Using probabilistic corrections to account for abstractor agreement in medical record reviews

The quality of medical record abstracts is often characterized in a reliability substudy. These results usually indicate agreement, but not the extent to which lack of agreement affects associations observed in the complete data. In this study, medical records were reviewed and abstracted for patients diagnosed with stage I or stage II breast cancer between 1990 and 1994 at one of six US Cancer Research Network sites. For a subsample, interrater reliability data were available. The authors calculated conventional hazard ratios and 95% confidence intervals for the association of demographic, tumor, and treatment characteristics with recurrence rate. These conventional estimates of effect were compared with three sets of estimates and 95% simulation intervals that took account of the uncertainty assessed by lack of agreement in the reliability substudy. The rate of recurrence was associated with increasing cancer stage and with treatment modality but not with demographic characteristics. The hazard ratios and simulation intervals that took account of the reliability data showed that the simulation interval grew wider as the sources of uncertainty taken into account grew more complete, but the associations expected a priori remained readily apparent. While many investigators use reliability data only as a metric for data quality, a more thorough approach can also quantitatively depict the uncertainty in the observed associations.

Mammography surveillance and mortality in older breast cancer survivors

PURPOSE

There are more than 2,000,000 breast cancer survivors in the United States today. While surveillance for asymptomatic recurrence and second primary is included in consensus recommendations, the effectiveness of this surveillance has not been well characterized. Our purpose is to estimate the effectiveness of surveillance mammography in a cohort of breast cancer survivors with complete ascertainment of surveillance mammograms and negligible losses to follow-up.

PATIENTS AND METHODS

We enrolled 1,846 stage I and II breast cancer patients who were at least 65 years old at six integrated health care delivery systems. We used medical record review and existing databases to ascertain patient, tumor, and therapy characteristics, as well as receipt of surveillance mammograms. We linked personal identifiers to the National Death Index to ascertain date and cause of death. We matched four controls to each breast cancer decedent to estimate the association between receipt of surveillance mammogram and breast cancer mortality.

RESULTS

One hundred seventy-eight women died of breast cancer during 5 years of follow-up. Each additional surveillance mammogram was associated with a 0.69-fold decrease in the odds of breast cancer mortality (95% CI, 0.52 to 0.92). The protective association was strongest among women with stage I disease, those who received mastectomy, and those in the oldest age group.

CONCLUSION

Given existing recommendations for post-therapy surveillance, trials to compare surveillance with no surveillance are unlikely. This large observational study provides support for the recommendations, suggesting that receipt of surveillance mammograms reduces the rate of breast cancer mortality in older patients diagnosed with early-stage disease.

Methodology, design, and analytic techniques to address measurement of comorbid disease

BACKGROUND

Measurement of comorbidity affects all variable axes that are considered in health care research: confounding, modifying, independent, and dependent variable. Comorbidity measurement particularly affects research involving older adults because they bear the disproportionate share of the comorbidity burden.

METHODS

We examine how well researchers can expect to segregate study participants into those who are healthier and those who are less healthy, given the variable axis for which they are measuring comorbidity, the comorbidity measure they select, and the analytic method they choose. We also examine the impact of poor measurement of comorbidity.

RESULTS

Available comorbidity measures make use of medical records, self-report, physician assessments, and administrative databases. Analyses using these scales introduce uncertainties that can be framed as measurement error or misclassification problems, and can be addressed by extant analytic methods. Newer analytic methods make efficient use of multiple sources of comorbidity information.

CONCLUSIONS

Consideration of the comorbidity measure, its role in the analysis, and analogous measurement error problems will yield an analytic solution and an appreciation for the likely direction and magnitude of the biases introduced.

Blood pressure and survival in the oldest old

OBJECTIVES

To determine the relationship between blood pressure (BP) and all-cause mortality in subjects aged 80 and older with hypertension.

DESIGN

Retrospective cohort study with 5 years of follow-up.

