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									National Cancer Institute
OF HEALTH AND HUMAN SERVICES
National Institutes of Health


         Applied Cancer Screening Research
                                        (slide 1 of 17)

                                Sarah Kobrin PhD, MPH
                    Division of Cancer Control & Population Sciences
                              Behavioral Research Program
                       Applied Cancer Screening Research Branch

                 http://cancercontrol.cancer.gov/ACSRB/index.html
                                       07/21/09


                                Outline (slide 2 of 17)
   [Speaker Notes] I’m going to spend much of my time talking about the nature of
   cancer screening as a set of behaviors. Understanding the process of screening, who is
   involved, how it plays out, and its context are essential to determining what social
   psych approaches are best suited to research with applications to screening.

      Cancer screening behavior(s)
      What we already know
      NCI’s priorities and opportunities
      BRP Theories Project


              What is a screening test? (slide 3 of 17)
   [Speaker Notes] The goal of screening is to reduce morbidity and mortality due to
   cancer. The ideal screening test is a simple, inexpensive test that simply sorts people
   into those who are unlikely to have the specific cancer in question and those who are
   likely to have the cancer.

   Note that the goal is not to diagnose cancer. The goal is to sort into these two broad
   categories: likely and unlikely. Many people are tested in order to find the few who
   appear likely to have the cancer. Most people who are screened are sorted into the
   “unlikely” group. These people have no more testing until the next recommended
   interval (which could be a year, 3, 5, or 10 years, depending on the test).

   However, some are sorted into “likely.” This finding does NOT mean the person has
   the cancer, but instead that further diagnostic testing is required. his further testing is
   often tremendously stressful and is an important place where we need better
   understanding of how people react, how we can help them, and how their reactions
   affect their subsequent screening behavior.

   It’s also important to remember that even the best screening tests are not perfect.
   They generate both types of mistakes, false positives – again a source of screening-
   related stress – and false negatives – which creates false reassurance. False negatives
   are hard to measure because the cancer is either discovered at a subsequent screening
   test – and is then a true positive – or when symptoms appear some time later, and then
   diagnostic testing finds the source of the problem.

   Unlike diagnostic tests and treatments, the people being screened are generally
   healthy and asymptomatic. I’ll get back to that point shortly, because it also has
   important implications for what theoretical perspectives might be valuable.

      A simple, inexpensive test of a large number of individuals to determine whether
       they are likely or unlikely to have the cancer
      Tests are imperfect – false positives and false negatives
      Not a diagnostic

Meissner et al, Cancer, 2004


         Estimated Consequences of a Single
           Screening Mammogram (slide 4 of 17)
[Speaker Notes] The mammogram to screen for breast cancer is one of the tests that is
recommended for population level screening. In the 1990s there was a lot of controversy
about how good a test it is, but, as I’m sure you know, it is recommended around the
world.

Russ Harris and Linda Kinsinger used SEER data to demonstrate how many women must
be screened with mammography to find a few breast cancers and how many of those
screened have false positives. These data are for women ages 50-70; in younger women –
the guidelines now recommend women start having screening mammograms at age 40 –
the false positive rates are even higher (and true positive rates even lower).

When these numbers are multiplied across the many annual mammograms women have –
and need to have for the mortality benefit – you can see that the proportion of women
who have some false positive experience in their lifetimes will be quite high.

As I said before, many people are tested in order to find the few who appear likely to
have the cancer. And when we’re thinking about promoting a screening test – or helping
someone with the decision making process, we have to think of all these potential
outcomes as part of the screening process.

[image] Estimated Consequences of a Single Screening Mammogram
      10,000 women age 50-70 have a single, annual screening mammogram
           o Normal result 9,500 (95%) (True negatives and false positives)
           o Abnormal Result 500 (5%)
                 Cancer found in follow-up 21-34 (true positives)
                 No cancer found in follow-up 466-479 (false positives)
[end image]

Harris & Kinsinger, 1995


    Principles of Screening for Disease (slide 5 of 17)
[Speaker Notes] That was an example from breast cancer, which is an accepted test. And
there are well established principles of what makes a screening test ready for prime time,
or population-level screening.

Notice that these principles include characteristics of the disease itself, the available
treatments for the disease, and the nature of the screening test. All of these components
are needed before a population level guideline is created for a new screening test.

      Disease is important health problem
      Disease has detectable, preclinical phase
      Early treatment is better than later treatment
      Screening test has positive cost/benefit ratio
      Screening test is acceptable to patients and providers
      Screening test has acceptable level of accuracy

Wilson (WHO), 1968


           Cancer Screening Behavior (slide 6 of 17)
[Speaker Notes] You’re going to hear over the next couple of days about many cancer
prevention and control-related behaviors. I want to highlight for a moment some of the
ways that screening behaviors are different from some of the others.

