Background: Adjuvant endocrine therapy (AET) improves outcomes in women with hormonereceptor positive (HR+) breast cancer (BC). Suboptimal AET adherence is common but data are lacking about symptoms and adherence in racial/ethnic minorities. We evaluated adherence by race and the relationship between symptoms and adherence.Methods: The Women's Hormonal Initiation and Persistence (WHIP) study included women diagnosed with non-recurrent HR+ BC who initiated AET. AET adherence was captured using validated items. Data regarding patient (e.g., race), medication-related (e.g., symptoms), cancer care delivery (e.g., communication), and clinicopathologic factors (e.g., chemotherapy) were collected via surveys and medical charts. Multivariable logistic regression models were employed to calculate odds ratios and 95% CIs associated with adherence.Results: Of the 570 participants, 92% were privately insured and nearly 1/3 were Black. Thirtysix percent reported nonadherent behaviors. In multivariable analysis, women less likely to report adherent behaviors were Black (vs. White) (OR: 0.43, 95%,

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COVID-19 has accelerated the expansion of telehealth, heralding an opportunity to integrate technology into clinical care delivery in new and purposeful ways. However, there are disparities among people in rural communities that limit opportunities to gain experience and comfort using technology for health information and services, including lower home broadband access, lower health literacy, and less use of online health information compared with urban populations. 1,2 In this survey study, we examine the use of and satisfaction with telehealth services during the pandemic in a predominantly rural sample and estimate the magnitude of the association between demographic and health characteristics, health literacy, internet access, and the odds of using telehealth. Methods SampleThe Virginia Commonwealth University institutional review board approved this study, which follows the American Association for Public Opinion Research (AAPOR) reporting guideline. Respondents were recruited through the Virginia Living Well Registry (VALW), a community-based convenience sample registry of adults residing in primarily rural Virginia counties (Rural-Urban Continuum Codes 4-9). A total of 401 participants registered to the VALW before January 2020 were invited to complete a self-administered consent and survey online or through mailed paper surveys between June 2020 and January 2021. A waiver of signed consent was obtained for mailed surveys to enable survey completion via telephone. Additional information on study methods is available in the eAppendix in the Supplement. The overall response rate was 61%. An additional 6 participants who completed the VALW after June 2020 were included. MeasuresOutcomes were self-reported telehealth use (yes vs no) and patient satisfaction with telehealth services 3 since March 2020. Telehealth included communication via telephone, video, or electronic monitoring systems. Single-item screeners were used to identify low or inadequate health literacy, 4 health insurance coverage, internet access, and overall perceived health. Health literacy was operationalized as perceived confidence completing medical forms independently, which has been shown to successfully identify individuals with low health literacy. 4 Race and ethnicity were selfreported using categories defined by Office of Management and Budget standards. Race and ethnicity were analyzed in this study because disparities in preventive care use by race/ethnicity are well documented; in Virginia, rural Black residents experience greater incidence and/or mortality for some screenable cancers compared with White residents, suggesting that there are disparities in access to care. Rurality was categorized as Rural-Urban Continuum Codes 4 to 9 using participant address. 5 Higher Perceived Stress Scale 6 scores indicated greater perceived stress and were included given the pandemic context, which may be associated with health care seeking.

