Pre-counseling education for low literacy women at risk of Hereditary Breast and Ovarian Cancer (HBOC): patient experiences using the Cancer Risk Education Intervention Tool (CREdIT)

The Cancer Risk Education Intervention Tool (CREdIT) is a computer-based (non-interactive) slide presentation designed to educate low-literacy, and ethnically and racially diverse public hospital patients at risk of Hereditary Breast and Ovarian Cancer (HBOC) about genetics. To qualitatively evaluate participants’ experience with and perceptions of a genetic education program as an adjunct to genetic counseling, we conducted direct observations of the intervention, semi-structured in person interviews with 11 women who viewed CREdIT, and post-counseling questionnaires with the two participating genetic counselors. Five themes emerged from the analysis of interviews: (1) genetic counseling and testing for breast/ovarian cancer was a new concept; (2) CREdIT’s story format was particularly appealing; (3) changes in participants’ perceived risk for breast cancer varied; (4) some misunderstandings about individual risk and heredity persisted after CREdIT and counseling; (5) the context for viewing CREdIT shaped responses to the presentation. Observations demonstrated ways to make the information provided in CREdIT and by genetic counselors more consistent. In a post-session counselor questionnaire, counselors’ rating of the patient’s preparedness before the session was significantly higher for patients who viewed CREdIT prior to their appointments than for other patients. This novel educational tool fills a gap in HBOC education by tailoring information to women of lower literacy and diverse ethnic/racial backgrounds. The tool was well received by interview participants and counselors alike. Further study is needed to examine the varied effects of CREdIT on risk perception. In addition, the implementation of CREdIT in diverse clinical settings and the cultural adaptation of CREdIT to specific populations reflect important areas for future work.

Adult daughters' influence on mothers' health-related decision making: an expansion of the subjective norms construct

This study of mother-adult daughter communication uses qualitative methods to explore the appropriateness of including adult daughters as referents in the measurement of subjective norms (a behavioral theory construct) related to the use of mammography and other health-related tests and services. The methods were chosen to approximate as closely as possible the mother-adult daughter relationship in the context of daily life. This inductive approach contrasts with the deductive origins of the construct. A sample of nine Mexican and Filipina immigrant and U.S.-born mothers and their adult daughters was recruited. Data were collected in two phases: (a) videotaped observations of mother-daughter dyads discussing health-related topics and (b) follow-up interviews designed to obtain an emic (insider) perspective of the videotaped interaction. Results show that adult daughters influence their mothers' ability to navigate the health care system and contribute to health-related decision making and behavior, suggesting that it may be appropriate to include adult daughters in the assessment of subjective norms.

Intention, subjective norms, and cancer screening in the context of relational culture

Research targeting disparities in breast cancer detection has mainly utilized theories that do not account for social context and culture. Most mammography promotion studies have used a conceptual framework centered in the cognitive constructs of intention (commonly regarded as the most important determinant of screening behavior), self-efficacy, perceived benefit, perceived susceptibility, and/or subjective norms. The meaning and applicability of these constructs in diverse communities are unknown. The purpose of this study is to inductively explore the social context of Filipina and Latina women (the sociocultural forces that shape people's day-to-day experiences and that directly and indirectly affect health and behavior) to better understand mammography screening behavior. One powerful aspect of social context that emerged from the findings was relational culture, the processes of interdependence and interconnectedness among individuals and groups and the prioritization of these connections above virtually all else. The authors examine the appropriateness of subjective norms and intentions in the context of relational culture and identify inconsistencies that suggest varied meanings from those intended by behavioral theorists.