Relative to smoking or physical activity for examples, screening is a very infrequent
behavior. The shortest recommended interval is a year (and the colonoscopy is only
recommended every 10 years). But, it’s also true that screening has to be repeated over
time in order to reduce mortality – these characteristics combined can make it
challenging to apply models of initiation and maintenance. Is doing something again a
year later maintenance? Or does an intervention to promote a second annual fecal occult
blood test require the same conceptual framework as the first test did?

Katie Couric effect here – what good does it do to get loads of people (perhaps too
young) to get a single colonoscopy?
It’s also important to remember that by definition the people who are screened for a
specific cancer are those who have no symptoms of it. This factor can influence
perceptions of risk, the salience of the test, and the perceived benefits of the test. The fact
that it’s a behavior – with costs now – for only a probability of benefits in the future also
affects these perceptions. And in fact most people never will get the cancer; as I’ve now
said several times – population-level screening only works when many people are tested
to find cancer in very few. Most of us will be lucky enough to get no benefit from our
screening.

      Infrequent behavior – once a year is “often”
      Must be repeated for mortality benefit
      Eligible people are asymptomatic, by definition
      Benefits only accrue in long-term (and most people get none)
      Generally, screening does not reduce risk of getting disease (control, not
       prevention)


        Recommended Screening Tests
    US Preventive Services Task Force (slide 7 of 17)
[Speaker Notes] NCI follows the recommendations of the US Preventive Services Task
Force, an independent group of scientists who evaluate and grade the evidence in support
of each test. They evaluate how well a new test meets the principles I described before as
well as the quality of the evidence.

Each test has recommended ages at which to start; in some cases the guidelines are
complicated by consideration of previous test results (e.g., after 3 normal annual Pap
tests, can lengthen interval to every 3 years). Only recently are people starting to think
about whether there’s an age at which to stop cancer screening.

Notice this list does not include the PSA test for prostate cancer (more on that shortly), or
breast self-exam, or the CA-125 blood test for ovarian cancer, or the spiral CT for lung
cancer. None of these tests has sufficient evidence that using it on a population level will
reduce mortality.

      Mammogram for breast cancer
      Pap test for cervical cancer
      Colon cancer screening
          o FOBT, annually
          o Sigmoidoscopy, every 5 years
          o Colonoscopy, every 10 years
      Not included:
          o PSA, BSE, CA-125, Spiral CT
       Applied Cancer Screening Research (slide 8 of 17)
The Applied Cancer Screening Research Branch (ACSRB) advances the field of cancer
screening through innovative applied research and creative leadership. This includes
effectiveness trials and related social and behavioral research to promote the use of
effective cancer screening tests, as well as strategies for informed decision making
regarding all cancer screening technologies in both community and clinical practice.

Overall, cancer screening is quite well adopted by Americans. Now I’ll show you some
recent data on screening rates for the tests we promote.

       Social and behavioral research to promote the use of effective cancer screening
        tests, and
       Strategies for informed decision making when evidence is uncertain (or multiple
        options are available)




      Mammogram Prevalence (%), by
     Educational Attainment and Health
 Insurance Status, Women 40 and Older, US,
              1991-2006 (slide 19 of 17)
[Speaker Notes] When we think about promoting effective tests it’s important to know
who is already being test and who still needs to get the promotion message.

The prevalence of women reporting a mammogram within the past year increased from
50% in 1991 to 64% in 2000, and has since declined to 61% in 2006. During this time,
mammogram utilization varied considerably by educational attainment. The prevalence
of women with less than a high school education reporting a recent mammogram was
approximately 10 percentage points lower than the prevalence for all women. Even more
striking is that the prevalence for women with no health insurance is approximately 25
percentage points lower than the prevalence for all women.

This is the percentage of women reporting a mammogram in the past year, which makes
it an underestimate of women who have had one in the past 1-2 years.

The National Health Interview Survey reports the recent decline as from 70% to 66%.

[image] chart reflecting information above
[Reference] *A mammogram within the past year. Note: Data from participating states
and the District of Columbia were aggregated to represent the United States.Source:
Behavior Risk Factor Surveillance System CD-ROM (1984-1995, 1996-1997, 1998,
1999) and Public Use Data Tape (2000, 2002, 2004, 2006), National Centers for Chronic
Disease Prevention and Health Promotion, Centers for Disease Control and Prevention,
1997, 1999, 2000, 2000, 2001, 2003, 2005, 2007


 Trends in Recent* Pap Test Prevalence (%),
    by Educational Attainment and Health
 Insurance Status, Women 18 and Older, US,
              1992-2006 (slide 10 of 17)
[Speaker Notes] This graph shows that the prevalence of women who have had a Pap test
within the past three years has remained high, and has increased during the late 1990s.
Throughout the decade, the prevalence among women with less than a high school
education as well as the prevalence among women with no health insurance was
approximately 10 percent lower than the percentage for all women.

