Implementation contextual factors related to community-based active travel to school interventions: a mixed methods interview study

Background

Active travel to school contributes to multiple physical and psychosocial benefits for youth, yet population rates of active travel to school are alarmingly low in the USA and many other countries. Though walking school bus interventions are effective for increasing rates of active travel to school and children’s overall physical activity, uptake of such interventions has been low. The objective of this study was to conduct a mixed methods implementation evaluation to identify contextual factors that serve as barriers and facilitators among existing walking school bus programs.

Methods

Semi-structured interviews guided by the Consolidated Framework for Implementation Research (CFIR) were conducted with leaders of low-sustainability (n = 9) and high-sustainability (n = 11) programs across the USA. A combination of quantitative (CFIR-based) coding and inductive thematic analysis was used. The CFIR-based ratings were compared between the low- and high-sustainability programs and themes, subthemes, and exemplary quotes were provided to summarize the thematic analysis.

Results

In both the low- and high-sustainability programs, three of the 15 constructs assessed were commonly rated as positive (i.e., favorable for supporting implementation): student/family needs and resources, implementation climate, and planning. Three constructs were more often rated as positive in the high-sustainability programs: organizational incentives and rewards, engaging students and parents, and reflecting and evaluating. Three constructs were more often rated as positive in the low-sustainability programs: student/family needs and resources - built environment, available resources, and access to knowledge and information. Four themes emerged from the thematic analysis: planning considerations, ongoing coordination considerations, resources and supports, and benefits.

Conclusions

Engagement of students, parents, and community members were among the factors that emerged across the quantitative and qualitative analyses as most critical for supporting walking school bus program implementation. The information provided by program leaders can help in the selection of implementation strategies that overcome known barriers for increasing the long-term success of community-based physical activity interventions such as the walking school bus.

Walking School Bus Programs: Implementation Factors, Implementation Outcomes, and Student Outcomes, 2017-2018

PURPOSE AND OBJECTIVES

Walking school bus programs increase children's physical activity through active travel to school; however, research to inform large-scale implementation of such programs is limited. We investigated contextual factors, implementation outcomes, and student outcomes in existing walking school bus programs in the United States and internationally.

INTERVENTION APPROACH

Walking school bus programs involve a group of children walking to school together with an adult leader. On the trip to school, these adults provide social support, address potential traffic and interpersonal safety, and serve as role models to the children while children increase their physical activity levels.

EVALUATION METHODS

We conducted surveys with existing walking school bus programs identified through internet searches, referrals, and relevant email listservs. Leaders from 184 programs that operated at least 1 trip per week completed the survey. We used regression analyses to compare differences in contextual factors by area income and location, associations between contextual factors and implementation outcomes, and associations between implementation outcomes and student outcomes.

RESULTS

Walking school bus programs in low-income communities had more route leaders and engaged in more active travel to school-related activities of being sustained than those in higher income. Programs that had no external funding, multiple route leaders, and coordination by a school or district staff member (as opposed to a parent) had greater student participation than other programs. Providing more trips than other programs per week was associated with reduced tardiness, reduced bullying, and improved neighborhood walkability. The greatest barriers to implementation were recruiting and maintaining students and identifying and maintaining route leaders.

IMPLICATIONS FOR PUBLIC HEALTH

Walking school bus programs can be implemented successfully in many contexts using various models. The involvement of several people in leadership roles is critical for sustainability. Evidence-based implementation strategies that overcome barriers can improve reach, implementation, and sustainability of walking school bus programs and can increase children's physical activity.

Knowledge translation for realist reviews: a participatory approach for a review on scaling up complex interventions

Background

Knowledge syntheses that use a realist methodology are gaining popularity. Yet, there are few reports in the literature that describe how results are summarised, shared and used. This paper aims to inform knowledge translation (KT) for realist reviews by describing the process of developing a KT strategy for a review on pathways for scaling up complex public health interventions.

Methods

The participatory approach used for the realist review was also used to develop the KT strategy. The approach included three main steps, namely (1) an international meeting focused on interpreting preliminary findings from the realist review and seeking input on KT activities; (2) a targeted literature review on KT for realist reviews; and (3) consultations with primary knowledge users of the review.

Results

The international meeting identified a general preference among knowledge users for findings from the review that are action oriented. A need was also identified for understanding how to tailor findings for specific knowledge user groups in relation to their needs. The literature review identified four papers that included brief descriptions of planned or actual KT activities for specific research studies; however, information was minimal on what KT activities or products work for whom, under what conditions and why. The consultations revealed that KT for realist reviews should consider the following: (1) activities closely aligned with the preferences of specific knowledge user groups; (2) key findings that are sensitive to factors within the knowledge user’s context; and (3) actionable statements that can advance KT goals, activities or products. The KT strategy derived from the three activities includes a planning framework and tailored KT activities that address preferences of knowledge users for findings that are action oriented and context relevant.

Conclusions

This paper provides an example of a KT strategy for realist reviews that blends theoretical and practical insights. Evaluation of the strategy’s implementation will provide useful insights on its effectiveness and potential for broader application.

Electronic supplementary material

The online version of this article (10.1186/s12961-018-0374-1) contains supplementary material, which is available to authorized users.

Training scholars in dissemination and implementation research for cancer prevention and control: a mentored approach

BACKGROUND

As the field of D&I (dissemination and implementation) science grows to meet the need for more effective and timely applications of research findings in routine practice, the demand for formalized training programs has increased concurrently. The Mentored Training for Dissemination and Implementation Research in Cancer (MT-DIRC) Program aims to build capacity in the cancer control D&I research workforce, especially among early career researchers. This paper outlines the various components of the program and reports results of systematic evaluations to ascertain its effectiveness.

METHODS

Essential features of the program include selection of early career fellows or more experienced investigators with a focus relevant to cancer control transitioning to a D&I research focus, a 5-day intensive training institute, ongoing peer and senior mentoring, mentored planning and work on a D&I research proposal or project, limited pilot funding, and training and ongoing improvement activities for mentors. The core faculty and staff members of the MT-DIRC program gathered baseline and ongoing evaluation data regarding D&I skill acquisition and mentoring competency through participant surveys and analyzed it by iterative collective reflection.

RESULTS

A majority (79%) of fellows are female, assistant professors (55%); 59% are in allied health disciplines, and 48% focus on cancer prevention research. Forty-three D&I research competencies were assessed; all improved from baseline to 6 and 18 months. These effects were apparent across beginner, intermediate, and advanced initial D&I competency levels and across the competency domains. Mentoring competency was rated very highly by the fellows--higher than rated by the mentors themselves. The importance of different mentoring activities, as rated by the fellows, was generally congruent with their satisfaction with the activities, with the exception of relatively greater satisfaction with the degree of emotional support and relatively lower satisfaction for skill building and opportunity initially.

CONCLUSIONS

These first years of MT-DIRC demonstrated the program's ability to attract, engage, and improve fellows' competencies and skills and implement a multicomponent mentoring program that was well received. This account of the program can serve as a basis for potential replication and evolution of this model in training future D&I science researchers.

