PURPOSE: Research has shown that cancer genetic risk is often not well understood by patients undergoing genetic testing and counseling. We describe the barriers to understanding genetic risk and the needs of high-risk persons and cancer survivors who have undergone genetic testing. METHODS: Using data from an internet survey of adults living in the USA who responded 'yes' to having ever had a genetic test to determine cancer risk (N = 696), we conducted bivariate analyses and multivariable logistic regression models to evaluate associations between demographic, clinical, and communication-related variables by our key outcome of having vs. not having enough information about genetics and cancer to speak with family. Percentages for yes and no responses to queries about unmet informational needs were calculated. Patient satisfaction with counseling and percentage disclosure of genetic risk status to family were also calculated. RESULTS: We found that a lack of resources provided by provider to inform family members and a lack of materials provided along with genetic test results were strongly associated with not having enough information about genetics and cancer (OR 4.54 95% CI 2.40-8.59 and OR 2.19 95% CI 1.16-4.14 respectively). Among participants undergoing genetic counseling, almost half reported needing more information on what genetic risk means for them and their family and how genetic testing results might impact future screening. CONCLUSION: High levels of satisfaction with genetic counseling may not give a full picture of the patient-provider interaction and may miss potential unmet needs of the patient. Accessible resources and ongoing opportunities for updating family history information could reinforce knowledge about genetic risk.

Social determinants of health and associated systems, policies and practices are important drivers of health disparities. American Indian and Alaska Native (AI/AN) populations in the United States have elevated incidence rates of stomach, liver, and colorectal cancers compared to other racial groups. This study examined incidence rates of three gastrointestinal cancers among non-Hispanic AI/AN (NH-AI/AN) and non-Hispanic White (NHW) populations by geographic region and social vulnerability index (SVI) score. Incident cases diagnosed during 2010-2019 were identified from population-based cancer registries linked with the Indian Health Service patient registration databases. Age-adjusted incidence rates (per 100,000) for stomach, liver, and colorectal cancers were compared within NH-AI/AN and between NH-AI/AN and NHW populations by SVI score. Rates were higher among NH-AI/AN populations in moderate and high SVI score counties in Alaska, the Southern Plains, and the East compared with low SVI counties. Incidence rates among NH-AI/AN were elevated when compared to NHW populations by SVI category. Results indicated that higher social vulnerability may drive elevated cancer incidence among NH-AI/AN populations. Additionally, disparities between NH-AI/AN and NHW populations persist even when accounting for SVI. Exploring social vulnerability can aid in designing more effective interventions to address root causes of cancer disparities among AI/AN populations.

Background: The U.S. Preventive Services Task Force recommends biennial screening mammography for average-risk women aged 50-74 years. We aim to generate county-level prevalence estimates for mammography use to examine disparities among counties. Materials and Methods: We used data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS) (n = 111,902 women) and linked them to county-level data from the American Community Survey. We defined two outcomes: mammography within the past 2 years (current); and mammography 5 or more years ago or never (rarely or never). We poststratified the data with U.S. Census estimated county population counts, ran Monte Carlo simulations, and generated county-level estimates. We aggregated estimates to state and national levels. We validated internal consistency between our model-based and BRFSS state estimates using Spearman and Pearson correlation coefficients. Results: Nationally, more than three in four women [78.7% (95% confidence interval {CI}: 78.2%-79.2%)] were current with mammography, although with large variations among counties. Also, nationally, about one in nine women [11% (95% CI: 10.8%-11.3%)] rarely or never had a mammogram. County estimates for being current ranged from 60.4% in New Mexico to 86.9% in Hawaii. Rarely or never having a mammogram ranged from 6% in Connecticut to 23.0% in Alaska, and on average, almost one in eight women in all the counties. Internal consistency correlation coefficient tests were ≥0.94. Conclusions: Our analyses identified marked county variations in mammography use across the country among women aged 50-74 years. We generated estimates for all counties, which may be helpful for targeted outreach to increase mammography uptake.

OBJECTIVES: To explore current literature on social determinants of health (SDOH) and cancer among American Indian and Alaska Native (AI/AN) populations. METHODS: We searched Ovid MEDLINE(®), CINAHL, and PsycINFO databases for articles published during 2000 to 2020, which included terms for SDOH and cancer occurrence in AI/AN populations. We derived the data extraction elements from the PROGRESS-Plus framework. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-Equity extension guided the evidence map. RESULTS: From 2180 screened articles, 297 were included. Most were observational (93.9%), employed a cross-sectional design (83.2%), were categorized as cancer occurrence and surveillance research (62%), and included no cancer-related risk factors (70.7%). Race, gender, and place were the most frequently included PROGRESS-Plus categories. Religion, relationship features, and characteristics of discrimination were least common. Only 12% of articles mentioned historical/current trauma or historical context. CONCLUSIONS: Gaps exist in our understanding of SDOH as drivers of cancer disparities in AI/AN populations. Future studies in health equity science may incorporate historical and cultural factors into SDOH frameworks tailored for AI/AN populations.

