Kathryn E. Weaver, Ph.D. - US grants

DESCRIPTION (provided by applicant): Americans living in rural areas have been identified by several federal agencies as a priority population affected by health disparities. Disparities have been identified in cancer screening, diagnosis and treatment for rural residents. However, although an estimated 21% or more of all United States cancer survivors reside in rural areas, little is known about their long-term cancer survivorship experience. This population may be at risk for poorer survivorship care and health outcomes due to a variety of reasons, including long travel distances to obtain care, a limited number of primary and specialty healthcare facilities, lower socioeconomic status, and limited cancer-related knowledge. This proposal seeks to: 1) establish the feasibility of using a hospital cancer registry to locate and recruit post-treatment cancer survivors residing in rural areas and 2) gather preliminary data on the cancer-related follow-up care experiences, perceived barriers to care, and information needs of two to five year cancer survivors residing in rural areas. This information will be obtained through a cross- sectional mail and telephone survey of approximately 180 breast, prostate and colorectal rural survivors, recruited from the cancer registry of an academic medical center serving a large rural population. The proposed research will expand our currently limited understanding of cancer-related follow-up care experiences, perceived barriers, and information needs among cancer survivors in rural areas. Increased knowledge about rural cancer survivors addresses an NCI Strategic Objective, to overcome cancer health disparities, and will guide future proposals to develop interventions addressing health disparities in rural cancer survivors. The data we collect in this exploratory R03 study about response rates and variability in outcomes are the necessary foundation for a larger observational study comparing urban and rural survivors. The information we will gather on follow-up care experiences, survivorship needs, and barriers to receipt of follow-up care will inform the development of soundly designed future interventions to improve the cancer-related follow-up care experiences of post-treatment survivors. These may include interventions designed to improve patient-physician communication and coordination among physicians via the development of survivorship care plans, or interventions focused on improving knowledge and understanding of follow-up care among rural survivors. Finally, this study will launch the career of a new investigator in cancer health disparities and build a foundation for her future work in rural cancer survivorship. PUBLIC HEALTH RELEVANCE: Despite documented rural health disparities in cancer screening, diagnosis and treatment, little is known about the post-treatment follow-up care experiences of rural cancer survivors. The goal of the proposed research is to survey rural breast, prostate, and colorectal cancer survivors recruited from an academic medical center cancer registry to gather preliminary data on the cancer-related follow-up care experiences, barriers, and information needs of two- to five-year cancer survivors residing in rural areas.

DESCRIPTION (provided by applicant): Americans living in rural areas have been identified by several federal agencies as a priority population affected by health disparities. Disparities have been identified in cancer screening, diagnosis and treatment for rural residents. However, although an estimated 21% or more of all United States cancer survivors reside in rural areas, little is known about the long-term cancer survivorship experience of rural persons with a history of cancer. Due to a variety of reasons such as long travel distances to obtain care and a limited number of primary and specialty healthcare facilities, this population may be at risk for poorer survivorship care and health outcomes. This lack of information about rural cancer survivors hinders public health planning, allocation of medical resources, and the development of interventions to target this potentially vulnerable population. This application seeks to provide population-based information about the characteristics and health status of adult cancer survivors who reside in rural areas of the United States. Specific aims are to: (1) characterize US cancer survivors residing in rural areas and identify how they may differ from non-rural survivors; (2) compare the health status of rural cancer survivors with that of non-rural survivors; and (3) assess whether differences in health between rural and non-rural survivors are accounted for by known risk factors including physical activity, body mass index, smoking history, socioeconomic status, and access to medical care. Health status outcomes will include self-reported health, prevalence of comorbid medical conditions, psychological distress, and health-related unemployment. Analyses will be conducted using data from the National Health Interview Survey (NHIS), an annual in person survey of 30-40,000 households that provides a representative sample of the US civilian, non-institutionalized population. The proposed research will generate the first population-based estimate of the number and proportion of cancer survivors who reside in rural areas in the US. Increased knowledge about rural cancer survivors addresses an NCI Strategic Objective, to overcome cancer health disparities, and will inform public health initiatives and guide future grant applications to develop interventions addressing health disparities in rural cancer survivors. PUBLIC HEALTH RELEVANCE: PROJECT NARRATIVE Despite the estimate that at least 21% of all cancer survivors reside in rural communities, the lack of knowledge about their health status impedes public health planning, allocation of resources, and development of interventions targeting this potentially vulnerable population. The goal of the proposed research is to use National Health Interview Survey data to provide population-based information about the characteristics and health status of adult cancer survivors residing in rural areas of the US.

