Publications

BACKGROUND: Although mobile health (mHealth) apps for tobacco cessation augment traditional cessation methods and have contributed to increases in cessation rates, Black adults are underrepresented in mHealth app studies for tobacco cessation. As a result, their mHealth app preferences are not well-known.

OBJECTIVE: Our goal was to identify features of mHealth apps for cessation that are important to Black adults who use tobacco products.

METHODS: We developed an online discrete choice experiment with 12 pairs of hypothetical mHealth apps for tobacco cessation. Inclusion criteria included being 21 years or older, current use of any tobacco product, and identifying as Black or African American. Participants had to be interested in tobacco cessation and have a history of mHealth app use or be willing to use one in the future. From each pair of hypothetical apps within the survey, participants had to choose the app they preferred. Each hypothetical app was made up of 7 features developed from existing mHealth literature and prior qualitative work: graphics, marketing, strategies for quitting, connection with others, personalization, benefits of quitting, and health information. Each feature had up to 4-5 levels (ie, variations of that attribute), and each hypothetical mHealth app was comprised of a random assortment of levels of features. Hierarchical Bayes estimation was used to determine the part-worth utility for each level within each feature for each participant, which was then used to calculate the importance score. Average importance scores across respondents were used to determine overall importance scores for each feature.

RESULTS: We had 901 adult participants. The mean age was 41 (SD 14.02) years, and about a third of participants (377/901, 42%) were female. Two-thirds of participants (549/901, 61%) had used an mHealth app in the past, and the great majority (786/901, 87%) indicated a willingness to use an app for health purposes in the future. The features had the following importance: graphics (16%), marketing (15%), strategies for quitting (15%), connection with others (14%), personalization (13%), benefits of quitting (13%), and health information (13%). Within features, strategies for quitting had the highest and third-highest levels of "making a step-by-step quit plan" and "recommendations to manage relapse or withdrawal," respectively. Marketing had the second-highest level of "Historically Black Colleges and Universities-endorsed app." Graphics had the fourth-highest level of "short video testimonials from people who successfully quit," while connection with others had the fifth-highest level of "quit buddy program for support and accountability."

CONCLUSIONS: This study identified features of mHealth apps important to Black adult tobacco users. To enhance the appeal of mHealth apps to such adults, prioritizing inclusion of highly preferred levels in apps may lead to higher use and improved cessation.

PURPOSE: To explore patterned processes of identity transformation among Chinese women living with breast cancer.

METHOD: An interpretive description qualitative study was conducted using in-depth narrative interviews with 18 Chinese women. Participants were recruited from multiple provinces across China through a tertiary oncology department and a survivor-led non-profit organization. Purposive and snowball sampling were used. Data were collected between June 2024 and March 2025 and analyzed using Braun and Clarke's reflexive thematic analysis (RTA).

RESULTS: Four themes and twelve subthemes were identified, capturing women's experiences of identity transformation following breast cancer: Identity Fracture at Diagnosis, Awakening of the Inner Self, Active Reconstruction of Self, and Identity Integrating and Expanding. This process was characterized by a dynamic pattern of attention reorientation, shifting from habitual other-focused absorption shaped by caregiving expectations, to forced and intentional self-focused attention, and in some narratives, to a meaning-driven re-engagement with others.

CONCLUSIONS: Breast cancer survivorship among Chinese women involves more than physical recovery. Women described ongoing processes of meaning reconstruction and identity realignment. Attention reorientation provides a culturally grounded explanation mechanism for understanding how women navigate identity reconstruction. These findings underscore the importance of attention-informed and culturally responsive nursing care that supports identity reconstruction and psychosocial adaptation across the survivorship continuum.

BACKGROUND: Patients, particularly those at the end of their lives, frequently receive goal-discordant care, and their surrogate decision-makers suffer long-term psychological injury. Contributors to these issues may include infrequent communication between clinicians and surrogates, failure to discuss prognosis, values, and treatment options that include comfort-focused care, and surrogates facing high-stakes decision-making while underprepared and overwhelmed psychologically and emotionally.

