Opportunities and strategies for breast cancer prevention through risk reduction

Due to the high incidence of breast cancer among US females, risk-reduction strategies are essential. Before considering approaches to breast cancer risk reduction, it is important for clinicians to complete individualized qualitative and quantitative assessments of risk for their patients in order to inform physicians' clinical decision making and management and to engage patients collaboratively in a thorough discussion of risks and benefits. This review will summarize information on potential pharmacologic, nutritional, surgical, and behavioral approaches to reducing breast cancer risk. While there is no clear evidence that specific dietary components can effectively reduce breast cancer risk, weight gain and obesity in adulthood are risk factors for the development of postmenopausal breast cancer. Alcohol consumption, even at moderate levels, increases breast cancer risk, although some of the detrimental effects may be reduced by sufficient folate intake. Women at increased risk of breast cancer can opt to reduce their breast cancer risk through the use of tamoxifen or raloxifene; other chemopreventive agents remain under investigation. Surgical approaches to risk reductions are restricted to those patients with a substantially increased risk of developing breast cancer. Patients should be encouraged to maintain a healthy lifestyle for their overall well-being and to remain up to date with recommendations for screening and surveillance.

Characterizing breast symptoms in family practice

PURPOSE

The frequency and outcome of breast symptoms have not been well characterized in primary care settings. To enhance and inform physician practice, this study aims to establish the proportion of visits and resultant diagnoses by age by examining longitudinal data on breast-related reasons for encounter.

METHODS

We used data from a prospective longitudinal sample of patients seeking care in Dutch family physician offices between 1985 and 2003 to provide routine family practice data on breast symptoms as the reason for encounter; all visits were coded using the International Classification of Primary Care. Data on breast symptom prevalence are based upon 84,285 active female patients and 367,834 total encounters.

RESULTS

Overall breast symptoms were reported in about 3% of all visits by female patients (29.7 per 1,000 active female patients per year); breast pain and breast mass were the most common breast-related complaints. Breast symptom complaints were highest among women aged 25 to 44 years (48 of 1,000) and among women aged 65 years and older (33 per 1,000). Of the women complaining of breast symptoms, 81 (3.2%) had breast cancer diagnosed. Breast mass had a markedly elevated positive likelihood ratio for breast cancer (15.04; 95% confidence interval, 11.74-19.28).

CONCLUSIONS

As expected, of patients with breast symptoms only a small subset was subsequently given a diagnosis of breast cancer (3.2%); however, the presence of a breast mass was associated with an elevated likelihood of breast cancer. These data illustrate the use of systematic data collection and classification from primary care offices to extract information regarding disease symptoms and diagnoses.

Medical care in long-term survivors of childhood cancer: a report from the childhood cancer survivor study

PURPOSE

To evaluate whether childhood cancer survivors receive regular medical care focused on the specific morbidities that can arise from their therapy.

PATIENTS AND METHODS

We conducted a cross-sectional survey of health care use in 8,522 participants in the Childhood Cancer Survivor Study, a multi-institutional cohort of childhood cancer survivors. We assessed medical visits in the preceding 2 years, whether these visits were related to the prior cancer, whether survivors received advice about how to reduce their long-term risks, and whether screening tests were discussed or ordered. Completion of echocardiograms and mammograms were assessed in patients at high risk for cardiomyopathy or breast cancer. We examined the relationship between demographics, treatment, health status, chronic medical conditions, and health care use.

RESULTS

Median age at cancer diagnosis was 6.8 years (range, 0 to 20.9 years) and at interview was 31.4 years (range, 17.5 to 54.1 years). Although 88.8% of survivors reported receiving some form of medical care, only 31.5% reported care that focused on their prior cancer (survivor-focused care), and 17.8% reported survivor-focused care that included advice about risk reduction or discussion or ordering of screening tests. Among survivors who received medical care, those who were black, older at interview, or uninsured were less likely to have received risk-based, survivor-focused care. Among patients at increased risk for cardiomyopathy or breast cancer, 511 (28.2%) of 1,810 and 169 (40.8%) of 414 had undergone a recommended echocardiogram or mammogram, respectively.

CONCLUSION

Despite a significant risk of late effects after cancer therapy, the majority of childhood cancer survivors do not receive recommended risk-based care.