Contextual factors related to implementation of classroom physical activity breaks

Brief structured physical activity in the classroom is effective for increasing student physical activity. The present study investigated the association between implementation-related contextual factors and intervention implementation after adoption of a structured classroom physical activity intervention. Six elementary-school districts adopted structured classroom physical activity programs in 2013-2014. Implementation contextual factors and intervention implementation (structured physical activity provided in past week or month, yes/no) were assessed using surveys of 337 classroom teachers from 24 schools. Mixed-effects models accounted for the nested design. Availability of resources (yes/no, ORs = 1.91-2.93) and implementation climate z-scores (ORs = 1.36-1.47) were consistently associated with implementation. Teacher-perceived classroom behavior benefits (OR = 1.29) but not student enjoyment or health benefits, and time (OR = 2.32) and academic (OR = 1.63) barriers but not student cooperation barriers were associated with implementation (all z-scores). Four implementation contextual factor composites had an additive association with implementation (OR = 1.64 for each additional favorable composite). Training and technical assistance alone may not support a large proportion of teachers to implement structured classroom physical activity. In addition to lack of time and interference with academic lessons, school climate related to whether administrators and other teachers were supportive of the intervention were key factors explaining whether teachers implemented the intervention. Evidence-based implementation strategies are needed for effectively communicating the benefits of classroom physical activity on student behavior and improving teacher and administrator climate/attitudes around classroom physical activity.

[Paleopathology of deafness: skulls of the Dupuytren Museum]

In the 18th and 19th centuries, the Dupuytren Museum was indispensable for the knowledge of pathological anatomy for physicians and surgeons. Nowadays, it is more a museum than a learning unit, but it provides an opportunity to understand through numerous scientific studies the origin of diseases, injuries mechanism and the functional consequences of which could suffer some patients. This study illustrates the interest of the study on pieces in pathological anatomy's museums, this time across selected skulls which belonged to hearing loss people. bizarre.

Canadian cancer screening disparities: a recent historical perspective

Across Canada, introduction of the Pap test for cervical cancer screening, followed by mammography for breast cancer screening and, more recently, the fecal occult blood test for colorectal cancer screening, has contributed to a reduction in cancer mortality. However, another contribution of screening has been disparities in cancer mortality between certain populations. Here, we explore the disparities associated with breast and cervical cancer screening and preliminary data concerning disparities in colorectal cancer screening. Although some disparities in screening utilization have been successfully reduced over time (for example, mammography and Pap test screening in rural and remote populations), screening utilization data for other populations (for example, low-income groups) clearly indicate that disparities have existed and continue to exist across Canada. Organized screening programs in Canada have been able to successfully engage 80% of women for regular cervical cancer screening and 70% of women for regular mammography screening, but of the women who remain to be reached or engaged in regular screening, those with the least resources, those who are the most isolated, and those who are least culturally integrated into Canadian society as a whole are over-represented. Population differences are also observed for utilization of colorectal cancer screening services. The research literature on interventions to promote screening utilization provides some evidence about what can be done to increase participation in organized screening by vulnerable populations. Adaption and adoption of evidence-based screening promotion interventions can increase the utilization of available screening services by populations that have experienced the greatest burden of disease with the least access to screening services.

Health care system collaboration to address chronic diseases: a nationwide snapshot from state public health practitioners

INTRODUCTION

Until recently, health care systems in the United States often lacked a unified approach to prevent and manage chronic disease. Recent efforts have been made to close this gap through various calls for increased collaboration between public health and health care systems to better coordinate provision of services and programs. Currently, the extent to which the public health workforce has responded is relatively unknown. The objective of this study is to explore health care system collaboration efforts and activities among a population-based sample of state public health practitioners.

METHODS

During spring 2013, a national survey was administered to state-level chronic disease public health practitioners. Respondents were asked to indicate whether or not they collaborate with health care systems. Those who reported "yes" were asked to indicate all topic areas in which they collaborate and provide qualitative examples of their collaborative work.

RESULTS

A total of 759 respondents (84%) reported collaboration. Common topics of collaboration activities were tobacco, cardiovascular health, and cancer screening. More client-oriented interventions than system-wide interventions were found in the qualitative examples provided. Respondents who collaborated were also more likely to use the Community Guide, use evidence-based decision making, and work in program areas that involved secondary, rather than primary, prevention.

CONCLUSION

The study findings indicate a need for greater guidance on collaboration efforts that involve system-wide and cross-system interventions. Tools such as the Community Guide and evidence-based training courses may be useful in providing such guidance.

Prevention of cancer and non-communicable diseases

Cancer is a leading cause of death worldwide, accounting for approximately 7.6 million deaths (13% of all deaths) in 2008. Cancer mortality is projected to increase to 11 million deaths in 2030, with the majority occurring in regions of the world with the least capacity to respond. However, cancer is not only a personal, societal and economic burden but also a potential societal opportunity in the context of functional life - the years gained through effective prevention and treatment, and strategies to enhance survivorship. The United Nations General Assembly Special Session in 2011 has served to focus attention on key aspects of cancer prevention and control. Firstly, cancer is largely preventable, by feasible means. Secondly, cancer is one of a number of chronic, non- communicable diseases that share common risk factors whose prevention and control would benefit a majority of the world's population. Thirdly, a proportion of cancers can be attributed to infectious, communicable causal factors (e.g., HPV, HBV, H.pylori, parasites, flukes) and that strategies to control the burden of infectious diseases have relevance to the control of cancer. Fourthly, that the natural history of non-communicable diseases, including cancer, from primary prevention through diagnosis, treatment and care, is underwritten by the impact of social, economic and environmental determinants of health (e.g., poverty, illiteracy, gender inequality, social isolation, stigma, socio-economic status). Session 1 of the 4th International Cancer Control Congress (ICCC-4) focused on the social, economic and environmental, as well as biological and behavioural, modifiers of the risk of cancer through one plenary presentation and four interactive workshop discussions. The workshop sessions concerned 1) the Global Adult Tobacco Survey and social determinants of tobacco use in high burden low- and middle-income countries; 2) the role of diet, including alcohol, and physical activity in modifying the risk of cancer and other non-communicable diseases; 3) the role of infections in modifying the risk of cancer; and 4) the public policies and actions that can be implemented to effectively reduce the risk of cancer at population levels. Workshop discussions highlighted the need for high quality data on the prevalence of modifiable factors in different settings, as well as the social, economic and environmental drivers of these factors, in order to inform prevention and control programs. For some factors, further work needs to be done to develop simple and valid measurement tools. Given that many of these factors are common to both cancer and other non-communicable diseases, cancer prevention should be viewed within the broader perspective of the prevention of non-communicable diseases and should engage all relevant actors, including the general public, health and other professionals, workplaces and institutions, the media, civil society, schools, governments, industry, and multinational bodies. Many policies and plans have been implemented in various settings to control the drivers of modifiable factors and promote health and well-being. Mapping, analysis, and contextualization of those policies that are relevant would be helpful to promote action around cancer prevention in different settings.

