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Addressing Social Determinants and Health-Risk Behaviors to Reduce Cancer Burden and Eliminate Cancer-Related Disparities

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Addressing Social Determinants and Health-Risk Behaviors to Reduce Cancer Burden and Eliminate Cancer-Related Disparities

October 05, 2022

Yale Cancer Center Grand Rounds | October 4, 2022

Presentation by: Dr. Hermine Poghosyan

ID
8139

Transcript

  • 00:00All right. Good afternoon, everyone.
  • 00:02We're going to go ahead and get started here.
  • 00:05It's my pleasure to introduce
  • 00:07Doctor Herman Pogosian.
  • 00:09She's an associate professor at
  • 00:11Yale University School of Nursing.
  • 00:12She received her Bachelor of Science in
  • 00:15nursing from Jonkoping University in Sweden,
  • 00:17and she received her pH.
  • 00:19D from the American University
  • 00:20of Armenia and her PhD from the
  • 00:22University of Massachusetts, Boston.
  • 00:24Doctor Pogosian completed a postdoctoral
  • 00:27fellowship and interprofessional
  • 00:28health services research at the
  • 00:30Betty Irene Moore School of Nursing.
  • 00:32At the University of California, Davis.
  • 00:34Her research focus is on cancer
  • 00:37epidemiology and survivorship
  • 00:38research with a particular interest
  • 00:40in cancer health disparities,
  • 00:42lung cancer screening survivors and their
  • 00:44social network members including families,
  • 00:47friends and others.
  • 00:48Doctor proposing is the principal
  • 00:50investigator of an NCI funded R1
  • 00:52that is investigating social networks
  • 00:54and effective states in the context
  • 00:56of smoking behaviors among adults
  • 00:58diagnosed with tobacco related cancer.
  • 01:00Please join me in welcoming Dr Prozium
  • 01:02to Yale Cancer Center grand rounds.
  • 01:04Thank you.
  • 01:09Thank you. Good afternoon everyone and
  • 01:13thank you Michael for the kind introduction.
  • 01:16And I'm very excited to be here today
  • 01:18and to share some of my work with you.
  • 01:21And I'll be talking a little bit about
  • 01:24lung cancer screening in the US and also
  • 01:26tobacco use among cancer survivors.
  • 01:29So just to give a little bit
  • 01:32of a background information,
  • 01:35we know that lung cancer is the 2nd
  • 01:39leading cause of cancer and the leading.
  • 01:42Leading cause of cancer related death
  • 01:45in the US in both men and women,
  • 01:47and this year it is estimated that
  • 01:50there will be about 236,000 new
  • 01:54lung cancer cases and about 130,000
  • 01:57deaths from lung cancer.
  • 02:01But when we look at the incidence and the
  • 02:04mortality rates for lung cancer by race,
  • 02:06ethnicity,
  • 02:07certain racial and ethnic minorities groups,
  • 02:11they suffer more from lung cancer and
  • 02:15they have worse clinical outcomes
  • 02:18compared to white individuals.
  • 02:20And in fact,
  • 02:22African American men have the highest
  • 02:25rate of lung cancer incidence rate
  • 02:28and the highest mortality rate.
  • 02:31Compared to other racial ethnic groups
  • 02:34and just for example one of the studies,
  • 02:38our earlier study that we published
  • 02:40in general thoracic oncology,
  • 02:42we found that black patients who had
  • 02:47got surgery for their lung cancer,
  • 02:50they had much lower post operative
  • 02:53mental health related quality of
  • 02:56life compared to white patients
  • 02:58undergoing lung cancer surgery.
  • 03:01And also in terms of survival like
  • 03:03there is again significant difference
  • 03:06in in a five year survival comparing.
  • 03:10Racial ethnic minority groups
  • 03:12with white individuals,
  • 03:13the five year survival.
  • 03:15The overall five year survival.
  • 03:16All stages combined is.
  • 03:20Among all the races is 22% but when
  • 03:23you compare the black individuals have
  • 03:26much have lower five year survival
  • 03:28from lung cancer compared white and
  • 03:32lung cancer has has a poor prognosis.
  • 03:36And early detection of lung cancer is
  • 03:39kind of the key to improve survival
  • 03:42among patients diagnosed with lung cancer.
  • 03:46And unfortunately a lot of work
  • 03:48has been done showing that.
  • 03:51The early diet,
  • 03:52the only less than 20% of patients are
  • 03:55diagnosed with early stage lung cancer.
  • 03:58Some of the studies suggest even like 16%,
  • 04:00around 16% are diagnosed with stage
  • 04:03one lung cancer when the more curative
  • 04:05treatment options are available
  • 04:07that help to improve the survival
  • 04:10among these patients and last kind
  • 04:12of 10 years or so about the sodium.
  • 04:17Screening for lung cancer with low
  • 04:20dose computed tomography has been
  • 04:22shown to reduce lung cancer mortality
  • 04:24among individuals at higher risk,
  • 04:26so one of them well known.