DESIGN: This is a multicenter, patient-randomized efficacy trial of a multi-component intervention, versus usual care, for 370 incapacitated, critically ill adults at high risk of death or severe disability, and their surrogate decision-makers, from 7 hospitals across the United States.

INTERVENTION: The intervention combines surrogate utilization of a digital Family Support Tool (FST) in real-time during their loved one's hospitalization with proactively scheduled family meetings, for which both surrogates and clinicians receive additional preparation, at set intervals during the ICU hospitalization. Those in the control arm will receive usual ICU care.

OUTCOMES: Our primary outcome is patient-centeredness of care, measured using the modified Patient Perceived Patient-Centeredness of Care (PPPC) scale. Secondary outcomes include surrogates' psychological symptom burden, communication and decision quality, and patients' health resource utilization and clinical outcomes.

CONCLUSION: This trial will provide robust evidence about the impact of combining the FST with increased and intentional communication, on patient, family, and health system outcomes for those hospitalized in the ICU.

BACKGROUND: Utilization of targeted agents and immunotherapy led to improved survival in women with metastatic breast cancer (MBC). However, a knowledge gap remains about the side effects and symptom burden associated with these therapies that are not fully described for people living with MBC. We examined patient-reported symptom severity, interference, and symptom burden related to MBC cancer treatments and identified correlated sociodemographic and clinical factors.

METHODS: This is a cross-sectional study. Women with MBC on systemic cancer treatment recruited from oncology clinics and advocacy organizations completed a survey from February to September 2024. We used the MD Anderson Symptom Inventory (MDASI) Immunotherapy module to describe symptom severity and interference of 20 symptoms and symptom burden. We conducted descriptive statistics and stepwise multiple linear regression to identify sociodemographic and clinical factors correlated with symptom severity, interference, and symptom burden.

RESULTS: In the sample of 209 participants, the mean age was 50.11 years (SD = 14.12); 76.6% were White. Most were HR+/HER2- subtype, with an average time of 4.35 years since MBC diagnosis. Fatigue, sleep disturbance, forgetfulness, drowsiness, and sadness were the most prevalent symptoms. Participants identified as non-White, have completed more lines of treatments reported higher symptom severity, interference, and total symptom burden. However, having dependent children (β = 0.32, 95% CI [0.04, 0.60], P = 0.027) was associated with more severe symptom interference.

CONCLUSION: The type and number of treatments, being non-White and caring for dependent children, were associated with a higher symptom burden. Symptom management interventions should be tailored for a specific MBC subgroup and to improve overall well-being for the MBC population.

While primary invasive lobular carcinoma (ILC) is well characterized, metastatic ILC remains understudied. Within the post-mortem tissue donation programs, UPTIDER (Belgium) and Hope for Others (USA), we first aimed to explore intra-patient heterogeneity of key prognostic and predictive markers (stromal tumor-infiltrating lymphocytes (sTIL), estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2) and KI67). Secondly, we compared detection of the metastases by pathology on autopsy samples versus pre-mortem imaging. In total, 306 metastases from 12 patients were collected at autopsy (median: 27 per patient). Both primary tumors (n = 15) and metastases (n = 232) had low sTIL levels, with a median of 2% (range: 0.67-6.67%) and 0.67% (range: 0-13.33%), respectively. Regression models showed lower ER- and PR-expression in metastases (respectively, n = 265 and n = 64) compared to primary tumors (both p < 0.01). KI67 was significantly higher in metastases (n = 262, p = 0.02). HER2-low metastases were found in all but one patient although in varying proportion of metastases (range: 7.5-100%). Central radiology and pathology review had a median concordance of 78% at organ level (range: 33.33-100%) and 71% at patient level (range: 55.88-85.29%). Our findings suggest that a single metastatic biopsy has great limitations to guide treatment and that more adequate methods are needed to detect and monitor ILC metastases.

