An examination of psychometric properties of study quality assessment scales in meta-analysis: Rasch measurement model applied to the firefighter cancer literature

Most existing quality scales have been developed with minimal attention to accepted standards of psychometric properties. Even for those that have been used widely in medical research, limited evidence exists supporting their psychometric properties. The focus of our current study is to address this gap by evaluating the psychometrics properties of two existing quality scales that are frequently used in cancer observational research: (1) Item Bank on Risk of Bias and Precision of Observational Studies developed by the Research Triangle Institute (RTI) International and (2) Newcastle-Ottawa Quality Assessment Scale (NOQAS). We used the Rasch measurement model to evaluate the psychometric properties of two quality scales based on the ratings of 49 studies that examine firefighters' cancer incidence and mortality. Our study found that RTI and NOQAS have an acceptable item reliability. Two raters were consistent in their assessment, demonstrating high interrater reliability. We also found that NOQAS has more items that show better fit than the RTI scale. The NOQAS produced lower study quality scores with a smaller variation, suggesting that NOQAS items are much easier to rate. Our findings accord with a previous study, which conclude that the RTI scale was harder to apply and thus produces more heterogenous quality scores than NOQAS. Although both RTI and NOQAS showed high item reliability, NOQAS items are better fit to the underlying construct, showing higher validity of internal structure and stronger psychometric properties. The current study adds to our understanding of the psychometric properties of NOQAS and RTI scales for future meta-analyses of observational studies, particularly in the firefighter cancer literature.

Cancer risk and mortality among firefighters: a meta-analytic review

Background

Firefighting is a hazardous occupation that is associated with an increased risk of select cancers. The number of studies has grown in recent years allowing for a synthesis of findings.

Methods

Following PRISMA guidelines, multiple electronic databases were searched to identify studies on firefighter cancer risk and mortality. We computed pooled standardized incidence risk (SIRE) and standardized mortality estimates (SMRE), tested for publication bias, and conducted moderator analyses.

Results

Thirty-eight studies published between 1978 and March 2022 were included for final meta-analysis. Overall, cancer incidence and mortality were significantly lower for firefighters (SIRE = 0.93; 95% CI: 0.91-0.95; SMRE = 0.93; 95% CI: 0.92 - 0.95) compared to the general population. Incident cancer risks were significantly higher for skin melanoma (SIRE = 1.14; 95% CI:1.08 - 1.21), other skin cancers (SIRE = 1.24; 95% CI:1.16-1.32), and prostate cancer (SIRE = 1.09; 95% CI: 1.04-1.14). Firefighters showed higher mortality for rectum (SMRE = 1.18; 95% CI: 1.02-1.36), testis (SMRE = 1.64; 95% CI: 1.00-2.67), and non-Hodgkin lymphoma (SMRE = 1.20; 95% CI: 1.02-1.40). There was evidence of publication bias for SIRE and SMRE estimates. Some moderators explained variations in study effects, including study quality scores.

Conclusion

Firefighters are at higher risk for several cancers; to the extent that some (e.g., melanoma and prostate) are screening amenable, more study into firefighter-specific recommendations for cancer surveillance is needed. Moreover, longitudinal studies with more detailed data on the specific length and types of exposures are necessary, as well as on unstudied subtypes of cancers (e.g., subtypes of brain cancer and leukemias) are needed.

HIV patients’ perceptions of a potential multi-component mindfulness-based smoking cessation smartphone application intervention

Objectives

Cigarette smoking rates among people living with HIV (PLWH) in the US is triple that of the general population. PLWH smokers are a high-risk group for smoking-related health disparities and should be a prime focus for smoking cessation efforts. Our team has developed a novel evidence-based Mindfulness Training (MT) smoking cessation smartphone application (app), “Craving-to-Quit.” Using qualitative focus groups among PLWH smokers, this study aims to tailor and optimize the app’s content and design to PLWH’s unique psychosocial profile and needs.

Methods

We conducted 8 focus groups among PLWH smokers (n = 59; 47.5% females; ≥18 years) to gain insight into participants’ perceptions about the app, MT, and the feasibility and acceptability of adding two additional strategies (CM: Contingency Management; self-monitoring of anti-retroviral therapies intake [ART]) to further optimize the app. Participants were asked to practice MTs and watch videos from the app presented on a screen in the conference room to discuss their experience. Sessions were audio-taped, transcribed verbatim, and analyzed thematically using NVivo.

Results

Most participants were non-Hispanic black (67.8%), on a federal health insurance program (61.0%). Participants considered it easy to learn the app and thought that MT is helpful in reducing stress and motivating quit attempts and were supportive of adding CM and recommended providing $20-$50 weekly cash incentives to help in quitting. Participants felt that adding self-monitoring of ART is helpful but were concerned about confidentiality in case they lost their phone. Participants recommended making the app cost-free and adding information about smoking cessation medications and the negative effects of smoking among PLWH.

Conclusions

Findings will guide the development of a novel multi-component smoking cessation intervention app integrating MT, CM, and ART self-monitoring strategies. This intervention has the potential to address several barriers to quitting in PLWH. Further clinical research is needed to test this intervention.

Social Susceptibility to Multiple Air Pollutants in Cardiovascular Disease

INTRODUCTION

Cardiovascular disease (CVD) is the leading cause of death in the United States, and substantial research has linked ambient air pollution to elevated rates of CVD etiology and events. Much of this research identified increased effects of air pollution in lower socioeconomic position (SEP) communities, where pollution exposures are also often higher. The complex spatial confounding between air pollution and SEP makes it very challenging, however, to disentangle the impacts of these very different exposure types and to accurately assess their interactions. The specific causal components (i.e., specific social stressors) underlying this SEP-related susceptibility remain unknown, because there are myriad pathways through which poverty and/or lower-SEP conditions may influence pollution susceptibility - including diet, smoking, coexposures in the home and occupational environments, health behaviors, and healthcare access. Growing evidence suggests that a substantial portion of SEP-related susceptibility may be due to chronic psychosocial stress - given the known wide-ranging impacts of chronic stress on immune, endocrine, and metabolic function - and to a higher prevalence of unpredictable chronic stressors in many lower-SEP communities, including violence, job insecurity, and housing instability. As such, elucidating susceptibility to pollution in the etiology of CVD, and in the risk of CVD events, has been identified as a research priority. This interplay among social and environmental conditions may be particularly relevant for CVD, because pollution and chronic stress both impact inflammation, metabolic function, oxidative stress, hypertension, atherosclerosis, and other processes relevant to CVD etiology. Because pollution exposures are often spatially patterned by SEP, disentangling their effects - and quantifying any interplay - is especially challenging. Doing so, however, would help to improve our ability to identify and characterize susceptible populations and to improve our understanding of how community stressors may alter responses to multiple air pollutants. More clearly characterizing susceptible populations will improve our ability to design and target interventions more effectively (and cost-effectively) and may reveal greater benefits of pollution reduction in susceptible communities, strengthening cost-benefit and accountability analyses, ultimately reducing the disproportionate burden of CVD and reducing health disparities.

METHODS

In the current study, we aimed to quantify combined effects of multiple pollutants and stressor exposures on CVD events, using a number of unique datasets we have compiled and verified, including the following. 1. Poverty metrics, violent crime rates, a composite socioeconomic deprivation index (SDI), an index of racial and economic segregation, noise disturbance metrics, and three composite spatial factors produced from a factor analysis of 27 community stressors. All indicators have citywide coverage and were verified against individual reports of stress and stressor exposure, in citywide focus groups and surveys. 2. Spatial surfaces for multiple pollutants from the New York City (NYC) Community Air Survey (NYCCAS), which monitored multiple pollutants year-round at 150 sites and used land use regression (LUR) modeling to estimate fine-scale (100-m) intra-urban spatial variance in fine particles (PM2.5), nitrogen dioxide (NO2), sulfur dioxide (SO2), and ozone (O3). 3. Daily data and time-trends derived from all U.S. Environmental Protection Agency (EPA) Air Quality System (AQS) monitors in NYC for 2005-2011, which we combined with NYCCAS surfaces to create residence- and day-specific spatiotemporal exposure estimates. 4. Complete data on in- and out-patient unscheduled CVD events presented in NYC hospitals for 2005-2011 (n = 1,113,185) from the New York State (NYS) Department of Health's Statewide Planning and Research Cooperative System (SPARCS). In the study, we quantified relationships between multiple pollutant exposures and both community CVD event rates and individual risk of CVD events in NYC and tested whether pollution-CVD associations varied by community SEP and social stressor exposures. We hypothesized (1) that greater chronic community-level SEP, stressor, and pollution exposures would be associated with higher community CVD rates; (2) that spatiotemporal variations in multiple pollutants would be associated with excess risk of CVD events; and (3) that pollution-CVD associations would be stronger in communities of lower SEP or higher stressor exposures.

RESULTS

To first understand the separate and combined associations with CVD for both stressors and pollutants measured at the same spatial and temporal scale of resolution, we used ecological cross-sectional models to examine spatial relationships between multiple chronic pollutant and stressor exposures and age-adjusted community CVD rates. Using census-tract-level annual averages (n = 2,167), we compared associations with CVD rates for multiple pollutant concentrations and social stressors. We found that associations with community CVD rates were consistently stronger for social stressors than for pollutants, in terms of both magnitude and significance. We note, however, that this result may be driven by the relatively greater variation (on a proportional basis) for stressors than for pollutants in NYC. We also tested effect modification of pollutant-CVD associations by each social stressor and found evidence of stronger associations for NO2, PM2.5, and wintertime SO2 with CVD rates, particularly across quintiles of increasing community violence or assault rates (P trend < 0.0001). To examine individual-level associations between spatiotemporal exposures to multiple pollutants and the risk of CVD events, across multiple lag days, we examined the combined effects of multiple pollutant exposures, using spatiotemporal (day- and residence-specific) pollution exposure estimates and hospital data on individual CVD events in case-crossover models, which inherently adjust for nontime-varying individual confounders (e.g., sex and race) and comorbidities. We found consistent significant relationships only for same-day pollutant exposures and the risk of CVD events, suggesting very acute impacts of pollution on CVD risk. Associations with CVD were positive for NO2, PM2.5, and SO2, as hypothesized, and we found inverse associations for O3 (a secondary pollutant chemically decreased ["scavenged"] by fresh emissions that, in NYC, displays spatial and temporal patterns opposite those of NO2). Finally, to test effect modification by chronic community social stressors on the relationships between spatiotemporal pollution measures and the risk of CVD events, we used individual-level case-crossover models, adding interaction terms with categorical versions of each social stressor. We found that associations between NO2 and the risk of CVD events were significantly elevated only in communities with the highest exposures to social stressors (i.e., in the highest quintiles of poverty, socioeconomic deprivation, violence, or assault). The largest positive associations for PM2.5 and winter SO2 were generally found in the highest-stressor communities but were not significant in any quintile. We again found inverse associations for O3, which were likewise stronger for individuals living in communities with greater stressor exposures.

