Performance of a prognostic 31-gene expression profile in an independent cohort of 523 cutaneous melanoma patients

BACKGROUND

The heterogeneous behavior of patients with melanoma makes prognostication challenging. To address this, a gene expression profile (GEP) test to predict metastatic risk was previously developed. This study evaluates the GEP's prognostic accuracy in an independent cohort of cutaneous melanoma patients.

METHODS

This multi-center study analyzed primary melanoma tumors from 523 patients, using the GEP to classify patients as Class 1 (low risk) and Class 2 (high risk). Molecular classification was correlated to clinical outcome and assessed along with AJCC v7 staging criteria. Primary endpoints were recurrence-free (RFS) and distant metastasis-free (DMFS) survival.

RESULTS

The 5-year RFS rates for Class 1 and Class 2 were 88% and 52%, respectively, and DMFS rates were 93% versus 60%, respectively (P < 0.001). The GEP was a significant predictor of RFS and DMFS in univariate analysis (hazard ratio [HR] = 5.4 and 6.6, respectively, P < 0.001 for each), along with Breslow thickness, ulceration, mitotic rate, and sentinel lymph node (SLN) status (P < 0.001 for each). GEP, tumor thickness and SLN status were significant predictors of RFS and DMFS in a multivariate model that also included ulceration and mitotic rate (RFS HR = 2.1, 1.2, and 2.5, respectively, P < 0.001 for each; and DMFS HR = 2.7, 1.3 and 3.0, respectively, P < 0.01 for each).

CONCLUSIONS

The GEP test is an objective predictor of metastatic risk and provides additional independent prognostic information to traditional staging to help estimate an individual's risk for recurrence. The assay identified 70% of stage I and II patients who ultimately developed distant metastasis. Its role in consideration of patients for adjuvant therapy should be examined prospectively.

Endometrial Cancer Associated Symptoms: A Case-Control Study

BACKGROUND

The majority of women with endometrial cancer (EC) present at an early stage with an associated 5-year survival rate of >90%. High rates of early detection are attributed to warning symptoms; however, the prevalence of such symptoms has not been well defined.

METHODS

A case-control study was conducted assessing the prevalence of symptoms in EC patients at a large cancer center compared with healthy controls. Controls included patients seen for an annual gynecologic care visit (AV) or for a gynecological problem-based visit (PV). A self-administered questionnaire was given to all participants addressing EC-associated symptoms, at the time of initial clinic visit. Odds ratios (ORs) were used to compare prevalence of symptoms between EC cases and controls. Logistic regression was used to determine the impact of menopausal status and obesity on symptom prevalence.

RESULTS

The cases (n = 75) were significantly older than the AV (n = 203) and PV (n = 151) controls (59.7 vs. 49.8 vs. 51.0 years, p < 0.01), had a higher body mass index (35.5 vs. 29.4 vs. 30.9 kg/m², p < 0.01), and were more likely to be postmenopausal (76% vs. 53.7% vs. 52.0%, p < 0.01). The cases were more likely to report postmenopausal bleeding (OR = 32.99 and 5.83, p < 0.01) and abnormal vaginal discharge (OR = 8.8 and 3.3, p < 0.01) compared with the AV and PV groups. Overall, 55.4% of cases reported abnormal vaginal discharge.

CONCLUSIONS

Symptoms of both postmenopausal bleeding and abnormal vaginal discharge were significantly higher in EC compared with controls. The presence of such symptoms should raise concern for malignant disease and prompt immediate gynecological evaluation.

Releasing test results directly to patients: A multisite survey of physician perspectives

OBJECTIVE

To determine physician perspectives about direct notification of normal and abnormal test results.

METHODS

We conducted a cross-sectional survey at five clinical sites in the US and Australia. The US-based study was conducted via web-based survey of primary care physicians and specialists between July and October 2012. An identical paper-based survey was self-administered between June and September 2012 with specialists in Australia.

RESULTS

Of 1417 physicians invited, 315 (22.2%) completed the survey. Two-thirds (65.3%) believed that patients should be directly notified of normal results, but only 21.3% were comfortable with direct notification of clinically significant abnormal results. Physicians were more likely to endorse direct notification of abnormal results if they believed it would reduce the number of patients lost to follow-up (OR=4.98, 95%CI=2.21-1.21) or if they had personally missed an abnormal test result (OR=2.95, 95%CI=1.44-6.02). Conversely, physicians were less likely to endorse if they believed that direct notification interfered with the practice of medicine (OR=0.39, 95%CI=0.20-0.74).

CONCLUSION

Physicians we surveyed generally favor direct notification of normal results but appear to have substantial concerns about direct notification of abnormal results.

PRACTICE IMPLICATIONS

Widespread use of direct notification should be accompanied by strategies to help patients manage test result abnormalities they receive.

Rubella monitoring in pregnancy as a means for evaluating a possible reemergence of rubella

OBJECTIVE

Although it is commonly accepted that rubella is well-controlled, a recent reemergence of both pertussis and measles might also predict a reemergence of rubella. This study was designed to estimate the current incidence of rubella exposure in pregnancy.

