BACKGROUND:Cancer screening disparities remain understudied, particularly among underrepresented groups at the county level. This study compared the use of preventive breast and colorectal cancer screening services between sexual and gender minority (SGM) adults and cisgender heterosexual adults in Missouri. METHODS:The 2022 Missouri County-Level Study, a probabilistic survey of health-related behaviors in each county, was used to estimate breast and colorectal cancer (BC and CRC) screening prevalence. Screening prevalence was calculated using weighted samples, and regression models were used to adjust for demographic composition and age eligibility for both cancer sites. RESULTS:Compared to cisgender heterosexual adults (n = 48,257), SGM adults (n = 2801) were significantly younger and more likely to reside in urban areas and be employed. Statewide, county-representative prevalence of breast cancer screening in the last 2 years was 75.6%, and colorectal cancer screening (i.e., colonoscopy in the last 10 years or sigmoidoscopy in the last 5 years) was 63.1%. In age-adjusted models for BC screening for participants (ages 40-74), age had a curvilinear association, increasing at younger ages but declining in later years. For CR screening (ages 45-75), age showed a strong, stable, positive effect. SGM adults had similar odds of breast cancer screening; however, for CRC, SGM adults had higher odds of ever being screened but similar odds to cisgender heterosexual adults of up-to-date screening. Differences largely reflect eligibility windows and initiation versus maintenance dynamics. CONCLUSIONS:In this large sample of Missouri county residents, breast cancer and colorectal cancer screening rates were comparable between SGM adults and cisgender heterosexual adults for up-to-date screening probability. Improving statewide cancer prevention will require addressing the broader structural and regional barriers that suppress screening uptake across Missouri communities. IMPACT:These findings demonstrate the importance of using age-appropriate, guideline-aligned analyses to accurately assess cancer screening equity and avoid overstating disparities among SGM populations. By identifying where differences do not exist, this work helps focus resources on the structural and regional barriers that continue to limit cancer prevention for all Missourians.

Background/Objective: Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have received widespread attention as effective obesity treatments. However, limited research has examined the perspectives of patients contemplating GLP-1RAs. This study explored perceptions, motivations, and barriers among individuals considering GLP-1RA therapy for obesity treatment, with the goal of informing patient-centered care and enhancing clinician engagement. Methods: Adults completed surveys and interviews between June and November 2025. In this pragmatic mixed-methods study, both survey and interview questions explored perceived benefits, barriers, and decision-making processes. Qualitative data, describing themes based on the Health Belief Model, were analyzed using Dedoose (version 9.0.107), and quantitative data were analyzed using SAS (version 9.4). Participant characteristics included marital status, income, educational attainment, employment status, insurance status, age, race/ethnicity, and sex. Anticipated length on GLP-1RA medication and selected self-reported health conditions (depression, anxiety, hypertension, heart disease, back pain, joint pain), reported physical activity level, and perceived weight loss competency were also recorded. Results: Among the 31 non-diabetic participants who were considering GLP-1RA medication for weight loss, cost emerged as the most significant barrier. Life course events, particularly (peri)menopause among women over 44, were commonly cited as contributors to weight gain. Participants expressed uncertainty about eligibility, long-term safety, and treatment expectations. Communication gaps were evident, as few participants initiated discussions and clinician outreach was rare, reflecting limited awareness and discomfort around the topic. Conclusions: Findings highlight that individuals considering GLP-1RA therapy face multifaceted emotional, financial, and informational barriers. Proactive, empathetic clinician engagement, through validation of prior efforts, clear communication of risks and benefits, and correction of misconceptions, can support informed decision-making and align treatment with patient goals.