CONCLUSIONS

In ecological models, we found stronger relationships with community CVD rates for social stressors than for pollutant exposures. In case-crossover analyses, higher exposures to NO2, PM2.5, and SO2 were associated with greater excess risk of CVD events but only on the case day (there were no consistent significant lagged-day effects). In effect-modification analyses at both the community and individual level, we found evidence of stronger pollution-CVD associations in communities with higher stressor exposures. Given substantial spatial confounding across multiple social stressors, further research is needed to disentangle these effects in order to identify the predominant social stressors driving this observed differential susceptibility.

Reach versus effectiveness: The design and protocol of randomized clinical trial testing a smartphone application versus in-person mindfulness-based smoking cessation intervention among young cancer survivors

Approximately 45% of young cancer survivors (18-40 years) are cigarette smokers. Continued smoking after cancer diagnosis leads to lower survival rates. A major logistical problem with smoking cessation efforts in this group is their geographic dispersion which makes them hard to reach. In addition, depression is a major predictor of smoking relapse and its rates are roughly twice as high in cancer survivors as the general population. Smartphone applications (apps) show promise in terms of efficacy, dissemination, and improving access to treatment. Mindfulness training (defined as maintaining attention on one's immediate experience and cultivating an attitude of acceptance toward this experience) is effective in improving smoking cessation outcomes by reducing psychological stress and controlling craving. Given that smartphone apps can address the issues of mobility and remote access, and mindfulness can address the high depression rate among cancer survivors, validating the feasibility and efficacy of a mindfulness-based smoking cessation intervention app in young cancer survivors is a high priority. Thus, the aims of the current study are: (1) test the feasibility, acceptability, and potential efficacy of the mindfulness-based smoking cessation app versus in-person mindfulness or usual care in a 3-arm pilot randomized clinical trial among young cancer survivors (n = 60; 18-40 years); and 2) conduct semi-structured exit interviews with participants in the two mindfulness groups to fine-tune the two active interventions based on feedback from participants. Findings will have implications for the development and dissemination of innovative and highly scalable tobacco cessation interventions designed for young cancer survivors.

Comparing cancer risk estimates using occupational record linkage approaches in male Florida firefighters

BACKGROUND

Firefighters have an increased risk of cancer, but variations in reported results could be due to differences in occupational case ascertainment. This study compares cancer risk estimates generated by identifying firefighters from their occupational title available in the Florida Cancer Data System (FCDS) versus identification by a linkage method between the FCDS and the Florida State Fire Marshal's Office.

METHODS

Florida firefighter employment records (1972-2012; n = 109,009) were linked with FCDS data (1981-2014; ~3.3 million records), identifying 3760 primary cancers in male firefighters. Using the FCDS occupational data field we identified 1831 male cancer cases in those classified as firefighters, first-line supervisors of firefighting and prevention workers, fire inspectors, emergency medical technicians, or paramedics. Age and calendar year-adjusted odds ratios (aOR) and 95% confidence intervals for firefighters versus non-firefighters were calculated for both groups.

RESULTS

For skin cancers the risk estimate for FCDS-indentified firefighters was substantially lower than in the employment-record-linked firefighters (aOR = 1.06; 0.87-1.29 vs. 1.54; 1.37-1.73), but for endocrine system cancers it was greater (aOR = 2.36; 1.77-3.14 vs. 2.08; 1.71-2.53). Remaining cancer risk estimates were in the same direction for the two samples except for lymphoma (aOR = 1.10; 0.90-1.34 vs. 0.86; 0.75-0.99).

CONCLUSION

Reliance on occupational title in cancer registry records to characterize firefighter cancer risk may result in estimates that are over- or underestimated depending on cancer site. The authors recommend moving toward national linkages between cancer registries and certification or other administrative records, which are a vital resource for firefighter cancer research.

Implementing a Novel Workplace Smoking Cessation Intervention Targeting Hispanic/Latino Construction Workers: A Pilot Cluster Randomized Trial

BACKGROUND

U.S. Hispanic/Latino construction workers constitute a large and historically underserved group in terms of smoking cessation services. Using formative research, we developed a worksite smoking cessation intervention tailored to the life/work circumstances of these workers.

AIMS

This study aims to examine the feasibility, acceptability, and potential efficacy of the developed intervention "Enhanced Care" (EC; one group behavioral counseling session provided around the food truck + fax referral to tobacco quitline [QL] + 8-week nicotine replacement treatment [NRT]) compared with "Standard Care" (SC; fax referral to tobacco QL + 8-week NRT) in a pilot, two-arm, cluster randomized controlled trial.

METHOD

In collaboration with construction site safety managers, a sample of 17 construction sites (EC: nine sites/65 smokers; SC: eight sites/69 smokers) was enrolled. Participants received two follow-ups at 3 and 6 months after enrollment. Feasibility outcomes were enrollment rate, adherence to treatment, and 6-month retention rates. The primary efficacy outcome was 6 months prolonged abstinence verified by expired carbon monoxide <10 ppm.

RESULTS

Enrollment rate was high (85.9%). Six-month follow-up rates were acceptable (EC = 76.9%, SC = 66.6%). Adherence to treatment was better in the EC group (received worksite intervention: EC = 93.8%, SC = 88.4%; contacted by QL: EC = 49.2%, SC = 40.6%). Abstinence rates were 27.7% for the EC and 20.3% for the SC (p = .315).

DISCUSSION

The developed intervention was feasible and acceptable, and it substantially improved abstinence among Hispanic/Latino workers. The involvement of safety managers was essential to the implementation of the intervention. Training safety managers to deliver the intervention has great potential to implement a sustainable smoking cessation service in the construction sector.

Impact of Mindfulness Training on the Well-Being of Educators

Objective: As awareness of educator stress and burnout is at the forefront of issues faced in the education system, programs are being implemented to focus on the well-being and betterment of educators. Mindfulness is one such practice that has been found to increase wellness and, in many cases, decrease negative outcomes. In this study, the effects of a Mindfulness-Based Stress Reduction Program were measured in grade-school (K-12) educators. Design: A longitudinal noncontrolled trial of educators who completed baseline and short- and long-term postintervention surveys. Location: Miami-Dade County. Subjects: Two hundred thirty-six educators who worked in K-12 public and private schools. Intervention: An 8-week Mindfulness-Based Stress Reduction Program. Outcome measures: Five Facet Mindfulness Questionnaire, Self-Compassion Scale, Maslach Burnout Inventory-Educators, Patient-Reported Outcome Measurement Information System (PROMIS-29) for measuring physical and mental health functionality. Results: The multiple linear regression analysis of the short-term cohort data yielded statistically significant improvements in mindfulness, self-compassion, and personal accomplishment and decreases in isolation, anxiety, fatigue, and emotional exhaustion. In the long-term cohort, repeated measures regression showed self-compassion and mindfulness continued to improve significantly, whereas negative outcomes of fatigue and sleep disturbance showed statistically significant decreases. Effect sizes were calculated for all the measures, many of which were medium sized, total mindfulness (0.69), self-compassion (0.051), and sleep disturbance (0.49). Conclusion: Findings are consistent with previous literature and support the need for such programs that impact the educator's personal and professional experience.

Cancer risk among career male and female Florida firefighters: Evidence from the Florida Firefighter Cancer Registry (1981-2014)

BACKGROUND

Firefighters are at increased risk for select cancers. However, many studies are limited by relatively small samples, with virtually no data on the cancer experience of female firefighters. This study examines cancer risk in over 100,000 career Florida firefighters including 5000 + females assessed over a 34-year period.

METHODS

Florida firefighter employment records (n = 109 009) were linked with Florida Cancer Data System registry data (1981-2014; ~3.3 million records), identifying 3760 male and 168 female-linked primary cancers. Gender-specific age and calendar year-adjusted odds ratios (aOR) and 95% confidence intervals for firefighters vs non-firefighters were calculated.

RESULTS

Male firefighters were at increased risk of melanoma (aOR = 1.56; 1.39-1.76), prostate (1.36; 1.27-1.46), testicular (1.66; 1.34-2.06), thyroid (2.17; 1.78-2.66) and late-stage colon cancer (1.19;1.00-1.41). Female firefighters showed significantly elevated risk of brain (2.54; 1.19-5.42) and thyroid (2.42; 1.56-3.74) cancers and an elevated risk of melanoma that approached statistical significance (1.68; 0.97-2.90). Among male firefighters there was additional evidence of increased cancer risk younger than the age of 50 vs 50 years and older for thyroid (2.55; 1.96-3.31 vs 1.69; 1.22-2.34), prostate (1.88; 1.49-2.36 vs 1.36; 1.26-1.47), testicular (1.60; 1.28-2.01 vs 1.47; 0.73-2.94), and melanoma (1.87; 1.55-2.26 vs 1.42; 1.22-1.66) cancers.

CONCLUSION

Male career firefighters in Florida are at increased risk for five cancers with typically stronger associations in those diagnosed younger than the age of 50, while there was evidence for increased thyroid and brain cancer, and possibly melanoma risk in female firefighters. Larger cohorts with adequate female representation, along with the collection of well-characterized exposure histories, are needed to more precisely examine cancer risk in this occupational group.