  • 04:28The study conducted in trial in the US
  • 04:31national lung cancer screening trial
  • 04:33showed that screening with low dose
  • 04:35computed tomographic decreases lung
  • 04:37cancer rate mortality rate by 20%
  • 04:40and another study recently that came
  • 04:44out more recently Nelson study trial.
  • 04:47And from Netherlands,
  • 04:48they showed that up to 26% reduction
  • 04:51in lung cancer mortality among those
  • 04:54who got screened for lung cancer
  • 04:57with low dose computed tomography.
  • 05:00So the and then since 2013,
  • 05:03we have a guideline in place by
  • 05:05US Preventive Service Task Force
  • 05:08recommending annual lung cancer
  • 05:10screening for high risk individuals.
  • 05:13And those individuals are asymptomatic
  • 05:15adults ages 50 to 80 years old and
  • 05:19current and former smokers who quit
  • 05:21within the past 15 years and they have
  • 05:24at least 20 pack years of smoking history.
  • 05:27So this guideline was updated last year.
  • 05:30To March of 2021 before the March 2021
  • 05:35the age range age started 55 years 55
  • 05:40to 80 years old and then the Smoking
  • 05:42Pack history was 30 pack year history.
  • 05:45So they decreased last year the the
  • 05:48guideline the criteria of 20 pack
  • 05:50year sister instead of 30 and 20
  • 05:53pack year sister means that someone
  • 05:55smokes at least one pack of cigarettes
  • 05:58per day for at least 20 years.
  • 06:02And Centers for Medicare and Medicaid
  • 06:05Services provides coverage for annual
  • 06:07lung cancer screening with low dose
  • 06:10computer tomography for eligible individuals.
  • 06:14And Affordable Care acts mandate
  • 06:16private insurance companies to
  • 06:19cover lung cancer screening.
  • 06:21So one of the main one of the
  • 06:24main reason that the screening
  • 06:26guideline was updated the decrease
  • 06:29the age and decrease the smoking.
  • 06:31Great because?
  • 06:34A lot of work has been done showing
  • 06:36that black individuals were less
  • 06:38often eligible under that guideline
  • 06:40for lung cancer screening despite
  • 06:43they have developing lung cancer
  • 06:45at much younger age and they have
  • 06:48a lower smoking intensity.
  • 06:50So it was hard to meet at 30 at
  • 06:52least 30 pack years of smoking,
  • 06:54smoking history criteria and and
  • 06:56also they have like when you look at
  • 06:59the smoking prevalence comparing non
  • 07:01Hispanic whites and non Hispanic blacks.
  • 07:04They have kind of a little bit
  • 07:06like similar smoking rates,
  • 07:08but they have much higher blocking
  • 07:10the doors have much higher incidence
  • 07:13rate from lung cancer,
  • 07:15mortality rate from lung cancer.
  • 07:17They are diagnosed with much earlier
  • 07:19age and they have a lower in smoking
  • 07:23intensity compared to white.
  • 07:24So that's why they expanded the
  • 07:27kind of change the criteria with
  • 07:29the hope that that more racial and
  • 07:31ethnic minorities group will meet.
  • 07:34Lung cancer screening criteria,
  • 07:37so become eligible.
  • 07:39And with that, with the earlier guideline,
  • 07:42the about studies show that about
  • 07:458,000,000 adults were eligible
  • 07:47for lung cancer.
  • 07:48With a new guideline about 14.5 million
  • 07:51adults are eligible for lung cancer.
  • 07:54And there have been studies showing
  • 07:57that when they changed the guidelines
  • 07:59just few came out that more like with
  • 08:02the new eligibility criteria,
  • 08:04higher proper high proportion
  • 08:07of African Americans meet.
  • 08:09Lucky meets the criteria for
  • 08:12lung cancer screening. So.
  • 08:14The current rate for lung
  • 08:17cancer screening is very low.
  • 08:20The utilization,
  • 08:20the uptake of lung cancer screening
  • 08:22is very low in the US the new
  • 08:25report that came out about in
  • 08:262019 was 6.6% and then 2020 it
  • 08:30dropped a little bit to 6.5%,
  • 08:33but there have been some studies
  • 08:35done and also our work that
  • 08:38showed a little bit higher rate.
  • 08:40So that's so,
  • 08:41but this the new report
  • 08:43showed much lower rate.
  • 08:45That's why I just wanted.
  • 08:46To bring to bring this numbers
  • 08:48here and a lot of work has been
  • 08:51done to show that lung cancer
  • 08:53screening rate uptake is much lower
  • 08:56among African American individuals
  • 08:59or Russian ethnic minorities
  • 09:00compared to white minorities.
  • 09:02But the guy since guideline
  • 09:04changed last March,
  • 09:06there's still a lot of work need
  • 09:08to be done to kind of have that
  • 09:10clear understanding of the lung
  • 09:12cancer screening uptake by race,
  • 09:14ethnicity and there has been.
  • 09:16Reports show saying that estimating
  • 09:19that if we implement national lung
  • 09:23cancer screening we could prevent up
  • 09:26to like 6000 deaths in the US so but
  • 09:31unfortunately the uptake is very low.
