Abstract P4-13-13: Risk Assessment and Personalized Decision Support: The University of California Athena Breast Health Network

Background: The Athena Breast Health Network is a University of California (UC) initiative to drive rapid innovation in patient-centered prevention, screening, and treatment of breast cancer. Athena is a collaborative of the five UC medical centers and UC Berkeley that integrates clinical care and research, rapidly mobilizing data and research to enable continuous improvement in patient care and outcomes. The first initiative of Athena was to implement risk assessment for women being screened for breast cancer and to offer tailored referrals for women found to be at increased risk of developing breast cancer.

Methods: Patients who enroll in Athena complete an electronic questionnaire to collect personal and family history data prior to their mammography screening visit. These data are used to generate multiple risk assessments using the NCCN and USPSTF guidelines, and BCRAT (Gail model). Data on established breast cancer risk factors such as chest wall radiation and history of hormone replacement therapy are also collected and used to identify women at potentially increased risk. Upon enrollment, women are given the opportunity to provide a blood or saliva sample for research purposes.

Women who meet Athena-defined criteria that identify them to be at increased risk receive a referral to a Breast Health Specialist (BHS). The BHS identifies individual patient needs for prevention and screening services, including genetic counseling and testing, provides referrals to a High Risk Breast Clinic or nurse practitioner, and conducts lifestyle modification counseling. BHS have special training in breast cancer risk assessment, and some are licensed genetic counselors. Primary care and/or referring providers are directly informed of risk assessment results through mailings or the electronic medical record.

Results: The recruitment goal enrollment for Athena is 150,000 and to date more than 17,000 women have been enrolled across the five centers. Of those enrolled, 32% indicated that they have a family history of cancer. 56% of the cohort consented to participate in research, and 40% provided a biospecimen for research purposes. Across the five centers, 32 educational outreach sessions about Athena were held, reaching approximately 375 providers.

Total laparoscopic hysterectomy: our 5-year experience (1998-2002)

PURPOSE

To review our experience performing total laparoscopic hysterectomy since we first introduced this procedure in 1998.

METHODS

A retrospective cohort study was performed for patients undergoing total laparoscopic hysterectomy at Ochsner Clinic Foundation from February 1998 through December 2002. Rates of complications, successful completion, length of hospital stay, readmission, and reoperation were determined for this period.

RESULTS

Among 511 patients who underwent attempted total laparoscopic hysterectomy, 487 procedures (95.3%) were completed by laparoscopy. The major intraoperative complication rate was 3.9%, and the major postoperative complication rate was 4.7%. No significant differences were seen in the intraoperative and postoperative complication rates of patients who were morbidly obese (body mass index ≥30 kg/m(2)), patients with enlarged uteri (≥300 g), or patients who underwent concomitant procedures (unilateral or bilateral salpingo-oophorectomy and lysis of adhesions). The readmission rate was 4.1%, and the reoperation rate was 2%. None of the variables studied, including age, medical problems, morbid obesity, concomitant procedures, or enlarged uterus, were found to have an association with readmission or reoperation rates.

CONCLUSIONS

Total laparoscopic hysterectomy can be performed successfully in most patients with benign indications. Morbidity is comparable to that of other types of hysterectomies, and this technique may be a more reasonable approach under some circumstances.

Use of "spydergrams" to present and interpret SF-36 health-related quality of life data across rheumatic diseases

The Medical Outcomes Study Short Form-36 (SF-36) is a generic measure of health-related quality of life (HRQOL), validated and cross-culturally translated, which has been extensively utilised in rheumatology. In randomised controlled trials and observational studies, SF-36 provides rich data regarding HRQOL; but as typically portrayed, patterns of disease and treatment-associated effects can be difficult to discern. "Spydergrams" offer a simplified means to visualise complex results across all domains of SF-36 in a single figure: depicting disease and population-specific patterns of decrements in HRQOL compared with age and gender-matched normative data, as well as providing a tool for interpreting complex treatment-associated or longitudinal changes. Utilising spydergrams as a standard format to illustrate and report changes in SF-36 across different rheumatic diseases can greatly facilitate analyses and interpretations of clinical trial results, as well as providing patients an accessible means to compare baseline scores and treatment-associated improvements with normative data from individuals without arthritis. Furthermore, SF-6D utility scores based on mean changes across all eight domains of SF-36 are suggested as a quantitative means of summarising changes illustrated by spydergrams, offering a universal metric for cost-effectiveness analyses of therapeutic interventions.

