Patient compliance is critical for equivalent clinical outcomes for breast cancer treated by breast-conservation therapy

Modifiable Barriers and Facilitators for Breast Cancer Care: A Thematic Analysis of Patient and Provider Perspectives

INTRODUCTION

We sought to examine patient and provider perspectives regarding modifiable contributors to breast cancer treatment and to assess perceptual alignment between these two groups.

MATERIALS

Participants were women≥18 y with stage 0-IV breast cancer who received all oncologic care in a single health system and physicians and advanced practice providers who provided medical, radiation, or surgical oncology care for breast cancer. All completed ∼45-min semistructured interviews that were recorded and transcribed verbatim. A 5-stage approach to thematic analysis was conducted, with emergent themes and exemplar quotes placed into clinical, psychological, social/logistical, financial, and lifestyle categories using a multilevel conceptual framework.

RESULTS

Eighteen patients (9 Black, 9 White, and median age 60 y) and 10 providers (6 physicians and 4 advanced practice providers) were interviewed from May to November 2018. Both patients and providers perceived suboptimal communication, parking and transportation, and competing family-caregiving responsibilities as modifiable barriers to care. Treatment costs were cited by patients as barriers that were inadequately addressed even with referrals to financial counselors, but providers did not raise the issue of cost unless prompted by patients and did not feel prepared to discuss the topic when it arose. Providers cited obesity as a barrier to treatment, a view not shared by patients.

CONCLUSIONS

Several modifiable factors were recognized by both patients and providers as either promoting or detracting from treatment receipt, but there was also significant incongruence and asymmetry. Alignment of provider and patient perceptions regarding contributors to guideline-concordant care receipt could mitigate disparities in breast cancer treatment and outcomes.

Facing problems in radiotherapy for breast cancer patients in Yogyakarta, Indonesia: A cohort retrospective study

BACKGROUND

The aim of this study is to explore problems in radiotherapy for breast cancer patients in Yogyakarta, Indonesia, focusing on overall treatment time (OTT) and completion rate.

METHODS

A retrospective cohort study was conducted based on data from the Insurance Unit at a tertiary hospital in Yogyakarta, Indonesia. The study included all female outpatients with breast cancer who were treated with radiotherapy from January to December 2017 and met the inclusion criteria. The primary outcomes were OTT and completion rate. The secondary outcomes included the number of radiotherapy fractions, radiotherapy doses, number of radiotherapy interruption days, and reasons for radiotherapy interruption. The chi-squared and Mann-Whitney U tests were used to assess the differences in outcomes between two insurance schemes (JKN-PBI (Beneficiaries of Health Insurance Contribution Assistance) and JKN-NON-PBI (Non-Beneficiaries of Health Insurance Contribution Assistance)).

RESULTS

The sample included 285 breast cancer patients (mean age: 53 years). The median OTT was 38 days (IQR: 17-48 days), with 123 (43.2%) patients having prolonged OTT. The completion rate was 57.9%. No significant differences in OTT (44.4% vs. 35.7%, p = 0.445) and completion rate (57.2% vs. 61.9%, p = 0.569) were found between the JKN-NON-PBI and JKN-PBI groups, respectively. In all, the data reported 3,022 interrupted days of radiotherapy across a total of 227 patients. The most common reason for radiotherapy interruption was unknown.

CONCLUSION

There are problems in timely delivery and low completion rate of radiotherapy among breast cancer patients in Indonesia. There are no significant differences in OTT and completion rate between the insurance schemes.

Changes in the survival of adult patients with metastasized melanoma with the approval of immune checkpoint inhibitors: A retrospective study from the United States database

BACKGROUND

Immune-checkpoint inhibitors (ICI) have revolutionized the treatment of metastatic melanoma. Ipilimumab and Ipilimumab-Nivolumab combination therapies were approved by the United States Food and Drug Administration in 2011 and 2015, respectively. We aimed to evaluate potential changes in the survival of patients with metastatic melanoma following the approval of these agents.

METHODS

We extracted data from the Surveillance, Epidemiology, and End Results (SEER) database (Nov 2021 submission). All patients aged 20 and above who were diagnosed with 'distant' melanoma (per 'combined summary stage') from 2007 through 2018 were included in the study. This time period was further sub-categorized into 2007-2010 (pre-ICI era), 2011-2014 (single-agent ICI era), and 2015-2018 (combination ICI era) based on the approval timeline of ICI.

RESULTS

The median overall survival (OS) was 8, 10, and 14 months in the pre-ICI, single-agent ICI, and combination ICI eras respectively (log-rank test, χ² = 189.03, p < 0.001). On Cox-proportional hazard analysis, patients diagnosed in the single-agent and combination ICI eras had a significantly lower risk of dying [HR 0.82 (95% CI 0.78-0.87) and 0.67 (0.64-0.71), respectively] compared to patients diagnosed in the pre-ICI era. Patients who were of the male gender, aged ≥ 65 years, and those receiving chemotherapy and/or radiotherapy were at a significantly higher risk of dying. Married individuals had a significantly lower risk of dying compared to patients who were divorced, separated, or widowed at the time of diagnosis. There was no significant difference in survival demonstrated among non-Hispanic blacks versus non-Hispanic whites.

CONCLUSION

Survival of patients with metastatic melanoma has improved in the era of immune checkpoint inhibitors. It implies that the survival of patients reported in trials can be correlated at a population level as well. Future analysis from the SEER database is needed when new data becomes available to see if there is a further increase in OS.

Impact of socioeconomic status on cancer staging, survival in non-small cell lung cancer

Purpose

We performed this study to evaluate the association of socioeconomic status (SES) factors with cancer-specific survival (CSS) of patients with non-small cell lung cancer (NSCLC). We further assessed the predictive value of a novel Tumor Node Metastasis (TNM)-SES staging system, combining the TNM stage with the SES stage.

Methods

Using the Surveillance, Epidemiology, and End Results (SEER) database, we selected 40,378 patients diagnosed with NSCLC from 2012 to 2016. Cox regression method and Harrell's concordance index (C-index) were performed to select the SES factors related to CSS and evaluate the predictive ability of the novel TNM-SES stage. We used Kaplan-Meier curves and a log-rank test to conduct a survival analysis.

Results

We identified four SES factors (marriage, insurance, education, and household income) associated with CSS and constructed the SES stage (SES-1 and SES-2). NSCLC patients with SES-2 stage (low SES) was associated with young adult, black race, male, squamous carcinoma, upper lobe site, and advanced stage. SES-2 stage patients were significantly associated with a dismal prognosis of patients with NSCLC, with a 21.0% increased risk (HR = 1.21, 95%CI (1.18-1.24), p < 0.001). The C-index of our novel TNM-SES stage was 0.732 [95% CI (0.728-0.736)], higher than the traditional TNM stage [0.717, 95% CI (0.715-0.719)], indicating superior predictive value.

Conclusion

Our population-based study indicated that SES was significantly associated with cancer staging and SCC in patients with NSCLC. Our novel TNM-SES staging system showed a superior predictive value to the traditional TNM stage. The impact of SES on patients with NSCLC should receive more concern in clinical management.

Perceived loss of resources and adherence to guidelines during the COVID-19 pandemic in Israel

Following the outbreak of the global COVID-19 pandemic, governments around the world issued guidelines designed to prevent contagion. This longitudinal study explored variables associated with citizens' adherence to these guidelines. Questionnaires were administered to a panel of Israeli citizens three times: in June (Time 1, n = 896), July (Time 2, n = 712) and August (Time 3, n = 662) 2020. The relationships of perceived loss of resources (e.g. stable employment) at Time 1 with adherence to guidelines at Time 2 and Time 3 were moderated by assumptions about controllability: The relationships were stronger for people who believed that appropriate behavior would lead to positive outcomes and prevent negative outcomes. The results indicate that messages about the pandemic should be accompanied by encouraging messages regarding the ability to control.