Integrating Worksite Smoking Cessation Services Into the Construction Sector: Opportunities and Challenges

Background. Smoking prevalence among Hispanic/Latino construction workers in the United States is very high (31%). Aims. To investigate tobacco use profiles in these minority workers and explore their management's views about implementing sustainable worksite smoking cessation services. Methods. Analysis of baseline data from a smoking cessation trial among Hispanic/Latino construction workers (n = 134; adult men ≥18 years), and semistructured, 45-minute interviews with 24 key personnel at six construction companies in south Florida were conducted. Interviews were recorded, transcribed, and analyzed thematically. Results. Overall, 43.3% of workers were Cuban, and 81.3% had low acculturation level. Nicotine dependence levels were "high" in 61.8% of workers. Half of the workers had a successful quit attempt but only 9.9% received advice from a physician to quit smoking, 16.7% used medication to quit, and 79.2% did not receive assistance. Participants in the interviews stated that nothing was provided to help smokers quit smoking and considered distributing self-help materials with free medications as the most appropriate service. Challenges to integrating the service were time restriction and cost. Recommendations for implementing the service were local/state government mandate. Discussion. Tailoring tobacco treatment to Hispanic/Latino construction workers' job circumstances and culture is essential to support their cessation efforts. Integrating worksite tobacco treatment services into other available health promotion programs (e.g., safety) and enforcing smoke-free legislation in the construction sector can facilitate its adoption. Conclusion. Involving key stakeholders and mandating the service by the State and local government are necessary to integrate sustainable worksite smoking cessation services in the construction sector.

Availability and accuracy of occupation in cancer registry data among Florida firefighters

OBJECTIVES

Occupational exposures significantly contribute to the risk of adverse cancer outcomes, and firefighters face many carcinogenic exposures. Occupational research using cancer registry data, however, is limited by missing and inaccurate occupation-related fields. The objective of this study is to determine the frequency and predictors of missing and inaccurate occupation data for a cohort of career firefighters in a state cancer registry.

METHODS

We conducted a linkage between data from the Florida Cancer Data System (1981-2014) and the Florida State Fire Marshal's Office (1972-2012). The percentage and the odds of having a firefighting-related occupation code in the cancer record were calculated, adjusting for other occupation and cancer-related factors.

RESULTS

Among 3,928 career firefighters, nearly half (47%) were missing a registry-dervived occupation code and only 17% had a firefighting-related code. Males were more likely to have a firefighting-related code (OR = 2.31;95%CI: 1.41-3.76), as were those with more recent diagnoses (OR1992-2002 = 2.98;95%CI: 1.57-5.67; OR2003-2014 = 11.40;95%CI: 6.17-21.03), and those of younger ages (OR45-64y = 1.26;95%CI: 1.03-1.54; OR20-44y = 2.26;95%CI: 1.73-2.95).

CONCLUSIONS

Accurate occupation data is key for identifying increased risk of advserse cancer outcomes. Cancer registry occupation fields, however, are overwhelmingly missing for firefighters and are missing disproportionally by sociodemographic and diagnosis characteristics. This study highlights the lack of accurate occupation data available for hypothesis-driven cancer research. Cancer registry linkage with external occupational data sources represents an essential resource for conducting studies among at-risk populations such as firefighters.

Hemostasis biomarkers and incident cognitive impairment: the REGARDS study

Essentials Cognitive disorders are increasing and vascular risk factors play a role in this. We performed a nested case control study of hemostasis biomarkers and cognitive impairment (CI). Higher baseline fibrinogen, factor VIII and D-dimer were related to incident CI over 3.5 years. Adjusted for other risk factors, 2+ abnormal markers (but not single ones) led to higher risk.

SUMMARY

Background Vascular risk factors are associated with cognitive impairment, a condition that imposes a substantial public health burden. We hypothesized that hemostasis biomarkers related to vascular disease would be associated with the risk of incident cognitive impairment. Methods We performed a nested case-control study including 1082 participants with 3.5 years of follow-up in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, a longitudinal cohort study of 30 239 black and white Americans aged ≥ 45 years. Participants were free of stroke or cognitive impairment at baseline. Baseline D-dimer, fibrinogen, factor VIII and protein C levels were measured in 495 cases who developed cognitive impairment during follow-up (based on abnormal scores on two or more of three cognitive tests) and 587 controls. Results Unadjusted odds ratios (ORs) for incident cognitive impairment were 1.32 (95% confidence interval [CI] 1.02-1.70) for D-dimer > 0.50 μg mL-1 , 1.83 (95% CI 1.24-2.71) for fibrinogen > 90th percentile, 1.63 (95% CI 1.11-2.38) for FVIII > 90th percentile, and 1.10 (95% CI 0.73-1.65) for protein C < 10th percentile. There were no differences in associations by race or region. Adjustment for demographic, vascular and health behavior risk factors attenuated these associations. However, having at least two elevated biomarkers was associated with incident cognitive impairment, with an adjusted OR of 1.73 (95% CI 1.10-2.69). Conclusion Elevated D-dimer, fibrinogen and FVIII levels were not associated with the occurrence of cognitive impairment after multivariable adjustment; however, having at least two abnormal biomarkers was associated with the occurrence of cognitive impairment, suggesting that the burden of these biomarkers is relevant.

A cluster randomized pilot trial of a tailored worksite smoking cessation intervention targeting Hispanic/Latino construction workers: Intervention development and research design

Construction workers have the highest smoking rate among all occupations (39%). Hispanic/Latino workers constitute a large and increasing group in the US construction industry (over 2.6 million; 23% of all workers). These minority workers have lower cessation rates compared to other groups due to their limited access to cessation services, and lack of smoking cessation interventions adapted to their culture and work/life circumstances. Formative research was conducted to create an intervention targeting Hispanic/Latino construction workers. This paper describes the intervention development and the design, methods, and data analysis plans for an ongoing cluster pilot two-arm randomized controlled trial comparing an Enhanced Care worksite cessation program to Standard Care. Fourteen construction sites will be randomized to either Enhanced Care or Standard Care and 126 participants (63/arm) will be recruited. In both arms, recruitment and intervention delivery occur around "food trucks" that regularly visit the construction sites. Participants at Enhanced Care sites will receive the developed intervention consisting of a single face-to-face group counseling session, 2 phone calls, and a fax referral to Florida tobacco quitline (QL). Participants at Standard Care sites will receive a fax referral to the QL. Both groups will receive eight weeks of nicotine replacement treatment and two follow-up assessments at three and six months. Feasibility outcomes are estimated recruitment yield, barriers to delivering the intervention onsite, and rates of adherence/compliance to the intervention, follow-ups, and QL enrollment. Efficacy outcomes are point-prevalence and prolonged abstinence rates at six month follow-up confirmed by saliva cotinine <15 ng/ml.

Eye Health Knowledge and Eye Health Information Exposure Among Hispanic/Latino Individuals: Results From the Hispanic Community Health Study/Study of Latinos

Importance

Routine eye care is important to maintaining eye health and preventing visual impairment. However, poor knowledge of ocular risk factors and disease as well as minimal exposure to eye health information may compromise adherence to eye care recommendations. Studies have shown that Hispanic/Latino people have poor eye care utilization, but little is known about their knowledge of eye health and exposure to eye health information.

Objective

To examine factors associated with more eye health knowledge and greater exposure to eye health information among Hispanic/Latino people.

Design, Setting, and Participants

This was a cross-sectional ocular study of 1235 participants living in the Miami, Florida, site of the Hispanic Community Health Study/Study of Latinos, a multisite epidemiologic study of disease prevalence and development among Hispanic/Latino people. Data were collected from October 1, 2011, through September 30, 2013, and data analyses were conducted between May 28, 2014, and March 18, 2015. Descriptive and multivariable regression analyses were performed for 3 ocular health care outcomes. Regression models were built sequentially, with variables conceptually grouped according to Andersen's Behavioral Model of Health Services Use and Behavioral Model for Vulnerable Populations.

Main Outcomes and Measures

Ability to identify 8 factors on a general eye health knowledge scale and number of eye health information sources seen or heard about in the past 12 months.

Results

Of the 1235 participants, 748 (73.4%) self-identified as being of Cuban descent and 407 (19.2%) self-identified as being from Central or South America, 478 (46.7%) were women and 757 (53.3%) were men, and the mean (SD) age was 53.6 (8.1) years. Participants with at least a high school degree or general educational development certificate had greater eye health knowledge (incidence rate ratio [IRR], 1.08; 95% CI, 1.01-1.15 and IRR, 1.11; 95% CI, 1.04-1.17, respectively) as did those with a higher mental health score on the Short Form 12-Item, version 2, Health Survey (IRR, 1.03; 95% CI, 1.01-1.04). Those with educational attainment beyond a high school degree or a general educational development certificate (IRR, 1.29; 95% CI, 1.07-1.54), those who were 60 years or older (IRR, 1.32; 95% CI, 1.06-1.63), and those with a household income in US dollars of $20 001 to $40 000 (IRR, 1.23; 95% CI, 1.05-1.44) or greater than $40 000 (IRR, 1.25; 95% CI, 0.98-1.59) were more likely to be exposed to at least 5 sources of eye health information in the past 12 months.

Conclusions and Relevance

Among Hispanic/Latino people, age, educational level, income, and mental health may be important correlates of eye disease knowledge and eye health information exposure. These findings might be used to support the development of targeted interventions designed to improve eye health in this population.

Acute joint pain in the emerging green collar workforce: Evidence from the linked National Health Interview Survey and Occupational Information Network (O*NET)

BACKGROUND

Green jobs are a rapidly emerging category of very heterogeneous occupations that typically involve engagement with new technologies and changing job demands predisposing them to physical stressors that may contribute to the development of joint pain.