SETTING

Ten Veterans AFFAIRS (VA) sites.

PARTICIPANTS

Four thousand seventy-one ambulatory patients aged 80 and older with hypertension.

MEASUREMENTS

The outcome measure was likelihood of survival during the follow-up period. Vital status was obtained from VA and Social Security files. Variables collected for adjustment in Cox regression models were baseline BP, medications, demographics, diagnoses, and health-related quality of life (HRQoL); HRQoL information was available on 1,289 subjects based on Veterans Health Study Short From-36 (SF-36) questionnaire scores.

RESULTS

Subjects with higher BP (up to a systolic BP (SBP) of 139 mmHg and a diastolic BP (DBP) of 89 mmHg) were less likely to die during follow-up than subjects with lower BP. After baseline adjustments, the hazard ratio for a 10-point increase in SBP was 0.82 (95% confidence interval (CI)=0.74-0.91), up to a SBP of 139 mmHg, and for DBP was 0.85 (95% CI=0.78-0.92), up to a DBP of 89 mmHg. There was no significant association between survival and BP levels in subjects with uncontrolled hypertension.

CONCLUSION

In a cohort of very old, hypertensive veterans, in subjects with controlled BPs, subjects with lower BP levels had a lower 5-year survival than those with higher BPs. This suggests that clinicians should use caution in their approach to BP lowering in this age group.

Recurrences and second primary breast cancers in older women with initial early-stage disease

BACKGROUND

The association between common breast cancer therapies and recurrences and second primary breast cancers in older women is unclear, although older women are less likely to receive common therapies.

METHODS

Women aged >or=65 years who were diagnosed with stage I or II breast cancer and who underwent mastectomy or breast-conserving surgery (BCS) from 1990 to 1994 were identified from automated data from 6 healthcare systems and then were followed for 10 years or until breast cancer recurrence, disenrollment, or death. Trained abstractors reviewed medical records to obtain recurrence, tumor, treatment and demographic data. The authors used proportional hazards models to examine predictors of recurrent and second primary breast cancers adjusted for demographic and tumor factors.

RESULTS

Of 1837 eligible women, 34% were ages 65 to 69 years, 46% were ages 70 to 79 years, and 20% were aged >or=80 years. In multivariable models that used mastectomy as the reference group, BCS without radiation therapy was associated with an increased risk of any recurrent and second primary breast cancer (hazard ratio [HR], 1.6; 95% confidence interval [CI], 1.1-2.3), particularly with the subgroup of women with local and regional recurrence (HR, 3.5; 95% CI, 2.0-6.0). Tamoxifen use for <1 year versus >or=5 years exhibited a borderline association with any recurrent or second primary breast cancer (HR, 1.9; 95% CI, 0.9-4.2).

CONCLUSIONS

Radiation therapy after BCS and 5 years of tamoxifen use were beneficial in reducing recurrences and second primary breast cancers in older women, regardless of their age or comorbidity burden.

Older breast cancer survivors: factors associated with change in emotional well-being

PURPOSE

During the 5 years after primary breast cancer diagnosis for women 65 years old, we examined factors associated with change in emotional well-being.

PATIENTS AND METHODS

We identified women diagnosed with primary breast cancer and selected women with stage I to IIIa disease, age 65 years, and for whom we had permission from the attending physician to contact. Data were collected during 5 years of follow-up from consenting patients' medical records and telephone interviews with patients. Outcomes included a five-question Mental Health Inventory general measure of emotional health (MHI5) and two cancer-specific measures: breast cancer-specific emotional health (BCSEH) and Cancer Rehabilitation Evaluation System-Short Form (CARES-SF) Psychosocial Summary Scale.

