Leveraging Technology to Enhance Research, Cancer Control and Prevention

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This content is from the “Advancing the Science of Cancer in Latinos: 2024 Conference Proceedings.”

Advances in Evidence-based Digital Solutions for Supporting Latino Cancer Patients

Dr. John Piette is Professor in the School of Public Health, and Director of the Center for Managing Chronic Disease (CMCD) at the University of Michigan.

Cognitive behavioral therapy

Dr. Piette’s presentation began by discussing how cognitive behavioral therapy (CBT) can be used for Latino cancer patients. CBT is the most common evidence-based intervention for cancer patients struggling with mental health, symptoms, stress, and sleep. In cancer patients, CBT has been shown to help manage distress and pain, alleviate insomnia, manage fear of cancer recurrence, and reduce emotional distress and improve quality of life. In Latino populations in particular, CBT has also been shown to be effective, specifically in survivors of systemic violence and in individuals with emotional disorders.

The use of technology with CBT has been validated, with video sessions shown to be as effective as in-person meetings for individuals with anxiety. Therefore, CBT is useful in cancer, in Latino patients, and is compatible with technological delivery. Dr. Piette’s own work involves the Rompiendo Fronteras project, delivering CBT to patients in Honduras via video sessions which may be conducted at a distance, even as far as the US.

A typical CBT program for cancer symptom management would involve 10 sessions covering rationale for treatment, defining treatment goals, working with healthcare teams, breathing, relaxation, unhelpful thoughts, living with cancer symptoms, promoting pleasant activities, sleep skills, and relapse prevention. Traditional patient barriers to such a program, however, include transportation, health and mobility problems, and scheduling. Systemic barriers include scarcity of therapists, challenges of supervision, and inadequate payment.

Artificial intelligence

Another technology discussed by Dr. Piette is artificial intelligence (AI), specifically in the realm of diagnosis, prognosis, and staging. Machine learning can be extremely useful in the identification of pathology slides, for example. Recommender systems, such as those used by Netflix and Amazon to recommend products, may also be useful in helping cancer patients navigate issues that are most important to them in their specific situation, prioritizing population- or patient-specific treatment goals.

AI may also be effective through the use of natural language processing (NLP) like ChatGPT and others. Communication between cancer patients and their physicians is known to be lacking, especially when language barriers are a factor. Embarrassment and emotionally charged topics can cause patients to withhold information as well. One use of NLP may be to analyze patient-clinician interactions to assess whether the clinician is dominating the conversation, or whether the patient is able to communicate in a more egalitarian way. NLP can also analyze whether providers are using best practices: affirming the patient, encouraging the patient, using open-ended questions, and noting emotion. This tool can be useful in improving the quality of patient-clinician communication.

In CBT intervention programs, although many patients need the full treatment schedule (e.g., 10 weeks), many others show significant improvement in a shorter time frame. Identifying which patients need less intervention, therefore, could alleviate clinician burden, and free up resources for the treatment of more patients. Reinforcement learning allows AI to learn from data about each individual, enabling prediction about what interventions are needed, and allowing for flexibility in visit number, visit length, and type of communication. Up-to-date feedback about each patient, combined with the patient’s history, gender, primary language, and more, allows for greater and greater intelligence about patient needs, and about the allocation of clinician resources.

A randomized comparative effectiveness trial conducted by Dr. Piette and colleagues compared patients receiving individualized AI-supported CBT intervention for pain care with a control group receiving the standard full CBT program. Results showed that patients receiving individualized AI-supported care achieved outcomes that were at least as good as standard care. Importantly, however, AI-supported care required less than half of the therapists’ time. This indicates that an AI-supported approach could allow for the treatment of twice as many patients, an important consideration given the many barriers to treatment that involve clinician resources.

Adapting evidence-based interventions

Dr. Piette closed by discussing the adaptation of evidence-based interventions in the Latino cancer context. Because most evidence-based interventions are not focused on Latino cancer care, these interventions must be adapted for a new audience and purpose. The process of adaptation should include input from two contingents: members of the target community and experts involved in the original intervention. First, community end-users, community health professionals, and community administrators can indicate areas that need to be modified in order to engage a new audience in a culturally sensitive way. However, input from those involved in the original intervention might also be useful. Intervention experts, relevant clinicians, community experts, and delivery mode experts who are familiar with the proven intervention can indicate which areas were most impactful and needed, identifying and retaining key elements. When input can be integrated from target community end-users and original intervention participants, adaptation for Latino cancer patients is most effective.

mHealth Smoking Cessation for Primary Care and Cancer Patients

Dr. Patricia Chalela is an Associate Professor in the Population Health Sciences Department and the Associate Director for Education and Training Programs at the Institute for Health Promotion Research at UT Health San Antonio.