Behavioral theory in a diverse society: like a compass on Mars

The behavioral theory constructs most often used to study mammography utilization-perceived benefit, perceived susceptibility, self-efficacy, intention, and subjective norms-have neither been developed nor sufficiently tested among diverse racial/ethnic subgroups. The authors explored these constructs and their underlying assumptions relating to the social context of Filipina and Latina women. The mixed-methods study included testing construct measures in the multilingual surveys of a concurrent intervention study of 1,463 women from five ethnic groups. An intensive inductive investigation then targeted Latina and Filipina women to elucidate connections between social context and individual screening behavior. In-depth interviews were conducted with 11 key informant scholars, 13 community gatekeepers, and 29 lay women, and a supplemental study videotaped and interviewed 9 mother-daughter dyads. Three social context domains emerged: relational culture, social capital, and transculturation and transmigration. The meaning and appropriateness of the five behavioral constructs were analyzed in relation to these domains. In contradistinction to tenets of behavioral theory, the authors found that social context can influence behavior directly, circumventing or attenuating the influence of individual beliefs; contextual influences, synthesized from multiple perspectives, can operate at an unconscious level not accessible to the individual; and contextual influences are dynamic, contingent on distal and proximal forces coming together in a given moment and are thus not consistent with an exclusive focus at the individual level. This article describes the study methods, summarizes main findings, and preview the detailed results presented in the other articles in this issue.

Induction chemotherapy followed by chemoradiation in locally advanced pancreatic cancer: an effective and well-tolerated treatment

AIMS

The treatment of locally advanced pancreatic cancer varies enormously both within the UK and internationally. Although chemoradiation is the treatment of choice in the USA, in the UK this modality is used infrequently because of concerns regarding both its efficacy and its toxicity. We reviewed our experience with induction chemotherapy and selective chemoradiation in an attempt to show that it is a well-tolerated treatment that may be superior to chemotherapy alone.

MATERIALS AND METHODS

Case notes of patients with locally advanced pancreatic cancer referred to the Velindre Cancer Centre between 1 March 2005 and 31 October 2007 were reviewed. Data on patient demographics, tumour characteristics, treatment and overall survival were collected retrospectively. Toxicity data during chemoradiation were collected prospectively. Patients who had non-progressive disease after 3 months of chemotherapy were planned for chemoradiation using three-dimensional conformal radiotherapy to a total dose of 4500-5040cGy in 25-28 daily fractions with gemcitabine as a radiosensitiser.

RESULTS

Of the 91 referrals, 69 (76%) were fit for active oncological treatment; 43/69 (62%) patients were considered for induction chemotherapy followed by chemoradiation and 16/43 (37%) patients received chemoradiation. The median overall survival for patients receiving primary chemotherapy (n=26) was 9.2 (6.8-11.9) months and was 15.3 (11.6-upper limit not reached) months for patients who received chemoradiation (n=16). During the induction chemotherapy 8/16 (50%) patients experienced grade 3/4 toxicity and there were five hospital admissions. During chemoradiation there were 6/16 (37.5%) cases of grade 3/4 toxicity and two hospital admissions. There were no treatment-related deaths. Overall, 94.5% of the intended radiotherapy dose and 84% of the concurrent chemotherapy dose was delivered.

CONCLUSIONS

In this UK network, about half of patients were considered for chemoradiation, but only 18% received it. Survival and treatment-related toxicity are consistent with data from other chemoradiation trials and in our series chemoradiation was tolerated better than chemotherapy alone. This supports the view that 'consolidation' chemoradiation is a viable treatment option that should be considered in selected patients with locally advanced non-metastatic pancreatic cancer.

Perceived susceptibility to illness and perceived benefits of preventive care: an exploration of behavioral theory constructs in a transcultural context

This article describes how the social context of transculturation (cultural change processes) and transmigration (migration in which relationships are sustained across national boundaries) can directly influence use of mammography screening. The authors conducted semistructured interviews with Latino and Filipino academics and social service providers and with U.S.-born and immigrant Latinas and Filipinas to explore direct and indirect influences of social context on health behavior (Behavioral Constructs and Culture in Cancer Screening study). Iterative analyses identified themes of the transcultural domain: colonialism, immigration, discrimination, and therapeutic engagement. In this domain, the authors examine two key behavioral theory constructs, perceptions of susceptibility to illness and perceptions of benefits of preventive medical care. The findings raise concerns about interventions to promote mammography screening primarily based on provision of scientific information. The authors conclude that social context affects behavior directly rather than exclusively through beliefs as behavioral theory implies and that understanding contextual influences, such as transculturation, points to different forms of intervention.

