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Brown B, Holt S, Dindinger-Hill K, Wolff EM, Javid S, Nyame Y, Gore JL. Urgent versus elective surgical disparities among American Indian and Alaska Native patients. World J Surg 2024; 48:1037-1044. [PMID: 38497974 DOI: 10.1002/wjs.12132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 02/20/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND American Indian and Alaska Native (AIAN) health issues are understudied despite documentation of lower-than-average life expectancy. Urgent surgery is associated with higher rates of postsurgical complications and postoperative death. We assess whether American Indian and Alaska Native (AIAN) patients in Washington State are at greater risk of requiring urgent rather than elective surgery compared with non-Hispanic Whites (NHW). METHODS We accessed data for the period 2009-2014 from the Washington State Comprehensive Hospital Abstract Reporting System (CHARS) database, which captures all statewide hospital admissions, to examine three common surgeries that are performed both urgently and electively: hip replacements, aortic valve replacements, and spinal fusions. We extracted patient race, age, insurance status, comorbidity, admission type, and procedures performed. We then constructed multivariable logistic regression models to identify factors associated with use of urgent surgical care. RESULTS AIAN patients had lower mean age at surgery for all three surgeries compared with NHW patients. AIAN patients were at higher risk for urgent surgery for hip replacements (OR = 1.49, 95% CI 1.19-1.88), spinal fusions (OR = 1.39, 95% CI 1.04-1.87), and aortic valve replacements (OR = 2.06, 95% CI 1.12-3.80). CONCLUSION AIAN patients were more likely to undergo urgent hip replacement, spinal fusion, and aortic valve replacement than NHW patients. AIAN patients underwent urgent surgery at younger ages. Medicaid insurance conferred higher risks for urgent surgery across all surgeries studied. Further research is warranted to more clearly identify the factors contributing to disparities among AIAN patients undergoing urgent surgery.
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Affiliation(s)
- Benjamin Brown
- Department of Urology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Sarah Holt
- Department of Urology, University of Washington, Seattle, Washington, USA
| | | | - Erika M Wolff
- Department of Urology, University of Washington, Seattle, Washington, USA
| | - Sara Javid
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Yaw Nyame
- Department of Urology, University of Washington, Seattle, Washington, USA
| | - John L Gore
- Department of Urology, University of Washington, Seattle, Washington, USA
- Department of Surgery, University of Washington, Seattle, Washington, USA
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Gore JL, Follmer K, Reynolds J, Nash M, Anderson CB, Catto JWF, Chamie K, Daneshmand S, Dickstein R, Garg T, Gilbert SM, Guzzo TJ, Kamat AM, Kates MR, Lane BR, Lotan Y, Mansour AM, Master VA, Montgomery JS, Morris DS, Nepple KG, O'Neil BB, Patel S, Pohar K, Porten SP, Riggs SB, Sankin A, Scarpato KR, Shore ND, Steinberg GD, Strope SA, Taylor JM, Comstock BA, Kessler LG, Wolff EM, Smith AB. Interruptions in bladder cancer care during the COVID-19 public health emergency. Urol Oncol 2024; 42:116.e17-116.e21. [PMID: 38087711 DOI: 10.1016/j.urolonc.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 10/19/2023] [Accepted: 11/10/2023] [Indexed: 03/23/2024]
Abstract
BACKGROUND Academic and community urology centers participating in a pragmatic clinical trial in non-muscle-invasive bladder cancer completed monthly surveys assessing restrictions in aspects of bladder cancer care due to the COVID-19 Public Health Emergency. Our objective was to describe pandemic-related restrictions on bladder cancer care. METHODS We invited 32 sites participating in a multicenter pragmatic bladder cancer trial to complete monthly surveys distributed through REDCap beginning in May 2020. These surveys queried sites on whether they were experiencing restrictions in the use of elective surgery, transurethral resection of bladder tumors (TURBT), radical cystectomy, office cystoscopy, and intravesical bacillus Calmette-Guerin (BCG) availability. Responses were collated with descriptive statistics. RESULTS Of 32 eligible sites, 21 sites had at least a 50% monthly response rate over the study period and were included in the analysis. Elective surgery was paused at 76% of sites in May 2020, 48% of sites in January 2021, and 52% of sites in January 2022. Over those same periods, coinciding with COVID-19 incidence waves, TURBT was restricted at 10%, 14%, and 14% of sites, respectively, radical cystectomy was restricted at 10%, 14%, and 19% of sites, respectively, and cystoscopy was restricted at 33%, 0%, and 10% of sites, respectively. CONCLUSIONS Bladder cancer care was minimally restricted compared with more pronounced restrictions seen in general elective surgeries during the COVID-19 pandemic.
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Affiliation(s)
- John L Gore
- Department of Urology, University of Washington, Seattle, WA.
| | - Kristin Follmer
- Department of Urology, University of Washington, Seattle, WA
| | - Jason Reynolds
- Department of Urology, University of Washington, Seattle, WA
| | - Michael Nash
- Department of Biostatistics, University of Washington, Seattle, WA
| | | | - James W F Catto
- Department of Urology, Sheffield Teaching Hospitals NHS (National Health Service) Foundation Trust, Sheffield, United Kingdom
| | - Karim Chamie
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Siamak Daneshmand
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Rian Dickstein
- University of Maryland Medical Center, Baltimore Washington Medical Center, Glen Burnie, MD; Chesapeake Urology, Baltimore, MD
| | - Tullika Garg
- Department of Urology, Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Scott M Gilbert
- Division of Genitourinary Oncology, H.Lee Moffitt Cancer Center and Research Institute, Tampa FL
| | - Thomas J Guzzo
- Division of Urology, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Ashish M Kamat
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Max R Kates
- Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD; Johns Hopkins Greenberg Bladder Cancer Institute, Baltimore, MD
| | - Brian R Lane
- Division of Urology, Spectrum Health, Grand Rapids, MI
| | - Yair Lotan
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Ahmed M Mansour
- Department of Urology, University of Texas Health, San Antonio, TX
| | - Viraj A Master
- Department of Urology and Winship Cancer Institute, Emory University, Atlanta, GA
| | | | | | | | - Brock B O'Neil
- Division of Urology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Sanjay Patel
- Department of Urology, University of Oklahoma, Oklahoma City, OK
| | - Kamal Pohar
- Department of Urology, The Ohio State University, Columbus, OH
| | - Sima P Porten
- Department of Urology, UCSF School of Medicine, San Francisco, CA
| | - Stephen B Riggs
- Department of Urology, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | | | - Kristen R Scarpato
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN
| | - Neal D Shore
- Carolina Urologic Research Center, Myrtle Beach, SC
| | - Gary D Steinberg
- Department of Urology, Rush University Medical Center, Chicago, IL
| | | | - Jennifer M Taylor
- Michael E. DeBakey VAMC, Scott Department of Urology, Baylor College of Medicine, Houston, TX
| | - Bryan A Comstock
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Larry G Kessler
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA
| | - Erika M Wolff
- Department of Urology, University of Washington, Seattle, WA
| | - Angela B Smith
- Department of Urology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Oluloro A, Comstock B, Monsell SE, Gross M, Wolff EM, Sage L, Alson J, Lavallee DC, Hempstead B, Moore A, Katz R, Doll KM. Study Protocol for the Social Interventions for Support During Treatment for Endometrial Cancer and Recurrence (SISTER) study: a community engaged national randomized trial. J Comp Eff Res 2024; 13:e230159. [PMID: 38348827 PMCID: PMC10945416 DOI: 10.57264/cer-2023-0159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 01/17/2024] [Indexed: 03/02/2024] Open
Abstract
Aim: Social isolation in cancer patients is correlated with prognosis and is a potential mediator of treatment completion. Black women with endometrial cancer (EC) are at increased risk for social isolation when compared with White patients. We developed the Social Interventions for Support during Treatment for Endometrial Cancer and Recurrence (SISTER) study to compare and evaluate interventions to address social isolation among Black women with high-risk EC in USA. The primary objective of the SISTER study is to determine whether virtual support interventions improve treatment completion compared with Enhanced Usual Care. Secondary objectives include comparing effectiveness virtual evidence-based interventions and evaluating barriers and facilitators to social support delivery. Patients & methods: This is a multi-site prospective, open-label, community-engaged randomized controlled trial, consisting of three intervention arms: enhanced usual care, facilitated support group and one-to-one peer support. Primary outcome will be measured using relative dose. Qualitative semi-structured interviews will be conducted with a subset of participants to contextualize the relative degree or lack thereof of social isolation, over time. Data analysis: Primary analysis will be based on an intent-to-treat analysis. Multivariable analysis will be performed to determine the effect of the intervention on the primary and secondary outcomes of interest, relative dose and social isolation score. Semi-structured interviews will be qualitatively analyzed using inductive and deductive approaches of content analysis. Discussion/conclusion: Endometrial cancer mortality disproportionately affects Black women, and social isolation contributes to this disparity. The SISTER study aims to identify whether and to what extent differing social support vehicles improve key outcomes for Black women in the United States with high-risk EC. Clinical Trial Registration: NCT04930159 (ClinicalTrials.gov).