Purpose: The purpose of the study was to fill scientific gaps about predictors of adherence to adjuvant endocrine therapy (AET) among Black and White women diagnosed with breast cancer (BC). AET is a critical therapy in that it improves survival in women with hormone receptor positive (HR+) BC but adherence to AET is suboptimal. Objective: To assess AET adherence in Black and White insured women using multiple measures, including one that uses an innovative statistical approach. Methods: Black and White women newly diagnosed with HR+ BC were identified from two health maintenance organizations. Pharmacy records captured the type of oral AET prescriptions and all fill dates. Multivariable logistic regression was used to identify predictors of adherence defined in terms of proportion of days covered (PDC) (≥80%) and medication gap of ≤10 days. A zero-inflated negative binomial (ZINB) regression model was used to identify variables associated with the total number of days of medication gaps. Results: A total of 1,925 women met inclusion criteria. Eighty percent of women were PDC –adherent (>80%); 44% had a medication gap of ≤10 days; and 24% of women had zero days without any medication gaps. Race and age were significant in all multivariable models. Black women were less likely to be adherent based on PDC than Whites (OR=0.72; 95%CI: 0.57–0.90; p<0.01), and they were less likely to have a medication gap of ≤10 days (OR=0.65; 95%CI: 0.54–0.79; p<0.01). Women 25–49 years old were less likely to be PDC adherent than women 65–93 years old (OR=0.65; 95%CI: 0.48–0.87; p<0.001). In the zero-inflated negative binomial model, women were without their medication for an average of 37 days (SD=50.5). Conclusions: Racial disparities in adherence to AET in the study highlight a need for interventions among insured women. Using various measures of adherence may help to understand various components of this multidimensional concept. Thus, there might be benefits from using both more common dichotomous measures (e.g., PDC) and also integrating novel statistical approaches to allow one to tailor adherence to patterns within a specific sample.

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Spirituality has been shown to be important to many individuals dealing with a cancer diagnosis. While African-American breast cancer survivors have been reported to have higher levels of spirituality compared to White women, little is known about how levels of spirituality may vary among African-American breast cancer survivors. The aims of this study were to examine factors associated with spirituality among African-American survivors and test whether spirituality levels were associated with women's attitudes about treatment or health care. The primary outcome, spirituality, was nine-item scale (Cronbach's α = .99). Participants completed standardized telephone interviews that captured sociocultural, healthcare process, and treatment attitudes. Medical records were abstracted post-adjuvant therapy for treatment and clinical information. In bivariate analysis, age was not correlated with spirituality (p = .40). Married/living as married women had higher levels of spirituality (m = 32.1) than single women (m = 30.1). Contextual factors that were associated with higher levels spirituality were: collectivism (r = .44; p < 0.0001, Afrocentric worldview (r = .185; p = .01), and self-efficacy scale (r = .17; p = .02). In multivariable analysis, sociodemographic factors were not significant. Collectivism remained a robust predictor (p < 0.0001). Attitudes about the efficacy of cancer treatment were not associated with spirituality. The high levels of spirituality in African-American survivors suggest consideration of integrating spiritual care within the delivery of cancer treatment. Future studies should consider how spirituality may contribute to positive coping and/or behaviors in African-American women with high levels of spirituality.

Studies indicate that Black patients report higher medical mistrust compared to their White counterparts. However, little is known about factors associated with higher medical mistrust among Black breast cancer patients. We examined predictors of medical mistrust and relationships between medical mistrust, subscales of mistrust, and process of care factors to identify opportunities to promote positive healthcare interactions between the trustees (e.g., providers) and Black breast cancer patients, or the trustors. A secondary analysis was conducted of survey data from 210 Black women with confirmed diagnosis of invasive breast cancer. Participants completed telephone surveys consisting of questions pertaining to sociodemographics, attitudes, and beliefs about medical care and breast cancer treatments. Multiple linear regression determined factors associated with medical mistrust and mistrust subscales. Most participants (61%) were over the age of 50 and currently single (64.8%). Women with greater medical mistrust reported less satisfaction with the trustee's technical ability (p < 0.0001) and greater satisfaction with their own propensity to access care (p < 0.05). Additionally, women with public insurance demonstrated greater mistrust (p < 0.01) and suspicion (p < 0.05) than women with private insurance, and women with less education reported greater perceived discrimination than women who have at least a bachelor's degree. Findings from this study may inform future endeavors to educate providers on ways to effectively interact with and treat Black breast cancer patients. Opportunities to develop interventions that address and tackle issues of mistrust as reported by Black patients may contribute to ongoing efforts to reduce health disparities.

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