A culturally specific dietary plan to manage weight gain among African American breast cancer survivors: a feasibility study.

Breast cancer survival rates are lower in African Americans (AAs) than in Caucasians, owing in part to a higher prevalence of obesity in the former, which increases the risk of recurrence and mortality. The Women's Intervention Nutrition Study (WINS) found that Caucasian women who followed a low-fat eating plan experienced a lower rate of cancer recurrence than women who maintained their usual diets. The purpose of this study was to test the feasibility of a WINS plan tailored to the cultural needs of AA breast cancer survivors. This feasibility pilot study was conducted at a university National Cancer Institute-designated comprehensive cancer center outpatient clinic with AA breast cancer survivors. The culturally specific WINS (WINS-c) plan included eight individual counseling sessions, five educational group meetings, and follow-up telephone calls over a 1-year period. Outcome measures included dietary fat, triglyceride, insulin and glucose levels, and fruit and vegetable intake. Participants (n = 8) had a mean age of 61.1 years (standard error of the mean (SEM) 3.1 years) and a mean BMI of 32 kg/m(2) (SEM 4.25 kg/m)(2). Baseline daily fat consumption decreased from 64.6 g (range 36.8-119.6g) to 44.0 g (21.6-73.4g) at 52 weeks (p = 0.07). Mean daily consumption of fruits and vegetables increased by 36% and 15%, respectively. Mean triglyceride levels decreased at 12 months (p < 0.05). Sustained hyperinsulinemia was noted in most participants, including those without diabetes. Mean calcium and vitamin D consumption decreased over the 1-year study period. In AA breast cancer survivors, the WINS-c program resulted in a trend toward reduced fat consumption and may represent a sustainable approach in this population for improvement of diet quality after breast cancer.

Community-based strategies for recruiting older, African Americans into a behavioral intervention study.

PURPOSE: To describe community-based strategies that were effective in recruiting older African Americans into a behavioral intervention study designed to increase eye examination behavior. METHODS: Sites were identified that targeted older African-Americans, including senior centers, senior housing, and church groups. We conducted presentations at these sites, networked with community organizations, placed ads on the radio and in newspapers, and attended health fairs. Potential participants also called us in response to flyers and through word of mouth. RESULTS: We conducted 147 activities at 118 sites. A total of 688 potential participants were screened, with 330 (48%) enrolling, 33% ineligible, and 19% not interested. Highest enrollment rates were for word of mouth (69%), flyers (67%), and senior centers (66%). Barriers to participation included hesitancy of seniors to leave their apartments to attend presentations and competing health issues taking precedence over eye concerns. CONCLUSIONS: A multifaceted recruitment approach incorporating both direct and indirect activities at a variety of sites should be used to recruit older African Americans into a behavioral intervention study. Establishing relationships in the community, both prior to initiating recruitment activities and as an ongoing process, was important to the study's success.

Knowledge, attitudes, and beliefs about dilated eye examinations among African-Americans.

PURPOSE: To understand factors that influence African-Americans' attitude toward eye examinations. METHODS: Ten focus groups were conducted with 86 African-Americans. Four focus groups were conducted with people 65 years of age and older who had not received a dilated fundus examination (DFE) in the past 2 years, two groups were held with people 65 years of age and older who had had a recent DFE, and two groups each were held with people 40 to 64 years of age, with and without recent DFEs. Focus group interviews were conducted by using a moderator guide to address perceived benefits of and barriers to getting an eye examination; motivators for getting DFEs; and knowledge of eye examinations, glaucoma, and diabetic retinopathy. Participants also completed a questionnaire that provided demographic information. Quantitative and qualitative analyses were conducted. RESULTS: Cost or lack of sufficient insurance was identified as the most important barrier to getting a DFE. Also frequently mentioned was not having any symptoms and being too busy. The most frequently cited benefit of getting a DFE was to help prevent eye disease, whereas the most frequently reported motivating factor was experiencing a vision problem. Regarding knowledge, many people did not know the risk factors for glaucoma, but seemed to have a better understanding of how to reduce the effects of diabetes on their eyes. CONCLUSIONS: Study findings identified important links between financial resources and experiencing a vision problem and the adoption of preventive eye care in an urban African-American population.

