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

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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.