Viola B. Leal

Bio: Viola B. Leal is an academic researcher from University of Texas MD Anderson Cancer Center. The author has contributed to research in topics: Lung cancer screening & Medicine. The author has an hindex of 10, co-authored 18 publications receiving 263 citations.

An entertainment‐education colorectal cancer screening decision aid for African American patients: A randomized controlled trial

Abstract: BACKGROUND Colorectal cancer screening rates for African American patients remain suboptimal. Patient decision aids designed with an entertainment-education approach have been shown to improve saliency and foster informed decision making. The purpose of this study was to assess whether an entertainment-education decision aid tailored for African American patients improved patients' decision making, attitudes, intentions, or colorectal cancer screening behavior. METHODS Eighty-nine participants were randomized to view 1) a patient decision aid video containing culturally tailored information about colorectal cancer screening options and theory-based support in decision making presented in an entertainment–education format or 2) an attention control video about hypertension that contained similarly detailed information. Participants met with their clinician and then completed follow-up questionnaires assessing their knowledge, decisional conflict, self-advocacy, attitudes, perceived social norms, and intentions. At 3 months, completion of screening was assessed by chart review. RESULTS Viewing the culturally tailored decision aid significantly increased African American patients' knowledge of colorectal cancer screening recommendations and options. It also significantly reduced their decisional conflict and improved their self-advocacy. No significant differences were observed in participants' attitudes, norms, or intentions. At three months, 23% of all patients had completed a colonoscopy. CONCLUSIONS Designing targeted, engaging patient decision aids for groups that receive suboptimal screening holds promise for improving patient decision making and self-advocacy. Additional research is warranted to investigate the effectiveness of such aids in clinical practices with suboptimal screening rates and on downstream behaviors (such as repeat testing). Cancer 2017;123:1401–1408. © 2016 American Cancer Society.

From guideline to practice: New shared decision-making tools for colorectal cancer screening from the American Cancer Society.

Abstract: The goal of the American Cancer Society (ACS) 2018 guideline update for colorectal cancer (CRC) screening is to reduce the incidence of and deaths from CRC for average-risk adults aged 45 years and older through the use of screening tests that are selected to align with a patient’s preferences and test availability. Beginning screening at age 45 years is a qualified recommendation, and regular screening of adults aged 50 years and older is a strong recommendation. The basis for the grading of these recommendations is described in the guideline update. For adults in good health with at least a 10-year life expectancy, screening should continue to age 75 years, whereas the decision to screen individuals ages 76 through 85 years should be individualized based on patient preferences, life expectancy, health status, and prior screening history (qualified recommendation). Clinicians should discourage individuals older than 85 years from continuing screening (qualified recommendation). The updated guideline includes details about the process for developing and rating the recommendations. In the updated guideline, the ACS Guideline Development Group placed greater emphasis on the importance of patient preferences and choice in selecting a screening test, with the goal of increasing CRC screening uptake and adherence. Six screening options are included in the new guideline, including 3 stool-based tests (fecal immunochemical test [FIT]; high-sensitivity guaiac-based fecal occult blood test [HSgFOBT]; and multitarget stool DNA test [mt-sDNA]) and 3 structural (visual) examinations (colonoscopy, computed tomography colonography [CTC], and flexible sigmoidoscopy [FS]). Each option is associated with unique operational and performance attributes as well as demands on patients, and there is an extensive literature demonstrating variability in how patients value the attributes of CRC screening options. These attributes, which include the frequency of testing, test procedures, and required preparation, alone or in combination, can impact a patient’s preference for CRC screening tests. Provider recommendations also strongly influence the uptake of screening and choice of test. Decision making about CRC screening therefore involves the patient weighing the importance of the test attributes when making a decision with a health care provider about which test is right for them. In the absence of the provider’s assessment of patient preferences, screening may not take place if the test offered is judged by the patient to be undesirable. There is evidence that screening intentions are higher among patients who are offered an option that is consonant with their preferences. The updated guideline emphasizes the importance of communication about CRC screening between health care providers and patients to improve CRC screening utilization. Shared decision making is a collaborative process that allows patients and their health care providers to make decisions together, accounting for the best scientific evidence available as well as the values and preferences of the patient. With the release of its updated CRC screening guideline, the ACS has developed decision support tools to engage patients and health care providers in making shared decisions about screening (cancer.org/health-care-professionals/ colon-md.html). Here, we introduce these new tools for supporting shared decision Professor, Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX; Program Manager, Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX; Project Manager, Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX; Associate Professor of Medicine, Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA; Vice President, Cancer Control Interventions, Prevention, and Early Detection, American Cancer Society, Atlanta, GA; Chief Cancer Control Officer, American Cancer Society, Atlanta, GA; Professor, Department of Family and Community Medicine, Thomas Jefferson University, Philadelphia, PA; Vice President, Cancer Screening, Cancer Control Department, American Cancer Society, Atlanta, GA.

