Attitudes of Colorado health professionals toward breast and cervical cancer screening in Hispanic women.

BACKGROUND: A variety of economic, cultural, and communication barriers appear to be involved in breast and cervical cancer screening among Hispanic women. These barriers include culture-based embarrassment both for mammography and for Pap smears and fear and hopelessness concerning a diagnosis of cancer. Cost and access barriers are shared by low-income women from various ethnic and racial groups, as is a purported lack of physician referral. Hispanic women may have the latter problem enhanced by a language barrier between physicians and patients when the physicians do not speak or understand Spanish. PURPOSE: The goal of this project, conducted by the Cancer Education Division of the University of Colorado Cancer Center, has been to determine the attitudes and practices among health care providers in areas of Colorado with relatively large Hispanic populations (concerning screening mammography, clinical breast examination, breast self-examination, and Pap testing) and to design interventions to address any deficiencies or problems recognized. These studies were coordinated with telephone surveys and focus groups involving Hispanic women, directed by E. Flores in the Department of Sociology of the University of Colorado at Boulder and by C. Chrvala at the Colorado Department of Health. METHODS: Data were collected from 520 primary care physicians, nurses, and allied health personnel in 11 Colorado counties through focus groups and mailed questionnaires. Responses were analyzed by considering a variety of demographic characteristics of the respondents and by stratifying the associated practices by percent of Hispanic patients. RESULTS: The physicians involved in the focus groups and responding to the questionnaires, as well as their associated nurses and other health care personnel, are generally familiar with the breast and cervical cancer-screening guidelines as developed and disseminated by several organizations, including the National Cancer Institute and the American Cancer Society. Major barriers to screening Hispanic women, as perceived by these health care providers, appear to be cost; lack of transportation, child care, and release from work; fear of diagnosis of cancer; patients considering the test unnecessary; discomfort; and embarrassment. The prompt use of colposcopy to evaluate patients whose Pap smears indicated dysplasia appeared less than optimal, especially among internists. CONCLUSIONS: Familiarity with guidelines for breast and cervical cancer screening is widespread among Colorado physicians and associated health care personnel, including those with high percentages of Hispanic patients in their practices. Increased continuing education efforts may be indicated concerning the application of colposcopy to the evaluation of women with abnormal Pap smears and concerning the application of computer technology to cancer-screening reminder systems. IMPLICATIONS: Educational approaches to primary care professionals may improve the effectiveness of breast and cervical cancer screening, although a variety of other approaches will also be necessary to decrease barriers to screening of Hispanic women.

Lymphocyte subclasses and immunoglobulins in adults receiving radiation treatment in infancy for thymic enlargement.

One-hundred and fifty-three subjects who were irradiated in infancy for an alleged enlarged thymus and 51 controls were studied to quantify the phenotypically different subpopulations of peripheral blood lymphocytes and immunoglobulins. These subjects were selected from a larger cohort which has been followed prospectively since the early 1950s. Previous studies of this cohort have shown a radiation dose-related increased risk of thyroid carcinomas and adenomas in the irradiated group as well as a recent excess of various extrathyroid neoplasms. In this substudy, no significant differences in lymphocyte subpopulations or immunoglobulin levels were observed between the irradiated and control groups. These findings support a hypothesis that the radiation-related excess of neoplasms in this cohort may have resulted from direct cellular damage with subsequent mutations rather than impaired immune function.

Leukemia in radiation-treated patients: cytogenetic studies in eight cases.

Abnormal chromosomes have been found in various clinical settings and in cancer patients. Eight patients developed leukemia several years after the diagnosis and treatment of a primary malignant disease. All the patients were being treated with irradiation, and five of them also received chemotherapy, notably, alkylating agents. The type of leukemias and the interval between irradiation and leukemia parallel very well with those reported from the atomic bomb casualties. Chromosomal abnormalities were seen in all the patients. These abnormalities have been reported in irradiated normal persons without developed leukemias. These findings suggest that the development of clinical cancer or leukemia may depend, not only on the presence of abnormal cells, but also on other factors. Perhaps the environment that allowed the original cancer to develop in our patients is capable of allowing the radiation-induced abnormal cells to be expressed as clinical leukemia.