Knowledge exchange--translating research into practice and policy

Substantial differences in population-based cancer control outcomes exist within and between nations. Optimal outcomes derive from 'what we know', 'what we apply in practice', and 'how complete and compliant is the population uptake of public health and clinical practice change'. This continuum of research (scientific discovery) to practice (application and uptake) to policy impacts the speed and completeness of practice change and is greatly influenced by the ability, opportunity and readiness of countries to implement evidence informed practices and policies through innovative change. Session 4 of the 4th International Cancer Control Congress focused on knowledge exchange through three plenary presentations and five interactive workshop discussions: 1) the role of epidemiological data as a basis for policy formulation; 2) existing global frameworks for cancer control; 3) knowledge exchange as it relates to public health practice and policy; 4) knowledge exchange in relation to primary, community, and specialist cancer care; and 5) the role of public engagement and advocacy in influencing cancer control policy. Common themes emerging from workshop discussions included the recognition of the importance of knowledge exchange processes, constituents and forums as key aspects of preparedness, awareness and readiness to implement public health and clinical practice change. The importance of cultural and contextual differences between nations was identified as a challenge requiring development of tools for generating relevant population/societal data (e.g., projection methodologies applied to population demographics, outcomes and resources, both societal, human and fiscal) and capacity building for facilitating knowledge transfer and exchange between the constituencies engaged in population-based public health practice and clinically based primary care and disease specialty practice exchange (researchers, health practitioners, health administrators, politicians, patients and families, and the private and public sectors). Understanding patient and public engagement advocacy and its role in influencing health and public policy investment priorities emerged as a critical and fundamental aspect of successful implementation of evidence-informed cancer control change.

The use of Omegaven in treating parenteral nutrition-associated liver disease

Parenteral nutrition (PN), containing fat emulsions derived from soybean, has been implicated in the progression of PN-associated liver disease and cholestasis, particularly in infants with short bowel syndrome. Clinical use of Omegaven, a parenteral fish-oil emulsion, has been shown in recent studies to be a promising therapy to reverse liver disease and cholestasis. This review summarizes the rationale, relevant clinical investigations and future direction of Omegaven therapy for PN-dependent infants.

Intervention to increase recommendation and delivery of screening for breast, cervical, and colorectal cancers by healthcare providers a systematic review of provider reminders

Most major medical organizations recommend routine screening for breast, cervical, and colorectal cancers. Screening can lead to early detection of these cancers, resulting in reduced mortality. Yet, not all people who should be screened are screened regularly or, in some cases, ever. This report presents results of systematic reviews of effectiveness, applicability, economic efficiency, barriers to implementation, and other harms or benefits of provider reminder/recall interventions to increase screening for breast, cervical, and colorectal cancers. These interventions involve using systems to inform healthcare providers when individual clients are due (reminder) or overdue (recall) for specific cancer screening tests. Evidence in this review of studies published from 1986 through 2004 indicates that reminder/recall systems can effectively increase screening with mammography, Pap, fecal occult blood tests, and flexible sigmoidoscopy. Additional research is needed to determine if provider reminder/recall systems are effective in increasing colorectal cancer screening by colonoscopy. Specific areas for further research are also suggested.

Approaching health disparities from a population perspective: the National Institutes of Health Centers for Population Health and Health Disparities

Addressing health disparities has been a national challenge for decades. The National Institutes of Health-sponsored Centers for Population Health and Health Disparities are the first federal initiative to support transdisciplinary multilevel research on the determinants of health disparities. Their novel research approach combines population, clinical, and basic science to elucidate the complex determinants of health disparities. The centers are partnering with community-based, public, and quasi-public organizations to disseminate scientific findings and guide clinical practice in communities. In turn, communities and public health agents are shaping the research. The relationships forged through these complex collaborations increase the likelihood that the centers' scientific findings will be relevant to communities and contribute to reductions in health disparities.

Client-directed interventions to increase community access to breast, cervical, and colorectal cancer screening a systematic review

Most major medical organizations recommend routine screening for breast, cervical, and colorectal cancers. Screening can lead to early detection of these cancers, resulting in reduced mortality. Yet not all people who should be screened are screened, either regularly or, in some cases, ever. This report presents the results of systematic reviews of effectiveness, applicability, economic efficiency, barriers to implementation, and other harms or benefits of interventions designed to increase screening for breast, cervical, and colorectal cancers by increasing community access to these services. Evidence from these reviews indicates that screening for breast cancer (by mammography) has been increased effectively by reducing structural barriers and by reducing out-of pocket client costs, and that screening for colorectal cancer (by fecal occult blood test) has been increased effectively by reducing structural barriers. Additional research is needed to determine whether screening for cervical cancer (by Pap test) can be increased by reducing structural barriers and by reducing out-of-pocket costs, whether screening for colorectal cancer (fecal occult blood test) can be increased by reducing out-of-pocket costs, and whether these interventions are effective in increasing the use of other colorectal cancer screening procedures (i.e., flexible sigmoidoscopy, colonoscopy, double contrast barium enema). Specific areas for further research are also suggested in this report.

Client-directed interventions to increase community demand for breast, cervical, and colorectal cancer screening a systematic review

Most major medical organizations recommend routine screening for breast, cervical, and colorectal cancers. Screening can lead to early detection of these cancers, resulting in reduced mortality. Yet not all people who should be screened are screened, either regularly or, in some cases, ever. This report presents the results of systematic reviews of effectiveness, applicability, economic efficiency, barriers to implementation, and other harms or benefits of interventions designed to increase screening for breast, cervical, and colorectal cancers by increasing community demand for these services. Evidence from these reviews indicates that screening for breast cancer (mammography) and cervical cancer (Pap test) has been effectively increased by use of client reminders, small media, and one-on-one education. Screening for colorectal cancer by fecal occult blood test has been increased effectively by use of client reminders and small media. Additional research is needed to determine whether client incentives, group education, and mass media are effective in increasing use of any of the three screening tests; whether one-on-one education increases screening for colorectal cancer; and whether any demand-enhancing interventions are effective in increasing the use of other colorectal cancer screening procedures (i.e., flexible sigmoidoscopy, colonoscopy, double contrast barium enema). Specific areas for further research are also suggested in this report.

Interventions to increase recommendation and delivery of screening for breast, cervical, and colorectal cancers by healthcare providers systematic reviews of provider assessment and feedback and provider incentives

Most major medical organizations recommend routine screening for breast, cervical, and colorectal cancers. Screening can lead to early detection of these cancers, resulting in reduced mortality. Yet not all people who should be screened are screened, either regularly or, in some cases, ever. This report presents results of systematic reviews of effectiveness, applicability, economic efficiency, barriers to implementation, and other harms or benefits of two provider-directed intervention approaches to increase screening for breast, cervical, and colorectal cancers. These approaches, provider assessment and feedback, and provider incentives encourage providers to deliver screening services at appropriate intervals. Evidence in these reviews indicates that provider assessment and feedback interventions can effectively increase screening by mammography, Pap test, and fecal occult blood test. Health plans, healthcare systems, and cancer control coalitions should consider such evidence-based findings when implementing interventions to increase screening use. Evidence was insufficient to determine the effectiveness of provider incentives in increasing use of any of these tests. Specific areas for further research are suggested in this report, including the need for additional research to determine whether provider incentives are effective in increasing use of any of these screening tests, and whether assessment and feedback interventions are effective in increasing other tests for colorectal cancer (i.e., flexible sigmoidoscopy, colonoscopy, or double-contrast barium enema).

