Communication of genetic test results to family and health-care providers following disclosure of research results

PURPOSE

Few studies have examined methods to promote communication following the return of DNA mismatch repair genetic test results obtained during research. The purpose of the present study was to evaluate a telephone protocol for returning research results of DNA mismatch repair gene testing to identify Lynch syndrome.

METHODS

We invited individuals with known DNA mismatch repair mutations in their family, who were enrolled in the Colon Cancer Family Registry at the Mayo Clinic, to participate in this study. Participants completed surveys before and 6 months after DNA mismatch repair test result disclosure.

RESULTS

Among 107 participants, 79% opted to learn their DNA mismatch repair test results; of these, 44 (41%) carried DNA mismatch repair mutations. After disclosure, 54% reported screening for any type of cancer. Among carriers, >74% reported communicating results to family; communication was predicted by baseline confidence in coping with the genetic test result (Z = 1.97; P = 0.04). Result disclosure to a physician was predicted by greater perceived cancer risk (Z = 2.08; P = 0.03) and greater intention to share results with family (Z = 3.07; P = 0.002).

CONCLUSION

Research versus clinically based gene disclosure presents challenges. A telephone disclosure process for the return of research-based results among Lynch syndrome families led to high rates of result uptake and participant communication of results to providers and family members.

Coordinating cancer care: Measurement and intervention approaches across the cancer continuum

103

Background: According to a landmark study by the Institute of Medicine, patients with cancer often receive poorly coordinated care in multiple settings from many providers. Lack of coordination is associated with poor symptom control, medical errors, and higher costs. The aims of this presentation are to: (1) describe the state-of-the science on cancer care coordination measures and intervention outcomes from a systematic review and meta-analysis of empirical papers published between 1980-2013; (2) explore the implications of these findings from the patient, provider, healthcare system, and national policy perspectives. No similar review has yet been published. Methods: Of 1,241 abstracts collected from a systematic search of PubMed, MeEMBASE, Medline, CINAHL, and Cochrane Library, 50 studies met the inclusion criteria. Each study had US or Canadian participants; comparison or control groups, measures, times, samples, and/or interventions. Two raters independently applied a standardized search strategy and coding scheme. Eight studies (14 outcomes) met the additional criteria for the meta-analysis. We used the Care Coordination Atlas (McDonald, 2010) definition of care coordination. Results: Overall, coordination improved cancer care across 83% (44) of the measured outcomes. Interventions led to more appropriate healthcare use (g = 0.37 [95% CI = 0.29 – 0.46]; I2= 0.00) across screening (patient navigation), treatment (home telehealth, nurse case management and education), and end-of-life care (early palliation). Measures varied considerably in psychometric quality and were limited in focus. They included; rates of guideline compliance (screening), timeliness of care (diagnosis), health-related quality of life (treatment), cancer-related distress (survivorship), and home death (end-of-life). Conclusions: The findings revealed effective interventions across the cancer continuum from screening to end-of-life. More, and better measures are needed across the cancer continuum. We discuss the implications of these findings for more and better measures, approaches to implement effective interventions in clinical settings, and to develop supportive policy (and reimbursement) contexts.

Psychosocial approaches to participation in BRCA1/2 genetic risk assessment among African American women: a systematic review

Breast cancer is a significant health concern for African American women. Nonetheless, uptake of genetic risk assessment (including both genetic counseling and testing) for breast cancer gene mutations among these populations remains low. This paper systematically reviews cognitive (i.e., beliefs) and affective (i.e., emotions) factors influencing BRCA1/2 genetic risk assessment among African American women as well as psychosocial interventions to facilitate informed decision making in this population. A systematic search of CINAHL, PubMed, and PsycINFO was undertaken, yielding 112 published studies. Of these, 18 met the eligibility criteria. African American woman are likely to participate in genetic risk assessment if they are knowledgeable about cancer genetics, perceive a high risk of developing breast cancer, have low expectancies of stigmatization from medical professionals, view themselves as independent from family, and have fatalistic beliefs and a future temporal orientation. Anticipated negative affective responses, such as an inability to “handle” the results of testing, are barriers to uptake. Specific perceptions, beliefs, and emotional factors are associated with genetic risk assessment among African American women. Understanding these factors is key in the development of interventions to facilitate informed decision making in this population.