Nutrition and cancer education at the University of Colorado Health Sciences Center.

BACKGROUND: The status of nutrition education at the University of Colorado Health Sciences Center since the 1980s is discussed. METHODS: A needs assessment with emphasis on nutrition education activities in the medical school curriculum led to the successful application for a NCI R25 Cancer Education Grant in 1988. RESULTS: A nutrition elective, Nutrition and Cancer, for health professions students and a section of the Biochemistry course, Principles of Nutrition, were generated. These have persisted to the present despite the scheduled expiration of the R25 grant. CONCLUSION: Topic-directed NCI Cancer Education Grants can stimulate and facilitate successful approaches to defined cancer education needs. The resulting activities can, and should, persist after the expiration of such grants.

The teaching of cancer medicine by educational objectives.

In this paper, the authors review the findings of a survey of cancer education activities in 110 U.S. medical schools conducted by the American Association for Cancer Education. Problems documented through this survey include the need for more coordination of multidisciplinary teaching; more exposure of students to patients with common malignancies, especially in an outpatient setting; and more uniform instruction in fundamental diagnostic procedures, such as proctosigmoidoscopy, bone marrow aspiration/biopsy, and indirect laryngoscopy. The present authors review these problems, particularly as they relate to educational functions of departments of medicine, and discuss an approach to the teaching of cancer medicine that employs the definition of educational objectives and relates these objectives to departmental teaching responsibilities. The authors suggest that the departments of medicine are in a unique position to stimulate and coordinate clinical cancer education by this approach.

Educational and consultative functions, topics, and methods of hospital general tumor conferences.

The educational and consultative functions, topics, and methods of 20 hospital general tumor conferences in Colorado were studied over a three-year period. Methods used included questionnaires completed by hospital admitting staff members, by tumor conference directors, and by conference attendees. Workshops were held in which a multidisciplinary panel of physicians, nurses, and cancer registrars discussed the educational and patient-management aspects of tumor conferences with tumor conference directors. The study design included evaluation of the effects of providing certain teaching aids, including newsletters, Physician Data Query printouts, and tumor registry data on the functions, topics, and methods of the conferences. Although certain temporal trends were suggested, the handouts as employed added little of perceived effectiveness for the busy clinicians attending. The characteristics of the tumor conferences were analyzed according to hospital size, presence of one or more residency programs, and location (metropolitan or otherwise). One observation was that relatively few primary care physicians attended these tumor conferences, especially those in large hospitals, and approaches to meeting the needs of that group are discussed. The importance of the interpersonal skills of the tumor conference director in the effectiveness of the conference was very evident.

Effects of warfarin administration on the immune response of mice.

Administration of warfarin to mice is shown to have little effect on the humoral immune response of these animals to sheep red blood cells (a thymus dependent antigen) or the trinitrophenyl hapten coupled to E. coli lipopolysaccharide (a thymus independent antigen). The ability of low doses of sheep red blood cells to prime T-cells in vivo for helper activity in the in vitro antibody-forming response to trinitrophenyl coupled to sheep red blood cells is also apparently unaffected. By contrast, delayed hypersensitivity responses, measured by foot pad swelling, are significantly stimulated by administration of the drug.

Evaluating the cancer education program: examining a range of approaches.

The objectives of this article are to provide people who are responsible for cancer education programs with a broadened perspective of the rich array of evaluation strategies available and responsive to the evaluation needs of cancer education programs, and to summarize selected literature resources useful for the development of an evaluation plan. This article reviews limitations found in previous evaluations of medical education programs and provides a descriptive survey of diverse strategies for the evaluation of cancer education programs. The characteristics, requirements, utility, audience, constraints, and resources are presented. Two cancer related case studies are discussed in detail as illustrations of the diversity of strategies available to evaluate cancer education programs.

A cancer education study in The Netherlands based on the AACE/NCI Cancer Education Survey.

A Dutch Cancer Education Study demonstrated that the data collection instruments developed for the U.S. AACE/NCI Cancer Education Survey could also be used for the same kind of studies in foreign countries. Where needed, the data collection instruments were modified to the Dutch national situation. In this way, an impression was obtained on several aspects concerning undergraduate cancer education in the Dutch medical schools. Based on the combined findings of the U.S. Cancer Education Survey and the Dutch Cancer Education Study, a number of recommendations can be made for application to student cancer education in The Netherlands.