OBJECTIVE:This study aimed to explore patients' perspectives on GLP-1 receptor agonists (GLP-1RAs) for weight loss across the continuum of contemplating use to discontinuation, with and without achieving weight loss goals. METHODS:From June to October 2025, participants completed a 30-item survey and ~30-question semi-structured interview regarding their perceptions of GLP-1RAs for weight loss. Interviews were tailored to six GLP-1RA groups: (1) considering use; (2) < 3 months on therapy; (3) ≥ 3 months on therapy without achieving weight loss goal; (4) ≥ 3 months on therapy with achieving weight loss goal; (5) discontinued without achieving goal; and (6) discontinued after achieving goal. Qualitative coding and thematic analysis were conducted in Dedoose (9.0.107); quantitative analyses used SAS 9.4. RESULTS:A total of 185 participants consented, and 141 completed data collection (76%). Descriptive profiles suggested heterogeneity across psychosocial and behavioral domains. Groups 3 and 4 showed stronger profiles (higher perceived competence, intrinsic motivation, and self-monitoring). After false discovery rate adjustment across 78 comparisons, perceived competence was the only statistically significant differentiator: Group 1 was lower (z = -3.15; q = 0.0347) and Group 4 higher (z = 4.44; q < 0.001). CONCLUSIONS:Findings underscore the importance of tailoring behavioral support to individuals' stage of engagement in GLP-1RA-supported weight loss journeys.

Purpose: The purpose of this study was to describe the characteristics of being a cancer survivor among those aged 45-64 and 65-80 years, inclusive of sexual and gender minority (SGM) status, using a national populationbased study dataset. Methods: We used the weighted data from the 2021 Behavioral Risk Factor and Surveillance System (BRFSS). Descriptive statistics describe the study population characteristics. Logistic regression models were used as exploratory tools to examine patterns in participant characteristics, including SGM status, with cancer survivor status as the dependent variable, stratified by sex (male and females) and by two age groups (45-64 years, 65-80 years). Results: BRFSS data in 2021 comprised 87,780 females (12,260 female cancer survivors) and 71,594 males (8478 male cancer survivors). Across both age groups and sexes, cancer survivors more frequently reported poorer selfreported health, and higher number of multiple chronic conditions. Older age groups reported cancer survivorship more often. Patterns in the adjusted models indicated non-Hispanic Blacks and another race had lower odds of reporting cancer survivorship in sex-age strata. Among younger men, but not older men, current smoking and binge drinking showed lower adjusted odds of reporting cancer survivorship compared to non-SGM peers. Current BMI patterns varied across age and sex groups. Conclusions: Cancer survivorship differs across demographic and health-related characteristics, with notable variations by age, sex, and race/ethnicity. These descriptive patterns suggest a need for longitudinal and causally informed research to better understand pathways leading to survivorship disparities.

The term sexual and gender minority (SGM) encompasses a diverse population whose unique health needs warrant thoughtful consideration by clinicians in primary care settings. In this article, we will provide a brief history and challenges faced by this population. Case vignettes, sticky points, and clinician care points will be presented. This paper seeks to foster reflective practice in working with SGM patients while recognizing the heterogeneity of personal identities and experiences.

Background: Understanding patient perceptions of cancer care is crucial for improving treatment experiences and health outcomes. This study explores female patient-reported experiences with cancer care. Our aim was to identify areas for improvement and enhance patient-centered approaches in specialty and primary care settings. Methods: This was a prospective observational study using ResearchMatch. Our eligibility criteria were 40 years or older adult cancer diagnosis, female, and treated for cancer in the United States. Results: Among the eligible participants (n = 1224), 64 responded to the invitation and 57 completed the survey (89% participation proportion). The majority of the respondents were not receiving treatment during the study period (68%). Of those, 89% completed the recommended treatment, and 10% stopped the treatment before completion. Nearly 80% of respondents saw the same oncologist during the treatment at every appointment, and only 8% reported changing clinicians during their primary cancer treatment. Over 63% of respondents were not seeing the same primary care clinician as they did when they were first diagnosed. Respondents reported facing challenges with employment and ability to return to work (26%), being able to afford medication (21%), and paying medical bills (15%). Discussion: This study, albeit for a small number of participants (n = 57) identified strengths and challenges in cancer care. Consistent oncologist involvement and proximity to care centers was consistently reported during active treatment. Discontinuity with primary care, however, may warrant further inquiry. Reported financial, employment and access issues support previous studies that identified these as major challenges during and after active cancer treatment. Our study underscored the need to enhance patient-centered coordination and support to improve cancer and survivorship care outcomes.