Challenges in cervical cancer prevention: a survey of U.S. obstetrician-gynecologists

BACKGROUND

Current cervical cancer prevention recommendations include human papillomavirus (HPV) vaccination, Pap and HPV co-testing, and Pap testing at 3- to 5-year intervals.

PURPOSE

To examine attitudes, practice patterns, and barriers related to HPV vaccination and cervical cancer screening guidelines among U.S. obstetrician-gynecologists.

METHODS

In 2011-2012, a national sample of members of the American Congress of Obstetricians and Gynecologists responded to a 15-item (some with multiple parts) questionnaire assessing sociodemographic characteristics, clinical practices, and perceived barriers to HPV vaccination and cervical cancer screening. Multivariate logistic regression was used to identify factors associated with guideline adherence. Analyses were conducted in 2012.

RESULTS

A total of 366 obstetrician-gynecologists participated. Ninety-two percent of respondents offered HPV vaccination to patients, but only 27% estimated that most eligible patients received vaccination. Parent and patient refusals were commonly cited barriers to HPV vaccination. Approximately half of respondents followed guidelines to begin cervical cancer screening at age 21 years, discontinue screening at age 70 years or after hysterectomy, and appropriately utilize Pap and HPV co-testing. Most physicians continued to recommend annual Paps (74% aged 21-29 years, 53% aged ≥30 years). Physicians felt that patients were uncomfortable with extended screening intervals and were concerned that patients would not come for annual exams without concurrent Paps. Solo practitioners were less likely to follow both vaccination and screening guidelines than those in group practices.

CONCLUSIONS

This survey of obstetrician-gynecologists indicates persistent barriers to the adoption of HPV vaccination and cervical cancer screening guidelines. Interventions to promote guideline adherence may help improve the quality of cervical cancer prevention.

Cancer care coordination systematic review and meta-analysis: Twenty-two years of empirical studies

6536

Background: To our knowledge, no systematic review of empirical papers describing cancer care coordination interventions has yet been conducted. The aim of this presentation is to describe the methods and findings from a systematic review and meta-analysis of all empirical papers describing cancer care coordination published between 1990-2012. Methods: Of 1241 abstracts collected from a search of PubMed and EMBASE, 108 studies were retrieved and reviewed; 49 were included in the systematic review. Each study had US or Canadian adult or child participants; each paper had comparison or control groups, measures, samples, and/or interventions. Two researchers independently applied a standardized search strategy, coding scheme, and on-line coding program to each study. Eight RCT’s met additional criteria for meta-analysis; a random effects estimation model was used for data analysis. Results: Among the 49 articles included in our systematic review, those that included implicit or explicit definitions of cancer care coordination described four components: (1) roles and models for communication and transfer of care between primary care physicians and oncologists during active treatment and survivorship; (2) care navigation through designated personnel or telecommunication processes among care team members; (3) treatment summaries and survivorship care plans; and (4) multidisciplinary communication accompanying patient and practice management within the framework of the Chronic Care Model (N=14). We found a medium-sized effect of cancer care coordination on care usage outcomes among the randomized clinical trials (e.g., reduced Emergency Department visits; g = 0.37 [95% CI = 0.29 - 0.44], I2= .000. Fail-safe N = 86). Conclusions: The findings from this current systematic review and meta-analysis will contribute to the evidence base on strategies that can improve the coordination of cancer care, particularly for patients with multiple chronic conditions, and thereby advance the goals of health care reform in the US.