Theorizing social context: rethinking behavioral theory

Major behavioral theories focus on proximal influences on behavior that are considered to be predominantly cognitive characteristics of the individual largely uninfluenced by social context. Social ecological models integrate multiple levels of influence on health behavior and are noted for emphasizing the interdependence of environmental settings and life domains. This theory-based article explains how social context is conceptualized in the social sciences and how the social science conceptualization differs from and can broaden the analytic approach to health behavior. The authors use qualitative data from the Behavioral Constructs and Culture in Cancer Screening study to illustrate our conceptualization of social context. We conclude that the incorporation into health behavior theory of a multidimensional socioculturally oriented, theoretical approach to social context is critical to understand and redress health disparities in multicultural societies like the United States.

Respiratory movement of upper abdominal organs and its effect on radiotherapy planning in pancreatic cancer

AIMS

Radiotherapy for pancreatic cancer is complicated by the frequent overlapping of the planning target volume (PTV) and the organ at risk (OAR), limiting the dose that can be safely delivered to the tumour. Individualising the margins applied to the clinical target volume (CTV) may reduce OAR irradiation without increasing the risk of geographical miss. We quantified the movement of the pancreas with respiration and evaluated whether individualised margins based on this motion reduced the dose to OARs.

MATERIALS AND METHODS

Planning computed tomography scans were acquired in quiet breathing, held expiration and held inspiration. Organ motion was evaluated from displacement of a reproducible point within the pancreas in all directions. Two sets of plans (standard plan: P(stan); individualised plan incorporating movement data: P(ind)) were generated for each patient. The PTV and doses to OARs were evaluated for both sets of plans.

RESULTS

The mean (standard deviation) movement of the pancreas in the superior-inferior, lateral and anterior-posterior directions were 15.3 mm (4.3), 5.2 mm (3.5) and 9.7 mm (6.1), respectively. The use of individualised margins reduced the mean PTV volume by 33.5% (9.8) (P=0.0051). The proportional reductions in the percentage of kidney receiving >10 Gy, small bowel >45 Gy and liver >30 Gy were 63.7% (P=0.0051), 29.3% (P=0.0125) and 29.2% (P=0.0107), respectively. For the same level of OAR constraints, individualised margins allowed dose escalation in six of the 10 patients to a mean dose of 63.2 Gy.

CONCLUSIONS

The present study shows a simple way of incorporating organ motion into the planning process and can be adopted by any centre without major strain on healthcare resources. The use of individualised margins reduced PTV volume and the dose to OARs. This may offer an opportunity for dose escalation to try and further improve local control.

[Central auditory prosthesis]

Deaf patients with severe sensory hearing loss can benefit from a cochlear implant (CI), which stimulates the auditory nerve fibers. However, patients who do not have an intact auditory nerve cannot benefit from a CI. The majority of these patients are neurofibromatosis type 2 (NF2) patients who developed neural deafness due to growth or surgical removal of a bilateral acoustic neuroma. The only current solution is the auditory brainstem implant (ABI), which stimulates the surface of the cochlear nucleus in the brainstem. Although the ABI provides improvement in environmental awareness and lip-reading capabilities, only a few NF2 patients have achieved some limited open set speech perception. In the search for alternative procedures our research group in collaboration with Cochlear Ltd. (Australia) developed a human prototype auditory midbrain implant (AMI), which is designed to electrically stimulate the inferior colliculus (IC). The IC has the potential as a new target for an auditory prosthesis as it provides access to neural projections necessary for speech perception as well as a systematic map of spectral information. In this paper the present status of research and development in the field of central auditory prostheses is presented with respect to technology, surgical technique and hearing results as well as the background concepts of ABI and AMI.

