Background: During the COVID-19 pandemic, caregiving responsibilities may have been associated with increased substance use.Objectives: To characterize substance use to cope with stress and willingness to seek help among (i) parents, (ii) unpaid caregivers of adults, and (iii) parent-caregivers.Methods: Data were analyzed for 10,444 non-probabilistic internet-based survey respondents of the COVID-19 Outbreak Public Evaluation (COPE) initiative (5227 females, 5217 males). Questions included new or increased substance use, substance use in the past 30 days to cope, insomnia, mental health, and willingness to seek help.Results: Nearly 20% of parents and unpaid caregivers of adults each reported new or increased use of substances to cope with stress or emotions; 65.4% of parent-caregivers endorsed this response. Compared to non-caregivers, all caregiver groups had higher odds of new or increased use of substances, with parent-caregivers showing the largest effect size (aOR: 7.19 (5.87-8.83), p < .001). Parent-caregivers had four times the adjusted odds of using drugs other than cannabis (aOR: 4.01 (3.15-5.09), p < .001) compared to non-caregivers.Conclusions: Caregivers may initiate or increase substance use as a coping strategy when under stress. The higher odds of substance use underscores the importance of efforts to screen for sleep disturbances and adverse mental health symptoms, particularly among parent-caregivers. Clinicians may consider asking patients about family situations more broadly to help identify people who may be experiencing stress related to caregiving and, if indicated, offer treatment to potentially alleviate some of the risks.

In 2021, the Centers for Disease Control and Prevention's (CDC) National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) funded community health workers (CHWs) for COVID Response and Resilient Communities (CCR). CCR is a 3-year, $350 million initiative to implement CHW strategies aimed at reducing COVID-19 impacts, building resilience, and improving health equity by addressing health-related social needs. This paper describes the CCR initiative and experiences to date, underscoring CHWs' critical role in CDC's pandemic response. CCR funds 67 recipients to reach communities who are disproportionately affected by long-standing health disparities (hereafter, priority populations). CCR aims to decrease the impact of COVID-19 and increase community resilience to respond to COVID-19 and future public health emergencies. Recipients implement three strategies: train CHWs to support the COVID-19 response, increase the workforce of CHWs to manage the spread of the disease, and improve utilization of community and clinical resources to engage CHWs to help strengthen communities' resilience to mitigate the impact of COVID-19. We funded three additional organizations to provide technical assistance to CCR recipients and collaborate with us on a national evaluation of the program. CCR recipients hired about 950 CHWs and integrated these CHWs into over 1,000 organizations and care teams. At the end of the second program year, CHWs made over 250,000 referrals to social services and over 150,000 referrals to address specific health conditions. CCR demonstrates that CHWs can be quickly mobilized to participate in a public health emergency and reach those most affected by COVID-19.

Community health workers (CHWs) are increasingly addressing health disparities in primary care settings; however, there is little information about how primary care practitioners (PCPs) interact with CHWs or perceive CHW roles. We examined PCP engagement with CHWs in adult primary care settings. Overall, 55% of 1504 PCPs reported working with CHWs; involvement with CHWs differed by some PCP demographic and practice-related factors. While PCPs perceived CHWs as engaging in most nationally endorsed CHW roles, they identified several barriers to integrating CHWs into care teams. Findings can inform ongoing efforts to advance health equity through integrating CHWs into primary care practices.

BACKGROUND: National organizations have issued comprehensive cancer survivorship care guidelines to improve care of cancer survivors, many of whom receive care from primary care providers (PCPs). METHODS: We analyzed Porter Novelli's 2019 fall DocStyles survey to assess use of cancer survivorship care guidelines, receipt of survivorship training, types of survivorship services provided, and confidence providing care among PCPs in the United States. We grouped PCPs by use of any guideline ("users") versus no guideline use ("nonusers"). We calculated descriptive statistics and conducted multivariable logistic regression analyses to examine guideline use, having received training on providing survivorship care services, and confidence in providing care. Within the panel, sampling quotas were set so that 1000 primary care physicians, 250 OB/GYNs, 250 pediatricians, and 250 nurse practitioners/physician assistants were recruited. RESULTS: To reach selected quotas, 2696 health professionals were initially contacted to participate, resulting in a response rate of 64.9%. Sixty-two percent of PCPs reported using guidelines and 17% reported receiving survivorship care training. Use of any guidelines or receiving training was associated with reporting providing a range of survivorship services and confidence in providing care. After adjusting for demographic characteristics, guideline users were more likely than nonusers to report assessing genetic cancer risk (OR = 2.65 95% confidence interval (CI) (1.68, 4.17)), screening for cancer recurrence (OR = 2.32 95% CI (1.70, 3.18)) or a new cancer (OR = 1.63, 95% CI (1.20, 2.22)), and treating depression (OR = 1.64, 95% CI (1.20, 2.25)). Receipt of training was also positively associated with providing genetic risk assessment, surveillance for recurrence, as well as assessing late/long-term effects, and treating pain, fatigue, and sexual side effects. CONCLUSION: Survivorship care guidelines and training support PCPs in providing a range of survivorship care services.