Treating smokers before the quit date: can nicotine patches and denicotinized cigarettes reduce cravings?

The present study investigated whether treatment with the combination of denicotinized cigarettes and 21-mg nicotine patch for 2 weeks before a designated quit date could lessen cravings for smoking, thereby helping smokers abstain from smoking. The study was a randomized controlled clinical trial conducted at Roswell Park Cancer Institute, Buffalo, New York, in 2004 and 2005. Patients included 98 adult heavy smokers (using 20 or more cigarettes/day). Half of the subjects received 2 weeks of combination of denicotinized cigarettes (Quest 3) and 21-mg nicotine patch for 2 weeks before the quit date. The remaining smokers were switched to light cigarettes (Quest 1) during the 2 weeks before the quit date. After the quit date, all subjects received counseling for smoking cessation and were provided nicotine patches for up to 8 weeks after the quit date. Self-reported cravings for smoking, withdrawal symptoms, and smoking abstinence were measured at predetermined intervals using phone-based surveys and in clinical visits. The group that used denicotinized cigarettes and nicotine patch before quitting reported less frequent and less intense cravings for cigarettes in the 2 weeks before and after the designated quit date. Self-reported withdrawal symptoms and quit rates did not differ significantly between the groups. The use of a denicotinized cigarette combined with the nicotine patch appears to lessen cravings to smoke in the immediate postcessation period. A larger, better-powered study is needed to test if this treatment combination has merit for increasing quit rates.

Colorectal cancer occurs earlier in those exposed to tobacco smoke: implications for screening

BACKGROUND

Colorectal cancer (CRC) is the third most common cancer in the USA. While various lifestyle factors have been shown to alter the risk for colorectal cancer, recommendations for the early detection of CRC are based only on age and family history.

METHODS

This case-only study examined the age at diagnosis of colorectal cancer in subjects exposed to tobacco smoke. Subjects included all patients who attended RPCI between 1957 and 1997, diagnosed with colorectal cancer, and completed an epidemiologic questionnaire. Adjusted linear regression models were calculated for the various smoking exposures.

RESULTS

Of the 3,540 cases of colorectal cancer, current smokers demonstrated the youngest age of CRC onset (never: 64.2 vs. current: 57.4, P < 0.001) compared to never smokers, followed by recent former smokers. Among never smokers, individuals with past second-hand smoke exposure were diagnosed at a significantly younger age compared to the unexposed.

CONCLUSION

This study found that individuals with heavy, long-term tobacco smoke exposure were significantly younger at the time of CRC diagnosis compared to lifelong never smokers. The implication of this finding is that screening for colorectal cancer, which is recommended to begin at age 50 years for persons at average risk should be initiated 5-10 years earlier for persons with a significant lifetime history of exposure to tobacco smoke.

Smokers' acceptance of "cold calls" offering quitline services

OBJECTIVE

A random sample of smokers was offered a transfer to the New York State Smokers' Quitline in order to assess smokers' acceptance of "cold calls" offering quitline services.

METHOD

A 30-minute survey to assess adult tobacco use was administered to 121 western New York smokers who were originally sampled for a random digit dialled survey in 2005, and then re-interviewed one year later, between April and July 2006. Smokers' interest in receiving immediate quitline assistance was assessed at the end of the survey, when the smokers could choose to be transferred to the New York State Smokers' Quitline in order to receive the quitline's cessation services.

RESULTS

41% of smokers accepted the offer for, and subsequently received, New York State Smokers' Quitline services. After controlling for factors related to cessation, women were more likely to respond to the offer.

CONCLUSIONS

Although telephone quitline utilisation is low, these data suggest that the demand is high and "cold calls" may be a strategy to extend the use of quitline cessation services.

Linked claims and medical records for cancer case management : evaluation of mammography abnormalities

BACKGROUND

Failure to obtain the requisite follow-up of patients with abnormal mammograms may delay cancer diagnosis and impact outcome. Up to 20% of women do not receive timely recommended follow-up. The current study tested the accuracy of the linkage of payer claims and clinical data to identify the appropriate treatment for patients with abnormal mammograms.