Implications of generating genetic test results for colon cancer in the international, population-based colon cancer family registry

3567

Background: The ability to genotype large numbers of people rapidly and inexpensively for research purposes highlights the need to develop guidelines for providing medically-relevant research results - including unanticipated findings - to study participants. The Colon Cancer Family Registry (C-CFR) is the oldest and largest international colon cancer population-based registry; its experience managing genetic research findings can offer guidance to clinicians and researchers. The C-CFR has enrolled 10,019 cases with colon cancer and 24,708 family members in six registries in the US, Canada, Australia, and New Zealand. Deleterious (“high risk”) germline mutations have been identified in DNA mismatch repair (MMR) genes (MLH1, MSH2, MSH6, PMS2) and the MutYH gene. The aims of this presentation are to: (1) report the uptake of genetic test results by C-CFR participants; (2) systematically compare disclosure protocols and barriers to uptake by registry; (3) make recommendations to guide clinicians and researchers. Methods: Uptake of genetic test results was calculated from data collected by the C-CFR; key investigators (KIs) from each registry completed a survey about disclosure decision-making; KIs also took part in discussions to generate recommendations. Results: Registry-wide molecular testing has identified deleterious MMR germline mutations for at least one member of 424 families (4%) and 48 biallelic MutYH gene carriers. Uptake of test results ranged from 56-86% (n= 1542) across registries. Barriers to disclosure include: (1) lack of pre-existing notification protocols; (2) logistics of re-consent; (3) limited involvement of genetic counselors at some registries; (4) in the US, the requirement that genetic testing be performed in a CLIA approved laboratory; (5) IRBs declining approval; and (6) budget constraints. Conclusions: Based on our international registry’s findings we recommend that researchers generating genetic information establish plans for disclosure at the outset; obtain subject consent a priori; consider subject knowledge and disclosure preferences; provide guidance and budget for clinical follow-up; and involve genetic counselors.

Multilevel interventions and racial/ethnic health disparities

To examine the impact of multilevel interventions (with three or more levels of influence) designed to reduce health disparities, we conducted a systematic review and meta-analysis of interventions for ethnic/racial minorities (all except non-Hispanic whites) that were published between January 2000 and July 2011. The primary aims were to synthesize the findings of studies evaluating multilevel interventions (three or more levels of influence) targeted at ethnic and racial minorities to reduce disparities in their health care and obtain a quantitative estimate of the effect of multilevel interventions on health outcomes among these subgroups. The electronic database PubMed was searched using Medical Subject Heading terms and key words. After initial review of abstracts, 26 published studies were systematically reviewed by at least two independent coders. Those with sufficient data (n = 12) were assessed by meta-analysis and examined for quality using a modified nine-item Physiotherapy Evidence Database coding scheme. The findings from this descriptive review suggest that multilevel interventions have positive effects on several health behavior outcomes, including cancer prevention and screening, as well improving the quality of health-care system processes. The weighted average effect size across studies for all health behavior outcomes reported at the individual participant level (k = 17) was odds ratio (OR) = 1.27 (95% confidence interval [CI] = 1.11 to 1.44); for the outcomes reported by providers or organizations, the weighted average effect size (k = 3) was OR = 2.53 (95% CI = 0.82 to 7.81). Enhanced application of theories to multiple levels of change, novel design approaches, and use of cultural leveraging in intervention design and implementation are proposed for this nascent field.

Meta-analysis of psychosocial interventions to reduce pain in patients with cancer

PURPOSE

Pain is one of the most common, burdensome, and feared symptoms experienced by patients with cancer. American Pain Society standards for pain management in cancer recommend both pharmacologic and psychosocial approaches. To obtain a current, stable, and comprehensive estimate of the effect of psychosocial interventions on pain-an important clinical topic-we conducted a meta-analysis of randomized controlled studies among adult patients with cancer published between 1966 and 2010.

METHODS

Three pairs of raters independently reviewed 1,681 abstracts, with a systematic process for reconciling disagreement, yielding 42 papers, of which 37 had sufficient data for meta-analysis. Studies were assessed for quality using a modified seven-item Physiotherapy Evidence Database (PEDro) coding scheme. Pain severity and interference were primary outcome measures.

RESULTS

Study participants (N = 4,199) were primarily women (66%) and white (72%). The weighted averaged effect size across studies for pain severity (38 comparisons) was 0.34 (95% CI, 0.23 to 0.46; P < .001), and the effect size for pain interference (four comparisons) was 0.40 (95% CI, 0.21 to 0.60; P < .001). Studies that monitored whether treatment was delivered as intended had larger effects than those that did not (P = .04).