STUDY DESIGN

This was a prospective, descriptive study, conducted in Houston, TX, at The Woman's Hospital of Texas. Women are typically screened for rubella immunity at the beginning of pregnancy. Rubella nonimmunity is defined as a titer less than 10 IU/mL in the US. Women who were non-immune early in pregnancy (<20 weeks) were recruited for this study and asked to be tested again for rubella immunity at the time of delivery.

RESULTS

Of 298 women who were rubella nonimmune (IgG <10 IU/mL) early in pregnancy, 19 converted to immune status (IgG >40 IU/mL, defined as at least a 4-fold increase) at time of delivery, a rate of 6.38% (4.12% to 9.75%; 95% Wilson-Score confidence interval). For the 19 patients who converted to immune status at time of delivery, 8 patients had levels of 40-150 IU/mL, 6 patients had levels of 151-300 IU/mL, 2 patients had levels of 301-500 IU/mL, and 3 patients had levels >500 IU/mL.

CONCLUSION

Pregnancy is a critical time to evaluate rubella exposure. This study estimated the current incidence of rubella exposure in pregnancy to be 6.38%.

Gene expression profile of primary cutaneous melanomas to distinguish between low and high risk of metastasis

9022

Background: Wide variability exists in metastatic rates of primary cutaneous melanoma (CM), even within TNM stage groupings. We developed an RT-PCR based gene expression profile (GEP) test to predict distant metastases in early stage CM. Methods: RNA was isolated from formalin-fixed, paraffin embedded biopsies or wide excisions of primary CM from patients with stage 1-4 CM (87% stage 1-2) converted to cDNA and analyzed using RT-PCR. All analyses were done using JMP Genomics and WinSTAT. Radial Basis Machine (RBM) modeling was used to predict metastasis-free survival (MFS) for the training set of 149 samples. Independent validation was performed on an additional 107 CM samples. RBM reports a binary Class 1 (low risk) and Class 2 (high risk). Results: Analysis of the training set resulted in a model with 85% receiver operating characteristic (ROC) and sensitivity of 82%. Prediction of metastatic risk for the validation set resulted in a 90% ROC and sensitivity of 89%. 30 of 33 stage 1-3 cases with a known metastatic event were accurately called Class 2. Kaplan-Meier analysis showed 5-year MFS rates of 88% and 25% for predicted Class 1 and Class 2, respectively, in the training set (p<0.0001, overall MFS=60%). Similarly, MFS was 95% and 26% for Class 1 and Class 2, respectively, in the independent validation set (p<0.0001, overall MFS=67%). Univariate Cox regression analysis of the validation set revealed that GEP, AJCC stage, Breslow thickness, and ulceration were each predictors of metastatic risk (HR=27.2, 11.4, 3.0, and 11.6, respectively, p<0.002 for each). Multivariate analysis showed GEP and AJCC stage were independent predictors of risk (HR=8.4 and 6.4 respectively, p<0.007 for both). Conclusions: This GEP signature provides an accurate stratification of metastatic risk in the training and validation samples independent of all other histologic factors. This test may serve as a prognostic tool for outcomes in patients with melanoma and for stratifying patients for clinical trials.

Ask-Advise-Connect: a new approach to smoking treatment delivery in health care settings

IMPORTANCE

Several national health care-based smoking cessation initiatives have been recommended to facilitate the delivery of evidence-based treatments, such as quitline (telephone-based tobacco cessation services) assistance. The most notable examples are the 5 As (Ask, Advise, Assess, Assist, Arrange) and Ask. Advise. Refer. (AAR) programs. Unfortunately, rates of primary care referrals to quitlines are low, and most referred smokers fail to call for assistance.

OBJECTIVE

To evaluate a new approach--Ask-Advise-Connect (AAC)--designed to address barriers to linking smokers with treatment.

DESIGN

A pair-matched, 2-treatment-arm, group-randomized design in 10 family practice clinics in a single metropolitan area. Five clinics were randomized to the AAC (intervention) and 5 to the AAR (control) conditions. In both conditions, clinic staff were trained to assess and record the smoking status of all patients at all visits in the electronic health record, and smokers were given brief advice to quit. In the AAC clinics, the names and telephone numbers of smokers who agreed to be connected were sent electronically to the quitline daily, and patients were called proactively by the quitline within 48 hours. In the AAR clinics, smokers were offered a quitline referral card and encouraged to call on their own. All data were collected from February 8 through December 27, 2011.

SETTING

Ten clinics in Houston, Texas.

PARTICIPANTS

Smoking status assessments were completed for 42,277 patients; 2052 unique smokers were identified at AAC clinics, and 1611 smokers were identified at AAR clinics.

INTERVENTIONS

Linking smokers with quitline-delivered treatment.

MAIN OUTCOME MEASURE

Impact was based on the RE-AIM (Reach, Efficacy, Adoption, Implementation, and Maintenance) conceptual framework and defined as the proportion of all identified smokers who enrolled in treatment.

RESULTS

In the AAC clinics, 7.8% of all identified smokers enrolled in treatment vs 0.6% in the AAR clinics (t4 = 9.19 [P < .001]; odds ratio, 11.60 [95% CI, 5.53-24.32]), a 13-fold increase in the proportion of smokers enrolling in treatment.