Not only are most American women having Pap tests, many are having too many Pap
tests. Data from a variety of surveys of both woman and their providers show that many
women continue to have annual Pap tests – and providers continue to recommend annual
Pap tests – even when they could increase the interval between tests to 3 years.

[image] chart reflecting information above

[Reference] * A Pap test within the past three years. Note: Data from participating states
and the District of Columbia were aggregated to represent the United States. Educational
attainment is for women 25 and older.Source: Behavior Risk Factor Surveillance System
CD-ROM (1984-1995, 1996-1997, 1998, 1999) and Public Use Data Tape (2000, 2002,
2004, 2006), National Center for Chronic Disease Prevention and Health Promotion,
Center for Disease Control and Prevention, 1997, 1999, 2000, 2000, 2001, 2003, 2005,
2007.


 Trends in Recent* Fecal Occult Blood Test
 Prevalence (%), by Educational Attainment
and Health Insurance Status, Adults 50 Years
      and Older, US, 1997-2006 (slide 11 of 17)
[Speaker Notes] In 2006, approximately 16% of US adults 50 and older had a fecal occult
blood test (FOBT) in the previous year. Adults with less than a high school education are
less likely to report a recent FOBT. The prevalence for adults with no health insurance is
about 8 percentage points lower than the prevalence for all adults.

[image] Chart reflecting above information
    Total Prevalence (%):
          o 1997: 20%
          o 1999: 21%
          o 2001: 24%
          o 2002: 22%
          o 2004:19%
          o 2006: 16%
    Less than high school education Prevalence (%):
          o 1997: 16%
          o 1999: 16%
          o 2001: 18%
          o 2002: 16%
          o 2004: 14%
          o 2006: 12%
    No Health Insurance Prevalence (%):
          o 1997: 8%
          o 1999: 9%
          o 2001: 12%
          o 2002” 9%
          o 2004: 9%
          o 2006: 8%
[end image]

[Reference] *A fecal occult blood test within the past year. Note: Data from participating
states and the District of Columbia were aggregated to represent the United States.
Source: Behavioral Risk Factor Surveillance System CD-ROM (1996-1997, 1999) and
Public Use Data Tape (2001, 2002, 2004, 2006), National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease Control and Prevention and
Prevention, 1999, 2000, 2002, 2003, 2005, 2007.


Trends in Recent* Flexible Sigmoidoscopy or
Colonoscopy Prevalence (%), by Educational
 Attainment and Health Insurance Status,
 Adults 50 Years and Older, US, 1997-2006
                                       (slide 12 of 17)

[Speaker Notes] While there has been a downward trend during recent years in the use of
FOBT, the prevalence of flexible sigmoidoscopy (FSIG) or colonoscopy has
continuously increased from 1997 to 2006. Adults with less than a high school education
were less likely to report FSIG or colonoscopy than all adults. Even more striking is that
the prevalence for adults with no health insurance is about half that for all adults.
Continuing efforts are needed to address health system barriers to colon cancer screening,
to encourage health care practitioners to promote screening to their patients, and to raise
awareness among eligible adults about the importance of getting screened for CRC.

[image] Chart reflecting above information

      Total Prevalence (%):
          o 1999: 44%
          o 2001: 44%
          o 2002: 45%
          o 2004: 50%
          o 2006: 16%
    Less than high school education Prevalence (%):
          o 1999: 37%
          o 2001: 36%
          o 2002: 36%
          o 2004: 41%
          o 2006: 43%
    No Health Insurance Prevalence (%):
          o 1999: 22%
          o 2001: 21%
          o 2002: 21%
          o 2004: 22%
          o 2006: 25%
[end image]

[Reference] *A flexible sigmoidoscopy or colonoscopy within the past ten years. Note:
Data from participating states and the District of Columbia were aggregated to represent
the United States. Source: Behavioral Risk Factor Surveillance System CD-ROM (1996-
1997, 1999) and Public Use Data Tape (2001, 2002, 2004, 2006), National Center for
Chronic Disease Prevention and Health Promotion, Centers for Disease Control and
Prevention and Prevention, 1999, 2000, 2002, 2003, 2005, 2007.