A comparison of timely completion of hypofractionated and traditional adjuvant radiation therapy in early-stage breast cancer: Evidence of impact on reducing racial and socioeconomic disparities

BACKGROUND

Timely completion of adjuvant radiation after breast conservation therapy is associated with decreased mortality and increased disease-free survival. Few data exist comparing timely completion between hypofractionated radiation and traditional radiation at a national level or across racial and socioeconomic cohorts.

METHODS

A retrospective review of the National Cancer Database (2012-2016) on patients undergoing breast conservation therapy for early-stage breast cancer, specifically T1 or T2, N0, M0 patients, was performed. Multivariable logistic regression models were used to compare timely completion of hypofractionated radiation (within 5 weeks of initiation) and traditional radiation (within 7 weeks) across patient, tumor, and facility characteristics.

RESULTS

In total, 210,816 patients met criteria, with 59.4% receiving traditional radiation (n = 125,140) and 40.6% receiving hypofractionated radiation (n = 85,676). Overall, 82.8% of patients achieved timely completion of radiation. Among hypofractionated radiation patients, 94.5% of patients achieved timely completion, whereas only 74.8% of traditional radiation patients achieved timely completion (P < .0001). Regarding race/ethnicity, all groups benefited substantially in timely completion of hypofractionated radiation over traditional radiation. However, both treatment cohorts demonstrated that Black (odds ratio (hypofractionated radiation) = 0.842, odds ratio (traditional radiation) = 0.821) and Hispanic (odds ratio (hypofractionated radiation) = 0.917, odds ratio (traditional radiation) = 0.907) patients had lower odds of timely completion compared to White patients (P < .0001). Lower high school graduation rate, median income for patients' ZIP code, and Medicaid were also associated with lower odds of timely completion for both hypofractionated radiation and traditional radiation (both P < .0001).

CONCLUSION

Timely completion of radiation therapy in breast conservation therapy is greater for patients receiving hypofractionated radiation than traditional radiation across racial and socioeconomic cohorts. Disparities in timely completion were substantially reduced with hypofractionated radiation utilization. However, there are treatment disparities across racial and socioeconomic cohorts that persist in both treatment groups.

The Impact of Socioeconomic Status on Staging, Prognosis in Hepatocellular Carcinoma

Purpose

We conducted this large population-based study to evaluate the impact of socioeconomic status (SES) factors on cancer-specific survival (CSS) of patients with hepatocellular carcinoma (HCC). We further assessed the value of a novel TNM-SES staging system, which incorporated these SES factors with TNM stage on staging and prognosis.

Methods

A total of 13,791 patients diagnosed with HCC from 2012 to 2016 were retrieved from one large population database. Cox proportional hazards regression model and Harrell’s concordance index (C-index) were used to identify the SES factors associated with CSS and analyze the prognostic value of TNM-SES stage. Kaplan–Meier curves and Log rank test were performed to evaluate CSS.

Results

Four SES factors (marital status, insurance status, education, household income) were identified as the prognostic factors associated with CSS. The SES-2 (lower SES) stage was significantly correlated to unfavorable CSS of the patients with HCC, with a 32.0% increased risk (HR = 1.32, 95% CI (1.26–1.39), P < 0.001), after adjusting for several confounders. The C-index of the TNM-SES stage was 0.735 (95% CI (0.729–0.741)) which was higher than that of the TNM stage (0.718, 95% CI (0.712–0.724)), indicating a high accuracy of prognostic prediction.

Conclusion

Our comprehensive study revealed that SES was significantly associated with prognosis of patients with HCC after adjusting several confounders. The novel TNM-SES staging system which combined TNM stage and SES stage had more superior predictive value than the traditional TNM stage. Disparity on SES should receive more attention for patients with HCC in clinical management.

Risk factors associated with loss to follow-up of breast cancer patients: A retrospective analysis

BACKGROUND

Loss to follow-up (LTFU) during post-operative surveillance of breast cancer patients is detrimental. The pattern of LTFU and its risk factors in Chinese breast cancer patients remains unknown.

METHOD

Eligible non-metastatic breast cancer patients who underwent surgery at our institution between 2009 and 2012 were included. The clinicopathological features, as well as the LTFU status, were retrieved from the REDCap database. LTFU was defined as the absence of patients for at least 12 months since her last contact. 5-year LTFU was defined as the LTFU status of each patients at 5 years after surgery. The incidence and potential risk factors of LTFU were analyzed. A LTFU-risk score was developed to quantify the risk of LTFU.

RESULTS

A total of 1536 patients with breast cancer were included, and 411(26.8%) patients were 5-year LTFU. 198 patients were LTFU in the first year. Univariate and multivariate analysis revealed that age (younger and older), a lack of medical insurance, longer distance from residence to the hospital, pathology (DCIS/Paget's/Phyllodes), lymph node metastasis, the absence of endocrine therapy and fewer than five contact numbers were significantly and independently associated with the risk of LTFU. A LTFU-risk score was developed and was predictive of LTFU.

CONCLUSIONS

A series of risk factors were significantly associated with post-operative LTFU of breast cancer patients. Patients with different risks of LTFU could possibly be identified, and surveillance plans could be individualized for different patients, so as to effectively reduce the overall LTFU rate, and optimize the allocation of medical resources.

Education level as a predictor of survival in patients with multiple myeloma

BACKGROUND

Disparities in multiple myeloma (MM) prognosis based on sociodemographic factors may exist. We investigated whether education level at diagnosis influenced Chinese MM patient outcomes.

METHODS

We performed a multicenter retrospective analysis of data from 773 MM patients across 9 centers in China from 2006 to 2019. Sociodemographic and clinical factors at diagnosis and treatment regimens were recorded, and univariate and multivariate analyses were performed.

RESULTS

Overall, 69.2% of patients had low education levels. Patients with low education levels differed from those with high education levels in that they were more likely to be older, and a higher proportion lived in rural areas, were unemployed, had lower annual incomes and lacked insurance. Additionally, compared to patients with high education levels, patients with low education levels had a higher proportion of international staging system (ISS) stage III classification and elevated lactate dehydrogenase (LDH) levels and underwent transplantation less often. Patients with high education levels had a median progression-free survival (PFS) of 67.50 (95% confidence interval (CI): 51.66-83.39) months, which was better than that of patients with low education levels (30.60 months, 95% CI: 27.38-33.82, p < 0.001). Similarly, patients with high education levels had a median overall survival (OS) of 122.27 (95% CI: 117.05-127.49) months, which was also better than that of patients with low education levels (58.83 months, 95% CI: 48.87-62.79, p < 0.001). In the multivariable analysis, patients with high education levels had lower relapse rates and higher survival rates than did those with low education level in terms of PFS and OS (hazard ratio (HR) = 0.50 [95% CI: 0.34-0.72], p < 0.001; HR = 0.32 [0.19-0.56], p < 0.001, respectively).

CONCLUSIONS

Low education levels may independently predict poor survival in MM patients in China.

Predictors of Whole Breast Radiation Therapy Completion in Early Stage Breast Cancer Following Lumpectomy

BACKGROUND

Whole breast radiation therapy (RT) has become standard of care in early stage breast cancer treatment following lumpectomy. Predictors of RT completion have been sparsely studied, with no previous nationwide examination of the impact of fractionation regimen on completion rate.

PATIENTS AND METHODS

The National Cancer Database identified patients with early stage breast cancer having undergone lumpectomy and RT from 2004 through 2015. Fraction size of 1.8-2.0 Gray (Gy) was defined as standard fractionation (SFRT); 2.66-2.70 Gy/fraction as hypofractionation (HFRT). RT completion was defined as receipt of at least 46 Gy for SFRT and 40 Gy for HFRT. A multivariable logistic regression model characterized RT completion predictors.

RESULTS

A total of 100,734 patients were identified where fraction size could be reliably characterized as above; more than 87% completed RT. Of these, 66.8% received SFRT, yet HFRT use significantly increased over time (5.2% increase/year; P < .0001). RT completion rates were significantly greater following HFRT (99.3%) versus SFRT (79.7%); patients receiving SFRT had higher odds of not completing RT (odds ratio, 41.5; 95% confidence interval, 36.6-47.1; P < .0001). Multivariable analysis revealed that African-American and Caucasian patients treated with SFRT versus HFRT had 22 and 43 times the odds of not completing RT, respectively (P < .0001).