CONCLUSIONS AND RELEVANCE

The system changes implemented in the AAC approach could be adopted broadly by other health care systems and have tremendous potential to reduce tobacco-related morbidity and mortality.

Correlates of self-reported colorectal cancer screening accuracy in a multi-specialty medical group practice

PURPOSE

We assessed whether accuracy of self-reported screening for colorectal cancer (CRC) varied by respondent characteristics or healthcare utilization.

METHODS

From 2005 to 2007, 857 respondents aged 51 - 74 were recruited from a multi-specialty medical group practice to answer a questionnaire about their CRC screening (CRCS) behaviors. Self-reports were compared with administrative and medical records to assess concordance, sensitivity, specificity, and report-to-records ratios for overall CRCS (fecal occult blood test, sigmoidoscopy, and/or colonoscopy).

RESULTS

Concordance was good (≥0.8 to <0.9) or fair (≥0.7 to <0.8) for most subgroups; respondents with >5 visits outside the clinic had poor (<0.7) concordance. Sensitivity estimates were mostly excellent (≥0.9) or good but poor for respondents whose healthcare provider did not advise a specific CRCS test. Specificity was poor for the following respondents: 65+ years, males, college graduates, family history of CRC, >5 visits outside of the clinic, or whose healthcare provider advised a specific CRCS test. Respondents 65+ years and with >5 outside visits over-reported CRCS.

CONCLUSIONS

With few exceptions, self-reports of CRCS in an insured population is reasonably accurate across subgroups. More work is needed to replicate these findings in diverse settings and populations to better understand subgroup differences and improve measures of CRCS.

Gene expression profile signature (DecisionDx-Melanoma) to predict visceral metastatic risk in patients with stage I and stage II cutaneous melanoma

8543

Background: The current AJCC TNM staging system has poor specificity for predicting visceral metastatic risk in patients diagnosed with stage I or stage II cutaneous melanoma. We, therefore, developed a gene expression profile signature (GEP) following in silico investigation of previously published microarray analyses. Methods: 60 formalin fixed paraffin embedded primary cutaneous melanoma samples from patients with stage I or II cutaneous melanoma with at least a follow up period of at least 6 years were macrodissected and analyzed blindly. RNA was isolated, converted to cDNA and RT-PCR was performed to assess the expression of the gene set. Expression data and biostatistical analysis was performed using GeNorm and JMP Genomics (SAS) Predictive modeling included Radial Basis Machine (RBM) and Partition Tree Analysis (PTA) Metastasis-free survival (MFS) was assessed using Kaplan-Meier analysis. The following clinical data was retrieved from medical records: survival, metastases, types of metastases. 20 out of 60 patients had developed visceral metastases in the follow up period. Results: GEP was developed following multiple analytical approaches.Two types of signatures emerged: Low risk (Class 1) and High risk (Class 2). Without optimizing for sensitivity, the analyses of the 60 sample cohort by radial basis machine (RBM) resulted in 92% ROC (met. accuracy = 90%, non-met. accuracy = 85%), while partition tree analysis (PTA) yielded 99% ROC (met. accuracy = 100%, non-met. accuracy = 95%). RBM classification showed 6-year MFS rates of 97% for Class 1 and 19% for predicted Class 2 of metastasis (median MFS = NR and 5.6 yrs, resp., P<0.0001 Log-Rank respectively). PTA showed 6-year MFS rates of 100% for predicted Class 1 and 14% for Class 2 of metastasis (median MFS = NR and 5.4 yrs, resp., P<0.0001 Log-Rank respectively). Conclusions: This study shows that DecisionDx-Melanoma GEP signature can provide excellent accuracy in predicting metastatic risk in stage I and II cutaneous melanoma.To our knowledge, the GEP provides the most accurate predictor to date for development of visceral metastases in patients with Stage I and II cutaneous melanoma.

Mediators of the association of major depressive syndrome and anxiety syndrome with postpartum smoking relapse

OBJECTIVE

Based on conceptual models of addiction and affect regulation, this study examined the mechanisms linking current major depressive syndrome (MDS) and anxiety syndrome (AS) to postpartum smoking relapse.

METHOD

Data were collected in a randomized clinical trial from 251 women who quit smoking during pregnancy. Simple and multiple mediation models of the relations of MDS and AS with postpartum relapse were examined using linear regression, continuation ratio logit models, and a bootstrapping procedure to test the indirect effects.

RESULTS

Both MDS and AS significantly predicted postpartum smoking relapse. After adjusting for MDS, AS significantly predicted relapse. However, after adjusting for AS, MDS no longer predicted relapse. Situationally based self-efficacy, expectancies of controlling negative affect by means other than smoking, and various dimensions of primary and secondary tobacco dependence individually mediated the effect of both MDS and AS on relapse. In multiple mediation models, self-efficacy in negative/affective situations significantly mediated the effect of MDS and AS on relapse.

CONCLUSIONS

The findings underscore the negative impact of depression and anxiety on postpartum smoking relapse and suggest that the effects of MDS on postpartum relapse may be largely explained by comorbid AS. The current investigation provided mixed support for affect regulation models of addiction. Cognitive and tobacco dependence-related aspects of negative and positive reinforcement significantly mediated the relationship of depression and anxiety with relapse, whereas affect and stress did not. The findings emphasize the unique role of low agency with respect to abstaining from smoking in negative affective situations as a key predictor of postpartum smoking relapse.