Background:Cancer is the second leading cause of death in the United States. Compelling evidence shows screening detects colorectal cancer (CRC) at earlier stages and prevents the development of CRC through the removal of precancerous polyps. The Healthy People 2030 goal for CRC screening is 68.3%, but only 36.5% of Missouri federally qualified health center patients aged 50-75 years are up-to-date on CRC screening. For average risk patients, there are three commonly used screening tests in the United States-two types of stool tests collected at home (fecal immunochemical test [FIT]-immunochemical fecal occult blood test [FOBT] and FIT-DNA, such as Cologuard) and colonoscopies completed at procedural centers. Objective:This study aims to examine variation by month for the three types of CRC testing to evaluate consistent patient care by clinical staff. Methods:Data from 31 federally qualified health center clinics in Missouri from 2011 to 2023 were analyzed. A sample of 34,124 unique eligible "average risk" patients defined as persons not having a personal history of CRC or certain types of polyps, family history of CRC, personal history of inflammatory bowel disease, and personal history of receiving radiation to the abdomen or pelvic to treat a previous cancer or confirmed or suspected hereditary CRC syndrome. Another eligibility criterion is that patients need to be seen at least once at the clinic to be included in the denominator for the screening rate calculation. Descriptive statistics characterize the sample, while bivariate analyses assess differences in screening types by month. Results:Completion of CRC screening yielded statistically significant differences for patients completing the different types of CRC screening by month. October-January had the highest proportions of patients (644-680 per month, 8.5%-10.2%) receiving a colonoscopy, while February-April had the lowest (509-578 per month, 6.9%-7.8%), with 614 being the average monthly number of colonoscopies. For FIT-FOBT, June-August had the higher proportions of patients receiving this test (563-613 per month, 8.9%-9.6%), whereas December-February had the lowest (453-495 per month, 7.1%-8%), with 541 being the average monthly number of FIT-FOBT kits used. For FIT-DNA, March was the most popular month with 11.3% (n=261 per month) of patients using the Cologuard test, followed by April, May, and November (207-220 per month, 8.7%-9.4%), and January and June (168-171 per month, 7.2%-7.3%) had the lowest proportion of patients using Cologuard, with 193 being the average monthly number of FIT-DNA kits used. Combining all tests, February had the fewest CRC tests completed (1153/16,173, 7.1%). Conclusions:Home-based tests are becoming popular, replacing the gold standard colonoscopy, but need to be repeated more frequently. Monthly variation of screening over the course of a year suggests that CRC screening efforts and patient care may be less than ideal. Months with lower rates of screening for each type of CRC test represent opportunities for improving CRC screening.

Emerging data suggest a causative link between endometriosis and the subsequent development of rare ovarian carcinomas.The coexistence of these two disease processes was first reported in 1925 by John A. Sampson, who described a case in which histological evaluation of a patient's tumor revealed both endometriosis and endometrioid ovarian carcinoma.[1] In 1980, German scientists postulated that endometriosis itself may be a true precancerous lesion, causing certain types of ovarian cancer.Data has since emerged, supporting that endometriosis may be a premalignant lesion in cases of clear cell and endometrioid ovarian carcinomas.We describe four cases of clear cell ovarian carcinoma in the presence of coexisting atypical endometriosis.Documenting such cases is essential to understanding how ovarian cancer and endometriosis may be linked, how specific cancer subtypes may evolve, and whether certain subtypes of endometriosis may be independent risk factors for the development of ovarian cancer.A case series of four women with clear cell ovarian cancer, with unexpected atypical endometriosis as precursor lesions

