In this issue of Cancer , Weiner et al present a US population–based analysis of the causes of death in prostate cancer survivors. Thoughts are presented on how their results can bring value to clinical practitioners, especially primary care physicians, who work on managing the health care of prostate cancer survivors in the complex environment of the COVID‐19 pandemic.

Maps are well recognized as an effective means of presenting and communicating health data, such as cancer incidence and mortality rates. These data can be linked to geographic features like counties or census tracts and their associated attributes for mapping and analysis. Such visualization and analysis provide insights regarding the geographic distribution of cancer and can be important for advancing effective cancer prevention and control programs. Applying a spatial approach allows users to identify location-based patterns and trends related to risk factors, health outcomes, and population health. Geographic information science (GIScience) is the discipline that applies Geographic Information Systems (GIS) and other spatial concepts and methods in research. This review explores the current state and evolution of GIScience in cancer research by addressing fundamental topics and issues regarding spatial data and analysis that need to be considered. GIScience, along with its health-specific application in the spatial epidemiology of cancer, incorporates multiple geographic perspectives pertaining to the individual, the health care infrastructure, and the environment. Challenges addressing these perspectives and the synergies among them can be explored through GIScience methods and associated technologies as integral parts of epidemiologic research, analysis efforts, and solutions. The authors suggest GIScience is a powerful tool for cancer research, bringing additional context to cancer data analysis and potentially informing decision-making and policy, ultimately aimed at reducing the burden of cancer.

IMPORTANCEBRCA genetic testing has substantial public health impact, yet little is known of the real-world experiences of the more than 100 000 Americans undergoing testing annually.OBJECTIVETo identify factors associated with use of BRCA testing, assess whether delivery of genetic counseling and testing services adheres to professional guidelines, and measure the impact on patient-reported outcomes.DESIGN, SETTING, AND PARTICIPANTSThe American BRCA Outcomes and Utilization of Testing (ABOUT) Study analyzed data from a consecutive national series of 11 159 women whose clinicians ordered BRCA testing between December 2011 and December 2012. Aetna mailed recruitment information across the United States to commercial health plan members whose clinicians had ordered BRCA testing. A total of 3874 women (34.7%) completed questionnaires. Deidentified clinician-reported data from all respondents and a random sample of 2613 nonrespondents were also analyzed.MAIN OUTCOMES AND MEASURESThe proportion of eligible participants who met testing criteria and respondents' report of receiving genetic counseling by a genetics clinician and its association with BRCA knowledge, understanding, and satisfaction were assessed.RESULTSAmong 3628 women respondents whose clinicians ordered comprehensive BRCA testing, most were white non-Hispanic (2502 [69.0%]), college educated (2953 [81.4%]), married (2751 [75.8%]), and had higher incomes (2011 [55.4%]). Approximately 16.4% (596) did not meet testing criteria. Mutations were identified in 161 (5.3%) of these women who received comprehensive testing. Only 1334 (36.8%) reported receiving genetic counseling from a genetics clinician prior to testing; the lowest rates (130 [12.3%]) were among patients of obstetrician/gynecologists. The most commonly reported reason for not receiving this clinical service was lack of clinician recommendation. Those who received it demonstrated greater knowledge about BRCA (mean score difference adjusted for demographics and clinician specialty, β = 0.99 [95% CI, 0.83-1.14]; P < .001) and expressed greater understanding (β = 0.47 [95% CI, 0.41-0.54]; P < .001) and satisfaction (β = 2.21 [95% CI, 1.60-2.81]; P < .001).CONCLUSIONS AND RELEVANCEDespite improved patient knowledge, understanding, and satisfaction among patients who receive genetic counseling provided by a genetics clinician, as well as multiple guidelines emphasizing the importance of genetic counseling, most US women undergoing BRCA genetic testing do not receive this clinical service. Lack of physician recommendation is the most commonly reported reason. These findings demonstrate important gaps in clinical genetics services. Recently mandated coverage of genetic counseling services as a preventive service without patient cost sharing should contribute to improving clinical genetics services and associated outcomes in the future.