METHODS

Electronic medical records in a staff model practice that was affiliated with a single health payer were scanned to identify the Breast Imaging Reporting and Data System (BI-RADS(R)) code for all mammograms. For each woman with a BI-RADS code 0, 3, 4, or 5 mammogram, the payer claims were searched for follow-up breast procedures (imaging, biopsy, and surgery) occurring within 2 months for BI-RADS code 0, 4, and 5 mammograms and within 8 months for BI-RADS code 3 mammograms. For women with >1 abnormal mammogram during the study period, only follow-up for the first abnormal mammogram was examined. The medical records of cases defined by claims as not having recommended follow-up care were reviewed to determine the accuracy of claims analyses.

RESULTS

A total of 17,329 women underwent 23,721 mammograms between January 1, 2001 and December 31, 2003. BI-RADS codes 0, 3, 4, or 5 occurred in 1,490 mammograms (6.3%). Among 1,206 women with a first abnormal mammogram who were eligible for claims follow-up, 16% did not receive recommended follow-up care. Medical record review demonstrated that the claims search accurately identified follow-up care in 97% of these cases.

CONCLUSIONS

Administrative claims supplemented with BI-RADS data were found to accurately identify the follow-up care of patients with abnormal mammograms. Case management using this method may assist physicians in ensuring that all patients receive appropriate care.

Clinical practice guideline: adult sinusitis

OBJECTIVE

This guideline provides evidence-based recommendations on managing sinusitis, defined as symptomatic inflammation of the paranasal sinuses. Sinusitis affects 1 in 7 adults in the United States, resulting in about 31 million individuals diagnosed each year. Since sinusitis almost always involves the nasal cavity, the term rhinosinusitis is preferred. The guideline target patient is aged 18 years or older with uncomplicated rhinosinusitis, evaluated in any setting in which an adult with rhinosinusitis would be identified, monitored, or managed. This guideline is intended for all clinicians who are likely to diagnose and manage adults with sinusitis.

PURPOSE

The primary purpose of this guideline is to improve diagnostic accuracy for adult rhinosinusitis, reduce inappropriate antibiotic use, reduce inappropriate use of radiographic imaging, and promote appropriate use of ancillary tests that include nasal endoscopy, computed tomography, and testing for allergy and immune function. In creating this guideline the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of allergy, emergency medicine, family medicine, health insurance, immunology, infectious disease, internal medicine, medical informatics, nursing, otolaryngology-head and neck surgery, pulmonology, and radiology.

RESULTS

The panel made strong recommendations that 1) clinicians should distinguish presumed acute bacterial rhinosinusitis (ABRS) from acute rhinosinusitis caused by viral upper respiratory infections and noninfectious conditions, and a clinician should diagnose ABRS when (a) symptoms or signs of acute rhinosinusitis are present 10 days or more beyond the onset of upper respiratory symptoms, or (b) symptoms or signs of acute rhinosinusitis worsen within 10 days after an initial improvement (double worsening), and 2) the management of ABRS should include an assessment of pain, with analgesic treatment based on the severity of pain. The panel made a recommendation against radiographic imaging for patients who meet diagnostic criteria for acute rhinosinusitis, unless a complication or alternative diagnosis is suspected. The panel made recommendations that 1) if a decision is made to treat ABRS with an antibiotic agent, the clinician should prescribe amoxicillin as first-line therapy for most adults, 2) if the patient worsens or fails to improve with the initial management option by 7 days, the clinician should reassess the patient to confirm ABRS, exclude other causes of illness, and detect complications, 3) clinicians should distinguish chronic rhinosinusitis (CRS) and recurrent acute rhinosinusitis from isolated episodes of ABRS and other causes of sinonasal symptoms, 4) clinicians should assess the patient with CRS or recurrent acute rhinosinusitis for factors that modify management, such as allergic rhinitis, cystic fibrosis, immunocompromised state, ciliary dyskinesia, and anatomic variation, 5) the clinician should corroborate a diagnosis and/or investigate for underlying causes of CRS and recurrent acute rhinosinusitis, 6) the clinician should obtain computed tomography of the paranasal sinuses in diagnosing or evaluating a patient with CRS or recurrent acute rhinosinusitis, and 7) clinicians should educate/counsel patients with CRS or recurrent acute rhinosinusitis regarding control measures. The panel offered as options that 1) clinicians may prescribe symptomatic relief in managing viral rhinosinusitis, 2) clinicians may prescribe symptomatic relief in managing ABRS, 3) observation without use of antibiotics is an option for selected adults with uncomplicated ABRS who have mild illness (mild pain and temperature <38.3 degrees C or 101 degrees F) and assurance of follow-up, 4) the clinician may obtain nasal endoscopy in diagnosing or evaluating a patient with CRS or recurrent acute rhinosinusitis, and 5) the clinician may obtain testing for allergy and immune function in evaluating a patient with CRS or recurrent acute rhinosinusitis.