PURPOSE: Women exposed to diethylstilbestrol (DES) in utero were at elevated risk of clear-cell adenocarcinoma of the vagina and cervix (CCA) as young women. Previous research suggested that this elevated risk of CCA may persist into adulthood. We extended a published analysis to measure CCA risk as these women aged. METHODS: Standardized incidence ratios (SIR) compared CCA risk among women born from 1947 through 1971 (the DES-era) to CCA risk among the comparison group of women born prior to 1947, using registry data that covered the US population. RESULTS: Incidence rates of CCA among both cohorts increased with age. Among the DES-era birth cohort, higher rates of CCA were observed across all age groups except 55-59 years. SIR estimates had wide confidence intervals that often included the null value. CONCLUSIONS: Results are consistent with prior research and suggest an elevated risk of CCA in midlife and at older ages among women exposed in utero to DES. These results highlight unresolved issues regarding cancer risk among aging DES daughters and appropriate screening guidance. The examination of population-based cancer surveillance data may be a useful tool for monitoring trends in the incidence of other rare cancers over time among specific birth cohorts.

The collection and evaluation of family health history in a clinical setting presents an opportunity to discuss cancer risk, tailor cancer screening recommendations, and identify people with an increased risk of carrying a pathogenic variant who may benefit from referral to genetic counseling and testing. National recommendations for breast and colorectal cancer screening indicate that men and women who have a first-degree relative affected with these types of cancers may benefit from talking to a healthcare provider about starting screening at an earlier age and other options for cancer prevention. The prevalence of reporting a first-degree relative who had cancer was assessed among adult respondents of the 2015 National Health Interview Survey who had never had cancer themselves (n = 27,999). We found 35.6% of adults reported having at least one first-degree relative with cancer at any site. Significant differences in reporting a family history of cancer were observed by sex, age, race/ethnicity, educational attainment, and census region. Nearly 5% of women under age 50 and 2.5% of adults under age 50 had at least one first-degree relative with breast cancer or colorectal cancer, respectively. We estimated that 5.8% of women had a family history of breast or ovarian cancer that may indicate increased genetic risk. A third of U.S. adults who have never had cancer report a family history of cancer in a first-degree relative. This finding underscores the importance of using family history to inform discussions about cancer risk and screening options between healthcare providers and their patients.

PURPOSE-: National screening estimates mask county-level variations. We aimed to generate county-level colorectal cancer (CRC) screening prevalence estimates for 2018 among adults aged 50-75 years and identify counties with low screening prevalence. METHODS-: We combined individual-level county data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS) (n=204,947) with the 2018 American Community Survey county poverty data as a covariate, and the 2018 U.S. Census county population count data to generate county-level prevalence estimates for being current with any CRC screening test, colonoscopy, and home stool blood test. Because BRFSS is a state-based survey, and because some counties did not have samples for analysis, we used correlation coefficients to test internal consistency between model-based and BRFSS state estimates. RESULTS-: Correlation coefficients tests were ≥0.97. Model-based national prevalence for any test was 69.9% (95% CI, 69.5%-70.4%) suggesting 30% are not current with screening test use. State mean estimates ranged from 62.1% in Alaska and Wyoming to 76.6% in Maine and Massachusetts. County mean estimates ranged from 42.2% in Alaska to 80.0% in Florida and Rhode Island. Most tests were performed with colonoscopy. CONCLUSIONS-: Estimates across all U.S. counties showed large variations. Estimates may be informative for planning by states and local screening programs.

BACKGROUND: In 2018, the US Preventive Services Task Force (USPSTF) recommended prostate cancer screening for men aged 55 to 69 years who express a preference for being screened after being informed about and understanding prostate-specific antigen (PSA) test benefits and risks. USPSTF recommended against screening men aged ≥70 years. We aim to generate county-level prevalence estimates, masked by national and state estimates, to identify counties with high PSA screening prevalence. METHODS: We fitted multilevel logistic regression mixed models for 4 age groups (≥40, 40 to 54, 55 to 69, ≥70 years), using data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS) (n = 116,654) and other sources. We evaluated consistency between our model-based state and BRFSS direct state estimates with Spearman and Pearson correlation coefficients. RESULTS: PSA screening prevalence increased with increasing age groups: 7.7% for men aged 40 to 54 years, 27.2% for men aged 55 to 69 years, and 33.7% among men age ≥70 years, and was largely clustered in the South and Appalachia. Many county estimates among men aged ≥70 years exceeded 40%, especially in the South. Correlation coefficients were 0.94 for men aged ≥40, and ≥0.85 for men aged 40 to 54 years, 55 to 69 years, and ≥70 years. CONCLUSIONS: PSA screening was highest among men ≥70 years, for whom it is not recommended, and in the South among all age groups. Screening varied substantially within states. IMPACT: In 2018, on average, more than 1 in 4 men aged 55 to 69 years and 1 in 3 men aged ≥70 years underwent PSA screening in the prior year, suggesting potential overuse among some men.