CONCLUSION

Psychosocial interventions had medium-size effects on both pain severity and interference. These robust findings support the systematic implementation of quality-controlled psychosocial interventions as part of a multimodal approach to the management of pain in patients with cancer.

Costs and cost effectiveness of a health care provider-directed intervention to promote colorectal cancer screening

PURPOSE

Colorectal cancer (CRC) screening remains underutilized in the United States. Prior studies reporting the cost effectiveness of randomized interventions to improve CRC screening have not been replicated in the setting of small physician practices. We recently conducted a randomized trial evaluating an academic detailing intervention in 264 small practices in geographically diverse New York City communities. The objective of this secondary analysis is to assess the cost effectiveness of this intervention.

METHODS

A total of 264 physician offices were randomly assigned to usual care or to a series of visits from trained physician educators. CRC screening rates were measured at baseline and 12 months. The intervention costs were measured and the incremental cost-effectiveness ratio (ICER) was derived. Sensitivity analyses were based on varying cost and effectiveness estimates.

RESULTS

Academic detailing was associated with a 7% increase in CRC screening with colonoscopy. The total intervention cost was $147,865, and the ICER was $21,124 per percentage point increase in CRC screening rate. Sensitivity analyses that varied the costs of the intervention and the average medical practice size were associated with ICERs ranging from $13,631 to $36,109 per percentage point increase in CRC screening rates.

CONCLUSION

A comprehensive, multicomponent academic detailing intervention conducted in small practices in metropolitan New York was clinically effective in improving CRC screening rates, but was not cost effective.

Abstract B15: HPV vaccinations among a multi-ethnic female outpatient clinic sample

B15

Background

High risk types of HPV are necessary though not sufficient causes of the vast majority of cervical cancers. With the approval by FDA of the HPV vaccine among women age 9-26, dissemination is critical. Fewer than one-third of the US population has heard of HPV. Few know about its association with cervical cancer, and how to prevent its spread. Yet, physician recommendation is key to vaccination.

Methods

The study examines vaccination intentions and practices among a sample of 235 multi-ethnic/racial, urban primary care physicians who are enrolled in an RCT of an educational intervention. Intention was measured via self-report prior to FDA approval. Vaccination rates were assessed two years post-FDA vaccine approval, among their multi-ethnic female patients, age 18-26, using medical audit.

Results

Prior to the approval of the vaccine, findings revealed strong intention to vaccinate among physicians, at 92% extremely or somewhat likely to vaccinate. Multivariate analyses of primary care physicians revealed that those who regularly performed recto-pelvic examinations on asymptomatic women (β=0.21, p=0.03), and those who were more familiar with the ACS screening guidelines held stronger intentions to vaccinate (β=0.24, p=0.01) than did comparable others. Female primary care physicians had stronger intentions to vaccinate for HPV than male providers (β=0.21, p=0.03). Two years post-approval, 10% of multi-ethnic female patients age 18-26 have received at least one inoculation, 2% have received the entire 3-dose protocol. Major barriers are awareness, cost, and availability of the vaccine. Conclusions: The findings reveal stronger intentions to vaccinate than contemporaneous population-based surveys (80%), but similar predictors in gender and knowledge. The rate of vaccination is comparable to the 14% for the Hepatitis B vaccine among children one year post-approval, but much lower than among pediatricians in a Boston metropolitan hospital (57%) during a similar period of time. This is the first study to observe vaccination intentions among urban physicians working in under-resourced communities, and to systematically report the HPV vaccination uptake among their young adult female patients. Targeted dissemination strategies to urban primary care physicians in under-resourced areas, with tailored messages, are critical. In addition to exploring the pragmatic issues in disseminating the vaccine, we will examine the ethical, political, and social contexts for population-based HPV vaccine inoculations.

Citation Information: Cancer Prev Res 2008;1(7 Suppl):B15.