METHODS

We estimated and compared the prevalence of self-reported acute (past 30 days) joint pain between green and non-green collar workers using pooled 2004-2012 National Health Interview Survey (NHIS) data linked to the Occupational Information Network Database (O*NET).

RESULTS

Green collar workers have a higher prevalence of acute joint pain as compared to non-green collar workers. Green collar workers with pain in the upper extremity joints were significantly greater than in the non-green collar workforce, for example, right shoulder [23.2% vs 21.1%], right elbow [13.7% vs 12.0%], left shoulder [20.1% vs 18.2%], and left elbow [12.0% vs 10.7%].

CONCLUSIONS

Acute joint pain reported by the emerging green collar workforce can assist in identifying at risk worker subgroups for musculoskeletal pain interventions.

Prevalence of Mindfulness Practices in the US Workforce: National Health Interview Survey

INTRODUCTION

Mindfulness-based practices can improve workers' health and reduce employers' costs by ameliorating the negative effect of stress on workers' health. We examined the prevalence of engagement in 4 mindfulness-based practices in the US workforce.

METHODS

We used 2002, 2007, and 2012 National Health Interview Survey (NHIS) data for adults (aged ≥18 y, n = 85,004) to examine 12-month engagement in meditation, yoga, tai chi, and qigong among different groups of workers.

RESULTS

Reported yoga practice prevalence nearly doubled from 6.0% in 2002 to 11.0% in 2012 (P < .001); meditation rates increased from 8.0% in 2002 to 9.9% in 2007 (P < .001). In multivariable models, mindfulness practice was significantly lower among farm workers (odds ratio [OR] = 0.42; 95% confidence interval [CI], 0.21-0.83]) and blue-collar workers (OR = 0.63; 95% CI, 0.54-0.74) than among white-collar workers.

CONCLUSION

Worker groups with low rates of engagement in mindfulness practices could most benefit from workplace mindfulness interventions. Improving institutional factors limiting access to mindfulness-based wellness programs and addressing existing beliefs about mindfulness practices among underrepresented worker groups could help eliminate barriers to these programs.

Occupational Psychosocial Hazards Among the Emerging US Green Collar Workforce

OBJECTIVE

To compare occupational psychosocial hazards in green collar versus non-green collar workers.

METHODS

Standard Occupational Classification codes were used to link the 2010 National Health Interview Survey to the 2010 Occupational Information Network Database. Multivariable logistic regressions were used to predict job insecurity, work life imbalance, and workplace harassment in green versus non-green collar workers.

RESULTS

Most participants were white, non-Hispanic, 25 to 64 years of age, and obtained greater than a high school education. The majority of workers reported no job insecurity, work life imbalance, or workplace harassment. Relative to non-green collar workers (n = 12,217), green collar workers (n = 2,588) were more likely to report job insecurity (Odds ratio [OR] = 1.13; 95% confidence interval [CI] = 1.02 to 1.26) and work life imbalance (1.19; 1.05 to 1.35), but less likely to experience workplace harassment (0.77; 0.62 to 0.95).

CONCLUSIONS

Continuous surveillance of occupational psychosocial hazards is recommended in this rapidly emerging workforce.

Ocular screening adherence across Hispanic/Latino heritage groups with diabetes: results from the Ocular SOL ancillary to the Miami site of the Hispanic Community Health Study/Study of Latinos (HCHS/SOL)

OBJECTIVE

The objective of this study was to examine the prevalence and correlates of ocular screening adherence among select Hispanics/Latinos living with diabetes.

RESEARCH DESIGN AND METHODS

Data were obtained through an ancillary study of the Hispanic Community Health Study/Study of Latinos (Miami site). Participants included Hispanics/Latinos aged 40+ years who underwent a baseline examination/risk factor assessment (2008-2011) and then completed a survey on vision health/knowledge (conducted October 2011-September 2013; sample n=1235; diabetic subsample=264). The dependent variable was having a dilated eye examination within the past 12 months. Covariate candidate selection for entry into sequential multivariable logistic regression models was guided by Anderson's Behavioral Model of Health Services Use and the Behavioral Model for Vulnerable Populations.

RESULTS

Participants aged 65+ were more likely to have dilated eye examinations (OR 2.62, 95% CI 1.22 to 5.60) compared with those aged 40-54 years. Participants less likely to have dilated examinations had a high school degree or general educational development (GED) (OR 0.30, 95% CI 0.10 to 0.96, compared to no degree) and those currently uninsured or never insured ((OR 0.34, 95% CI 0.14 to 0.83) and (OR 0.19, 95% CI 0.07 to 0.51)) compared to those currently insured. Participants who heard or saw something about eye health from two or more sources (eg, media outlets, doctor's office, relatives/friends) compared to those who reported no sources in the past 12 months were more likely to have a dilated eye examination (OR 2.82, 95% CI 1.26 to 6.28).

CONCLUSIONS

Lack of health insurance is strongly associated with low screening uptake in Hispanics/Latinos living with diabetes. Health promotion strategies stressing the importance of annual dilated eye examinations and increasing sources of information on eye health are other potential strategies to increase screening uptake in Hispanics/Latinos.

Factors Associated With Ocular Health Care Utilization Among Hispanics/Latinos: Results From an Ancillary Study to the Hispanic Community Health Study/Study of Latinos (HCHS/SOL)

IMPORTANCE

Regular ocular care is critical to early detection and prevention of eye disease and associated morbidity and mortality; however, there have been relatively few studies of ocular health care utilization among Hispanics/Latinos of diverse backgrounds.

OBJECTIVE

To examine factors associated with ocular health care utilization among Cuban, Central American, and South American Hispanics/Latinos in a cohort study.

DESIGN, SETTING, AND PARTICIPANTS

An ancillary study to the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) evaluating ocular health, knowledge, risk factors, and health care use was conducted with 1235 HCHS/SOL participants (aged ≥40 years) at the Miami, Florida, study site. Data were collected from October 17, 2011, to September 30, 2013, and analyses were conducted from May 28, 2014, to March 18, 2015. Descriptive and multivariable logistic regression analyses were performed for 3 ocular health care outcomes. Regression models were built sequentially with variables conceptually grouped according to Andersen's Behavioral Model of Health Services Use.

MAIN OUTCOMES AND MEASURES

Ever having an eye examination, having an eye examination performed within the past 2 years, and difficulty obtaining needed eye care in the past year.

RESULTS

Of the 1235 participants, 478 were men and 757 were women, and they had a mean (SD) age of 53.6 (8.1) years. Those who never had insurance were less likely to have had an eye examination (with data reported as odds ratios [95% CIs]) ever, 0.19 (0.07-0.53) and in the past 2 years, 0.22 (0.15-0.33) and were more likely to have had difficulty obtaining needed eye care in the past year (3.72 [1.75-7.93]). Those with less than excellent or good self-rated eyesight were less likely to ever have had an eye examination (0.26 [0.12-0.56]) and more likely to have had difficulty obtaining care (3.00 [1.48-6.11]). Men were less likely to ever have had an eye examination (0.31 [0.18-0.53]). Older (55-64 years) Hispanics/Latinos (3.04 [1.47-6.31]) and those with a high school degree or general educational development certification (2.06 [1.02-4.13]) or higher levels of education (4.20 [2.12-8.30]) were more likely to ever have had an eye examination. Finally, those living in the United States for more than 15 years (0.42 [0.21-0.82]) were less likely to have had difficulty obtaining care.

CONCLUSIONS AND RELEVANCE

Our findings suggest that increasing insurance coverage, decreasing the costs of care, and increasing the availability of care for Hispanics/Latinos with poor self-rated eyesight are relevant issues to address to improve ocular health care use among Hispanics/Latinos of diverse backgrounds.

Smoking behavior among adult childhood cancer survivors: what are we missing?

PURPOSE

Childhood cancer survivors are a growing population at increased risk for smoking-related health complications. This study compared smoking prevalence, age at smoking initiation, and time trend of smoking prevalence from 1997 to 2010 between adult survivors of childhood cancer and adults without a cancer history (controls) and identified predictors of smoking among these survivors.

METHODS

Data were pooled from the 1997-2010 National Health Interview Survey (survivors, n = 1438; controls, n = 383,805). Smoking prevalence by age group was calculated using weighted least square regression analysis and weighted linear regression of prevalence on year for trend analysis. Logistic regression analyses adjusting for sample weights and design effects were performed to identify predictors of smoking among survivors.

RESULTS

Compared to controls, survivors were significantly more likely to be younger, female, non-Hispanic White, unemployed, with lower income, and to weigh less and smoke more. Survivors initiated smoking earlier than controls. Smoking prevalence among survivors peaked at age 30 and 40 years old, compared to age 25 years in controls. Smoking prevalence decreased consistently from 1997 to 2010 among controls, with larger significant declines in survivors that were subject to more year-to-year variability. Compared to nonsmoking survivors, those who smoke were significantly more likely to be non-Hispanic White, young, uninsured, poor, to have a high school education or less, and to report drinking alcohol.

CONCLUSION

Smoking in adult survivors of childhood cancer continues as a persistent risk factor across socioeconomic groups.

IMPLICATIONS FOR CANCER SURVIVORS

Targeted and tailored smoking cessation/prevention interventions for these survivors are needed.

Linking the National Health Interview Survey with the Florida Cancer Data System: A Pilot Study

Cancer registry data are vital for the surveillance of cancer trends, but registries are limited in the number of data items that can be collected for hypothesis-driven research. Linkage with other databases can add valuable information and is a potentially effective tool for increasing our understanding of and identifying the causes of cancer and health disparities along the cancer continuum. We conducted a pilot study to link data from the 1981-2010 Florida Cancer Data System (FCDS) with data from the 1986-2009 National Health Interview Survey (NHIS). The NHIS data contain important information on sociodemographics, screening behaviors, comorbidities, risk factors, health care access, and quality of life, which are not available from FCDS. The linkage resulted in a total of 6,281 linked cases. After removing cases with a first cancer diagnosis before 1981 (prior to FCDS creation) or missing date of diagnosis information, there were 1,908 cases diagnosed with cancer prior to their NHIS interview and 4,367 cases diagnosed after their NHIS interview. The enriched data set resulting from the linkage allows us to evaluate risk factors associated with developing cancer as well as conduct analyses on cancer survivorship issues and mortality. This pilot study demonstrates the feasibility and utility of a linkage between cancer registries and national health surveys, while also acknowledging the cost and challenges associated with such linkages.