ContextHospice is a core component of end-of-life care in the United States, designed to provide comprehensive support for patients and their families. While utilization has expanded, concerns remain about whether growth has translated into equitable access. Geographic, socioeconomic, and organizational factors, such as ownership and quality, may shape the availability and type of hospice care patients receive.ObjectivesTo examine geographic and sociodemographic disparities in access to hospice providers across Pennsylvania, a geographically and demographically diverse state.MethodsThis study used 2023 Centers for Medicare & Medicaid Services (CMS) Provider of Services data to identify hospices by ownership type and quality rating. Provider addresses were geocoded, and 60-minute drive-time catchments were generated. Census tract-level hospice access was assessed using the Getis-Ord Gi* statistic to identify cold spots, defined as clusters of tracts with significantly lower access relative to statewide patterns. Tract-level sociodemographic characteristics were drawn from the 2023 American Community Survey, and mean differences were evaluated using two-sample t-tests.ResultsIn total, 2.3 million Pennsylvanians, or 17% of the state population, reside in census tracts classified as cold spots. Cold spots were concentrated in rural and socioeconomically disadvantaged regions. Compared with other tracts, cold spot tracts were lower income, less educated, older, more reliant on public insurance, and less racially diverse. Patterns were consistent when restricting to high quality hospice and nonprofit hospices.ConclusionGeographic disparities in hospice access compound existing sociodemographic inequities. Addressing these inequities will require efforts to expand high-quality hospice availability in underserved communities.

PURPOSE: Cancer treatment-induced bone loss (CTIBL) is a common adverse effect among women with breast cancer receiving endocrine therapy, which negatively affects recovery and quality of life. Bone health management is important in this population. This study aimed to evaluate the feasibility and preliminary outcomes of the Rebuilding Osteo Strength with Exercise (ROSE) program for women with breast cancer.

METHODS: A non-randomized controlled trial was conducted among 72 women with breast cancer receiving endocrine therapy. Participants self-selected into the intervention or control group, receiving either the ROSE program or enhanced health education. The 12-week, online-delivered ROSE program comprised health education, exercise interventions, and behavior change strategies. Feasibility was evaluated through recruitment, retention, and exercise adherence rates. Preliminary bone-health outcomes included changes in bone mineral density (BMD), physical fitness, osteoporosis-related symptoms, knowledge, self-efficacy, and quality of life.

RESULTS: Recruitment rate was 78.3%, with retention rates of 75% at 3 months and 50% at 6 months. High adherence to the exercise plan was observed: 92% for aerobic exercise, 91.7% for impact exercise, and 58% for resistance exercise. Small to moderate positive trends were found in physical fitness, osteoporosis-related symptoms, knowledge, and self-efficacy, though BMD and quality of life showed limited changes.

CONCLUSIONS: The ROSE program appears to be a feasible and safe approach for promoting bone health in breast cancer survivors. Future studies with longer follow-up and a larger sample are warranted to validate its long-term efficacy and mechanisms.

BACKGROUND: Mobile health (mHealth) interventions show promise in supporting tobacco cessation. However, Black adults who use tobacco products are not well represented in mHealth studies for tobacco cessation, and their preferred features of mHealth apps are not well known. Identifying types of mHealth app features for tobacco cessation preferred by Black adults is critical to developing a culturally adapted app, with increased uptake by the target population.

OBJECTIVE: The goal of this study was to explore culturally relevant preferences for features of smoking cessation mHealth apps among Black adults who use tobacco products.

METHODS: A comprehensive list of features of mHealth apps for tobacco cessation was developed based on previous research and a review of existing mHealth literature. Through a content analysis, this list was divided into subgroups and used to develop a focus group guide. We recruited participants from Instagram, a social media platform. Eligible focus group participants included people who reported current use of a tobacco product, identified as being African American or Black, were 21 years old or older, and had access to Wi-Fi or the internet. Participants had to indicate interest in the use of an mHealth app for tobacco cessation. Participants discussed their opinions about different app features, including what features they felt would increase the use of an app by Black adults. Recordings from the focus groups were transcribed and coded deductively and inductively. We conducted a thematic content analysis of the resulting transcripts.

