Severity of Chronic Graft-versus-Host Disease and Late Effects Following Allogeneic Hematopoietic Cell Transplantation for Adults with Hematologic Malignancy

The study aimed to determine the association of chronic graft-versus-host disease (cGVHD) diagnosis and severity with the development of subsequent neoplasms (SN) and nonmalignant late effects (NM-LE) in 2-year disease-free adult survivors following hematopoietic cell transplantation (HCT) for a hematologic malignancy. To do so, we conducted a retrospective analysis of 3884 survivors of HCT for hematologic malignancy in the Center of International Blood and Marrow Transplant Research database. We conducted a landmark analysis at the 2-year post-transplantation date, comparing first SN and NM-LE in survivors with and without cGVHD. The cumulative incidence (CuI) of SN and NM-LE were estimated through 10 years post-HCT in both groups, with death or disease relapse as a competing risk. Cox proportional hazards models were used to evaluate the associations of cGVHD and its related characteristics with the development of SN and NM-LE. The estimated 10-year CuI of SN in patients with GVHD (n = 2669) and patients without cGVHD (n = 1215) was 15% (95% confidence interval [CI], 14% to 17%) versus 9% (7.2% to 11%) (P < .001). cGVHD by 2 years post-HCT was independently associated with SN (hazard ratio [HR], 1.94; 95% CI, 1.53 to 2.46; P < .0001) with a standardized incidence ratio of 3.2 (95% CI, 2.9 to 3.5; P < .0001). Increasing severity of cGVHD was associated with an increased risk of SN. The estimated 10-year CuI of first NM-LE in patients with and without cGVHD was 28 (95% CI, 26% to 30%) versus 13% (95% CI, 11% to 15%) (P < .001). cGVHD by 2 years post-HCT was independently associated with NM-LE (HR, 2.23; 95% CI, 1.81 to 2.76; P < .0001). Multivariate analysis of cGVHD-related factors showed that increasing severity of cGVHD, extensive grade, having both mucocutaneous and visceral involvement, and receiving cGVHD treatment for >12 months were associated with the greatest magnitude of risk for NM-LE. cGVHD was closely associated with both SN and NM-LE in adult survivors of HCT for hematologic malignancy. Patients identified as having more severe involvement and both mucocutaneous and visceral organ involvement may warrant enhanced monitoring and screening for SNs and NM-LEs. However, caution is warranted when interpreting these results, as patients with cGVHD may have more vigilant post-transplantation health care and surveillance for late effects.

Effect of donor age in patients with acute myeloid leukemia undergoing haploidentical hematopoietic cell transplantation vary by conditioning intensity and recipient age

We investigated the impact of donor age (younger [≤35 years] vs. older [>35 years]) after accounting for other non-HLA and HLA factors on outcomes of patients with acute myeloid leukemia undergoing HLA-haploidentical hematopoietic cell transplantation (n = 790). The effect differed by conditioning-partly related to the differences in the recipient age in myeloablative (MAC; median 46 years) versus reduced-intensity/non-myeloablative conditioning (RIC/NMA; median 61 years) groups. With MAC (n = 320), donor age had no impact on acute graft-versus-host disease (GVHD), but older donors were associated with a significantly higher risk of chronic GVHD (hazard ratio [HR]: 1.6, 95% confidence interval [CI]: 1.10-2.30, p = .02) independent of recipient age and other factors. Donor age had no impact on either relapse or non-relapse mortality (NRM). The impact of donor/recipient age on overall survival changed over time. Older donors were associated with significantly higher late overall mortality (>6 months) in younger recipients (≤ 50 years; HR: 2.2, 95% CI: 1.03-4.6, p = .04) but not older recipients. With RIC/NMA (n = 470), neither recipient's nor donor's age influenced the risk of GVHD. Donor age had no significant impact on the risk of relapse, but older donors were associated with a significantly higher risk of NRM (HR: 1.6, 95% CI: 1.02-2.6, p = .04) independent of recipient age. Older donor age was associated with significantly higher late overall mortality (>9 months) in older recipients (>50 years; HR: 1.66, 95% CI: 1.0-2.67; p = .049) but not in younger recipients. Donor selection based on donor age may require a tailored approach for a particular recipient.

Association of Chronic Graft-versus-Host Disease with Late Effects following Allogeneic Hematopoietic Cell Transplantation for Children with Hematologic Malignancy

Chronic graft-versus-host disease (cGVHD) occurs in up to 25% of children following allogeneic hematopoietic cell transplantation (HCT) and continues to be a major cause of late morbidity and poor quality of life among long-term survivors of pediatric HCT. Late effects (LEs) of HCT are well documented in this population, and cGVHD has been identified as a risk factor for subsequent neoplasms (SNs) and several nonmalignant LEs (NM-LEs); however, the reported correlation between cGVHD and LEs varies among studies. We compared LEs occurring ≥2 years following childhood HCT for a hematologic malignancy in 2-year disease-free survivors with and without cGVHD and further evaluated the association of cGVHD features on the development of LEs. This systematic retrospective analysis used data from the Center of International Blood and Marrow Transplant Research (CIBMTR) on a large, representative cohort of 1260 survivors of pediatric HCT for hematologic malignancy to compare first malignant LEs and NM-LEs in those with a diagnosis of cGVHD and those who never developed cGVHD. The cumulative incidences of any first LE, SN, and NM-LE were estimated at 10 years after HCT, with death as a competing risk for patients with cGVHD versus no cGVHD. Cox proportional hazards models were used to evaluate the impact of cGVHD and its related characteristics on the development of first LEs. The estimated 10-year cumulative incidence of any LE in patients with and without cGVHD was 43% (95% CI, 38% to 48.2%) versus 32% (95% confidence interval [CI], 28.5% to 36.3%) (P < .001), respectively. The development of cGVHD by 2 years post-HCT was independently associated with any LE (hazard ratio [HR], 1.38; 95% CI, 1.13 to 1.68; P = .001) and NM-LE (HR, 1.37; 95% CI, 1.10 to 1.70; P = .006), but not SN (HR, 1.30; 95% CI, .73 to 2.31; P = .38). cGVHD-related factors linked with the development of an NM-LE included having extensive grade cGVHD (HR, 1.60; 95% CI, 1.23 to 2.08; P = .0005), severe cGVHD (HR, 2.25; 95% CI, 1.60 to 3.17; P < .0001), interrupted onset type (HR, 1.57; 95% CI, 1.21 to 2.05; P = .0008), and both mucocutaneous and visceral organ involvement (HR, 1.59; 95% CI, 1.24 to 2.03; P = .0002). No significant association between cGVHD-specific variables and SN was identified. Finally, the duration of cGVHD treatment of cGVHD with systemic immunosuppression was not significantly associated with SNs or NM-LEs. cGVHD was more closely associated with NM-LEs than with SNs among survivors of pediatric HCT for hematologic malignancy. In this analysis, the development of SNs was strongly associated with the use of myeloablative total body irradiation. cGVHD-related characteristics consistent with a state of greater immune dysregulation were more closely linked to NM-LEs.