Identifying misclassification in youth self-reported smoking status: testing different consent processes of biological sample collection to capture misclassification

INTRODUCTION

In Florida, since 1998, identical survey items have been used to measure youth smoking status for the CDC sponsored state school-based survey and the tobacco control program evaluation telephone survey. The two surveys should parallel one another to track tobacco use. Tobacco items collected in the two surveys closely paralleled one another until recently. Since 2008, data show dramatically divergent youth smoking estimates (e.g., relative differences as high as 50%), which cannot be explained by differences in survey and sampling design. As a first step in detecting misclassification of smoking status, we examined the feasibility of asking youth to self-report their smoking behavior and collect a biological sample, with the expectation that some youth will misreport their smoking status.

METHODS

Using a cross-sectional population level telephone survey, youth were randomly assigned to one of three groups to test mode effects of collecting biological data with self-reported survey data (n = 303).

RESULTS

It showed two groups of youth (those who are not asked for a biological and those asked for a biological with an indirect explanation of its use) had similar response rates and self-reported smoking status, while the third group (biological request with a direct explanation of its use) had a substantially lower response rate and self-reported smoking status.

CONCLUSIONS

The data show youth who are given an indirect explanation of how biological data are to be used were as likely to self-report their smoking status as youth who were not asked to provide a biological sample.

Factors associated with receipt of radiation therapy for rectal cancer

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Background: Appropriate treatment for rectal cancer is vital to increasing the likelihood of survival. Disparities in receipt of appropriate radiation treatment have been observed with respect to race/ethnicity and socioeconomic status. We used enriched cancer registry data to identify alternative factors associated with receipt of appropriate radiation therapy for rectal cancer. Methods: Data were obtained from the Florida Cancer Data System and were enriched with detailed treatment information collected from a Centers for Disease Control and Prevention Comparative Effectiveness Research study. Using multivariable regression, we evaluated factors associated with receipt of radiation therapy among rectal cancer cases summary stage II/III. Our sample (n=403) included cases diagnosed in Florida in 2011 who were 18 years and older. Cases clinically staged as 0/1/4 were excluded. Though patients over age 80 years (n=67) and those with stage IIA disease (n=185) may not routinely be prescribed radiation, these cases were included in order to maximize the sample size. Results: Our sample was an average of 64 years-old, more often male (59%), NH White (56%), diagnosed with stage III disease (54%), insured (92%), had received surgical intervention (87%), chemotherapy (68%), or radiation (57%), were in the highest SES quartile (56%), and had one or more comorbid condition (57%). Older age (OR=0.96; 95%CI=0.94-0.97), the presence of more than one comorbidity (0.61; 0.39-0.96), and receipt of surgical intervention (0.44; 0.22-0.90) were predictors of not receiving radiation. Conclusions: Contrary to our hypothesis, socio-demographic factors such as race/ethnicity, insurance status, and socioeconomic status, did not influence the receipt of radiation. Further research is needed, however, to understand why age, comorbidity, and surgery present a barrier to radiation, particularly given that radiotherapy is a well-tolerated modality.

Colorectal cancer mortality among Cuban and non-Cuban Hispanics

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Background: We examined all-cause mortality of Floridian colorectal cancer (CRC) patients among Hispanics of Cuban and non-Cuban origin, non-Hispanic Whites (NHWs) and non-Hispanic Blacks (NHBs). We hypothesized that Cuban Hispanics would have a higher mortality risk relative to other Hispanics in Florida with CRC. Methods: We obtained data from the Florida Cancer Data System for all incident CRC cases (2007-2011) among Floridians 18+ years and linked these files with data from Florida’s Agency for Health Care Administration and the 2006-2010 American Community Survey (n=46,579). Race/ethnic groups were Cuban, non-Cuban Hispanic, NHW, and NHB. Log-rank tests were performed among race/ethnic groups with multivariable Cox proportional hazard regression models for mortality adjusting for demographic and clinical factors to produce adjusted hazard ratios (HR). Results: Cubans’ mortality were not significantly different from NHWs (p=0.8254) or NHBs (p=0.3047) but significantly different from non-Cuban Hispanics (p=0.0006). Adjusting for all covariates and compared with highest SES within each race/ethnicity, residing in lower SES neighborhoods was associated with increased mortality risk for NHWs (HR=1.19; 95%CI=1.12-1.27) and NHBs (1.33; 1.13-1.57) but not for Hispanics. Among Hispanics, Cubans with proximal CRC had a 42% higher mortality risk than those with distal disease (1.42; 1.11-1.82); however, tumor location was not predictive of mortality for other racial/ethnic groups. Single or widowed Cuban Hispanics had higher mortality risk compared to those who were married (1.42; 1.07-1.88 for both comparisons) but this was not true for non-Cuban Hispanics. Conclusions: Cuban Hispanics are a distinct and understudied population group who should not be aggregated into a general category of Hispanic with respect to CRC mortality studies. Further research to understand the Cuban Hispanic differences in CRC mortality risk is needed to reduce the burden of disease, especially in the ever growing Hispanic population.

Linkage of 1986-2009 National Health Interview Survey with 1981-2010 Florida Cancer Data System

BACKGROUND

National survey data linked with state cancer registry data has the potential to create a valuable tool for cancer prevention and control research. A pilot project-developed in a collaboration of the Centers for Disease Control and Prevention's National Center for Health Statistics (NCHS) and the Florida Cancer Data System (FCDS) at the University of Miami -links the records of the 1986-2009 National Health Interview Survey (NHIS) and the 1981-2010 FCDS. The project assesses the feasibility of performing a record linkage between NCHS survey data and a state-based cancer registry, as well as the value of the data produced. The linked NHIS-FCDS data allow researchers to follow NHIS survey participants longitudinally to examine factors associated with future cancer diagnosis, and to assess the characteristics and quality of life among cancer survivors.

METHODS

This report provides a preliminary evaluation of the linked national and state cancer data and examines both analytic issues and complications presented by the linkage.

CONCLUSIONS

Residential mobility and the number of years of data linked in this project create some analytic challenges and limitations for the types of analyses that can be conducted. However, the linked data set offers the ability to conduct analyses not possible with either data set alone.

Visual acuity and increased mortality: the role of allostatic load and functional status

PURPOSE

Poor vision may detrimentally impact functional status and affect allostatic load (AL), a measure of cumulative physiological wear and tear on the body's regulatory systems. We examined the direct effects of visual acuity (VA) on mortality and its indirect effect on mortality through its impact on functional status and AL in older adults.

METHODS

Data from 4981 participants (age ≥ 60 years) from the 1999-2004 National Health and Nutrition Examination Survey (NHANES) with mortality linkage through 2006 were analyzed. Functional status was assessed by activities of daily living (ADL) and instrumental activities of daily living (IADL). The AL index was composed of 10 biomarkers: systolic and diastolic blood pressures, body mass index (BMI), glycosylated hemoglobin, total cholesterol, triglycerides, albumin, C-reactive protein, homocysteine, and creatinine clearance. Visual acuity was categorized as no (20/20-20/25), mild (20/30-20/40), moderate (20/50-20/80), or severe (≥20/200) visual impairment. Structural equation modeling using three mediating variables representing ADL, IADL, and AL examined the effects of VA on all-cause and cardiovascular disease (CVD)-related mortality.

RESULTS

Adjusting for all covariates, a one-unit change in VA category increased mortality risk (hazard ratio [HR] = 1.17; 95% confidence interval [CI] 1.05, 1.32); IADL and AL predicted mortality (HR = 1.15; CI 1.10, 1.20 and HR = 1.13; CI 1.06, 1.20, respectively). Activities of daily living did not predict mortality (HR = 0.98; CI 0.91, 1.05). Worse VA was associated with increased AL (β = 0.11; P = 0.013) and worse IADL (β = 1.06; P < 0.001). Worse VA increased mortality risk indirectly through AL (HR = 1.01; CI 1.00, 1.03) and IADL (HR = 1.16; CI 1.09, 1.23). The total effect of VA on mortality including through IADL and AL was HR = 1.38 (CI 1.23, 1.54). Similar but slightly stronger patterns of association were found when examining CVD-related mortality, but not cancer-related mortality.

CONCLUSIONS

Allostatic load and particularly IADL may function as mediators between VA impairment and mortality. Older adults with VA impairment could potentially benefit from interventions designed to prevent IADL functional status decline to reduce the risk of mortality.

Geographical variation in health-related quality of life among older US adults, 1997-2010

Introduction

Health-related quality of life (HRQOL) is an important predictor of morbidity and mortality; however, its geographical variation in older adults in the United States has not been characterized. We compared HRQOL among older adults in the 50 US states and the District of Columbia using the Health and Activities Limitation Index (HALex). We also compared the HRQOL of 4 regions: South, West, Midwest, and Northeast.

Methods

We analyzed pooled data from 1997 through 2010 from the National Health Interview Survey for participants aged 65 or older. HALex scores (which range from 0 to 1.00, with higher values indicating better health) were calculated by combining data on participants’ perceived health and activity limitations. We ranked states by mean HALex score and performed multivariable logistic regression analyses to compare low scores (defined as scores in the lowest quintile) among US regions after adjustment for sociodemographics, health behaviors, and survey design.

Results

Older residents of Alaska, Alabama, Arkansas, Mississippi, and West Virginia had the lowest mean HALex scores (range, 0.62–0.68); residents of Arizona, Delaware, Nevada, New Hampshire, and Vermont had the highest mean scores (range, 0.78–0.79). Residents in the Northeast (odds ratio [OR], 0.66; 95% confidence interval [CI], 0.57–0.76) and the Midwest (OR, 64; 95% CI, 0.56–0.73) were less likely than residents in the South to have scores in the lowest quintile after adjustment for sociodemographics, health behaviors, and survey design.