Breast and colorectal cancer risk communication approaches with low-income African-American and Hispanic women: implications for healthcare providers.

BACKGROUND: Information on breast and colorectal cancer risk factors is widely available to women and the physicians who provide their healthcare; however, many women are unable to identify the major risk factors, continue to misperceive their personal risk of developing these cancers, and do not engage in routine early detection. METHODS: Qualitative methods were used to investigate breast and colorectal cancer risk knowledge, perceptions, behaviors, and risk communication formats with low-income African-American and Hispanic study participants in Harlem, NY, aged 40-60 years. RESULTS: Focus group results indicated strong participant interest in strategies necessary to understand and reduce the risk of developing breast and colorectal cancers. Preferred risk communication tools presented information about family history and personal risk in graphic and quantitative formats. CONCLUSIONS: Healthcare professionals who serve low-income African-American and Hispanic female populations should deliver information to them about the personal risk of developing targeted cancers and ways to reduce this risk in formats that are meaningful and effectively address the special needs of these populations.

Characteristics associated with the initiation of radiation therapy after breast-conserving surgery among African American and white women diagnosed with early-stage breast cancer in Maryland, 2000-2006.

PURPOSE: Socioeconomic status appears to be an important independent barrier to breast cancer care, irrespective of insurance inequalities. Receiving radiation therapy (RT) reduces local recurrence and mortality in patients receiving breast-conserving surgery (BCS). We investigated racial and socioeconomic determinants of RT initiation after BCS in Maryland. METHODS: Maryland Cancer Registry breast cancer data for the diagnosis years 2000 through 2006 were analyzed for characteristics associated with receipt of RT after BCS. We used generalized regression models to estimate RT initiation among low-income patients, adjusting for racial, demographic, and clinical covariates. RESULTS: Low-income women were more likely to be African American; older; uninsured or to use Medicare, Medicaid, or Maryland breast cancer insurance; and have tumors that were estrogen receptor and progesterone-receptor negative. Among low-income women, those at risk of not initiating RT after BCS were more likely to be African American, be older than 80 years of age, and have tumors >2 cm. CONCLUSIONS: Socioeconomic disparities were identified in the initiation of RT after BCS in Maryland from 2000 to 2006. In addition, racial disparities in RT after BCS were apparent for women diagnosed from 2000 to 2003. Additional research is needed to investigate uptake of prescribed treatments after BCS and develop strategies for reducing barriers to obtaining treatments among patients at risk for incomplete cancer care.

Tailored and targeted interventions to encourage dilated fundus examinations in older African Americans.

OBJECTIVES: To compare the effects of a tailored (individualized) and targeted (designed for a subgroup) print intervention in promoting dilated fundus examinations (DFEs) in older African Americans and to determine whether other factors (eg, demographics, preventive health practices, health literacy score, behavioral intentions, and DFE rates) are associated with getting a DFE. METHODS: African Americans aged 65 years or older who had not had a DFE in at least 2 years were recruited from community settings. Participants were randomized to receive either a tailored or targeted newsletter. Telephone follow-up was conducted at 1, 3, and 6 months to ascertain eye examination status. All participant-reported DFEs were confirmed by contacting their eye doctor (optometrist or ophthalmologist) by telephone. Main Outcome Measure  Eye doctor-confirmed DFE at 6 months. RESULTS: Of the 329 participants enrolled, 128 (38.9%) had an eye doctor-confirmed DFE. No significant difference was noted in this measure by intervention group (relative risk, 1.07; 95% confidence interval, 0.82-1.40), with 66 participants in the tailored group (40.2%) and 62 participants in the targeted group (37.6%) having an eye doctor-confirmed DFE. Based on logistic regression analysis, reading the newsletter (odds ratio, 1.76; 95% confidence interval, 1.08-2.87) and planning to make an appointment for a DFE (odds ratio, 2.46; 95% confidence interval, 1.42-4.26) were significant predictors for DFE. CONCLUSIONS: The tailored and targeted interventions were equally effective in promoting eye doctor-confirmed DFEs at 6 months. Given the increased cost and effort associated with tailoring, our results suggest that well-designed targeted print messages can motivate older African Americans to get DFEs. Trial Registration  clinicaltrials.gov Identifier: NCT00649766.