Exploring older women's approaches to cervical cancer screening

The purpose of this qualitative study (N = 98, 11 focus groups) is to investigate how low-income, African American and Hispanic older women make decisions about cervical cancer screening. Using the health belief model to guide content analysis of transcripts, we found that primary barriers to screening were; embarrassment with, fear of, and pain from the test, difficulty in accessing screening, stigma associated with Medicaid coverage, and prior negative experiences with cancer detection. Women experienced cues to screening from their own bodies, in symptoms, and relied on spiritual beliefs to support them in coping with their health problems. Enhanced understanding of these factors could increase uptake of cervical cancer screening among the unscreened and underscreened.

Awareness of genetic testing for cancer among United States Hispanics: the role of acculturation

BACKGROUND

The purpose of this study was to determine how acculturation affected awareness of genetic testing for cancer among Hispanic Americans.

METHODS

Subjects were 10,883 Hispanic respondents from the 2000 and 2005 National Health Interview Surveys. Acculturation was measured with language use and the length of time subjects had lived in the US. Weighted logistic regression was used to determine subjects' awareness of genetic susceptibility testing.

RESULTS

Greater use of English (adjusted odds ratio, OR = 1.25, 95% confidence interval, CI = 1.15-1.36) was associated with increased awareness of genetic testing. Residence in the US for less than 5 years (adjusted OR = 0.55, 95% CI 0.36-0.83) was associated with lower awareness of testing.

CONCLUSIONS

To better inform diverse American groups about genetic testing, intercultural variations and language skills must be taken into account.

Implementing academic detailing for breast cancer screening in underserved communities

BACKGROUND

African American and Hispanic women, such as those living in the northern Manhattan and the South Bronx neighborhoods of New York City, are generally underserved with regard to breast cancer prevention and screening practices, even though they are more likely to die of breast cancer than are other women. Primary care physicians (PCPs) are critical for the recommendation of breast cancer screening to their patients. Academic detailing is a promising strategy for improving PCP performance in recommending breast cancer screening, yet little is known about the effects of academic detailing on breast cancer screening among physicians who practice in medically underserved areas. We assessed the effectiveness of an enhanced, multi-component academic detailing intervention in increasing recommendations for breast cancer screening within a sample of community-based urban physicians.

METHODS

Two medically underserved communities were matched and randomized to intervention and control arms. Ninety-four primary care community (i.e., not hospital based) physicians in northern Manhattan were compared to 74 physicians in the South Bronx neighborhoods of the New York City metropolitan area. Intervention participants received enhanced physician-directed academic detailing, using the American Cancer Society guidelines for the early detection of breast cancer. Control group physicians received no intervention. We conducted interviews to measure primary care physicians' self-reported recommendation of mammography and Clinical Breast Examination (CBE), and whether PCPs taught women how to perform breast self examination (BSE).

RESULTS

Using multivariate analyses, we found a statistically significant intervention effect on the recommendation of CBE to women patients age 40 and over; mammography and breast self examination reports increased across both arms from baseline to follow-up, according to physician self-report. At post-test, physician involvement in additional educational programs, enhanced self-efficacy in counseling for prevention, the routine use of chart reminders, computer- rather than paper-based prompting and tracking approaches, printed patient education materials, performance targets for mammography, and increased involvement of nursing and other office staff were associated with increased screening.

CONCLUSION

We found some evidence of improvement in breast cancer screening practices due to enhanced academic detailing among primary care physicians practicing in urban underserved communities.

Intraurban influences on physician colorectal cancer screening practices

BACKGROUND

Community social and economic resources influence colorectal (CRC) screening decisions by physicians and patients. The aim of this study is to systematically assess the differences in screening recommendations of primary care physicians within two urban communities that are distinct in socioeconomic characteristics.

METHODS

Two-hundred-sixty-four primary care community (i.e., not hospital-based) physicians were stratified by community. Using self-report questionnaires, we examined primary care physicians' CRC screening practices, knowledge of risk factors and perceived physician and patient barriers to screening, Physicians practicing in upper-socioeconomic status (SES) communities were compared with those of participants practicing in lower SES communities.

RESULTS

Physicians practicing in low-SES urban communities were significantly more likely to screen with fecal occult blood test than were physicians in upper-SES areas. Alternatively, upper-SES physicians were significantly more likely to recommend screening colonoscopy than were lower-SES physicians. The number of physicians (N=11) who screened for CRC using the double-contrast barium enema were few.