Genotypic analysis of Mycobacterium leprae strains from different regions of India on the basis of rpoT

Mycobacterium leprae strains from Indian leprosy patients were analyzed using the six base tandem repeat, GACATC, in rpoT gene as genetic marker. DNA was extracted from slit-skin smears and nasal swabs of new untreated as well as treated leprosy patients living in different regions of India. PCR amplification of rpoT gene and sequencing of amplicons showed the presence of two genotype of M. leprae in this study, 73.4% having three copies (ancient Indian type) and 26.6% contain 4 copies (considered to be Japanese and Korean). These genotypes along with other short tandem repeats may help in studying the historical spread of disease and the strains of M. leprae disseminated by various human races that migrated to India from other places of Asia and European countries during our history.

Diversity of participants in clinical trials in an academic medical center: the role of the 'Good Study Patient?'

BACKGROUND

Only 2.5% of adults and even fewer minorities participate in cancer therapeutic trials. Researchers have concluded that many barriers to participation stem from how recruitment is performed by clinician investigators. The objective of the current research was to document specifically how these barriers impede recruitment in the clinical setting.

METHODS

The authors conducted a case study of recruitment in an academic medical center using ethnographic research methods (direct observation of provider-patient interactions and in-depth interviews with providers) to collect data. Qualitative data analysis was used to identify themes related to the provider's role in the recruitment processes.

RESULTS

In the clinics that were studied, the authors observed that providers subjectively assessed which patients seemed to be 'good study patients' to target for recruitment. 'Good study patients' were identified as those who were able to adhere to complex trial protocols, thus helping clinician researchers to complete studies in a timely and efficient manner. These patients were perceived as meticulous, proactive, and compliant; they were considered good communicators; and they were embedded in the kinds of strong social support networks that facilitated their trials participation.

CONCLUSIONS

The providers that were studied sought 'good study patients' for therapeutic trials because they wanted to perform studies in a timely and efficient manner. Future research should examine whether providers in other settings also target their recruitment efforts for this or other reasons. Further research also should consider whether differentially recruiting 'good patients' can impact the ethnic/racial diversity or other characteristics of trial participants in ways that may bias the outcomes or conclusions of therapeutic trials.

Hydrocephalus complicating a cervical spine fracture in a patient with ankylosing spondylitis

We present a case of obstructive hydrocephalus secondary to ascending spinal cord oedema, sustained after cervical spine fracture in a patient with ankylosing spondylitis. To our knowledge, this is the first report of ascending oedema from a cervical cord injury causing obstructive hydrocephalus.

BRCA testing in underserved women: a qualitative study of intepretations and impacts

Abstract #3109

Background: As BRCA testing becomes more available to underserved populations, it is important to understand how the BRCA testing process is interpreted by these patients and their families. It is also essential to study the medical and psycho-social effects of BRCA testing for underserved populations. This study aims to explore the impact of BRCA results and the process of BRCA testing in underserved women.
 Methods: Underserved women at San Francisco General Hospital (SFGH) who underwent BRCA testing received individual, in-depth, 1-2 hour, semi-structured interviews by a medical anthropologist. Interviews addressed: personal background, initial referral, delivery of test results, understanding of test results, sharing of test results and impact of testing and results on the patient and her family. Interviews were transcribed verbatim, coded using a qualitative data analysis system (Atlas-ti), and analyzed by two authors. Participants were chosen to include the diverse range of patients at SFGH.
 Results: Of 130 women at SFGH who received BRCA testing, 8 to date have been interviewed (age 35-56). Four had breast cancer. BRCA results include: 4 negative, 2 variant, and 2 positive. Six participants were white; 2 African American. Preliminary data analysis shows that the idea of genetic testing and counseling for breast cancer was completely new at the time of referral for most participants. Participants with breast cancer wanted testing for their children and siblings. "I definitely wanted to know…so that we would have information as far as my son and my sister, and we would have a heads up and know, because early detection is what saved my life." Participants who did not have cancer but who perceived a lot of cancer in the family were interested in and reassured by the genetic counseling/testing experience. “I've been held captive with the word “cancer” all my life." Those with inconclusive results (uninformative negative and variant) had a limited understanding of the implications of their test results for their cancer risk and that of their relatives and struggled with what to communicate to family members. An affected women with negative results said, "With my sister …we have the same parents, but if mine came back negative, I don't know if that means she's totally out of the dark for herself." Participants consistently had positive feelings about their experience with genetic counseling and testing.
 Conclusions: Given our sample size and methodology, it is not appropriate to generalize. But, this preliminary data suggests that many variables relate to individual understanding and interpretation of BRCA results including: cancer diagnosis and health status at time of testing; BRCA result; experience with counseling; and time since counseling and BRCA testing to process and interpret results.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3109.