The Quitxt smoking cessation program

Dr. Chalela’s presentation focused on the Quitxt smoking cessation program, which is implemented at UT San Antonio in collaboration with Dr. David Akopian and his team at the University of Texas at San Antonio. Quitxt was developed with the goal of reaching Latino young adult smokers living in South Texas and was promoted through social media and community outreach. Although several social media platforms have been utilized, Facebook has so far been the most effective in generating participation in the program.

Phase 1 of the program involved the enrollment and evaluation of 798 Latino participants, 21% of which self-reported being smoke free at 7 months. Based on these results, two additional grants were awarded, and phases 2 and 3 of the Quitxt program were initiated. In phase 2, the primary population was expanded to include African American and non-Hispanic White young adult smokers living in South Texas.

Dr. Chalela and colleagues also developed the first  Facebook Messenger chat intervention tailored to young adults. Facebook Messenger allows more graphic content such as GIFs and memes, which are appealing to young adults. The Messenger app also allows participants to choose from several response options, instead of typing in their response, making  it more user friendly. Links to videos are also visible as animations, instead of just the URL link in a text message.

In phase 3, the Quitxt program was adapted to the patient population of the Primary Care Center and the Mays Cancer Center at UT Health San Antonio. Healthcare providers (HCPs) have unparalleled access to smokers, with about 70% of smokers visiting primaryHCPs each year. Furthermore, research shows that smokers consider their physician’s advice an important motivator for quitting smoking. To facilitate easy access to Quitxt by HCPs, the program was integrated into EPIC, the electronic health records (EHR) system.

Every patient is asked about tobacco use. If the patient is a current tobacco user, the EPIC Quitxt Best Practice Advisory (BPA) banner prompts HCPs to provide quitting advice, offer nicotine replacement therapy (NRT) if needed, and recommend enrollment in the Quitxt program. Once the program is selected in EPIC, follow-up by the program patient navigator is activated. The patient navigator conducts follow-ups and provides support, motivation, positive reinforcement, and help enrolling in Quitxt if needed.

Quitxt enrollment cards help providers start the conversation about enrolling in Quitxt and include simple instructions on how to enroll by texting a code word to the program phone number or by scanning a QR code. Instructions on how to enroll in the program are also part of the patient’s after-visit summary. The patient navigator’s follow-up notes in the EHR keep HCPs informed about patients’ progress and HCPs can provide support as needed. A vaping protocol is also being finalized for use at both treatment sites.

Lessons learned from the Quitxt program

Some of the lessons learned through the implementation of the program include the following: pretesting is critical, and simplification is important to keep participants engaged. It is essential to engage key players early, starting with program design, i.e., program champions, the Chief Health Informatics Officer, and the EPIC team. Program champions play a key role in program promotion and implementation. Adaptability to unexpected circumstances is vital. The COVID-19 pandemic impacted the implementation of the program in many ways. The Quitxt team acted quickly and adapted CME training for HCPs to a short 8-minute video. A patient navigator was integrated into the program to follow up with participants and reduce HCPs’ burden. Patients who are not ready to quit are more likely to make a quit attempt if their HCPs recommend it. In this regard, EPIC notes have been very helpful in keeping HCPs informed so that they can provide positive reinforcement and support to patients as needed.  Keeping HCPs engaged through regular reports and quarterly presentations at meetings can also be helpful. Finally, addressing technical issues quickly for both patients and HCPs is imperative, as well as listening to patient feedback and refining the program accordingly.

Integrating Quitxt into the healthcare setting greatly increases the accessibility and utilization of a bilingual evidence-based smoking cessation program among primary care and cancer patients. Quitxt can be easily replicated and represents an affordable approach to reaching tobacco-using patients, producing a public health impact, and reducing healthcare costs and tobacco-related diseases and mortality. Phase 4 of the intervention is currently underway and involves a 2-group parallel randomized controlled trial to assess the effectiveness of Quitxt on smoking cessation, comparing Quitxt to a traditional abbreviated text message intervention.