  • 09:34So we are interested in this study.
  • 09:37So since some work has been done to
  • 09:39show like uptake is low and then the
  • 09:41uptake specifically it is much lower
  • 09:43among racial and ethnic minorities.
  • 09:45So we were interested to conduct
  • 09:48this study to understand the
  • 09:50intention of high risk individuals
  • 09:52to get screened for the for lung
  • 09:55cancer if their primary care
  • 09:56provider if the healthcare providers
  • 09:59recommended it so specifically.
  • 10:03In this study,
  • 10:04we investigated the association
  • 10:06between worry about future health
  • 10:09issues of smoking and intention
  • 10:12to undergo recommended lung
  • 10:14cancer screening with low dose
  • 10:17computed tomography within the
  • 10:19next three months when if the
  • 10:22healthcare provider recommended it.
  • 10:26This was a cross-sectional survey
  • 10:28who conducted the online survey.
  • 10:30We used Qualtrics research panel
  • 10:33to recruit study subjects.
  • 10:35In this study we included 152 adults
  • 10:38aged between 55 to 74 years old with
  • 10:42at least 30 pack years of smoking.
  • 10:45So this was part of a much larger
  • 10:47study we had that we looked into
  • 10:50electronic cigarette use as well
  • 10:52and the total sample size of
  • 10:54the original study was eight.
  • 10:56121 and out of 800 twenty 152 who
  • 11:00made the criteria of at least
  • 11:02having 30 pack years of smoking.
  • 11:04So we used 30 pack years of smoking
  • 11:07because of the prior guideline for
  • 11:10lung cancer screening and the age
  • 11:12range we used 55 to 74 based on
  • 11:15the national lung cancer screening
  • 11:18eligible eligibility criteria.
  • 11:20The outcome variable was the intention
  • 11:23to undergo lung cancer screening
  • 11:25with low dose computed tomography
  • 11:27within the next three months if if
  • 11:30healthcare provider recommended it
  • 11:32and the predictive was the worry
  • 11:35about health consequences of smoking.
  • 11:37It also collected some covered
  • 11:39coverage as well.
  • 11:41We used Stata to conduct descriptive
  • 11:44statistics and logistic regression,
  • 11:47so this table shows sample characteristics.
  • 11:50Majority of them were about 80%
  • 11:53were ages between 55 to 64 years
  • 11:58and about 60% were male.
  • 12:01We oversampled a racial and ethnic
  • 12:04minoritized individuals in our sample.
  • 12:07So about
  • 12:1021.7% self reported as black
  • 12:14individuals and 42.8% self reported
  • 12:17as white and 12.5% as Asians.
  • 12:21And we had like 25% of the sample.
  • 12:25We are Hispanics.
  • 12:27In terms of the income,
  • 12:29kind of a little bigger portion of
  • 12:32the participants 36.8% had the lower
  • 12:36than 25,000 annual household income.
  • 12:42So we found that majority
  • 12:46of the samples about 86.2%,
  • 12:49they're willing to undergo lung
  • 12:51cancer screening if healthcare
  • 12:53provider recommended it so.
  • 12:55And also found that 67.7%
  • 12:59were very much worried,
  • 13:02moderately or very much
  • 13:04worried about them smoking
  • 13:05related health consequences.
  • 13:09So in this this table shows the
  • 13:12participants smoking history and the
  • 13:15mean pug years tobacco smoking was
  • 13:1850.8 and the mean number of years
  • 13:20they've been smoking cigarette was
  • 13:2444.9. So in the in the regression analysis,
  • 13:29we found that, you know, high individuals,
  • 13:32high risk individuals who were
  • 13:35moderately or very much worried about
  • 13:37the health consequences of smoking.
  • 13:39They are much more willing to undergo
  • 13:43recommended lung cancer screening.
  • 13:45We didn't find difference by age groups
  • 13:47and but we also found that men had much
  • 13:51the men had much higher odds of reporting
  • 13:54willingness to undergo lung cancer.
  • 13:57Training if they were recommended by
  • 14:00their healthcare provider compared
  • 14:02to female and also the interesting
  • 14:04finding where the black individuals,
  • 14:07those self reported black individuals
  • 14:09at high risk for developing lung cancer.
  • 14:12They were they had much lower
  • 14:15odds ratio of reporting,
  • 14:17willingness to undergo recommended
  • 14:19lung cancer screening and we didn't
  • 14:23find differences in by by ethnicity.
  • 14:29So for the conclusion and the study we
  • 14:32it was obvious that many individuals at
  • 14:35high risk for developing lung cancer,
  • 14:38they were willing to get screened for lung
  • 14:43cancer and but the screening by race,
  • 14:47ethnicity, African self reported
  • 14:49black individuals have much lower
  • 14:52odds of being willing to get screened
  • 14:55and I think like that.
  • 14:56So this was a quantitative study,
  • 14:58one of the steps will be I think.
  • 15:00To conduct kind of qualitative
  • 15:02study just to understand why they
  • 15:05don't want to get screened.