Introduction to the Special Section on Dissemination: Dissemination Research and Research Dissemination: How Can We Close the Gap?

One of the greatest challenges facing health promotion and disease prevention is translating research findings into evidence-based public health and clinical practices that are actively disseminated and widely adopted. Despite the tremendous strides made in developing effective disease prevention and control programs, there has been little study of effective dissemination of evidence-based programs to and adoption by community, public health, and clinical practice settings. This special section provides a venue in which to highlight exemplary dissemination research efforts while also identifying limitations in research to date and framing important future research questions. This issue establishes a resource for investigators interested in dissemination research, with relevance to health psychology. In this sense, it can serve as a benchmark by which to examine subsequent progress. The 6 articles reflect the state of the science in dissemination research for the promotion and adoption of health behavior change interventions.

The cancer prevention and control research network

The Cancer Prevention and Control Research Network is a national network recently established to focus on developing new interventions and disseminating and translating proven interventions into practice to reduce cancer burden and disparities, especially among minority and medically underserved populations. Jointly funded by the Centers for Disease Control and Prevention and the National Cancer Institute, the Cancer Prevention and Control Research Network consists of sites administered through Prevention Research Centers funded by the Centers for Disease Control and Prevention. The five sites are located in Kentucky, Massachusetts, South Carolina, Texas, Washington State, and West Virginia. The Cancer Prevention and Control Research Network's intervention areas include primary prevention of cancer through healthy eating, physical activity, sun avoidance, tobacco control, and early detection of cancer through screening. The Cancer Prevention and Control Research Network uses the methods of community-based participatory research and seeks to build on the cancer-relevant systematic reviews of the Guide to Community Preventive Services. Initial foci for the Cancer Prevention and Control Research Network's research work groups include projects to increase screening for breast, cervical, and colorectal cancers; to promote informed decision making for prostate cancer screening; and to validate educational materials developed for low-literacy populations.

Promoting informed decisions about cancer screening in communities and healthcare systems

Individuals are increasingly involved in decisions about their health care. Shared decision making (SDM), an intervention in the clinical setting in which patients and providers collaborate in decision making, is an important approach for informing patients and involving them in their health care. However, SDM cannot bear the entire burden for informing and involving individuals. Population-oriented interventions to promote informed decision making (IDM) should also be explored. This review provides a conceptual background for population-oriented interventions to promote informed decisions (IDM interventions), followed by a systematic review of studies of IDM interventions to promote cancer screening. This review specifically asked whether IDM interventions (1) promote understanding of cancer screening, (2) facilitate participation in decision making about cancer screening at a level that is comfortable for individuals; or (3) encourage individuals to make cancer-screening decisions that are consistent with their preferences and values.Fifteen intervention arms met the intervention definition. They used small media, counseling, small-group education, provider-oriented strategies, or combinations of these to promote IDM. The interventions were generally consistent in improving individuals' knowledge about the disease, accuracy of risk perceptions, or knowledge and beliefs about the pros and cons of screening and treatment options. However, few studies evaluated whether these interventions resulted in individuals participating in decision making at a desirable level, or whether they led to decisions that were consistent with individuals' values and preferences. More research is needed on how best to promote and facilitate individuals' participation in health care. Work is especially needed on how to facilitate participation at a level desired by individuals, how to promote decisions by patients that are consistent with their preferences and values, how to perform effective and cost-effective IDM interventions for healthcare systems and providers and in community settings (outside of clinical settings), and how to implement these interventions in diverse populations (such as populations that are older, nonwhite, or disadvantaged). Finally, work is needed on the presence and magnitude of barriers to and harms of IDM interventions and how they might be avoided.

Predictors of long-term outcomes in older breast cancer survivors: perceptions versus patterns of care

PURPOSE

There are few data on sequelae of breast cancer treatments in older women. We evaluated posttreatment quality of life and satisfaction in a national population.

PATIENTS AND METHODS

Telephone surveys were conducted with a random cross-sectional sample of 1,812 Medicare beneficiaries 67 years of age and older who were 3, 4, and 5 years posttreatment for stage I and II breast cancer. Regression models were used to estimate the adjusted risk of decrements in physical and mental health functioning by treatment. In a subset of women (n = 732), additional data were used to examine arm problems, impact of cancer, and satisfaction, controlling for baseline health, perceptions of ageism and racism, demographic and clinical factors, region, and surgery year.

RESULTS

Use of axillary dissection was the only surgical treatment that affected outcomes, increasing the risk of arm problems four-fold (95% confidence interval, 1.56 to 10.51), controlling for other factors. Having arm problems, in turn, exerted a consistently negative independent effect on all outcomes (P </=.001). Processes of care were also associated with quality of life and satisfaction. For example, women who perceived high levels of ageism or felt that they had no choice of treatment reported significantly more bodily pain, lower mental health scores, and less general satisfaction. These same factors, as well as high perceived racism, were significantly associated with diminished satisfaction with the medical care system.

CONCLUSION

With the exception of axillary dissection, the processes of care, and not the therapy itself, are the most important determinants of long-term quality of life in older women.

Existing data on breast cancer in African-American women: what we know and what we need to know

BACKGROUND

Much of what is known about breast cancer in African-American (AA) women is based on existing cancer surveillance data. Thus, it is important to consider the accuracy of these resources in describing the impact of breast cancer in AA populations.

METHODS

National cancer surveillance data bases are described, their most recent findings are presented, their limitations are outlined, and recommendations are made for improving their utility.

RESULTS

Breast cancer characteristics have been studied well in urban (but not in rural) and Southern AA populations. The recent Surveillance, Epidemiology, and End Results (SEER) Program expansion and the continued improvement of state cancer registry operations will provide opportunities to study larger and more diverse AA subpopulations. Recommendations for improving the utility of surveillance data bases include adding new items to better describe correlates of advanced stage at diagnosis and reduced survival of AA women with breast cancer by linking surveillance data bases with other large data bases to provide area-level socioeconomic status, health insurance status, and retrieving new information about patient comorbidities and biomarkers from medical records; improving the completeness and accuracy of treatment and survival information already collected for all patients; working to improve the dissemination of appropriate cancer data to nonresearch consumer communities, including clinicians, patients, advocates, politicians, and health officials; and the development of new training programs for cancer registrars and researchers.

CONCLUSIONS

The continued improvement of cancer surveillance systems should be considered important activities in this research agenda, because these data will play a far-reaching role in the prevention and control of breast cancer in AA women.