BACKGROUND: More than one-half of breast cancer cases are diagnosed among women aged younger than 62 years, which may result in employment challenges. This study examined whether cancer-related employment disruption was associated with increased financial hardship in a national US study of women with breast cancer. METHODS: Women with breast cancer who were enrolled in the Sister or Two Sister Studies completed a survivorship survey in 2012. Employment disruption was defined as stopping work completely or working fewer hours after diagnosis. Financial hardship was defined as: 1) experiencing financial problems paying for cancer care, 2) borrowing money or incurring debt, or 3) filing for bankruptcy because of cancer. Prevalence ratios and 95% confidence intervals for the association between employment disruption and financial hardship were estimated using multivariable Poisson regression with robust variance. RESULTS: We analyzed data from women employed at diagnosis (n = 1628). Women were a median age of 48 years at diagnosis and 5.6 years from diagnosis at survey completion. Overall, 27.3% of women reported employment disruption (15.4% stopped working; 11.9% reduced hours), and 21.0% experienced financial hardship (16.0% had difficulty paying for care; 12.6% borrowed money or incurred debt; 1.8% filed for bankruptcy). In adjusted analysis, employment disruption was associated with nearly twice the prevalence of financial hardship (prevalence ratio = 1.93, 95% confidence interval = 1.58 to 2.35). CONCLUSIONS: Women experiencing employment disruptions after breast cancer may be more vulnerable to financial hardship. Findings highlight the need to target risk factors for employment disruption, facilitate return to work or ongoing employment, and mitigate financial consequences after cancer.

Purpose Women undergoing diagnosis and treatment for breast cancer may face challenges in employment. We investigated the impact of demographic, clinical, workplace, and psychosocial characteristics on loss of employment after a breast cancer diagnosis and treatment. We further describe changes in work status and work environment for cancer survivors who sustain employment. Methods We analyzed responses from a survey of breast cancer survivors from the Sister Study and the Two Sister Study cohorts who reported being employed at the time of their breast cancer diagnosis and who reported employment status (lost vs. sustained employment) at the time of survey administration. Multivariate logistic regression was used to identify the effects of lymphedema, neuropathy, problems with memory or attention, social support, health insurance, and sick leave on lost employment, adjusting for demographic characteristics, cancer stage, treatment, and general health. Results Of the 1675 respondents who reported being employed at the time of diagnosis, 83.5% reported being 'currently' employed at the time of the survey. Older age, peripheral neuropathy, lack of sick leave, late stage at diagnosis, a recurrence or a new cancer, problems with memory or attention, and poor general health were significantly associated with lost employment. Conclusions The long-term effects of breast cancer treatment and workplace provisions for leave and accommodation may have a substantial effect on women's ability to sustain employment. The findings from this study highlight challenges reported by cancer survivors that may inform clinical and occupational interventions to support survivors' return to work.

Background: Asbestos is an established cause of several cancers, including mesothelioma and ovarian cancer. Incidence of mesothelioma, the sentinel asbestos-associated cancer, varies by state, likely reflecting different levels of asbestos exposure. We hypothesized that states with high mesothelioma incidence may also have high ovarian cancer incidence. Materials and Methods: Using data from the Centers for Disease Control and Prevention National Program for Cancer Registries and the National Cancer Institute Surveillance, Epidemiology, and End Results Program, we examined the geographic co-occurrence of mesothelioma and ovarian cancer incidence rates by U.S. state for 2003-2015. Results: By state, mesothelioma incidence ranged from 0.5 to 1.3 cases per 100,000 persons and ovarian cancer incidence ranged from 9 to 12 cases per 100,000 females. When states were grouped by quartile of mesothelioma incidence, the average ovarian cancer incidence rate was 10% higher in states with the highest mesothelioma incidence than in states with the lowest mesothelioma incidence. Ovarian cancer incidence tended to be higher in states with high mesothelioma incidence (Pearson correlation r = 0.54; p < 0.0001). Conclusions: Data from state cancer registries show ovarian cancer incidence was positively correlated with mesothelioma incidence, suggesting asbestos may be a common exposure. The potential for asbestos exposure has declined since the 1970s because fewer products contain asbestos; however, some products, materials, and buildings may still release asbestos and thousands of workers may be exposed. Ensuring that people are protected from exposure to asbestos in their workplaces, homes, schools, and communities may reduce the risk of several cancers.