  • 15:07So with this only we know that yes the
  • 15:10percentage is lower and they don't want.
  • 15:12But I think that we need kind of to
  • 15:15go more in depth to understand like
  • 15:17why they don't want to get this life
  • 15:21saving screening and we should have
  • 15:23like a public health initiative to
  • 15:26increase awarenesses of lung cancer
  • 15:28screening among specifically among.
  • 15:30Racial and ethnic minorities groups,
  • 15:33and there has been some some other
  • 15:36studies showing that the awarenesses
  • 15:39public among general population about
  • 15:42lung cancer screening is quite low.
  • 15:46So we should do some public health
  • 15:49initiatives to increase that awarenesses.
  • 15:55So one of the interesting thing for the
  • 15:57for getting screened for lung cancer
  • 15:59is the sheer decision making visits.
  • 16:01So CMS mandates that healthcare
  • 16:04providers have to have a shared decision
  • 16:07screening visit with with patients then
  • 16:11refer them to lung cancer screening.
  • 16:14So during that visit healthcare providers
  • 16:16need to identify if the patient is eligible
  • 16:19for screening based on their age and.
  • 16:22Smoking history and they also need
  • 16:25to discuss about benefits and the
  • 16:28risks of lung cancer screening.
  • 16:30They need to use your decision making
  • 16:32aid that talks about risks and benefits
  • 16:34of lung cancer screening and during
  • 16:36that visit they also need to discuss
  • 16:38about that if with current smokers
  • 16:40they need to discuss emphasize the
  • 16:42importance of quitting smoking and
  • 16:44if those who are former smokers,
  • 16:46they need to discuss the importance
  • 16:48of being existent from from smoking.
  • 16:51So we conducted.
  • 16:52And I use this study to understand
  • 16:54like just rate of patient provider
  • 16:57discussion about lung cancer screening
  • 16:59is it happening or not happening and
  • 17:01then to understand how it is related to.
  • 17:05Quite attempts so specifically in this
  • 17:08study invested in investigated the
  • 17:10relationship between patient provider
  • 17:12discussions about lung cancer screening
  • 17:15and smoking quit attempts among adults
  • 17:17eligible for lung cancer screening.
  • 17:19So I used this data from that main
  • 17:22the study that I mentioned earlier,
  • 17:25like 821 subjects.
  • 17:27Out of them,
  • 17:28282 met the criteria of at least
  • 17:3120 pack years of smoking history.
  • 17:34So outcome variable was the the quit attempt.
  • 17:38They tried to quit smoking within
  • 17:40the past 12 months.
  • 17:42And for the predictor variable,
  • 17:44participants were asked the question
  • 17:46at any time in the past year.
  • 17:48Have you talked with your doctor or other?
  • 17:50Other health professional about having
  • 17:53a test to check for lung cancer.
  • 17:58So this is the the sample
  • 18:01characteristics again.
  • 18:02So majority were between 55 to 64 years
  • 18:06of age female 62% and 26% were identified
  • 18:12as self identified black individuals,
  • 18:1618% self identified Asian individuals
  • 18:19and 37% white individuals.
  • 18:21And in terms of lung cancer screening it
  • 18:25was kind of surprising to see that much.
  • 18:28Majority of them 84% did not have
  • 18:31discussion with their healthcare
  • 18:33provider about lung cancer screening.
  • 18:36Even if even though they were at
  • 18:37high with the new guideline they are,
  • 18:40they were they are at much higher risk
  • 18:43for developing lung cancer screening
  • 18:45because we use a 20 pack years the
  • 18:48criteria to include study subjects.
  • 18:50Only 16% reported that they discussed.
  • 18:56But discussed have had a discussion with
  • 18:59their provider about lung cancer screening.
  • 19:02So this table shows participants smoking
  • 19:06history and about the mean park year
  • 19:10of tobacco use was 39.4 and the mean
  • 19:14number of years they smoked cigarette was
  • 19:1644.4 and majority of the participants.
  • 19:2059% of the participants had at least 30 or
  • 19:24more pack year smoking history and 39% of
  • 19:29the participants they tried to quit smoking.
  • 19:33In the past year we also asked participant
  • 19:37what which what methods they used
  • 19:41to help them to quit smoking and the
  • 19:44surprisingly a lot of them reported.
  • 19:47Switching to electronic cigarette,
  • 19:49use that with the hope that it
  • 19:53will help them to quit smoking.
  • 19:56But we know from the later evidence
  • 19:58that that's not the case.
  • 20:00It's it.
  • 20:01It doesn't help individuals to
  • 20:04quit smoking and stay existence
  • 20:07successfully for a longer time.
  • 20:10And so in the regression analysis
  • 20:13we found found that those who had
  • 20:17discussion with their healthcare
  • 20:19providers about lung cancer screening,
  • 20:21they're much more likely to try to
  • 20:24quit smoking compared to those who did
  • 20:27not have discussion we didn't find.