Impact of undergoing prostate carcinoma screening on prostate carcinoma-related knowledge and distress

BACKGROUND

Despite the ongoing controversy regarding the utility of prostate carcinoma (PCa) screening, the prevalence of asymptomatic men who participate in free PCa screening programs is on the rise. However, this increased awareness has not been associated with increased knowledge about the potential limitations of PCa creening. We conducted a prospective assessment to delineate men's motivations for undergoing screening and to determine the impact of screening on psychological distress and on men's knowledge about PCa screening.

METHODS

We conducted two telephone interviews with a group of 136 men registered to undergo free PCa screening at two hospital-based sites. The first interview was conducted before screening and the second interview followed receipt of the screening results. Interviews assessed demographics and screening history, reasons for undergoing the current screening, cancer-related and general psychological distress, knowledge of risk factors for PCa, and knowledge of the benefits and limitations of screening. Only participants with normal screening results were included in these analyses.

RESULTS

"Seeking peace of mind about prostate cancer" was rated as the most important reason for undergoing screening. PCa-related distress decreased following receipt of a negative result (P < 0.01). Stratified analyses indicated that this was particularly true among younger men and African American men (both Ps < 0.001). Awareness of the benefits of screening was very high, but awareness of limitations was low, with fewer limitations reported following screening compared with prescreening (P < 0.01). Although awareness of the established risk factors improved following screening, controversial risk factors (i.e., those with limited empirical support) and factors that were unrelated to PCa risk were also rated as more important in the development of PCa than they were before screening (all Ps < 0.05). Therefore, the results may reflect that following screening, participants were simply more likely to endorse plausible risk factors, rather than actually reflecting an increase in participants' knowledge.

CONCLUSIONS

These results suggest the importance of developing informed consent procedures and educational programs for the asymptomatic men who participate in free prostate screening programs each year, as the decision to be screened is being made without the benefit of a full understanding of the current state of medical knowledge about PCa screening. Until the definitive results of the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial are available, improved patient education is needed to assist men in making screening decisions consistent with their own preferences.

Feasibility of mobile cancer screening and prevention

Many areas have high cancer mortality rates and medically underserved populations. This study describes the feasibility (acceptability and costs) of an urban multiphasic (multiple cancers) screening van. Feasibility was evaluated by literature review and informant interviews. Costs were estimated by resource use from urban mobile screening units; decision analysis estimated the costs per cancer detected for breast, cervix, colorectal, and prostate cancer screening. Acceptability of a multiphasic van varied by the informant's perspective. Feasibility and costs were most sensitive to four parameters: age, prior screening history, risk factors, and volume of simultaneous examinations. Subsidized mobile screening facilities may have the potential to reduce cancer morbidity and mortality if they target hard-to-reach underscreened groups, maintain high volume, coordinate with primary care providers, and build on an infrastructure that provides diagnostic and treatment services regardless of ability to pay. It is unclear whether the investment required will translate into a reasonable cost per year of life saved.

The emotional consequences of false positive mammography: African-American women's reactions in their own words

High false positive rates associated with screening for breast cancer in the United States have an unintended psychological consequence for women (Lerman et al., 1991) that has raised concerns in recent years (Sox, 1998). This study uses inductive qualitative analysis of open-ended interviews with 45 African American women living in New York City who were part of a larger study of women and their experiences after receiving an abnormal mammogram. Themes resulting from the analyses included: inadequate provider-patient communication, anxieties exacerbated by waiting and wondering, and fears of iatrogenic effects of follow-up tests such as biopsies and repeat mammograms. While more research is needed on message-framing strategies for women entering mammographic testing and follow-up, modest changes in service delivery such as improved medical communication can help to alleviate fears and enhance trust.

Aging skeletal muscle mitochondria in the rat: decreased uncoupling protein-3 content

The goal of the present study was to discern the cellular mechanism(s) that contributes to the age-associated decrease in skeletal muscle aerobic capacity. Skeletal muscle mitochondrial content, a parameter of oxidative capacity, was significantly lower (25 and 20% calculated on the basis of citrate synthase and succinate dehydrogenase activities, respectively) in 24-mo-old Fischer 344 rats compared with 6-mo-old adult rats. Mitochondria isolated from skeletal muscle of both age groups had identical state 3 (ADP-stimulated) and ADP-stimulated maximal respiratory rates and phosphorylation potential (ADP-to-O ratios) with both nonlipid and lipid substrates. In contrast, mitochondria from 24-mo-old rats displayed significantly lower state 4 (ADP-limited) respiratory rates and, consequently, higher respiratory control ratios. Consistent with the tighter coupling, there was a 68% reduction in uncoupling protein-3 (UCP-3) abundance in mitochondria from elderly compared with adult rats. Congruent with the respiratory studies, there was no age-associated decrease in carnitine palmitoyltransferase I and carnitine palmitoyltransferase II activities in isolated skeletal muscle mitochondria. However, there was a small, significant decrease in tissue total carnitine content. It is concluded that the in vivo observed decrease in skeletal muscle aerobic capacity with advanced age is a consequence of the decreased mitochondrial density. On the basis of the dramatic reduction of UCP-3 content associated with decreased state 4 respiration of skeletal muscle mitochondria from elderly rats, we propose that an increased free radical production might contribute to the metabolic compromise in aging.

Rat liver mitochondrial contact sites and carnitine palmitoyltransferase-I

In hepatic mitochondria, the outer membrane enzyme, carnitine palmitoyltransferase-I (CPT-I), appears to colocalize with contact sites. We have prepared contact sites that are essentially devoid of noncontact site membranes. The contact site fraction has a high specific activity for CPT-I and contains a protein at 88 kDa that is recognized by antibodies directed at two different peptide epitopes on CPT-I. Similarly long-chain acyl-CoA synthetase (LCAS) specific activity is high in this fraction; a protein at 79 kDa is recognized by an antibody against LCAS. Although activity of carnitine palmitoyltransferase-II (CPT-II) is present, it is not enriched in the contact site fraction, and a protein of 68 kDa weakly reacted with anti-CPT-II antibody. Likewise, carnitine-acylcarnitine translocase (CACT) protein is present, but at a somewhat reduced level. Using an analytical continuous sucrose gradient, we demonstrate that the activities of CPT-I and LCAS and their associated immunoreactive proteins are present in a constant amount throughout the contact site subfractions. The enzymatic activity of CPT-II and its associated immunoreactive protein, as well as immunoreactive CACT, is absent in the lighter density gradient subfractions and is present in the higher density subfractions only in trace amounts. This heterogeneity of the contact site fraction is due to unvarying amounts of outer membrane and increasing amounts of attached inner membrane with increasing density of the subfractions.