Breaking Bad News: Relationship between the Experience Receiving Breast Cancer Diagnosis and Early Psychological Adjustment

Experiences at time of breast cancer (BC) diagnosis are associated with patient psychological health several months to years later; however, little investigation of this relationship during initial period following diagnosis has been undertaken.METHODS:This prospective study was designed to characterize the experience of receiving cancer diagnosis in women initiating treatment for BC (Stage 0 to III) and to identify associations between this experience and early psychological adjustment, hopefulness, and satisfaction with medical care. 121 women who recently received BC diagnosis prompting referral to specialty center responded to questionnaires assessing their experiences and coping styles:1. Experience Receiving Breast Cancer Diagnosis (ERBCD), categorizing patient demographic, medical, and psychosocial factors; context factors (location, privacy); clinician factors and behaviors.2. Cancer Diagnostic Interview Scale (CDIS) for perceived psychotherapeutic techniques used by clinican conveying cancer diagnosis.3. Mental Adjustment to Cancer Scale (MAC) for coping styles of fighting spirit, hopelessness/helplessness, anxious preoccupation, fatalism, and avoidance.Subjects completed the Profile of Mood States (POMS), Spielberger State-Trait Anxiety Inventory (STAI) and ratings of hopefulness and satisfaction. Multivariate regression analysis was employed with scores from POMS, STAI, hopefulness and satisfaction as dependent variables and values from ERBCD, CDIS and MAC as independent variables.RESULTS:Patients received diagnosis from general physicians, surgeons, radiologists, nurses, NP/PAs, gynecologists, breast specialists, family members, and secretaries. BC diagnosis was disclosed by telephone (59%), face-to-face (40%), letter (1%) and spouse (1%). Mean CDIS-Caring score was 3.4 ± 1.1 and CDIS-Competence was 4.0 ± 0.9 of 5.0. Results of multivariate regression analysis are shown:POMS-Total Mood DisturbanceIndependent VariableParameterSEP ValueAge-0.6600.2760.0183MAC-Fighting Spirit-1.1550.4360.0093MAC-Anxious Preoccupation5.2720.780< 0.001 STAI-State AnxietyIndependent VariableParameterSEP ValueRecent Stress Level0.9420.3710.0127MAC-Fighting Spirit-0.3670.1480.0147MAC-Anxious Preoccupation1.9740.271<0.0001MAC-Avoidant4.4671.4950.0036 Satisfaction was predicted by CDIS-Caring, individual conveying diagnosis, type of information helpful, feeling concerns were understood.CONCLUSIONS:Experiences receiving BC diagnosis are variable and associated with hopefulness and satisfaction. Age, recent stress level and predominant coping style appear more predictive of psychological adjustment (POMS, STAI) than experience receiving BC diagnosis. Understanding these relationships provides direction for future research and clinical interventions to identify patients at risk for early mood disturbance and anxiety following BC diagnosis and to modify aspects of conveying BC diagnosis that influence hopefulness and satisfaction with medical care.HopefulnessIndependent VariableParameterSEP ValueCDIS-Caring0.4270.088<0.0001Diagnosis by Telephone0.3810.1770.0338Opportunity to Ask Questions0.4440.2270.0535Recent Stress Level-0.0820.0290.0057MAC-Fighting Spirit0.0430.0120.0005MAC-Anxious Preoccupation-0.0610.0230.0098 

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1069.

Sharing BRCA results: are there disparities?

Abstract #1101

Background: BRCA is a unique breast cancer biomarker; it defines risk not only for an individual, but also for a family. Little is known about sharing BRCA results with relatives. This study aims to determine which relatives are told of BRCA results and which relatives pursue BRCA testing. This study also explores whether patient and relative characteristics can account for differences in sharing BRCA results and BRCA testing of relatives.
 Methods: As part of the UCSF Cancer Risk Program Cohort, all women who receive genetic counseling and BRCA testing at the UCSF/Mt. Zion Comprehensive Cancer Center (CCC) and at San Francisco General Hospital (SFGH) are sent a survey regarding their health habits and their genetic testing experience. Women surveyed are asked: whether they have shared BRCA results; if so, with whom; and whether other family members have pursued BRCA testing. Patient-level variables examined include: cancer status, hospital site, and BRCA results. Relative-level variables examined include: gender and degree of relationship (first- or second-degree).
 Results: Over 80% of women surveyed have responded to date (n = 151). Overall, 95% report sharing BRCA results with at least one relative, and 41% indicate that other relatives have received BRCA testing. Tables 1 and 2 show rates of telling relatives and of BRCA testing in relatives based on patient and relative characteristics. Although the proportion of BRCA carriers is similar at both sites (22% at the CCC and 20% at SFGH), relatives of SFGH patients are significantly less likely to pursue BRCA testing (p=0.001).
 
 
 
 Conclusions: After BRCA testing, women are less likely to share results with male and second-degree relatives. The proportion of BRCA carriers is similar at SFGH and at the CCC. Rates of telling relatives of BRCA results are also similar at both sites. A large and significant disparity exists, however, in BRCA testing of relatives of women from SFGH (8% from SFGH vs. 47% from the CCC, p = 0.001). Future research will examine the reasons for low uptake of BRCA testing in this population, barriers to BRCA testing, and potential interventions.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1101.