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Affiliation(s)
- Ann Oluloro
- Department of Obstetrics & Gynecology, Fred Hutchinson Cancer Center, University of Washington, Seattle, WA 98195, USA
| | - Bryan Comstock
- University of Washington, Center for Biomedical Statistics, Seattle, WA 98195, USA
| | - Sarah E Monsell
- University of Washington, Center for Biomedical Statistics, Seattle, WA 98195, USA
| | - Maya Gross
- Department of Obstetrics & Gynecology, Fred Hutchinson Cancer Center, University of Washington, Seattle, WA 98195, USA
| | - Erika M Wolff
- Department of Urology, University of Washington, Seattle, WA 98195, USA
| | - Liz Sage
- Department of Obstetrics & Gynecology, Fred Hutchinson Cancer Center, University of Washington, Seattle, WA 98195, USA
| | - Julianna Alson
- Department of Obstetrics & Gynecology, Fred Hutchinson Cancer Center, University of Washington, Seattle, WA 98195, USA
| | | | | | - Adrienne Moore
- Department of Obstetrics & Gynecology, Fred Hutchinson Cancer Center, University of Washington, Seattle, WA 98195, USA
| | - Ronit Katz
- Department of Obstetrics & Gynecology, Fred Hutchinson Cancer Center, University of Washington, Seattle, WA 98195, USA
| | - Kemi M Doll
- Department of Obstetrics & Gynecology, Fred Hutchinson Cancer Center, University of Washington, Seattle, WA 98195, USA
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Hammarlund N, Holt SK, Basu A, Etzioni R, Morehead D, Lee JR, Wolff EM, Gore JL, Nyame YA. Isolating the Drivers of Racial Inequities in Prostate Cancer Treatment. Cancer Epidemiol Biomarkers Prev 2024; 33:435-441. [PMID: 38214587 PMCID: PMC10922444 DOI: 10.1158/1055-9965.epi-23-0892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 10/20/2023] [Accepted: 01/10/2024] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Black individuals in the United States are less likely than White individuals to receive curative therapies despite a 2-fold higher risk of prostate cancer death. While research has described treatment inequities, few studies have investigated underlying causes. METHODS We analyzed a cohort of 40,137 Medicare beneficiaries (66 and older) linked to the Surveillance Epidemiology and End Results (SEER) cancer registry who had clinically significant, non-metastatic (cT1-4N0M0, grade group 2-5) prostate cancer (diagnosed 2010-2015). Using the Kitagawa-Oaxaca-Blinder decomposition, we assessed the contributions of patient health and health care delivery on the racial difference in localized prostate cancer treatments (radical prostatectomy or radiation). Patient health consisted of comorbid diagnoses, tumor characteristics, SEER site, diagnosis year, and age. Health care delivery was captured as a prediction model with these health variables as predictors of treatment, reflecting current treatment patterns. RESULTS A total of 72.1% and 78.6% of Black and White patients received definitive treatment, respectively, a difference of 6.5 percentage points. An estimated 15% [95% confidence interval (CI): 6-24] of this treatment difference was explained by measured differences in patient health, leaving the remaining estimated 85% (95% CI: 74-94) attributable to a potentially broad range of health care delivery factors. Limitations included insufficient data to explore how specific health care delivery factors, including structural racism and social determinants, impact differential treatment. CONCLUSIONS Our results show the inadequacy of patient health differences as an explanation of the treatment inequity. IMPACT Investing in studies and interventions that support equitable health care delivery for Black individuals with prostate cancer will contribute to improved outcomes.
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Affiliation(s)
- Noah Hammarlund
- Department of Health Services Research Management & Policy, University of Florida, Gainesville, FL, USA
- Department of Urology, University of Washington Medical Center, Seattle WA, USA
| | - Sarah K. Holt
- Department of Urology, University of Washington Medical Center, Seattle WA, USA
| | - Anirban Basu
- The CHOICE Institute, School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Ruth Etzioni
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Danté Morehead
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
| | - Jenney R Lee
- Department of Urology, University of Washington Medical Center, Seattle WA, USA
| | - Erika M. Wolff
- Department of Urology, University of Washington Medical Center, Seattle WA, USA
| | - John L. Gore
- Department of Urology, University of Washington Medical Center, Seattle WA, USA
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Yaw A. Nyame
- Department of Urology, University of Washington Medical Center, Seattle WA, USA
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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Kensler KH, Johnson R, Morley F, Albrair M, Dickerman BA, Gulati R, Holt SK, Iyer HS, Kibel AS, Lee JR, Preston MA, Vassy JL, Wolff EM, Nyame YA, Etzioni R, Rebbeck TR. Prostate cancer screening in African American men: a review of the evidence. J Natl Cancer Inst 2024; 116:34-52. [PMID: 37713266 PMCID: PMC10777677 DOI: 10.1093/jnci/djad193] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 08/25/2023] [Accepted: 08/30/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Prostate cancer is the most diagnosed cancer in African American men, yet prostate cancer screening regimens in this group are poorly guided by existing evidence, given underrepresentation of African American men in prostate cancer screening trials. It is critical to optimize prostate cancer screening and early detection in this high-risk group because underdiagnosis may lead to later-stage cancers at diagnosis and higher mortality while overdiagnosis may lead to unnecessary treatment. METHODS We performed a review of the literature related to prostate cancer screening and early detection specific to African American men to summarize the existing evidence available to guide health-care practice. RESULTS Limited evidence from observational and modeling studies suggests that African American men should be screened for prostate cancer. Consideration should be given to initiating screening of African American men at younger ages (eg, 45-50 years) and at more frequent intervals relative to other racial groups in the United States. Screening intervals can be optimized by using a baseline prostate-specific antigen measurement in midlife. Finally, no evidence has indicated that African American men would benefit from screening beyond 75 years of age; in fact, this group may experience higher rates of overdiagnosis at older ages. CONCLUSIONS The evidence base for prostate cancer screening in African American men is limited by the lack of large, randomized studies. Our literature search supported the need for African American men to be screened for prostate cancer, for initiating screening at younger ages (45-50 years), and perhaps screening at more frequent intervals relative to men of other racial groups in the United States.
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Affiliation(s)
- Kevin H Kensler
- Department of Population Health Sciences, Weill Cornell Medical Center, New York, NY, USA
| | - Roman Johnson
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA
| | - Faith Morley
- Department of Population Health Sciences, Weill Cornell Medical Center, New York, NY, USA
| | - Mohamed Albrair
- Department of Global Health, University of Washington, Seattle, WA, USA
- Division of Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Barbra A Dickerman
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Roman Gulati
- Division of Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Sarah K Holt
- Department of Urology, University of Washington, Seattle, WA, USA
| | - Hari S Iyer
- Section of Cancer Epidemiology and Health Outcomes, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Adam S Kibel
- Department of Urology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Jenney R Lee
- Department of Urology, University of Washington, Seattle, WA, USA
| | - Mark A Preston
- Department of Urology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Jason L Vassy
- VA Boston Healthcare System, Boston, MA, USA
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Erika M Wolff
- Department of Urology, University of Washington, Seattle, WA, USA
| | - Yaw A Nyame
- Division of Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Department of Urology, University of Washington, Seattle, WA, USA
| | - Ruth Etzioni
- Division of Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Timothy R Rebbeck
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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Gadzinski AJ, Dwyer EM, Reynolds J, Stewart B, Abarro I, Wolff EM, Ellimoottil C, Holt SK, Gore JL. Interstate Telemedicine for Urologic Cancer Care. J Urol 2024; 211:55-62. [PMID: 37831635 PMCID: PMC10842529 DOI: 10.1097/ju.0000000000003749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 09/29/2023] [Indexed: 10/15/2023]
Abstract
PURPOSE US states eased licensing restrictions on telemedicine during the COVID-19 pandemic, allowing interstate use. As waivers expire, optimal uses of telemedicine must be assessed to inform policy, legislation, and clinical care. We assessed whether telemedicine visits provided the same patient experience as in-person visits, stratified by in- vs out-of-state residence, and examined the financial burden. MATERIALS AND METHODS Patients seen in person and via telemedicine for urologic cancer care at a major regional cancer center received a survey after their first appointment (August 2019-June 2022) on satisfaction with care, perceptions of communication during their visit, travel time, travel costs, and days of work missed. RESULTS Surveys were completed for 1058 patient visits (N = 178 in-person, N = 880 telemedicine). Satisfaction rates were high for all visit types, both interstate and in-state care (mean score 60.1-60.8 [maximum 63], P > .05). More patients convening interstate telemedicine would repeat that modality (71%) than interstate in-person care (61%) or in-state telemedicine (57%). Patients receiving interstate care had significantly higher travel costs (median estimated visit costs $200, IQR $0-$800 vs median $0, IQR $0-$20 for in-state care, P < .001); 55% of patients receiving interstate in-person care required plane travel and 60% required a hotel stay. CONCLUSIONS Telemedicine appointments may increase access for rural-residing patients with cancer. Satisfaction outcomes among patients with urologic cancer receiving interstate care were similar to those of patients cared for in state; costs were markedly lower. Extending interstate exemptions beyond COVID-19 licensing waivers would permit continued delivery of high-quality urologic cancer care to rural-residing patients.