Mitochondrial dysfunction in cardiac disease: ischemia--reperfusion, aging, and heart failure

Mitochondria contribute to cardiac dysfunction and myocyte injury via a loss of metabolic capacity and by the production and release of toxic products. This article discusses aspects of mitochondrial structure and metabolism that are pertinent to the role of mitochondria in cardiac disease. Generalized mechanisms of mitochondrial-derived myocyte injury are also discussed, as are the strengths and weaknesses of experimental models used to study the contribution of mitochondria to cardiac injury. Finally, the involvement of mitochondria in the pathogenesis of specific cardiac disease states (ischemia, reperfusion, aging, ischemic preconditioning, and cardiomyopathy) is addressed.

Improving knowledge of the prostate cancer screening dilemma among African American men: an academic-community partnership in Washington, DC

OBJECTIVE

Studies have shown that African American men are at greater risk than other men for prostate cancer in terms of both incidence and mortality. At the same time, the utility of screening asymptomatic men for prostate cancer remains controversial. The combination of high incidence and high mortality with the uncertain benefits of screening poses a difficult problem for African American men. This study was part of an ongoing project that sought to develop and evaluate health education materials designed to help African American men make an informed decision about prostate cancer screening. The project represented a collaboration between the Most Worshipful Prince Hall Grand Lodge of the District of Columbia and the Lombardi Cancer Center of Georgetown University.

METHODS

The authors conducted eight focus groups with 44 members of the Prince Hall Masons. The focus groups covered men's understanding of prostate cancer screening and their preferences for methods of health education.

RESULTS

Participants demonstrated a high level of awareness of the availability of prostate cancer screening, a low awareness of the screening controversy, and a desire for detailed epidemiologic information and information about the benefits and limitations of screening. The preferred forms of educational materials were video and print-based materials, which the research team has recently developed.

CONCLUSIONS

These findings demonstrate the feasibility of developing an academic-community collaboration with the goal of improving a health-related problem in the African American community. A randomized trial is underway to evaluate the impact of the video and print education materials.

Growth in human milk-Fed very low birth weight infants receiving a new human milk fortifier

BACKGROUND/AIMS

Human milk fortification has been advocated to enhance premature infants' growth. We, therefore, undertook this study of a new human milk fortifier containing more protein than a reference one.

METHODS

Open, randomized, controlled, multiclinic trial, with weekly growth parameters and safety evaluations in premature infants <1,500 g.

RESULTS

The 2 groups did not differ in demographic and baseline characteristics. The adjusted daily milk intake was significantly higher in the infants fed reference human milk fortifier (n = 29; 154.2 +/- 2.1 vs. 144.4 +/- 2.5 ml/kg/day, mean +/- SE; p < 0.05). Both human milk fortifiers produced increases over baseline in weight, length, and head circumference, with greater gains observed in the new human milk fortifier-fed infants for the former two parameters (weight gain 26.8 +/- 1.3 and 20.4 +/- 1.2 g/day, p < 0.05; head circumference 1.0 +/- 0.1 and 0.8 +/- 0.1 cm/week; length 0.9 +/- 0.1 and 0.8 +/- 0.1 cm/week, respectively). Serum chemistries were normal and acceptable for age. Study events were typical for premature infants and similar in both groups.

CONCLUSIONS

This new human milk fortifier had comparable safety to the reference human milk fortifier and promoted faster weight gain and head circumference growth.

Fatty acid import into mitochondria

The mitochondrial carnitine system plays an obligatory role in beta-oxidation of long-chain fatty acids by catalyzing their transport into the mitochondrial matrix. This transport system consists of the malonyl-CoA sensitive carnitine palmitoyltransferase I (CPT-I) localized in the mitochondrial outer membrane, the carnitine:acylcarnitine translocase, an integral inner membrane protein, and carnitine palmitoyltransferase II localized on the matrix side of the inner membrane. Carnitine palmitoyltransferase I is subject to regulation at the transcriptional level and to acute control by malonyl-CoA. The N-terminal domain of CPT-I is essential for malonyl-CoA inhibition. In liver CPT-I activity is also regulated by changes in the enzyme's sensitivity to malonyl-CoA. As fluctuations in tissue malonyl-CoA content are parallel with changes in acetyl-CoA carboxylase activity, which in turn is under the control of 5'-AMP-activated protein kinase, the CPT-I/malonyl-CoA system is part of a fuel sensing gauge, turning off and on fatty acid oxidation depending on the tissue's energy demand. Additional mechanism(s) of short-term control of CPT-I activity are emerging. One proposed mechanism involves phosphorylation/dephosphorylation dependent direct interaction of cytoskeletal components with the mitochondrial outer membrane or CPT-I. We have proposed that contact sites between the outer and inner mitochondrial membranes form a microenvironment which facilitates the carnitine transport system. In addition, this system includes the long-chain acyl-CoA synthetase and porin as components.

A 22 kDa polyanion inhibits carnitine-dependent fatty acid oxidation in rat liver mitochondria

The transport of activated fatty acids across the mitochondrial outer membrane has not been fully addressed. A polyanion (M(n)=22 kDa) inhibited the ADP-stimulated carnitine-dependent oxidation of both palmitoyl-CoA and palmitate plus CoA as well as mitochondrial hexokinase binding. In contrast, the oxidation of palmitoylcarnitine plus malate, as well as glutamate oxidation, was essentially unaffected. Mitochondrial carnitine palmitoyltransferase-1 was not inhibited by the polyanion. The data suggest an additional component in carnitine-dependent mitochondrial fatty acid oxidation, possibly porin.

Correlation between pre-operative periprosthetic bone density and post-operative bone loss in THA can be explained by strain-adaptive remodelling

Periprosthetic adaptive bone remodelling after total hip arthroplasty can be simulated in computer models, combining bone remodelling theory with finite element analysis. Patient specific three-dimensional finite element models of retrieved bone specimens from an earlier bone densitometry (DEXA) study were constructed and bone remodelling simulations performed. Results of the simulations were analysed both qualitatively and quantitatively. Patterns of predicted bone loss corresponded very well with the DEXA measurements on the retrievals. The amount of predicted bone loss, measured quantitatively by simulating DEXA on finite element models, was found to be inversely correlated with the initial bone mineral content. It was concluded that the same clinically observed correlation can therefore be explained by mechanically induced remodelling. This finding extends the applicability of numerical pre-clinical testing to the analysis of interaction between implant design and initial state of the bone.

Breast and cervix cancer screening among multiethnic women: role of age, health, and source of care

OBJECTIVE

The aim of this study was to evaluate the relationships between age, health status, access to care, and breast and cervical cancer screening among multiethnic elderly and nonelderly women.

METHODS

A structured telephone survey of a quota sample of 1,420 New York City women from four Hispanic groups (Columbian, Dominican, Puerto Rican, Ecuadorian) and three black groups (U.S., Caribbean, and Haitian) was performed. Outcome measures included "ever" and "recent" self-reported use of mammography, clinical breast examination (CBE), and Pap smears. Logistic regression models assessed the predictors of screening use.