Feasibility of an expressive-disclosure group intervention for post-treatment colorectal cancer patients: results of the Healthy Expressions study

BACKGROUND

Adjusting to cancer requires effective cognitive and emotional processing. Written and verbal disclosure facilitate processing and have been studied independently in cancer survivors. Combined written and verbal expression may be more effective than either alone, particularly for patients with difficult to discuss or embarrassing side effects. Thus, the authors developed and tested the efficacy of a 12-session combined written and verbal expression group program for psychologically distressed colorectal cancer (CRC) patients.

METHODS

Forty post-treatment patients with CRC (stages I-III) identified as psychologically distressed using the Brief Symptom Inventory (BSI) were randomized to an intervention group (Healthy Expressions; n = 25) or standard care (control group; n = 15). Assessments were completed at baseline, Month 2, and Month 4 (postintervention). Primary outcomes were psychological functioning and quality of life (QOL).

RESULTS

Most participants were women (63%), white (63%), and non-Hispanic (75%). The Healthy Expressions group demonstrated significantly greater changes in distress compared with the control group at Month 2 on the BSI Global Severity Index (GSI) and the Centers for Epidemiologic Studies Depression scale (CES-D) scores (P < .05 for each); differences in the European Organization for Research and Treatment of Cancer (EORTC) global QOL scores approached significance (P = .063). The BSI GSI and Positive Symptom Total, CES-D, and EORTC emotional functioning subscale scores were all significant at Month 4 (P < .05 for each).

CONCLUSIONS

The Healthy Expressions program improved psychological functioning in CRC patients who reported experiencing distress. Findings demonstrate the program's feasibility and provide strong support for conducting a larger randomized trial.

A randomized controlled trial of a tailored interactive computer-delivered intervention to promote colorectal cancer screening: sometimes more is just the same

BACKGROUND

There have been few studies of tailored interventions to promote colorectal cancer (CRC) screening.

PURPOSE

We conducted a randomized trial of a tailored, interactive intervention to increase CRC screening.

METHODS

Patients 50-70 years completed a baseline survey, were randomized to one of three groups, and attended a wellness exam after being exposed to a tailored intervention about CRC screening (tailored group), a public web site about CRC screening (web site group), or no intervention (survey-only group). The primary outcome was completion of any recommended CRC screening by 6 months.

RESULTS

There was no statistically significant difference in screening by 6 months: 30%, 31%, and 28% of the survey-only, web site, and tailored groups were screened. Exposure to the tailored intervention was associated with increased knowledge and CRC screening self-efficacy at 2 weeks and 6 months. Family history, prior screening, stage of change, and physician recommendation moderated the intervention effects.

CONCLUSIONS

A tailored intervention was not more effective at increasing screening than a public web site or only being surveyed.

Cost effectiveness of interventions to promote screening for colorectal cancer: a randomized trial

Objectives

Screening for colorectal cancer is considered cost effective, but is underutilized in the U.S. Information on the efficiency of "tailored interventions" to promote colorectal cancer screening in primary care settings is limited. The paper reports the results of a cost effectiveness analysis that compared a survey-only control group to a Centers for Disease Control (CDC) web-based intervention (screen for life) and to a tailored interactive computer-based intervention.

Methods

A randomized controlled trial of people 50 and over, was conducted to test the interventions. The sample was 1224 partcipants 50-70 years of age, recruited from Kelsey-Seybold Clinic, a large multi-specialty clinic in Houston, Texas. Screening status was obtained by medical chart review after a 12-month follow-up period. An "intention to treat" analysis and micro costing from the patient and provider perspectives were used to estimate the costs and effects. Analysis of statistical uncertainty was conducted using nonparametric bootstrapping.

Results

The estimated cost of implementing the web-based intervention was $40 per person and the cost of the tailored intervention was $45 per person. The additional cost per person screened for the web-based intervention compared to no intervention was $2602 and the tailored intervention was no more effective than the web-based strategy.

Conclusions

The tailored intervention was less cost-effective than the web-based intervention for colorectal cancer screening promotion. The web-based intervention was less cost-effective than previous studies of in-reach colorectal cancer screening promotion. Researchers need to continue developing and evaluating the effectiveness and cost-effectiveness of interventions to increase colorectal cancer screening.

The role of prepartum motivation in the maintenance of postpartum smoking abstinence

OBJECTIVE

Motivation plays an important role in a variety of behaviors, including smoking cessation, and is integral to theory and treatment of smoking. For many women, pregnancy offers a motivational shift that helps them stop smoking and maintain abstinence during pregnancy. However, women's motivation to maintain smoking abstinence postpartum is not well-understood and may play a role in high postpartum relapse rates. The current study utilized multiple measures of prepartum motivation to maintain smoking abstinence to predict postpartum smoking abstinence.

METHODS

As part of a randomized clinical trial on postpartum smoking relapse prevention, pregnant women who quit smoking during pregnancy reported their motivation to continue smoking abstinence at a prepartum baseline session. Biochemically verified continued smoking abstinence was assessed at 8 and 26 weeks postpartum.