CONCLUSIONS

SFRT remained the majority of RT fractionation in the studied time period, although HFRT use has increased over time. Patients residing > 10 miles from a treatment facility or of African-American race had lower odds of completing RT, as were patients treated with SFRT versus HFRT. These findings suggest compliance advantages of HFRT for patients with early stage breast cancer having undergone lumpectomy.

Health literacy: Impact on quality of life in head and neck cancer survivors

OBJECTIVES

Although inadequate health literacy has been shown to impact health outcomes in other cancers, little is known about its impact in head and neck cancer (HNC). This study aimed to determine the prevalence and predictors of inadequate health literacy and evaluate the association between health literacy and quality of life (QOL) in HNC survivors.

METHODS

We conducted a retrospective analysis of HNC survivors evaluated in a multidisciplinary HNC survivorship clinic. Survivors had to be ≥1-year postcompletion of treatment to be included in the analysis. Health literacy was assessed via self-report with the Brief Health Literacy Screen (score <10 indicating inadequate health literacy), and QOL was measured using the University of Washington QOL questionnaire. Linear regression with robust standard errors was utilized to evaluate the association between health literacy and QOL.

RESULTS

Of the 218 survivors evaluated, 13.8% (n = 30) demonstrated inadequate health literacy. After adjusting for age, marital status, site, stage, treatment modality, and years since treatment completion, social-emotional QOL scores for survivors with adequate health literacy were estimated to be 10.67 points higher than those with inadequate health literacy (P = .013). Health literacy was not significantly associated with physical QOL after adjusting for covariates (P = .130).

CONCLUSION

Inadequate health literacy is associated with a lower social QOL in HNC survivors, and among those with inadequate health literacy, interventions to ameliorate the impact on QOL are needed.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:2354-2359, 2020.

Communication with patients using negative wound pressure therapy and their adherence to treatment

Objective:

The purpose of this study was to explore the challenges of communication between patients and health professionals, and patient adherence to treatment for hard-to-heal wounds when using negative wound pressure therapy (NPWT).

Methods:

Face-to-face, semi-structured interviews were conducted with patients undergoing NPWT. Specific features of the NPWT device were the priority for discussion although other factors central to communication and adherence were also explored.

Results:

A total of 24 patients took part in the study. Data saturation was achieved during the analysis. Patients required ongoing support to understand complex and often protracted treatment and this was particularly important when specialist technology was used. A distinction was highlighted between those who decided not to adhere with therapy and those who did so unintentionally. Participants faced difficulties in their communications with health professionals and in ensuring their needs were listened to and addressed.

Conclusion:

Further research is needed to achieve a better understanding of this distinction and to evaluate interventions which can sustain adherence behaviours. Further exploration of how to establish concordant patient/health professional communications is warranted.

Compliance to treatment guidelines and survival in women undergoing interval debulking surgery for advanced epithelial ovarian cancer

BACKGROUND

One of the primary treatment strategies for advanced epithelial ovarian cancers includes neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS) and adjuvant chemotherapy. Compliance to treatment is important to possibly improve outcomes.

AIM

To audit treatment compliance and its effect on overall survival (OS) and disease free survival (DFS) in women undergoing IDS.

METHODS AND RESULTS

Women diagnosed with advanced epithelial ovarian cancer undergoing IDS were included. Details of compliance to chemotherapy and surgery as per standard guidelines were assessed, and correlation with survival was studied. Reasons for protocol deviation at various levels were documented and analysed. A total of 182 patients were included. The total number of deviations was 134 with deviation at any level being 89 (48.9%) and at all levels 5%. Both patient- and treatment-related factors contributed towards deviation. Deviation or noncompliance towards treatment resulted in a significantly reduced 5-year OS (34.4% vs 58.2%; P = .001) compared with compliant patients, which retained its significance on multivariate analysis (P = .024) as well.

CONCLUSION

Deviation from treatment guidelines resulted in a significantly lower 5-year OS compared with those who remained treatment compliant. Both patient- and treatment-related factors contributed towards noncompliance and hence towards lower survival.

Influence of Sociodemographic Factors on Treatment Decisions in Non-Small-Cell Lung Cancer

INTRODUCTION

In stage IV non-small-cell lung cancer (NSCLC), survival has significantly improved. Despite such trends, it has been noted that patients frequently refuse treatment. Therefore, we explored the factors associated with treatment refusal in NSCLC.

PATIENTS AND METHODS

Utilizing the National Cancer Data Base (NCDB), we identified all stage IV NSCLC cases from 2004 to 2014. Patients who received cancer treatment outside of the reporting facility were excluded. Multivariable logistic regression models were used to determine associations with treatment refusal.

RESULTS

A total of 341,993 patients were identified; 5.4% of patients refused radiotherapy and 10.3% refused chemotherapy despite provider recommendations. The proportion of patients refusing radiotherapy and chemotherapy increased over time from 4.2% to 7.3% and 7.9% to 15%, respectively (P < .001). In multivariable analysis, men were less likely to refuse treatment compared to women (respectively, odds ratio = 0.80; 95% confidence interval, 0.76-0.84; P < .001; odds ratio = 0.82; 95% confidence interval, 0.80-0.85; P < .001, respectively). Factors associated with radiotherapy refusal included: Medicaid or Medicare as primary insurance, uninsured status, low household median income, and lower educational level. Regarding chemotherapy, uninsured patients, Medicaid patients, and patients with a high comorbidity index were more likely to refuse chemotherapy. Asians had lower rates of chemotherapy refusal relative to non-Hispanic whites. Non-Hispanic whites, Hispanics, and Asians had increasing chemotherapy refusal rates over time, while non-Hispanic blacks had less pronounced trends over time.

CONCLUSION

Socioeconomic factors rather than race/ethnicity appear to influence the refusal of cancer treatment in patients with stage IV NSCLC. Assessing socioeconomic challenges should be an essential part of patient evaluation when discussing treatment options.

Marital status and survival in patients with rectal cancer: A population-based STROBE cohort study

To examine the impact of marital status on overall survival (OS) and rectal cancer-specific survival (RCSS) for aged patients.We used the Surveillance, Epidemiology and End Results database to identify aged patients (>65 years) with early stage rectal cancer (RC) (T1-T4, N0, M0) in the United States from 2004 to 2010. Propensity score matching was conducted to avoid potential confounding factors with ratio at 1:1. We used Kaplan-Meier to compare OS and RCSS between the married patients and the unmarried, respectively. We used cox proportion hazard regressions to obtain hazard rates for OS, and proportional subdistribution hazard model was performed to calculate hazard rates for RCSS.Totally, 5196 patients were included. The married (2598 [50%]) aged patients had better crude 5-year overall survival rate (64.2% vs 57.3%, P < .001) and higher crude 5-year cancer-specific survival rate (80% vs 75.9%, P < .001) than the unmarried (2598 (50%)), respectively. In multivariate analyses, married patients had significantly lower overall death than unmarried patients (HR = 0.77, 95% CI = 0.71-0.83, P < .001), while aged married patients had no cancer-specific survival benefit versus the unmarried aged patients (HR = 0.92, 95% CI = 0.81-1.04, P = .17).Among old population, married patients with early stage RC had better OS than the unmarried, while current evidence showed that marital status might have no protective effect on cancer-specific survival.