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Affiliation(s)
| | - Erin M Dwyer
- Department of Urology, University of Washington, Seattle, Washington
| | - Jason Reynolds
- Department of Urology, University of Washington, Seattle, Washington
| | - Blair Stewart
- Department of Urology, University of Washington, Seattle, Washington
| | - Isabelle Abarro
- Department of Urology, University of Washington, Seattle, Washington
| | - Erika M Wolff
- Department of Urology, University of Washington, Seattle, Washington
| | - Chad Ellimoottil
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Sarah K Holt
- Department of Urology, University of Washington, Seattle, Washington
| | - John L Gore
- Department of Urology, University of Washington, Seattle, Washington
- Department of Surgery, University of Washington, Seattle, Washington
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, Washington
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Gore JL, Wolff EM, Comstock BA, Follmer KM, Nash MG, Basu A, Chisolm S, MacLean DB, Lee JR, Lotan Y, Porten SP, Steinberg GD, Chang SS, Gilbert SM, Kessler LG, Smith AB. Protocol of the Comparison of Intravesical Therapy and Surgery as Treatment Options (CISTO) study: a pragmatic, prospective multicenter observational cohort study of recurrent high-grade non-muscle invasive bladder cancer. BMC Cancer 2023; 23:1127. [PMID: 37980511 PMCID: PMC10657633 DOI: 10.1186/s12885-023-11605-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 11/02/2023] [Indexed: 11/20/2023] Open
Abstract
BACKGROUND Bladder cancer poses a significant public health burden, with high recurrence and progression rates in patients with non-muscle-invasive bladder cancer (NMIBC). Current treatment options include bladder-sparing therapies (BST) and radical cystectomy, both with associated risks and benefits. However, evidence supporting optimal management decisions for patients with recurrent high-grade NMIBC remains limited, leading to uncertainty for patients and clinicians. The CISTO (Comparison of Intravesical Therapy and Surgery as Treatment Options) Study aims to address this critical knowledge gap by comparing outcomes between patients undergoing BST and radical cystectomy. METHODS The CISTO Study is a pragmatic, prospective observational cohort trial across 36 academic and community urology practices in the US. The study will enroll 572 patients with a diagnosis of recurrent high-grade NMIBC who select management with either BST or radical cystectomy. The primary outcome is health-related quality of life (QOL) at 12 months as measured with the EORTC-QLQ-C30. Secondary outcomes include bladder cancer-specific QOL, progression-free survival, cancer-specific survival, and financial toxicity. The study will also assess patient preferences for treatment outcomes. Statistical analyses will employ targeted maximum likelihood estimation (TMLE) to address treatment selection bias and confounding by indication. DISCUSSION The CISTO Study is powered to detect clinically important differences in QOL and cancer-specific survival between the two treatment approaches. By including a diverse patient population, the study also aims to assess outcomes across the following patient characteristics: age, gender, race, burden of comorbid health conditions, cancer severity, caregiver status, social determinants of health, and rurality. Treatment outcomes may also vary by patient preferences, health literacy, and baseline QOL. The CISTO Study will fill a crucial evidence gap in the management of recurrent high-grade NMIBC, providing evidence-based guidance for patients and clinicians in choosing between BST and radical cystectomy. The CISTO study will provide an evidence-based approach to identifying the right treatment for the right patient at the right time in the challenging clinical setting of recurrent high-grade NMIBC. TRIAL REGISTRATION ClinicalTrials.gov, NCT03933826. Registered on May 1, 2019.
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Affiliation(s)
- John L Gore
- Department of Urology, University of Washington, Seattle, WA, USA.
| | - Erika M Wolff
- Department of Urology, University of Washington, Seattle, WA, USA
| | - Bryan A Comstock
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | | | - Michael G Nash
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Anirban Basu
- Departments of Pharmacy, Health Services, and Economics, University of Washington, Seattle, WA, USA
| | | | | | - Jenney R Lee
- Department of Urology, University of Washington, Seattle, WA, USA
| | - Yair Lotan
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sima P Porten
- Department of Urology, UCSF School of Medicine, San Francisco, CA, USA
| | - Gary D Steinberg
- Department of Urology, Rush University Medical Center, Chicago, IL, USA
| | - Sam S Chang
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H. Lee Moffit Cancer Center and Research Institute, Tampa, FL, USA
| | - Larry G Kessler
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
| | - Angela B Smith
- Department of Urology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Cabral J, Holt SK, Washington SL, Dwyer E, Lee JR, Wolff EM, Gore JL, Nyame YA. Inequities in Definitive Treatment for Localized Prostate Cancer Among Those With Clinically Significant Mental Health Disorders. Urol Pract 2023; 10:656-663. [PMID: 37754206 PMCID: PMC10681572 DOI: 10.1097/upj.0000000000000457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 08/18/2023] [Indexed: 09/28/2023]
Abstract
INTRODUCTION Patients with mental health disorders are at risk for receiving inequitable cancer treatment, likely resulting from various structural, social, and health-related factors. This study aims to assess the relationship between mental health disorders and the use of definitive treatment in a population-based cohort of those with localized, clinically significant prostate cancer. METHODS We conducted a cohort study analysis in SEER (Surveillance, Epidemiology, and End Results)-Medicare (2004-2015). History of a mental health disorder was defined as presence of specific ICD (International Classification of Diseases)-9 or ICD-10 diagnostic codes in the 2 years preceding cancer diagnosis. Descriptive statistics were performed using Wilcoxon rank-sum and χ2 testing. Multivariable logistic regression was used to evaluate the relationship between mental health disorders and definitive treatment utilization (defined as surgery or radiation). RESULTS Of 101,042 individuals with prostate cancer, 7,945 (7.8%) had a diagnosis of a mental health disorder. They were more likely to be unpartnered, have a lower socioeconomic status, and less likely to receive definitive treatment (61.8% vs 68.2%, P < .001). Definitive treatment rates were >66%, 62.8%, 60.3%, 58.2%, 54.3%, and 48.1% for post-traumatic stress disorder, depressive disorder, bipolar disorder, anxiety disorder, substance abuse disorder, and schizophrenia, respectively. After adjusting for age, race and ethnicity, marital status and socioeconomic status, history of a mental health disorder was associated with decreased odds of receiving definitive treatment (OR 0.74, 95% CI 0.66-0.83). CONCLUSIONS Individuals with mental health disorders and prostate cancer represent a vulnerable population; careful attention to clinical and social needs is required to support appropriate use of beneficial treatments.
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Affiliation(s)
- Joshua Cabral
- Section of Urology, University of Chicago, Chicago, Illinois
| | - Sarah K Holt
- Department of Urology, University of Washington, Seattle, Washington
- Division of Public Health Sciences, Fred Hutch Cancer Center, Seattle, Washington
| | - Samuel L Washington
- Department of Urology, University of California-San Francisco, San Francisco, California
- Department of Epidemiology & Biostatistics, University of California-San Francisco, San Francisco, California
| | - Erin Dwyer
- Department of Urology, University of Washington, Seattle, Washington
| | - Jenney R Lee
- Department of Urology, University of Washington, Seattle, Washington
| | - Erika M Wolff
- Department of Urology, University of Washington, Seattle, Washington
| | - John L Gore
- Department of Urology, University of Washington, Seattle, Washington
- Division of Public Health Sciences, Fred Hutch Cancer Center, Seattle, Washington
| | - Yaw A Nyame
- Department of Urology, University of Washington, Seattle, Washington
- Division of Public Health Sciences, Fred Hutch Cancer Center, Seattle, Washington
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Dwyer ER, Holt SK, Wolff EM, Stewart B, Katz R, Reynolds J, Gadzinski AJ, Gore JL. Patient-centered outcomes of telehealth for the care of rural-residing patients with urologic cancer. Cancer 2023; 129:2887-2892. [PMID: 37221660 DOI: 10.1002/cncr.34848] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/27/2023] [Accepted: 04/14/2023] [Indexed: 05/25/2023]
Abstract
BACKGROUND Patients residing in rural areas with urologic cancers confront significant obstacles in obtaining oncologic care. In the Pacific Northwest, a sizeable portion of the population lives in a rural county. Telehealth offers a potential access solution. METHODS Patients receiving urologic care through telehealth or an in-person appointment at the Fred Hutchinson Cancer Center in Seattle, Washington, were surveyed to assess appointment-related satisfaction and travel costs. Patients' residences were classified as rural or urban based on their self-reported ZIP code. Median patient satisfaction scores and appointment-related travel costs were compared by rural versus urban residence within telehealth and in-person appointment groups using Wilcoxon signed-rank or χ2 testing. RESULTS A total of 1091 patients seen for urologic cancer care between June 2019 and April 2022 were included, 28.7% of which resided in a rural county. Patients were mostly non-Hispanic White (75%) and covered by Medicare (58%). Among rural-residing patients, telehealth and in-person appointment groups had the same median satisfaction score (61; interquartile ratio, 58, 63). More rural-residing than urban-residing patients in the telehealth appointment groups strongly agreed that "Considering the cost and time commitment of my appointment, I would choose to meet with my provider in this setting in the future" (67% vs. 58%, p = .03). Rural-residing patients with in-person appointments carried a higher financial burden than those with telehealth appointments (medians, $80 vs. $0; p <.001). CONCLUSIONS Appointment-related costs are high among rural-residing patients traveling for urologic oncologic care. Telehealth provides an affordable solution that does not compromise patient satisfaction.