DESCRIPTION (provided by applicant): The Institute of Medicine and others have strongly recommended survivors exiting active treatment receive a comprehensive survivorship care plan addressing surveillance, late effects symptoms, psychosocial needs, and general health maintenance, as well as indicating which providers will handle which components of the plan. Despite this recommendation, survivorship care planning and communication are often inadequate, leaving survivors confused and uncertain about their care. In addition, little is known about communication- related barriers to survivorship care, which may be of particular concern for rural-residing survivors who often live at some distance from their oncology specialist(s) and have limited primary care access. To reduce confusion and uncertainty, and to avoid duplication of medical effort, we envision a formal planning and communication process that integrates patient preferences with recommendations from multiple providers to generate a comprehensive survivorship care plan. [We believe effective implementation of this process requires a clinically-oriented individual like a nurse, nurse practitioner, physician assistant, or physician to facilitate and coordinate communications between survivors and their primary care and oncology specialty providers.] Our goal is to generate information needed to create and evaluate a process designed specifically to accommodate the needs of rural-residing survivors while also meeting the needs of suburban and urban survivors. Thus we aim to: (1) describe breast cancer survivors' knowledge about, perceived importance of, and barriers to survivorship care planning and communication; (2) assess survivors' current and preferred communication with oncology specialists and primary care providers about their survivorship care plans; and (3) explore the relationship between current survivor and provider survivorship care planning and communication with survivors' cancer-related uncertainty and quality of life. All data will be collected via a survey relying heavily on questions drawn from previously validated instruments and administered via hard copy mail, on-line or telephone interview. Our analytic approach will include descriptive statistics, correlation, and regression modeling. Both this proposal and the resulting testable intervention of a clinical model of survivorship care planning and communication will substantially advance our understanding of cancer survivorship care, particularly for rural-residing breast cancer survivors.

DESCRIPTION (provided by applicant): Lung cancer is the second-most common cancer diagnosed in the US, yet little survivorship research has been conducted with this population. The proportion of lung cancer survivors diagnosed with early stage disease, whose 5-year survival exceeds 50%, is likely to increase with the uptake of lung cancer screening in the US. Lung cancer survivors frequently report more medical and psychosocial concerns and worse health-related quality of life compared to survivors of other cancers, yet we know little about how these concerns are addressed during the two years after initial treatment or what sort of survivorship care planning early stage lung cancer (ESLC) patients experience or desire. The proposed mixed-methods study will focus on an understudied, but growing population, ESLC survivors, and gather novel data on their follow-up care transition experiences and needs. This study will recruit patients diagnosed with localized lung cancer who have completed primary treatment within the past 3-24 months through our institutional cancer registry, provider referral and community organizations. Aim 1 (qualitative) will use semi-structured interviews (n=15-20) to explore ESLC survivors' experiences in the two years after initial treatment, focusing on their health needs, communication with treatment team, and psychosocial concerns. Data from Aim 1 will be used to develop a survey to address Aim 2 (quantitative) that optimally reflects patient perspectives. For Aim 2, we will document ESLC survivors' (n=70) reports of a) experienced and desired follow-up care communication, including discussions with providers and written care plans, b) current health-related information and supportive care needs, and c) persistent symptoms and quality of life after primary lung cancer treatment completion. It is expected that a majority of participants will report having some discussion with their provider(s) about follow-up care, yet a majority will report wanting a written care plan and more communication with their provider than what they experienced. It is also expected that a majority of participants (>50%) will identify at least one unmet health-related or supportive care need, and that health-related quality of life will be lower in ESLC survivors after primary treatment completion compared to established general cancer patient norms. The results of this study will provide preliminary data to develop a survivorship care planning intervention that meets the needs of ESLC patients. Future applications will examine the impact of care planning interventions, as well as targeted symptom-focused interventions, specifically for the growing population of ESLC patients.