Research to date regarding identification and management of hereditary breast and ovarian cancer syndrome (HBOC) in the U.S. has been confined primarily to academic center-based studies with limited patient engagement. To begin to understand and address the current gaps and disparities in delivery of services for the appropriate identification and optimal risk management of individuals with HBOC, we designed and have initiated the American BRCA Outcomes and Utilization of Testing (ABOUT) Study. ABOUT relies on a collaborative patient advocacy, academic and industry partnership to recruit and engage U.S. individuals who are at increased risk for HBOC and investigate their experiences, decisions and outcomes. It utilizes an extensive research infrastructure, including an interactive web-based data system and electronic interfaces for secure online participation and automated data exchange. We describe the novel recruitment approach that was designed for collaboration with a national commercial health plan partner to identify all individuals for whom a healthcare provider orders a BRCA test and mail to each individual an invitation to participate and study packet. The study packet contains detailed information about the study, a baseline questionnaire and informed consent for participation in the study, for release of relevant medical and health plan records and for ongoing research engagement. This approach employs patient-reported, laboratory-reported and health plan-reported outcomes and facilitates longitudinal engagement. We believe that the type of innovative methodology and collaborative framework we have developed for ABOUT is an ideal foundation for a patient-powered research network. This approach can make substantial contributions to identifying current and best practices in HBOC, leading to improved strategies for clinical care and optimal health outcomes among individuals with high inherited risk for cancer.

1608 Background: An estimated 100,000 individuals currently undergo genetic testing for hereditary susceptibility to breast and ovarian cancer annually in the U.S., yet little is known about their characteristics, testing experience or outcomes. Research in this high-risk group has been limited to patients recruited at academic medical centers where case ascertainment, health services delivery, decision-making and, quite likely, outcomes are different from those in the community setting where the majority of individuals currently receive healthcare services. Methods: Eligible subjects include 10,000 consecutive individuals requesting BRCA testing through the nation’s third-largest health insurer, Aetna, beginning in December, 2011. De-identified data are analyzed from each test request form submitted by the ordering provider. Each eligible subject is mailed a study packet inviting them to complete a questionnaire (by mail, online or telephone) designed to investigate informational and healthcare services, test results, knowledge, risk perception and medical intentions. Results: Of 442 subjects contacted during the first two weeks of accrual, 143 (32%) have completed the questionnaire to date. Similar to Aetna member demographics, 7% are African-American and 7% report Hispanic ethnicity. Based on Chi-Square tests, there were no differences between respondents and non-respondents with regard to age (51% under age 50), race, ethnicity or personal history of cancer (58%). Among respondents, deleterious mutations were identified in 8%. Testing for a known familial mutation was performed in 8%. Among women with breast cancer, 13% were undergoing testing prior to initial surgical treatment. Updated results from 3000 eligible subjects will be presented. Conclusions: This innovative, academic-industry collaboration enables an unprecedented investigation of significant issues surrounding individuals at increased risk for hereditary breast and ovarian cancer and undergoing genetic testing in the U.S. The results will guide the development and dissemination of more targeted decision-support tools and strategies to improve medical outcomes for such individuals.

The American Cancer Society (ACS) and Coalition of Cancer Cooperative Groups (CCCG) provide a clinical trial (CT) information/matching/eligibility service (Clinical Trials Matching Service [CTMS]). Patients' demographic and clinical data, enrollment status, and self-reported barriers to CT participation were analyzed to assess enrollment rates and determinants of enrollment. During 3 years beginning October 1, 2007, the CTMS served 6,903 patients via the ACS call center. Among the 1,987 patients with follow-up information on enrollment, 219 (11.0%) enrolled in a CT; 48 of these 219 enrollees chose a CT they found via the CTMS. Patients were less likely to enroll if they had poor ECOG performance status (P = 0.032); were African American (P = 0.0003), were uninsured or had Medicaid coverage (P = 0.024), or had lower stage disease (P = 0.018). Enrollment varied by trial type/cancer site/system (P = .026). Several barriers significantly predicted nonenrollment. Broader availability of a CTMS might help improve patient participation in cancer clinical trials.