BACKGROUND: Responding to calls for additional research that identifies effective distress screening (DS) processes, including referral practices subsequent to screening and receipt of recommended care, we engaged in qualitative research as part of a larger (mixed methods) study of distress screening. This qualitative inquiry of oncology professionals across different facilities in the United States examined routine DS implementation, facilitators and challenges staff encounter with DS processes, and staff members' perceived value of DS. PARTICIPANTS AND METHODS: We conducted key informant interviews and focus groups with staff in 4 Commission on Cancer (CoC)-accredited oncology facilities (a total of 18 participants) to understand implementation of routine DS within oncology care. We used a rigorous data analysis design, including inductive and deductive approaches. RESULTS: Respondents believe DS enhances patient care and described ways to improve DS processes, including administering DS at multiple points throughout oncology care, using patient-administrated DS methods, and enhancing electronic health records infrastructure to better collect, record, and retrieve DS data. Respondents also identified the need for additional psychosocial staff at their facilities to provide timely psychosocial care. CONCLUSIONS: Results reinforce the value of DS in cancer care, including the importance of follow-up to screening with psychosocial oncology providers. Understanding and resolving the barriers and facilitators to implementing DS are important to ensure appropriate psychosocial care for people with cancer. Insights from oncology staff may be used to enhance the quality of DS and subsequent psychosocial care, which is an essential component of oncology care.

PURPOSE: Since 2016, the American College of Surgeons' Commission on Cancer (CoC) has required routine distress screening (DS) of cancer survivors treated in their accredited facilities to facilitate early identification of survivors with psychosocial concerns. Lung and ovarian cancer survivors have relatively low 5-year survival rates and may experience high levels of distress. We examined the extent to which ovarian and lung cancer survivors received CoC-mandated DS and whether DS disparities exist on the basis of diagnosis, sociodemographic factors, or facility geography (urban/rural). METHODS: This study included a quantitative review of DS documentation and follow-up services provided using existing electronic health records (EHRs). We worked with 21 CoC-accredited facilities across the United States and examined EHRs of 2,258 survivors from these facilities (1,618 lung cancer survivors and 640 ovarian cancer survivors) diagnosed in 2016 or 2017. RESULTS: Documentation of DS was found in half (54.8%) of the EHRs reviewed. Disparities existed across race/ethnicity, cancer type and stage, and facility characteristics. Hispanic/Latino and Asian/Pacific Islander survivors were screened at lower percentages than other survivors. Patients with ovarian cancer, those diagnosed at earlier stages, and survivors in urban facilities had relatively low percentages of DS. Non-Hispanic Black survivors were more likely than non-Hispanic White survivors to decline further psychosocial services. CONCLUSION: Despite the mandate for routine DS in CoC-accredited oncology programs, gaps remain in how many and which survivors are screened for distress. Improvements in DS processes to enhance access to DS and appropriate psychosocial care could benefit cancer survivors. Collaboration with CoC during this study led to improvement of their processes for collecting DS data for measuring standard adherence.

BACKGROUND: For this study, the authors examined whether specific programmatic factors were associated with the sustainability of patient navigation programs. METHODS: This cross-sectional survey explored navigation programmatic factors associated with 3 measures of sustainability: 1) length of program existence, 2) reliance on sustainable funding, and 3) participation in alternative payment models. In total, 750 patient navigators or program administrators affiliated with oncology navigation programs in clinical-based and community-based settings completed the survey between April and July 2019. RESULTS: Associations were observed between both accreditation and work setting and measures of program sustainability. Accredited programs and larger, more resourced clinical institutions were particularly likely to exhibit multiple measures of sustainability. The results also identified significant gaps at the programmatic level in data collection and reporting among navigation programs, but no association was observed between programmatic data collection/reporting and sustainability. CONCLUSIONS: Navigation is not currently a reimbursable service and has historically been viewed as value-added in oncology settings. Therefore, factors associated with sustainability are critical to understand how to build a framework for successful navigation programs within the current system and also to develop the case for potential reimbursement in the future.