SARS-CoV-2 has caused over 6.9 million deaths and continues to produce lasting health consequences. COVID-19 manifests broadly from no symptoms to death. In a retrospective cross-sectional study, we developed personalized risk assessment models that predict clinical outcomes for individuals with COVID-19 and inform targeted interventions. We sequenced viruses from SARS-CoV-2-positive nasopharyngeal swab samples between July 2020 and July 2022 from 4450 individuals in Missouri and retrieved associated disease courses, clinical history, and urban-rural classification. We integrated this data to develop machine learning-based predictive models to predict hospitalization, ICU admission, and long COVID.The mean age was 38.3 years (standard deviation = 21.4) with 55.2% (N = 2453) females and 44.8% (N = 1994) males (not reported, N = 4). Our analyses revealed a comprehensive set of predictors for each outcome, encompassing human, environment, and virus genome-wide genetic markers. Immunosuppression, cardiovascular disease, older age, cardiac, gastrointestinal, and constitutional symptoms, rural residence, and specific amino acid substitutions were associated with hospitalization. ICU admission was associated with acute respiratory distress syndrome, ventilation, bacterial co-infection, rural residence, and non-wild type SARS-CoV-2 variants. Finally, long COVID was associated with hospital admission, ventilation, and female sex.Overall, we developed risk assessment models that offer the capability to identify patients with COVID-19 necessitating enhanced monitoring or early interventions. Of importance, we demonstrate the value of including key elements of virus, host, and environmental factors to predict patient outcomes, serving as a valuable platform in the field of personalized medicine with the potential for adaptation to other infectious diseases. Model summary and motivation. Individuals infected with SARS-CoV-2 experience a wide spectrum of clinical manifestations ranging from no symptoms to death. Using the Virus-Human Outcomes Prediction (ViHOP) algorithm, we aim to utilize the individual's clinical characteristics, the individual's location, and the infecting SARS-CoV-2 virus characteristics obtained by whole genome sequencing to determine their likelihood of admission to the hospital, admission to the intensive care unit (ICU), or experiencing long COVID. This model allows clinicians to identify at-risk patients for further monitoring and/or early treatment.

PURPOSE:We present findings from an assessment of award recipients' partners from the Centers for Disease Control and Prevention's Colorectal Cancer Control Program (CRCCP). We describe partners' processes of identifying and tracking patients undergoing stool-based screening. METHODS:We analyzed data from eight CRCCP award recipients purposively sampled and their partner health systems from 2019 to 2023. The data included number of stool-based tests distributed and returned; abnormal findings; referrals and completion of follow-up colonoscopies; and colonoscopy findings. We also report on strategies to improve tracking of stool-based tests and facilitation of follow-up colonoscopies. RESULTS:Five of eight CRCCP award recipients reported that all or some partner health systems were able to report stool test return rates. Six had health systems that were able to report abnormal stool test findings. Two reported that health systems could track time to follow-up colonoscopy completion from date of referral, while four could report colonoscopy completion but not the timeframe. Follow-up colonoscopy completion varied substantially from 24.2 to 75.5% (average of 47.9%). Strategies to improve identifying and tracking screening focused mainly on the use of electronic medical records; strategies to facilitate follow-up colonoscopy were multi-level. CONCLUSION:Health systems vary in their ability to track steps in the stool-based screening process and few health systems can track time to completion of follow-up colonoscopy. Longer time intervals can result in more advanced disease. CRCCP-associated health systems participating in this study could support the implementation of multicomponent strategies at the individual, provider, and health system levels to improve tracking and completion of follow-up colonoscopy.