Abstract 2251: Alu retroelement copy number, leukocyte telomere length, and lung cancer risk in the prospective Prostate, Lung, Colorectal and Ovarian Cancer (PLCO) Screening Trial

Prospective cohort and genome-wide association studies have found consistent associations between longer leukocyte telomere length (LTL) and increased lung cancer risk. These findings present a paradox in the traditional expectations of telomere dynamics in cancer development, as longer telomeres are generally considered to be reflective of less advanced age and greater genomic stability. We posited that longer LTL may reflect or lead to delayed cellular senescence allowing cells to accumulate genomic abnormalities that drive lung carcinogenesis. Furthermore, increased copy number of Alu retroelements, repetitive mobile DNA sequences that are approximately 300 base pairs in length, could also reflect genomic instability. We previously found that exposure to diesel exhaust, a known lung carcinogen, was associated with increased Alu copy number and suspect that increased Alu retrotransposition could influence lung carcinogenesis. However, the interrelationship between Alu retroelements, LTL, and lung cancer is unknown. Therefore, we investigated associations between Alu copy number, LTL, and lung cancer risk in the prospective Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial.

We conducted a nested case-control study of 410 confirmed incident lung cancer cases and 416 controls individually matched on age, sex, race/ethnicity, study center, and blood draw date. Quantitative PCR was used to measure Alu copy number and telomere length relative to albumin (Alb) copy number (Alu/Alb and T/S ratio, respectively) in pre-diagnostic leukocytes. Conditional logistic regression was used to estimate associations between quartiles (Q) of Alu/Alb ratio (reference=Q1) and lung cancer risk, adjusted for matching factors, smoking status and packyears, and LTL. Additionally, we dichotomized Alu/Alb ratio and LTL at their medians and created a cross-combination variable to assess combined effects.

We found a positive dose-response relationship between Alu/Alb ratio and lung cancer risk (odds ratio (OR), 95% confidence intervals (CI): Q2: 1.34 (0.73, 2.48); Q3:1.89 (0.94, 3.84); Q4: 2.66 (1.03, 5.63); p-trendordinal=0.02). The association was apparent for lung adenocarcinoma (LUAD) (Q2: 1.32 (0.46, 3.77); Q3: 2.88 (0.90, 9.25); Q4: 5.07 (1.29, 19.87); p-trendordinal=0.02). We have previously reported that longer measured LTL was also associated with an increased risk of LUAD (Q4: 2.82 (1.16-6.85); p-trend=0.011). The combined effect of both a higher Alu/Alb ratio and longer LTL was 6.07 (1.75, 21.04; p=4.5x10-3) for LUAD compared with lower/shorter levels of both.

Higher Alu copy number and longer LTL were associated with increased risk of lung cancer, especially LUAD. Our findings require replication. If confirmed, evaluation of Alu copy number and LTL in risk stratification and prediction analyses is warranted.

Citation Format: Jason Yat-Yang Wong, Richard Cawthon, Wei Hu, Somayina Ezennia, Shahinaz Gadalla, Charles Breeze, Batel Blechter, Neal Freedman, Wen-Yi Huang, H. Dean Hosgood, Wei Jie Seow, Bryan Bassig, Mohammad Rahman, Richard Hayes, Nathaniel Rothman, Qing Lan. Alu retroelement copy number, leukocyte telomere length, and lung cancer risk in the prospective Prostate, Lung, Colorectal and Ovarian Cancer (PLCO) Screening Trial [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 2251.

Comparison of total body irradiation versus non-total body irradiation containing regimens for de novo acute myeloid leukemia in children

With limited data comparing hematopoietic cell transplant outcomes between myeloablative total body irradiation (TBI) containing and non-TBI regimens in children with de novo acute myeloid leukemia, the aim of this study was to compare transplant-outcomes between these regimens. Cox regression models were used to compare transplant-outcomes after TBI and non-TBI regimens in 624 children transplanted between 2008 and 2016. Thirty two percent (n=199) received TBI regimens whereas 68% (n=425) received non-TBI regimens. Five-year non-relapse mortality was higher with TBI regimens (22% vs. 11%, P<0.0001) but relapse was lower (23% vs. 37%, P<0.0001) compared to non-TBI regimens. Consequently, overall (62% vs. 60%, P=1.00) and leukemia-free survival (55% vs. 52%, P=0.42) did not differ between treatment groups. Grade 2-3 acute graft versus host disease was higher with TBI regimens (56% vs. 27%, P<0.0001) but not chronic graft versus host disease. The 3-year incidence of gonadal or growth hormone deficiency was higher with TBI regimens (24% vs. 8%, P<0.001) but there were no differences in late pulmonary, cardiac or renal impairment. In the absence of a survival advantage, the choice of TBI or non-TBI regimen merits careful consideration with the data favoring non-TBI regimens to limit the burden of morbidity associated with endocrine dysfunction.