PURPOSE: We conducted a 12-month pilot study of 2 complementary strategies for improving rural cancer survivorship outcomes: (1) Project ECHO, a telementoring model to increase knowledge and skills about cancer survivorship among multidisciplinary health care provider teams in rural areas and (2) patient navigation (PN) services to connect rural cancer survivors with resources for enhancing health and wellness. METHODS: We recruited 4 CDC-funded National Comprehensive Cancer Control Program sites to implement Project ECHO and PN interventions for a defined rural population in each of their jurisdictions. Sites received ongoing technical assistance and a stipend to support implementation. We conducted a mixed-methods evaluation consisting of quantitative performance monitoring data and qualitative interviews with site staff to assess implementation. FINDINGS: Site teams delivered 21 cancer survivorship ECHO sessions to rural providers resulting in 329 participant encounters. Almost all (93%) ECHO participants reported enhanced knowledge of cancer survivorship issues, and 80% reported intent to apply learnings to their practices. Site teams engaged 16 patient navigators who navigated 164 cancer survivors during the study period. Successful implementation required strong partnerships, clear avenues for recruitment of rural providers and cancer survivors, and activities tailored to local needs. Fostering ongoing relationships among sites through community of practice calls also enhanced implementation. CONCLUSIONS: Sites successfully implemented a novel approach for enhancing care for cancer survivors in rural communities. Pairing Project ECHO to address structural barriers and PN to address individual factors affecting survivorship may help bridge the health equity gap experienced by cancer survivors in rural communities.

Public health agencies have played a critical role in addressing the complex health and mental health needs of cancer survivors. We conducted a mixed-methods evaluation via a Web-based survey (n = 51) and focus groups (n = 11) with National Comprehensive Cancer Control Program (NCCCP) recipients and interviews (n = 9) with survivors, health care providers (HCPs), and patient navigators to explore these audiences' cancer survivorship information needs and strategies to improve resource dissemination. Participants revealed a need for tailored resources and support for survivors on healthy lifestyle, post-treatment survivorship concerns, psychosocial health, and navigating the health system. HCP needs included education on survivorship care plans and care coordination to facilitate the transition between oncology and primary care. HCPs were survivors' most trusted source for information; however, participants noted difficulties engaging HCPs in survivorship care. These findings can help public health practitioners focus their efforts to better meet the needs of cancer survivors and their HCPs.

Introduction: Postpartum depression (PPD) is a serious public health crisis disproportionately affecting women of color. We examine whether interpersonal racial discrimination is associated with higher odds of postpartum depressive symptoms (PPDS) among women of color and how it may vary by race/ethnicity and maternal educational attainment. Materials and Methods: We present a secondary analysis of cross-sectional data from Pregnancy Risk Assessment Monitoring System (PRAMS) postnatal surveys conducted in nine jurisdictions between 2012 and 2015 that included a question about being upset by experiences of racial discrimination within 12 months before giving birth. Results: Being upset by racial discrimination was associated with nearly three times higher odds of PPDS. Among women of color with at least some college education, the higher odds of PPDS associated with racial discrimination were greater than threefold, and for women with less than a high school education were less than twofold. Conclusion: Addressing risk factors for PPD, including racial discrimination, may inform strategies to reduce racial disparities in maternal mental health.

BACKGROUND/PURPOSE: There is much interest in screening for and treating psychosocial distress in cancer patients; however, little is known about if and how psychosocial services are provided for patients demonstrating significant levels of distress. Oncology social workers (OSWs) are the primary providers of psychosocial care for cancer patients and their families, yet there is no widely-used and empirically-validated instrument that captures the range of interventions provided by OSWs. The purpose of this paper is to describe the development of the Oncology Social Work Intervention Index (OSWii), designed to measure interventions provided by OSWs, and the results of testing the instrument. METHODS: We conducted a content analysis of data collected by the Association of Oncology Social Work's Project to Assure Quality Cancer Care (APAQCC). We analyzed 3,194 responses from an open-ended question that described social work interventions following a distress screen. Five investigators coded the data in an iterative process to enhance instrument validity. The resulting instrument measuring OSWii was piloted with 38 oncology social workers across 156 individual cases. RESULTS: OSWs who piloted the OSWii spent a majority of time (72%) engaging in clinical interventions. The user assessment revealed that data entry was rapid, the instrument was easy to use, and the content was relevant to the cancer treatment setting. CONCLUSIONS AND IMPLICATIONS: Using a standardized instrument that reflects OSWs' clinical interventions is critical for researchers to examine the impact of psychosocial interventions on patient outcomes. This index may also advance the translation of scientific findings into patient-centered psychosocial cancer care. This pilot test suggests that the OSWii is both scalable and useful.

Receptive anal intercourse (RAI) contributes significantly to HIV acquisition underscoring the need to develop HIV prevention options for populations engaging in RAI practices. We explored the feasibility of formulating rectal suppositories with potent antiviral drugs for on-demand use. A fixed-dose combination of tenofovir (TFV) and elvitegravir (EVG) (40 mg each) was co-formulated in six different suppository bases (three fat-and three water-soluble). Fat-soluble witepsol H15 and water-soluble polyethylene glycol (PEG) based suppositories demonstrated favorable in vitro release and were advanced to assess in vivo pharmacokinetics following rectal administration in macaques. In vivo drug release profiles were similar for both suppository bases. Median concentrations of TFV and EVG detected in rectal fluids at 2 h were 1-and 2-logs higher than the in vitro IC50, respectively; TFV-diphosphate levels in rectal tissues met or exceeded those associated with high efficacy against rectal simian HIV (SHIV) exposure in macaques. Leveraging on these findings, a PEG-based suppository with a lower dose combination of tenofovir alafenamide (TAF) and EVG (8 mg each) was developed and found to achieve similar rectal drug exposures in macaques. This study establishes the utility of rectal suppositories as a promising on-demand strategy for HIV PrEP and supports their clinical development. © 2021 by the authors. Licensee MDPI, Basel, Switzerland.