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.

Evidence-based care for breast cancer survivors: communicating the Institute of Medicine Guidelines in medical practice.

OBJECTIVE: To investigate patient reports of physician communication about the 2006 Institute of Medicine (IOM) Guidelines for Survivorship Care, and patient follow-up care behaviors in a sample of African American and Caucasian breast cancer survivors. METHODS: Fifteen-minute telephone interviews were conducted in a cross-sectional study with a sample of African American (n=30) and Caucasian (n=69) breast cancer patients, who were within 5 years of their diagnosis and primary treatment for breast cancer at two Baltimore, Maryland medical centers, during the summer of 2006. Multiple items assessed patient reports of physician discussions about IOM Guidelines, their recurrence concerns, and their follow-up treatment, screening, diet and exercise practices. RESULTS: Patients with higher incomes, more education, female physicians, and of younger ages reported more complete physician discussions of the IOM Guidelines. No significant differences were noted between African American and Caucasian patients. CONCLUSION: Patients at greatest risk for breast cancer recurrence - those with less education, income, and resources - report limited guidance from their physicians about evidence-based, follow-up care guidelines, designed to minimize their risk. PRACTICE IMPLICATIONS: Physicians need strategies for effectively delivering the IOM Guidelines for Survivorship Care to disadvantaged breast cancer patients, to promote enhanced quality of life and reduced risk of recurrence.

Influence of family history and preventive health behaviors on colorectal cancer screening in African Americans.

BACKGROUND: African Americans (AAs) have low rates of colorectal cancer (CRC) screening. To the authors' knowledge, factors that influence their participation, especially individuals with a family history of CRC ("family history"), are not well understood. METHODS: A secondary analysis of the 2002 Maryland Cancer Survey data examined predictors of risk-appropriate, timely CRC screening ("screening") in AAs with a family history and in individuals without a family history. Predictors that were evaluated included age, sex, family history, mammogram or prostate-specific antigen (PSA) screening, body mass index, activity, fruit/vegetable consumption, alcohol, smoking, perceived risk of cancer, education, employment, insurance, access to a healthcare provider, and healthcare provider recommendation of fecal occult blood test (FOBT) and/or sigmoidoscopy/colonoscopy. RESULTS: In individuals without a family history of CRC (N = 492), recommendation for FOBT (odds ratio [OR] of 11.90; 95% confidence interval [95% CI], 6.84-20.71) and sigmoidoscopy/colonscopy (OR of 7.06; 95% CI, 4.11-12.14), moderate/vigorous activity (OR of 1.74; 95% CI, 1.06-2.28), and PSA screening history (OR of 2.68; 95% CI, 1.01-7.81) were found to be predictive of screening. In individuals with a family history (N = 88), recommendation for sigmoidoscopy/colonscopy (OR of 24.3; 95%, CI 5.30-111.34) and vigorous activity (OR of 5.21; 95% CI, 1.09-24.88) were found to be predictive of screening. However, family history did not predict screening when the analysis was controlled for age, education, and insurance. AAs who had a family history were less likely to screen compared with their white counterparts (N = 293) and compared with AAs who were at average risk for CRC (P < .05). CONCLUSIONS: Regardless of family history, healthcare provider recommendation and activity level were important predictors of screening. Lower screening rates were observed in AAs who had a family history compared with individuals who did not. The authors believe that, for AAs who have a family history, further examination of barriers and facilitators to CRC screening within the cultural context is warranted.