Sequential and combination chemotherapy of advanced gastric cancer.

One hundred and forty-six previously untreated patients with advanced gastric cancer were assigned at random to therapy with the following regimens: 1) Methyl CCNU alone; 2) Methyl CCNU with cyclophosphamide induction; 3) 5-fluorouracil (5-FU) + methyl CCNU; and 4) 5-FU + methyl CCNU with cyclophosphamide induction. Cyclophosphamide induction produced an objective response rate of only 8%. In addition, it added to hematologic toxicity and detracted from the therapeutic activity of subsequent treatment. Methyl CCNU was relatively ineffective therapy with an overall objective response rate of 8%. The response rate to 5-FU + methyl CCNU without cyclophosphamide induction was 40% and this was significantly superior to all other regimens. The survival time of all patients treated with 5-FU + methyl CCNU was significantly superior to that of all patients treated with methyl CCNU alone.

Treatment of metastatic breast cancer with aminoglutethimide.

Seventy-three women with metastatic breast cancer were treated with aminoglutethimide and dexamethasone. No complete responses occurred. Ten patients (16%) achieved partial responses (mean duration, 12 months). The proportions of patients responding by disease site were breast (50%), nodes (33%), skin (23%), bone (16%), lung (11%), and liver (7%). Response did not correlate with age, menopausal status, performance status, or cortisol suppression. Ninety percent of responders had had previous responses to hormonal manipulations. No responses occurred in estrogen receptor negative patients. An additional 20% of patients had disease stabilization of eight or more months (mean, 17 months). Severe bone pain was present in 47 patients and was relieved in 19. Side effects occurred in 75% but caused discontinuation of therapy in only four patients. Somnolence, nausea, rash, Cushings syndrome, and leukopenia were the most frequent side effects. Aminoglutethimide with dexamethasone is an effective hormonal treatment for metastatic breast cancer.

Changing the cancer curriculum: a curriculum committee's response to the results of the AACE Cancer Education Survey II. Cancer Education Survey II: cancer education in United States medical schools.

The AACE Cancer Education Survey-II offers an unusual opportunity based on data from 125 medical schools and 1,035 experienced cancer educators to effect constructive change with regard to cancer education. The changes suggested include more coordination; integration; and a shift of emphasis to include more on topics of prevention, early diagnosis, tumor biology, rehabilitation, palliative care, and psychosocial issues. Ample opportunities, especially in the ambulatory care arena, exist at most medical schools, and there is a great deal of interest in improving the situation. This article reviews the factors contributing to resistance to change, the data on adult learning, and the major movements and dilemmas facing medical education today. It also discusses some of the external forces like the Liaison Committee on Medical Education (LCME) and foundation support, which are being harnessed to effect change. Given these barriers, forces, and opportunities, the article ends with a possible action plan for an individual, an institution, and national bodies interested in cancer education. The knowledge, skills, values, and attitudes must be defined, taught effectively, and evaluated. It is an opportune time, armed with this useful data, to bring about change in how cancer subjects are taught. The ultimate goal is more knowledgeable and effective practitioners and scientists who can decrease the morbidity and mortality from cancer.

Cancer prevention education in United States medical schools. Cancer Education Survey II: cancer education in United States medical schools.

The Cancer Education Survey collected data from 126 of 128 US Medical Schools on the current status of cancer-related educational activities for undergraduate medical students. The study was conducted by a Supervisory Committee of the American Association for Cancer Education, with funding from the American Cancer Society. The survey obtained data concerning institutional characteristics in support of undergraduate medical student cancer education, ie, administrative structures, current cancer-related curricula, sources of financial support, and anticipated changes in these characteristics. Institutions were also queried on specific topics of cancer prevention, detection, and diagnosis that might be taught as identifiable areas of instruction for medical students. Three-fourths of the institutions had a lecture on the principles of cancer screening, and, among those, nearly three-fourths classified it as a part of a required course or rotation. Detection of common cancers is taught in virtually all institutions. The least likely cancer prevention lecture topics are related to prevention and cessation of smoking, a well-verified cancer risk. Also, no consistent pattern emerges that might indicate that association with a cancer center imparts to a medical school a greater emphasis on delivery of cancer prevention topics.