RESULTS

During 5 years of follow-up of older breast cancer survivors, 57% had less than a +/- 10-point change in MHI5, 38% had less than a +/- 10-point change in BCSEH, and 52% had less than a +/- 10-point change in CARES-SF Psychosocial Summary Scale. Women with less than 12 years of education were at greatest risk for having negative changes in both general and breast cancer-specific emotional health. Moreover, we also found that women who perceived themselves as never being cured had greater negative changes in all outcomes. Conversely, those who had better physical function, emotional social support, and positive ratings regarding the quality of medical interactions at baseline were less likely to have poor emotional health during follow-up.

CONCLUSION

For the majority of older breast cancer survivors, cancer-specific well-being and general emotional health do not change substantially after a breast cancer diagnosis. Among those in whom change occurs, risk factors are similar and may be related to other age-related diseases.

Predictors of subjective memory complaint in cognitively normal relatives of patients with Alzheimer's disease

The authors utilized a family-based, case-control study to identify factors predicting subjective memory complaint in relatives of Alzheimer's disease patients. The authors ascertained 1,499 cognitively healthy relatives of Alzheimer's disease patients at 15 centers, who contributed demographic and medical information, including self-assessment of memory. First-degree relatives of Alzheimer's disease patients reported subjective memory complaint more than spouses of Alzheimer's disease patients. Relatives with past depression symptoms endorsed subjective memory complaint more than those without such history. Clinicians counseling family members of Alzheimer's disease patients who express subjective memory complaint should first evaluate cognition. If cognition is intact, depression should be considered.

Breast cancer treatment of older women in integrated health care settings

PURPOSE

A substantial literature describes age-dependent variations in breast cancer treatment, showing that older women are less likely to receive standard treatment than younger women. We sought to identify patient and tumor characteristics associated with the nonreceipt of standard primary tumor and systemic adjuvant therapies.

PATIENTS AND METHODS

We studied 1,859 women age 65 years or older with stage I and II breast cancer diagnosed between 1990 and 1994 who were cared for in six geographically dispersed community-based health care systems. We collected demographic, tumor, treatment, and comorbidity data from electronic data sources, including cancer registry, administrative, and clinical databases, and from subjects' medical records.

RESULTS

Women 75 years of age or older and women with higher comorbidity indices were more likely to receive nonstandard primary tumor therapy, to not receive axillary lymph node dissection, and to not receive radiation therapy after breast-conserving surgery (BCS). Asian women were less likely to receive BCS, and African American women were less likely to be prescribed tamoxifen. Although nonreceipt of most therapies was associated with a lower baseline risk of recurrence, an important minority of high-risk women (16% to 30%) did not receive guideline therapies.

CONCLUSION

Age is an independent risk factor for nonreceipt of effective cancer therapies, even when comorbidity and risk of recurrence are taken into account. Information regarding treatment effectiveness in this age group and tools that allow physicians and patients to estimate the benefits versus the risks of therapies, taking into account age and comorbidity burden, are critically needed.

Effect of undertreatment on the disparity in age-related breast cancer-specific survival among older women

OBJECTIVES

Assess the relationship between age and breast cancer-specific survival among older women and determine whether the observed age-related disparities in survival is explained by differences in breast cancer treatments received.

METHODS

Women > or =65 years old at diagnosis with stage I-IIIA breast cancer diagnosed between 1997 and 1998 were recruited from four regions of the United States and followed prospectively for 5 years after diagnosis. Data was obtained from tumor registries, medical records, and telephone interviews. The primary endpoint was breast cancer-specific survival. Our independent variables were age operationalized as < or =75 years vs. >75 years, and receipt of recommended guideline therapy, adapted from the National Institutes of Health guideline consensus conference.

RESULTS

Of 689 women, 36% were >75 years. Women >75 years were less likely to have received the following; axillary lymph node dissection (84% vs. 93%, P = 0.0003), radiotherapy (40% vs. 54%, P = 0.0003), definitive primary therapy (71% vs. 84%, P < 0.0001), chemotherapy (9% vs. 28%, P < 0.0001), and guideline therapy (31% vs. 54%, P < 0.0001). The 5-year breast cancer-specific survival was 95% (95% confidence interval [CI], 90%, 97%) for those < or =75 years who received guideline therapy, 94% (95% CI, 90%, 97%) for those < or =75 years who did not receive guideline therapy, 96% (95% CI, 88%, 99%) for those >75 years who received guideline therapy and 83% (95% CI, 74%, 89%) for those >75 years who did not receive guideline therapy, (P = 0.002) by the log-rank test.