This study compares pandemic experiences of Missouri's 115 counties based on rurality and sociodemographic characteristics during the 1918-20 influenza and 2020-21 COVID-19 pandemics. The state's counties and overall population distribution have remained relatively stable over the last century, which enables identification of long-lasting pandemic attributes. Sociodemographic data available at the county level for both time periods were taken from U.S. census data and used to create clusters of similar counties. Counties were also grouped by rural status (RSU), including fully (100%) rural, semirural (1-49% living in urban areas), and urban (>50% of the population living in urban areas). Deaths from 1918 through 1920 were collated from the Missouri Digital Heritage database and COVID-19 cases and deaths were downloaded from the Missouri COVID-19 dashboard. Results from sociodemographic analyses indicate that, during both time periods, average farm value, proportion White, and literacy were the most important determinants of sociodemographic clusters. Furthermore, the Urban/Central and Southeastern regions experienced higher mortality during both pandemics than did the North and South. Analyses comparing county groups by rurality indicated that throughout the 1918-20 influenza pandemic, urban counties had the highest and rural had the lowest mortality rates. Early in the 2020-21 COVID-19 pandemic, urban counties saw the most extensive epidemic spread and highest mortality, but as the epidemic progressed, cumulative mortality became highest in semirural counties. Additional results highlight the greater effects both pandemics had on county groups with lower rates of education and a lower proportion of Whites in the population. This was especially true for the far southeastern counties of Missouri ("the Bootheel") during the COVID-19 pandemic. These results indicate that rural-urban and socioeconomic differences in health outcomes are long-standing problems that continue to be of significant importance, even though the overall quality of health care is substantially better in the 21st century.

In the United States, rural populations comprise 60 million individuals and suffered from high COVID-19 disease burdens. Despite this, surveillance efforts are biased toward urban centers. Consequently, how rurally circulating SARS-CoV-2 viruses contribute toward emerging variants remains poorly understood. In this study, we aim to investigate the role of rural communities in the evolution and transmission of SARS-CoV-2 during the early pandemic. We collected 544 urban and 435 rural COVID-19-positive respiratory specimens from an overall vaccine-naïve population in Southwest Missouri between July and December 2020. Genomic analyses revealed 53 SARS-CoV-2 Pango lineages in our study samples, with 14 of these lineages identified only in rural samples. Phylodynamic analyses showed that frequent bi-directional diffusions occurred between rural and urban communities in Southwest Missouri, and that four out of seven Missouri rural-origin lineages spread globally. Further analyses revealed that the nucleocapsid protein (N):R203K/G204R paired substitutions, which were detected disproportionately across multiple Pango lineages, were more associated with urban than rural sequences. Positive selection was detected at N:204 among rural samples but was not evident in urban samples, suggesting that viruses may encounter distinct selection pressures in rural versus urban communities. This study demonstrates that rural communities may be a crucial source of SARS-CoV-2 evolution and transmission, highlighting the need to expand surveillance and resources to rural populations for COVID-19 mitigation.

By 2040, an anticipated 26.1 million people with a history of cancer will be part of the healthcare system. The purpose of this study was to explore Missouri-based non-oncology clinicians’ perspectives on caring for patients with a history of cancer to identify needs of rural-based clinicians to optimize their patients’ survivorship care. Using an interpretive qualitative descriptive approach, we conducted semi-structured interviews with 17 non-oncology clinicians. We encouraged clinicians to discuss their approach to caring for patients with a history of cancer and invited them to talk about what might help them increase their knowledge of survivorship care best practices. Through interpretive qualitative descriptive analysis methods including first level coding and constant comparison, we found there is consensus that cancer survivorship care is important; however, training that now guides our clinicians occurred mostly during residency, if at all. Clinicians relied on previous patient encounters and oncology notes combined with their patients’ personal account of treatment history to inform the best next steps. Clinicians expressed strong interest in having a simple protocol of their patient’s treatment with prompts of known long-term cancer treatment–related effects and a patient-centric follow-up monitoring schedule (mandatory vs recommended vs optional). Clinicians expressed interest in educational opportunities about cancer care and ability for curbside consults with oncologists. They consistently noted the limited resources available in rural areas and that rural patients may have different preferences and approaches to cancer survivorship. There is a clear opportunity to improve non-oncology clinicians’ knowledge of the needs of people with a history of cancer as well as their own knowledge base and self-efficacy, especially in rural settings.