Marital status and survival in patients with non-small cell lung cancer: an analysis of 70006 patients in the SEER database

Marital status has been demonstrated to be related to the survival of patients in various cancer types, but the relationship in the large population of non-small cell lung cancer (NSCLC) has rarely been studied. In this study, we retrospectively extracted 70006 eligible NSCLC patients from the Surveillance, Epidemiology, and End Results (SEER) database in the period from 2004 to 2012. Marital status was categorized as married, divorced/separated, widowed, and never married. Chi-square tests were used to investigate the association between marital status and other variables. The Kaplan-Meier test was adopted to compare survival curves of different groups. Multivariate Cox regression analyses were conducted to estimate the effect of marital status on overall survival (OS) and NSCLC cause-specific survival (CSS). We further performed subgroup analyses according to TNM stage and surgery condition. The results showed that marital status was an independent prognostic factor for OS and CSS of NSCLC patients. Subgroup analyses showed that the relationship between marital status and prognosis varies according to different conditions. Widowed patients with surgery were at greater risk of death across all stages and non-surgical unmarried patients at advanced stages suffered poorer prognosis than the married. To conclude, in the NSCLC patients, married patients had advantage over the unmarried in both OS and CSS.

Marital status and survival in epithelial ovarian cancer patients: a SEER-based study

Marital status has been proved to be correlated to the survival of patients in various cancer types, except for that in the large female population of epithelial ovarian cancer (EOC). In this study, we retrospectively extracted 10905 eligible EOC patients from the Surveillance, Epidemiology, and End Results (SEER) database in the period from 2004 to 2012. We categorized marital status as married, divorced/separated, widowed, and never married. Chi-square test was used to investigate the association between marital status and other variables. The Kaplan-Meier test was adopted to compare survival curves of different groups. Multivariate Cox regression analyses were conducted to estimate the effect of marital status on overall survival (OS) and epithelial ovarian cancer-specific survival (EOCSS). To explore how marital status affected patients diagnosed at the same stage, we further performed subgroup analyses according to TNM stage. The results showed that marital status was an independent predictor for OS and EOCSS. Subgroup analyses indicated that the relationship between marital status and prognosis varied according to different conditions. Widowed patients had poorer prognosis than the other groups in most conditions, while the never married group showed similar risk of mortality as the married ones.

Prognostic value of marital status on stage at diagnosis in hepatocellular carcinoma

Marital status have been found as an independent prognostic factor for survival and spousal support could provide a survival advantage in various cancer types. However, the specific effect of marital status on survival in hepatocellular carcinoma (HCC) has not been explored in detail. In this study, we used the Surveillance, Epidemiology and End Results program to identify iagnosed with HCC between 1988 and 2007. Kaplan-Meier methods and multivariable Cox regression models were used to analyze long-term cancer-specific survival (CSS) outcomes and risk factors stratified by marital status. There were significant differences among these different marital status subgroups with regard to 5-year CSS rates (P < 0.001). Married HCC patients had a better 5 year CSS rate than those unmarried patients, and widowed patients were more likely to die of their cancer. A stratified analysis showed that widowed patients always had the lowest CSS rate across different cancer stage, age and gender subgroups. Even after adjusting for known confounders, unmarried patients were at greater risk of cancer-specific mortality. Social support aimed at this population could improve the likelihood of achieving cure.

Measurement of the Relationship between Patient Wait Time and Patient Satisfaction at each Stage of an Appointment

Patient satisfaction is associated with self-reported treatment compliance and patient outcomes. One factor that influences patient satisfaction is wait time– how long a patient waits during a visit to a health care facility. Here, we measured the time spent at each component of a patient's visit to a cancer treatment facility and its correlation with patient satisfaction. Results suggest that reducing the total time of a patient's visit to a health care facility will improve not only patient satisfaction with how long the entire visit takes, but also satisfaction with other aspects of the visit not including waiting. Moreover, results suggest that the time spent in the examination room waiting for the doctor is highly associated with patient satisfaction with overall time spent during the entire visit. In short, our results suggest several ways to improve patient satisfaction at a cancer treatment facility. The implication is that such improvements will lead to greater treatment compliance and ultimately to better patient outcomes.

EMDR Resource Methods for Women With Breast Cancer

The diagnosis and treatment of breast cancer can involve a series of life-altering, traumatic experiences, leading to distress, reduced quality of life, and long-standing fears of recurrence. Distress may exacerbate physical symptoms, impair coping, impact health behaviors, and reduce compliance with cancer treatment. Psychological treatments have focused on alleviating distress and improving quality of life. Given the growing evidence of the role of stress and behavior on cancer outcomes, a biobehavioral approach to treatment may serve to achieve these traditional treatment goals while also impacting disease course. Shapiro’s (2001) eye movement desensitization and reprocessing (EMDR) protocol for illness and somatic disorders was greatly informed by her interest in mind–body approaches to health and the newly emerging (1992) field of psychoneuroimmunology. The protocol includes first identifying and addressing the realistic fears and challenges a woman faces. Once appropriate, EMDR therapy turns to the reprocessing of past memories, present triggers, and the development of positive future templates of health. This article focuses on situations, usually in the early diagnosis and intensive phases of cancer treatment, when the reprocessing phases of EMDR therapy need to be delayed because of the demands of cancer treatment or insufficient client stability. Resourcing interventions that are compatible with biobehavioral goals are provided, with brief clinical examples.

Factors associated with radiation therapy incompletion for patients with early-stage breast cancer

PURPOSE

The purpose of the study was to examine factors associated with adjuvant radiation treatment (RT) incompletion for women with breast cancer within a large national cancer database.

METHODS

We identified 394,334 women diagnosed with stage I-III breast cancer during 2004-2012 in the national cancer database who initiated adjuvant external beam adjuvant RT and examined the proportion of women not completing treatment. We used multivariable logistic regression to examine patient, clinical, and facility factors associated with RT incompletion for those who had breast-conserving surgery (BCS), defined as <15 fractions and <3990 centiGray [cGy] (accounting for adoption of hypofractionation), and mastectomy (PMRT, defined as <5000 cGy and <25 fractions), separately. We also examined RT incompletion after BCS using more traditional definitions of <25 fractions and <4500 cGy for diagnosis years ≤2010.

RESULTS

Among the 319,003 women who underwent BCS and the 75,331 women who underwent mastectomy and initiated RT, 98.4 and 97.8 % completed radiation, respectively. In adjusted analyses, older age was associated with RT incompletion (odds ratio [O.R.] for age ≥80 = 2.53 for BCS-treated, 95 % confidence interval [CI] 2.19-2.92; O.R. for PMRT incompletion = 2.33, 95 % CI 1.84-2.96; both versus age <50). In addition, those with ≥2 comorbidities and lower-risk disease had higher odds of RT incompletion. After defining RT completion using more traditional definitions, 94.0 % completed treatment.

CONCLUSIONS

Reassuringly, we found a very low proportion of patients not completing RT, though we observed a higher likelihood for treatment incompletion in some sub-groups, most notably older women. Further studies should focus on reasons for treatment discontinuation in populations at risk for suboptimal treatment.

Factors associated with contralateral preventive mastectomy

INTRODUCTION

Contralateral prophylactic mastectomy (CPM) is an option for women who wish to reduce their risk of breast cancer or its local recurrence. There is limited data on demographic differences among patients who choose to undergo this procedure.

METHODS

The population-based Florida cancer registry, Florida's Agency for Health Care Administration data, and US census data were linked and queried for patients diagnosed with invasive breast cancer from 1996 to 2009. The main outcome variable was the rate of CPM. Primary predictors were race, ethnicity, socioeconomic status (SES), marital status and insurance status.

RESULTS

Our population was 91.1% White and 7.5% Black; 89.1% non-Hispanic and 10.9% Hispanic. Out of 21,608 patients with a single unilateral invasive breast cancer lesion, 837 (3.9%) underwent CPM. Significantly more White than Black (3.9% vs 2.8%; P<0.001) and more Hispanic than non-Hispanic (4.5% vs 3.8%; P=0.0909) underwent CPM. Those in the highest SES category had higher rates of CPM compared to the lowest SES category (5.3% vs 2.9%; P<0.001). In multivariate analyses, Blacks compared to Whites (OR =0.59, 95% CI =0.42-0.83, P=0.002) and uninsured patients compared to privately insured (OR =0.60, 95% CI =0.36-0.98, P=0.043) had significantly less CPM.