Background Most smokers attempt to quit on their own even though cessation aids can substantially increase their chances of success. Millions of smokers seek cessation advice on the Internet, so using it to promote cessation products and services is one strategy for increasing demand for treatments. Little is known, however, about what cessation aids these smokers would find most appealing or what predicts their preferences (eg, age, level of dependence, or timing of quit date). Objective The objective of our study was to gain insight into how Internet seekers of cessation information make judgments about their preferences for treatments, and to identify sociodemographic and other predictors of preferences. Methods An online survey assessing interest in 9 evidence-based cessation products and services was voluntarily completed by 1196 smokers who visited the American Cancer Society’s Great American Smokeout (GASO) webpage. Cluster analysis was conducted on ratings of interest. Results In total, 48% (572/1196) of respondents were “quite a bit” or “very much” interested in nicotine replacement therapy (NRT), 45% (534/1196) in a website that provides customized quitting advice, and 37% (447/1196) in prescription medications. Only 11.5% (138/1196) indicated similar interest in quitlines, and 17% (208/1196) in receiving customized text messages. Hierarchical agglomerative cluster analysis revealed that interest in treatments formed 3 clusters: interpersonal – supportive methods (eg, telephone counseling, Web-based peer support, and in-person group programs), nonsocial – informational methods (eg, Internet programs, tailored emails, and informational booklets), and pharmacotherapy (NRT, bupropion, and varenicline). Only 5% (60/1196) of smokers were “quite a bit” or “very much” interested in interpersonal–supportive methods compared with 25% (298/1196) for nonsocial–informational methods and 33% (399/1196) for pharmacotherapy. Multivariate analyses and follow-up comparisons indicated that level of interest in pharmacotherapy (“quite a bit or “very much” vs. “not at all”) varied as a function of education (n = 575, χ2 3 =16.6, P = .001), age (n = 528, χ2 3 = 8.2, P = .04), smoking level (n = 514, χ2 3 = 9.5, P = .02), and when smokers were planning to quit (n = 607, χ2 4 = 34.0, P < .001). Surprisingly, greater age was associated with stronger interest in nonsocial–informational methods (n = 367, χ2 3 = 10.8, P = .01). Interest in interpersonal–supportive methods was greater if smokers had used a quitline before (n = 259, χ2 1 = 18.3, P < .001), or were planning to quit earlier rather than later (n = 148, χ2 1 = 4.9, P = .03). Conclusions Smokers accessing the Internet for information on quitting appear to differentiate cessation treatments by how much interpersonal interaction or support the treatment entails. Quitting date, smoking level, and sociodemographic variables can identify smokers with varying levels of interest in the 3 classes of cessation methods identified. These results can potentially be used to more effectively target and increase demand for these treatments among smokers searching the Internet for cessation information.

Patient-reported outcomes (PROs) are measures completed by patients to capture outcomes that are meaningful and valued by patients. To help standardize PRO measures in patient navigation research and program evaluation, the Patient-Reported Outcomes Working Group (PROWG) was convened as part of the American Cancer Society's National Patient Navigator Leadership Summit. METHODS: The PROWG consisted of clinicians, researchers, and program managers from a variety of perspectives who developed a set of recommended PRO measures across the cancer continuum (ie, screening, diagnostic follow-up, treatment, survivorship, end of life) as well as those useful for assessing family caregivers. Measures were recommended based on face validity, responsiveness to navigation, reliability, and construct validity in relevant populations. Other considerations included readability, existence of multiple language versions, the existence of norm groups, and respondent burden. RESULTS: The PROWG reached consensus on measures for use in the domains of treatment adherence; perceived barriers to care; satisfaction with cancer care; satisfaction with patient navigation services; working alliance with patient navigator; perceived knowledge/competence/self-efficacy; functional assessment/symptom burden; global quality of life; specific quality-of-life symptoms (eg, depression, anxiety); and perceived cultural competency of the navigator. In domains where validated measures were found lacking, recommendations were made for areas of needed scale development. CONCLUSIONS: These measures should guide research and programmatic evaluation of patient navigation. Cancer 2011;117(15 suppl):3603-17. (C) 2011 American Cancer Society.

The majority of smokers attempt to quit smoking on their own, but in any given year, only 5% or less are successful. To improve cessation rates, tapping social networks for social support during quitting has been recommended or tested in some interventions. Prior reviews of this research, however, have concluded that there is little to no evidence that partner support interventions are effective.Given the theoretical importance of the concept of social support, its demonstrated value in treatments that are implicitly supportive (e.g., telephone counseling), and the general lack of a guiding conceptual framework for research on the effects of peer or partner support for cessation, we describe theoretical models that explicitly incorporate social support constructs in predicting motivation for and success in quitting.Better differentiation of support concepts and elucidating causal pathways will lead to studies that demonstrate the value of social relationships in improving smokers' likelihood of cessation.