Maintenance Tyrosine Kinase Inhibitors Following Allogeneic Hematopoietic Stem Cell Transplantation for Chronic Myelogenous Leukemia: A Center for International Blood and Marrow Transplant Research Study

It remains unknown whether the administration of tyrosine kinase inhibitors (TKIs) targeting BCR-ABL1 after allogeneic hematopoietic cell transplantation (HCT) is associated with improved outcomes for patients with chronic myelogenous leukemia (CML). In this registry study, we analyzed clinical outcomes of 390 adult patients with CML who underwent transplantation between 2007 and 2014 and received maintenance TKI following HCT (n = 89) compared with no TKI maintenance (n = 301), as reported to the Center for International Blood and Marrow Transplant Research. All patients received TKI therapy before HCT. The majority of patients had a disease status of first chronic phase at HCT (n = 240; 62%). The study was conducted as a landmark analysis, excluding patients who died, relapsed, had chronic graft-versus-host disease, or were censored before day +100 following HCT. Of the 89 patients who received TKI maintenance, 77 (87%) received a single TKI and the other 12 (13%) received multiple sequential TKIs. The most common TKIs used for maintenance were dasatinib (n = 50), imatinib (n = 27), and nilotinib (n = 27). As measured from day +100, the adjusted estimates for 5-year relapse (maintenance, 35% versus no maintenance, 26%; P = .11), leukemia-free survival (maintenance, 42% versus no maintenance, 44%; P = .65), or overall survival (maintenance, 61% versus no maintenance, 57%; P = .61) did not differ significantly between patients receiving TKI maintenance or no maintenance. These results remained unchanged in multivariate analysis and were not modified by disease status before transplantation. In conclusion, our data from this day +100 landmark analysis do not demonstrate a significant impact of maintenance TKI therapy on clinical outcomes. The optimal approach to TKI administration in the post-transplantation setting in patients with CML remains undetermined.

Abstract 2333: Aspirin may extend biliary tract cancer survival: Results from population-based cohort

Background: Biliary tract cancers (BTCs) are rare, but lethal cancers with a median survival of &lt;12 months. Because of this poor prognosis, there is a critical need for treatments that extend survival. Cyclooxygenase-2 (COX-2) is an enzyme responsible for producing prostaglandin E (PGE). PGEs increase mucin production and reduce bile flow in the gallbladder, leading to gallstones, a precursor to gallbladder cancer. Overexpression of COX-2 due to chronic inflammation from cholangiocarcinoma has been found to enhance PGE production and promote tumor growth. Previous research suggests that COX-2 inhibitors, such as aspirin, may slow cancer cell growth. We investigated aspirin use following diagnosis and overall survival in a large cohort of patients with BTCs.

Methods: All patients diagnosed with incident biliary tract cancer between 1990 to 2017 were selected from the population-based United Kingdom’s Clinical Practice Research Datalink. Site-specific associations between aspirin use after BTC diagnosis and overall survival was analyzed using Cox proportional hazards models with aspirin use modeled as time-dependent, adjusting for age at diagnosis, sex, comorbidities, history of aspirin use, and use of statins, using follow-up time as the time scale.

Results: We identified 3,211 biliary tract cancer cases in which 2,694 (84%) deaths occurred after an overall median follow-up time of 5 months. The table presents the number of cases by cancer subtype, deaths, and median survival time. Aspirin use following a diagnosis of BTC was associated with a reduction in mortality for each of the BTC sites: gallbladder, HR 0.41 (95% CI: 0.28, 0.61); cholangiocarcinoma, HR 0.46 (95% CI: 0.36, 0.60); ampulla of Vater, HR 0.24 (95% CI: 0.11, 0.51); and mixed, HR: 0.51 (95% CI: 0.33, 0.78).

Conclusions: The use of aspirin after BTC diagnosis was associated with a lower risk of overall mortality. These results warrant additional studies to understand the mechanisms underlying improved survival with aspirin use.

Table.Association between post-BTC diagnosis aspirin use versus no use and survival in the UK CPRD datasetCancer siteBTC patients N (%)Mortality N (%)Median survival time in months (interquartile range)HR (95% CI)*Gallbladder668 (23)555 (83)3.9 (2 - 11)0.41 (0.28, 0.61)Cholangiocarcinoma1,560 (53)1321 (85)4.8 (2 - 12)0.46 (0.36, 0.60)Ampulla of Vater224 (8)142 (63)9 (4 - 21)0.24 (0.11, 0.51)Mixed484 (16)401 (83)5 (2 - 13)0.51 (0.33, 0.78)*Adjusted for age at diagnosis, comorbidities, prior aspirin use, and use of statins.Abbreviations: CPRD, Clinical Practice Research Datalink; CI, confidence interval; HR, hazard ratio; N, number; and UK, United Kingdom.

Citation Format: Sarah S. Jackson, Bin Zhu, Ruth Pfeiffer, Zhiwei Liu, Shahinaz Gadalla, Jill Koshiol. Aspirin may extend biliary tract cancer survival: Results from population-based cohort [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 2333.