PURPOSE: Few studies have examined the practices of U.S. oncology social workers since the implementation of distress screening. This study presents data about oncology social work practice behaviors, including participation in distress screening and interdisciplinary team integration. DESIGN: Using a cross-sectional survey design, Association of Oncology Social Work (AOSW) members were invited to complete the anonymous web-based survey between June and September 2019. SAMPLE: AOSW members (N = 1116) were invited through email and listserv posts to participate in the survey with 533 (47.8%) responding. METHODS: A quantitative on-line survey was used to investigate demographics, distress screening roles and other practice behaviors. Descriptive analyses were conducted on the data. RESULTS: Respondents engaged in a range of practice behaviors consistent with the Standards and Scope of Practice published by AOSW, primarily engaging in patient-focused work. They reported viewing their role as integrated with the interdisciplinary team. Respondents were highly involved in distress screening processes, primarily receiving referrals from distress screening but also collecting/reviewing screening results and referring patients to other providers based on those results. IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS: Knowledge about the ways that oncology social workers enact their role across settings and locations could be useful to those developing effective and integrated psychosocial oncology programs, especially distress screening protocols. Specific knowledge about the practice behaviors of oncology social workers in the U.S. may also help to delineate the role from the work of other interdisciplinary oncology team members.

Early during the COVID-19 pandemic, nearly two thirds of unpaid caregivers of adults reported adverse mental or behavioral health symptoms, compared with approximately one third of noncaregivers(†) (1). In addition, 27% of parents of children aged <18 years reported that their mental health had worsened during the pandemic (2). To examine mental health during the COVID-19 pandemic among U.S. adults on the basis of their classification as having a parenting role (i.e., unpaid persons caring for children and adolescents aged <18 years, referred to as children in this report) or being an unpaid caregiver of adults (i.e., persons caring for adults aged ≥18 years),(§) CDC analyzed data from cross-sectional surveys that were administered during December 2020 and February-March 2021 for The COVID-19 Outbreak Public Evaluation (COPE) Initiative.(¶) Respondents were categorized as parents only, caregivers of adults only, parents-caregivers (persons in both roles), or nonparents/noncaregivers (persons in neither role). Adjusted odds ratios (aORs) for any adverse mental health symptoms, particularly suicidal ideation, were higher among all respondents who were parents, caregivers of adults, or both compared with respondents who were nonparents/noncaregivers and were highest among persons in both roles (parents-caregivers) (any adverse mental health symptoms: aOR = 5.1, 95% confidence interval [CI] = 4.1-6.2; serious suicidal ideation: aOR = 8.2, 95% CI = 6.5-10.4). These findings highlight that parents and caregivers, especially those balancing roles both as parents and caregivers, experienced higher levels of adverse mental health symptoms during the COVID-19 pandemic than adults without these responsibilities. Caregivers who had someone to rely on for support had lower odds of experiencing any adverse mental health symptoms. Additional measures are needed to improve mental health among parents, caregivers, and parents-caregivers.

OBJECTIVE: People with cancer are increasingly more likely to visit an emergency department for acute care than the general population. They often have long wait times and more exposure to infection and receive treatment from staff less experienced with cancer-related problems. Our objective was to examine emergency department (ED) visits among people with cancer to understand how often and why they seek care. METHODS: We conducted a retrospective study of ED visits using the National Syndromic Surveillance Program BioSense Platform. Cancer reported during an ED visit was identified using International Classification of Diseases, Tenth Revision codes for any cancer type, including bladder, breast, cervical, colorectal, kidney, liver, lung, ovary, pancreas, prostate, or uterine cancers. Symptoms prompting the visit were identified for people with cancer who visited EDs in the United States from June 2017 to May 2018 in ≈4500 facilities, including 3000 EDs in 46 states and the District of Columbia (66% of all ED visits during a 1-year period). RESULTS: Of 97 million ED visits examined, 710,297 (0.8%) were among people with cancer. Percentages were higher among women (50.1%) than men (49.5%) and among adults aged ≥65 years (53.6%) than among those ≤64 years (45.7%). The most common presenting symptoms were pain (19.1%); gastrointestinal (13.8%), respiratory (11.5%), and neurologic (5.3%) complaints; fever (4.9%); injury (4.1%); and bleeding (2.4%). Symptom prevalence differed significantly by cancer type. CONCLUSIONS: The Centers for Medicare & Medicaid Services encourages efforts to reduce acute care visits among people with cancer. We characterized almost 70% of ED visits among this population.