Telephone quitlines efficiently deliver cessation services, but few smokers use them. This article describes an unsolicited direct mail campaign designed to increase calls to the New York State Smokers' Quitline. Two post-cards advertising the quitline and the availability of free nicotine patches were sent to 77,527 smoker households between August and October 2005. One postcard emphasized the effectiveness of the nicotine patch, whereas the other contrasted the risks of smoking and patch use. Response was evaluated using geographically linked calls to the quitline 15 days before and after each mailing. The postcard campaign increased call volume by 36%, with no difference between the two postcard versions. Those who reported calling the quitline in response to a mailing were more likely to request nicotine patches (91% versus 82%, p < .001). Direct mail can be used to increase quitline call volume and should be one of the promotional tools used by quitlines.

Arizona was one of the first few states to implement a comprehensive tobacco control program. The effect of that program is examined using a computer-simulation model (SimSmoke) developed for the purposes of evaluation, planning, and justifying policies. This approach assesses the impact to date of tobacco control policies on smoking prevalence and generates predictions about the effects of tobacco control policies on past and future smoking prevalence and associated future premature mortality. SimSmoke estimates indicate that tobacco control policies reduced smoking rates in Arizona by about 20 percent over the period 1993-2002. A previous CDC study obtains similar effects, but does not net out the effects of individual policies. SimSmoke attributes much of the reduction, about 61 percent, to price increases and attributes 38 percent of the overall effect to media policies, leaving only a small percentage of the smoking reductions attributed to quitlines, youth access policies, and the weak clean air laws. Tobacco control policies implemented as comprehensive strategies have significantly affected smoking rates in Arizona, which leads to large reductions in deaths attributable to smoking. It will be important to maintain these efforts over time to reduce or keep smoking prevalence down and to minimize smoking-attributable deaths.

OBJECTIVE:To identify the prevalence and correlates of behaviors related to the risk of cigarette-caused fires.DESIGN AND SETTING:Random-digit-dialed telephone survey in Ontario, Canada, July-September, 2005.SUBJECTS:596 current cigarette smokers.OUTCOME MEASURES:Prevalence of fire-risk events and behaviors such as burning clothing or objects in the home, leaving lit cigarettes unattended, dozing while smoking, and smoking in bed and correlates of these behaviors. Respondents were also asked if they ever worry about cigarette-caused fires.RESULTS:One in four smokers admitted to leaving lit cigarettes unattended in the last 30 days, while 15% admitted to smoking while in bed. Leaving lit cigarettes unattended was independent of demographic, socioeconomic or nicotine dependence indicators, but was related to worry about burning other persons with a cigarette (OR 1.72, 95% CI 1.04 to 2.85) and smoking inside the home (OR 2.98, 95% CI 1.66 to 5.35). Persons who were not white (OR 3.97, 95% CI 1.80 to 8.80), aged 18-24 years (OR 3.75, 95% CI 1.41 to 9.96), who had high nicotine dependence (OR 9.13, 95% CI 2.22 to 37.52) and worried about burning objects in their home (OR 2.43, 95% CI 1.31 to 4.52) were more likely to smoke in bed. 10 (1.7%) smokers reported having ever had a fire in their home started by a cigarette.CONCLUSIONS:Smokers engage in behaviors such as smoking in bed and leaving lit cigarettes unattended that may place them at an increased risk of cigarette-caused fires. As governments move to regulate cigarette ignition propensity, it is important to establish surveillance for behaviors related to fire risk.

These include: References http://injuryprevention.bmj.com/cgi/content/full/13/4/237#BIBL This article cites 13 articles, 6 of which can be accessed free at: Rapid responses http://injuryprevention.bmj.com/cgi/eletter-submit/13/4/237 You can respond to this article at: service Email alerting the top right corner of the article Receive free email alerts when new articles cite this article sign up in the box at

Although previous empirical studies have shown that tobacco control policies are effective at reducing smoking rates, such studies have proven of limited effectiveness in distinguishing how the effect of policies depend on the other policies in place, the length of adjustment period, the way the policy is implemented, and the demographic groups considered. An alternative and complementary approach to purely statistical equations is simulation models. We describe the SimSmoke simulation model and how we used it to assess tobacco control policy in a specific case study. Simulation models are not only useful for policy prediction and planning but also may help to broaden our understanding of the role of different public health policies within a complex, dynamic social system.