CONCLUSION

CPM rates were significantly different among patients of different race, socio-economic class, and insurance coverage. This observation is not accounted for by population distribution, incidence or disease stage. More in-depth study of the causes of these disparities in health care choice and delivery is critically needed.

Treatment preference, adherence and outcomes in patients with cancer: literature review and development of a theoretical model

OBJECTIVE

A patient's preference may guide their behavior and influence their willingness to take medication or undergo treatment affecting outcomes, such as health-related quality of life, or survival. The importance of understanding patient preferences within oncology is unclear and few adherence studies exist compared with other therapeutic areas.

RESEARCH DESIGN AND METHODS

This study was designed to review the literature regarding patient preferences, adherence and their link to outcomes specifically in the oncology setting and to propose a theoretical model. An in-depth review was conducted, using Embase, MEDLINE and Cochrane Library databases to search for published data examining patient preference, adherence and oncology-specific outcomes, from 1982-2012. Articles were reviewed independently by two authors and rated for relevance and quality. Information from high-quality articles and discussion with oncology and patient preference experts were used to identify associations between important individual concepts as a basis for a theoretical model.

RESULTS

In total, 1362 abstracts were identified. After removal of duplicates and initial review, 1269 were excluded and 93 reviewed in detail. Of these publications, 18 were deemed 'high-quality' and used to develop the final model. Variables associated with patient preference, adherence and outcome were identified. External variables included communication, treatment and mode of administration; patient beliefs and values were identified as cognitive variables; and adherence was attributed as a behavioral variable. Relationships between patient preference, adherence and clinical outcomes were established. Adverse events had a strong relationship with adherence; patient beliefs and values were identified as having a moderating effect on adherence. Adherence behavior had a direct relationship to outcomes.

CONCLUSIONS

Improving our understanding of patient preference may improve clinical outcomes in oncology patients. Although the proposed theoretical model is limited, it provides a basis to develop testable hypotheses for the relationships between patient preference, adherence and outcomes specific to oncology.

A Narrative Review of the Confluence of Breast Cancer and Low-wage Employment and Its Impact on Receipt of Guideline-recommended Treatment

Breast cancer is the leading cause of cancer among women in the United States, costing the healthcare system, employers, and society billions of dollars each year. Despite improvements in screening and treatment, significant breast cancer treatment and survivorship disparities exist among various groups of women. One variable that has not been explored extensively as a possible contributor to breast cancer treatment disparities is employment. This is concerning, given the changing economic and employment trends in the United States favoring low-wage employment. Currently, one-quarter to one-third of all US workers are considered to be working poor, and women are disproportionally represented in this group. Characteristics of low-wage work-limited paid time off, minimal health benefits, schedule inflexibility, and economic insecurity-may become even more significant in the event of a breast cancer diagnosis. To date, there has been limited research into how job conditions inherent to low-wage work may influence working poor survivors' receipt of guideline-recommended breast cancer treatment. Therefore, the purpose of this narrative review was to critically examine the current literature to further our understanding of how employment context may impact treatment decisions and adherence-and therefore receipt of guideline-recommended care-among newly diagnosed, working poor breast cancer survivors. After undertaking a comprehensive review, we failed to identify any published literature that explicitly addressed low-wage employment and receipt of guideline-recommended breast cancer treatment. Four articles reported circumstances where women delayed, missed, or quit treatments due to work interference, or alternatively, developed strategies that allowed them to continue to work and obtain their breast cancer treatment concurrent with medical and economic challenges. An additional five articles, while focused on other cancer and employment outcomes, described the need for increased patient-provider communication about the influence of work on treatment decisions and the development of alternative treatment plans. Due to the paucity of research in this area, future policy, practice, and research efforts should focus on the employment context of working poor breast cancer survivors as a potential contributor to cancer disparities. Engagement of women, employers, oncology providers, healthcare systems, and interdisciplinary researchers is warranted to improve cancer outcomes among this disparate population of working women.

Marital status and survival in patients with cancer

PURPOSE

To examine the impact of marital status on stage at diagnosis, use of definitive therapy, and cancer-specific mortality among each of the 10 leading causes of cancer-related death in the United States.

METHODS

We used the Surveillance, Epidemiology and End Results program to identify 1,260,898 patients diagnosed in 2004 through 2008 with lung, colorectal, breast, pancreatic, prostate, liver/intrahepatic bile duct, non-Hodgkin lymphoma, head/neck, ovarian, or esophageal cancer. We used multivariable logistic and Cox regression to analyze the 734,889 patients who had clinical and follow-up information available.

RESULTS

Married patients were less likely to present with metastatic disease (adjusted odds ratio [OR], 0.83; 95% CI, 0.82 to 0.84; P < .001), more likely to receive definitive therapy (adjusted OR, 1.53; 95% CI, 1.51 to 1.56; P < .001), and less likely to die as a result of their cancer after adjusting for demographics, stage, and treatment (adjusted hazard ratio, 0.80; 95% CI, 0.79 to 0.81; P < .001) than unmarried patients. These associations remained significant when each individual cancer was analyzed (P < .05 for all end points for each malignancy). The benefit associated with marriage was greater in males than females for all outcome measures analyzed (P < .001 in all cases). For prostate, breast, colorectal, esophageal, and head/neck cancers, the survival benefit associated with marriage was larger than the published survival benefit of chemotherapy.

CONCLUSION

Even after adjusting for known confounders, unmarried patients are at significantly higher risk of presentation with metastatic cancer, undertreatment, and death resulting from their cancer. This study highlights the potentially significant impact that social support can have on cancer detection, treatment, and survival.

The consequence of undertreatment of patients treated with breast conserving therapy for ductal carcinoma in-situ

BACKGROUND

The use of clinical features to allocate adjuvant therapy in the treatment of ductal carcinoma in situ with breast-conserving therapy remains controversial.

METHODS

A review of patients with ductal carcinoma in situ treated with breast-conserving therapy was performed. The recurrence rate was examined in relation to patient age, tumor characteristics, Van Nuys Prognostic Index, and the receipt of prescribed adjuvant therapies.

RESULTS

Six percent of patients (17 of 294) had developed local recurrences after a median follow-up period of 63 months. Fifty-nine percent of patients (91 of 154) with estrogen receptor-positive tumors did not receive prescribed tamoxifen. Thirty-one percent of patients (45 of 147) with Van Nuys Prognostic Index scores ≥7 did not receive recommended radiation therapy. Receipt of prescribed adjuvant therapy did not result in a decrease in the rate of local recurrence. Patient age was the only factor associated with local recurrence on univariate but not on multivariate analysis (P = .374).

CONCLUSIONS

A low rate of local recurrence was achieved despite a large number of patients' not receiving prescribed adjuvant therapies.

Adherence to recommended treatments for early invasive breast cancer: decisions of women attending surgeons in the breast cancer audit of Australia and New Zealand

AIM

The study aim was to determine the frequency with which women decline clinicians' treatment recommendations and variations in this frequency by age, cancer and service descriptors.

DESIGN

The study included 36,775 women diagnosed with early invasive breast cancer in 1998-2005 and attending Australian and New Zealand breast surgeons. Rate ratios for declining treatment were examined by descriptor, using bilateral and multiple logistic regression analyses. Proportional hazards regression was used in exploratory analyses of associations with breast cancer death.

RESULTS

3.4% of women declined a recommended treatment of some type, ranging from 2.6% for women under 40 years to 5.8% for those aged 80 years or more, and with parallel increases by age presenting for declining radiotherapy (p<0.001) and axillary surgery (p=0.006). Multiple regression confirmed that common predictors of declining various treatments included low surgeon case load, treatment outside major city centres, and older age. Histological features suggesting a favourable prognosis were often predictive of declining various treatments, although reverse findings also applied with women with positive nodal status being more likely to decline a mastectomy and those with larger tumours more likely to decline chemotherapy. While survival analyses lacked statistical power due to small numbers, higher risks of breast cancer death were suggested, after adjusting for age and conventional clinical risk factors, (1) for women not receiving breast surgery for unstated reasons (RR=2.29; p<0.001); and (2) although not approaching statistical significance p≥ 0.200), for women declining radiotherapy (RR=1.22), a systemic therapy (RR1.11), and more specifically, chemotherapy (RR=1.41).