CONCLUSION

Receipt of guideline therapy may reduce the age-related disparity in breast cancer survival among older women.

Reduced mortality rate associated with annual mammograms after breast cancer therapy

Guidelines have been developed for appropriate posttherapy surveillance for breast cancer recurrence. One purpose of posttherapy surveillance is to detect potentially curable local recurrences and new cancers in the opposite breast. The objective of this investigation was to assess the impact of annual mammography on all-cause mortality in breast cancer survivors. We conducted a case-control analysis nested in a cohort of 865 stage I or II breast cancer patients diagnosed from 1996 to 1999. The exposure variable was the number of mammograms received after completing primary therapy. Cases were decedents and we used risk-set sampling to match eight controls to each case on follow-up time. The mortality rate declined with an increasing number of mammograms (p for trend=0.007). The age- and therapy-adjusted odds ratio associating receipt of an additional mammogram, compared with receipt of no mammogram, equaled 0.77 (95% confidence interval [CI] 0.53-1.1). These results are consistent with a protective effect of regular surveillance mammography after completing therapy for early stage breast cancer.

Risk of decline in upper-body function and symptoms among older breast cancer patients

BACKGROUND

Decline in upper-body function and development of upper-body symptoms are adverse effects of breast cancer therapy and may affect functional independence, particularly among older survivors. The long-term risks and predictors are poorly understood.

OBJECTIVE

To characterize the risk of decline in upper-body function and development of symptoms over 4 years of follow-up.

DESIGN

We used a prospective cohort design.

PARTICIPANTS

Six hundred and forty-four early stage breast cancer patients 65 years old or older at surgery enrolled in Rhode Island, North Carolina, Minnesota, and Los Angeles between 1996 and 1999.

MEASUREMENTS

Upper-body function and symptoms were self-reported at baseline, 6, 15 months, and annually thereafter to 51 months after surgery.

RESULTS

One half of the participants had a decline in upper-body function and one-quarter developed upper-body symptoms. Breast cancer patients were 5-fold more likely to have a decline in upper-body function over 4 years of follow-up than a similar cohort without breast cancer. Better baseline mental health protected against a decline in upper-body function (odds ratio [OR]=0.93, 95% confidence interval [CI] 0.88 to 0.97 for 8-point higher mental health index). Baseline obesity (OR for body mass index [BMI] > or =30 kg/m2 vs <30 kg/m2=2.5, CI=1.6 to 4.0) and axillary node dissection (OR for axillary dissection vs not=3.9, CI=1.1 to 14) predicted the development of upper-body symptoms.

CONCLUSIONS

Primary care physicians should address upper-body function and symptoms with older breast cancer patients, and inform them that these complications of breast cancer treatment are common.

Adherence to tamoxifen over the five-year course

PURPOSE

To estimate the proportion of older women who fail to complete 5 years of tamoxifen therapy and to identify predictors of non-adherence.

PATIENTS AND METHODS

We followed 462 women 65-years-old or older with stage I-IIIA breast cancer diagnosed in four US regions between 1996 and 1999 and who initiated tamoxifen therapy. We interviewed patients annually to assess tamoxifen adherence and collected information about predictors of adherence by medical record review, patient interview, and physician questionnaire.