DISCLAIMER

This clinical practice guideline is not intended as a sole source of guidance for managing adults with rhinosinusitis. Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. It is not intended to replace clinical judgment or establish a protocol for all individuals with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem.

Breast Cancer Risk Reduction and Counseling: Lifestyle, Chemoprevention, and Surgery

Qualitative and quantitative approaches to risk assessment are useful for identifying women at increased risk for developing breast cancer for whom genetics consultation, individualized surveillance recommendations, or chemoprevention may be appropriate. A comprehensive medical and family history review can be used to stratify women into categories of breast cancer risk. A quantitative estimate of the probability of developing breast cancer can be determined using risk assessment tools, such as the Gail and Claus models. Women at increased risk for breast cancer may benefit from individualized approaches to breast cancer risk reduction. Prevention strategies for reducing breast cancer risk include lifestyle modifications, chemoprevention, surgical approaches, and pharmacotherapy.

Genetic polymorphisms and disease prevention

Building upon the resources of traditional epidemiology, molecular epidemiology has extended our understanding that disease risk varies based not only upon acquired factors (e.g., exposures, behaviors, demographics), but also as a function of inherited factors (e.g., genetic polymorphisms). Individual susceptibility to cancer is influenced by polymorphisms in phase I enzymes (e.g., activation), phase 2 enzymes (e.g., detoxification), defects in the repair of DNA damage and other cancer susceptibility genes. Because tobacco use and nutrition represent behaviors/exposures which account for a significant number of cancer cases and deaths, these two factors are used to illustrate the relationship between genetic polymorphisms and disease prevention. Susceptibility to the health risks of smoking appears to be influenced by genetic factors that impact initiation, dependence, and nicotine metabolism. Nutrient metabolism also involves polymorphic enzyme pathways and gene-nutrient interactions may influence cancer risk. While the discipline of molecular epidemiology continues to face methodologic challenges related to the need to study large numbers of subjects, current knowledge can be applied to prevention activities. Genetic polymorphisms, and other molecular markers, can be used to develop clinical prevention studies targeted to unique subsets of persons at the highest risk of developing disease. Knowledge about the relationships between polymorphisms and disease outcomes can also be used for reinforcing healthy lifestyles, motivating positive behavior changes, helping to target medical therapy, and aiding in better focusing surveillance activities.

Research productivity among recipients of AAFP foundation grants

PURPOSE

This study examines research productivity generated by the American Academy of Family Physicians (AAFP) Foundation and the AAFP Joint Grant Awards Program (JGAP) based upon projects funded during the period 1990 through 2000.

METHODS

A structured questionnaire was mailed to all JGAP applicants who were funded between 1990 and 2000 (N = 95). The cross-sectional questionnaire included items reflective of research productivity: (1) numbers of publications, (2) numbers of presentations, and (3) numbers and types of subsequent grants. An additional comparison examined publication productivity among a subset of funded (n = 17) and nonfunded applicants (n = 36).

RESULTS

The 69 funded respondents reported 91 publications and 129 presentations deriving from JGAP-supported research; 26 subsequent grants were funded ($9.6 million total costs). Funded and nonfunded applicants showed a significant increase in the overall number of publications during the 5-year period after their application when compared with the 5-year period before their application. Funded applicants had a greater number of publications during both the 5 years before and the 5 years after their JGAP grant submission.

CONCLUSION

Projects supported by the JGAP have generated a considerable body of publications and presentations, as well as subsequent grant activity. This program appears to be important in supporting the early career development of family medicine researchers.