RESULTS

Direct relationships among multiple measures of motivation were significant, and ranged in strength from weak to moderate. All motivation measures individually predicted continuous smoking abstinence, after controlling for treatment group, demographics, and prequit tobacco use. When tested simultaneously, a global motivation measure and parenthood motives for quitting remained significant predictors of abstinence. Backward selection modeling procedures resulted in a reduced model of prepartum predictors of postpartum abstinence including global motivation, parenthood motives, and stage of change.

CONCLUSIONS

Global motivation for smoking abstinence and parenthood motives for quitting are particularly important motivational constructs for pregnant women's continued smoking abstinence.

Rapid method for determination of DNA repair capacity in human peripheral blood lymphocytes amongst smokers

Background

DNA repair capacity is an important determinant of susceptibility to cancer. The hOGG1 enzyme is crucial for repairing the 8-oxoguanine lesion that occurs either as a byproduct of oxidative metabolism or as a result of exogenous sources such as exposure to cigarette smoke. It has been previously reported that smokers with low hOGG1 activity had significantly higher risk of developing lung cancer as compared to smokers with high hOGG1 activity.

Methods

In the current study we elucidate the association between plasma levels of 8-OHdG and the OGG1 repair capacity. We used the commercially available 8-OHdG ELISA (enzyme-linked immunosorbent assay), the Comet assay/FLARE hOGG1 (Fragment Length Analysis by Repair Enzymes) assay for quantification of the levels of 8-OHdG and measured the constitutive, induced and unrepaired residual damage, respectively. We compared the DNA repair capacity in peripheral blood lymphocytes following H₂O₂ exposure in 30 lung cancer patients, 30 non-, 30 former and 30 current smoker controls matched by age and gender.

Results

Our results show that lung cancer cases and current smoker controls have similar levels of 8-OHdG lesions that are significantly higher compared to the non-smokers controls. However, lung cancer cases showed significantly poorer repair capacity compared to all controls tested, including the current smokers controls. After adjustment for age, gender and family history of smoking-related cancer using linear regression, we observed a 5-fold increase in risk of lung cancer associated with high levels of residual damage/reduced repair capacity. Reduced OGG1 activity could be expected to be a risk factor in other smoking-related cancers.

Conclusion

Our study shows that the Comet/FLARE assay is a relatively rapid and useful method for determination of DNA repair capacity. Using this assay we could identify individuals with high levels of residual damage and hence poor repair capacity who would be good candidates for intensive follow-up and screening.

Abstract LB-400: Conventional and anti-microbial pesticide exposures and increased risk of lung cancer in Mexican Americans

Objective: We investigated demographic factors, environmental and occupational exposures, and medical and family cancer histories in a population of Mexican-American lung cancer cases and controls from the Houston Metropolitan area.

Methods: Data were collected as a part of a multi-racial/ethnic on-going lung cancer case-control study. Cases included 212 Mexican American lung cancer cases. Controls (n=328) were recruited from Houston's largest multispecialty group practice and frequency matched to the cases by age (±5 years), sex and ethnicity. Odds ratios and 95% confidence intervals were calculated using logistic regression analysis. Environmental and occupational factors were analyzed individually; however pesticides were analyzed as: 1) any exposure to conventional or antimicrobial pesticides; 2) exposure to conventional pesticides only; and 3) exposure to antimicrobial pesticides only.

Results: We detected elevated risks of lung cancer associated with asbestos, wood dust, fibers, SVF, benzene, toluene/xylene, dry cleaning fluids, vehicle exhaust, glues and plastics; however only pesticide exposure was statistically significant. We found both conventional and anti-microbial pesticide exposures were associated with an increased risk of lung cancer in Mexican Americans (conventional pesticides and antimicrobial pesticides combined: OR=1.80, 95%CI 1.13-2.86; conventional pesticides: OR=2.05, 95% CI 1.23-2.39; and anti-microbial pesticides: OR=2.48, 95% CI 1.46-4.21).

Conclusions: Although we found over a two-fold increased risk of lung cancer among Mexican Americans for conventional and anti-microbial pesticides, we were not able to identify individual pesticides. Our findings are descriptive in nature and we believe are a necessary and important preliminary step in identifying factors that are specifically associated with lung cancer risk among this minority subgroup.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr LB-400.

Travel and travelers' diarrhea in patients with irritable bowel syndrome

This study evaluated occurrence of travel and travelers' diarrhea in patients with irritable bowel syndrome (IBS). A survey was mailed to 591 patients of a clinical practice who had IBS. Based on survey responses, patients were categorized as having IBS, post-infectious IBS (PI-IBS), unclassified functional bowel disorder (UFBD), or post-infectious UFBD (PI-UFBD). Of 201 persons who returned questionnaires meeting inclusion criteria, 57.7%, 11.4%, 24.9%, and 6.0% had IBS, UFBD, PI-IBS, and PI-UFBD, respectively. Travel during six months before illness onset was more common in patients with PI-IBS or PI-UFBD than in persons with idiopathic IBS or UFBD (P = 0.006). Survey results demonstrated that 16.1% of post-infectious bowel disorder cases and 7.5% of overall IBS cases in a general medical population developed chronic disease within six months of an international trip. Symptoms of established functional bowel disorder in each clinical category were shown to worsen after travel-related acute diarrhea.