Increasing incidence of chronic graft-versus-host disease in allogeneic transplantation: a report from the Center for International Blood and Marrow Transplant Research

Although transplant practices have changed over the last decades, no information is available on trends in incidence and outcome of chronic graft-versus-host disease (cGVHD) over time. This study used the central database of the Center for International Blood and Marrow Transplant Research (CIBMTR) to describe time trends for cGVHD incidence, nonrelapse mortality, and risk factors for cGVHD. The 12-year period was divided into 3 intervals, 1995 to 1999, 2000 to 2003, and 2004 to 2007, and included 26,563 patients with acute leukemia, chronic myeloid leukemia, and myelodysplastic syndrome. Multivariate analysis showed an increased incidence of cGVHD in more recent years (odds ratio = 1.19, P < .0001), and this trend was still seen when adjusting for donor type, graft type, or conditioning intensity. In patients with cGVHD, nonrelapse mortality has decreased over time, but at 5 years there were no significant differences among different time periods. Risk factors for cGVHD were in line with previous studies. This is the first comprehensive characterization of the trends in cGVHD incidence and underscores the mounting need for addressing this major late complication of transplantation in future research.

Abstract 5100: Development of a direct-measurement molecular assay to determine telomere length in human samples

Telomere length (TL) is a recognized biomarker in cancer. Epidemiology studies suggest that blood and/or buccal cell TL is associated with certain cancers; however, TL measurement is still an under-utilized biomarker in clinical trials. The molecular testing platforms currently used for TL determination are not optimal due to inherent technical limitations. While qPCR based assays have high throughput and are inexpensive, they are difficult to develop and are very sensitive to subtle permutations in reaction components. We evaluated a strategy that relies on direct hybridization and detection of the telomere target utilizing the NanoString nCounter System (NS). The NS is a semi-quantitative assay that compares the number of reporter probe hybridization events of telomere-specific versus chromosomal invariant regions in DNA samples. Performed without nucleic acid amplification, it has potential to more accurately quantify telomeric sequences than any other assay currently in use. NS uses moderate DNA quantities per test (600ng), and has a throughput that can be expanded in multiples of 12. In each sample, the Ratio of Telomere Length (RTL) is obtained by normalizing the signal produced by the telomere specific code set probes to the signal produced by multiple control probes as compared to commercial normal human DNA.

NS was validated in a three stage process using commercial DNA (n=3), cell lines (n=11) and human clinical samples (n=43) that had previously been tested by other TL tests. A blinded panel of six research samples previously tested in-house by multiplex monochrome quantitative PCR (qPCR) was sent to NanoString for in-house testing. NS exactly reproduced the panel's previous RTL ranking. The telomere code sets were subsequently tested at NCI on a panel of 11 established cell lines. Good correlation was observed compared with our in-house qPCR assay (R2 = 0.89). For the third stage of the validation, we evaluated the assay's utility on human clinical samples for which 43 whole blood leukocyte DNA samples were tested (18 dyskeratosis congenita (DC) patients with very short TL, 25 mutation-free (normal) DC relatives) and compared against leukocyte flow cytometry with in situ hybridization (flow-FISH, FF) TL measurement; FF is the gold standard in clinical testing for DC. The correlation between NS and FF lymphocyte TL was high, R2 = 0.72. Notably, the two sample t test showed that the NS assay could discriminate RTL between normals and DC patients (p = 4.6x10-8); normal relatives have longer telomeres. These data suggest that the NS RTL assay has the ability to be specific and sensitive to differences in TL between individuals with DC and healthy individuals. To determine the assay's exact clinical parameters a greater number of samples will need to be tested. The NS assay is less costly than the FF test by at least one half and if shown to be reproducible would be a viable alternative to FF and qPCR, especially in a diagnostic setting.

Citation Format: Daniel C. Edelman, David Petersen, Allison Gomez, Shahinaz Gadalla, Philippa Webster, Lucas Dennis, Mike Krouse, Sharon Savage, Paul S. Meltzer. Development of a direct-measurement molecular assay to determine telomere length in human samples. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 5100. doi:10.1158/1538-7445.AM2014-5100

Patient understanding of diabetes self-management: participatory decision-making in diabetes care

OBJECTIVE

Our aim was to determine whether patient participation in decision-making about diabetes care is associated with understanding of diabetes self-management and subsequent self-care practices. We also identified issues that would impact messaging for use in mobile diabetes communication.

RESEARCH DESIGN AND METHODS

A cross-sectional observational study was conducted with type 2 diabetes patients (n = 81) receiving their care at the University of Maryland Joslin Diabetes Center. A convenience sample of patients were eligible to participate if they were aged 25-85 years, had type 2 diabetes, spoke English, and visited their physician diabetes manager within the past 6 months. In-person patient interviews were conducted at the time of clinic visits to assess patient understanding of diabetes management, self-care practices, and perceptions of participation in decision-making about diabetes care.

RESULTS

African Americans reported fewer opportunities to participate in decision-making than Caucasians, after controlling for education [mean difference (MD) = -2.4, p = .02]. This association became insignificant after controlling for patient-physician race concordance (MD = -1.5, p = .21). Patient understanding of self-care was predicted by having greater than high school education (MD = 3.6, p = .001) and having physicians who involved them in decision-making about their care. For each unit increase in understanding of diabetes self-care, the mean patient self-care practice score increased by 0.16 (p = .003), after adjustment for patient race and education.

CONCLUSIONS

Patient participation in decision-making is associated with better understanding of care. Participation in decision-making plays a key role in patient understanding of diabetes self-management and subsequent self-care practices. Patients with limited education need specific instruction in foot care, food choices, and monitoring hemoglobin A1c.