Mortality experiences among 15+ year survivors of childhood and adolescent cancers

BACKGROUND

Studies of childhood and adolescent cancer survivorship have tended to focus on limited survival intervals (e.g., 5 and 10 years). Our report evaluates gender-specific overall mortality, as well as mortality by age group, and by cause, among 15+ year survivors of cancer diagnosed during childhood or adolescence.

PROCEDURE

This was a retrospective cohort study of 565 15+ year childhood cancer survivors from Roswell Park Cancer Institute's Long-Term Follow-Up Project. Sex- and age-specific person-years at risk were accumulated and applied to age-specific mortality rates for New York State, excluding New York City. Standardized mortality ratios (SMRs), and 95% confidence intervals, were calculated and compared to mortality risks of the general population.

RESULTS

Second malignancy was the leading cause of death among male and female survivors (15/38 deaths, 39%). Excess overall mortality was noted among both males (SMR = 284) and females (SMR = 371). Significant mortality excesses were seen in both genders for deaths due to primary malignant neoplasms and secondary malignancies, as well as cardiac deaths among males. Excess mortality was noted across most age strata. In the scenario of no cancer relapse, overall mortality in both genders did not differ significantly from the general population.

CONCLUSIONS

Long-term survivors of childhood and adolescent cancers continue to demonstrate significant excess mortality. However, overall mortality among 15+ year survivors without a relapse appears to be comparable to the general population. The leading cause of death among 15+ year survivors is second malignancy in this study, which represents a novel and important finding in terms of long-term follow-up.

Protecting our patients from HPV and HPV-related diseases: the role of vaccines

The clinical burden of disease resulting from human papillomavirus (HPV) infection is substantial and extends from genital warts to cytologic abnormalities to cervical, vaginal, and vulvar cancers and their associated precursor lesions. In addition, HPV is implicated in anal, penile, and head and neck cancers. Thus, HPV-related disease constitutes a significant burden for both men and women. Large phase 2 and 3 clinical trials with a quadrivalent preventive HPV vaccine (HPV 6/11/16/18) and phase 2 trials with a bivalent preventive HPV vaccine (HPV 16/18) have demonstrated that both products are highly efficacious in preventing type-specific HPV infections and HPV-related disease and are well tolerated. Nearly all recipients demonstrate a robust immunologic response that currently appears to be durable for 4 or more years. Immunogenicity data among girls 9 to 15 years of age were used to "bridge" efficacy data from quadrivalent HPV vaccine trials completed to date. In June 2006, the US Food and Drug Administration approved the quadrivalent HPV vaccine for use among females 9 to 26 years of age. The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices has recommended the 3-dose series for girls 11 to 12 years of age, catch-up vaccination for girls and women 13 to 26 years of age, and permissive use as early as age 9. Computer models projecting the impact of these preventive HPV vaccines predict that they will be cost-effective and beneficial to the population; the use of preventive HPV vaccines will complement continued cytologic screening programs. Trials are under way to evaluate the duration of immune response as well as efficacy among men and women 27 years of age and older. Girls and women within the targeted age ranges should be offered vaccination to achieve the disease prevention potential of these vaccines.

A Phase II study of St. John's Wort for smoking cessation

OBJECTIVES

To examine the feasibility and efficacy of St. John's Wort (SJW) for smoking cessation.

DESIGN

This one-arm Phase II study utilized an exact two-stage group sequential design with a 1-week run-in period between the start of SJW treatment and the designated quit date. A total of 37 smokers (ages 18-65 years, smoking > or = 10 cigarettes/day) were started on SJW. Thirteen failed to make a verified quit attempt on the predesignated date and were taken off study resulting in 24 evaluable subjects.

SETTING

Smokers completed clinic visits at a cancer center with interval telephone calls and mailings.

INTERVENTION

Standardized SJW, 450 mg capsules taken orally twice daily along with cessation counseling messages.

MAIN OUTCOME MEASURES

Subjects completed validated surveys and a focused physical examination at baseline. Evaluable subjects were defined as those subjects who made a confirmed quit attempt on their "quit date" 1 week following initiation of SJW. Smoking status was determined through self-report and bioverification using carbon monoxide (CO) testing.

RESULTS

Among evaluable subjects, the 12-week quit rate was 37.5% (9/24). Quitters had no significant change in weight from baseline to 12-weeks cessation. Use of SJW was generally well tolerated.