Conclusion

Significant regional differences exist in HRQOL of older Americans. Future research could provide policy makers with information on improving HRQOL of older Americans.

Correlates of leisure time physical activity compliance in colorectal cancer survivors

INTRODUCTION

Physical inactivity is a risk factor for cancer morbidity and mortality, but its influence in colorectal cancer (CRC) survivors is understudied. We investigated sociodemographic, physically limiting, and behavioral predictors influencing leisure time physical activity (LTPA) among CRC survivors.

METHODS

Pooled 1997-2010 National Health Interview Survey data (N=2378) were used to evaluate LTPA compliance in CRC survivors according to Healthy People 2010 recommendations. Univariate and multivariable logistic regression analyses were performed to identify predictors of LTPA compliance among CRC survivors. Independent variables included: age, gender, race/ethnicity, education, health insurance, body mass index (BMI), ≥2 chronic conditions limiting physical activity, time since cancer diagnosis, and poverty, marital, smoking and alcohol status.

RESULTS

Multivariable regression models reveal that Hispanics, non-Hispanic Blacks, those with ≥2 physically limiting chronic conditions, and current smokers were less likely to comply with LTPA recommendations. CRC survivors who were of "other" race, more than one race, those with some college degree or college degree, and current drinkers were more likely to comply.

DISCUSSION

Hispanics, non-Hispanic Blacks, those with >2 physically limiting chronic conditions and current smokers warrant additional efforts to encourage physical activity and to determine the impact of regular physical activity on CRC survivorship.

Young adult former ever smokers: the role of type of smoker, quit attempts, quit aids, attitudes/beliefs, and demographics

OBJECTIVE

Young adults who smoke are often nondaily users who either quit or transition into dependent smokers. Further, this age group often has been considered an extension of the adult population. This study aims to examine young adult former ever smokers to understand factors associated with their stopping smoking.

METHOD

Telephone interviews were conducted in 2010 with 4401 young adults in Florida. We examined the association between former ever smokers and sociodemographics, smoking behavior, quit attempts, quit aids, and attitudes/beliefs about smoking.

RESULTS

Thirty-seven percent of young adults were former smokers, 20% were current smokers, and 43% were never smokers. Former smokers were more likely to be female, situational smokers (compared to occasional or established), more likely to have stopped smoking without acknowledging making a quit attempt, less likely to have used a quit aid, and less likely to display pro-tobacco attitudes/beliefs.

CONCLUSION

Young adult former and current smokers have unique patterns of smoking and stopping smoking. Young adults may require novel intervention techniques to promote prevention and cessation based on these unique smoking patterns. Future research is needed to understand motivations to quit smoking among young adults.

Blood-pressure targets in patients with recent lacunar stroke: the SPS3 randomised trial

BACKGROUND

Lowering of blood pressure prevents stroke but optimum target levels to prevent recurrent stroke are unknown. We investigated the effects of different blood-pressure targets on the rate of recurrent stroke in patients with recent lacunar stroke.

METHODS

In this randomised open-label trial, eligible patients lived in North America, Latin America, and Spain and had recent, MRI-defined symptomatic lacunar infarctions. Patients were recruited between March, 2003, and April, 2011, and randomly assigned, according to a two-by-two multifactorial design, to a systolic-blood-pressure target of 130-149 mm Hg or less than 130 mm Hg. The primary endpoint was reduction in all stroke (including ischaemic strokes and intracranial haemorrhages). Analysis was done by intention to treat. This study is registered with ClinicalTrials.gov, number NCT 00059306.

FINDINGS

3020 enrolled patients, 1519 in the higher-target group and 1501 in the lower-target group, were followed up for a mean of 3·7 (SD 2·0) years. Mean age was 63 (SD 11) years. After 1 year, mean systolic blood pressure was 138 mm Hg (95% CI 137-139) in the higher-target group and 127 mm Hg (95% CI 126-128) in the lower-target group. Non-significant rate reductions were seen for all stroke (hazard ratio 0·81, 95% CI 0·64-1·03, p=0·08), disabling or fatal stroke (0·81, 0·53-1·23, p=0·32), and the composite outcome of myocardial infarction or vascular death (0·84, 0·68-1·04, p=0·32) with the lower target. The rate of intracerebral haemorrhage was reduced significantly (0·37, 0·15-0·95, p=0·03). Treatment-related serious adverse events were infrequent.

INTERPRETATION

Although the reduction in stroke was not significant, our results support that in patients with recent lacunar stroke, the use of a systolic-blood-pressure target of less than 130 mm Hg is likely to be beneficial.

FUNDING

National Institutes of Health-National Institute of Neurological Disorders and Stroke (NIH-NINDS).

Risky drinking in the older population: a comparison of Florida to the rest of the US

INTRODUCTION

While alcohol use has traditionally been thought to decrease with age, several recent studies have shown an increase in heavy drinking among retirees. Florida's unique population distribution that includes a higher proportion of elderly residents warrants an in-depth look at the drinking patterns in the elderly and how they may differ from those in other areas of the country. However, state-level comparisons of excessive alcohol consumption are limited.

METHODS

We compared risky drinking (defined as ten or more drinks/week in men and seven or more drinks/week in women; or five or more drinks at one sitting, one or more times/year for both men and women) in Florida to the rest of the US. We used pooled data from the 1997-2010 National Health Interview Survey (NHIS).

RESULTS

The prevalence of risky drinking for those aged ≥65 in Florida and the rest of the US was 24.1%, and 21.8%, respectively, compared to 31.9% and 37.4% for all ages in Florida and the rest of the US, respectively. In multivariable analyses of those aged ≥65 years, risky drinking was significantly associated with male gender, younger age, non-Hispanic White race/ethnicity, more than a high school education, unemployment (including retirement), lower BMI, and current or former smoking. Floridians aged ≥65 were significantly more likely to report risky drinking than their counterparts in the rest of the US (Odds ratio=1.13; 95% CI: 1.04-1.21), in contrast to analyses of all ages where Floridians were less likely to report risky drinking compared to the rest of the US (0.77; 0.67-0.86).

DISCUSSION

Excessive alcohol consumption is an important modifiable risk factor for cancer, cardiovascular disease, and liver disease; a reduction among the elderly has great potential to reduce disease burden. Although Floridians overall were less likely to be risky drinkers than the rest of the US, almost a third of the Florida population reported this behavior. It is, therefore, an important public health concern, particularly in Florida's older population who are more likely to engage in this behavior than their counterparts in the rest of the US.

State variations of chronic disease risk factors in older Americans

The objective of this study was to examine and compare 3 key health behaviors associated with chronic disease (ie, risky drinking, smoking, and sedentary lifestyle). We used data from the National Health Interview Survey from 1997 through 2010 to calculate the prevalence of these behaviors among older Americans and rank each state, and we analyzed overall trends in prevalence for each behavior over the 14 years. Older adults residing in Arkansas and Montana had the worst chronic disease risk profile compared with other states. These findings indicate the need for improved or increased targeted interventions in these states.

Dry eye medication use and expenditures: data from the medical expenditure panel survey 2001 to 2006

PURPOSE

To study dry eye medication use and expenditures from 2001 to 2006 using a nationally representative sample of US adults.

METHODS

This study retrospectively analyzed dry eye medication use and expenditures of participants of the 2001 to 2006 Medical Expenditure Panel Survey, a nationally representative subsample of the National Health Interview Survey. After adjusting for survey design and for inflation using the 2009 inflation index, data from 147 unique participants aged 18 years or older using the prescription medications Restasis and Blephamide were analyzed. The main outcome measures were dry eye medication use and expenditures from 2001 to 2006.

RESULTS

Dry eye medication use and expenditures increased between the years 2001 and 2006, with the mean expenditure per patient per year being $55 in 2001 to 2002 (n=29), $137 in 2003 to 2004 (n=32), and $299 in 2005 to 2006 (n=86). This finding was strongly driven by the introduction of topical cyclosporine emulsion 0.05% (Restasis; Allergan, Irvine, CA). In analysis pooled over all survey years, demographic factors associated with dry eye medication expenditures included gender (female: $244 vs. male: $122, P<0.0001), ethnicity (non-Hispanic: $228 vs. Hispanic: $106, P<0.0001), and education (greater than high school: $250 vs. less than high school: $100, P<0.0001).

CONCLUSIONS

We found a pattern of increasing dry eye medication use and expenditures from 2001 to 2006. Predictors of higher dry eye medication expenditures included female gender, non-Hispanic ethnicity, and greater than a high school education.

Vascular risk factors and cognitive impairment in a stroke-free cohort

OBJECTIVE

To examine vascular risk factors, as measured by the Framingham Stroke Risk Profile (FSRP), to predict incident cognitive impairment in a large, national sample of black and white adults age 45 years and older.

METHODS

Participants included subjects without stroke at baseline from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study with at least 2 cognitive function assessments during the follow-up (n = 23,752). Incident cognitive impairment was defined as decline from a baseline score of 5 or 6 (of possible 6 points) to the most recent follow-up score of 4 or less on the Six-item Screener (SIS). Subjects with suspected stroke during follow-up were censored.

RESULTS

During a mean follow-up of 4.1 years, 1,907 participants met criteria for incident cognitive impairment. Baseline FSRP score was associated with incident cognitive impairment. An adjusted model revealed that male sex (odds ratio [OR] = 1.59, 95% confidence interval [CI] 1.43-1.77), black race (OR = 2.09, 95% CI 1.88-2.35), less education (less than high school graduate vs college graduate, OR = 2.21, 95% CI 1.88-2.60), older age (10-year increments, OR = 2.11, per 10-year increase in age, 95% CI 2.05-2.18), and presence of left ventricular hypertrophy (LVH, OR = 1.29, 95% CI 1.06-1.58) were related to development of cognitive impairment. When LVH was excluded from the model, elevated systolic blood pressure was related to incident cognitive impairment.