  • 20:30I didn't find the differences by
  • 20:33race or ethnicity,
  • 20:35and also didn't find the differences
  • 20:38in them in the having.
  • 20:40Non cancerous discussion would healthcare
  • 20:42providers by race and or or ethnicity.
  • 20:47So,
  • 20:48so one of the the main finding of
  • 20:50many individuals who are eligible
  • 20:53for lung cancer screening,
  • 20:55they don't do, they don't get,
  • 20:57they don't have a discussion with their
  • 21:00healthcare providers about lung cancer
  • 21:02screening which is kind of required
  • 21:04mandated by CMS before getting screen.
  • 21:07So they have to have the shared
  • 21:09decision making and also.
  • 21:11And the one the some other
  • 21:15research shows that improving,
  • 21:18providing education training for
  • 21:20healthcare providers about lung
  • 21:22cancer screening kind of will help
  • 21:25to improve the lung cancer uptake.
  • 21:27So the having the discussion with
  • 21:30patients about lung cancer screening
  • 21:32it kind of it helps to kind of
  • 21:35improve the lung cancer screening
  • 21:37uptake as well as it will improve,
  • 21:40it will help patients to get motivated.
  • 21:42Try to quit smoking and maybe
  • 21:44eventually help them to quit smoking.
  • 21:47So also another way is then
  • 21:49people who get screened,
  • 21:51there has been another work
  • 21:53including our earlier.
  • 21:54So those who get actually get to the
  • 21:57point to get screened for lung cancer.
  • 22:00So they are more motivated to
  • 22:03try to quit smoking.
  • 22:05So that's why like this are
  • 22:07kind of very much related.
  • 22:08So first helping patients to
  • 22:10quit smoking or referring them
  • 22:12to lung cancer screening.
  • 22:13So help them also to to quit smoking.
  • 22:20And so one of the other big part of my
  • 22:23work has been focused on understanding
  • 22:27tobacco use among cancer survivors,
  • 22:30and I use the NCI definition for cancer
  • 22:33survivors and individuals are considered
  • 22:35cancer survivors from the time of
  • 22:38diagnosis through the balance of life
  • 22:40and their family members, caregivers,
  • 22:43friends are all impacted by the survivorship
  • 22:47experience and they're included.
  • 22:49And this definition, so we know that.
  • 22:54And do two major advancement in cancer
  • 22:58screening or detection and treatment.
  • 23:01So many individuals these days live
  • 23:04with the history of cancer diagnosis.
  • 23:07In fact, in 1971 about 3,000,000
  • 23:11individuals who live in cancer history.
  • 23:13And as of January this year about 18
  • 23:16million individuals are living with
  • 23:19cancer history and it is projected
  • 23:21to increase significantly by 2014.
  • 23:24There will be about 26 million
  • 23:27cancer survivors.
  • 23:28So in order to maximize the
  • 23:31overall well-being of this growing
  • 23:33population of cancer survivors,
  • 23:35identifying the health risk behaviors and
  • 23:38helping them to change will help will
  • 23:41help improve their overall well-being.
  • 23:43And one of the health risk behaviors
  • 23:45is tobacco use is,
  • 23:47which is still prevalent among among
  • 23:51individuals diagnosed with cancer even
  • 23:52though a lot of work has been done.
  • 23:55And tobacco use decreased significantly
  • 23:57over the past five decades.
  • 24:00Still,
  • 24:00many individuals continue to
  • 24:03smoke after the cancer diagnosis,
  • 24:06and the prevalence of the tobacco
  • 24:09use varies by by by cancer type.
  • 24:14And those who are diagnosed with
  • 24:16the tobacco related cancer,
  • 24:17they have the highest rate of smoking
  • 24:20compared to those who are not diagnosed
  • 24:23with tobacco related cancers.
  • 24:25And we know that continued tobacco use
  • 24:28among cancer survivors significantly
  • 24:30reduces the cancer treatment effectiveness
  • 24:33and it worsens treatment side effects,
  • 24:36reduces overall survival.
  • 24:38It also increases the risk of
  • 24:41recurrence and symptom burden and also.
  • 24:43Increases the risk of smoking related
  • 24:46comorbidities and we know that there are,
  • 24:50there is a.
  • 24:52Evidence based tobacco treatment
  • 24:55guidelines available in the US and
  • 24:57that healthcare provider that would
  • 25:00help health healthcare providers to
  • 25:02use that to follow that guideline
  • 25:04to help individuals smokers to
  • 25:07quit quit smoking.
  • 25:09So the gold standard for tobacco
  • 25:13treatment is using combining the use
  • 25:17of pharmacotherapy and behavioral
  • 25:20intervention and healthcare.
  • 25:22Providers.
  • 25:23First they need to assess and
  • 25:25document tobacco use,
  • 25:27then provide advice to quit those who smoke,
  • 25:31and then assist them with their
  • 25:33pharmacotherapy and behavioral counseling.
  • 25:36And they also own a regular basis.
  • 25:38They have to reassess smoking status
  • 25:41among former smokers to make sure they
  • 25:44are still absent from tobacco use.