BACKGROUND: The US Preventive Services Task Force recommends biennial screening mammography for average-risk women aged 50 to 74 years. County-level information on population measures of mammography use can inform targeted intervention to reduce geographic disparities in mammography use. County-level estimates for mammography use nationwide are rarely presented. METHODS: We used data from the 2014 Behavioral Risk Factor Surveillance System (BRFSS) (n=130,289 women), linked it to the American Community Survey poverty data, and fitted multilevel logistic regression models with two outcomes: mammography within the past 2 years (up-to-date); and most recent mammography 5 or more years ago or never (rarely/never). We post-stratified the data with US Census population counts to run Monte Carlo simulations. We generated county-level estimates nationally and by urban-rural county classifications. County-level prevalence estimates were aggregated into state and national estimates. We validated internal consistency between our model-based state-specific estimates and urban-rural estimates with BRFSS direct estimates using Spearman correlation coefficients and mean absolute differences. RESULTS: Correlation coefficients were 0.94 or larger. Mean absolute differences for the 2 outcomes ranged from 0.79 to 1.03. Although 78.45% (95% CI: 77.95% horizontal line 78.92%) of women nationally were up-to-date with mammography, more than half of the states had counties with >15% of women rarely/never using a mammogram, many in rural areas. CONCLUSIONS: We provided estimates for all U.S. counties and identified marked variations in mammography use. Many states and counties were far from the 2020 target (81.1%). IMPACT: Our results suggest a need for planning and resource allocation on a local level to increase mammography uptake.

Although annual breast magnetic resonance imaging (MRI) is recommended for women at high risk for breast cancer as an adjunct to screening mammography, breast MRI use remains low. We examined factors associated with breast MRI use in a cohort of women with a family history of breast cancer but no personal cancer history. Study participants came from the Sister Study cohort, a nationwide, prospective study of women with at least 1 sister who had been diagnosed with breast cancer but who themselves had not ever had breast cancer (n = 17 894). Participants were surveyed on breast cancer beliefs, cancer worry, breast MRI use, provider communication, and genetic counseling and testing. Logistic regression was used to assess factors associated with having a breast MRI overall and for those at high risk. Breast MRI was reported by 16.1% and was more common among younger women and those with higher incomes. After adjustment for demographics, ever use of breast MRI was associated with actual and perceived risk. Odds ratios (OR) were 12.29 (95% CI, 8.85-17.06), 2.48 (95% CI, 2.27-2.71), and 2.50 (95% CI, 2.09-2.99) for positive BRCA1/2 test, lifetime breast cancer risk >/= 20%, and being told by a health care provider of higher risk, respectively. Women who believed they had much higher risk than others or had higher level of worry were twice as likely to have had breast MRI; OR = 2.23 (95% CI, 1.82-2.75) and OR = 1.76 (95% CI, 1.52-2.04). Patterns were similar among women at high risk. Breast cancer risk, provider communication, and personal beliefs were determinants of breast MRI use. To support shared decisions about the use of breast MRI, women could benefit from improved understanding of the chances of getting breast cancer and increased quality of provider communications.

Background: The U.S. Preventive Services Task Force recommends routine screening for colorectal cancer for adults ages 50 to 75 years. We generated small-area estimates for being current with colorectal cancer screening to examine sociogeographic differences among states and counties. To our knowledge, nationwide county-level estimates for colorectal cancer screening are rarely presented.Methods: We used county data from the 2014 Behavioral Risk Factor Surveillance System (BRFSS; n = 251,360 adults), linked it to the American Community Survey poverty data, and fitted multilevel logistic regression models. We post-stratified the data with the U.S. Census population data to run Monte Carlo simulations. We generated county-level screening prevalence estimates nationally and by race/ethnicity, mapped the estimates, and aggregated them into state and national estimates. We evaluated internal consistency of our modeled state-specific estimates with BRFSS direct state estimates using Spearman correlation coefficients.Results: Correlation coefficients were >/=0.95, indicating high internal consistency. We observed substantial variations in current colorectal cancer screening estimates among the states and counties within states. State mean estimates ranged from 58.92% in Wyoming to 75.03% in Massachusetts. County mean estimates ranged from 40.11% in Alaska to 79.76% in Florida. Larger county variations were observed in various race/ethnicity groups.Conclusions: State estimates mask county variations. However, both state and county estimates indicate that the country is far behind the "80% by 2018" target.Impact: County-modeled estimates help identify variation in colorectal cancer screening prevalence in the United States and guide education and enhanced screening efforts in areas of need, including areas without BRFSS direct-estimates. Cancer Epidemiol Biomarkers Prev; 27(3); 245-53. (c)2018 AACR.