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Affiliation(s)
- Erin R Dwyer
- Department of Urology, University of Washington, Seattle, Washington, USA
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, USA
| | - Sarah K Holt
- Department of Urology, University of Washington, Seattle, Washington, USA
| | - Erika M Wolff
- Department of Urology, University of Washington, Seattle, Washington, USA
| | - Blair Stewart
- Department of Urology, University of Washington, Seattle, Washington, USA
| | - Ronit Katz
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, USA
| | - Jason Reynolds
- Department of Urology, University of Washington, Seattle, Washington, USA
| | | | - John L Gore
- Department of Urology, University of Washington, Seattle, Washington, USA
- Fred Hutchinson Cancer Center, Seattle, Washington, USA
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10
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Smith AB, Lee JR, Lawrence SO, Ho O, Lavallee DC, Chisolm S, MacLean DB, Louwers RK, Wolff EM, Kessler LG, Follmer KM, Gore JL. Patient and public involvement in the design and conduct of a large, pragmatic observational trial to investigate recurrent, high-risk non-muscle-invasive bladder cancer. Cancer 2022; 128:103-111. [PMID: 34495550 DOI: 10.1002/cncr.33897] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 06/28/2021] [Accepted: 07/21/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Patient-centered approaches to research design are particularly important for diseases with complex treatment decision-making, such as recurrent, high-grade non-muscle-invasive bladder cancer (NMIBC). The objective of this article is to describe patient and public involvement (PPI) in designing a large, pragmatic observational trial and to articulate barriers, challenges, and lessons learned for future design. METHODS Through multistakeholder involvement, a large, pragmatic observational trial was designed to investigate the outcomes of high-risk, recurrent NMIBC, and it was titled Comparison of Intravesical Therapy and Surgery as Treatment Options for Bladder Cancer (CISTO). CISTO's design used the Guidance for Reporting Involvement of Patients and the Public 2 reporting checklist for PPI and built on prior engagement infrastructure in partnership with the Bladder Cancer Advocacy Network. RESULTS CISTO's PPI began with research prioritization to identify the highest priority questions facing patients with NMIBC. A pragmatic observational study design was selected and refined through stakeholder input. PPI included patients and caregivers organized into an advocate advisory board and clinicians, researchers, payers, and industry representatives organized into an external advisory board. An engagement plan was created to define the stages of PPI and the level and nature of the involvement of each group. PPI was measured quantitatively and qualitatively through evaluation surveys and iterative feedback from board members, with changes made for continuous improvement. CONCLUSIONS Through intentional PPI, CISTO aims to produce pragmatic and generalizable results that will allow patients to make informed decisions for recurrent, high-risk NMIBC based on their personal experiences. LAY SUMMARY Involving patients and other stakeholders in research ensures that it reflects the outcomes that matter most to them. This is especially important when research focuses on conditions in which patients face difficult decisions about treatment options. This article describes the key role that stakeholders played in shaping the Comparison of Intravesical Therapy and Surgery as Treatment Options for Bladder Cancer (CISTO) study. It compares treatments for recurrent noninvasive bladder cancer and describes how stakeholders were engaged to design and develop the study and the practices that supported their involvement.
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Affiliation(s)
- Angela B Smith
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jenney R Lee
- Department of Urology, University of Washington, Seattle, Washington
| | - Sarah O Lawrence
- Department of Surgery, University of Washington, Seattle, Washington
| | - On Ho
- Virginia Mason Franciscan Health, Seattle, Washington
| | - Danielle C Lavallee
- British Columbia Academic Health Science Network, Vancouver, British Columbia, Canada
- Department of Health Services, University of Washington, Seattle, Washington
| | | | - Doug B MacLean
- Comparison of Intravesical Therapy and Surgery as Treatment Options for Bladder Cancer Advocate Advisory Board, Seattle, Washington
| | - Renata K Louwers
- Comparison of Intravesical Therapy and Surgery as Treatment Options for Bladder Cancer Advocate Advisory Board, Seattle, Washington
| | - Erika M Wolff
- Department of Urology, University of Washington, Seattle, Washington
| | - Larry G Kessler
- Department of Health Services, University of Washington, Seattle, Washington
| | - Kristin M Follmer
- Department of Urology, University of Washington, Seattle, Washington
| | - John L Gore
- Department of Urology, University of Washington, Seattle, Washington
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11
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Hantouli MN, Fennern EB, Jeffrey Droullard D, Cook SB, Wolff EM, Benson LS, Reed Flum D, Hystad Davidson G. Management of Acute Cholecystitis During Pregnancy. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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12
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Monu J, Triplette M, Wood DE, Wolff EM, Lavallee DC, Flum DR, Farjah F. Evaluating Knowledge, Attitudes, and Beliefs About Lung Cancer Screening Using Crowdsourcing. Chest 2020; 158:386-392. [PMID: 32035910 DOI: 10.1016/j.chest.2019.12.048] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 12/21/2019] [Accepted: 12/27/2019] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Lung cancer screening, despite its proven mortality benefit, remains vastly underutilized. Previous studies examined knowledge, attitudes, and beliefs to better understand the reasons underlying the low screening rates. These investigations may have limited generalizability because of traditional participant recruitment strategies and examining only subpopulations eligible for screening. The current study used crowdsourcing to recruit a broader population to assess these factors in a potentially more general population. METHODS A 31-item survey was developed to assess knowledge, attitudes, and beliefs regarding screening among individuals considered high risk for lung cancer by the United States Preventive Services Task Force. Amazon's crowdsourcing platform (Mechanical Turk) was used to recruit subjects. RESULTS Among the 240 respondents who qualified for the study, 106 (44%) reported knowledge of a screening test for lung cancer. However, only 36 (35%) correctly identified low-dose CT scanning as the appropriate test. A total of 222 respondents (93%) reported believing that early detection of lung cancer has the potential to save lives, and 165 (69%) were willing to undergo lung cancer screening if it was recommended by their physician. Multivariable regression analysis found that knowledge of lung cancer screening, smoking status, chronic pulmonary disease, and belief in the efficacy of early detection of lung cancer were associated with willingness to screen. CONCLUSIONS Although a minority of individuals at high risk for lung cancer are aware of screening, the majority believe that early detection saves lives and would pursue screening if recommended by their primary care physician. Health systems may increase screening rates by improving patient and physician awareness of lung cancer screening.
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Affiliation(s)
- John Monu
- Department of Surgery, University of Washington, Seattle, WA
| | - Matthew Triplette
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Douglas E Wood
- Department of Surgery, University of Washington, Seattle, WA
| | - Erika M Wolff
- Department of Surgery, University of Washington, Seattle, WA
| | | | - David R Flum
- Department of Surgery, University of Washington, Seattle, WA
| | - Farhood Farjah
- Department of Surgery, University of Washington, Seattle, WA.
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13
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Fennern EB, Chen JY, Khandelwal S, Verdial FC, Cook TB, Wolff EM, Farjah F. Post-Discharge Heparin Prophylaxis Use and Risk of Venous Thromboembolism and Bleeding after Bariatric Surgery: A Population-Based Study. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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14
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Moskowitz D, Gioia KT, Wolff EM, Massman JD, Lucioni A, Kobashi KC, Lee UJ. Analysis of the Completely Dry Rate Over Time After Mid-urethral Sling in a Real-world Clinical Setting. Urology 2019; 126:65-69. [PMID: 30634028 DOI: 10.1016/j.urology.2018.12.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 12/23/2018] [Accepted: 12/29/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To improve patient counseling regarding mid-urethral slings (MUS), we performed an analysis of MUS patients dry at initial follow-up to evaluate probability of remaining dry over time, and analyzed clinical factors potentially influencing the probability of remaining dry. METHODS A retrospective review of our prospectively-collected institutional database identified patients who underwent retropubic MUS (RMUS) or transobturator MUS (TMUS) between January 2001 and March 2016 and were completely dry, defined as an answer of "not at all" to UDI-6 question 3, at first follow-up within 1.5 years of surgery. Proportion remaining dry over time was estimated by Kaplan-Meier. Associated factors were evaluated using Cox proportional hazards modeling. Proportion with urge urinary incontinence at time of sling failure was assessed. RESULTS Of 1102 patients undergoing MUS, 38.4% returned questionnaires and 47.5% of these were completely dry at initial follow-up (139 RMUS, 62 TMUS). Probability (95% CI, n = total patients) of remaining dry after RMUS at 3, 5, and 10 years was 72% (64%-81%, n = 70), 60% (51%-70%, n = 51), and 26% (18%-43%, n = 17). Probability estimates for TMUS at 3 and 5 years were 74% (62%-88%, n = 27) and 50% (35%-70%, n = 14). Obesity (Hazard ratio 2.22, P = .003) and age (Hazard ratio 1.043, P < .001) were associated with lower probability of remaining dry after RMUS. Of patients no longer completely dry at last follow-up, 72% RMUS and 75% TMUS had urge urinary incontinence. CONCLUSION In our real-world cohort, patients who are dry within the first 1.5 years following MUS have ≥50% chance of remaining dry for 4 more years.
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Affiliation(s)
- Dena Moskowitz
- Department of Urology, University of California, Irvine, CA
| | - Kevin T Gioia
- Hackensack Meridian Medical Group, Urology, Hackensack, NJ
| | - Erika M Wolff
- University of Washington, Department of Surgery, Seattle, WA
| | | | - Alvaro Lucioni
- Virginia Mason Medical Center, Section of Urology and Renal Transplantation, Seattle, WA
| | - Kathleen C Kobashi
- Virginia Mason Medical Center, Section of Urology and Renal Transplantation, Seattle, WA
| | - Una J Lee
- Virginia Mason Medical Center, Section of Urology and Renal Transplantation, Seattle, WA
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15
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Doll KM, Khor S, Odem-Davis K, He H, Wolff EM, Flum DR, Ramsey SD, Goff BA. Role of bleeding recognition and evaluation in Black-White disparities in endometrial cancer. Am J Obstet Gynecol 2018; 219:593.e1-593.e14. [PMID: 30291839 DOI: 10.1016/j.ajog.2018.09.040] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 08/24/2018] [Accepted: 09/25/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Advanced stage at diagnosis is an independent, unexplained contributor to racial disparity in endometrial cancer. OBJECTIVE We sought to investigate whether, prior to diagnosis, provider recognition of the cardinal symptom of endometrial cancer, postmenopausal bleeding, differs by patient race. STUDY DESIGN Black and White women diagnosed with endometrial cancer (2001 through 2011) from Surveillance, Epidemiology, and End Results-Medicare who had at least 2 years of claims prior to diagnosis were identified. Bleeding diagnoses along with procedures done prior to diagnosis were captured via claims data. Multinomial logistic regression was used to evaluate the association of race with diagnostic workup and multivariate models built to determine the association of appropriate diagnostic procedures with stage at diagnosis. RESULTS In all, 4354 White and 537 Black women diagnosed with endometrial cancer were included. Compared to White women, Black women were less likely to have guideline-concordant care: postmenopausal bleeding and appropriate diagnostic evaluation (70% vs 79%, P < .001), with adjusted relative risk ratios of 1.12-1.73 for different nonguideline-concordant pathways: bleeding without diagnostic procedures, alternative bleeding descriptions, and neither bleeding nor procedures. These pathways were associated with higher odds of advanced stage at diagnosis (adjusted odds ratio, 1.90-2.88). CONCLUSION The lack of recognition and evaluation of postmenopausal bleeding is associated with advanced stage at diagnosis in endometrial cancer. Older Black women are at highest risk for the most aggressive histology types, yet they are less likely to have guideline-concordant evaluation of vaginal bleeding. Efforts aimed at improving recognition-among patients and providers-of postmenopausal bleeding in Black women could substantially reduce disparities in endometrial cancer.