BACKGROUND: We sought to understand barriers and facilitators to implementing distress screening (DS) of cancer patients to inform and promote uptake in cancer treatment facilities. We describe the recruitment and data collection challenges and recommendations for assessing DS in oncology treatment facilities. METHODS: We recruited CoC-accredited facilities and collected data from each facility's electronic health record (EHR). Collected data included cancer diagnosis and demographics, details on DS, and other relevant patient health data. Data were collected by external study staff who were given access to the facility's EHR system, or by facility staff working locally within their own EHR system. Analyses are based on a pilot study of 9 facilities. RESULTS: Challenges stemmed from being a multi-facility-based study and local institutional review board (IRB) approval, facility review and approval processes, and issues associated with EHR systems and the lack of DS data standards. Facilities that provided study staff remote-access took longer for recruitment; facilities that performed their own extraction/abstraction took longer to complete data collection. CONCLUSION: Examining DS practices and follow-up among cancer survivors necessitated recruiting and working directly with multiple healthcare systems and facilities. There were a number of lessons learned related to recruitment, enrollment, and data collection. Using the facilitators described in this manuscript offers increased potential for working successfully with various cancer centers and insight into partnering with facilities collecting non-standardized DS clinical data.

BACKGROUND: To estimate the infectious period of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in older adults with underlying conditions, we assessed duration of coronavirus disease 2019 (COVID-19) symptoms, reverse-transcription polymerase chain reaction (RT-PCR) positivity, and culture positivity among nursing home residents. METHODS: We enrolled residents within 15 days of their first positive SARS-CoV-2 test (diagnosis) at an Arkansas facility from July 7 to 15, 2020 and instead them for 42 days. Every 3 days for 21 days and then weekly, we assessed COVID-19 symptoms, collected specimens (oropharyngeal, anterior nares, and saliva), and reviewed medical charts. Blood for serology was collected on days 0, 6, 12, 21, and 42. Infectivity was defined by positive culture. Duration of culture positivity was compared with duration of COVID-19 symptoms and RT-PCR positivity. Data were summarized using measures of central tendency, frequencies, and proportions. RESULTS: We enrolled 17 of 39 (44%) eligible residents. Median participant age was 82 years (range, 58-97 years). All had ≥3 underlying conditions. Median duration of RT-PCR positivity was 22 days (interquartile range [IQR], 8-31 days) from diagnosis; median duration of symptoms was 42 days (IQR, 28-49 days). Of 9 (53%) participants with any culture-positive specimens, 1 (11%) severely immunocompromised participant remained culture-positive 19 days from diagnosis; 8 of 9 (89%) were culture-positive ≤8 days from diagnosis. Seroconversion occurred in 12 of 12 (100%) surviving participants with ≥1 blood specimen; all participants were culture-negative before seroconversion. CONCLUSIONS: Duration of infectivity was considerably shorter than duration of symptoms and RT-PCR positivity. Severe immunocompromise may prolong SARS-CoV-2 infectivity. Seroconversion indicated noninfectivity in this cohort.

CONTEXT: The Centers for Disease Control and Prevention supports the engagement of community health workers (CHWs) to help vulnerable populations achieve optimum health through a variety of initiatives implemented in several organizational units. PROGRAM: This article provides a unified and comprehensive logic model for these initiatives that also serves as a common framework for monitoring and evaluation. IMPLEMENTATION: We developed a logic model to fully describe the levels of effort needed to effectively and sustainably engage CHWs. We mapped monitoring and evaluation metrics currently used by federally funded organizations to the logic model to assess the extent to which measurement and evaluation are aligned to programmatic efforts. EVALUATION: We found that the largest proportion of monitoring and evaluation metrics (61%) currently used maps to the "CHW intervention level" of the logic model, a smaller proportion (37%) maps to the "health system and community organizational level," and a minimal proportion (3%) to the "statewide infrastructure level." DISCUSSION: Organizations engaging CHWs can use the logic model to guide the design as well as performance measurement and evaluation of their CHW initiatives.

Natural-product derived lectins can function as potent viral inhibitors with minimal toxicity as shown in vitro and in small animal models. We here assessed the effect of rectal application of an anti-HIV lectin-based microbicide Q-Griffithsin (Q-GRFT) in rectal tissue samples from rhesus macaques. E-cadherin(+) cells, CD4(+) cells and total mucosal cells were assessed using in situ staining combined with a novel customized digital image analysis platform. Variations in cell numbers between baseline, placebo and Q-GRFT treated samples were analyzed using random intercept linear mixed effect models. The frequencies of rectal E-cadherin(+) cells remained stable despite multiple tissue samplings and Q-GRFT gel (0.1%, 0.3% and 1%, respectively) treatment. Whereas single dose application of Q-GRFT did not affect the frequencies of rectal CD4(+) cells, multi-dose Q-GRFT caused a small, but significant increase of the frequencies of intra-epithelial CD4(+) cells (placebo: median 4%; 1% Q-GRFT: median 7%) and of the CD4(+) lamina propria cells (placebo: median 30%; 0.1-1% Q-GRFT: median 36-39%). The resting time between sampling points were further associated with minor changes in the total and CD4(+) rectal mucosal cell levels. The results add to general knowledge of in vivo evaluation of anti-HIV microbicide application concerning cellular effects in rectal mucosa.