INTRODUCTION: Women facing complex and uncertain situations such as cancer in their families may seek information from a variety of sources to gain knowledge about cancer risk and reduce uncertainty. We describe and assess the relative importance of information sources about familial breast cancer at the individual, family, and healthcare provider levels influencing women's reporting they had enough information to speak with daughters about breast cancer. This outcome we refer to as being informed about breast cancer. MATERIALS AND METHODS: Sister Study participants, a cohort of women with a family history of breast cancer, were surveyed on family cancer history, family communication, social support, and interactions with healthcare providers (n = 11,766). Adjusted percentages and 95% confidence intervals for being informed about breast cancer versus not being informed were computed for individual-, family-, and provider-level characteristics in three steps using multivariate logistic regression models. RESULTS: We found 65% of women reported being informed about breast cancer while 35% did not. Having a trusted person with whom to discuss cancer concerns, having a lower versus higher perceived risk of breast cancer, having undergone genetic counseling, and being satisfied with physician discussions about breast cancer in their families were predictors of being informed about breast cancer. CONCLUSIONS: Although acquiring objective risk information, such as through genetic counseling, may contribute to a basic level of understanding, communication with providers and within other trusted relationships appears to be an essential component in women's reporting they had all the information they need to talk with their daughters about breast cancer.

PURPOSE: Adolescents with cancer have had less improvement in survival than other populations in the United States. This may be due, in part, to adolescents not receiving treatment at Children's Oncology Group (COG) institutions, which have been shown to increase survival for some cancers. The objective of this ecologic study was to examine geographic distance to COG institutions and adolescent cancer mortality. METHODS: We calculated cancer mortality among adolescents and sociodemographic and healthcare access factors in four geographic zones at selected distances surrounding COG facilities: Zone A (area within 10 miles of any COG institution), Zones B and C (concentric rings with distances from a COG institution of >10-25 miles and >25-50 miles, respectively), and Zone D (area outside of 50 miles). RESULTS: The adolescent cancer death rate was highest in Zone A at 3.21 deaths/100,000, followed by Zone B at 3.05 deaths/100,000, Zone C at 2.94 deaths/100,000, and Zone D at 2.88 deaths/100,000. The United States-wide death rate for whites without Hispanic ethnicity, blacks without Hispanic ethnicity, and persons with Hispanic ethnicity was 2.96 deaths/100,000, 3.10 deaths/100,000, and 3.26 deaths/100,000, respectively. Zone A had high levels of poverty (15%), no health insurance coverage (16%), and no vehicle access (16%). CONCLUSIONS: Geographic access to COG institutions, as measured by distance alone, played no evident role in death rate differences across zones. Among adolescents, socioeconomic factors, such as poverty and health insurance coverage, may have a greater impact on cancer mortality than geographic distance to COG institution.

Pediatricians have a long tradition as advocates for disease prevention and social welfare. Many pediatricians, however, may not appreciate the connection between the early life of children and the prevention of cancer later in life. Most cancers are diagnosed in adulthood and messages about cancer prevention have emphasized “lifestyle” as the focus of prevention efforts. The words we use can frame the discussion and direct our focus. Although a person’s lifestyle or way of life can reflect larger social and ecological factors as well as individual behaviors, contemporary use of the term lifestyle tends to steer us away from contextual factors and instead toward an individual-focused approach. Lifestyle medicine, for example, focuses on adult behaviors, such as smoking, diet, physical activity, and alcohol use. 2 A consideration of the factors in early life that influence cancer risk highlights some of the inherent limitations of using the term lifestyle when describing modifiable risk factors and opportunities for prevention.

PURPOSE: Screening has been shown to lower the morbidity and mortality for breast, cervical, and colorectal cancers. Despite the availability of cancer screening, nearly 70,000 women die each year from these cancers. We conducted a study in 2008 within a privately-insured patient population of women who were members of an integrated health care system in Southeastern Michigan, for whom information on ovarian cancer risk as well as personal and family history of cancer was available. METHODS: We used a population-based, weighted stratified random sample of women from a single health care institution to assess the proportion with up-to-date breast, cervical, and colorectal screening. Multivariable analyses were conducted to identify predictors of screening behavior. RESULTS: In our study, women reported cervical and breast cancer screening above 90% and colorectal cancer screening above 75%. CONCLUSIONS: The results of our study hold promise that Healthy People 2020 cancer screening objectives might be obtainable as access to health insurance is expanded among US residents.