CONCLUSIONS

Total FSRP score, elevated blood pressure, and LVH predict development of clinically significant cognitive dysfunction. Prevention and treatment of high blood pressure may be effective in preserving cognitive health.

Racial differences in venous thromboembolism

The incidence of venous thrombosis (VTE) varies by race, with African-Americans having over 5-fold greater incidence than Asian-ancestry populations, and an intermediate risk for European and Hispanic populations. Known racial differences in genetic polymorphisms associated with thrombosis do not account for this gradient of risk, nor do known racial variations in environmental risk factors. Data on the incidence of and risk factors for VTE outside of Europe and North America and in non-European ancestry populations are sparse. Common genetic polymorphisms in European-Ancestry populations, such as factor V Leiden and prothrombin G20210A, and environmental risk factors, such as obesity, may account for some of the increased risk in European populations, and high factor VIII, high von Willebrand factor and low protein C levels and increased prevalence of obesity may explain some of the increased risk in African-Americans. The low rates in Asian populations may be partially explained by low clinical suspicion in a perceived low-risk population and lack of access to healthcare in other populations. As risk factors for thrombosis, such as surgery and treatment for cancer, are applicable to more people, as obesity increases in prevalence in the developing world, and as surveillance systems for VTE improve, VTE may increase in previously low-risk populations. While differences in VTE by race due to genetic predisposition will probably always be present, understanding the reasons for racial differences in VTE will help providers develop strategies to minimize VTE in all populations.

Emergency evacuation readiness of full-time wheelchair users with spinal cord injury

OBJECTIVES

To determine the percentage of full-time wheelchair users with spinal cord injuries who felt they could evacuate from various locations, and the percentage who have a plan for evacuation. Study results will help clinicians and emergency officials understand needs related to evacuation preparedness.

DESIGN

Convenience sample survey.

SETTING

Six Spinal Cord Injury Model System centers, part of the national database funded through the Department of Education, National Institute on Disability and Rehabilitation Research.

PARTICIPANTS

People (N=487) with spinal cord injuries who use a wheelchair more than 40 hours a week.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The percentage of wheelchair users who felt they would be able to safely evacuate, had a plan for safe evacuation, or reported a need for assistive technology and human assistance to evacuate from various locations in the event of an emergency.

RESULTS

The highest percentage of participants felt they would be able to safely evacuate and had a plan for work evacuation. The lowest percentage of participants reported they could evacuate from their city/town in the event of an emergency and had a plan to evacuate their city/town in the event of a natural disaster. A large difference exists between the percentage of participants who felt they could evacuate and those who have a plan for evacuation.

CONCLUSIONS

A large discrepancy exists between the perception that one can evacuate and actually having a plan. The perception that one can evacuate without a plan or the use of assistive technology is an area of concern that must be further addressed by educators. Education must emphasize the need to have a defined evacuation plan and effective utilization of assistive technology.

Higher incidence of head and neck cancers among Vietnamese American men in California

BACKGROUND

Our aim was to determine the incidence rates of head and neck cancer in Vietnamese Californians compared with other Asian and non-Asian Californians.

METHODS

Age-adjusted incidence rates of head and neck cancer between 1988 and 2004 were computed for Vietnamese Californians compared with other racial/ethnic groups by time period, ethnicity, neighborhood-level socioeconomic status (SES), and sex using data from the population-based California Cancer Registry (CCR). Data by smoking and alcohol status were tabulated from the California Health Interview Survey.

RESULTS

Vietnamese men had a higher incidence rate of head and neck cancer than other Asian men. Specifically, the laryngeal cancer rate was significantly higher for Vietnamese men (6.5/100,000; 95% confidence interval [CI], 5.0-8.2) than all other Asian men (range, 2.6-3.8/100,000), except Korean men (5.1/100,000; 95% CI, 3.9-6.4). Both Vietnamese and Korean men had the highest percentage of current smokers. Neighborhood SES was inversely related to head and neck cancer rates among Vietnamese men and women.

CONCLUSION

The higher incidence rate of head and neck cancer in Vietnamese men may correspond to the higher smoking prevalence in this group. Individual-level data are needed to establish the link of tobacco, alcohol, and other risk factors with head and neck cancer in these patients.

Papillary thyroid cancer incidence rates vary significantly by birthplace in Asian American women

OBJECTIVE

To investigate how birthplace influences the incidence of papillary thyroid cancer among Asian American women.

METHODS

Birthplace- and ethnic-specific age-adjusted and age-specific incidence rates were calculated using data from the California Cancer Registry for the period 1988-2004. Birthplace was statistically imputed for 30% of cases using a validated imputation method based on age at Social Security number issuance. Population estimates were obtained from the US Census. Incidence rate ratios (IRR) and 95% confidence intervals (CI) were estimated for foreign-born vs. US-born women.

RESULTS

Age-adjusted incidence rates of papillary thyroid cancer among Filipina (13.7 per 100,000) and Vietnamese (12.7) women were more than double those of Japanese women (6.2). US-born Chinese (IRR = 0.48, 95% CI: 0.40-0.59) and Filipina women (IRR = 0.74, 95% CI: 0.58-0.96) had significantly higher rates than those who were foreign-born; the opposite was observed for Japanese women (IRR = 1.55, 95% CI: 1.17-2.08). The age-specific patterns among all foreign-born Asian women and US-born Japanese women showed a slow steady increase in incidence until age 70. However, among US-born Asian women (except Japanese), substantially elevated incidence rates during the reproductive and menopausal years were evident.

CONCLUSIONS

Ethnic- and birthplace-variation in papillary thyroid cancer incidence can provide insight into the etiology of this increasingly common and understudied cancer.

The Levels of Inflammatory Markers in the Treatment of Stroke study (LIMITS): inflammatory biomarkers as risk predictors after lacunar stroke

BACKGROUND

Inflammation is increasingly recognised as playing a central role in atherosclerosis, and peripheral blood markers of inflammation have been associated with incident and recurrent cardiac events. The relationship of these potentially modifiable risk markers to prognosis after ischaemic stroke is less clear. The Levels of Inflammatory Markers in the Treatment of Stroke (LIMITS) study will address hypotheses related to the role of inflammatory markers in secondary stroke prevention in an efficient manner using the well-established framework of the Secondary Prevention of Small Subcortical Strokes (SPS3) trial (NCT00059306).

METHODS

SPS3 is an ongoing Phase III multicentre secondary prevention trial focused on preventing recurrent stroke in patients with small vessel ischaemic stroke, or lacunes. In SPS3, patients are assigned in a factorial design to aspirin vs. aspirin plus clopidogrel, and to usual vs. aggressive blood pressure targets. The purpose of LIMITS is to determine whether serum levels of inflammatory markers - including high-sensitivity C-reactive protein, serum amyloid A, CD40 ligand, and monocyte chemoattractant protein-1 - predict recurrent stroke and other vascular events among lacunar stroke patients. The project will also determine whether these markers predict which people will respond best to dual antiplatelet therapy with clopidogrel and aspirin, as well the relationship to cognitive function.

ANALYSIS

plan Multivariable Cox proportional hazard regression modeling will be used to estimate hazard ratios for the effect of marker levels on risk of recurrent stroke and other outcomes after adjusting for additional potential risk factors, including age, gender, ethnicity, treatment arm, and traditional stroke risk factors. Interactions between marker levels and treatment assignment for both arms of the SPS3 study will be assessed. Observations will be censored at the time of last follow-up visit.

CONCLUSIONS

LIMITS represents an efficient approach to the identification of novel inflammatory biomarkers for use in risk prediction and treatment selection in patients with small vessel disease.

Wheelchair repairs, breakdown, and adverse consequences for people with traumatic spinal cord injury

McClure LA, Boninger ML, Oyster ML, Williams S, Houlihan B, Lieberman JA, Cooper RA. Wheelchair repairs, breakdown, and adverse consequences for people with traumatic spinal cord injury.

OBJECTIVES

To investigate the frequency of repairs that occurred in a 6-month period and the consequences of breakdowns on wheelchair users living with spinal cord injuries (SCIs), and to determine whether certain wheelchair and subject characteristics are associated with an increased number of repairs and adverse consequences.

DESIGN

Convenience sample survey.

SETTING

Sixteen Model Spinal Cord Injury Systems Centers that are part of the national database funded through the Department of Education, National Institute on Disability and Rehabilitation Research.

PARTICIPANTS

People with SCI who use a wheelchair for more than 40h/wk (N=2213).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

The frequency of wheelchair repairs and occurrence of adverse consequences caused by a wheelchair breakdown in a 6-month period.

RESULTS

Within a 6-month period, 44.8% of full-time wheelchair users completed a repair, and 8.7% had an adverse consequence occur. People who use power wheelchairs required significantly more repairs (P<.001), and adverse consequences occurred more frequently (P<.001) compared with manual wheelchair users. The presence of power seat functions, and a person's occupational status or sex did not influence the number of repairs or adverse consequences.

CONCLUSIONS

Frequent repairs and breakdown can negatively impact a person's life by decreasing community participation and threatening health and safety. Mandatory compliance with the American National Standards Institute and the Rehabilitation Engineering and Assistive Technology Society of North America standards, changes in insurance reimbursement policy, and patient and clinician education are necessary to reduce the number of repairs and adverse consequences that occur.

Availability and accuracy of medical record information on language usage of cancer patients from a multi-ethnic population

Documentation of language usage in medical settings could be effective in identifying and addressing language barriers and would improve understanding of health disparities. This study evaluated the availability and accuracy of medical records information on language for 1,664 cancer patients likely to have poor English proficiency. Accuracy was assessed by comparison to language obtained from interview-based research studies. For patients diagnosed at facilities where information on language was not abstracted electronically, 81.6% had language information in their medical records, most often in admissions documents. For all 37 hospitals, agreement between medical records and interview language was 79.3% overall and was greater for those speaking English than another language. Language information is widely available in hospital medical records of cancer patients. However, for the data to be useful for research and reducing language barriers in medical care, the information must be collected in a consistent and accurate manner.