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

Abstract #2101

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

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

Effects of phase duration and pulse rate on loudness and pitch percepts in the first auditory midbrain implant patients: Comparison to cochlear implant and auditory brainstem implant results

The auditory midbrain implant (AMI), which is designed for stimulation of the inferior colliculus (IC), is now in clinical trials. The AMI consists of a single shank array (20 contacts) and uses a stimulation strategy originally designed for cochlear implants since it is already approved for human use and we do not yet know how to optimally activate the auditory midbrain. The goal of this study was to investigate the effects of different pulse rates and phase durations on loudness and pitch percepts because these parameters are required to implement the AMI stimulation strategy. Although each patient was implanted into a different region (i.e. lateral lemniscus, central nucleus of IC, dorsal cortex of IC), they generally exhibited similar threshold versus phase duration, threshold versus pulse rate, and pitch versus pulse rate curves. In particular, stimulation with 100 mus/phase, 250 pulse per second (pps) pulse trains achieved an optimal balance among safety, energy, and current threshold requirements while avoiding rate pitch effects. However, we observed large differences across patients in loudness adaptation to continuous pulse stimulation over long time scales. One patient (implanted in dorsal cortex of IC) even experienced complete loudness decay and elevation of thresholds with daily stimulation. Comparing these results with those of cochlear implant and auditory brainstem implant patients, it appears that stimulation of higher order neurons exhibits less and even no loudness summation for higher rate stimuli and greater current leakage for longer phase durations than that of cochlear neurons. The fact that all midbrain regions we stimulated, which includes three distinctly different nuclei, exhibited similar loudness summation effects (i.e. none for pulse rates above 250 pps) suggests a possible shift in some coding properties that is affected more by which stage along the auditory pathway rather than the types of neurons are being stimulated. However, loudness adaptation occurs at multiple stages from the cochlea up to the midbrain.

Recruiting low-income healthy women to research: an exploratory study

OBJECTIVE

The study goals were (1) to assess the feasibility of using an existing telephone health information and referral service for low-income, ethnically diverse women to recruit women for research participation; (2) to assess the feasibility of recruiting low-income, African American and Latino men into health research through the women callers to the telephone service; and (3) to describe the challenges women face and the strategies they use when talking to men about the men's health and research participation.

DESIGN

We recruited women for individual semi-structured qualitative interviews via the Every Woman Counts (EWC) telephone information and referral service, a California Department of Health Services Cancer Detection Program. This paper describes our eligibility and recruitment assessment, and our qualitative data from 23 interviews with low-income African American and Latino women who called EWC.

RESULTS

We found that it was feasible to recruit women, but not to recruit men through women who call this telephone service. Almost 50% (113) of women demographically eligible for recruitment, completed our screening questionnaire, despite calling EWC for a different purpose. Some 48% (54) of those women were eligible for an interview. Of interview-eligible women, 58% (10) of African Americans and 35% (13) of Latinos completed an interview. Only 17% (4) of women referred a man for participation in an interview for our study. Several themes emerged from our analysis of interview data: (1) women's role in men's health can be significant but is often uneasy; (2) challenges when talking to men about their health include health access, gender dynamics, and men's fear of health care; (3) women's understanding of research may be limited; (4) women use a range of strategies to address and overcome men's resistance to taking care of their health and participating in research.

CONCLUSIONS

The challenges women face when talking with men about their health affect their ability to effectively speak to men about research participation. However, EWC and similar telephone health services may be an effective means for recruiting low-income women to chemoprevention and other studies requiring healthy participants.