  • 25:47And then we conducted this study
  • 25:50so to understand how how cancer
  • 25:53programs are implementing this
  • 25:56evidence based tobacco treatments.
  • 25:58So we conduct in this study we know
  • 26:02that from other work that tobacco
  • 26:05use still is prevalent among among
  • 26:08individuals diagnosed with cancer.
  • 26:10So in this study we just wanted to
  • 26:14understand more like how this evidence based.
  • 26:17Michael,
  • 26:17Guideline is implemented and then the
  • 26:21results we found that only 7% of those.
  • 26:27Cancer programs in the Northeast region,
  • 26:30they had optimal integration of the
  • 26:33guidelines into their into their
  • 26:36delivery system and only about 39%
  • 26:40of this program had a had a system
  • 26:43in place that healthcare providers
  • 26:46they can easily identify screen for
  • 26:50tobacco use and then document the
  • 26:53tobacco use and also only 25% they had.
  • 26:56System in place that they could easily
  • 27:00prescribe pharmacotherapy and refer
  • 27:02them to a counseling so and so all
  • 27:06found that the tobacco treatments
  • 27:10were not delivered consistently
  • 27:12and routinely among among cancer
  • 27:15survivors so and one of the some
  • 27:18of the Bears identified in the.
  • 27:21Oh, identified in the work related
  • 27:24to not having the optimal strategy in
  • 27:26place to identify to screen for tobacco
  • 27:29use and document a lot of providers.
  • 27:32They reported the limited time,
  • 27:34so they didn't have enough time
  • 27:36to screen for that as well.
  • 27:38And then.
  • 27:40Limited reimbursement for clinicians
  • 27:43to provide tobacco treatment was
  • 27:46also another another barrier.
  • 27:49So NCI identifies as well like that
  • 27:54the screening for tobacco use,
  • 27:56documenting tobacco use and treating
  • 28:00is kind of has and hasn't been that
  • 28:03well in the in this country and
  • 28:05since in 2017 is NCI launched Cancer
  • 28:10Center cessation initiative which
  • 28:12was funded part of the NCI Cancer
  • 28:16Moonshine Program and the overall like.
  • 28:20Long term goal of this.
  • 28:24Of this initiative is that to provide
  • 28:27funding to cancer centers and to help
  • 28:31them to build an implement sustainable
  • 28:34tobacco cessation treatment programs
  • 28:37that can help healthcare providers
  • 28:41routinely address tobacco sensation
  • 28:45among cancer survivors and since 2017,
  • 28:50fifty two NCI designated cancer centers.
  • 28:54You said this funding and yells
  • 28:56Cancer Center is one of those 52
  • 29:00and there has been some studies
  • 29:02already came out showing kind of
  • 29:05positive outcome those centers who
  • 29:07got the funding that they have them.
  • 29:11Kind of a system in place to identify
  • 29:14to screen and document tobacco use
  • 29:17and help smokers to quit smoking,
  • 29:20but it's been since 2017 so like
  • 29:23I think sustainability should be
  • 29:26evaluated so for longer term to
  • 29:29see if if it's still moving on.
  • 29:32So from.
  • 29:35From my work and from the work of
  • 29:38other researchers kind of we understand
  • 29:41how the we know that tobacco use
  • 29:44is still is a problem is is still.
  • 29:49And common among individuals were diagnosed
  • 29:52with lung individuals who had cancer.
  • 29:55So we decided to conduct this study
  • 29:58and it was funded by NCI to understand
  • 30:02the role of social networks and
  • 30:05affective States and in smoking
  • 30:08behavior among cancer patients.
  • 30:10So I have done some work looking at the
  • 30:12role of social networks and I'm sure you
  • 30:14know like the Yale has a big team who
  • 30:16looks at the social network as well.
  • 30:18It really shows how important it is to.
  • 30:21Involve your social network members
  • 30:23to help to change the smoking behavior
  • 30:26or health risk behaviors.
  • 30:28But when you look at the intervention
  • 30:31side like smoking cessation programs,
  • 30:33those are mostly focused on an
  • 30:35individual and we know that those if
  • 30:38they get a treatment get the referral.
  • 30:41But when they go back home,
  • 30:43like get the treatment by get home in
  • 30:45their network and someone is in the
  • 30:48network smoking it increases their
  • 30:49chance of like starting smoking.
  • 30:51So that's why so we discount,
  • 30:53we are hoping,
  • 30:54hoping that we can develop social
  • 30:56network best smoking cessation
  • 30:58interventions for patients diagnosed
  • 31:00with tobacco related cancers.
  • 31:01So hopefully we can help them to quit
  • 31:05smoking and stay quit for a longer term.
  • 31:08So on this grant I am working with them.
  • 31:13Team then if I have like really great team,
  • 31:16excellent collaborators from
  • 31:18Dana Farber Cancer Institute,
  • 31:20Northeastern University and Dartmouth College
  • 31:23and I have a consultants from MGH and.
  • 31:28And University of Pennsylvania,
  • 31:31we just started the recruitment.
  • 31:33So this is the specific aims.