Background: We evaluated the impact of a community-based tobacco control project that was implemented in the city of Tucson, Arizona, USA, between 1996 and 2001.Aim: The project's goal was to reduce the prevalence of youth smoking through change in social norms at schools and in communities and workplaces. As is often the case, these community-based health promotion interventions were implemented in conjunction with other broader programmes, in this case implemented on the state level.Method: Taking into account state level interventions as well as changes in sociodemographic and economic environment over the course of the project (e.g. increases in cigarette prices), we measure the net effect of the intervention in terms of the number of people who quit or did not initiate smoking and by the discounted life-years gained. To establish the value of investing into community-based intervention, we calculated the real discounted cost per quit and per lifeyear gained of $US3789 and $US3942, respectively. These compare favourably with the real cost per quit of $US4270 when implementing the 1996 US Clinical Practice Guideline for smoking cessation but exceed the real cost of $US2923 per discounted life-year gained when following the guideline.Results: A sensitivity analysis that assumed 5% programme persistence (i.e. 5% of the programme's impact would last forever in the absence of future funding for the programme), one-third would relapse and that one-third of those who quit may have quit smoking even without the programme, suggested a lower cost per discounted life-year saved of $US3476. The cost effectiveness of this project compares favourably with other tobacco control interventions.Conclusion: Despite its relatively small target group, this community-based intervention was cost effective.

Background: We evaluated the impact of a community-based tobacco control project that was implemented in the city of Tucson, Arizona, USA, between 1996 and 2001.

Purpose. To assess the long-term effect of a randomized community-based trial of smoking cessation and to examine the effect of exposure to large state-based tobacco-control programs on smoking cessation. Design. Longitudinal tobacco-use telephone surveys conducted in 1988, 1993, and 2001. Setting and Participants. Baseline smokers (6603) from 20 communities in 9 states completed a survey in 2001 (35% of the original sample). Intervention. The Community Intervention Trial for Smoking Cessation (COMMIT) intervention was a randomized community-based smoking-cessation intervention between 1988 and 1993. In addition, cohort data were used to evaluate quasi-experimental differences in the strength of state-level tobacco control programs and policies. Measures. Multivariate logistic regression was used to compare quit rates among those who were exposed to community- or state-level tobacco-control programming and those who were not between 1988 and 2001. Results. Quit rates were higher in the COMMIT intervention communities during the period when the trial was funded (Relative Risk [RR] = 1.19) but were no different than comparison communities 8 years later after funding stopped. Quit rates were highest in those communities in states with both strong tobacco-control policies and aggressive tobacco-control programs, such as California and Massachusetts (RR = 1.44) compared with those communities in states that had little tobacco-control activity, such as Iowa, New Mexico, and North Carolina. Conclusions. The findings suggest that well-funded tobacco-control programming coupled with tobacco-control policies may be associated with increases in cessation rates.

This article presents results from two population-based promotions for free cessation products used to induce smokers to call the New York State Smokers'. The first promotion was a press announcement urging smokers to call the quitline to get a voucher for a free 2-week supply of nicotine patches or gum (nicotine replacement therapy [NRT]). The second promotion involved comparing response to two newspaper advertisements for the quitline, one of which offered a free stop smoking guide and one that offered the guide plus a free stop smoking aide called Better Quit (BQ). Responses to each promotion were monitored by tracking the call volume to the quitline-before, during, and after each of the promotions. The NRT voucher promotion increased median call volume 25-fold compared to prepromotion levels, whereas the BQ newspaper advertisement increased median call volume 2-fold compared to a newspaper advertisement for the quitline, which did not offer BQ. A random sample of 732 smokers who received the free NRT voucher were followed up 4 to 6 months later to determine their use of NRT and smoking behavior. Embedded within this follow-up study was a randomized experiment in which half the smokers were mailed a quit kit with BQ included and the other half received just the quit kit. Seventy percent of follow-up survey respondents said that they had redeemed the NRT voucher and used the medication to try to quit smoking. Twenty-two percent reported they were no longer smoking, compared with the 12 percent among a comparison group of quitline callers who had not received the free NRT voucher (odds ratio = 1.77; 95% confidence interval: 1.17-2.68). There was no difference in quit rates between those that were sent the BQ cigarette substitute and those that did not get the BQ. This study shows that offering a free 2-week voucher for NRT is a cost-effective method to increase calls to a stop smoking quitline and may also increase the odds of quitting for those who get the free NRT.