BACKGROUND: The Centers for Disease Control and Prevention supports the implementation of evidence-based interventions to prevent and control cancer, including patient navigation (PN); however, PN lacks standardized tools to measure effectiveness and aggregate data across programs. Using a mobile application (app) could provide a systematic infrastructure for cataloging PN activities and measuring patient outcomes. OBJECTIVE: Our goal was to evaluate the feasibility of using a mobile app to assist with PN services within cancer control programs. METHODS: Seven navigators in 6 geographically diverse PN programs evaluated the mobile app over a period of 5 to 9 months by using the app to track their daily activities. We evaluated the app's capability for collecting and reporting core data elements, such as time spent on outreach, patient care, and administrative tasks, as well as standardized metrics for program evaluation and monitoring. We obtained qualitative data during calls with the navigators through weekly journals and in-depth interviews. RESULTS: The app was effective in tracking caseload, profiling patients' health challenges and barriers to screening and treatment, and capturing PN activities performed during patient encounters. App limitations included an unreliable reporting function, a requirement for internet connectivity, patient privacy concerns, and evolving technology. DISCUSSION: Lessons learned from this evaluation will be useful in developing an app with more robust capabilities while retaining user-friendly features. CONCLUSION: Mobile technology may reduce individual and health system barriers to accessing cancer care and treatment and support posttreatment cancer survivors while also assisting navigators in conducting their work efficiently and effectively.

Lung and bronchus (lung) cancer is the leading cause of cancer death in the United States (1). In 2016, 148,869 lung cancer deaths were reported.* Most lung cancers can be attributed to modifiable exposures, such as tobacco use, secondhand smoke, radon, and asbestos (1). Exposure to lung cancer risk factors vary over time and by characteristics such as sex, age, and nonmetropolitan or metropolitan residence that might affect lung cancer rates (1,2). A recent report found that lung cancer incidence rates were higher and decreased more slowly in nonmetropolitan counties than in metropolitan counties (3). To examine whether lung cancer incidence trends among nonmetropolitan and metropolitan counties differed by age and sex, CDC analyzed data from U.S. Cancer Statistics during 2007-2016, the most recent years for which data are available. During the 10-year study period, lung cancer incidence rates were stable among females aged <35, 45-64, and >/=75 years in nonmetropolitan counties, were stable among females aged <35 years in metropolitan counties, and decreased in all other groups. Overall, among males, lung cancer incidence rates decreased from 99 to 82 per 100,000 in nonmetropolitan areas and from 83 to 63 in metropolitan areas; among females, lung cancer incidence rates decreased from 61 to 58 in nonmetropolitan areas and from 57 to 50 in metropolitan areas. A comprehensive approach to lung cancer prevention and control includes such population-based strategies as screening for tobacco dependence, promoting tobacco cessation, implementing comprehensive smoke-free laws, testing all homes for radon and using proven methods to lower high radon levels, and reducing exposure to lung carcinogens such as asbestos (1). Increasing the implementation of these strategies, particularly among persons living in nonmetropolitan counties, might help to reduce disparities in the decline of lung cancer incidence.

PURPOSE: Patient navigation (PN) is an increasingly recognized element of high-quality, patient-centered cancer care, yet PN in many cancer programs is absent or limited, often because of concerns of extra cost without tangible financial benefits. METHODS: Five real-world examples of PN programs are used to demonstrate that in the pure fee-for-service and the alternative payment model worlds of reimbursement, strong cases can be made to support the benefits of PN. RESULTS: In three large programs, PN resulted in increased patient retention and increased physician loyalty within the cancer programs, leading to increased revenue. In addition, in two programs, PN was associated with a reduction in unnecessary resource utilization, such as emergency department visits and hospitalizations. PN also reduces burdens on oncology providers, potentially reducing burnout, errors, and costly staff turnover. CONCLUSION: PN has resulted in improved patient outcomes and patient satisfaction and has important financial benefits for cancer programs in the fee-for-service and the alternative payment model worlds, lending support for more robust staffing of PN programs.

PURPOSE: Recent advances in cancer treatment have resulted in greatly improved survival, and yet many patients in the USA have not benefited due to poor access to healthcare and difficulty accessing timely care across the cancer care continuum. Recognizing these issues and the need to facilitate discussions on how to improve navigation services for patients with cancer, the National Cancer Policy Forum of the National Academies of Sciences, Engineering, and Medicine (NASEM) held a workshop entitled, "Establishing Effective Patient Navigation Programs in Oncology. The purpose of this manuscript is to disseminate the conclusions of this workshop while providing a clinically relevant review of patient navigation in oncology. DESIGN: Narrative literature review and summary of workshop discussions RESULTS: Patient navigation has been shown to be effective at improving outcomes throughout the spectrum of cancer care. Work remains to develop consensus on scope of practice and evaluation criteria and to align payment incentives and policy. CONCLUSION: Patient navigation plays an essential role in overcoming patient- and system-level barriers to improve access to cancer care and outcomes for those most in need.