BACKGROUND: Evidence shows underutilization of cancer genetics services. To explore the reasons behind this underutilization, this study evaluated characteristics of women who were referred for genetic counseling and/or had undergone BRCA1/2 testing. METHODS: An ovarian cancer risk perception study stratified 16,720 eligible women from the Henry Ford Health System into average-, elevated-, and high-risk groups based on family history. We randomly selected 3,307 subjects and interviewed 2,524 of them (76.3% response rate). RESULTS: Among the average-, elevated-, and high-risk groups, 2.3, 10.1, and 20.2%, respectively, reported genetic counseling referrals, and 0.8, 3.3, and 9.5%, respectively, reported having undergone BRCA testing. Personal breast cancer history, high risk, and perceived ovarian cancer risk were associated with both referral and testing. Discussion of family history with a doctor predicted counseling referral, whereas belief that family history influenced risk was the strongest BRCA testing predictor. Women perceiving their cancer risk as much higher than other women their age were twice as likely (95% confidence interval: 2.0-9.6) to report genetic counseling referral. CONCLUSION: In a health system with ready access to cancer genetic counseling and BRCA testing, women who were at high risk underutilized these services. There were strong associations between perceived ovarian cancer risk and genetic counseling referral, and between a belief that family history influenced risk and BRCA testing.

INTRODUCTION: Studies suggest that both affective and cognitive processes are involved in the perception of vulnerability to cancer and that affect has an early influence in this assessment of risk. We constructed a path model based on a conceptual framework of heuristic reasoning (affect, resemblance, and availability) coupled with cognitive processes involved in developing personal models of cancer causation. METHODS: From an eligible cohort of 16 700 women in a managed care organization, we randomly selected 2524 women at high, elevated, and average risk of ovarian cancer and administered a questionnaire to test our model (response rate 76.3%). Path analysis delineated the relationships between personal and cognitive characteristics (number of relatives with cancer, age, ideas about cancer causation, perceived resemblance to an affected friend or relative, and ovarian cancer knowledge) and emotional constructs (closeness to an affected relative or friend, time spent processing the cancer experience, and cancer worry) on perceived risk of ovarian cancer. RESULTS: Our final model fit the data well (root mean square error of approximation (RMSEA) = 0.028, comparative fit index (CFI) = 0.99, normed fit index (NFI) = 0.98). This final model (1) demonstrated the nature and direction of relationships between cognitive characteristics and perceived risk; (2) showed that time spent processing the cancer experience was associated with cancer worry; and (3) showed that cancer worry moderately influenced perceived risk. DISCUSSION: Our results highlight the important role that family cancer experience has on cancer worry and shows how cancer experience translates into personal risk perceptions. This understanding informs the discordance between medical or objective risk assessment and personal risk assessment.

This paper provides highlights from a CDC-hosted meeting on opportunities for cancer prevention during midlife (roughly ages 45-64 years). Positive changes during this phase of life have the potential to prevent cancer incidence later in life, making this phase an opportune time for targeted prevention efforts to facilitate healthy aging and increased longevity. Risk and protective factors discussed during the meeting included exposure to radiation from medical imaging procedures, circadian disruption, chemical exposures, dietary factors, alcohol consumption, obesity, physical activity, diabetes, and the human microbiome. Although many of these factors are well recognized as being related to cancer incidence, others are not as widely recognized or have emerged as growing areas of research. Meeting participants discussed promising strategies for cancer prevention targeting this age group. Just as there are multiple determinants of cancer risk, there are likely multiple solutions. Changes to social and physical environments may facilitate healthy behaviors and minimize harmful exposures. Information shared during the meeting about health disparities in the U.S. highlighted the need to go beyond traditional approaches to cancer prevention to truly reach vulnerable populations. Partnerships are also a key component to prevention efforts; community-based and nonprofit organizations, the healthcare system, research institutions, state health departments, and federal agencies were all noted as important partners in prevention efforts. Coordinated, multi-disciplinary efforts across multiple chronic diseases may provide opportunities for synergistic effects. Further, leveraging key partnerships and existing communication channels can maximize success and facilitate timely translation of research findings into public health practice.

This article challenges the idea that cancer cannot be prevented among older adults by examining different aspects of the relationship between age and cancer. Although the sequential patterns of aging cannot be changed, several age-related factors that contribute to disease risk can be. For most adults, age is coincidentally associated with preventable chronic conditions, avoidable exposures, and modifiable risk behaviors that are causally associated with cancer. Midlife is a period of life when the prevalence of multiple cancer risk factors is high and incidence rates begin to increase for many types of cancer. However, current evidence suggests that for most adults, cancer does not have to be an inevitable consequence of growing older. Interventions that support healthy environments, help people manage chronic conditions, and promote healthy behaviors may help people make a healthier transition from midlife to older age and reduce the likelihood of developing cancer. Because the number of adults reaching older ages is increasing rapidly, the number of new cancer cases will also increase if current incidence rates remain unchanged. Thus, the need to translate the available research into practice to promote cancer prevention, especially for adults at midlife, has never been greater.