CONCLUSIONS

Based upon these results (which suggest that SJW may be effective in maintaining smoking cessation) and the high compliance and few AEs, we conclude that SJW demonstrates feasibility for use in smoking cessation. If SJW proves to be effective in larger controlled studies, it could represent a less expensive, more readily accessible and well-tolerated agent to promote tobacco cessation.

BI-RADS classification for management of abnormal mammograms

The Breast Imaging Reporting and Data System (BI-RADS), developed by the American College of Radiology, provides a standardized classification for mammographic studies. This system demonstrates good correlation with the likelihood of breast malignancy. The BI-RADS system can inform family physicians about key findings, identify appropriate follow-up and management and encourage the provision of educational and emotional support to patients.

Approaches to tobacco control & lung cancer screening among physician assistants

BACKGROUND

This study explores physicians' assistants' (PA) knowledge and practice regarding tobacco cessation counseling, approaches to lung cancer early detection and management of patients at high risk of developing lung cancer.

METHODS

A cross-sectional survey design was used to examine approaches to tobacco use prevention and the early detection of lung cancer among PAs from Western New York State.

RESULTS

PAs report promoting use of the nicotine patch, nicotine spray and bupropion when counseling smokers on cessation. Reported management strategies for a patient at high risk of developing lung cancer were not supported by current literature.

CONCLUSION

These findings suggest the need for professional educational programs aimed not only at conveying the continued importance of tobacco cessation counseling, but also information on the appropriate management options for patients at increased risk of developing lung cancer.

Early evidence on the effectiveness of clean indoor air legislation in New York State

In July 2003, New York State implemented the Clean Indoor Air Act (CIAA) to reduce exposure to environmental tobacco smoke (ETS). In this cross-sectional study, workers (n=168) completed an interview assessing ETS exposure and provided urine for cotinine analysis. Hospitality workers recruited after implementation of the CIAA had significant reductions in ETS exposure and urine cotinine, compared with those recruited before implementation. The New York State CIAA yielded measurable reductions in ETS exposure for hospitality workers.

St. John's wort

St. John's wort has been used to treat a variety of conditions. Several brands are standardized for content of hypericin and hyperforin, which are among the most researched active components of St. John's wort. St. John's wort has been found to be superior to placebo and equivalent to standard antidepressants for the treatment of mild to moderate depression. Studies of St. John's wort for the treatment of major depression have had conflicting results. St. John's wort is generally well tolerated, although it may potentially reduce the effectiveness of several pharmaceutical drugs.

Correlates of obesity among patients attending an urban family medical center

Urban populations face unique health challenges. We used data from a cross-sectional comprehensive health risk assessment survey conducted at an urban family medicine center to explore demographic and clinical correlates of obesity among 923 adults ages 20-64 years. Based on univariate analyses, there were no significant differences for body mass index (BMI) categories or health status ratings by racial group. A logistic model revealed that obese respondents (BMI >30.0) were significantly less likely to be female, white and to report a body image of overweight. Overall, just 25% of persons with a BMI of >30 classified themselves as being overweight. A second logistic model revealed that respondents reporting a body image of overweight were significantly more likely to be age 50-64 years, female, white and to report their health as good or fair/poor, which may reflect differing cultural and social beliefs of how individuals perceive their weight. This misperception between calculated BMI and reported body image in this urban population may serve to moderate attempts to address weight control as a health issue.

Childhood leukaemia in Belarus, Russia, and Ukraine following the Chernobyl power station accident: results from an international collaborative population-based case–control study

BACKGROUND

There is little evidence regarding the risk of leukaemia in children following exposure to radionuclides from the Chernobyl Nuclear Power Plant explosion on April 26, 1986.

METHODS

This population-based case-control study investigated whether acute leukaemia is increased among children who were in utero or <6 years of age at the time of the Chernobyl accident. Confirmed cases of leukaemia diagnosed from April 26, 1986 through December 31, 2000 in contaminated regions of Belarus, Russia, and Ukraine were included. Two controls were matched to each case on sex, birth year, and residence. Accumulated absorbed radiation dose to the bone marrow was estimated for each subject.

RESULTS

Median estimated radiation doses of participants were <10 mGy. A significant increase in leukaemia risk with increasing radiation dose to the bone marrow was found. This association was most evident in Ukraine, apparent (but not statistically significant) in Belarus, and not found in Russia.