Population-based study of autoimmune conditions and the risk of specific lymphoid malignancies

Some autoimmune conditions are associated with increased risk of lymphoid malignancies, but information on specific malignancy subtypes is limited. From the U.S. Surveillance Epidemiology and End Results-Medicare database, we selected 44,350 lymphoid malignancy cases (> or =67 years) and 122,531 population-based controls. Logistic regression was used to derive odds ratios (ORs) comparing the prevalence of autoimmune conditions in cases and controls, by lymphoid malignancy subtype, adjusted for gender, age at malignancy/selection, year of malignancy/selection, race and number of physician claims. The strongest associations observed by non-Hodgkin lymphoma (NHL) subtypes were diffuse large B-cell lymphoma with rheumatoid arthritis (OR 1.4, 95%CI 1.2-1.5) and Sjögren syndrome (2.0, 1.5-2.8); T-cell lymphoma with hemolytic anemia (9.7, 4.3-22), psoriasis (3.1, 2.5-4.0), discoid lupus erythematosus (4.4, 2.3-8.4) and celiac disease (5.0, 2.4-14.); and marginal zone lymphoma with Sjögren syndrome (6.6, 4.6-9.5), systemic lupus erythematosus (2.8, 1.7-4.7) and hemolytic anemia (7.4, 3.1-18). Hodgkin lymphoma was associated with systemic lupus erythematosus (3.5, 1.9-6.7). Multiple myeloma was associated only with pernicious anemia (1.5, 1.3-1.7). Several autoimmune conditions were associated with increased risk of lymphoid neoplasms, especially NHLs of diffuse large B-cell, marginal zone and T-cell subtypes. These results support a mechanism whereby chronic antigenic stimulation leads to lymphoid malignancy.

Risks of myeloid malignancies in patients with autoimmune conditions

Autoimmune conditions are associated with an elevated risk of lymphoproliferative malignancies, but few studies have investigated the risk of myeloid malignancies. From the US Surveillance Epidemiology and End Results (SEER)-Medicare database, 13 486 myeloid malignancy patients (aged 67+ years) and 160 086 population-based controls were selected. Logistic regression models adjusted for gender, age, race, calendar year and number of physician claims were used to estimate odds ratios (ORs) for myeloid malignancies in relation to autoimmune conditions. Multiple comparisons were controlled for using the Bonferroni correction (P<0.0005). Autoimmune conditions, overall, were associated with an increased risk of acute myeloid leukaemia (AML) (OR 1.29) and myelodysplastic syndrome (MDS, OR 1.50). Specifically, AML was associated with rheumatoid arthritis (OR 1.28), systemic lupus erythematosus (OR 1.92), polymyalgia rheumatica (OR 1.73), autoimmune haemolytic anaemia (OR 3.74), systemic vasculitis (OR 6.23), ulcerative colitis (OR 1.72) and pernicious anaemia (OR 1.57). Myelodysplastic syndrome was associated with rheumatoid arthritis (OR1.52) and pernicious anaemia (OR 2.38). Overall, autoimmune conditions were not associated with chronic myeloid leukaemia (OR 1.09) or chronic myeloproliferative disorders (OR 1.15). Medications used to treat autoimmune conditions, shared genetic predisposition and/or direct infiltration of bone marrow by autoimmune conditions, could explain these excess risks of myeloid malignancies.

Exploring patient-physician communication in breast cancer care for African American women following primary treatment

PURPOSE/OBJECTIVES

To investigate patient-physician communication from the patient's perspective about guidelines and sources of information used in developing survivorship care and preferred avenues for information delivery to African American breast cancer survivors.

DESIGN

Qualitative.

SETTING

Medical centers in the eastern United States.

SAMPLE

39 African American breast cancer survivors with a mean age of 55.

METHODS

Each participant contributed to one of four two-hour focus group discussions and completed brief questionnaires regarding sociodemographic characteristics and cancer-specific data. Focus group topics included involvement in discussions and decision making about survivorship care, specific instructions and information that physicians provided regarding follow-up medical care and preventive health actions, concerns about recurrence and ways to prevent it, and sources of information used to develop survivorship care plans.

MAIN RESEARCH VARIABLES

Survivorship care, patient-provider communication, information delivery methods, and African American breast cancer survivors.

FINDINGS

Participants reported gaps in the information given to them by physicians about their diagnosis, treatments, side effects, and guidelines for follow-up care. Participants expressed strong interest in self-care practices aimed at reducing their risk of recurrence and receiving evidence-based information and guidelines from healthcare providers. The majority (about 90%) reported physician checkups and mammography screening during the prior year, whereas only 54% reported making daily efforts to improve their health and reduce their risk of recurrence. Although evidence-based guidelines are available to healthcare providers delivering follow-up care to breast cancer survivors, more than 90% of participants in the present study reported a lack of specific recommendations regarding diet or physical activity as ways to improve quality of life and health as a cancer survivor.

CONCLUSIONS

The present study underscores 2006 findings from the Institute of Medicine that strategies for delivering information and guidance to cancer survivors and coordinating their care remain important issues for patients and their healthcare providers.

IMPLICATIONS FOR NURSING

The present study's findings highlight the need expressed by breast cancer survivors for comprehensive guidance from healthcare providers in developing plans of care that improve patients' quality of life and target recurrence risk. Guidelines are available for dissemination and use in medical settings; however, the guidelines have not been incorporated into standard medical practice for patients with cancer. Information about long-term follow-up care after primary treatment should target the specific needs of survivors from diverse ethnic, socioeconomic, and educational backgrounds to promote understanding of surveillance to detect recurrence, long-term effects of cancer treatments, and general health maintenance.