Low-income women with breast cancer who rely on public transportation may have difficulty in completing recommended radiation therapy due to inadequate access to radiation facilities. Using a geographic information system (GIS) and network analysis we quantified spatial accessibility to radiation treatment facilities in the Atlanta, Georgia metropolitan area. We built a transportation network model that included all bus and rail routes and stops, system transfers and walk and wait times experienced by public transportation system travelers. We also built a private transportation network to model travel times by automobile. We calculated travel times to radiation therapy facilities via public and private transportation from a population-weighted center of each census tract located within the study area. We broadly grouped the tracts by low, medium and high household access to a private vehicle and by race. Facility service areas were created using the network model to map the extent of areal coverage at specified travel times (30, 45 and 60 min) for both public and private modes of transportation. The median public transportation travel time to the nearest radiotherapy facility was 56 min vs. approximately 8 min by private vehicle. We found that majority black census tracts had longer public transportation travel times than white tracts across all categories of vehicle access and that 39% of women in the study area had longer than 1 h of public transportation travel time to the nearest facility. In addition, service area analyses identified locations where the travel time barriers are the greatest. Spatial inaccessibility, especially for women who must use public transportation, is one of the barriers they face in receiving optimal treatment.

INTRODUCTION: Understanding the characteristics of early and late survey responders has implications for recruitment efforts and for informing potential response bias. The main objective of this analysis was to examine survey responder status (ie, early vs late response) by sociodemographic characteristics and by salience of study variables among respondents. METHODS: We analyzed data from a survey on family cancer history and perceived cancer risk among women at a large managed health-care organization. For baseline and 12-month follow-up surveys, we defined early versus late responder status according to the 95th percentile of the number of days it took to obtain completed interviews. RESULTS: We found no significant associations between responder status and sociodemographic characteristics at baseline or follow-up. At baseline, early responders were significantly more likely than late responders to have a personal history of breast cancer (5.2% vs 3.4%, P = .04) and to have been referred for genetic counseling (4.6% vs 2.0%, P = .004). The association between personal history of breast cancer and responder status persisted at follow-up; only 3.5% of late responders at baseline were also late responders at follow-up. Follow-up survey nonresponse rates did not vary by baseline responder status. CONCLUSION: Survey topic salience is associated with early response and is important for recruitment. However, once recruited, late responders do not remain late responders at follow-up, suggesting that extra efforts made to recruit late responders are worthwhile. Health-related agencies that conduct surveys should consider survey salience in survey administration and recruitment strategies.

BACKGROUND: In 2005, the United States Preventive Services Task Force (USPSTF) released guidelines which outlined specific family history patterns associated with an increased risk for BRCA1/2 mutations, and recommended at-risk individuals be referred for genetic counseling and evaluation for BRCA testing. The purpose of this study was to assess the prevalence of individuals with a USPSTF increased-risk family history pattern, the frequency with which specific patterns were met, and resulting healthcare actions among women from the Henry Ford Health System. METHODS: As part of a study evaluating ovarian cancer risk perception and screening, 2,524 randomly selected participants completed a detailed interview (response rate 76%) from an initial eligible cohort of 16,720 women. RESULTS: Approximately 6% of participants had a family history fulfilling one or more of the USPSTF patterns. Although 90% of these women had shared their family history with their provider, less than 20% had been referred for genetic counseling and only 8% had undergone genetic testing. Caucasian women with higher income and education levels were more likely to receive referrals. Among the 95 participants in the total study cohort who reported BRCA testing, 78% did not have a family history that met one of the USPSTF patterns. CONCLUSIONS: These results suggest a higher prevalence of women with an increased-risk family history than originally predicted by the USPSTF, and lack of provider recognition and referral for genetic services. IMPACT: Improvements in healthcare infrastructure and clinician education will be required to realize population level benefits from BRCA genetic counseling and testing.

Given the continued growth in the number of persons with cancer in the United States, the primary prevention of cancer remains an urgent public health priority. As the field of cancer prevention continues to mature and scientific knowledge evolves, it is imperative to challenge the status quo and embrace new approaches to cancer prevention. In this commentary, we summarize recent trends and some of the scientific advances that have been made over the past few decades regarding the complex process of cancer development and the interaction of individual and social risk factors. We examine some of the assumptions and terminology that have characterized cancer prevention approaches for more than a quarter century and the impact of these assumptions and our use of terminology. We propose that it is possible for today's youth to experience lower cancer incidence rates as adults compared with previous generations. To accomplish this goal, a more transdisciplinary and multifaceted approach is needed, adapted as appropriate for different populations and stages of life. The greatest improvements in cancer prevention may occur as a result of innovative, multilevel interventions that build on the expanding scientific evidence base.