Second primary breast cancer occurrence according to hormone receptor status

BACKGROUND

Contralateral second primary breast cancers occur in 4% of female breast cancer survivors. Little is known about differences in risk for second primary breast cancers related to the estrogen and progesterone receptor (hormone receptor [HR]) status of the first tumor.

METHODS

We calculated standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) for contralateral primary breast cancers among 4927 women diagnosed with a first breast cancer between January 1, 1992, and December 31, 2004, using the National Cancer Institute's Surveillance, Epidemiology, and End Results database.

RESULTS

For women whose first breast tumors were HR positive, risk of contralateral primary breast cancer was elevated, compared with the general population, adjusted for age, race, and calendar year (SIR = 2.22, 95% CI = 2.15 to 2.29, absolute risk [AR] = 13 cases per 10 000 person-years [PY]), and was not related to the HR status of the second tumor. For women whose first breast tumors were HR negative, the risk of a contralateral primary tumor was statistically significantly higher than that for women whose first tumors were HR positive (SIR = 3.57, 95% CI = 3.38 to 3.78, AR = 18 per 10 000 PY), and it was associated with a much greater likelihood of an HR-negative second tumor (SIR for HR-positive second tumors = 1.94, 95% CI = 1.77 to 2.13, AR = 20 per 10 000 PY; SIR for HR-negative second tumors = 9.81, 95% CI = 9.00 to 10.7, AR = 24 per 10 000 PY). Women who were initially diagnosed with HR-negative tumors when younger than 30 years had greatly elevated risk of HR-negative contralateral tumors, compared with the general population (SIR = 169, 95% CI = 106 to 256, AR = 77 per 10 000 PY). Incidence rates for any contralateral primary cancer following an HR-negative or HR-positive tumor were higher in non-Hispanic blacks, Hispanics, and Asians or Pacific Islanders than in non-Hispanic whites.

CONCLUSIONS

Risk for contralateral second primary breast cancers varies substantially by HR status of the first tumor, age, and race and/or ethnicity. Women with HR-negative first tumors have nearly a 10-fold elevated risk of developing HR-negative second tumors, compared with the general population. These findings warrant intensive surveillance for second breast cancers in women with HR-negative tumors.

Socioeconomic status and prostate cancer incidence and mortality rates among the diverse population of California

Background

The racial/ethnic disparities in prostate cancer rates are well documented, with the highest incidence and mortality rates observed among African-Americans followed by non-Hispanic Whites, Hispanics, and Asian/Pacific Islanders. Whether socioeconomic status (SES) can account for these differences in risk has been investigated in previous studies, but with conflicting results. Furthermore, previous studies have focused primarily on the differences between African-Americans and non-Hispanic Whites, and little is known for Hispanics and Asian/Pacific Islanders.

Objective

To further investigate the relationship between SES and prostate cancer among African-Americans, non-Hispanic Whites, Hispanics, and Asian/Pacific Islanders, we conducted a large population-based cross-sectional study of 98,484 incident prostate cancer cases and 8,997 prostate cancer deaths from California.

Methods

Data were abstracted from the California Cancer Registry, a population-based surveillance, epidemiology, and end results (SEER) registry. Each prostate cancer case and death was assigned a multidimensional neighborhood-SES index using the 2000 US Census data. SES quintile-specific prostate cancer incidence and mortality rates and rate ratios were estimated using SEER*Stat for each race/ethnicity categorized into 10-year age groups.

Results

For prostate cancer incidence, we observed higher levels of SES to be significantly associated with increased risk of disease [SES Q1 vs. Q5: relative risk (RR) = 1.28; 95% confidence interval (CI): 1.25–1.30]. Among younger men (45–64 years), African-Americans had the highest incidence rates followed by non-Hispanic Whites, Hispanics, and Asian/Pacific Islanders for all SES levels. Yet, among older men (75–84 years) Hispanics, following African-Americans, displayed the second highest incidence rates of prostate cancer. For prostate cancer deaths, higher levels of SES were associated with lower mortality rates of prostate cancer deaths (SES Q1 vs. Q5: RR = 0.88; 95% CI: 0.92–0.94). African-Americans had a twofold to fivefold increased risk of prostate cancer deaths in comparison to non-Hispanic Whites across all levels of SES.

Conclusions

Our findings suggest that SES alone cannot account for the greater burden of prostate cancer among African-American men. In addition, incidence and mortality rates of prostate cancer display different age and racial/ethnic patterns across gradients of SES.

Electronic supplementary material

The online version of this article (doi:10.1007/s10552-009-9369-0) contains supplementary material, which is available to authorized users.

Improvements in survival after follicular lymphoma by race/ethnicity and socioeconomic status: a population-based study

PURPOSE

A recent report suggested improvements in survival after follicular lymphoma (FL), but not for all racial/ethnic groups. To better understand the reasons for these FL survival differences, we examined the joint influences of diagnostic period, race/ethnicity, and neighborhood socioeconomic status (SES) on survival in a large population-based case series.

METHODS

All patients (n = 15,937) diagnosed with FL between 1988 and 2005 in California were observed for vital status through November 2007. Overall and FL-specific survival were analyzed with Kaplan-Meier and Cox proportional hazards regression. Neighborhood SES was assigned from United States Census data using residence at diagnosis.

RESULTS

Overall and FL-specific survival improved 22% and 37%, respectively, from 1988 to 1997 to 1998 to 2005, and were observed in all racial/ethnic groups. Asian/Pacific Islanders had better survival than non-Hispanic white, Hispanic, and black patients who had similar outcomes. Lower neighborhood SES was associated with worse survival in patients across all stages of disease (P for trend < .01). Patients with the lowest SES quintile had a 49% increased risk of death from all causes (hazard ratio [HR] = 1.49, 95% CI, 1.30 to 1.72) and 31% increased risk of death from FL (HR = 1.31; 95% CI, 1.06 to 1.60) than patients with the highest SES.

CONCLUSION

Evolving therapies have likely led to improvements in survival after FL. Although improvements have occurred within all racial/ethnic groups, lower neighborhood SES was significantly associated with substantially poorer survival.

Differences in breast cancer subtype distribution exist among ethnic subgroups of Asian women in California

Abstract #2088

Background: Distinct breast cancer subtypes have been identified by gene expression analysis. Little is known about the distribution of these subtypes among Asian women. We previously reported an increased frequency of HER2-positive breast cancers among certain ethnic subgroups of Asian women in California. To follow up on that finding in detail, we undertook the current analysis to explore factors associated with differences in breast cancer subtype distribution among Asian women in California.&#x2028; Methods: We defined immunohistochemical surrogates for each breast cancer subtype among Chinese, Japanese, Filipina, Korean, Vietnamese and South Asian patients in the population-based California Cancer Registry diagnosed in the period 1999-2005. Subtypes were defined using combinations of immunohistochemical markers: luminal A (ER+ and/or PR+, HER2-), luminal B (ER+ and/or PR+, HER2+), basal-like (ER-, PR-, HER2-) and HER2+/ER- (ER-, PR-, HER2+). Polytomous logistic regression was used to evaluate associations between breast cancer subtype and age, race, AJCC stage, tumor grade, tumor histology, socioeconomic status, nativity and hospital ownership (private vs. public). Models were used to compare differences in these characteristics simultaneously across the four breast cancer subtypes.&#x2028; Results: Of 12,245 Asian women diagnosed with invasive breast cancer, 7,217 (59%) women had data for all three immunohistochemical markers. The majority of breast cancers among Japanese women were of the luminal A subtype (67%), with a low frequency of basal-like (10%) and HER2+ (22%) cancers. Korean, Filipina and Vietnamese women had a high frequency of HER2+ cancers (35%, 31% and 31%, respectively) compared to Non-Hispanic White women diagnosed during this period (n=12,996, 21%). In regression analyses among Asian women, the four subtypes varied significantly in their associations with age group (p=0.01), detailed Asian ethnicity (p&lt;0.0001), stage (p&lt;0.0001), grade (p&lt;0.0001), histology (p&lt;0.0001), year of diagnosis (continuous; p=0.03) and hospital ownership (p&lt;0.0001). However, there was no significant variation among the subtypes in their relationships with socioeconomic status (p=0.94) or nativity (p=0.29).&#x2028; Conclusions: Differences in the distribution of breast cancer subtypes exist among Asian women according to ethnicity, as well as other demographic and disease characteristics. These differences were not associated with place of birth or socioeconomic status. Breast cancers among Japanese women had the most favorable subtype distribution, while Korean women had the least favorable distribution. Further study may identify genetic and environmental risk factors responsible for these differences, with implications for prevention and treatment.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2088.

Comprehensive evaluation of community-based diabetic patients: effect of feedback to patients and their physicians: a randomized controlled trial

OBJECTIVE

To demonstrate improvements in diabetes care stimulated by comprehensive evaluation of community-based diabetic patients with feedback to the patients and their physicians.

RESEARCH DESIGN AND METHODS

A comprehensive evaluation of community-based diabetic patients with annotated reporting of results to both patients and their physicians (universal intervention) was followed by random assignment of 50% of patients to individual counseling (randomized intervention). In four communities, two large and two small, 55 type 1 and 376 type 2 diabetic patients were recruited, evaluated, and reassessed at 1 year. Outcome measures were HbA1c, serum cholesterol, and systolic and diastolic blood pressure.

RESULTS

There were significant improvements in all outcome measures for type 2 diabetic patients randomized to individual counseling (P = 0.03; follow-up rate 84%) and significant improvements in all outcome measures for all high-risk type 2 patients (highest P value = 0.004; follow-up rate 85%).

CONCLUSIONS

Comprehensive evaluation of diabetic patients at the community level with annotated reporting of results to the patients and their physicians was associated with improvement of mean HbA1c, cholesterol, and systolic and diastolic blood pressure, particularly in patients in high-risk status for these outcome variables. Individual counseling of 50% of patients, randomly selected, enhanced these results.