Project Summary Cardiovascular (CV) disease is a significant competing cause of death for many survivors of common early-stage cancers. Up to 90% of survivors have multiple CV risk factors, and many receive cancer therapies with potentially cardiotoxic side effects. Yet cardiovascular health (CVH) is rarely addressed during routine post-treatment survivorship care. CVH assessment could increase patient and provider awareness of CVH and treatment-related cardiotoxicity risk, and promote CVH and cardiotoxicity management during survivorship care, thereby reducing CV disease and cancer recurrence. Such an assessment may be especially critical for the 20% of survivors who do not have a primary care provider and those who received potentially cardiotoxic treatments. Our electronic subsequently adapted Community usability factors clinical examine cancer research team developed an automated health record (EHR)-based CVH assessment tool, deployed it in a primary care setting, and adapted it for use with cancer survivors. Here we propose to implement and evaluate this tool, called the Automated Heart Health Application (AH-HA), among survivors in the NCI Oncology Research Program (NCORP) network. Evaluations in our pilot indicated high and acceptability among oncology providers and survivors. AH-HA incorporates traditional CV risk and potentially cardiotoxic cancer treatment data, and can be easily implemented into routine practice. Thus, we propose a mixed methods, hybrid effectiveness-implementation study to the effects of the AH-HA tool among survivors of breast, prostate, colorectal, and endometrial who are now in survivorship care.Our central hypothesis is that the AH-HA tool will increase (1) CVH awareness and discussions among patients and oncology providers, (2) appropriate referrals and visits to primary care and cardiology, and (3) CV risk reduction and health promotion activities compared to usual care. We seek to speed translation of the AH-HA tool into practice by simultaneously collecting mixed method process data regarding current and future implementation, guided by the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) framework. Our Specific Aims are to: (1) Assess the impact of the AH-HA tool on providers' efforts to discuss CVH, refer survivors to primary care and cardiology, and manage CV risk; (2) Measure the impact of the AH-HA tool on survivors' completed primary care and cardiology visits and CVH; and (3) Examine factors influencing current and future implementation of the AH-HA tool. The results of our proposed study will guide future dissemination efforts, with the ultimate goal of improving CVH among the rapidly growing population of cancer survivors. Use of the established NCORP network is efficient and provides an excellent opportunity to test our intervention in community oncology settings, where most cancer survivors receive care.

Description (provided by the applicant): The Wake Forest NCORP Cancer Center Research Base will continue to utilize the unique resources and expertise of the established and productive Wake Forest Cancer Center CCOP Research Base and build on established collaborations with our NCORP community partners, consultants and other Research Bases to address cancer and treatment-related symptoms and toxicities, cancer care delivery issues, and cancer related health disparities as outlined below. Specific Aim 1: To expand our cancer control clinical trial activities in the following areas: 1) Cardiovascular complications of cancer therapy including early diagnosis, intervention and prevention strategies; 2) Neurocognitive complications of cancer therapy with an emphasis on prevention and early treatment of radiation and chemotherapy-induced neuro-cognitive effects, as well as identification and treatment of patients with established toxicity; and 3) Additional cancer and treatment-related symptoms and toxicities experienced across the spectrum from diagnosis through long-term survivorship. Specific Aim 2: To grow and strengthen our CCDR portfolio in conjunction with NCORP community sites and collaboration with other NCORP research bases. We will emphasize studies that complement our established thematic areas of expertise in cardiovascular complications and survivorship. Specific Aim 3: To elucidate the basic mechanisms underlying cancer and treatment-related symptoms and toxicities through bio specimen collection and correlative science accompanying our clinical investigations. These efforts will facilitate a better understanding of treatment outcomes and efficacy, and identification of individuals for whom specific interventions will or wil not be effective. Specific Aim 4: To maintain and build on our success in recruiting racial and ethnic minority and underserved populations across all research investigations pursued by the Wake Forest NCORP Cancer Center Research Base. Specific Aim 5: To train the next generation of medical and public health researchers through involvement and mentoring of early career faculty, medical oncology and radiation oncology trainees, and public health post-doctoral fellows and students in Wake Forest NCORP Research Base activities.