Survey design and observations relating to cancer education funding. Cancer Education Survey II: cancer education in United States medical schools (conducted by The American Association for Cancer Education with the support of the American Cancer Society).

A survey has been conducted of cancer education programs for medical students in United States medical schools by the American Association for Cancer Education with grant support from the Department of Detection and Treatment of the American Cancer Society (formerly the Professional Education Department). Two questionnaires were used, an Educational Resources Questionnaire (ERQ), which 126 of the 128 medical schools completed and returned, and a Faculty and Curriculum Questionnaire (FCQ), which was completed and returned by 1,035 faculty members who had been named as active in undergraduate medical student cancer education by respondents in each school who had been designated by the Dean's Office to complete the ERQ. Overall conclusions included: (1) increased coordination of cancer education activities is a major need in many schools; (2) there is widespread interest in the further development of cancer education objectives; (3) development of a national cancer education curriculum is needed; (4) there is interest in the development of improved instructional materials and methods; (5) development of evaluation methods is needed for cancer education programs; and (6) an ongoing funding process is needed to provide support for interdepartmental coordination of cancer education activities. Cancer prevention and detection topics were ranked above cancer treatment in plans for future curriculum emphasis. More detailed conclusions and recommendations are provided in this publication and three subsequent articles in this issue of the Journal of Cancer Education.

Instructional methods and the use of teaching resources in cancer education curricula. Cancer Education Survey II: cancer education in United States medical schools.

The findings on cancer teaching methodology presented in this abstract come from an American Association for Cancer Education (AACE)/American Cancer Society-sponsored survey of American allopathic medical schools in 1989 and 1990 to determine how and how well cancer is presented in the medical school curriculum. Responses were received from 126 institutional and approximately 1,000 faculty respondents. Approximately one-third (368) of faculty respondents indicated the use of specific learning objectives; utilization does vary across disciplines. The lecture remains the dominant form of instructional method. Computers were reported as an instructional modality by only 16% of the faculty respondents. Prepared audiovisual instructional materials appeared to be widely utilized. Use varied from 86% for 35mm slides to 11% for video discs. Faculty favored the development of new teaching materials for ten topic areas ranging from approximately 40% for early detection and prevention to a low of approximately 25% for rehabilitation and continuing care. The survey identified an underutilization of existing outpatient facilities and tumor registries for cancer teaching purposes. The findings give rise to questions concerning the appropriateness of the match between specific instructional goals and the teaching methods employed. Eight recommendations designed to strengthen cancer training are made.

Phase II study of adriamycin and bleomycin in patients with multiple myeloma.

Twenty-seven patients with far-advanced multiple myeloma, resistant to standard agents, were treated with either adriamycin (eight patients) or bleomycin (19 patients). Adriamycin was given iv at a dose of 60 mg/m2 every 3 weeks and bleomycin was administered im at a dose of 15 mg/m2 weekly. Drug toxicity was modest. One partial response was seen with each agent, both occurring in "good-risk" patients.

Survival of nodular versus diffuse pattern lymphocytic poorly differentiated lymphoma.

Response and survival were analyzed in 97 patients with NLPD (Nodular Lymphocytic Poorly Differentiated Lymphoma) and 77 with DLPD (Diffuse Lymphocytic Poorly Differentiated) treated by intensive versus moderate chemotherapy regimens. The complete and overall response rate in NLPD of 47% and 81% was significantly superior to 25% and 59% obtained in DLPD. The estimated two year survival of 83% in NLPD was also significantly superior to 47% two year survivorship of DLPD (p less than .001). The chemotherapy responsiveness had a significantly favorable effect on DLPD survivorship with two year survivals of 84% for CR, 58% for PR and 17% for PD. In NLPD the effect of chemotherapy responsiveness on survival was less striking (CR 91%, PR 85%, and PD 72% surviving two years). The data, in our opinion, confirm the rationale for the use of aggressive multiple agent chemotherapy regimens in DLPD where achievement of compelte response appears to be the single most important factor in improving survivorship. On the other hand NLPD, with excellent survival rates which appear to be only partially dependent on chemotherapy responsiveness might serve as an ideal model for moderate intensity or single agent chemotherapy trials.