Mobile Health to Improve Cancer Prevention in Latino Patients

Dr. Yasmin Genevieve Hernandez-Barco is Director of the Pancreas Program at Massachusetts General Hospital and Instructor at Harvard Medical School.

Cancer in Latino populations

The objectives of Dr. Hernandez-Barco’s presentation included the following: to understand the barriers to effective cancer screening and prevention in Latino patients, to identify potential mobile-based solutions to overcome these barriers, and to think about how to leverage existing technology to help improve health for Latino patients. The presentation began by sharing several case studies.

In one example, a 60-year-old Latina woman with no past medical history noticed a bruise on her left breast in 2013. She was diagnosed with estrogen receptor (ER)-positive, progesterone receptor (PR)-negative, human epidermal growth factor receptor 2 (HER2)-positive adenocarcinoma, but the patient was uninsured and without employment and refused care due to feelings of shame and embarrassment. After 2 years the tumor ulcerated through her skin leading to bleeding and foul smell. The family worked together to pay for private coverage, and she was maintained on 3 years of Herceptin^© (trastuzumab) infusions. After deciding to self-discontinue in 2020, the tumor grew back, and in 2022 she developed a metastatic fracture of her left arm, leaving her incapacitated. She was enrolled in hospice and passed away at home 4 months later.

Cancer is the leading cause of death among Latino patients, with 42,700 deaths annually. Prostate, breast, and colon cancer are the most common among Latino individuals, all of which are detectable through cancer screening. There are significant disparities in cancer screening in Latino versus non-Hispanic White individuals, many of which are driven by social determinants of health: economic stability, education, social and community context, health and health care, and neighborhoods and built environment.

Barriers to cancer screening include financial considerations, such as access to health insurance and obtaining transportation or taking time off work. A lack of understanding of medical recommendations and the rationale behind them can also be a barrier for non-English speakers. Finally, cultural considerations, including the use of natural remedies and the value of familism (putting the family above oneself), may also present as barriers.

The core tenets for cancer prevention include avoiding tobacco, limiting alcohol, following a healthy diet, reducing air pollution, avoiding excess sun, receiving vaccinations, and undergoing cancer screening. Although some of these tenets may be inaccessible for some populations, age-appropriate cancer screenings should be an emphasis for intervention.

MobileHealth and Latino cancer patients

MobileHealth (mHealth) is defined by the World Health Organization (WHO) as a medical and public health tool supported by mobile devices such as mobile phones, personal digital assistants, patient monitoring devices, and other wireless devices. Advantages of mHealth include low cost, ease of use, the ability to frequently contact patients, and the ability to tailor the technology to patients’ social and demographic profiles. Access to smartphones is similar across all demographic groups, and mHealth has been shown to improve cancer screening behavior in the Latino population.

However, there is a paucity of research on the use of mHealth in Latino individuals. Furthermore, very few mobile apps are available for mHealth in Spanish. The limited existing studies have shown that a Spanish touch screen interactive explanation of the usefulness of colorectal cancer screening, given in a clinician’s office, can be useful in increasing screening rates. Spanish text message reminders can also be effective in promoting breast cancer screenings.

An intervention initiated by Dr. Hernandez-Barco and colleagues used text message reminders to improve the no-show rate for colonoscopies. Patients scheduled for a colonoscopy received regular reminders, including a pre-procedure checklist, medication instructions, a reminder to start a clear liquid diet, instructions on what to bring, and post-care instructions. The text messages were in Spanish, and were accompanied by instructional videos, also in Spanish. A significant decrease in no-show rates was observed among individuals receiving the text messages, and bowel preparation was also significantly improved. The level of patient engagement with the text messages was also correlated with improved no-show rates.

The majority of studies to date are based on providing education regarding the importance of cancer screening to Latino patients, and these interventions are primarily provided in clinics. This leaves an enormous need for app-based resources. Although there are thousands of apps which exist for cancer prevention, only a small percentage exist in the Spanish language or are specifically aimed at Latino patients. Video-based learning appears to be most helpful, and text-based interventions represent a clear opportunity for growth with high engagement and success across several cancer types.