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16
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Thornblade LW, Mulligan MS, Odem-Davis K, Hwang B, Waworuntu RL, Wolff EM, Kessler L, Wood DE, Farjah F. Challenges in Predicting Recurrence After Resection of Node-Negative Non-Small Cell Lung Cancer. Ann Thorac Surg 2018; 106:1460-1467. [PMID: 30031845 DOI: 10.1016/j.athoracsur.2018.06.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 06/06/2018] [Accepted: 06/07/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND One in 5 patients with completely resected early-stage non-small cell lung cancer will recur within 2 years. Risk stratification may facilitate a personalized approach to the use of adjuvant therapy and surveillance imaging. We developed a prediction model for recurrence based on five clinical variables (tumor size and grade, visceral pleural and lymphovascular invasion, and sublobar resection), and tested the hypothesis that the addition of several new molecular markers of poor long-term outcome (vascular endothelial growth factor C; microRNA precursors 486 and 30d) would enhance prediction. METHODS We performed a retrospective cohort study of patients with completely resected, node-negative non-small cell lung cancer from 2011 to 2014 (follow-up through 2016) using the Lung Cancer Biospecimen Resource Network. Cox regression was used to estimate the 2-year risk of recurrence. Our primary measure of model performance was the optimism-corrected C statistic. RESULTS Among 173 patients (mean tumor size, 3.6 cm; 12% sublobar resection, 32% poorly differentiated, 16% lymphovascular invasion, 26% visceral pleural invasion), the 2-year recurrence rate was 23% (95% confidence interval, 17% to 31%). A prediction model using five known risk factors for recurrence performed only slightly better than chance in predicting recurrence (optimism-corrected C statistic, 0.54; 95% confidence interval, 0.51 to 0.68). The addition of biomarkers did not improve the model's ability to predict recurrence (corrected C statistic, 0.55; 95% confidence interval, 0.52 to 0.71). CONCLUSIONS We were unable to predict lung cancer recurrence using a risk-prediction model based on five well-known clinical risk factors and several biomarkers. Further research should consider novel predictors of recurrence to stratify patients with completely resected early-stage non-small cell lung cancer according to their risk of recurrence.
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Affiliation(s)
| | | | - Katherine Odem-Davis
- Clinical & Translational Research, Seattle Children's Hospital, Seattle, Washington
| | - Billanna Hwang
- Department of Surgery, University of Washington, Seattle, Washington
| | | | - Erika M Wolff
- Department of Surgery, University of Washington, Seattle, Washington
| | - Larry Kessler
- Department of Health Services, University of Washington, Seattle, Washington
| | - Douglas E Wood
- Department of Surgery, University of Washington, Seattle, Washington
| | - Farhood Farjah
- Department of Surgery, University of Washington, Seattle, Washington.
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17
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Davidson GH, Flum DR, Talan DA, Kessler LG, Lavallee DC, Bizzell BJ, Farjah F, Stewart SD, Krishnadasan A, Carney EE, Wolff EM, Comstock BA, Monsell SE, Heagerty PJ, Ehlers AP, DeUgarte DA, Kaji AH, Evans HL, Yu JT, Mandell KA, Doten IC, Clive KS, McGrane KM, Tudor BC, Foster CS, Saltzman DJ, Thirlby RC, Lange EO, Sabbatini AK, Moran GJ. Comparison of Outcomes of antibiotic Drugs and Appendectomy (CODA) trial: a protocol for the pragmatic randomised study of appendicitis treatment. BMJ Open 2017; 7:e016117. [PMID: 29146633 PMCID: PMC5695382 DOI: 10.1136/bmjopen-2017-016117] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Several European studies suggest that some patients with appendicitis can be treated safely with antibiotics. A portion of patients eventually undergo appendectomy within a year, with 10%-15% failing to respond in the initial period and a similar additional proportion with suspected recurrent episodes requiring appendectomy. Nearly all patients with appendicitis in the USA are still treated with surgery. A rigorous comparative effectiveness trial in the USA that is sufficiently large and pragmatic to incorporate usual variations in care and measures the patient experience is needed to determine whether antibiotics are as good as appendectomy. OBJECTIVES The Comparing Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial for acute appendicitis aims to determine whether the antibiotic treatment strategy is non-inferior to appendectomy. METHODS/ANALYSIS CODA is a randomised, pragmatic non-inferiority trial that aims to recruit 1552 English-speaking and Spanish-speaking adults with imaging-confirmed appendicitis. Participants are randomised to appendectomy or 10 days of antibiotics (including an option for complete outpatient therapy). A total of 500 patients who decline randomisation but consent to follow-up will be included in a parallel observational cohort. The primary analytic outcome is quality of life (measured by the EuroQol five dimension index) at 4 weeks. Clinical adverse events, rate of eventual appendectomy, decisional regret, return to work/school, work productivity and healthcare utilisation will be compared. Planned exploratory analyses will identify subpopulations that may have a differential risk of eventual appendectomy in the antibiotic treatment arm. ETHICS AND DISSEMINATION This trial was approved by the University of Washington's Human Subjects Division. Results from this trial will be presented in international conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT02800785.
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Affiliation(s)
- Giana H Davidson
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - David R Flum
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - David A Talan
- Department of Emergency Medicine, Olive-View UCLA Medical Center, Sylmar, California, USA
| | - Larry G Kessler
- Department of Health Services, University of Washington, Seattle, Washington, USA
| | | | - Bonnie J Bizzell
- The Comparative Effectiveness Research Translation Network, CODA Chair, Patient Advisory Group, Seattle, Washington, USA
| | - Farhood Farjah
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Skye D Stewart
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Anusha Krishnadasan
- Department of Emergency Medicine, Olive-View UCLA Medical Center, Sylmar, California, USA
| | - Erin E Carney
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Erika M Wolff
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Bryan A Comstock
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Sarah E Monsell
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Patrick J Heagerty
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Annie P Ehlers
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Daniel A DeUgarte
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, Califorina, USA
| | - Amy H Kaji
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Heather L Evans
- Department of Surgery, Harborview Medical Center, Seattle, Washington, USA
| | - Julianna T Yu
- Department of Emergency, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Katherine A Mandell
- Department of Surgery, Swedish Medical Center-First Hill, Seattle, Washington, USA
| | - Ian C Doten
- Department of Emergency Medicine, Swedish Medical Center-First Hill, Seattle, Washington, USA
| | - Kevin S Clive
- Department of Surgery, Madigan Army Medical Center, Fort Lewis, Washington, USA
| | - Karen M McGrane
- Department of Emergency Medicine, Madigan Army Medical Center, Fort Lewis, Washington, USA
| | - Brandon C Tudor
- Department of Emergency Medicine, Providence Regional Medical Center, Everett, Washington, USA
| | - Careen S Foster
- Department of Trauma and Acute Care Surgery, Providence Regional Medical Center, Everett, WA, USA
| | - Darin J Saltzman
- Department of Surgery, Olive-View UCLA Medical Center, Sylmar, California, USA
| | - Richard C Thirlby
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Erin O Lange
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Amber K Sabbatini
- Department of Emergency Medicine, Harborview Medical Center, Seattle, Washington, USA
| | - Gregory J Moran
- Department of Emergency Medicine, Olive-View UCLA Medical Center, Sylmar, California, USA
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Stamm AW, Banerji JS, Wolff EM, Slee A, Akapame S, Dahl K, Massman I I I JD, Soung MC, Pittenger KR, Corman JM. A decision aid versus shared decision making for prostate cancer screening: results of a randomized, controlled trial. Can J Urol 2017; 24:8910-8917. [PMID: 28832310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Shared decision making (SDM) is widely encouraged by both the American Urological Association and Choosing Wisely for prostate cancer screening. Implementation of SDM is challenging secondary to time constraints and competing patient priorities. One strategy to mitigate the difficulties in implementing SDM is to utilize a decision aid (DA). Here we evaluate whether a DA improves a patient's prostate cancer knowledge and affects prostate-specific antigen (PSA) screening rates. MATERIALS AND METHODS Patients were randomized to usual care (UC), DA, or DA + SDM. Perception of quality of care was measured using the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. Outcomes were stratified by long term provider relationship (LTPR, > 3 years) versus short term provider relationship (STPR, < 3 years). Knowledge of prostate cancer screening and the decision regarding screening were assessed. Groups were compared using ANOVA and logistic regression models. RESULTS A total of 329 patients were randomized. Patients in the DA + SDM arm were significantly more likely to report discussing the implication of screening (33% DA + SDM, 22% UC, 16% DA, p = 0.0292) and answered significantly more knowledge questions correctly compared to the UC arm (5.03 versus 4.46, p = 0.046). However, those in the DA arm were significantly less likely to report that they always felt encouraged to discuss all health concerns (72% DA, 78% DA + SDM, 87% UC, p = 0.0285). Interestingly, STPR patients in the DA arm were significantly more likely to undergo PSA-based prostate cancer screening (41%) than the UC arm (8%, p = 0.019). This effect was not observed in the LTPR group. CONCLUSIONS Providing patients a DA without a personal interaction resulted in a greater chance of undergoing PSA-based screening without improving knowledge about screening or understanding of the consequences of this decision. This effect was exacerbated by a shorter term provider relationship. With complex issues such as the decision to pursue PSA-based prostate cancer screening, tools cannot substitute for direct interaction with a trusted provider.
