancer is a significant public health problem. A more systematic, comprehensive approach to preventing and controlling cancer is essential. Methods: Through the West Virginia Program to Increase Colorectal Cancer Screening, primary care systems across the state received data-informed practice facilitation designed to increase screening rates. Results: Year-1 cohort health systems had an overall baseline screening rate of 28.4% during calendar year 2014. This rate increased and remained steady during the three follow-up measurement time periods, with a rate of 49.5% during calendar year 2018. This increase is notably greater than comparable health systems not part of the initiative. Implications: Lessons learned in increasing colorectal cancer screening rates are applicable to other priority health needs as well

A Cluster Randomized Controlled Trial for a Multi-Level, Clinic-Based Smoking Cessation Program with Women in Appalachian Communities: Study Protocol for the Break Free Program

BACKGROUND: The cervical cancer burden is high among women living in Appalachia. Cigarette smoking, a cervical cancer risk factor, is also highly prevalent in this population. This project aims to increase smoking cessation among women living in Appalachia by embedding a smoking cessation program within a larger, integrated cervical cancer prevention program. METHODS: The broader program, the Take CARE study, is a multi-site research collaborative designed to address three risk factors for cervical cancer incidence and mortality: tobacco use, human papillomavirus (HPV) infection, and cervical cancer screening. Break Free is a primary care clinic-based implementation program that aims to promote smoking cessation among female smokers in Appalachia by standardizing clinical practice protocols. Break Free includes: (1) implementation of a tobacco user identification system in the Electronic Health Record, (2) clinic staff and provider training on the Ask, Advise and Refer (AAR) model, (3) provider implementation of AAR to identify and treat women who want to quit smoking within the next 6 months, (4) facilitated access to cessation phone counseling plus pharmacotherapy, and (5) the bundling of Break Free tobacco cessation with HPV vaccination and cervical cancer screening interventions in an integrated approach to cervical cancer prevention. The study spans 35 Appalachian health clinics across 10 healthcare systems. We aim to enroll 51 adult female smokers per health system (total N = 510). Baseline and follow-up data will be obtained from participant (provider and patient) surveys. The primary outcome is self-reported 12-month point prevalence abstinence among enrolled patients. All randomized patients are asked to complete follow-up surveys, regardless of whether they participated in tobacco treatment. Data analysis of the primary aims will follow intent-to-treat methodology. Secondary outcomes will assess program implementation and cost effectiveness. DISCUSSION: Addressing high tobacco use rates is critical for reducing cervical cancer morbidity and mortality among women living in Appalachia. This study evaluates the implementation and effectiveness of a smoking cessation program in increasing smoking cessation among female smokers. If results demonstrate effectiveness and sustainability, implementation of this program into other health care clinics could reduce both rates of smoking and cervical cancer. Trial registration NCT04340531 (April 9, 2020)

A new communication approach to encourage lung cancer screening action in rural eligible populations

Objective: The purpose of this study was to develop an effective communication approach to encourage lung cancer screening action within rural screening-eligible populations. Methods: An iterative research approach using targeted engagement with the priority population was used. Findings were triangulated through multiple methods, including two surveys and concept testing interviews. The Health Belief Model and the Extended Parallel Process Model served as study frameworks. Results: Initial findings suggest that threat levels are high in the priority population and an emphasis on barrier mitigation messaging may drive action. Health campaign posters integrating these findings were developed and tested with the priority population. The new health campaign posters were tested against examples of previously used health campaign posters. Findings suggest that the new health campaign posters were more effective in spurring lung cancer screening motivation and intention to act in the priority population compared to current health campaign poster examples. Conclusion: Messaging focused on gain-framing, inoculation messaging, and barrier mitigation may be more effective in encouraging lung cancer screening action in rural eligible populations. Innovation: This project outlines a systematic process to developing effective, targeted communication approaches using behavior change and persuasive communication frameworks along with engagement from priority populations

A Health Information Technology Protocol to Enhance Colorectal Cancer Screening

This study addresses barriers to electronic health records–based colorectal cancer screening and follow-up in primary care through the development and implementation of a health information technology protocol