RESULTS

Having a regular source of care significantly predicted all screening use for both elderly and nonelderly, controlling for ethnicity, sociodemographics, health status, access to care, proportion of life in the United States, and cancer attitudes. Elderly women (>/=65 years) were significantly less likely to have ever had (OR = 0.79, 95% CI 0.65-0. 96) and to have recently had (OR = 0.67, 95% CI 0.57-0.79) Pap smears than younger women, controlling for the other variables; being elderly also tended to be an independent predictor of ever and recent mammography and CBE use. Interestingly, there was a trend for health status to act differently in predicting Pap smear use for the two age groups. For younger women, being in poor health increased the odds of Pap smear screening, while for elderly women, being in good health increased the odds of screening.

CONCLUSIONS

Elderly women reported being screened less than younger women; interactions between health status and age need further exploration.

Racial differences in testing motivation and psychological distress following pretest education for BRCA1 gene testing

OBJECTIVES

We conducted a randomized trial to investigate racial differences in response to two alternate pretest education strategies for BRCA1 genetic testing: a standard education model and an education plus counseling (E + C) model.

MATERIALS AND METHODS

Two hundred twenty-eight Caucasian women and 70 African American women with a family history of breast or ovarian cancer were contacted for a baseline telephone interview to assess sociodemographic characteristics, number of relatives affected with cancer, and race before pretest education. Outcome variables included changes from baseline to 1-month follow-up in cancer-related distress and genetic testing intentions, as well as provision of a blood sample after the education session.

RESULTS

African American women were found to differ significantly from Caucasian women in the effects of the interventions on testing intentions and provision of a blood sample. Specifically, in African American women, E + C led to greater increases than education only in intentions to be tested and provision of a blood sample. These effects were independent of socioeconomic status and referral mechanisms. In Caucasian women, there were no differential effects of the interventions on these outcomes. Reductions in cancer-specific distress were evidenced in all study groups. However, this decrease, although not significantly different, was smallest among African American women who received E + C.

CONCLUSIONS

In low- to moderate-risk African American women, pretest education and counseling may motivate BRCA1 testing. Further research is needed to explore the mechanisms of impact of the alternate pretest education strategies and to increase the cultural sensitivity of education and counseling protocols.

Acculturation and breast cancer screening among Hispanic women in New York City

OBJECTIVES

This study investigated whether acculturation was associated with the receipt of clinical breast examinations and mammograms among Colombian, Ecuadorian, Dominican, and Puerto Rican women aged 18 to 74 years in New York City in 1992.

METHODS

A bilingual, targeted, random-digit-dialed telephone survey was conducted among 908 Hispanic women from a population-based quota sample. Outcome measures included ever and recent use of clinical breast examinations and mammograms. Multivariate logistic regression models were used to assess the effect of acculturation on screening use.

RESULTS

When demographic, socioeconomic, and health system characteristics and cancer attitudes and beliefs were controlled for, women who were more acculturated had significantly higher odds of ever and recently receiving a clinical breast examination (P < or = .01) and of ever (P < or = .01) and recently (P < or = .05) receiving a mammogram than did less acculturated women. For all screening measures, there was a linear increase in the adjusted probability of being screened as a function of acculturation.

CONCLUSIONS

Neighborhood and health system interventions to increase screening among Hispanic women should target the less acculturated.

The malonyl-CoA-sensitive form of carnitine palmitoyltransferase is not localized exclusively in the outer membrane of rat liver mitochondria

The data used to support the idea that malonyl-coenzyme A (CoA)-sensitive carnitine palmitoyltransferase (CPT-I) is localized on the outer mitochondrial membrane are based on harsh techniques that disrupt mitochondrial physiology. We have turned to the use of the French press, which produces a shearing force that denudes mitochondria of their outer membrane without the physiologically disruptive effects characteristic of phosphate swelling. Our results indicate that the mitoplasts contain just 15-19% of the outer membrane marker enzyme activity while retaining 85% of the total CPT activity and 50% of both CPT-I, as well as long-chain acyl-CoA synthase activity, the latter two supposed outer membrane enzymes. These mitoplasts were shown by electron microscopy to have the configuration of mitochondria that merely have been divested of their outer membranes. Carnitine-dependent fatty acid oxidation was retained in the mitoplasts, showing that they were physiologically intact. Moreover, protein immunoblotting analysis showed that CPT-I, as well as the inner CPT-II, was localized in the mitoplast fraction. The outer membrane fraction, which consisted of membrane "ghosts," contained most (50-60%) of marker enzyme activity, monoamine oxidase-B and porin proteins, but only about 27-29% CPT-I activity. Because CPT-I and long-chain acyl-CoA synthetase appear to be associated with both inner and outer membranes, we postulate that these enzymes reside in contact sites, which represent a melding of both limiting membranes.

Genetic disorders of carnitine metabolism and their nutritional management

Carnitine functions as a substrate for a family of enzymes, carnitine acyltransferases, involved in acyl-coenzyme A metabolism and as a carrier for long-chain fatty acids into mitochondria. Carnitine biosynthesis and/or dietary carnitine fulfill the body's requirement for carnitine. To date, a genetic disorder of carnitine biosynthesis has not been described. A genetic defect in the high-affinity plasma membrane carnitine-carrier(in) leads to renal carnitine wasting and primary carnitine deficiency. Myopathic carnitine deficiency could be due to an increase in efflux moderated by the carnitine-carrier(out). Defects in the carnitine transport system for fatty acids in mitochondria have been described and are being examined at the molecular and pathophysiological levels. the nutritional management of these disorders includes a high-carbohydrate, low-fat diet and avoidance of those events that promote fatty acid oxidation, such as fasting, prolonged exercise, and cold. Large-dose carnitine treatment is effective in systemic carnitine deficiency.

Beta-receptor blockade decreases carnitine palmitoyl transferase I activity in dogs with heart failure

BACKGROUND

Pharmacological inhibition of carnitine palmitoyl transferase I (CPT-I), the enzyme controlling the rate of fatty acid transport into the mitochondria, prevents the contractile dysfunction, myosin isozyme shift and deterioration in sarcoplasmic reticulum Ca2+ handling that occurs in rat models of left ventricular hypertrophy. In this study we examine whether the improved cardiac function with beta blockade therapy in heart failure is associated with an alteration in CPT-I activity.

METHODS AND RESULTS

We examined dogs with coronary microembolism-induced heart failure treated for 12 weeks with metoprolol (25 mg twice daily). Myocardial activities of CPT-I, medium-chain acyl co-enzyme A dehydrogenase (MCAD, a beta-oxidation enzyme), citrate synthase, and triglyceride content were measured. The progressive decrease in cardiac function was prevented by treatment with metoprolol, as reflected by an improved ejection fraction over 12 weeks in the metoprolol group (from 35% to 40%) compared to the untreated heart failure dogs (decrease from 36% to 26%). Dogs treated with metoprolol had a marked decrease in CPT-I activity (0.46 +/- 0.03 vs. 0.64 +/- 0.02 micromol min(-1) g(-1) wet weight; P < .02) along with an increase in triglyceride concentration compared to untreated heart failure dogs (3.9 +/- 0.3 v 4.9 +/- 0.2 micromol/g wet weight, respectively; P < .003). By contrast, MCAD and citrate synthase activities did not change.