CONCLUSIONS

Women have the right to choose their treatments but reasons for declining recommendations require further study to ensure that choices are well informed and clinical outcomes are optimized.

Predictors of non-compliance in autologous hematopoietic SCT patients undergoing out-patient transplants

Non-compliance has received significant attention in medicine, yet few studies have examined its correlates in autologous hematopoietic SCT (AHSCT) patients. This study examined predictors of non-compliance in a sample of 151 AHSCT patients treated in an outpatient setting. Before AHSCT, participants completed a validated measure of mood and retrospective chart reviews were conducted to assess non-compliance during AHSCT, defined as refusal of oral hygiene, prescribed exercise programs, oral nutrition and/or prescribed medications. We found 121 patients (80%) were non-compliant with an aspect of the AHSCT regimen on 1 or more days; mean percentage of non-compliant days was 16.6 (s.d. 15.6). Men were more likely than women to be non-compliant (P<0.05); as were participants with an elevated depression score (P<0.05). Stepwise regression models identified significant predictors of non-compliance: gender, depression, global distress and nausea and vomiting severity (P-values all <0.01). Further analysis revealed that the interaction of the psychological variables with gender was a more robust predictor of non-compliance (P<0.001). For outpatient AHSCT, our findings suggest the need to broaden conceptualizations of risk factors for non-compliance and the importance of assessing patient barriers to compliance to ensure optimal treatment outcome.

Cancer treatment adherence among low-income women with breast or gynecologic cancer: a randomized controlled trial of patient navigation

BACKGROUND

The authors implemented a controlled, randomized trial that compared 2 interventions: the provision of written resource navigation information (enhanced usual care [EUC]) versus written information plus patient navigation (TPN) aimed at improving adjuvant treatment adherence and follow-up among 487 low-income, predominantly Hispanic women with breast cancer or gynecologic cancer.

METHODS

Women were randomized to receive either TPN or EUC; and chemotherapy, radiation therapy, hormone therapy, and follow-up were assessed over 12 months. Patients with breast cancer were analyzed separately from patients with gynecologic cancer.

RESULTS

Overall adherence rates ranged from 87% to 94%, and there were no significant differences between the TPN group and the EUC group. Among women with breast cancer, 90% of the EUC group and 88% of the TPN group completed chemotherapy (14% of the EUC group and 26% of the TPN group delayed the completion of chemotherapy), 2% of the EUC group and 4% of the TPN group failed to complete chemotherapy, and 8% of the EUC group and 7% of the TPN group refused chemotherapy. Radiation treatment adherence was similar between the groups: Ninety percent of patients completed radiation (40% of the EUC group and 42% of the TPN group delayed the completion of radiation); in both groups, 2% failed to complete radiation, and 8% refused radiation. Among gynecologic patients, 87% of the EUC group and 94% of the TPN group completed chemotherapy (41% of the EUC group and 31% of the TPN group completed it with delays), 7% of the EUC group and 6% of the TPN group failed to complete chemotherapy, 6% of the EUC refused chemotherapy, 87% of the EUC group and 84% of the TPN group completed radiation (51% of the EUC group and 42% of the TPN with delays), 5% of the EUC group and 8% of the TPN group failed to complete radiation, and 8% of the EUC group and 5% of the TPN group refused radiation.

CONCLUSIONS

Treatment adherence across randomized groups was notably higher than reported in previous studies, suggesting that active telephone patient navigation or written resource informational materials may facilitate adherence among low-income, predominantly Hispanic women. Adherence also may have be facilitated by federal-state breast and cervical cancer treatment funding.

Computational analysis of non-adherence and non-attendance using the text of narrative physician notes in the electronic medical record

Non-adherence to physician recommendations is common and is thought to lead to poor clinical outcomes. However, no techniques exist for a large-scale assessment of this phenomenon. We evaluated a computational approach that quantifies patient non-adherence from an analysis of the text of physician notes. Index of non-adherence (INA) was computed based on the number of non-adherence word tags detected in physician notes. INA was evaluated by comparing the results to a manual patient record review at the individual sentence and patient level. The relationship between INA and frequency of Emergency Department visits was determined. The positive predictive value of identification of individual non-adherence word tags was 93.3%. The Pearson correlation coefficient between the INA and the number of documented instances of non-adherence identified by manual review was 0.62. The frequency of ED visits was more than twice as high for patients with INA in the highest quartile (least adherent) than for patients with INA in the lowest (most adherent) quartile (p < 0.0001). We have described the design and evaluation of a novel approach that allows quantification of patient non-adherence with physician recommendations through an analysis of physician notes. This approach has been validated at several levels and demonstrated to correlate with clinical outcomes.

Completion of adjuvant radiation therapy among women with breast cancer

BACKGROUND

Optimal treatment for breast cancer often involves lengthy multimodality care including 5 to 6 weeks of radiotherapy, but few studies have evaluated adherence to radiotherapy outside the context of a therapeutic clinical trial.

METHODS

Using a SEER-Medicare database, the authors identified women age 66 years or older with Stage I to III breast cancer diagnosed between 1992 and 2002. They evaluated rates of completion of radiotherapy, defined as a minimum of 25 sessions. Multivariate logistic regression analyses were performed to determine factors associated with completion of radiotherapy, and Cox multivariate models were used to determine the impact of radiotherapy completion on local recurrence.

RESULTS

Some 24,510 patients were included in the study. Eighty-seven percent of patients completed 25 or more radiotherapy sessions. In multivariate logistic regression models, mastectomy (HR 1.26, 95% CI 1.10-1.43), hospitalization during treatment (2.87, 2.49-3.31), earlier year of diagnosis, and black race (1.36, 1.14-1.63) were associated with increased risk of non-completion of radiotherapy. Among 21,269 patients treated with breast conservation, incomplete radiotherapy was associated with higher risk of local recurrence. A total of 96.6% [corrected] of patients who did not complete radiation therapy were free of recurrence at 5 years vs. 97.5% of patients who completed radiation therapy (HR 1.46, CI 1.09-1.95).

CONCLUSION

This study demonstrates relatively high rates of completion of radiation therapy among a population of older woman with breast cancer. However, those who did not complete a full course of radiotherapy had small but statistically significant higher risk of breast cancer recurrence. Future efforts should focus on intervening with women at high risk of not receiving adjuvant radiotherapy and increasing rates of radiotherapy completion.

Barriers to adequate follow-up during adjuvant therapy may be important factors in the worse outcome for Black women after breast cancer treatment

Introduction

Black women appear to have worse outcome after diagnosis and treatment of breast cancer. It is still unclear if this is because Black race is more often associated with known negative prognostic indicators or if it is an independent prognostic factor. To study this, we analyzed a patient cohort from an urban university medical center where these women made up the majority of the patient population.

Methods

We used retrospective analysis of a prospectively collected database of breast cancer patients seen from May 1999 to June 2006. Time to recurrence and survival were analyzed using the Kaplan-Meier method, with statistical analysis by chi-square, log rank testing, and the Cox regression model.

Results

265 female patients were diagnosed with breast cancer during the time period. Fifty patients (19%) had pure DCIS and 215 patients (81%) had invasive disease. Racial and ethnic composition of the entire cohort was as follows: Black (N = 150, 56.6%), Hispanic (N = 83, 31.3%), Caucasian (N = 26, 9.8%), Asian (N = 4, 1.5%), and Arabic (N = 2, 0.8%). For patients with invasive disease, independent predictors of poor disease-free survival included tumor size, node-positivity, incompletion of adjuvant therapy, and Black race. Tumor size, node-positivity, and Black race were independently associated with disease-specific overall survival.

Conclusion

Worse outcome among Black women appears to be independent of the usual predictors of survival. Further investigation is necessary to identify the cause of this survival disparity. Barriers to completion of standard post-operative treatment regimens may be especially important in this regard.