  • 31:36Basically we want to understand
  • 31:38the role of social network members,
  • 31:41how they impact the smoking behavior
  • 31:44of cancer population and also we want
  • 31:48to know that how the cancer diagnosis.
  • 31:51Impacts on the social network
  • 31:54members smoking behavior.
  • 31:55So I have done some work to look into
  • 31:59the the cancer diagnosis that it
  • 32:02kind of motivates network members to
  • 32:05change their health risk behaviors.
  • 32:07So this is a mixed method design.
  • 32:11The phase one we're conducting it's
  • 32:14a quantitative approach.
  • 32:16We're using egocentric social network
  • 32:18approach to identify tobacco late,
  • 32:21hence individual stagnant with tobacco
  • 32:23related cancer and then after the
  • 32:26phase one and date it's a one year
  • 32:29follow up and we'll we're conducting
  • 32:31a best line then three months,
  • 32:33six months and 12 months and then after 12.
  • 32:37Months do we want to do a qualitative
  • 32:41dieting interviews with the cancer
  • 32:43survivor and self identify significant
  • 32:45network member to understand how do
  • 32:48they impact on their health risk behaviors,
  • 32:51their relationship.
  • 32:52So we just started a screening,
  • 32:55we are recruiting from Dana Farber
  • 32:58Cancer Institute and we are.
  • 33:00So we have some discussions that maybe
  • 33:02later we can open up to the recruitment
  • 33:05to include your Cancer Center.
  • 33:07As well.
  • 33:09So this is just the illustration
  • 33:11of the egocentric social network.
  • 33:13So basically all information,
  • 33:15the ego here represents the the
  • 33:17individual diagnosis tobacco related
  • 33:19cancer and then network members
  • 33:22they are who they identify.
  • 33:24So,
  • 33:25so far actually it's going well
  • 33:28and so collect
  • 33:29collecting the social network data is
  • 33:33quite rich and so we are doing via zoom,
  • 33:38so our program manager. Michael?
  • 33:41Research coordinator, they meet via zoom,
  • 33:43so we collect the data via zoom
  • 33:45and so far it's been great and
  • 33:48we'll see how it's going to be.
  • 33:51Our sample size is 4 point 24129,
  • 33:56so hopefully we can reach our sample
  • 33:59size and then to see how the the
  • 34:03role of social network in the.
  • 34:05And the smoking behavior.
  • 34:07So this is I would like to thank
  • 34:10everyone that helped me to to build
  • 34:12my program of research and what I did,
  • 34:15my education and the team and everyone
  • 34:18that I'm working with and if you have any
  • 34:22questions I'll be happy to to answer.
  • 34:25Thank you.
  • 34:27Good.
  • 34:34Questions for Doctor Symposium?
  • 34:40We have at least. OK, go ahead. Thank you.
  • 34:46Do you see a correlation between
  • 34:48either willingness to quit or
  • 34:51willingness willingness to screen?
  • 34:53I thought that for either your personal
  • 34:56studies with the number of pack years,
  • 34:58also with their accuracy with the risk of.
  • 35:03The risk of getting token cancer efficiently.
  • 35:07So thank you. So for the willingness of the
  • 35:11the being willing to go to get screening.
  • 35:15We include everyone with at least
  • 35:1730 pack years, but I didn't look
  • 35:20at by like are you saying like
  • 35:23categorized between 30 to 404075?
  • 35:27Yeah, we didn't. We didn't look at that.
  • 35:31We didn't look at that,
  • 35:33but there have been some work that
  • 35:35they look like having the park
  • 35:38here as a continuous variable.
  • 35:40So when it increases,
  • 35:42their intention also increases to
  • 35:44screen from other researchers work.
  • 35:47But we just we didn't
  • 35:49look at that separately.
  • 35:53I actually had a related question to that.
  • 35:55So for those, so in your study,
  • 35:57you looked at whether or not a
  • 36:00conversation with their provider
  • 36:01about lung cancer screening then
  • 36:05impacted their willingness or
  • 36:06their attempts to quit, correct.
  • 36:09I was wondering if actual.
  • 36:11So that was the discussion.
  • 36:12I was wondering if there was any idea
  • 36:15to look at actual people who actually
  • 36:17received lung cancer screening and
  • 36:18then whether or not that then directly
  • 36:20impacted their willingness to quit.
  • 36:22So yeah, that's actually.
  • 36:23That's like I have like some research
  • 36:26project working on like we have to do like
  • 36:29a longitudinal to see if they get the,
  • 36:31if they have the referral,
  • 36:32the discussion, then the referral,
  • 36:35then the actual screening,
  • 36:36if it helps them to quit
  • 36:39smoking so from other works.
  • 36:41So that's all like when I saw the the
  • 36:43the literature review we did people who
  • 36:45actually get to that point who get screened,
  • 36:48they are more likely to be motivated
  • 36:51and they make quit attempts but
  • 36:53we know that the smoking.
  • 36:55Is like just they need to get help.
  • 36:58Just trying the quit attempt is a first step
  • 37:01but successfully quit they need to get help.