CONCLUSIONS

Community-level SES influences physician cancer screening practices. Further understanding of these relationships may guide the development of interventions targeted to specific neighborhoods within urban areas.

Decision making in cancer primary prevention and chemoprevention

BACKGROUND

We know very little about how individuals decide to undertake, maintain, or discontinue cancer primary prevention or chemoprevention.

PURPOSE

The aims of this article are to (a) examine whether and, if so, how traditional health behavior change models are relevant for decision making in this area; (b) review the application of decision aids to forming specific, personal choices between options; and (c) identify the challenges of evaluating these decision processes to suggest areas for future research.

METHODS

Theoretical models and frameworks derived from the health behavior change and decision-making fields were applied to cancer primary prevention choices. Decision aids for the human papillomavirus (HPV) vaccine, Hormone Replacement Therapy (HRT), and tamoxifen were systematically examined.

RESULTS

Traditional concepts such as decisional balance and cues to action are relevant to understanding cancer primary prevention choices; Motivational Interviewing, Self-Determination Theory, and the Preventive Health Model may also explain the facilitators of decision making. There are no well-tested HPV vaccine decision aids, although there have been some studies on aids for HPV testing. There are several effective decision aids for HRT and tamoxifen; evidence-based decision aid components have also been identified.

CONCLUSIONS

Additional theory-based empirical research on decision making in cancer primary prevention and chemoprevention, particularly at the interface of psychology and behavioral economics, is suggested.

Delays in breast cancer diagnosis and treatment by racial/ethnic group

BACKGROUND

Although white women have the highest incidence of breast cancer, African American, followed by Hispanic, American Indian/Alaskan Native, and Asian American or Pacific Islander, women have higher death rates from the disease. Timely initiation of treatment has been shown to improve survival, and may help to lessen the mortality differences among racial/ethnic groups.

METHODS

The purpose of this study was to describe time delays in the initial diagnosis and treatment of primary breast carcinoma across diverse ethnic/racial groups. Data are from the Surveillance, Epidemiology, and End Results-Medicare database. Women in this study were diagnosed as having breast cancer between January 1, 1992, and December 31, 1999. Billing claims from outpatient and inpatient visits were used. A total of 49 865 female Medicare recipients 65 years and older were enrolled in the study. Racial/ethnic groups were compared in their diagnostic, treatment, and clinical delay (ie, women with a diagnostic and treatment delay).

RESULTS

African American women experienced the greatest diagnostic, treatment, and clinical delay. After controlling for other predictors, compared with white women, African American women had a 1.39-fold odds (95% confidence interval, 1.18-1.63) of diagnostic delay beyond 2 months, a 1.64-fold odds (95% confidence interval, 1.40-1.91) of treatment delay beyond 1 month, and a 2.24-fold odds (95% confidence interval, 1.75-2.86) of having a combined clinical delay.

CONCLUSIONS

In a population-based study, African American women experienced the most delays in initial diagnosis and initiation of breast cancer treatment, relative to women of other racial/ethnic subgroups. Despite the limitations of a claims database, the magnitude and direction of the findings are consistent across the research, suggesting the critical importance of reducing these delays.

Health care access among individuals involved in same-sex relationships

OBJECTIVES

We used data from the National Health Interview Survey to compare health care access among individuals involved in same-sex versus opposite-sex relationships.

METHODS

We conducted descriptive and logistic regression analyses from pooled data on 614 individuals in same-sex relationships and 93418 individuals in opposite-sex relationships.

RESULTS

Women in same-sex relationships (adjusted odds ratio [OR]=0.60; 95% confidence interval [CI]=0.39, 0.92) were significantly less likely than women in opposite-sex relationships to have health insurance coverage, to have seen a medical provider in the previous 12 months (OR=0.66; 95% CI=0.46, 0.95), and to have a usual source of health care (OR=0.50; 95% CI=0.35, 0.71); they were more likely to have unmet medical needs as a result of cost issues (OR=1.85; 95% CI=1.16, 2.96). In contrast, health care access among men in same-sex relationships was equivalent to or greater than that among men in opposite-sex relationships.