The Fun Families Study: intervention to reduce children's TV viewing

Media consumption may contribute to childhood obesity. This study developed and evaluated a theory-based, parent-focused intervention to reduce television and other media consumption to prevent and reduce childhood obesity. Families (n = 202) with children ages 6-9 were recruited from a large, urban multiethnic population into a randomized controlled trial (101 families into the intervention group and 101 into the control group), and were followed for 6 months. The intervention consisted of a 2-hour workshop and six bimonthly newsletters. Behavioral objectives included: (i) reduce TV watching; (ii) turn off TV when nobody is watching; (iii) no TV with meals; (iv) no TV in the child's bedroom; and (v) engage in fun non-media related activities. Parents were 89% female, 44% white, 28% African American, 17% Latino, and 11% Asian, mean age 40 years (s.d. = 7.5); 72% were married. Children were 49% female, mean age 8 years (s.d. = 0.95). Sixty-five percent of households had three or more TVs and video game players; 37% had at least one handheld video game, and 53% had three or more computers. Average children's weekday media exposure was 6.1 hours. At 6 months follow-up, the intervention group was less likely to report the TV being on when nobody was watching (adjusted odds ratio (AOR) = 0.23, P < 0.05), less likely to report eating snacks while watching TV (AOR = 0.47, P < 0.05), and less likely to have a TV in the child's bedroom (AOR = 0.23, P < 0.01). There was a trend toward reducing actual media consumption but these outcomes did not reach statistical significance. Effective strategies to reduce children's TV viewing were identified.

Generalized anxiety disorder in older medical patients: diagnostic recognition, mental health management and service utilization

BACKGROUND

Primary care physicians often treat older adults with Generalized Anxiety Disorder. Objective To estimate physician diagnosis and recognition of anxiety and compare health service use among older adults with GAD with two comparison samples with and without other DSM diagnoses.

METHODS

Participants were 60+ patients of a multi-specialty medical organization. Administrative database and medical records were reviewed for a year. Differences in frequency of health service use were analyzed with logistic regression and between-subjects analysis of covariance.

RESULTS

Physician diagnosis of GAD was 1.5% and any anxiety was 9%, and recognition of anxiety symptoms was 34% in older adults with GAD. After controlling for medical comorbidity, radiology appointments were increased in the GAD group relative to those with and without other psychiatric diagnoses, chi(2) (2, N = 225) = 4.75, p < .05.

CONCLUSIONS

Most patients with anxiety do not have anxiety or symptoms documented in their medical records.

Reliability and validity of a questionnaire to measure colorectal cancer screening behaviors: does mode of survey administration matter?

Valid and reliable self-report measures of cancer screening behaviors are important for evaluating efforts to improve adherence to guidelines. We evaluated test-retest reliability and validity of self-report of the fecal occult blood test (FOBT), sigmoidoscopy (SIG), colonoscopy (COL), and barium enema (BE) using the National Cancer Institute colorectal cancer screening (CRCS) questionnaire. A secondary objective was to evaluate reliability and validity by mail, telephone, and face-to-face survey administration modes. Consenting men and women, 51 to 74 years old, receiving care at a multispecialty clinic for at least 5 years who had not been diagnosed with colorectal cancer were stratified by prior CRCS status and randomized to survey mode (n = 857). Within survey mode, respondents were randomized to complete a second survey at 2 weeks, 3 months, or 6 months. Comparing self-report with administrative and medical records, concordance estimates were 0.91 for COL, 0.85 for FOBT, 0.85 for SIG, and 0.92 for BE. Overall sensitivity estimates were 0.91 for COL, 0.82 for FOBT, 0.76 for SIG, and 0.56 for BE. Specificity estimates were 0.91 for COL, 0.86 for FOBT, 0.89 for SIG, and 0.97 for BE. Sensitivity and specificity varied little by survey mode for any test. Report-to-records ratio showed overreporting for SIG (1.1), COL (1.15), and FOBT (1.57), and underreporting for BE (0.82). Reliability at all time intervals was highest for COL; there was no consistent pattern according to survey mode. This study provides evidence to support the use of the National Cancer Institute CRCS questionnaire to assess self-report with any of the three survey modes.

The influence of subjective social status on vulnerability to postpartum smoking among young pregnant women

OBJECTIVES

Associations between subjective social status, a subjective measure of socioeconomic status, and predictors of risk for postpartum smoking were examined among 123 pregnant women (aged 18-24 years) who stopped smoking because of pregnancy. The goal was to identify how subjective social status might influence the risk for postpartum smoking and to elucidate targets for intervention.

METHODS

We used multiple regression equations to examine the predictive relations between subjective social status and tobacco dependence, self-rated likelihood of postpartum smoking, confidence, temptations, positive and negative affect, depression, stress, and social support. Adjusted analyses were also conducted with control for race/ethnicity, education, income, and whether participant had a partner or not (partner status).

RESULTS

In unadjusted and adjusted analyses, subjective social status predicted tobacco dependence, likelihood of postpartum smoking, confidence, temptations, positive affect, negative affect, and social support. Adjusted analyses predicting depression and stress approached significance.