  • 37:04So in our study we just
  • 37:06looked only the discussion.
  • 37:07We didn't follow up,
  • 37:09it was just cross-sectional.
  • 37:10We didn't follow up to see if
  • 37:12they actually screened and then
  • 37:14if they screened they steal.
  • 37:15The quit attempts are higher
  • 37:17or lower and also the.
  • 37:19I'm in that say I looked
  • 37:22on the use the criteria,
  • 37:24updated criteria 20 pack years.
  • 37:27So one of the explanation can be
  • 37:29such a low rate of discussion that
  • 37:32healthcare providers they didn't know
  • 37:34that the guideline would be changed.
  • 37:37So I looked at 20 but the
  • 37:40study collected 2017 so.
  • 37:43It might have been lower,
  • 37:45so if the guideline was updated earlier.
  • 37:49So we have a question from
  • 37:50the chat from Doctor Silver,
  • 37:52she asked under resource,
  • 37:53patients poor as well as ethnic and
  • 37:56racial minoritized groups are more
  • 37:57likely to roll their own cigarettes
  • 38:00due to expense and maybe under
  • 38:01counted when it comes to pack years.
  • 38:04Any thoughts about trying to
  • 38:06capture those who do not bypass?
  • 38:09So yeah, that's a very important
  • 38:11question and that's a good question.
  • 38:13So yes, that's another issue.
  • 38:16But in order to Umm the way to measure it,
  • 38:20it's very difficult if they
  • 38:22roll their own cigarettes.
  • 38:24So that's kind of one of the limitation
  • 38:27that we're going to miss those
  • 38:30population just healthcare providers,
  • 38:32they have to follow whatever CMS mandates.
  • 38:35So first they have to count their
  • 38:38tobacco use, then they each and then meet
  • 38:41the guidelines so without, so that's.
  • 38:43The limitation is it will be very
  • 38:45hard to identify those people
  • 38:47who roll their own cigarettes.
  • 38:49So one of the requirements that
  • 38:51they have to meet to smoke at least
  • 38:5320 pack years of a cigarette,
  • 38:55that's the history.
  • 39:02OK. Well, I have one. I have one
  • 39:03other additional question.
  • 39:04This is a pretty big picture one now.
  • 39:07So and that first study that
  • 39:09you presented presented,
  • 39:09you said that you found about 86%
  • 39:12of the patients or the participants
  • 39:14had reported a willingness to
  • 39:17undergo lung cancer screening.
  • 39:19However, like an actual real-world
  • 39:21practice that the percentage
  • 39:23actually who are eligible,
  • 39:24who actually do undergo screening
  • 39:26is under 10%, correct.
  • 39:27Do you have any thoughts about like what
  • 39:30that disconnect is or ways to study it?
  • 39:32Or even down the roadways
  • 39:34to address it potentially.
  • 39:35So yeah that's very important.
  • 39:38So even though they are Wheeling,
  • 39:40I think we have to kind
  • 39:42of so they meet a lot of,
  • 39:44there has been a lot of work song,
  • 39:46so they meet, they get discussion,
  • 39:47they get referral that they have to
  • 39:49screen and then they don't show up.
  • 39:50So like that's why screening rate
  • 39:52is low and I think there would be
  • 39:55like community enrich like programs
  • 39:57or like the patient navigator.
  • 39:59So I think they should be
  • 40:01some system in place.
  • 40:02That whoever like during the
  • 40:05discussion during the sheer decision
  • 40:07making visit expressed willingness
  • 40:09to go through the screening.
  • 40:12So I think we have to have some,
  • 40:14some system in place that we can follow up
  • 40:17and to see today make the screening or not.
  • 40:20So for now it's high they want but.
  • 40:23An actual number of last
  • 40:26year of 2020 was 6.5%.
  • 40:29So those two numbers are very different.
  • 40:32So we had like,
  • 40:33we don't have that.
  • 40:35System to identify follow
  • 40:36up and bring them back
  • 40:39and other, you know,
  • 40:40other cancer screening also
  • 40:42saw a dip in the 202020.
  • 40:44Yeah, because yeah,
  • 40:46that could be impacting.
  • 40:49States. So that report that I presented
  • 40:52some from that they showed like in
  • 40:54some states it's quite stable and then
  • 40:57some states were higher or lower.
  • 40:59So it wasn't like across
  • 41:01the US that it dropped,
  • 41:03there were states were doing much
  • 41:05better compared to other states.
  • 41:11Any final questions for Doctor
  • 41:13Pogosian about this important work?
  • 41:17Well, thank you, everyone.
  • 41:18So, Umm for being here for this time.
  • 41:22And I just want to say like,
  • 41:24I'm new at Yale. It's been not new.
  • 41:26It's been a year and I'll be very
  • 41:29much interested if you have any
  • 41:31similar research interests or areas,
  • 41:33I'll be happy to collaborate
  • 41:35with any one of you. OK.
  • 41:38Thank you. Thanks for coming.
  • 41:39Thanks so much, everyone.