Development and evaluation of a cancer risk educational tool (CREdIT) for women with a family history of breast and ovarian cancer

Abstract #2101

Introduction: In underserved, lower literacy and multiethnic women at risk of Hereditary Breast and Ovarian Cancer (HBOC), there is a need for culturally appropriate educational tools. The purpose of this Phase I study is to evaluate the use of a Cancer Risk Educational Intervention Tool (CREdIT) as an adjunct to genetic counseling for HBOC for underserved women at San Francisco General Hospital (SFGH).
 Methods: CREdIT is a 15 minute audio-visual powerpoint story presentation (available in English and Spanish) which employs non-scientific images and language specifically designed for use by our target population. Participant questionnaires, administered before and after the intervention, evaluate patient satisfaction, risk perception, knowledge of cancer genetics, and anxiety. Genetic counselor questionnaires address counselor satisfaction and time-flow.
 Results: To date, we have recruited 23 women of diverse backgrounds (mean age of 46, range: 26 to 63). Of these, seven (30%) are first-generation immigrants and four (17%) have less than a high school diploma. Eight (35%) have had cancer, and eighteen (78%) reported that cancer runs in their families. We have found an increase in knowledge following the CREdIT presentation, specifically vis-à-vis BRCA inheritance, BRCA-associated cancer risk, and risk-reducing options (all p < 0.05). These improvements occur without an increase in patient anxiety (p > 0.05). All participants believed that the presentation helped them learn more about cancer risk, and genetic counselors reported increased patient preparedness and counselor satisfaction as a result of CREdIT use (p < 0.05). Mean genetic counselor consultation time decreased by 5.5 minutes after CREdIT use.
 Conclusions: CREdIT appears to increase knowledge and improve understanding of BRCA-associated risks without raising anxiety in underserved women at risk of HBOC. Genetic counselors report increased satisfaction and patient preparedness, and decreased counseling time with CREdIT. Future work will involve examining long-term outcomes of CREdIT use; subgroup analyses to identify patient populations most likely to benefit from CREdIT; further evaluation using clinical trial methodology; and strategies for its dissemination to other settings working with underserved, multiethnic populations.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2101.

Uterine weight as a predictor of morbidity after a benign abdominal and total laparoscopic hysterectomy

OBJECTIVE

To determine if an enlarged uterus is associated with an increased rate of intraoperative and postoperative complications and prolonged hospital length of stay (LOS) after benign total abdominal hysterectomy (TAH) or total laparoscopic hysterectomy (TLH).

STUDY DESIGN

Women who underwent TAH or TLH were stratified, according to uterine weight, into 3 groups: group 1, uterine weight < 200 g; group 2, 201-500 g; and group 3, > 500 g. Indications included uterine leiomyomas, chronic pelvic pain, prolapsed uterus, endometriosis and adenomyosis, dysfunctional uterine bleeding; all had benign final pathology. Statistical analysis compared risks of intraoperative and postoperative morbidity and prolonged hospital stay.

RESULTS

Prolonged hospital stay risk increased for uterine weight > 500 g (p < or = 0.001). There was a significant association between postoperative complications and uterine size (p < or = 0.001). Mean estimated blood loss (EBL) also increased with uterine weight > 500 g (p < or = 0.001). TLH was associated with fewer postoperative complications, shorter LOS and reduced EBL (p < or = 0.001).

CONCLUSION

Average LOS and risk of blood loss, blood transfusion and other postoperative complications after hysterectomy for benign disease increased with increasing uterine weight. TLH is an excellent alternative for enlarged uteri; it was strongly associated with decreased morbidity, shorter LOS, and reduced EBL and blood transfusion rate in all uterine weight groups when adjusted for other variables.

Comparative study of two Japanese rhinoconjunctivitis quality-of-life questionnaires

CONCLUSION

Two questionnaires were used to assess quality of life (QOL) in allergic rhinitis: the Japanese translation of the Rhino-conjunctivitis Quality of Life Questionnaire (RQLQJ) and an original Japanese QOL questionnaire (JRQLQ). Either questionnaire may be used to assess QOL depending on differences in target domains.

OBJECTIVES

Although pollinosis is a common disease which has a major impact on patient QOL, no internationally standardized questionnaire has been available in Japan until now. The aim of this study was to compare two currently available QOL questionnaires for allergic rhinitis in Japan-the RQLQJ and JRQLQ-in terms of their appropriateness for clinical use and their psychometric properties.

MATERIAL AND METHODS

A multicenter, inter-group, cross-sectional study was conducted in 187 adult symptomatic patients with Japanese cedar pollinosis in 2003. Patient scores on the two questionnaires were compared in terms of both overall and comparable domains. We also examined the acceptability, construct and reliability of both questionnaires.

RESULTS

The questionnaires were highly correlated in terms of both overall and comparable domain scores. In addition, both questionnaires had equal and satisfactory psychometric validity, demonstrating that they are both useful tools for assessing QOL in rhinitis. However, when compared with each other, the JRQLQ focuses mainly on activities of daily life and is simpler, while the RQLQJ focuses mainly on rhinitis-related health and is more responsive.