CONCLUSIONS

Among young pregnant women who quit smoking because of pregnancy, low subjective social status was associated with a constellation of characteristics indicative of increased vulnerability to postpartum smoking. Subjective social status provided unique information on risk for postpartum smoking over and above the effects of race/ethnicity, objective socioeconomic status, and partner status.

Randomized pilot test of a lifestyle physical activity intervention for breast cancer survivors

OBJECTIVE

This paper will report the results of a pilot test of a 6-month, 21-session intervention to increase breast cancer survivors' physical activity by teaching them to incorporate short periods of moderate activity into their daily routines (lifestyle intervention). The effect of the intervention on physical performance, quality of life, and physical activity are reported.

METHODS

Sixty breast cancer survivors were randomized to either a lifestyle intervention or a standard care control group. Physical performance, quality of life (Medical outcomes study short form-36 [SF-36]), and physical activity (7-day recall and motivation readiness), were assessed at baseline and 6 months.

RESULTS

The lifestyle group had significantly better performance in the 6-min walk task than the controls (p=0.005) at 6 months. The intervention had positive effects on the bodily pain (p=0.020) and general health (p=0.006) subscales from the SF-36. The lifestyle group had a greater motivational readiness for physical activity at 6-month than standard care, but no significant differences were seen between the two in terms of number of minutes of moderate or more intense physical activity or number of days on which they did > or =30 min of moderate or more intense activity.

CONCLUSIONS

Despite the small sample size, the lifestyle intervention showed promise for improving physical functioning and quality of life and increasing physical activity, and should be tested in a larger randomized trial.

PRACTICE IMPLICATIONS

If the lifestyle approach is shown to be effective in a larger trial, it represents a highly feasible intervention that it can be delivered to cancer survivors by health care institutions or community organizations without dedicated exercise facilities and equipment.

Estimating development cost for a tailored interactive computer program to enhance colorectal cancer screening compliance

The authors used an actual-work estimate method to estimate the cost of developing a tailored interactive computer education program to improve compliance with colorectal cancer screening guidelines in a large multi-specialty group medical practice. Resource use was prospectively collected from time logs, administrative records, and a design and computing subcontract. Sensitivity analysis was performed to examine the uncertainty of the overhead cost rate and other parameters. The cost of developing the system was Dollars 328,866. The development cost was Dollars 52.79 per patient when amortized over a 7-year period with a cohort of 1,000 persons. About 20% of the cost was incurred in defining the theoretic framework and supporting literature, constructing the variables and survey, and conducting focus groups. About 41% of the cost was for developing the messages, algorithms, and constructing program elements, and the remaining cost was to create and test the computer education program. About 69% of the cost was attributable to personnel expenses. Development cost is rarely estimated but is important for feasibility studies and ex-ante economic evaluations of alternative interventions. The findings from this study may aid decision makers in planning, assessing, budgeting, and pricing development of tailored interactive computer-based interventions.

Primary care patients' understanding of colorectal cancer screening

PURPOSE

To determine the current level of awareness and understanding about colorectal cancer (CRC) and colorectal cancer screening (CRCS) among primary care patients in order to develop interventions to educate patients about options for CRCS, help them identify CRCS preferences and make informed choices about CRCS options.

METHODS

During the spring of 2001 and 2003, two sets of focus groups with primary care patients were conducted at a large multi-specialty group practice in Houston, Texas.

RESULTS

Participants (n = 42) in both sets of focus groups had low knowledge about CRC and expressed fear and embarrassment about CRC and CRCS. Attitudes towards the fecal occult blood test (FOBT) were mixed, with some participants considering it difficult to finish and others preferring the privacy it afforded. Some participants initially failed to recognize the difference between sigmoidoscopy (SIG) and colonoscopy (COL), and several endoscopy-specific barriers were identified such as fear of pain, embarrassment/humiliation, and dislike or fear of test preparation. Some participants felt that endoscopy was likely to be more effective than FOBT, and others clearly preferred COL to SIG. System-specific barriers to endoscopy (e.g. difficulty scheduling appointments and insurance coverage) were also identified. We found little change in the barriers reported by primary care patients, despite a two-year difference between focus groups. Participants also provided suggestions for improving CRCS including telephone, letters and/or email reminders from the clinic, videotapes and websites.

CONCLUSIONS

Future interventions focused on improving informed decision-making by educating primary care patients about the risks and benefits of specific test options and about the importance of early detection of CRC could prove to be effective for increasing CRCS.

Determinants of treatment adherence in ethnically diverse, economically disadvantaged patients with rheumatic disease

OBJECTIVE

To explore the determinants of adherence to medical recommendations, including drug therapy and appointment-keeping, among ethnically diverse and economically disadvantaged patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE).

METHODS

Patients with RA and SLE were identified through chart review and were invited to participate in focus groups to examine their attitudes and beliefs regarding adherence to treatment and medical appointments. Eight focus groups (4 RA, 4 SLE) were conducted, with a total of 40 participants (22 SLE patients and 18 RA patients). Transcripts were analyzed using grounded theory techniques and qualitative analysis software to facilitate coding interpretation.