Health-related quality of life before and after a breast cancer diagnosis

While many reports describe health-related quality of life (QOL) among breast cancer survivors, few compare QOL before and after diagnosis and whether changes in QOL substantially differ from changes experienced by all women during aging. QOL was examined in a cohort of female residents of Beaver Dam, Wisconsin, aged 43-86 years at the time of a 1988-1990 baseline examination (N = 2,762; 83% of eligible). Participants were re-contacted four times through 2002 to ascertain QOL using the 36-item Short Form Health Survey (SF-36). QOL data for 114 incident breast cancer cases identified by data linkage with the statewide cancer registry were compared with data for 2,527 women without breast cancer. Women with breast cancer averaged 4.5 (95% CI: 1.6, 7.3) points lower than control women on the SF-36 Physical Component Summary (PCS) scale, regardless of time since diagnosis (up to 13 years). Women with breast cancer also reported lower scores on the SF-36 Mental Component Summary (MCS) scale within two years after diagnosis, but not at more distant times. In longitudinal analyses, 26 women who completed the SF-36 before and after breast cancer diagnosis experienced larger declines than age-matched controls in seven of the eight SF-36 health domains (all but role-emotional) and reported relative declines of -7.0 (95% CI: -11.5, -2.6) and -2.9 (95% CI: -6.3, 0.6) on the PCS and MCS scales, respectively. These results suggest that breast cancer survivors experience relative declines in health-related QOL across a broad spectrum of domains, even many years after diagnosis.

Health literacy, antiretroviral adherence, and HIV-RNA suppression: a longitudinal perspective

BACKGROUND

Low health literacy has been associated with worse adherence to antiretroviral therapy (ART) and higher HIV-RNA levels, but these relationships have not been evaluated in longitudinal analyses.

METHODS

We evaluated literacy using the Rapid Estimate of Adult Literacy in Medicine (REALM) (< or = 6th grade, 7th to 8th grade, > or = 9th grade) in the HIV-Alcohol Longitudinal Cohort study of HIV-infected persons with a history of alcohol problems, conducted from 1997 to 2001. We tested HIV-RNA levels and administered a standardized questionnaire regarding demographics, substance use, receipt of ART, and adherence with ART, every 6 months for up to 7 occasions. Among the 235 subjects on ART, we investigated the relationship between literacy and 2 outcomes: 100% 3-day self-reported adherence and HIV-RNA suppression (<500 copies).

RESULTS

Subjects' literacy levels were the following: 14% < or = 6th grade, 29% 7th to 8th grade, and 57% > or = 9th grade. In 66% of the observations (478/725), subjects reported 100% 3-day adherence with ART. Of the 685 HIV-RNA assays from these subjects, 62% had <500 copies. In unadjusted analyses, subjects with the lowest literacy level (< or = 6th grade) had a higher odds of adherence (odds ratio [OR] 2.23, 95% confidence interval 1.15 to 4.30) and HIV-RNA suppression (OR 2.01, 95% confidence interval 1.03 to 3.90) compared with those with > or = 9th grade literacy. This trend persisted but was no longer statistically significant in adjusted models of adherence (AOR 1.93, 95% confidence interval 0.86 to 4.31) and HIV-RNA suppression (AOR 1.70, 95% confidence interval 0.79 to 3.65).

CONCLUSION

Contrary to our hypothesis, low literacy was not associated with a lower odds of adherence or virologic suppression in this longitudinal analysis of HIV-infected patients with a history of alcohol problems. Indeed, trends in these data suggest the possibility that low literacy may be associated with a higher odds of adherence and virologic suppression. These counterintuitive findings underscore the need to pursue a fuller understanding of the mechanisms by which literacy affects health outcomes.

Satisfaction, utilisation and perceived benefit of individual psychosocial support for breast cancer patients--a randomised study of nurse versus psychologist interventions

OBJECTIVE

In a prospective, randomised study, individual psychosocial support performed by: (1) specially trained oncology nurses (INS) or (2) psychologists (IPS) were compared with respect to utilisation, satisfaction and perceived benefit.

METHODS

Between December 1997 and December 1999, consecutive breast cancer patients (n=120) were included at start of adjuvant therapy (chemo-, endocrine and/or loco-regional radiotherapy). Data were collected by an extended version of the 'IPS-patient satisfaction questionnaire' within 1 week after termination of the support intervention. Questionnaires were also mailed to all patients 6, 12 and 18-24 months after inclusion. Levels of distress were collected with the Hospital Anxiety and Depression Scale (HADS) and Impact of Event Scale (IES) questionnaires.

RESULTS

The patients were highly satisfied with the individual psychosocial support intervention they received, irrespective of which profession provided the support. However, the patients in the INS group reported higher levels of benefit regarding disease-related problems, regardless if the patients at baseline reported low or high levels of distress.

CONCLUSIONS

Patients were highly satisfied with an individual psychosocial support intervention. In areas dealing with somatic aspects, the group intervened by nurses were more satisfied than the one by psychologists.

PRACTICE IMPLICATIONS

Individual psychosocial support by specially trained nurses is a realistic alternative in routine cancer care.

Ductal Carcinoma in Situ: Trends in Geographic, Temporal, and Demographic Patterns of Care and Survival

While long-term prognosis is excellent, treatment of ductal carcinoma in situ (DCIS) remains controversial and inconsistent. The purpose of this study was to track geographic and temporal patterns of care for women diagnosed with DCIS, and analyze subsequent cancer-specific risk of mortality. Subjects for this study were 41,245 women diagnosed with primary DCIS in the National Surveillance, Epidemiology, and End Results (SEER) program from 1973 through 2000. Variables analyzed included patient age, year of diagnosis, SEER site of residence at the time of diagnosis, treatment (surgery, radiation), race, age, and hormone (estrogen and progesterone) receptor status. The percentage of women diagnosed with DCIS out of the total number of women diagnosed with breast cancer increased steadily between 1973 and 2000, with the largest increase occurring around 1985. Breast conserving surgery (BCS) utilization increased over time for each SEER site to the current proportions, ranging from 49.5% in Utah to 76.9% in Connecticut. Younger women were significantly more likely to receive mastectomy and had significantly lower risk of death. Women receiving BCS who also had radiation therapy (RT) had a significantly lower risk of death, although those receiving mastectomy had the lowest risk of death. Black women and Asian/Pacific island women were significantly more likely to receive BCS, although black women were less likely to receive follow-up RT and had a significantly increased risk of death. Racial and age differences in the treatment of DCIS resulted in significantly disparate rates of survival, which should be considered in public health programming. Mastectomy utilization resulted in improved survival, although additional studies may elucidate the interaction of treatment with patient age.

The challenge of patient adherence

Quality healthcare outcomes depend upon patients' adherence to recommended treatment regimens. Patient nonadherence can be a pervasive threat to health and wellbeing and carry an appreciable economic burden as well. In some disease conditions, more than 40% of patients sustain significant risks by misunderstanding, forgetting, or ignoring healthcare advice. While no single intervention strategy can improve the adherence of all patients, decades of research studies agree that successful attempts to improve patient adherence depend upon a set of key factors. These include realistic assessment of patients' knowledge and understanding of the regimen, clear and effective communication between health professionals and their patients, and the nurturance of trust in the therapeutic relationship. Patients must be given the opportunity to tell the story of their unique illness experiences. Knowing the patient as a person allows the health professional to understand elements that are crucial to the patient's adherence: beliefs, attitudes, subjective norms, cultural context, social supports, and emotional health challenges, particularly depression. Physician-patient partnerships are essential when choosing amongst various therapeutic options to maximize adherence. Mutual collaboration fosters greater patient satisfaction, reduces the risks of nonadherence, and improves patients' healthcare outcomes.

Is education associated with mortality for breast cancer and cardiovascular disease among black and white women?