Effect of a Patient Decision Aid on Lung Cancer Screening Decision-Making by Persons Who Smoke: A Randomized Clinical Trial

Abstract: Importance Lung cancer screening with low-dose computed tomography lowers lung cancer mortality but has potential harms. Current guidelines support patients receiving information about the benefits and harms of lung cancer screening during decision-making. Objective To examine the effect of a patient decision aid (PDA) about lung cancer screening compared with a standard educational material (EDU) on decision-making outcomes among smokers. Design, Setting, and Participants This randomized clinical trial was conducted using 13 state tobacco quitlines. Current and recent tobacco quitline clients who met age and smoking history eligibility for lung cancer screening were enrolled from March 30, 2015, to September 12, 2016, and followed up for 6 months until May 5, 2017. Data analysis was conducted between May 5, 2017, and September 30, 2018. Interventions Participants were randomized to the PDA videoLung Cancer Screening: Is It Right for Me?(n = 259) or to EDU (n = 257). Main Outcomes and Measures The primary outcomes were preparation for decision-making and decisional conflict measured at 1 week. Secondary outcomes included knowledge, intentions, and completion of screening within 6 months of receiving the intervention measured by patient report. Results Of 516 quit line clients enrolled, 370 (71.7%) were younger than 65 years, 320 (62.0%) were female, 138 (26.7%) identified as black, 47 (9.1%) did not have health insurance, and 226 (43.8%) had a high school or lower educational level. Of participants using the PDA, 153 of 227 (67.4%) were well prepared to make a screening decision compared with 108 of 224 participants (48.2%) using EDU (odds ratio [OR], 2.31; 95% CI, 1.56-3.44;P Conclusions and Relevance In this study, a PDA delivered to clients of tobacco quit lines improved informed decision-making about lung cancer screening. Many smokers eligible for lung cancer screening can be reached through tobacco quit lines. Trial Registration ClinicalTrials.gov identifier:NCT02286713

Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society

Abstract: In the United States, colorectal cancer (CRC) is the fourth most common cancer diagnosed among adults and the second leading cause of death from cancer. For this guideline update, the American Cancer Society (ACS) used an existing systematic evidence review of the CRC screening literature and microsimulation modeling analyses, including a new evaluation of the age to begin screening by race and sex and additional modeling that incorporates changes in US CRC incidence. Screening with any one of multiple options is associated with a significant reduction in CRC incidence through the detection and removal of adenomatous polyps and other precancerous lesions and with a reduction in mortality through incidence reduction and early detection of CRC. Results from modeling analyses identified efficient and model-recommendable strategies that started screening at age 45 years. The ACS Guideline Development Group applied the Grades of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria in developing and rating the recommendations. The ACS recommends that adults aged 45 years and older with an average risk of CRC undergo regular screening with either a high-sensitivity stool-based test or a structural (visual) examination, depending on patient preference and test availability. As a part of the screening process, all positive results on noncolonoscopy screening tests should be followed up with timely colonoscopy. The recommendation to begin screening at age 45 years is a qualified recommendation. The recommendation for regular screening in adults aged 50 years and older is a strong recommendation. The ACS recommends (qualified recommendations) that: 1) average-risk adults in good health with a life expectancy of more than 10 years continue CRC screening through the age of 75 years; 2) clinicians individualize CRC screening decisions for individuals aged 76 through 85 years based on patient preferences, life expectancy, health status, and prior screening history; and 3) clinicians discourage individuals older than 85 years from continuing CRC screening. The options for CRC screening are: fecal immunochemical test annually; high-sensitivity, guaiac-based fecal occult blood test annually; multitarget stool DNA test every 3 years; colonoscopy every 10 years; computed tomography colonography every 5 years; and flexible sigmoidoscopy every 5 years. CA Cancer J Clin 2018;68:250-281. © 2018 American Cancer Society.