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Affiliation(s)
- Andrew W Stamm
- Virginia Mason, Section of Urology and Renal Transplantation, Seattle, Washington, USA
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Banerji JS, Hurwitz LM, Cullen J, Wolff EM, Levie KE, Rosner IL, Brand TC, LʼEsperance JO, Sterbis JR, Porter CR. A prospective study of health-related quality-of-life outcomes for patients with low-risk prostate cancer managed by active surveillance or radiation therapy. Urol Oncol 2017; 35:234-242. [DOI: 10.1016/j.urolonc.2016.12.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 12/06/2016] [Accepted: 12/20/2016] [Indexed: 11/30/2022]
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20
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Banerji JS, Odem-Davis K, Wolff EM, Nichols CR, Porter CR. Patterns of Care and Survival Outcomes for Malignant Sex Cord Stromal Testicular Cancer: Results from the National Cancer Data Base. J Urol 2016; 196:1117-22. [DOI: 10.1016/j.juro.2016.03.143] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2016] [Indexed: 10/22/2022]
Affiliation(s)
- John S. Banerji
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, Washington
| | | | - Erika M. Wolff
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, Washington
- Surgical Outcomes Research Center, University of Washington, Seattle, Washington
| | - Craig R. Nichols
- Testicular Cancer Multidisciplinary Clinic, Virginia Mason Medical Center, Seattle, Washington
| | - Christopher R. Porter
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, Washington
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21
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Pham KN, Cullen J, Hurwitz LM, Wolff EM, Levie KE, Odem-Davis K, Banerji JS, Rosner IL, Brand TC, L’Esperance JO, Sterbis JR, Porter CR. Prospective Quality of Life in Men Choosing Active Surveillance Compared to Those Biopsied but not Diagnosed with Prostate Cancer. J Urol 2016; 196:392-8. [DOI: 10.1016/j.juro.2016.02.2972] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2016] [Indexed: 01/22/2023]
Affiliation(s)
| | - Jennifer Cullen
- Center for Prostate Disease Research, Department of Defense, Rockville, Maryland
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Lauren M. Hurwitz
- Center for Prostate Disease Research, Department of Defense, Rockville, Maryland
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | | | - Katherine E. Levie
- Center for Prostate Disease Research, Department of Defense, Rockville, Maryland
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Katherine Odem-Davis
- Center for Biomedical Statistics, Seattle, Washington
- Institute of Translational Health Sciences, Seattle, Washington
| | | | - Inger L. Rosner
- Center for Prostate Disease Research, Department of Defense, Rockville, Maryland
- Urology Service, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Timothy C. Brand
- Madigan Army Medical Center, Tacoma, Washington
- Center for Prostate Disease Research, Department of Defense, Rockville, Maryland
| | - James O. L’Esperance
- Center for Prostate Disease Research, Department of Defense, Rockville, Maryland
- Naval Medical Center San Diego, San Diego, California
| | - Joseph R. Sterbis
- Center for Prostate Disease Research, Department of Defense, Rockville, Maryland
- Tripler Army Medical Center, Honolulu, Hawaii
| | - Christopher R. Porter
- Virginia Mason, Seattle, Washington
- Center for Prostate Disease Research, Department of Defense, Rockville, Maryland
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Halpern JA, Lee UJ, Wolff EM, Mittal S, Shoag JE, Lightner DJ, Kim S, Hu JC, Chughtai B, Lee RK. Women in Urology Residency, 1978-2013: A Critical Look at Gender Representation in Our Specialty. Urology 2016; 92:20-5. [DOI: 10.1016/j.urology.2015.12.092] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 11/22/2015] [Accepted: 12/07/2015] [Indexed: 10/22/2022]
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23
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Banerji JS, Wolff EM, Slee AE, Akapame S, Dahl K, Auerbach ET, Massman III JD, Soung MC, Pittenger KR, Corman JM. PD17-06 DOES EMPLOYING A DECISION AID IMPROVE PATIENT EDUCATION AND PERCEPTION OF QUALITY OF CARE. J Urol 2016. [DOI: 10.1016/j.juro.2016.02.1171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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24
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Alsinnawi M, Slee AE, Banerji JS, Dahl KL, Akapame S, Massman III JD, Wolff EM, Corman JM. MP04-09 DOES A CLEAR UNDERSTANDING OF LIFE EXPECTANCY INCREASE DECISIONAL CONFLICT AND ANXIETY FOR MEN WITH NEWLY DIAGNOSED PROSTATE CANCER? J Urol 2016. [DOI: 10.1016/j.juro.2016.02.1944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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25
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Banerji JS, Wolff EM, Massman JD, Odem-Davis K, Porter CR, Corman JM. Prostate Needle Biopsy Outcomes in the Era of the U.S. Preventive Services Task Force Recommendation against Prostate Specific Antigen Based Screening. J Urol 2016; 195:66-73. [DOI: 10.1016/j.juro.2015.07.099] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2015] [Indexed: 10/23/2022]
Affiliation(s)
- John S. Banerji
- Section of Urology and Renal Transplantation, Virginia Mason, Seattle, Washington
| | - Erika M. Wolff
- Section of Urology and Renal Transplantation, Virginia Mason, Seattle, Washington
| | - John D. Massman
- Section of Urology and Renal Transplantation, Virginia Mason, Seattle, Washington
| | | | | | - John M. Corman
- Section of Urology and Renal Transplantation, Virginia Mason, Seattle, Washington
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26
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Jeldres C, Cullen J, Hurwitz LM, Wolff EM, Levie KE, Odem-Davis K, Johnston RB, Pham KN, Rosner IL, Brand TC, L'Esperance JO, Sterbis JR, Etzioni R, Porter CR. Prospective quality-of-life outcomes for low-risk prostate cancer: Active surveillance versus radical prostatectomy. Cancer 2015; 121:2465-73. [PMID: 25845467 DOI: 10.1002/cncr.29370] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Revised: 02/16/2015] [Accepted: 02/23/2015] [Indexed: 01/22/2023]
Abstract
BACKGROUND For patients with low-risk prostate cancer (PCa), active surveillance (AS) may produce oncologic outcomes comparable to those achieved with radical prostatectomy (RP). Health-related quality-of-life (HRQoL) outcomes are important to consider, yet few studies have examined HRQoL among patients with PCa who were managed with AS. In this study, the authors compared longitudinal HRQoL in a prospective, racially diverse, and contemporary cohort of patients who underwent RP or AS for low-risk PCa. METHODS Beginning in 2007, HRQoL data from validated questionnaires (the Expanded Prostate Cancer Index Composite and the 36-item RAND Medical Outcomes Study short-form survey) were collected by the Center for Prostate Disease Research in a multicenter national database. Patients aged ≤75 years who were diagnosed with low-risk PCa and elected RP or AS for initial disease management were followed for 3 years. Mean scores were estimated using generalized estimating equations adjusting for baseline HRQoL, demographic characteristics, and clinical patient characteristics. RESULTS Of the patients with low-risk PCa, 228 underwent RP, and 77 underwent AS. Multivariable analysis revealed that patients in the RP group had significantly worse sexual function, sexual bother, and urinary function at all time points compared with patients in the AS group. Differences in mental health between groups were below the threshold for clinical significance at 1 year. CONCLUSIONS In this study, no differences in mental health outcomes were observed, but urinary and sexual HRQoL were worse for patients who underwent RP compared with those who underwent AS for up to 3 years. These data offer support for the management of low-risk PCa with AS as a means for postponing the morbidity associated with RP without concomitant declines in mental health.