INTRODUCTION:: Mental health and substance use are growing public health concerns, but established surveillance methods do not measure the burden of these conditions among women of reproductive age. We developed a standardized indicator from administrative data to identify inpatient hospitalizations related to mental health or substance use (MHSU) among women of reproductive age, as well as co-occurrence of mental health and substance use conditions among those hospitalizations. MATERIALS AND METHODS:: We used inpatient hospital discharge data from 2012-2014 for women aged 15-44 residing in Illinois and Wisconsin. We identified MHSU-related hospitalizations through the principal International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis and first-listed ICD-9-CM external cause of injury code (E code). We classified hospitalizations as related to 1 of 3 mutually exclusive categories: a mental disorder, a substance use disorder, or an acute MHSU-related event. We defined co-occurrence as the presence of both mental health and substance use codes in any available diagnosis or E-code field. RESULTS:: Of 1 173 758 hospitalizations of women of reproductive age, 150 318 (12.8%) were related to a mental disorder, a substance use disorder, or an acute MHSU-related event, for a rate of 135.6 hospitalizations per 10 000 women. Of MHSU-related hospitalizations, 115 163 (76.6%) were for a principal mental disorder, 22 466 (14.9%) were for a principal substance use disorder, and 12 709 (8.5%) were for an acute MHSU-related event; 42.4% had co-occurring mental health codes and substance use codes on the discharge record. PRACTICE IMPLICATIONS:: MHSU-related disorders and events are common causes of hospitalization for women of reproductive age, and nearly half of these hospitalizations involved co-occurring mental health and substance use diagnoses or events. This new indicator may improve public health surveillance by establishing a systematic and comprehensive method to measure the burden of MHSU-related hospitalizations among women of reproductive age.

PURPOSE: The prevalence of smoking among cancer survivors is similar to the general population. However, there is little evidence on the prevalence of specific smoking cessation behaviors among adult cancer survivors. METHODS: The 2015 National Health Interview Survey (NHIS) data were analyzed to examine the prevalence of smoking cessation behaviors and use of treatments among cancer survivors. Weighted self-reported prevalence estimates and 95% confidence intervals were calculated using a sample of 2527 cancer survivors. RESULTS: Among this sample of US cancer survivors, 12% were current smokers, 37% were former smokers, and 51% were never smokers. Compared with former and never smokers, current smokers were younger (< 65 years), less educated, and less likely to report being insured or Medicaid health insurance (p < 0.01). More males were former smokers than current or never smokers. Current smokers reported wanting to quit (57%), a past year quit attempt (49%), or a health professional advised them to quit (66%). Current smokers reported the use of smoking cessation counseling (8%) or medication (38%). CONCLUSIONS: Even after a cancer diagnosis, about one in eight cancer survivors continued to smoke. All could have received advice to quit smoking by a health professional, but a third did not. IMPLICATIONS FOR CANCER SURVIVORS: Health professionals could consistently advise cancer survivors about the increased risks associated with continued smoking, provide them with cessation counseling and medications, refer them to other free cessation resources, and inform them of cessation treatments covered by their health insurance.

Purpose: Health disparities persist across the cancer care continuum. Patient navigator (PN) and community health worker (CHW) interventions are designed to increase health equity. National Comprehensive Cancer Control Program (NCCCP) awardees develop and implement plans to coordinate cancer prevention and control activities, including supporting PN and CHW interventions. This content analysis examined NCCCP action plans to assess the extent to which jurisdictions report engaging in PN and/or CHW activities. Methods: We abstracted PN and CHW content from NCCCP action plans and coded content according to specific areas of PN and/or CHW intervention (e.g., screening, survivorship, and cancer type), used descriptive statistics to characterize overall results, and calculated chi-squares to determine whether programs engaged PNs and CHWs differently. Results: Eighty-two percent (n=53) of 65 NCCCP action plans had content related to PN and/or CHW activities, with more PN language (83%) than CHW (58%). These action plans described engaging PNs and CHWs in activities across the cancer continuum, but particularly for screening (60%) and survivorship (55%). Eighty-one percent of these plans described activities related to workforce development, such as training and standardizing roles and competencies. Programs engaged CHWs more often than PNs for outreach and in community settings. Conclusion: The majority of NCCCP awardees reported engaging in PN and/or CHW activities. Understanding how NCCCP awardees engage PNs and CHWs, including awardees' needs for workforce development in this area, can help Centers for Disease Control and Prevention provide more focused technical assistance as programs increase engagement of PNs and CHWs to improve health equity.