Access to screening mammography may be limited by the availability of facilities and machines, and nationwide mammography capacity has been declining. We assessed nationwide capacity at state and county levels from 2003 to 2009, the most recent year for which complete data were available. Using mammography facility certification and inspection data from the Food and Drug Administration, we geocoded all mammography facilities in the United States and determined the total number of fully accredited mammography machines in each US County. We categorized mammography capacity as counties with zero capacity (i.e., 0 machines) or counties with capacity (i.e.,≥1 machines), and then compared those two categories by sociodemographic, health care, and geographic characteristics. We found that mammography capacity was not distributed equally across counties within states and that more than 27 % of counties had zero capacity. Although the number of mammography facilities and machines decreased slightly from 2003 to 2009, the percentage of counties with zero capacity changed little. In adjusted analyses, having zero mammography capacity was most strongly associated with low population density (OR = 11.0; 95 % CI 7.7-15.9), low primary care physician density (OR = 8.9; 95 % CI 6.8-11.7), and a low percentage of insured residents (OR = 3.3; 95 % CI 2.5-4.3) when compared with counties having at least one mammography machine. Mammography capacity has been and remains a concern for a portion of the US population-a population that is mostly but not entirely rural.

BACKGROUND: Preventive health care services, such as cancer screening can be particularly vulnerable to a lack of paid leave from work since care is not being sought for illness or symptoms. We first describe the prevalence of paid sick leave by broad occupational categories and then examine the association between access to paid sick leave and cancer testing and medical care-seeking in the U.S. workforce. METHODS: Data from the 2008 National Health Interview survey were analyzed by using paid sick leave status and other health-related factors to describe the proportion of U.S. workers undergoing mammography, Pap testing, endoscopy, fecal occult blood test (FOBT), and medical-care seeking. RESULTS: More than 48 million individuals (38%) in an estimated U.S. working population of 127 million did not have paid sick leave in 2008. The percentage of workers who underwent mammography, Pap test, endoscopy at recommended intervals, had seen a doctor during the previous 12 months or had at least one visit to a health care provider during the previous 12 months was significantly higher among those with paid sick leave compared with those without sick leave after controlling for sociodemographic and health-care-related factors. CONCLUSIONS: Lack of paid sick leave appears to be a potential barrier to obtaining preventive medical care and is a societal benefit that is potentially amenable to change.

OBJECTIVE: To describe the development and psychometric testing of items measuring connection to the cancer experience through a close friend or relative. METHODS: Ten items assess four aspects of connection to cancer: emotional and cognitive involvement, kind and amount of shared experience, perceived similarity to the affected person, and negative change witnessed. Interviews were conducted with 2200 women close to someone with cancer. The sample was split into two samples for exploratory and confirmatory factor analysis. Sample 1 (n=1342) was used to examine the underlying structure of the items. Sample 2 (n=858) was used for CFA. Internal consistency and reliability analysis were also conducted. RESULTS: Three factors with moderate correlation were extracted: general closeness, resemblance, and cognitive processing. Results from the CFA analysis confirmed a good fit of the three-factor model (Bentler-Bonett NIF=0.973, Bentler-Bonett NNFI=0.975, RMSEA=0.040 and CFI=0.984) and all path coefficients were statistically significant. CONCLUSION: Findings provide preliminary evidence for the reliability and construct validity of the CONNECS scale in measuring individuals' connection to the cancer experience through a close friend or relative. PRACTICE IMPLICATIONS: CONNECS may be a useful tool for examining the impact of the cancer experience on risk perceptions, cancer worry, and medical decision making.

Although the association between in utero exposure to diethylstilbestrol (DES) and clear cell adenocarcinoma of the cervix and vagina (CCA) was first reported among young women, subsequent case reports and cohort studies suggest that an elevated risk for CCA may persist with age. Data from the National Program of Cancer Registries (NPCR) and the Surveillance, Epidemiology and End Results (SEER) Program were used to construct indirect standardized incidence ratios (SIR) comparing CCA risk among women born during the exposure period 1947 through 1971, when DES was prescribed to pregnant women, to the relevant time period for nonexposed women born before or after DES exposure period. CCA incidence among the women born before the DES exposure period (ages 30-54 at diagnosis of CAA) or after the DES exposure period (ages 15-29 at diagnosis) were used to calculate the expected rates for women born during the DES exposure period. Among women aged 15-29 years, CCA risk increased with age and peaked in the 25-29 year age group, but the risk estimates were unstable (SIR = 6.06; 95% CI: 0.97, -251.07, SEER data). Among women aged 40-54 years, CCA risk was greatest in the 40-44 year age group (SIR = 4.55; 95% CI: 1.11, 40.19, SEER data and SIR = 3.94; 95% CI: 1.06, 33.01, NPCR/SEER data) and remained significantly elevated throughout this age group in the combined data set. Risk was not elevated among women aged 30-39 years. The observed risk of CCA, if causally related to DES exposure, reflects a persistent health impact from in utero exposure that is widespread in the general population. When assessing a woman's cancer risks, whether her mother took DES while pregnant may still be a relevant aspect of the medical history for women born during the period of DES use in pregnancy.