BCVPP chemotherapy for advanced Hodgkin's disease: evidence for greater duration of complete remission, greater survival, and less toxicity than with a MOPP regimen. Results of the Eastern Cooperative Oncology Group study.

Two chemotherapy regimens for treatment of patients with advanced Hodgkin's disease, BCVPP (carmustine, cyclophosphamide, vinblastine, procarbazine, and prednisone) and MOPP (mechlorethamine hydrochloride, vincristine, procarbazine, and prednisone), were compared in a randomized prospective study. Two hundred ninety-three patients were evaluable in the induction phase of this study. The complete remission rate with BCVPP was 76% (112/147) and with MOPP, 73% (106/146) (p = 0.51). The duration of complete remissions for previously untreated patients given BCVPP was significantly longer than that for previously untreated patients given MOPP (p = 0.02). Although hematologic toxicities were similar, BCVPP caused less gastrointestinal (p = 0.0001) and neurologic toxicity (p = 0.01) than MOPP. Previously untreated patients achieving complete remission with BCVPP survived significantly longer than those receiving MOPP (p = 0.03). As primary induction chemotherapy for advanced Hodgkin's disease, BCVPP is an effective alternative to MOPP, having equal or greater therapeutic benefit with less toxicity.

Pediatric oncologists' assessment of oncology education in U.S. medical schools: Cancer Education Survey II.

The status of cancer education in U.S. medical schools was reassessed in the Cancer Education Survey II, which was initiated in 1989. One thousand and thirty-five cancer educators from 126 of the country's 128 medical schools participated, including 65 pediatric oncologists and 36 family physicians. All agreed that the most important aspects of cancer to teach medical students are early detection and cancer prevention; they considered less important electives in basic science, radiation therapy, and surgical oncology. The 101 pediatric oncologists and family physicians believed that more curriculum time should be devoted to cancer epidemiology, psychosocial aspects, and palliative care. Approximately one third of these 101 physicians also expressed the desire to have more teaching materials available in five general areas: patient education about pediatric cancer, nutrition, epidemiology, palliative care, and continuing care. Lay-language information about pediatric cancer, participation in clinical trials, and current cancer research is still needed.

Treatment of advanced Hodgkin's disease: 10-year experience in the Eastern Cooperative Oncology group.

Between 1972 and 1981, the Eastern Cooperative Oncology Group completed two major studies of advanced Hodgkin's disease. The first trial EST 2472, demonstrated that the five-drug combination of carmustine (BCNU), cyclophosphamide, vinblastine, procarbazine, and prednisone (BCVPP) is an effective alternative to mechlorethamine, vincristine, prednisone, and procarbazine (MOPP) chemotherapy. Although the complete remission (CR) rate for BCVPP (77%) was similar to that for MOPP (73%) in this randomized trial, the choice of induction chemotherapy significantly influenced CR duration. Patients achieving CR with BCVPP had a significantly greater disease-free survival than those who achieved CR with MOPP (65% vs 50%, respectively, at 5 years, P = 0.02). Overall survival is not different at this time between patients who received BCVPP and those who received MOPP. BCVPP produced significantly less gastrointestinal toxicity and neurotoxicity than MOPP. There was no influence on CR duration or survival with maintenance chemotherapy or BCG immunotherapy when compared to no further treatment. In the second trial, EST 1476, there was only a 58% CR rate with six cycles of low-dose bleomycin-MOPP induction chemotherapy. Complete responders and continuing partial responders were then randomized to receive either non-cross-resistant chemotherapy with doxorubicin, bleomycin, vinblastine, and DTIC (dacarbazine) (ABVD) or low-dose radiotherapy to all sites of pretreatment involvement except bone marrow. Fifty percent of the partial responses were converted to CR with either ABVD or radiotherapy consolidation. The overall CR rate at the end of consolidation was 68%. At the present time, there is no significant difference in disease-free or overall survival between ABVD and radiotherapy.