Hematopoietic malignancies associated with viral and alcoholic hepatitis

Hepatitis C virus (HCV) and hepatitis B virus (HBV) have been associated with hematopoietic malignancies, but data for many subtypes are limited. From the U.S. Surveillance, Epidemiology, and End Results-Medicare database, we selected 61,464 cases (> or = 67 years) with hematopoietic malignancies and 122,531 population-based controls, frequency-matched by gender, age, and year (1993--2002). Logistic regression was used to compare the prevalence of HCV, HBV, and alcoholic hepatitis in cases and controls, adjusted for matching factors, race, duration of Medicare coverage, and number of physician claims. HCV, HBV, and alcoholic hepatitis were reported in 195 (0.3%), 111 (0.2%), and 404 (0.7%) cases and 264 (0.2%), 242 (0.2%), and 798 (0.7%) controls, respectively. HCV was associated with increased risk of diffuse large B-cell lymphoma [odds ratio (OR) 1.52, 95% confidence interval (95% CI) 1.05-2.18], Burkitt lymphoma (OR 5.21, 95% CI 1.62-16.8), follicular lymphoma (OR 1.88, 95% CI 1.17-3.02), marginal zone lymphoma (OR 2.20, 95% CI 1.22-3.95), and acute myeloid leukemia (OR 1.54, 95% CI 1.00-2.37). In contrast, HBV was unrelated to any hematopoietic malignancies. Alcoholic hepatitis was associated with decreased risk of non-Hodgkin lymphoma overall, but increased risk of Burkitt lymphoma. In summary, HCV, but not other causes of hepatitis, was associated with the elevated risk of non-Hodgkin lymphoma and acute myeloid leukemia. HCV may induce lymphoproliferative malignancies through chronic immune stimulation.

Evaluation of serum biomarkers of fibrosis and injury in Egyptian patients with chronic hepatitis C

BACKGROUND/AIMS

We evaluated whether surrogate serum biomarkers for liver injury are comparable to liver biopsy in Egyptian patients with hepatitis C virus (HCV) infection.

SUBJECTS

Two hundred and twenty Egyptian patients, 91% infected with genotype-4 HCV, undergoing liver biopsy during evaluation for interferon/ribavirin therapy.

METHODS

Liver biopsy scored by the Ishak method was compared to biochemical tests, platelet count and two fibrosis biomarkers: hyaluronic acid (HA) and YKL-40. Univariate and logistic regression analyses determined independent predictors of fibrotic, inflammatory, and fatty changes. Biomarkers were evaluated for ability to differentiate between severe fibrosis/cirrhosis and no/mild fibrosis.

RESULTS

Although increasing age, HA, YKL-40, AST, reduced platelet count, and AST and HA/platelet count ratios were associated with fibrosis by univariate analysis, the other variables were not significant after controlling for HA (p=0.0001) and age (p=0.004). Although age and some biomarkers were associated with inflammation, none remained significant after controlling for fibrosis. YKL-40 (p=0.04) and aspartate aminotransferase (p=0.05) remained associated with steatosis after controlling for fibrosis.

CONCLUSIONS

In Egyptians with chronic HCV, young patients with low levels of HA are at very low risk of fibrosis. This can limit the number of liver biopsies to those whose clinical findings conflict with the biomarker results.

Family Perspectives on Communication With Healthcare Providers During End-of-Life Cancer Care

PURPOSE/OBJECTIVES

To assess healthcare provider communication about end-of-life (EOL) and hospice care with patients with terminal cancer and their families, from the perspective of the family members.

DESIGN

Exploratory, qualitative study using focus group discussion.

SETTING

University of Maryland Greenebaum Cancer Center.

SAMPLE

24 spouses and first-degree relatives of deceased patients with cancer who had been treated at the cancer center from 2000-2002.

METHODS

Family members participated in one of two focus group discussions and completed a short questionnaire regarding their sociodemographic characteristics and the type of EOL care their deceased relatives had received. Quantitative data were analyzed using descriptive statistics. Qualitative data were audiotaped and analyzed by comparing, contrasting, and summarizing content themes from the focus groups using NUD IST 5(N5) software.

MAIN RESEARCH VARIABLES

Family perceptions of communication with the healthcare team in EOL cancer care.

FINDINGS

Participants associated the information, content, style, language, and timing of communication about EOL and hospice care from healthcare professionals with patient age, attitudes, and compliance with medical decisions. Informed decisions about EOL care by patients and their family members, including the use of hospice services, appeared to be compromised by these types of communication biases.

CONCLUSIONS

Satisfaction with EOL care was associated with the perceived quality of communication among patients, family members, and the healthcare team.

IMPLICATIONS FOR NURSING

Study findings highlight the importance of training healthcare professionals in the content, timing, and potential biases associated with information delivery to facilitate informed decisions about EOL and hospice care to dying patients and their families.

Oral cancer exams among cigarette smokers in Maryland

BACKGROUND

Current and former smokers are at increased risk to develop oral cancer. This analysis was performed to determine whether current and former smokers are more likely to undergo an exam for oral cancer than non-smokers.

METHODS

The Maryland Cancer Survey performed in 2002 was a population-based random digit dial, statewide survey on cancer screening and risk behaviors, targeting adults aged 40 years and older. The dataset contains self-reported information on oral cancer examinations, current smoking status, and health care access information for 4840 Maryland residents.

RESULTS

2062 (42.6%) of Marylanders aged 40 years and older reported ever having had an oral cancer examination. Dentists and dental hygienists performed 90.9% of the exams. Current and former smokers were no more likely than those who have never smoked to have ever had the examination (adjusted OR = 1.02, 95% CI = 0.85-1.23 and OR = 1.09, 95% CI = 0.94-1.25, respectively). Other predictors associated with having an oral cancer exam included having more than a high school of education, being female, non-black, being in good to excellent health, and having a recent physical exam. Having visited the dentist in the last year had the highest odds of having ever had an oral cancer exam.

CONCLUSIONS

Current and former smokers are a high-risk group who need to be targeted for oral cancer exams by dental professionals and primary care physicians.