CONCLUSIONS

In this study involving a nationwide probability sample, we found some important differences in access to health care between individuals in same-sex and opposite-sex relationships, particularly women.

Effectiveness of academic detailing on breast cancer screening among primary care physicians in an underserved community

BACKGROUND

Urban minority groups, such as those living in northern Manhattan and the South Bronx, are generally underserved with regard to breast cancer prevention and screening practices. Primary care physicians are critical for the recommendation of mammography and clinical breast examinations to their patients.

DESIGN

Two medically underserved communities were matched and block randomized. The aim of the study was to assess the efficacy of academic detailing in increasing recommendations for breast cancer screening in community-based primary care physicians.

SETTING/PARTICIPANTS

Ninety-four primary care community-based (ie, not hospital-based) physicians in northern Manhattan were compared with 74 physicians in the South Bronx who received no intervention.

INTERVENTION

INTERVENTION participants received multicomponent physician-directed education, academic detailing, using the American Cancer Society guidelines for the early detection of breast cancer.

MAIN OUTCOME MEASURES

We administered interviews to ask about primary care physicians' recommendation of mammography and clinical breast examination. They were also queried about their knowledge of major risk factors and perceived barriers to breast cancer screening. We conducted medical audits of 710 medical charts 2 years before and after the intervention.

RESULTS

Using a mixed models linear analysis, we found a statistically significant intervention effect on the recommendation of mammography and clinical breast examination (according to medical audit) by female patients age 40 and over. INTERVENTION group physicians correctly identified significantly more risk factors for breast cancer, and significantly fewer barriers to practice, than did comparison physicians.

CONCLUSIONS

We found some evidence of improvement in breast cancer screening practices due to academic detailing among primary care physicians practicing in urban underserved communities.

A model of stage of change to recommend colonoscopy among urban primary care physicians

Theory is little used in the prediction of physician cancer screening stage of change. Structural equation modeling was used to evaluate the theoretical predictors of stage of change to recommend colonoscopy among 235 urban physicians. Constructs from the theory of planned behavior, social-cognitive theory, and the transtheoretical model were systematically tested. As predicted, contextual factors, such as the physicians' ages, their race-ethnicities, patient race-ethnicity, and office-related barriers to preventive care were associated with stage of change through self-efficacy, normative beliefs, and negative behavioral beliefs. The findings demonstrate the relevance of these models to studying the behavior of physicians and support the development of interventions that are tailored to normative beliefs and specific physician cognitions for colonoscopy recommendation.

Treatment for Breast Cancer in Patients with Alzheimer's Disease

OBJECTIVES

To report use of breast cancer treatment (surgery, radiation, and chemotherapy) by patients with Alzheimer's disease (AD).

DESIGN

Retrospective cohort study.

SETTING

Surveillance, Epidemiology, and End Results (SEER) is a population-based cancer registry covering 14% of the U.S. population.

PARTICIPANTS

Fifty thousand four hundred sixty breast cancer patients aged 65 and older, of whom 1,935 (3.8%) had a diagnosis of AD before or up to 6 months after cancer diagnosis.

MEASUREMENTS

Diagnosis of AD was taken from International Classification of Diseases, Ninth Revision, diagnostic codes accompanying Medicare billing claims between 1992 and 1999. The SEER program reported surgery and radiation. Chemotherapy was taken from Medicare billing records.

RESULTS

Subjects with AD were diagnosed with breast cancer at later stages, when tumors were larger and the likelihood of lymph node involvement had increased. Patients with AD had a lower likelihood of surgery (odds ratio (OR)=0.60, 95% confidence interval (CI)=0.46-0.81), radiation (OR=0.31, 95% CI=0.23-0.41), and chemotherapy (OR=0.44, 95% CI=0.34-0.58) than those without AD.

CONCLUSION

Overall, AD patients receive less treatment for breast cancer than do comparable female Medicare beneficiaries. Chemotherapy and radiation are administered less frequently to women with AD than to other comparable patients. It is unclear whether suboptimal medical care has an effect on their survival. Further research on the effect of screening and treatment decision-making for these patients is warranted.