RESULTS

Thirty-one percent of patients who started tamoxifen failed to complete the recommended 5-year course. Patients who had initial severe side effects [hazard ratio (HR) per side effect=1.2, 95% confidence interval (CI) 0.97, 1.5] or developed them (HR per new side effect=1.3, 95% CI 1.0, 1.6) were more likely to discontinue. Patients with more prescription medications at baseline were less likely to discontinue (HR per baseline prescription equaled 0.90, 95% CI 0.81, 0.99), whereas patients who added a prescription were more likely to discontinue (HR per new prescription equaled 1.2, 95% CI 1.0, 1.4). Patients with positive views of tamoxifen at baseline (HR for a 10-point higher score=0.93, 95% CI 0.83, 1.0) and an improving view over follow-up (HR for a 10-point positive change=0.93, 95% CI 0.87, 1.0) were less likely to discontinue.

CONCLUSION

Five years of tamoxifen confers a significant benefit beyond 1-2 years of tamoxifen, so physicians should ask patients about side effects, other prescriptions, and beliefs about tamoxifen and should educate them about the benefits of completing adjuvant therapy.

Breast cancer survival of American Indian/Alaska Native women, 1973-1996

OBJECTIVE

To assess breast cancer mortality rates among American Indian/Alaska Native women compared with non-Hispanic White women in the five years after diagnosis.

METHODS

Surveillance, Epidemiology, and End Results data from 1973-1996 were used to compare survival in the two races, controlling for age, marital status, stage, and therapy.

RESULTS

The adjusted relative hazard of death was 58% higher for American Indian/Alaska Native women than for non-Hispanic White women (HR = 1.58, 95% Cl 1.26-2.00). The survival disparity persisted even when limited to women who received definitive therapy, i.e. mastectomy with axillary node dissection or breast-conserving surgery with axillary node dissection and radiation treatment (HR = 1.88, 95% Cl 1.40-2.52).

CONCLUSIONS

American Indian/Alaska Native women were at greater risk for breast cancer mortality than non-Hispanic White women, even when restricted to women who received definitive breast cancer therapy.

Physicians' Assessments of Adjuvant Tamoxifen's Effectiveness in Older Patients with Primary Breast Cancer

OBJECTIVES

To examine physicians' assessments of tamoxifen effectiveness in breast cancer patients, identify predictors of these assessments, and estimate the relationship between these assessments and receipt of tamoxifen prescription.

DESIGN

A cohort of breast cancer patients aged 65 and older at diagnosis and their physicians were surveyed using mailed questionnaires and telephone interviews.

SETTING

Community and academic hospitals in Rhode Island; North Carolina; Minnesota; and Los Angeles, California between 1996 and 1998.

PARTICIPANTS

Physicians completed treatment recommendation forms for 496 of 865 Stage Ic to IIIa breast cancer patients.

MEASUREMENTS

Visual scales measured physicians' assessments of the risk that individual patients would have a breast cancer recurrence or die of breast cancer with, and without, tamoxifen therapy.

RESULTS

The mean risk ratio+/-standard deviation comparing risk of recurrence without tamoxifen with the risk with tamoxifen was 1.8+/-1.0 and for breast cancer mortality was 1.8+/-1.2. Only estrogen-receptor status and enrollment site emerged as significant predictors of recurrence and mortality risk ratios in regression models. Patients for whom the physician estimated that the recurrence or mortality risk doubled without tamoxifen were more likely to receive a tamoxifen prescription than patients for whom the physician estimated that tamoxifen would have no effect (odds ratio (OR)=1.4, 95% confidence interval (CI)=0.98-2.1 for recurrence risk, OR=1.8; 95% CI=1.2-2.6 for mortality risk).

CONCLUSION

Estrogen receptor status most strongly influenced physicians' assessments of tamoxifen's effectiveness in individual patients; this effectiveness was not found to be associated with advancing patient age. Estrogen receptor status and enrollment site were related to receipt of tamoxifen prescription, but advancing age was not after accounting for physician's individualized assessment of tamoxifen's effectiveness. These findings suggest that an evidence-based approach for hormonal therapy has been widely adopted for care of older patients with breast cancer.