CONCLUSION

Taken at face value, these findings suggest that prolonged exposure to very low radiation doses may increase leukaemia risk as much as or even more than acute exposure. However the large and statistically significant dose-response might be accounted for, at least in part, by an overestimate of risk in Ukraine. Therefore, we conclude this study provides no convincing evidence of an increased risk of childhood leukaemia as a result of exposure to Chernobyl radiation, since it is unclear whether the results are due to a true radiation-related excess, a sampling-derived bias in Ukraine, or some combination thereof. However, the lack of significant dose-responses in Belarus and Russia also cannot convincingly rule out the possibility of an increase in leukaemia risk at low dose levels.

Patterns of childhood mortality in a region of Belarus, 1980-2000

The public health infrastructure of the former Soviet Union was impacted by both the Chernobyl disaster in 1986 and the Soviet breakup in 1991. This paper examines mortality patterns among children aged 1-14 years within the Mogilev region of Belarus between 1980 and 2000. This study utilized a regional cohort design that included all childhood deaths (ages 1-14 years) occurring among persons residing within the Mogilev oblast of Belarus between 1980 and 2000. Patterns of death and death rates were examined across three intervals: 1980-1985 (pre-Chernobyl), 1986-1991 (post-Chernobyl and pre-Former Soviet Union (FSU) breakup) and 1992-2000 (post-Chernobyl and post-FSU breakup) based upon administrative death files. Annual death rates among children aged 1-4 years declined between 1980 and 2000, while mortality rates among children aged 5-9 years and 10-14 years remained steady over this time period. Average annual mortality rates among males aged 5-9 years and 10-14 years increased significantly between 1986 and 1991. Compared to the baseline interval, mortality among both males and females aged 1-4 years was significantly decreased during 1986-1990 and 1992-2000. In general, mortality rates among males were 24%-95% greater compared to females. Injuries and poisonings accounted for the largest proportion of deaths across all age and gender groups examined. Subsequent to the Chernobyl disaster, significant decreases were noted in mortality rates among children aged 1-4 years while mortality rates among children aged 5-9 and 10-14 remained stable.

CONCLUSION

Similar to the findings in other countries, injuries and poisonings predominated as the leading cause of death among Belarussian children.

Disparity in the use of smoking cessation pharmacotherapy among Medicaid and general population smokers

BACKGROUND

The prevalence of smoking remains higher among the Medicaid population compared with the general population. To reduce this disparity, the majority of state Medicaid programs now provide coverage for smoking cessation pharmacotherapy. The objectives of this study were to (1) assess awareness of this benefit among Medicaid smokers and (2) compare the use of pharmacotherapy among a sample of Medicaid smokers with smokers in the general population of western New York.

METHODS

This report summarizes findings from two cross-sectional studies conducted in western New York State during 2002 to 2003: (1) Medicaid smokers (n = 1,174) completed an interviewer-administered questionnaire in the Office of Medicaid Management and (2) smokers from the general population (n = 852) completed a telephone survey.

RESULTS

The majority of Medicaid smokers (54%) remain unaware of the program benefit providing coverage for smoking cessation pharmacotherapies. Medicaid smokers were much less likely (odds ratio = 0.33, 95% confidence interval = 0.25-0.44) than the general population to report having ever used pharmacotherapies.

CONCLUSIONS

Highlighting the availability of the smoking cessation pharmacotherapy benefit to Medicaid program participants may be one strategy to enhance quit attempts among this population. Future research should identify other potential barriers to the use of effective pharmacotherapies among poorer smokers.

Patients with a family history of cancer: identification and management

A family history of certain malignancies, especially breast, ovarian, colorectal, and prostate cancers, can place persons at increased risk of developing these cancers. By constructing a pedigree that includes 3 generations, family physicians can identify patients at increased risk because of family cancer history. Persons at increased cancer risk because of family history warrant a surveillance strategy for early detection. Genetic professionals represent an important resource in assessing genetic risk and possible testing. Persons identified as being at increased risk of various cancers based on their family history should understand the surveillance plan that is recommended and the importance of maintaining a healthy lifestyle and remaining up to date on other cancer screening tests.