PURPOSE: As of 2016, an estimated 15.5 million cancer survivors were living in the United States and the number of cancer survivors is expected to increase to 20.3 million by 2026. Numerous clinical studies have shown that comorbidities, such as obesity and diabetes, and unhealthy lifestyle choices, such as physical inactivity and heavy smoking, negatively influence overall quality of life and long-term survival of cancer survivors. Accordingly, survivorship programs seek to focus on overall wellness, including symptom management, monitoring for late effects of treatment, monitoring for recurrence, helping patients adapt healthy behaviors, and quality of life. This paper provides a broad overview of public health efforts to address the needs of cancer survivors. METHODS: To describe a range of examples of survivorship initiatives in comprehensive cancer control, we analyzed documents from comprehensive cancer control programs and coalitions and solicited detailed examples from several national partners. RESULTS: Comprehensive cancer control programs, coalitions, and partners are undertaking myriad initiatives to address cancer survivorship and building upon evidence-based interventions to promote healthy behaviors for cancer survivors across the country. CONCLUSION: A coordinated public health approach to caring for the growing population of cancer survivors can help address the long-term physical, psychosocial, and economic effects of cancer treatment on cancer survivors and their families.

Policy, systems, and environmental (PSE) approaches are commonly used to improve population health. Cancer-related examples include providing data and education to stakeholders about policies that support healthy living, or health systems changes such as universal reminders about recommended cancer screening. The National Comprehensive Cancer Control Program (NCCCP) funds health departments to form cancer coalitions that develop and implement cancer plans. NCCCP initiated a demonstration program in 13 of 65 funded grantees to determine whether skilled, dedicated staffing and using a strategic process to examine data, form a workgroup, and develop an agenda would enhance their capacity to implement PSE approaches, recruit new partners, and provide data and education to stakeholders. The objective of this study was to compare demonstration program grantees to other NCCCP grantees on their ability to develop and implement PSE strategies, and the short-term results that were achieved. Program directors (PDs) from each NCCCP-funded jurisdiction completed web surveys at 2 time points during implementation to assess changes in their capacity for PSE approaches, identify implementation activities, and document short-term outcomes. Responses from demonstration program PDs and other PDs at both time points were compared in a descriptive analysis. Demonstration program grantees experienced greater increases in skills and capacity to address PSE approaches, engaged in necessary implementation activities more often, and achieved greater improvements in stakeholder and decision maker awareness and support for PSE strategies, compared to nonparticipating NCCCP grantees. These findings support continued implementation of PSE approaches for sustainable cancer prevention and control.

Development and implementation of policy, systems, and environmental (PSE) change is a commonly used public health approach to reduce disease burden. The Centers for Disease Control and Prevention's National Comprehensive Cancer Control Program conducted a demonstration with 13 programs to determine whether and to what extent dedicated resources would enhance the adoption of PSE strategies. This paper describes results of the qualitative portion of a longitudinal, mixed-methods evaluation of this demonstration. Case studies were conducted with a diverse subset of the 13 programs, and 106 in-depth interviews were completed with state/tribal program staff, community partners, and decision makers. Interviews addressed PSE change planning and capacity building, partnerships, local context, and how programs achieved PSE change. Dedicated PSE resources, including a policy analyst, helped increase PSE change capacity, intensify focus on PSE change overall, and accomplish specific PSE changes within individual jurisdictions. Stakeholders described PSE change as a gradual process requiring preparation and prioritization, strategic collaboration, and navigation of local context. Findings suggest that the demonstration program, including PSE-dedicated funds and a policy analyst, was successful in both increasing PSE change capacity and achieving PSE change itself. These results may be useful to other state, tribal, territorial, and public health organizations planning or implementing PSE change strategies.

Topical microbicides are being explored as an HIV prevention method for individuals who practice receptive anal intercourse. In vivo studies of these microbicides are critical to confirm safety. Here, we evaluated the impact of a rectal microbicide containing the antiviral lectin, Griffithsin (GRFT), on the rectal mucosal proteome and microbiome. Using a randomized, crossover placebo-controlled design, six rhesus macaques received applications of hydroxyethylcellulose (HEC)- or carbopol-formulated 0.1% GRFT gels. Rectal mucosal samples were then evaluated by label-free tandem MS/MS and 16 S rRNA gene amplicon sequencing, for proteomics and microbiome analyses, respectively. Compared to placebo, GRFT gels were not associated with any significant changes to protein levels at any time point (FDR < 5%), but increased abundances of two common and beneficial microbial taxa after 24 hours were observed in HEC-GRFT gel (p < 2E-09). Compared to baseline, both placebo formulations were associated with alterations to proteins involved in proteolysis, activation of the immune response and inflammation after 2 hours (p < 0.0001), and increases in beneficial Faecalibacterium spp. after 24 hours in HEC placebo gel (p = 4.21E-15). This study supports the safety profile of 0.1% GRFT gel as an anti-HIV microbicide and demonstrates that current placebo formulations may associate with changes to rectal proteome and microbiota.