Every year, nearly 1.5 million Americans are diagnosed with cancer, and more than 500,000 Americans die of the disease. Globally, cancer accounts for an estimated 13 percent of all deaths. According to the World Health Organization, more than 30 percent of those deaths could be prevented by modifying or avoiding key risk factors, especially tobacco use.
[Photo: UNC cancer researchers, clockwise from top left are Drs. Stephanie Wheeler, Carmina Valle, Deborah Tate, Cleo Samuel, Hazel Nichols and Sarah Birken.]
Researchers at the University of North Carolina Gillings School of Global Public Health work to promote healthier lifestyles, earlier detection, better access to effective, affordable treatment, and improved quality of life for cancer survivors. Collaboration with UNC’s Lineberger Comprehensive Cancer Center and the support of the University Cancer Research Fund have helped position UNC as a transformative leader in the progress against cancer. The Research Fund has stimulated new understanding of the genetic changes that play a role in cancer and has supported researchers in developing new therapies to treat patients and optimize cancer outcomes for the 40,000 North Carolinians diagnosed each year.
A sampling of recent work from the UNC Gillings School includes the following.
A study, co-authored by Drs. Daniel Erim and Stephanie Wheeler (doctoral student and associate professor, respectively, in health policy and management), found that neoadjuvant chemotherapy (NACT), a first step used to shrink a tumor prior to surgery, was found to be more cost-efficient than primary surgery in women with advanced-stage epithelial ovarian cancer. NACT also resulted in a greater boost to quality of life. The study was published online Dec. 19, 2017, in the journal Gynecologic Oncology.
Dr. Wheeler also was co-author of an article, published Jan. 16 in Cancer, about breast cancer gene expression profiling (GEP). GEP has been adopted for early breast cancer and can aid in decision making about chemotherapy. Study results regarding racial disparities in testing are conflicting, and may reflect different care settings. Data regarding the influence of provider factors on testing are scarce.
Dr. Wheeler and colleagues used a statewide, multipayer, insurance claims database linked to cancer registry records to examine the impact of race and provider characteristics on GEP uptake in a cohort of patients newly diagnosed with breast cancer between 2005 and 2012.
Among 11,958 eligible patients, 23 percent of black and 26 percent of non-Hispanic white patients received GEP. Among patients with no disease, black individuals were 16 percent less likely to receive testing after adjustment for clinical factors and the provider’s specialty and volume of patients with breast cancer. Adjustment for provider characteristics did not attenuate the effect of race on testing. Patients of middle-volume providers were more likely to be tested compared with those with either high-volume or low-volume providers, whereas patients seeing a medical oncologist were more likely to be tested, compared with those whose only providers were from surgical specialties.
Provider volume and specialty were found to be significant predictors of GEP use, but did not explain racial disparities in testing. Further research concerning the key contributors to lagging test use among black women is needed to optimize the equitable use of GEPs and support personalized treatment decision making for all patients.
Drs. Carmina Valle and Deborah Tate (assistant professor and professor, respectively, in nutrition), in an article published in the December 2017 issue of Translational Behavioral Medicine, examine the engagement of young adult cancer survivors within a Facebook-based physical activity intervention.
Young adult cancer survivors participated in one of two Facebook groups as part of a 12-week randomized trial of a physical activity intervention (FITNET), compared to a self-help comparison condition. A moderator actively prompted group discussions in the FITNET Facebook group, while social interaction was unprompted in the self-help group.
There researchers found that there were no group differences in the number of Facebook comments posted over 12 weeks or the proportion of participants that reported engaging within Facebook group discussions at least 1 – 2 days/week. The proportion of participants that made any posts decreased over time in both groups. Self-help participants were more likely than FITNET participants to agree that group discussions caused them to become physically active and that group members were supportive. Participant-initiated posts elicited significantly more comments and likes than moderator-initiated posts. Responses posted on Facebook were significantly associated with light physical activity at 12 weeks across groups. Further research is needed to examine how cancer survivors engage within social networking sites and to capitalize on common experiences in ways that facilitate improvements in health behavior change.