CONCLUSION

Metoprolol induced a decrease in CPT-I activity and an increase in triglyceride content. These results suggest that the improved function observed with beta blockers in heart failure could be due, in part, to a decrease in CPT-I activity and less fatty acid oxidation by the heart.

Ethnic differences in knowledge and attitudes about BRCA1 testing in women at increased risk

Informed consent for BRCA1 mutation testing will require adequate knowledge of patterns of inheritance of cancer and the benefits, limitations, and risks of DNA testing. This study examined knowledge about the inheritance of breast cancer and attitudes about genetic testing for breast-ovarian cancer susceptibility in women at increased risk. Knowledge and attitudes were measured in 407 African American and Caucasian women aged 18-75 who had at least one first-degree relative (FDR) with breast and/or ovarian cancer. The average knowledge score was 6.0 out of a total of 11 (S.D. = 2.15). Compared to Caucasian women, African American women had lower levels of knowledge and had more positive attitudes about the benefits of genetic testing. There were no significant ethnic differences in attitudes about the limitations and risks of testing, however, income was negatively associated with this outcome. Ethnic differences in knowledge and attitudes about genetic testing for breast-ovarian cancer risk may be attributable to differences in exposure to genetic information and referral by health care providers.

Continuity of care and the use of breast and cervical cancer screening services in a multiethnic community

OBJECTIVE

To examine how continuity of care affects the use of breast and cervical cancer screening in a multiethnic population.

METHODS

All data came from a structured telephone survey of a population-based quota sample designed to determine the cancer prevention needs of multiethnic blacks and Hispanics in New York, NY, in 1992. The study included 1420 women of 7 racial/ethnic groups: US-born blacks, English-speaking Caribbean-born blacks, Haitian blacks, and Puerto Rican, Dominican, Colombian, and Ecuadorian Hispanics. The main outcome measures were ever and recently having had a Papanicolaou smear, clinical breast examination (CBE), or mammogram.

RESULTS

Among respondents who qualified for the survey on the basis of age and ethnicity, the refusal rate for completing the interview was 2.1%. Compared with women without a usual site of care, those with a usual site, but no regular clinician, were 1.56, 2.45 (P < or = .01), and 2.32 (P < or = .05) times as likely ever to have received a Papanicolaou smear, CBE, or mammogram, respectively and 1.84, 1.92 (P < or = .05), and 1.75 times as likely to have received a recent Papanicolaou smear, CBE, or mammogram, respectively. Compared with women without a usual site of care, women with a regular clinician at that usual site of care were 2.63 (P < or = .01), 2.83 (P < or = .01), and 2.30 (P < or = .05) times as likely ever to have received a Papanicolaou smear, CBE, or mammogram, and were 2.00 (P < or = .05), 2.65 (P < or = .01), and 1.40 times as likely to have recently received a Papanicolaou smear, CBE, or mammogram, respectively (adjusted odds ratios). For uninsured women, presence of a usual site of care was associated with increases in recent use of cancer screening for all screening tests.

CONCLUSIONS

There is a linear trend in increasing breast and cervical cancer screening rates when one goes from having no usual source of care, to having a usual source, and to having a regular clinician at that usual source. Emphasis on continuity of care, especially on usual source of care, may help to bridge the gap in access to cancer prevention services faced by minority women.

The costs and effects of cervical and breast cancer screening in a public hospital emergency room. The Cancer Control Center of Harlem

OBJECTIVES

This study assessed the cost-effectiveness of cervix and breast cancer screening in a public hospital emergency room.

METHODS

Age-eligible women with nonurgent conditions and without recent screening were offered screening by a nurse. A decision analysis compared the costs and outcomes of emergency room screening and standard hospital screening efforts.

RESULTS

The undiscounted cost-effectiveness results for establishing new programs were $4050 (cervical cancer), $403,203 (breast cancer), and $4375 (joint cervix and breast cancer) per year of life saved. If screening is added to an existing program, results are more favorable ($429, $21,324, and $479 per year of life saved for cervix, breast, and joint screening, respectively). Results were most sensitive to volume and probability of receiving treatment after an abnormal screen.

CONCLUSIONS

Emergency room screening was cost-effective for cervical cancer; breast cancer screening was relatively expensive given the low number of women reached. More intensive recruitment and follow-up strategies are needed to maximize the cost-effectiveness of such programs.

Controlled trial of pretest education approaches to enhance informed decision-making for BRCA1 gene testing

BACKGROUND

In response to the isolation of the BRCA1 gene, a breast-ovarian cancer-susceptibility gene, biotechnology companies are already marketing genetic tests to health care providers and to the public. Initial studies indicate interest in BRCA1 testing in the general public and in populations at high risk. However, the optimal strategies for educating and counseling individuals have yet to be determined.

PURPOSE

Our goal was to evaluate the impact of alternate strategies for pretest education and counseling on decision-making regarding BRCA1 testing among women at low to moderate risk who have a family history of breast and/or ovarian cancer.

METHODS

A randomized trial design was used to evaluate the effects of education only (educational approach) and education plus counseling (counseling approach), as compared with a waiting-list (control) condition (n = 400 for all groups combined). The educational approach reviewed information about personal risk factors, inheritance of cancer susceptibility, the benefits, limitations, and risks of BRCA1 testing, and cancer screening and prevention options. The counseling approach included this information, as well as a personalized discussion of experiences with cancer in the family and the potential psychological and social impact of testing. Data on knowledge of inherited cancer and BRCA1 test characteristics, perceived risk, perceived benefits, limitations and risks of BRCA1 testing, and testing intentions were collected by use of structured telephone interviews at baseline and at 1-month follow-up. Provision of a blood sample for future testing served as a proxy measure of intention to be tested (in the education and counseling arms of the study). The effects of intervention group on study outcomes were evaluated by use of hierarchical linear regression modeling and logistic regression modeling (for the blood sample outcome). All P values are for two-sided tests.

RESULTS

The educational and counseling approaches both led to significant increases in knowledge, relative to the control condition (P < .001 for both). The counseling approach, but not the educational approach, was superior to the control condition in producing significant increases in perceived limitations and risks of BRCA1 testing (P < .01) and decreases in perceived benefits (P < .05). However, neither approach produced changes in intentions to have BRCA1 testing. Prior to and following both education only and education plus counseling, approximately one half of the participants stated that they intended to be tested; after the session, 52% provided a blood sample.

CONCLUSIONS

Standard educational approaches may be equally effective as expanded counseling approaches in enhancing knowledge. Since knowledge is a key aspect of medical decision-making, standard education may be adequate in situations where genetic testing must be streamlined. On the other hand, it has been argued that optimal decision-making requires not only knowledge, but also a reasoned evaluation of the positive and negative consequences of alternate decisions. Although the counseling approach is more likely to achieve this goal, it may not diminish interest in testing, even among women at low to moderate risk. Future research should focus on the merits of these alternate approaches for subgroups of individuals with different backgrounds who are being counseled in the variety of settings where BRCA1 testing is likely to be offered.