Predictors and outcomes of surgeons' referral of older breast cancer patients to medical oncologists

BACKGROUND

Older women are less likely than younger women to receive definitive care for a new diagnosis of breast cancer, but the reasons are not well understood. Although coordination of referral among specialists is an important component of quality of care, it has not been studied as a factor that contributes to observed age-related variations in breast cancer care.

METHODS

Treatment recommendations by 191 surgeons of 559 patients aged > or = 65 years with Stage I to IIIa breast cancer provided patient-specific assessments of comorbidity and medical oncologist referral. Demographic, tumor, and treatment characteristics from medical records and telephone interviews were evaluated by statistical regression methods to identify factors associated with referral to a medical oncologist and to evaluate whether a referral resulted in discussion and prescription of tamoxifen.

RESULTS

Estrogen receptor protein negativity and higher tumor stage increased the likelihood of referral (odds ratio [OR] = 5.6, 95% confidence interval [CI] = 1.9-16.7, and OR = 4.2, 95% CI = 1.7-10.3, respectively), whereas a moderate to severely ill health status decreased the likelihood of referral (OR = 0.4, 95% CI = 0.2-0.9). Those referred were twice as likely to report having a discussion about tamoxifen (OR = 2.0, 95% CI = 1.06-3.7) and to have been prescribed tamoxifen (OR = 2.1, 95% CI = 0.99-4.3).

CONCLUSIONS

Referral to medical oncologists is associated with receipt of adjuvant tamoxifen therapy. The current study findings suggest that more consistent referral of older women to medical oncologists may enhance quality of discussion and participation in decisions concerning treatment options.

Breast cancer treatment in older women: impact of the patient-physician interaction

OBJECTIVES

To assess the impact of the patient-physician interaction on breast cancer care in older women.

DESIGN

Cross-sectional survey.

SETTING

Los Angeles County, California.

PARTICIPANTS

Two hundred twenty-two consecutively identified breast cancer patients aged 55 and older who were within 6 months of breast cancer diagnosis and/or 1 month posttreatment.

MEASUREMENTS

Dependent variables were patient breast cancer knowledge, treatment delay, and receipt of breast-conserving surgery (BCS). Key independent variables were five dimensions of the patient-physician interaction by patient report, including physician provision of tangible and interactive informational support, physician provision of emotional support, physician participatory decision-making style, and patient perceived self-efficacy in the patient-physician interaction. Age and ethnicity were additional important independent variables.

RESULTS

In multiple logistic regression models, only physician interactive informational support had significant relationships with all three dependent variables, controlling for a wide range of patient sociodemographic and case-mix characteristics, visit length, number of physicians seen, social support, and physician sociodemographic and practice characteristics. Specifically, informational support positively predicted patient breast cancer knowledge (adjusted odds ratio (AOR)=1.18, 95% confidence interval (CI)=1.00-1.38), negatively predicted treatment delays (AOR=0.80, 95% CI=0.67-0.94), and positively predicted receipt of BCS (AOR=1.29, 95% CI=1.07-1.56). Age and ethnicity were not significant predictors in these models.

CONCLUSION

One specific domain of the patient-physician interaction, interactive informational support, may provide an avenue to ensure adequate breast cancer knowledge for patient treatment decision-making, decrease treatment delay, and increase rates of BCS for older breast cancer patients, thereby potentially mitigating known healthcare disparities in this vulnerable population of breast cancer patients.

Reduced rates of cancer-related worries and mortality associated with guideline surveillance after breast cancer therapy

OBJECTIVE

Guidelines have been developed for appropriate post-therapy surveillance for breast cancer recurrence. Two objectives of post-therapy surveillance are to support and counsel patients and to detect potentially curable local recurrences and new cancers in the opposite breast. The objective of this investigation was to assess the impact of guideline surveillance (history, physical examination, and annual mammography) on cancer-related worries and all-cause mortality.