Cancer screening in the United States, 2019: A review of current American Cancer Society guidelines and current issues in cancer screening.

Abstract: Each year, the American Cancer Society publishes a summary of its guidelines for early cancer detection, data and trends in cancer screening rates, and select issues related to cancer screening. In this issue of the journal, the current American Cancer Society cancer screening guidelines are summarized, and the most current data from the National Health Interview Survey are provided on the utilization of cancer screening for men and women and on the adherence of men and women to multiple recommended screening tests.

An official American Thoracic Society/American College of Chest Physicians policy statement: implementation of low-dose computed tomography lung cancer screening programs in clinical practice.

Abstract: Rationale: Annual low-radiation-dose computed tomography (LDCT) screening for lung cancer has been shown to reduce lung cancer mortality among high-risk individuals and is now recommended by multiple organizations. However, LDCT screening is complex, and implementation requires careful planning to ensure benefits outweigh harms. Little guidance has been provided for sites wishing to develop and implement lung cancer screening programs.Objectives: To promote successful implementation of comprehensive LDCT screening programs that are safe, effective, and sustainable.Methods: The American Thoracic Society (ATS) and American College of Chest Physicians (CHEST) convened a committee with expertise in lung cancer screening, pulmonary nodule evaluation, and implementation science. The committee reviewed the evidence from systematic reviews, clinical practice guidelines, surveys, and the experience of early-adopting LDCT screening programs and summarized potential strategies to implement LDCT screening programs su...

Evaluation of Interventions Intended to Increase Colorectal Cancer Screening Rates in the United States: A Systematic Review and Meta-analysis.

Abstract: Importance Colorectal cancer screening (CRC) is recommended by all major US medical organizations but remains underused. Objective To identify interventions associated with increasing CRC screening rates and their effect sizes. Data Sources PubMed, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, and ClinicalTrials.gov were searched from January 1, 1996, to August 31, 2017. Key search terms includedcolorectal cancerandscreening. Study Selection Randomized clinical trials of US-based interventions in clinical settings designed to improve CRC screening test completion in average-risk adults. Data Extraction and Synthesis At least 2 investigators independently extracted data and appraised each study’s risk of bias. Where sufficient data were available, random-effects meta-analysis was used to obtain either a pooled risk ratio (RR) or risk difference (RD) for screening completion for each type of intervention. Main Outcomes and Measures The main outcome was completion of CRC screening. Examination included interventions to increase completion of (1) initial CRC screening by any recommended modality, (2) colonoscopy after an abnormal initial screening test result, and (3) continued rounds of annual fecal blood tests (FBTs). Results The main review included 73 randomized clinical trials comprising 366 766 patients at low or medium risk of bias. Interventions that were associated with increased CRC screening completion rates compared with usual care included FBT outreach (RR, 2.26; 95% CI, 1.81-2.81; RD, 22%; 95% CI, 17%-27%), patient navigation (RR, 2.01; 95% CI, 1.64-2.46; RD, 18%; 95% CI, 13%-23%), patient education (RR, 1.20; 95% CI, 1.06-1.36; RD, 4%; 95% CI, 1%-6%), patient reminders (RR, 1.20; 95% CI, 1.02-1.41; RD, 3%; 95% CI, 0%-5%), clinician interventions of academic detailing (RD, 10%; 95% CI, 3%-17%), and clinician reminders (RD, 13%; 95% CI, 8%-19%). Combinations of interventions (clinician interventions or navigation added to FBT outreach) were associated with greater increases than single components (RR, 1.18; 95% CI, 1.09-1.29; RD, 7%; 95% CI, 3%-11%). Repeated mailed FBTs with navigation were associated with increased annual FBT completion (RR, 2.09; 95% CI, 1.91-2.29; RD, 39%; 95% CI, 29%-49%). Patient navigation was not associated with colonoscopy completion after an initial abnormal screening test result (RR, 1.21; 95% CI, 0.92-1.60; RD, 14%; 95% CI, 0%-29%). Conclusions and Relevance Fecal blood test outreach and patient navigation, particularly in the context of multicomponent interventions, were associated with increased CRC screening rates in US trials. Fecal blood test outreach should be incorporated into population-based screening programs. More research is needed on interventions to increase adherence to continued FBTs, follow-up of abnormal initial screening test results, and cost-effectiveness and other implementation barriers for more intensive interventions, such as navigation.