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Affiliation(s)
- Claudio Jeldres
- Section of Urology and Renal Transplantation, Virginia Mason, Seattle, Washington.,University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Jennifer Cullen
- Center for Prostate Disease Research, Department of Defense, Rockville, Maryland.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Lauren M Hurwitz
- Center for Prostate Disease Research, Department of Defense, Rockville, Maryland.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Erika M Wolff
- Section of Urology and Renal Transplantation, Virginia Mason, Seattle, Washington
| | - Katherine E Levie
- Center for Prostate Disease Research, Department of Defense, Rockville, Maryland.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | | | - Richard B Johnston
- Section of Urology and Renal Transplantation, Virginia Mason, Seattle, Washington
| | - Khanh N Pham
- Section of Urology and Renal Transplantation, Virginia Mason, Seattle, Washington
| | - Inger L Rosner
- Center for Prostate Disease Research, Department of Defense, Rockville, Maryland.,Urology Service, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Timothy C Brand
- Center for Prostate Disease Research, Department of Defense, Rockville, Maryland.,Department of Urology, Madigan Army Medical Center, Tacoma, Washington
| | - James O L'Esperance
- Center for Prostate Disease Research, Department of Defense, Rockville, Maryland.,Department of Urology, Naval Medical Center San Diego, San Diego, California
| | - Joseph R Sterbis
- Center for Prostate Disease Research, Department of Defense, Rockville, Maryland.,Department of Urology, Tripler Army Medical Center, Honolulu, Hawaii
| | - Ruth Etzioni
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Christopher R Porter
- Section of Urology and Renal Transplantation, Virginia Mason, Seattle, Washington.,Center for Prostate Disease Research, Department of Defense, Rockville, Maryland
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27
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Lee EW, Chang A, Lee UJ, Lucioni A, Massman JD, Wolff EM, Govier FE, Kobashi KC. PD28-06 OUTCOMES OF AUTOLOGOUS RECTUS FASCIA PUBOVAGINAL SLING FOR SEVERE INTRINSIC SPHINCTER DEFICIENCY AND/OR RECURRENT STRESS URINARY INCONTINENCE: UP TO 11-YEAR FOLLOW-UP. J Urol 2015. [DOI: 10.1016/j.juro.2015.02.1903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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28
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Banerji JS, Hurwitz LM, Cullen J, Odem-Davis K, Wolff EM, Levie K, Pham KN, Porter CR. MP42-13 A PROSPECTIVE STUDY OF HEALTH-RELATED QUALITY OF LIFE OUTCOMES FOR LOW-RISK PROSTATE CANCER PATIENTS MANAGED BY ACTIVE SURVEILLANCE OR RADIATION THERAPY. J Urol 2015. [DOI: 10.1016/j.juro.2015.02.1598] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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29
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Wolff EM, Chihara Y, Pan F, Weisenberger DJ, Siegmund KD, Sugano K, Kawashima K, Laird PW, Jones PA, Liang G. Unique DNA methylation patterns distinguish noninvasive and invasive urothelial cancers and establish an epigenetic field defect in premalignant tissue. Cancer Res 2010; 70:8169-78. [PMID: 20841482 DOI: 10.1158/0008-5472.can-10-1335] [Citation(s) in RCA: 132] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Urothelial cancer (UC) develops along two different genetic pathways, resulting in noninvasive or invasive tumors. However, it is unknown whether there are also different epigenetic pathways in UC. UC is also characterized by a high rate of recurrence, and the presence of a field defect has been postulated. In this study, we compared the DNA methylation patterns between noninvasive and invasive UC and the DNA methylation patterns between normal-appearing urothelium from bladders with cancer and urothelium from cancer-free bladders. We used the Illumina GoldenGate methylation assay at 1,370 loci in 49 noninvasive urothelial tumors, 38 invasive tumors with matched normal-appearing urothelium, and urothelium from 12 age-matched UC-free patients. We found distinct patterns of hypomethylation in the noninvasive tumors and widespread hypermethylation in the invasive tumors, confirming that the two pathways differ epigenetically in addition to genetically. We also found that 12% of the loci were hypermethylated in apparently normal urothelium from bladders with cancer, indicating an epigenetic field defect. X-chromosome inactivation analysis indicated that this field defect did not result in clonal expansion but occurred independently across the urothelium of bladders with cancer. The hypomethylation present in noninvasive tumors may counterintuitively provide a biological explanation for the failure of these tumors to become invasive. In addition, an epithelium-wide epigenetic defect in bladders with cancer might contribute to a loss of epithelial integrity and create a permissible environment for tumors to arise.
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Affiliation(s)
- Erika M Wolff
- Department of Urology, USC Epigenome Center, and Department of Preventive Medicine, USC Norris Comprehensive Cancer Center, University of Southern California, Keck School of Medicine, Los Angeles, CA 90089, USA
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Wolff EM, Byun HM, Han HF, Sharma S, Nichols PW, Siegmund KD, Yang AS, Jones PA, Liang G. Hypomethylation of a LINE-1 promoter activates an alternate transcript of the MET oncogene in bladders with cancer. PLoS Genet 2010; 6:e1000917. [PMID: 20421991 PMCID: PMC2858672 DOI: 10.1371/journal.pgen.1000917] [Citation(s) in RCA: 219] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2009] [Accepted: 03/19/2010] [Indexed: 12/31/2022] Open
Abstract
It was recently shown that a large portion of the human transcriptome can originate from within repetitive elements, leading to ectopic expression of protein-coding genes. However the mechanism of transcriptional activation of repetitive elements has not been definitively elucidated. For the first time, we directly demonstrate that hypomethylation of retrotransposons can cause altered gene expression in humans. We also reveal that active LINE-1s switch from a tetranucleosome to dinucleosome structure, acquiring H2A.Z- and nucleosome-free regions upstream of TSSs, previously shown only at active single-copy genes. Hypomethylation of a specific LINE-1 promoter was also found to induce an alternate transcript of the MET oncogene in bladder tumors and across the entire urothelium of tumor-bearing bladders. These data show that, in addition to contributing to chromosomal instability, hypomethylation of LINE-1s can alter the functional transcriptome and plays a role not only in human disease but also in disease predisposition. A surprisingly large portion of our transcriptome originates within repetitive elements, most commonly LINE-1s. However, the mechanism of activation has not been definitively shown. We directly demonstrate for the first time the causal relationship between DNA hypomethylation and transcriptional activation of LINE-1 promoters. Hypomethylation of specific LINE-1 promoters can alter the transcriptome, including activating an alternate transcript of the MET oncogene, not only in primary bladder tumors but also in premalignant urothelium across entire bladders with tumors. Our study has important implications for tumor biology, cancer detection, and treatment, and it also answers the long-standing question of whether hypomethylation of retrotransposons induces ectopic gene expression and influences disease susceptibility in humans, a phenomenon first described in agouti mice.
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Affiliation(s)
- Erika M. Wolff
- Department of Urology, Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, California, United States of America
| | - Hyang-Min Byun
- Department of Hematology, Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, California, United States of America
| | - Han F. Han
- Department of Urology, Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, California, United States of America
- Department of Pharmacology and Pharmaceutical Sciences, Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, California, United States of America
| | - Shikhar Sharma
- Department of Urology, Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, California, United States of America
| | - Peter W. Nichols
- Department of Pathology, Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, California, United States of America
| | - Kimberly D. Siegmund
- Department of Preventive Medicine, Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, California, United States of America
| | - Allen S. Yang
- Department of Hematology, Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, California, United States of America
| | - Peter A. Jones
- Department of Urology, Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, California, United States of America
| | - Gangning Liang
- Department of Urology, Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, California, United States of America
- * E-mail:
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31
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Choi SH, Worswick S, Byun HM, Shear T, Soussa JC, Wolff EM, Douer D, Garcia-Manero G, Liang G, Yang AS. Changes in DNA methylation of tandem DNA repeats are different from interspersed repeats in cancer. Int J Cancer 2009; 125:723-9. [PMID: 19437537 DOI: 10.1002/ijc.24384] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Hypomethylation of DNA repetitive elements is a common finding in cancer, but very little is known about the DNA methylation changes of different types of DNA repetitive elements, such as interspersed repeats (LINE1 and Alu Yb8) and tandem repeats (Sat-alpha, NBL-2 and D4Z4). We used bisulfite-PCR Pyrosequencing to quantitatively measure the DNA methylation of five different DNA repetitive elements in normal tissue and cancer. In all we studied 10 different tissues from four individuals undergoing autopsy, 34 paired normal and tumor tissues from patients with bladder cancer, 58 patients with chronic myelogenous leukemia and 23 patients with acute promyelocytic leukemia. We found that the DNA methylation of interspersed repeats (LINE1 and Alu Yb8) was very consistent from person to person and tissue to tissue while tandem DNA repeats appeared more variable in normal tissues. In bladder cancer we found clear hypomethylation of LINE1, Alu Yb8, Sat-alpha and NBL-2. Conversely, we found an increase in the DNA methylation levels of D4Z4 from normal to cancer. In contrast leukemia showed no significant changes in the DNA methylation of LINE1 and Alu Yb8, but DNA methylation increases in NBL-2 and D4Z4 tandem repeats. Our findings show that the changes in DNA methylation levels of individual DNA repetitive elements are unique for each repetitive element, which may reflect distinct epigenetic factors and may have important implications in the use of DNA methylation of repetitive elements as global DNA methylation biomarkers.
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Affiliation(s)
- Si Ho Choi
- Jane Anne Nohl Division of Hematology, Center for Blood Diseases, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
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Friedman JM, Liang G, Liu CC, Wolff EM, Tsai YC, Ye W, Zhou X, Jones PA. The putative tumor suppressor microRNA-101 modulates the cancer epigenome by repressing the polycomb group protein EZH2. Cancer Res 2009; 69:2623-9. [PMID: 19258506 DOI: 10.1158/0008-5472.can-08-3114] [Citation(s) in RCA: 340] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The Polycomb Repressive Complex 2 (PRC2) mediates epigenetic gene silencing by trimethylating histone H3 lysine 27 (H3K27me3) and is known to aberrantly silence tumor suppressor genes in cancer. EZH2, the catalytic subunit of PRC2, enhances tumorigenesis and is commonly overexpressed in several types of cancer. Our microRNA profiling of bladder transitional cell carcinoma (TCC) patient samples revealed that microRNA-101 (miR-101) is down-regulated in TCC, and we showed that miR-101 inhibits cell proliferation and colony formation in TCC cell lines. Furthermore, our results confirm that miR-101 directly represses EZH2 and stable EZH2 knockdowns in TCC cell lines create a similar growth suppressive phenotype. This suggests that abnormal down-regulation of miR-101 could lead to the overexpression of EZH2 frequently seen in cancer. We conclude that miR-101 may be a potent tumor suppressor by altering global chromatin structure through repression of EZH2.