STUDY DESIGN AND SETTING

We collected data on a cohort of 303 Massachusetts women with stages I or II breast cancer diagnosed between 1992 and 1994. Cases were women with increasing cancer-related worries or decedents. We used risk-set sampling to match five controls to each case on follow-up time. Cases and members of their matched risk set were characterized with respect to receipt of guideline surveillance and covariates preceding the date of their outcomes.

RESULTS

The adjusted odds ratio associating guideline surveillance in the preceding year with an increase in cancer-related worries equaled 0.37 (95% CI = 0.14-0.99). The adjusted odds ratio associating continuous guideline surveillance with all-cause mortality equaled 0.66 (95% CI = 0.51-0.86).

CONCLUSION

The results are consistent with the stated objectives of surveillance follow-up of breast cancer patients after the completion of their primary therapy.

Faculty Development in Geriatrics for Clinician Educators: A Unique Model for Skills Acquisition and Academic Achievement

As the size of the aged American population increases, so too does the shortage of trained providers in geriatrics. Educational strategies to train physicians at all levels of experience within adult medical and surgical disciplines are needed to complement fellowship training, given the small size of most academic faculties in geriatrics. This article describes a unique faculty development program that creates geriatrically oriented faculty in multiple disciplines. The Boston University Center of Excellence in Geriatrics (COE), funded by the John A. Hartford Foundation, has trained 25 faculty members. Four to six scholars enter the program each year and participate in the COE 1 day per week. Nine months are spent in four content modules-Geriatrics Content, Clinical Teaching, Evidence-based Medicine, and Health Care Systems; 3 months are spent in supervised scholarly activities and clinical settings. A self-report questionnaire and a structured interview were used to evaluate the outcomes of participation in the COE. The results from the first 4 years of the program are reported. The response rate was 83% for the self-report questionnaire and 75% for the structured interview. The results indicate that the COE is effective in improving scholars' assessment and management of older patients. The structured interview revealed that the COE program promotes the integration of geriatrics into clinical teaching at the medical student and resident level. Participants also completed scholarly projects in geriatrics. This program effectively trains faculty scholars to better care for older adults and to teach others to do likewise.

Mental health outcomes in older women with breast cancer: Impact of perceived family support and adjustment

OBJECTIVES

(1) To examine the mental health of older women with breast cancer in relation to support provided by, and the adjustment of, significant others including partners, children, and other family members or friends and (2) to document how often physicians address the women's significant others and the helpfulness of doing so.

METHODS

A cross-sectional survey of newly diagnosed breast cancer patients aged 55 years or older (n = 222) was conducted.

RESULTS

Partners, and in many instances children and other family members or friends, provided support. Support from partners and adjustment of both partners and children independently predicted less depression and anxiety among the study participants. For racial/ethnic minorities, support from, and adjustment of, adult children assumed particular importance. Nonetheless, women reported that their physicians rarely asked their significant others how they were coping (15%) or referred them to a support group (3%), even though both behaviors were rated as extremely helpful.

CONCLUSION

For older women with breast cancer, both partners and adult children were important sources of support and their adjustment affected the women's mental health. Support sources and their impact on women's mental health varied among racial/ethnic groups, suggesting the importance of culturally sensitive provision of care by clinicians.

Comorbidity: implications for research and practice in geriatric oncology

The aging of the population and the emergence of cancer as a major disease of older age require the development of new strategies of cancer management in older adults, in particular, strategies based on the special characteristics of older patients, such as the effects of concurrent health conditions, i.e. comorbidity. This paper is a consideration of the implications of current research on comorbidity for research and practice in geriatric oncology. Subjects include considerations of representative measures of comorbidity; sources of data; screening and early diagnosis; prognosis, treatment, and outcome; and physiological mechanisms. Recommendations for future research include the development of (a) more refined measures of comorbidity; (b) new studies of comorbidity and cancer treatment; (c) investigations of the contributions of comorbidity for geriatric assessment and a new generation of clinical trials, (d) examinations of physiological mechanisms linking comorbidity with health outcomes; and (e) the development of an epidemiology of comorbidity.