RESULTS: Forty adults aged 21-69 (mean 43, SD 13.6) years participated in 8 focus groups. Fifty-seven percent were female, and 88% endorsed current cigarette use. Four central themes that represented app features emerged. (1) Participants wanted representation and inclusivity through personalization and featuring people with similar lived experiences, including representative images and relevant health information. (2) Participants desired the app to feature a diversity of experiences such as testimonials from individuals from different backgrounds rather than solely focusing on racial identity or excessive targeting of the Black community. (3) Participants desired accountability through trusted connections with health care professionals and other support groups within the app, as well as app tracking capability. (4) Encouragement and motivation were more salient incentives than monetary rewards.

CONCLUSIONS: Black adults who use tobacco products prefer a tobacco cessation app with features that are inclusive, relatable, supportive, and motivating. These findings can serve as the groundwork for the development of an mHealth app that will appeal to Black adults, potentially leading to increased app use, successful cessation, and health equity.

BACKGROUND: : Although mobile health (mHealth) apps for tobacco cessation augment traditional cessation methods and have contributed to increases in cessation rates, Black adults are under-represented in mHealth app studies for tobacco cessation. As a result, their mHealth app preferences are not well known.

OBJECTIVE: Our goal was to identify features of mHealth apps for cessation that are important to Black adults who use tobacco products.

METHODS: We developed an online discrete choice experiment with 12 pairs of hypothetical mHealth apps for tobacco cessation. Participants included: age > 21 years, current use of any tobacco product, and identifying as Black or African American. Participants had to be interested in tobacco cessation and have a history of mHealth app usage or be willing to use one in the future. From each pair of hypothetical apps within the survey, participants had to choose the app they preferred. Each hypothetical app was made up of seven features developed from existing mHealth literature and prior qualitative work: graphics, marketing, strategies for quitting, connection with others, personalization, benefits of quitting, and health information. Each feature had up to 4 -5 levels (i.e., variations of that attribute), and each hypothetical mHealth app was comprised of a random assortment of levels of features. Hierarchical Bayes estimation was used to determine the part-worth utility for each level within each feature for each participant, which was then used to calculate the importance score. Average.

RESULTS: We had 901 adults participants. The mean age was 41 (SD 14.02), and 377 (42%) were female. Two thirds of participants (549/901, 61%) had used an mHealth app in the past, and the great majority (786/901, 87%) indicated a willingness to use an app for health purposes in the future. The features had the following importance: graphics (16.5%); marketing (15.1%); strategies for quitting (15.0%); connection with others (14.3%); personalization (13.4%); benefits of quitting (13.1%) and health information (12.6%). Within features, strategies for quitting had the highest and third-highest levels of "making a step-by-step quit plan" and "recommendations to manage relapse or withdrawal" respectively. Marketing had the second highest level of "HBCU-endorsed app." Graphics had the fourth highest level of " short video testimonials from people who successfully quit" while connection with others had the fifth highest level of "quit buddy program for support and accountability."

CONCLUSIONS: This study identified features of mHealth apps important to Black adult tobacco users. To enhance the appeal of mHealth apps to such adults, prioritizing inclusion of highly preferred levels in apps may lead to higher usage and improved cessation.

For patients with serious illnesses, goals of care conversations improve quality of life and patient and family satisfaction and may reduce healthcare costs. However, these conversations often happen late in a serious illness or not at all. To better integrate goals of care into routine clinical practice, health systems across the country have implemented initiatives to increase and document these conversations. In this paper, we describe the landscape of goals of care initiatives across eight large health systems in the United States and identify core elements for effective programs: 1) Defining the purpose of the initiative; 2) Identifying the target patient population using patient diagnoses, artificial intelligence algorithms, or length of stay; 3) Engaging key stakeholders, including patient, caregiver, frontline provider, and leadership; 4) Encouraging the conversation through clinician and patient education and electronic health record prompts; 5) Documenting conversations within the electronic health record; 6) Measuring data by building electronic health record and information technology infrastructure; and 7) Planning for sustainability and scalability through leadership and funding support. These core elements can help inform how health systems plan goals of care initiatives, build infrastructure, and garner support to successfully implement these initiatives.