BACKGROUND

Although low socioeconomic status (SES) has been found to be an important risk factor for all-cause mortality in women, the association is inconsistent across specific causes of death. SES appears to have different associations with 2 common causes of mortality in women: low SES is associated with greater cardiovascular disease (CVD) mortality in women but may also be associated with lower breast cancer mortality.

OBJECTIVE

We examined the association between SES and CVD and breast cancer mortality among black and white women.

METHODS

Our analysis sample included black and white women participating in the National Longitudinal Mortality Study, which links US Census Bureau Current Population Surveys with the National Death Index between 1979 and 1989. Education and income were used as SES indicators. For each cause of death, we used multivariate logistic regression to estimate variation in mortality risk across SES levels within each racial group.

RESULTS

The sample included 21,303 black women and 186,322 white women. Unadjusted cumulative incidence (over a mean follow-up period of 8.7 years) of CVD mortality was 4.2% among black women and 2.3% among white women, and of breast cancer mortality was 0.3% among black women and 0.4% among white women. After adjustment for age, marital status, and urban or rural residence, less education was still associated with greater CVD mortality among black women (odds ratio [OR], 1.8; 95% Cl, 1.03-3.0) and white women (OR, 1.4; 95% Cl, 1.3-1.6). However, less than a high school education was associated with lower breast cancer mortality among white women (OR, 0.73; 95% CI, 0.6-0.9) but not among black women (OR, 1.1; 95% Cl, 0.5-2.3). Similar ORs were obtained when income was examined.

CONCLUSIONS

The association between SES and cause-specific mortality may differ between black and white women for breast cancer death but not CVD death. Better understanding of these inter actions could guide the targeting of more effective interventions.

Factors that affect breast cancer treatment: underserved and minority populations

Breast cancer treatment in underserved populations continues to deviate from established guidelines. Significant barriers persist at the system, physician, and patient levels that ultimately may affect survival adversely. Successful strategies to reduce the disparities must be developed to improve outcomes in this population of women.

The prevalence of limited health literacy

OBJECTIVE

To systematically review U.S. studies examining the prevalence of limited health literacy and to synthesize these findings by evaluating demographic associations in pooled analyses.

DESIGN

We searched the literature for the period 1963 through January 2004 and identified 2,132 references related to a set of specified search terms. Of the 134 articles and published abstracts retrieved, 85 met inclusion criteria, which were 1) conducted in the United States with > or =25 adults, 2) addressed a hypothesis related to health care, 3) identified a measurement instrument, and 4) presented primary data. The authors extracted data to compare studies by population, methods, and results.

MAIN RESULTS

The 85 studies reviewed include data on 31,129 subjects, and report a prevalence of low health literacy between 0% and 68%. Pooled analyses of these data reveal that the weighted prevalence of low health literacy was 26% (95% confidence interval [CI], 22% to 29%) and of marginal health literacy was 20% (95% CI, 16% to 23%). Most studies used either the Rapid Estimate of Adult Literacy in Medicine (REALM) or versions of the Test of Functional Health Literacy in Adults (TOFHLA). The prevalence of low health literacy was not associated with gender (P=.38) or measurement instrument (P=.23) but was associated with level of education (P=.02), ethnicity (P=.0003), and age (P=.004).

CONCLUSIONS

A pooled analysis of published reports on health literacy cannot provide a nationally representative prevalence estimate. This systematic review exhibits that limited health literacy, as depicted in the medical literature, is prevalent and is consistently associated with education, ethnicity, and age. It is essential to simplify health services and improve health education. Such changes have the potential to improve the health of Americans and address the health disparities that exist today.

Predictors of breast conservation therapy

BACKGROUND

Despite the National Institutes of Health consensus statement in 1991 that breast-conserving surgery (BCS) followed by radiotherapy is an appropriate approach to the treatment of early-stage breast carcinoma, studies have shown a relatively low rate of BCS in the United States. The current study investigated predictors of breast conservation therapy in a large, diverse patient population.

METHODS

Between 1990 and 1998, 43,111 patients underwent surgery for breast carcinoma and were entered into the Cancer Surveillance Program database for Los Angeles County. Of these, 29,666 (68.3%) had complete data on patient demographics, staging, surgeon, type of surgery, and hospital. Data were collected regarding extent of disease, lymph node status, tumor size, age, race, socioeconomic status (SES), surgeon specialization, surgeon volume, hospital specialization, and hospital volume. Univariate and multivariate analyses were performed.

RESULTS

Univariate analysis showed that extent of disease, lymph node status, tumor size, age, race, SES, surgeon and hospital specialization, and surgeon and hospital volume all were significantly associated with surgery type (P <0.0001). Multivariate analysis showed that not only did extent of disease impact choice of surgery, but so did race, SES, hospital volume, surgeon volume, and surgeon specialization (P <0.0001).

CONCLUSIONS

These results suggest that not only does the extent of locoregional disease play a role in the likelihood of a woman undergoing breast conservation therapy, but patient age, socioeconomic status, racial/ethnic factors, and the experience of both the surgeon and hospital have an effect.

Literacy and health outcomes: a systematic review of the literature

OBJECTIVE

To review the relationship between literacy and health outcomes.

DATA SOURCES

We searched MEDLINE, Cumulative Index to Nursing and Allied Health (CINAHL), Educational Resources Information Center (ERIC), Public Affairs Information Service (PAIS), Industrial and Labor Relations Review (ILLR), PsychInfo, and Ageline from 1980 to 2003.

STUDY SELECTION

We included observational studies that reported original data, measured literacy with any valid instrument, and measured one or more health outcomes. Two abstractors reviewed each study for inclusion and resolved disagreements by discussion.

DATA EXTRACTION

One reviewer abstracted data from each article into an evidence table; the second reviewer checked each entry. The whole study team reconciled disagreements about information in evidence tables. Both data extractors independently completed an 11-item quality scale for each article; scores were averaged to give a final measure of article quality.

DATA SYNTHESIS

We reviewed 3,015 titles and abstracts and pulled 684 articles for full review; 73 articles met inclusion criteria and, of those, 44 addressed the questions of this report. Patients with low literacy had poorer health outcomes, including knowledge, intermediate disease markers, measures of morbidity, general health status, and use of health resources. Patients with low literacy were generally 1.5 to 3 times more likely to experience a given poor outcome. The average quality of the articles was fair to good. Most studies were cross-sectional in design; many failed to address adequately confounding and the use of multiple comparisons.

CONCLUSIONS

Low literacy is associated with several adverse health outcomes. Future research, using more rigorous methods, will better define these relationships and guide developers of new interventions.

Literacy and health outcomes: a systematic review of the literature

OBJECTIVE

To review the relationship between literacy and health outcomes.

DATA SOURCES

We searched MEDLINE, Cumulative Index to Nursing and Allied Health (CINAHL), Educational Resources Information Center (ERIC), Public Affairs Information Service (PAIS), Industrial and Labor Relations Review (ILLR), PsychInfo, and Ageline from 1980 to 2003.

STUDY SELECTION

We included observational studies that reported original data, measured literacy with any valid instrument, and measured one or more health outcomes. Two abstractors reviewed each study for inclusion and resolved disagreements by discussion.

DATA EXTRACTION

One reviewer abstracted data from each article into an evidence table; the second reviewer checked each entry. The whole study team reconciled disagreements about information in evidence tables. Both data extractors independently completed an 11-item quality scale for each article; scores were averaged to give a final measure of article quality.

DATA SYNTHESIS

We reviewed 3,015 titles and abstracts and pulled 684 articles for full review; 73 articles met inclusion criteria and, of those, 44 addressed the questions of this report. Patients with low literacy had poorer health outcomes, including knowledge, intermediate disease markers, measures of morbidity, general health status, and use of health resources. Patients with low literacy were generally 1.5 to 3 times more likely to experience a given poor outcome. The average quality of the articles was fair to good. Most studies were cross-sectional in design; many failed to address adequately confounding and the use of multiple comparisons.

CONCLUSIONS

Low literacy is associated with several adverse health outcomes. Future research, using more rigorous methods, will better define these relationships and guide developers of new interventions.