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Affiliation(s)
- Jeffrey M Friedman
- Department of Urology, Biochemistry and Molecular Biology, Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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33
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Wolff EM, Liang G, Cortez CC, Tsai YC, Castelao JE, Cortessis VK, Tsao-Wei DD, Groshen S, Jones PA. RUNX3 methylation reveals that bladder tumors are older in patients with a history of smoking. Cancer Res 2008; 68:6208-14. [PMID: 18676844 DOI: 10.1158/0008-5472.can-07-6616] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Exposure to tobacco smoke is associated with increased DNA methylation at certain genes in both lung and bladder tumors. We sought to identify interactions in bladder cancer between DNA methylation and a history of smoking, along with any possible effect of aging. We measured DNA methylation in 342 transitional cell carcinoma tumors at BCL2, PTGS2 (COX2), DAPK, CDH1 (ECAD), EDNRB, RASSF1A, RUNX3, TERT, and TIMP3. The prevalence of methylation at RUNX3, a polycomb target gene, increased as a function of age at diagnosis (P = 0.031) and a history of smoking (P = 0.015). RUNX3 methylation also preceded methylation at the other eight genes (P < 0.001). It has been proposed that DNA methylation patterns constitute a "molecular clock" and can be used to determine the "age" of normal tissues (i.e., the number of times the cells have divided). Because RUNX3 methylation increases with age, is not present in normal urothelium, and occurs early in tumorigenesis, it can be used for the first time as a molecular clock to determine the age of a bladder tumor. Doing so reveals that tumors from smokers are "older" than tumors from nonsmokers (P = 0.009) due to tumors in smokers either initiating earlier or undergoing more rapid cell divisions. Because RUNX3 methylation is acquired early on in tumorigenesis, then its detection in biopsy or urine specimens could provide a marker to screen cigarette smokers long before any symptoms of bladder cancer are present.
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Affiliation(s)
- Erika M Wolff
- Department of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California 90089, USA
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Abstract
Loss of imprinting (LOI) is a common epigenetic event in cancer and may serve as an early biomarker in some cancers. To obtain a better understanding of LOI, we studied 41 bladder tumors and their adjacent normal bladder mucosa. We found 2/9 (22.2%) cases that displayed LOI of IGF2 and 2/16 (12.5%) that had LOI of H19, as determined by the evaluation of mRNA for biallelic expression. In addition, we examined allele-specific methylation of the differentially methylated regions (DMR) of IGF2 and H19 using a new allele-specific pyrosequencing assay. We found that DNA methylation changes were a common finding (21/30, 70%) in the DMR regions, but could not clearly link DNA methylation changes with LOI as measured by biallelic expression. LOI and allele-specific DNA methylation changes are present in bladder cancer; however, a better understanding of the biology of LOI and its relationship to DNA methylation changes is needed before its use as an epigenetic biomarker.
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Affiliation(s)
- Hyang-Min Byun
- Division of Hematology, University of Southern California/Norris Comprehensive Cancer Center, Los Angeles, California 90033, USA
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35
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Wolff EM, Liang G, Jones PA. Mechanisms of Disease: genetic and epigenetic alterations that drive bladder cancer. ACTA ACUST UNITED AC 2005; 2:502-10. [PMID: 16474624 DOI: 10.1038/ncpuro0318] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2005] [Accepted: 08/23/2005] [Indexed: 12/31/2022]
Abstract
There is substantial evidence for the existence of mutually exclusive molecular pathways to tumorigenesis, in the formation of papillary and invasive carcinomas, respectively. The most common genetic alterations in low grade papillary transitional-cell carcinoma (TCC) are loss of heterozygosity of part or all of chromosome 9 and activating mutations of the fibroblast growth factor receptor 3 (FGFR3). The pathway to development of invasive TCC seems to start with dysplasia, progress to carcinoma in situ, followed by invasion of the lamina propria. The most frequent genetic alteration in dysplasia and carcinoma in situ is mutation of TP53, followed by loss of heterozygosity of chromosome 9. A marker for progression in TCC is loss of chromosome 8p, which occurs in approximately 60% of bladder tumors. Global trends of increased genomic instability and aberrant methylation of cytosine residues in DNA correlate with increased tumor invasion and progression. When researching markers of bladder cancer for clinical use, it is important that biomedical pathways and their alterations are measured in the same tumor populations. This review examines the published data and proposes a model for the mechanisms behind bladder cancer development.
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Affiliation(s)
- Erika M Wolff
- Department of Biochemistry, University of Southern California, Los Angeles, CA 90089, USA
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36
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Guarné A, Ramon-Maiques S, Wolff EM, Ghirlando R, Hu X, Miller JH, Yang W. Structure of the MutL C-terminal domain: a model of intact MutL and its roles in mismatch repair. EMBO J 2004; 23:4134-45. [PMID: 15470502 PMCID: PMC524388 DOI: 10.1038/sj.emboj.7600412] [Citation(s) in RCA: 149] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2004] [Accepted: 08/20/2004] [Indexed: 12/19/2022] Open
Abstract
MutL assists the mismatch recognition protein MutS to initiate and coordinate mismatch repair in species ranging from bacteria to humans. The MutL N-terminal ATPase domain is highly conserved, but the C-terminal region shares little sequence similarity among MutL homologs. We report here the crystal structure of the Escherichia coli MutL C-terminal dimerization domain and the likelihood of its conservation among MutL homologs. A 100-residue proline-rich linker between the ATPase and dimerization domains, which generates a large central cavity in MutL dimers, tolerates sequence substitutions and deletions of one-third of its length with no functional consequences in vivo or in vitro. Along the surface of the central cavity, residues essential for DNA binding are located in both the N- and C-terminal domains. Each domain of MutL interacts with UvrD helicase and is required for activating the helicase activity. The DNA-binding capacity of MutL is correlated with the level of UvrD activation. A model of how MutL utilizes its ATPase and DNA-binding activities to mediate mismatch-dependent activation of MutH endonuclease and UvrD helicase is proposed.
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Affiliation(s)
- Alba Guarné
- Laboratory of Molecular Biology, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Santiago Ramon-Maiques
- Laboratory of Molecular Biology, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Erika M Wolff
- Department of Microbiology, Immunology, and Molecular Genetics, The Molecular Biology Institute, University of California, Los Angeles, CA, USA
| | - Rodolfo Ghirlando
- Laboratory of Molecular Biology, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Xiaojian Hu
- Laboratory of Molecular Biology, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Jeffrey H Miller
- Department of Microbiology, Immunology, and Molecular Genetics, The Molecular Biology Institute, University of California, Los Angeles, CA, USA
| | - Wei Yang
- Laboratory of Molecular Biology, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
- Laboratory of Molecular Biology, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 9000 Rockville Pike, Building 5, Rm B1-03, Bethesda, MD 20892, USA. Tel.: +1 301 402 4645; Fax: +1 301 496 0201; E-mail:
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Wolff EM. Systems management: evaluating nursing departments as a whole. Nurs Manag (Harrow) 1986; 17:40-3. [PMID: 3633492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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38
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Wolff EM. An Approach to a Self-Study. J Contin Educ Nurs 1984; 15:113-6. [PMID: 6430975 DOI: 10.3928/0022-0124-19840701-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Wolff EM, Sophangisa E. The health needs of urban black aged in Cape Town. Curationis 1979; 2:30-1. [PMID: 260908 DOI: 10.4102/curationis.v2i3.495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
It is well known that urbanization leads to a break down in the extended family structure; this has particular relevance to the aged in a Black community. A study was therefore designed to assess the health needs of urbanized Black aged and what facilities would be needed for their care.
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Wolff EM. Health needs of geriatric patients discharged from hospital. S Afr Med J 1978; 54:116-21. [PMID: 211653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
In a survey of the health needs of White and Coloured geriatric patients discharged from hospital it was found that community services were not effectively utilized to meet existing needs. While the White elderly suffered less financial hardship and had better access to medical care, they complained of more symptoms, more loneliness and more depression than their Coloured counterparts.
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Dick B, Spencer IW, Watermeyer GS, Bourne DE, Wolff EM, Moyle GD. Chronic illness in non-institutionalized persons. Part II. Who cares? S Afr Med J 1978; 53:928-37. [PMID: 694650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
A survey was conducted to evaluate the care being received by non-institutionalized chronically ill persons in the Black, Coloured and White communities residing in the Municipality of Cape Town. Of the chronically ill persons identified, 170 (71%) of the Blacks, 188 (62%) of the Coloureds and 43 (86%) of the Whites were receiving care at the time of the survey, and the type, location and duration of this care are outlined. Only 26% of the chronically ill persons were considered to be receiving optimal care, and new recommendations for care were made for 201 (84%) of the Blacks, 203 (67%) of the Coloureds and 36 (72%) of the Whites. Of the patients for whom new recommendations were made, 37% were not currently receiving any care. The financial and occupational repercussions of chronic illness are considered, and methods of improving the comprehensive care of chronically ill persons are discussed.
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Dick B, Spencer IW, Watermeyer GS, Bourne DE, Wolff EM, Moyle GD. Chronic illness in non-institutionalized persons. Part I. Prevalence and epidemiology. S Afr Med J 1978; 53:892-904. [PMID: 684549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
A survey was conducted to investigate the prevalence and epidemiology of chronic illness in non-institutionalized persons residing in the Municipality of Cape Town. The Black, Coloured and White communities were independently surveyed and the standardized prevalence proportions of chronic illness were 24,7/1 000, 37,4/1 000 and 11,6/1 000 respectively. The epidemiological parameters investigated included age, sex, marital status, income, education occupation and the associated diseases, and the influence of these factors on the prevalence proportions are considered. Methodological problems of chronic illness surveys are discussed.
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Wolff EM. Teaching research in the public health nursing education field. SA Nurs J 1977; 44:11. [PMID: 586824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Wolff EM, Sophangisa EB. Some aspects of mental retardation in a black community. SA Nurs J 1976; 43:11-2, 20. [PMID: 1046283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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