Nicotine dependance among adult male smokers in rural Egypt

Nicotine dependence is a significant public health problem. This study describes the nicotine dependence status among male adults in rural communities in Egypt. A survey was carried out in five rural villages in Egypt to study the smoking prevalence. A total of 938 current smokers were identified and their nicotine dependence status was studied. About 9% of all smokers in the studied villages were found to have heavy dependence to nicotine. Heavy dependence was associated with younger age of smoking initiation (p<0.05) and more smoking in the first hours of the day (p<0.001). Heavy dependent smokers are less likely to quit smoking (p<0.001), lack the confidence to quit by themselves (p<0.001) and less likely to have tried to quit earlier (p<0.001). Dependent smokers are more likely to smoke in the presence of their children (p<0.001). Reasons for smoking included the habit of smoking helping them to keep them going when tired, to make them alert and not knowing what to do with their hands without a cigarette. The main reasons they identified for restarting smoking after quitting were the signs of withdrawal namely headaches, irritability and difficulty in concentration. Nicotine dependence status and attributes were comparable to studies reported in other countries around the world. Enhanced behavioral and medical intervention strategies are needed to motivate helping both low and heavy nicotine dependent smokers to increase the number and effectiveness of quit attempts.

Water pipe (Sisha) smoking in cafes in Egypt

Shisha café patrons in Cairo, Egypt were interviewed to assess their knowledge, attitudes and practices regarding smoking and health. The median age of initiation of Shisha smoking is 20 years. Shisha smokers know about the hazards of smoking and believe that Shisha smoking is less dangerous than cigarette smoking. Over half the Shisha smokers have tried to quit in the past year. The younger adults who smoke Shisha also tend to smoke more often with friends, smoke cigarettes in addition to Shisha and prefer fruit flavored tobacco as compared to tobacco mixed with molasses favored by Shisha smokers who are older. Heavy Shisha smoking was not related to age.

Prevalence of smoking among rural secondary school students in Qualyobia governorate

A cross sectional study was carried out in two rural secondary schools in Qualyobia governorate in the academic year 2002-2003 in order to assess the students' knowledge, attitudes and practice toward smoking. An anonymous self-administered questionnaire was used. A total of 635 students, 416 males and 219 females were interviewed. The response rate was 100%. The prevalence of ever tried cigarette was 29% (40% among males and 7% among females) with a median age of initiation at 11 years of age. The prevalence of current cigarette smoking among all students was 7.7 (11.5% among males and 0% among females). Waterpipe (Shisha) smoking was reported by 19% (26% among males and 5% among females) with median age of initiation at 12 yearsof age. The risk of smoking is higher among sons of highly educated mothers (OR=3.7, 95% CI=1-12), Boy only school students have almost half the risk of smoking than mixed school male students (OR=0.4, 95% CI=0.2-0.8). On studying the effect of having a smoker family member or friends on students smoking, having a smoker friend increases the risk of male students three time (OR=3, 95%CI=2-5) while others smoking was not statistically significant. More than 90% of the students (both males and females) thought that active and passive smoking are harmful. More females than males thought smoking is addictive (89% of the females and 81% of the males) while more males than females agreed that smokers have more friends (34% of males, 26% of the females) and that smoking makes boys look handsome (8% of males, 3% of females).

Nasal hyperosmolar challenge with a dry powder of mannitol in patients with allergic rhinitis. Evidence for epithelial cell involvement

BACKGROUND

The responses to airway hyperosmolar challenges probably involve various inflammatory mediators. However, it is not fully understood which cell type/types are the source of these mediators. Potential cell types include mast cell, epithelial cell and the sensory c-fibre nerve cell.

OBJECTIVE

To clarify which cell types are involved with the mediator response to hyperosmolarity in the human airway.

METHODS

Ten healthy subjects, 11 patients with nonactive allergic rhinitis, and nine with active allergic rhinitis were challenged intranasally with mannitol powder, and with sham provocation, on separate days. Symptoms were assessed by visual analogue scales and nasal patency by measuring the nasal peak inspiratory flow (nPIF). Nasal lavage fluid levels of alpha(2)-macroglobulin (an index of plasma extravasation), substance P (an index of sensory nerve cell activation), tryptase (an index of mast cell activation) and 15-hydroxyeicosatetraenoic acid (15-HETE, an index of epithelial cell activation) were analysed.

RESULTS

Immediate, although transient burning was the most prominent symptom in all groups whereas only the patients with active rhinitis experienced a fall in nPIF. Mannitol significantly increased the nasal lavage fluid 15-HETE levels in the allergic patients (P < 0.01 vs the sham challenge), but not in the healthy subjects. The increase in 15-HETE correlated with nasal symptoms for itching (r(s) = 0.65, P = 0.019) and burning (r(s) = 0.72, P = 0.009). Detectable levels of tryptase was found only in five allergic subjects. Lavage levels of substance P and alpha(2)-macroglobulin did not not change.

CONCLUSION

Epithelial cell seems to be involved with the mediator response to airway hyperosmolar challenge. The roles of sensory c-fibre nerve cell and mast cell remained less clear.

Obstetric deaths in Menoufia Governorate, Egypt

A survey of all registered deaths which occurred during 1981-1983 in women of reproductive age was carried out in Menoufia Governorate, Egypt. Surviving family members were interviewed by trained social workers, and information was collected on symptoms of the disease that led to death. The completed questionnaires were reviewed by a panel of local physicians and a cause of death was assigned by the panel. Maternal mortality was a leading cause of death, second only to heart disease. There were 190 maternal deaths per 100,000 livebirths and 45 maternal deaths per 100,000 married women aged between 15 and 49 years. Most of the maternal deaths (63%) were due to direct obstetric causes of which haemorrhage was the main cause. Another 27% of the maternal deaths were due to indirect obstetric causes of which rheumatic heart disease was the main cause.