Recent* Prostate-Specific Antigen (PSA) Test
Prevalence (%), by Educational Attainment
and Health Insurance Status, Men 50 Years
and Older, US, 2001-2006 (slide 13 of 17)
[Speaker Notes] This graph shows that the percentage of men who have had a PSA test
within the past year decreased 4 percentage points from 2001 to 2006. Men with less
than a high school education and men with no health insurance were less likely to report a
PSA test than all men 50 and older.

Like the excessive Pap testing, this overwhelming uptake of the PSA test – in the absence
of evidence supporting the mortality benefit – is likely over screening.
[image] Chart reflecting above information

      Total Prevalence (%):
          o 2001: 58%
          o 2002: 56%
          o 2004: 52%
          o 2006: 54%
    Less than high school education Prevalence (%):
          o 2001: 46%
          o 2002: 42%
          o 2004: 39%
          o 2006: 40%
    No Health Insurance Prevalence (%):
          o 2001: 30%
          o 2002: 28%
          o 2004: 25%
          o 2006: 27%
[end image]

[Reference] *A prostate-specific antigen (PSA) test within the past year. Note: Data from
participating states and the District of Columbia were aggregated to represent the United
States. Source: Behavioral Risk Factor Surveillance System Public Use Data Tape (2001,
2002, 2004, 2006), National Center for Chronic Disease Prevention and Health
Promotion, Centers for Disease Control and Prevention, 2002, 2003, 2005, 2007.


             What we already know… (slide 14 of 17)
      Screening almost always takes place in health care system
           o Provider recommendation is essential and influential
           o Access to health care essential
           o Reminder systems very effective
      Interventions to promote screening – or decision making – should consider
       influences at multiple levels
           o Health policy, insurance coverage, practice patterns and guidelines,
              provider needs and preferences
           o Team should include expertise at these levels


               NCI’s Research Priorities
            Applied Cancer Screening (slide 15 of 17)
      Theory and methods, for example:
          o Development and testing of theories not generally applied in cancer
              screening, including macro-level
          o Role of habit in health behavior maintenance
          o Cultural relevance of existing theoretical constructs
          o Role of social support and interactions in screening
      Decision making, for example:
          o Effects of attributions on attitudes towards informed decision making
          o Determine how genetic risk assessment should be incorporated into
              screening programs


             NCI’s Theories Project:
       Improving Theories of Health Behavior
                                      (slide 16 of 17)

      Projects
          o Health Behavior Constructs: Theory, Measurement, and Research
                   http://cancercontrol.cancer.gov/brp/constructs/
          o Advanced Training Institute on Health Behavior Theory
                   http://cancercontrol.cancer.gov/workshop/
          o Simulating Advances in Behavioral Theory: Applications to Cancer
              Screening, 12-06
          o How is health behavior theory described in cancer screening intervention
              grant applications? A review of the ACSRB grant portfolio
          o How is health behavior theory described in cancer screening intervention
              publications? A review of the literature
          o Applying Social Psychological Theory to Health Communication and
              Intervention, Society for Behavioral Medicine, 03-07
      Home Page
          o http://cancercontrol.cancer.gov/brp/theories_project/index.html

           What is a Program Director? (slide 17 of 17)
[Speaker Notes] I want to start by letting you know that PD’s are a valuable resource to
you prior to submitting your grant application as well as throughout the funding period of
your grant.

Most PDs are doctorally trained; in our program they have PhDs in clinical and social
psychology, in public health, in sociology, and anthropology. Also have MDs with
research experience.

We have knowledge of NCI priorities and know the NCI grant portfolio so we can help
you gauge whether or not your planned research project compliments our funded grant
portfolio and if it represents an area of research NCI is interested in supporting. If the
reviewers of your grant know that we are enthusiastic about your research this may give
your application a funding leg up.

Another important reason to make contact with a program director is to get immediate
feedback on how your application fared during the grant review meeting. We can give
feedback on the strengths and weaknesses of your application and help you figure out if
you should revise or resubmit. Many applicants appreciate the immediate feedback and
our early comments are helpful in the interpretation the the official summary statement
which you get 6-8 weeks and sometimes longer after the review of your grant.

A word about language, you may also hear “Program Officer” which is a more general
term, and “Project Officer,” which is supposed to be used only in the context of contracts
(rather than grants).

      Our job is to help you (contact by email first)
      We know and help to shape NCI’s research priorities
      Help to guide you to the right mechanism and study section
      Know the current portfolio (what NCI already funds)
      Advise about research plan
      Match you with teams who need your expertise, or help you identify health-
       related expertise you need for your team

								
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