Drs. Valle and Tate, along with Dr. Chantel Martin (postdoctoral fellow in epidemiology), also were citation award winners for an oral presentation at the 38th Annual Meeting and Scientific Sessions of the Society of Behavioral Medicine, in San Diego. Their study explored the association of nonadherence to daily self-weighing and daily activity tracking with corresponding weight fluctuations among African-American breast cancer survivors participating in a six‐month pilot randomized controlled trial of weight gain prevention interventions. Their findings suggest that nonadherence to daily self-weighing was associated with weight gain among breast cancer survivors. Weight loss was enhanced during periods of daily self-weighing and daily activity tracking.
In a study published Jan. 4 in the International Journal of Cancer, epidemiology faculty members Drs. Hazel Nichols (senior author) and Stephanie Engel analyzed health indicators for children born to young breast cancer survivors in North Carolina. This included evaluating whether newborns were born preterm (less than 37 weeks), if they were below normal weight, small for gestational age, or if they were born through a Cesarean delivery. Overall, there was not an increase in the prevalence of preterm birth, C-section, small for gestational age, or low birth weight for newborns across all breast cancer types.
However, when they examined the data by breast cancer type, researchers found increased risk of preterm birth, low birth weight, and C-section delivery for women with estrogen receptor-negative breast cancer. Researchers cautioned that further studies are needed to confirm the finding.
As part of the Cancer Health Accountability for Managing Pain and Symptoms (CHAMPS) study, Dr. Cleo Samuel, CHAMPS principal investigator and assistant professor of health policy and management, and colleagues conducted focus groups to examine racial differences in symptom management experiences among black and white breast cancer survivors (BCS). Black BCS commonly reported having to advocate for themselves to get information about treatment-related symptoms, and indicated dissatisfaction regarding clinicians’ failure to disclose potential treatment-related symptoms or provide medications to address symptoms. White BCS commonly described dissatisfaction regarding inadequate information on symptom origins and clinicians’ failure to offer reassurance. Findings from this study elucidate opportunities for future research aimed at improving equity and overall quality in cancer treatment-related symptom management. The study was published online Nov. 18, 2017, in Supportive Care in Cancer.
CHAMPS is a National Cancer Institute (NCI)-funded, community-based participatory research study exploring racial differences in treatment-related symptoms, symptom management and treatment completion among stage I-IV black and white breast cancer survivors. As a supplemental project to the NCI-funded Accountability for Cancer Care through Undoing Racism and Equity intervention study, CHAMPS is grounded in principles of system-level transparency (e.g., monitoring overall and race-specific clinical data) and accountability (e.g., “audit and feedback” to clinicians on clinical performance) for promoting racial equity in cancer care. Leveraging a 14-year community-medical-academic partnership, the CHAMPS research team includes partners from the University of North Carolina at Chapel Hill, Greensboro Health Disparities Collaborative, University of Pittsburgh Medical Center- Hillman Cancer Center, Cone Health Cancer Center, and Sisters Network Greensboro.
In her dissertation research, UNC Gillings School alumna Dr. Lisa DiMartino assessed the influence of strategies intended to promote palliative care referrals for medical and gynecologic oncology patients. Dr. DiMartino found using a combination of informal strategies was more effective in promoting palliative care referrals than one formal strategy.
Dr. DiMartino worked under the supervision of a number of UNC health policy and management faculty members, including Dr. Morris Weinberger, distinguished professor and chair; Dr. Justin Trogdon, associate professor; and Dr. Sarah Birken, research assistant professor.
Dr. Birken, who conducts research on the implementation of cancer survivorship care plans (SCPs) and the translation of other interventions into clinical practice, also collaborated with others to advocate for the use of implementation science to inform research on the effectiveness of SCPs, which summarize diagnosis and treatment information and outline follow-up care, depends in part upon their successful implementation; if SCPs do not contain complete, accurate information, or are not delivered to survivors and their primary care providers, then they cannot fulfill the goal of improving coordination and communication among survivors and follow-up care providers. Implementation science provides the tools necessary to account for implementation in studies of SCPs’ effectiveness.
The article was published in November 2016 in the Journal of Clinical Oncology.