A comparison of two cause-of-death classification systems for deaths among women of reproductive age in Menoufia, Egypt

Mortality data ascertained from sources other than a death registration system can validate the accuracy of the system, but this information is rarely obtained. Data on 1979 deaths among reproductive age women were collected in the 1981-1983 Reproductive Age Mortality Survey (RAMOS) in the governorate of Menoufia, Egypt, and compared with data on these deaths as recorded by the Egyptian death registration system. Although the distribution of the causes of death were similar, there were substantial differences between classification systems for deaths due to particular causes. Over half of the deaths classified differently by the systems were those assigned to circulatory disease on the death certificate. In contrast, there was a high rate of agreement between systems in the classification of trauma deaths. About half (52.4%) of cancer deaths had the same site-specific cancer diagnosis assigned by RAMOS. The percentage of deaths assigned to maternal causes was three times higher in RAMOS (19.2%) than on death certificates (6.1%). Reported mortality rates for this often-preventable cause of death have been substantially underestimated in national death registration systems. Such underreporting masks the need for additional prenatal care and maternal health programmes.

Maternal mortality in Indonesia and Egypt

Twenty-three percent of deaths to women of reproductive age (15-49 years) in Bali, Indonesia and Menoufia, Egypt were due to maternal causes. Among the younger women, the percentage was even higher. In both areas complications of pregnancy and childbirth were a leading cause of death (the first cause in Bali, the second in Menoufia). In both sites, postpartum hemorrhage was the most common cause of maternal death. Relative to the United States, the number of maternal deaths per 100,000 live births was 20 times higher in Menoufia and 78 times higher in Bali. Families of women of reproductive age who died were interviewed about the conditions leading to death and other characteristics of the deceased. Completed histories were reviewed by a Medical Panel who were able to assign a cause of death in more than 90% of cases. Two-thirds of the maternal deaths occurred to women who were over 30 and/or who had 3 children--the usual targets of family planning programs. Other possible intervention strategies include antenatal outreach programs, training of traditional birth attendants, and better hospital management of obstetric emergencies.

The determinants of fertility in rural Egypt: a study of Menoufia and Beni-Suef governorates

High levels of fertility in rural areas of many developing societies are an issue of considerable concern to the scientific community and to those interested in public policy. This paper reports on the determinants of fertility in two rural areas in Egypt: Menoufia and Beni-Suef governorates. There are important differences in fertility between the two areas; the total fertility rate is 7·88 in Beni-Suef and 6·03 in Menoufia. These aggregate differences are the result of even larger differences between the two areas in the proximate determinants of fertility, particularly age at marriage, breast-feeding and contraceptive use. Much of the difference in breast-feeding behaviour can be explained by differences in the educational composition of the two populations; the level of female education in Menoufia is considerably higher than in Beni-Suef. However, differences in contraceptive use cannot be explained by differences in the socioeconomic composition of the two populations. The differences may be the result of greater institutional support for contraceptive use and lower fertility in Menoufia, where intensive family planning and maternal health programmes have been in operation for several years.

Accidental burn deaths to Egyptian women of reproductive age

Among women of reproductive age in Menoufia, Egypt, deaths from burns constitute a major public health problem. Burns account for 9 per cent of the deaths occurring to women aged 15-49, and were the third cause of death (after disease of the circulatory system and complications of pregnancy and childbirth). Nearly two-thirds of the burns were caused by kerosene cooking stoves. The data were obtained from a population-based survey of all deaths to women of reproductive age. There were 1691 deaths from all causes during the 3 years of the study, 152 of these were due to burns. Information on the cause of death was gathered from interviews with surviving family members; interviews were reviewed by physicians and a cause of death established. Although hospital-based studies provide valuable information for the management of burn injuries presenting for treatment, establishing rates of injury, comparing the incidence in one population group relative to another, or comparing the incidence of burns relative to other forms of injury requires a population-based study.

Reproductive mortality in two developing countries

Reproductive mortality includes mortality attributable to pregnancy, termination of pregnancy, childbirth and its sequelae, and contraception. Reproductive mortality has been estimated for the United Kingdom, the United States, and for states of the US. However, it has not previously been measured for developing countries, where maternal mortality often remains distressingly high. This paper reports on data from one governorate of Egypt, where reproductive mortality was 46 per 100,000 married women ages 15-49 (2.2 per cent of this was attributable to contraception), and one province of Indonesia, where reproductive mortality was 70 per 100,000 (of which 1.4 per cent was due to contraception). In both locations, complications of pregnancy and childbirth were a leading cause of death in the age group studied (the first cause in Indonesia, second in Egypt). Contraceptive prevalence was 24 per cent of married women ages 15-49 in Egypt and 48 per cent of this age group in Indonesia.

How the number of living sons influences contraceptive use in Menoufia Governorate, Egypt

Couples in rural areas of many Arab societies, including Egypt, have consistently reported strong preferences for having sons. However, these reported preferences are not always reflected in reproductive behavior. In 38 rural villages in Menoufia Governorate in Egypt, women's responses to a community-based contraceptive distribution program were examined, taking into consideration both the number of living children and the number of living sons each women reported having. Controlling for number of living children, women with more sons were more likely to be using contraception before the distribution program began. Among women not using contraception before the program, those with more sons were more likely to initiate contraceptive use and were more likely to continue use for a nine-month period following the distribution. These findings imply that in addition to obstacles related to contraceptive availability, there are several cultural, social, and economic factors that influence fertility behavior and exert considerable pressure on married couples to have large families, including several sons. Unless the pressure exerted by these factors is changed or reduced, the impact of family planning programs is likely to reach a plateau at a relatively low prevalence level.

Household distribution of contraceptives in rural Egypt

Oral contraceptives were offered to all married, fecund women 15-44 years of age living in 38 Egyptian villages with a population of 200,000. Before the household distribution, contraceptive prevalence was 19.1 percent. Nine months after the distribution, the contraceptive prevalence increased to 27.7 percent, a relative increase of 45 percent. Based on this study, a modified delivery system is currently being tested on a governoratewide basis. The modified system will include a wider range of fertility regulation methods and will also have health and community development components.