RESULTS

The majority of participants reported experiencing difficulty in adhering to their treatment at least occasionally. Both SLE and RA patients reported similar barriers to treatment adherence: fear of side effects, financial problems, difficulty in navigating the public health system, and perceived treatment inefficacy. RA and SLE patients also revealed barriers to appointment keeping, including difficulties in scheduling, financial costs, transportation, and functional impairment limiting their ability to attend the clinic.

CONCLUSION

Patients' perceptions of and experiences with the health system, physicians, medication effectiveness, and side effects influence their adherence to treatment and other medical recommendations. Strategies to improve adherence could include the following: attempting to modify patients' beliefs and perceptions regarding medication effectiveness, promoting realistic expectations about risk/benefit ratios, and improving access to health care by reducing barriers that limit the interaction between patients and the health system.

Do men know that they have had a prostate-specific antigen test? Accuracy of self-reports of testing at 2 sites

This study determined the accuracy of self-reports of prostate-specific antigen (PSA) testing. Men (N = 402) attending 2 outpatient clinics were asked: "Did you have a PSA test today?" and their medical records were checked. Concordance, sensitivity, and false-negative values were 65%, 67%, and 33%, respectively, at 1 clinic site and 88%, 64%, and 36% at the other. The accuracy of self-reports of PSA testing should be interpreted with caution.

Informed consent for cancer screening with prostate-specific antigen: how well are men getting the message?

OBJECTIVES

This study examined knowledge about prostate-specific antigen (PSA) screening among African Americans and Whites. Because PSA screening for prostate cancer is controversial, professional organizations recommend informed consent for screening.

METHODS

Men (n = 304) attending outpatient clinics were surveyed for their knowledge about and experience with screening.

RESULTS

Most men did not know the key facts about screening with PSA. African Americans appeared less knowledgeable than Whites, but these differences were mediated by differences in educational level and experience with prostate cancer screening.

CONCLUSIONS

Public health efforts to improve informed consent for prostate cancer screening should focus on highlighting the key facts and developing different approaches for men at different levels of formal education and prior experience with screening.

Complementary/alternative medicine use in a comprehensive cancer center and the implications for oncology

PURPOSE

Oncologists are aware that their patients use complementary/alternative medicine (CAM). As cancer incidence rates and survival time increase, use of CAM will likely increase. This study assessed the prevalence and predictors of CAM use in a comprehensive cancer center.

SUBJECTS AND METHODS

Subjects were English-speaking cancer patients at least 18 years of age, attending one of eight outpatient clinics at The University of Texas M.D. Anderson Cancer Center, Houston, TX, between December 1997 and June 1998. After giving written informed consent, participants completed a self-administered questionnaire. Differences between CAM users and nonusers were assessed by chi(2) and univariate logistic regression analysis. A multivariate logistic regression model identified the simultaneous impact of demographic, clinical, and treatment variables on CAM use; P values were two-sided.

RESULTS

Of the 453 participants (response rate, 51.4%), 99.3% had heard of CAM. Of those, 83.3% had used at least one CAM approach. Use was greatest for spiritual practices (80.5%), vitamins and herbs (62.6%), and movement and physical therapies (59.2%) and predicted (P <.001) by sex (female), younger age, indigent pay status, and surgery. After excluding spiritual practices and psychotherapy, 95.8% of participants were aware of CAM and 68.7% of those had used CAM. Use was predicted (P <.0001) by sex (female), education, and chemotherapy.

CONCLUSION

In most categories, CAM use was common among outpatients. Given the number of patients combining vitamins and herbs with conventional treatments, the oncology community must improve patient-provider communication, offer reliable information to patients, and initiate research to determine possible drug-herb-vitamin interactions.

Barriers to cancer treatment: a review of published research

PURPOSE/OBJECTIVES

To review published research on barriers to cancer treatment to provide a foundation for subsequent research and program and policy development directed at diminishing these barriers.

DATA SOURCES

Relevant literature from medical and behavioral science data bases published between 1964 and 1994. Researchers reviewed 752 abstracts; they identified 160 articles that related directly to research on barriers to cancer treatment. Of these 160 articles, researchers chose 61 for a subsequent review using criteria to evaluate the strength of the study design and sampling procedures.

DATA SYNTHESIS

The major barriers consistently documented to influence whether or not patients with cancer sought or continued treatment included communication problems between patients and providers, lack of information on side effects, cost of treatment, difficulties in obtaining and maintaining insurance coverage, and absence of social support networks. Access barriers generally were greater for older women, members of minority groups, and patients of lower socioeconomic status. The vast majority of the studies were conceptual or descriptive in nature and were based on nonprobability clinic-based samples.

CONCLUSIONS

The limitations of existing research point to the need for studies on barriers to cancer treatment based on analytic population-based study designs that examine the relative importance of factors derived from multivariate explanatory models. This information may be used to develop programs and policies to ameliorate treatment barriers for patients with cancer.

IMPLICATIONS FOR NURSING PRACTICE

The research priorities set forth by the Oncology Nursing Society also indicate a need for this type of research because quality of life, cost containment, and outcomes assessment all are directly or indirectly affected by the timely diagnosis of cancer. Treatment barriers have the potential to significantly affect an individual's ability to seek care and ultimately to increase the cost of care associated with adverse outcomes that may result from delays in seeking treatment.