OBJECTIVE:To examine the influence of habitus on women's health behavior regarding breastfeeding and subsequent COVID-19 vaccination.DESIGN:A qualitative descriptive design, guided by Pierre Bourdieu's concept of habitus.SAMPLE:Eighteen women who were postpartum, breastfeeding, and vaccinated against COVID- 19 either during pregnancy or while breastfeeding postpartum.MEASURES:Individual semi-structured interviews.RESULTS:Two major themes shaped participants' habitus: health-focused knowledge, and attitudes and beliefs. Attitudes and beliefs included five subthemes: (1) exposure/acceptance/expectations from family, (2) community acceptance of breastfeeding and COVID-19 vaccination, (3) socioeconomic status, (4) easily accessed support, and (5) outside experiences and exposure.DISCUSSION:An individual's habitus impacts one's knowledge, attitudes, and beliefs and interacts with past behaviors when discussing options for infant feeding and health promoting behaviors such as vaccinations. A better understanding of how health care providers assess and utilize habitus in clinical management is needed.

After the COVID-19 pandemic reached Missouri, the Show-Me ECHO (Extension for Community Healthcare Outcomes) project initiated COVID-19 ECHO virtual knowledge-sharing networking sessions. These live-interactive weekly sessions inform participants about up-to-date evidence-based recommendations and guidelines through expert didactic lectures followed by real-life case discussions. We conducted a qualitative analysis of pre-session surveys and questions asked during sessions to learn about information needs of community members during first months of public health emergency. This was a pilot project using qualitative analysis of registration questions regarding anticipated COVID-19 community information needs, and participants' questions asked during sessions collected from March 23 until May 4, 2020. We also analyzed participants' satisfaction surveys collected in December 2020. A total of 761 unique participants attended COVID-19 ECHO during the study period. Survey was completed by 692 respondents. Participants asked 315 questions resulting in 797 identified community information needs. Five thematic categories were recognized: patient care, information seeking, minimizing exposure, financial themes, and general comments. Most attendees rated content quality, logistics, and technical operations as good or excellent on a five-point Likert scale. The COVID-19 ECHO model was responsive to the needs of participants by sharing and discussing up-to-date recommendations and guidelines regarding COVID-19. Sessions were well-attended, and the didactic presenters were invited to deliver same or similar presentations at Boone County Medical Society (BCMS) weekly seminars, suggesting the value of the project to healthcare providers and other community members caring for or working with the most vulnerable populations.

We describe intrauterine fetal demise in unvaccinated women with mild symptoms of SARS-CoV-2 Delta variant infection. Histology and elevated proinflammatory responses of the placenta suggest that fetal demise was associated with placental malperfusion due to Delta variant infection. Background Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has a higher infection rate in pregnant women than age-matched adults. With increased infectivity and transmissibility, the Delta variant is predominant worldwide. Methods In this study, we describe intrauterine fetal demise in unvaccinated women with mild symptoms of SARS-CoV-2 Delta variant infection. Results Histology and elevated proinflammatory responses of the placenta suggest that fetal demise was associated with placental malperfusion due to Delta variant infection. Conclusions This study suggests that the Delta variant can cause severe morbidity and mortality to fetuses. Vaccination should continue to be advocated and will likely continue to reduce SARS-CoV-2 infection risks for pregnant women and their fetuses.

As SARS-CoV-2 and influenza viruses co-circulate, co-infections with these viruses generate an increasing concern to public health. To evaluate the prevalence and clinical impacts of SARS-CoV-2 and influenza A virus co-infections during the 2021-2022 influenza season, SARS-CoV-2-positive samples from 462 individuals were collected from October 2021 to January 2022. Of these individuals, 152 tested positive for influenza, and the monthly co-infection rate ranged from 7.1% to 48%. Compared to the Delta variant, individuals infected with Omicron were less likely to be co-infected and hospitalized, and individuals who received influenza vaccines were less likely to become co-infected. Three individuals had two samples collected on different dates, and all three developed a co-infection after their initial SARS-CoV-2 infection. This study demonstrates high prevalence of co-infections in central Missouri during the 2021-2022 influenza season, differences in co-infection prevalence between the Delta and the Omicron waves, and the importance of influenza vaccinations against co-infections.