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.

Profiles of tamoxifen-related side effects by race and smoking status in women with breast cancer.

BACKGROUND: Tamoxifen (TAM) is a selective estrogen receptor modulator (SERM) that is widely used as adjuvant therapy in breast cancer patients; however, it is also associated with undesirable side effects. The goal of this study was to investigate TAM-related side effects, and determine profiles of side effects by race and by smoking status. METHODS: A secondary data analysis was conducted using cross-sectional study data from 138 African American and Caucasian women with breast cancer taking TAM 20mg daily for at least 30 days prior to enrollment. Participants completed questionnaires that obtained information about demographic characteristics, reproductive history, health and lifestyle characteristics, TAM use and its related side effects. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals. RESULTS: Compared to never smokers, a significantly greater percentage of current smokers reported ever experiencing TAM-related nausea (28.0% versus 5.0%, P=0.007), depression (40.0% versus 7.1%, P=0.001) and migraines (19.2% versus 1.7%, P=0.02). These differences remained statistically significant after controlling for race, age, obesity, tumor stage, and duration of TAM treatment. No significant differences by race were noted in women reporting TAM side effects. CONCLUSION: The findings from this study suggest that current smokers with breast cancer should be informed of the increased probability of reporting TAM-related side effects such as nausea, depression and migraines, and counseled about smoking cessation which may reduce the incidence of these side effects.

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.

Mammography screening and breast cancer biology in African American women--a review.

This review examines some of the key issues in early detection and breast cancer biology for African American (AA) women which contribute to their diagnoses at more advanced stages than white women, and poorer long-term prognoses. While screening mammography is considered an essential factor in eliminating these disparities, its optimal application for AAs is not fully understood. There is a paucity of information on the success with which mammography screening programs are maintained over time in the AA population, and on screening guidelines with regard to age of initiation and frequency. No randomized clinical trials targeting AA women have been reported. This type of information is critical since breast cancer in AA women occurs at younger ages, and frequently demonstrates aggressive tumor biology at diagnosis. Studies are required to determine the incidence of interval cancers in current screening programs, and the influence of the biological characteristics which are known to differ in the breast tumors of AA and white women. Recognition of molecular and cellular characteristics which identify the potential invasiveness of ductal carcinomas in situ is also required. These studies would assist in establishing the criteria for identifying the subpopulation of younger pre-menopausal AA women who would benefit from early initiation of screening. Finally, the epidemiology and biology of mammographic densities, a risk factor for breast cancer and, perhaps, markers of aggressive disease require further study in both AA and white women.

Discussing breast cancer risk in primary care.

Options for managing breast cancer risk now include screening, genetic testing, lifestyle modification, medication, and surgery. A woman's knowledge of her risk factors for breast cancer, her perceptions of that risk, and her concerns about cancer all shape her decisions about cancer screening and prevention. Physicians should involve women patients in making informed screening decisions, while reviewing their health risks and the benefits and risks associated with different courses of action. All women should be involved in this process, with special attention to older socioeconomically disadvantaged women, who are frequently left out of such discussions. Physicians can play a major role in reducing cancer disparities and the corresponding rates of breast cancer morbidity and mortality by keeping current in their knowledge of risk assessment, broadening the range of patients with whom they communicate about risk, and enhancing their communication skills to address diverse patient needs.

Does access to screening through health maintenance organization membership translate into improved breast cancer outcomes for African American patients?

OBJECTIVE: To investigate breast cancer outcomes in a group of African American and white patients offered the same access to mammography screening in a health maintenance organization located in suburban Philadelphia, Pennsylvania. METHODS: We used medical chart reviews and retrospective tumor tissue studies to investigate disparities in the mode of diagnosis and breast cancer outcomes among African American and white patients in a health maintenance organization. RESULTS: African American women were more likely to have detected their breast cancers accidentally and to have breast tumors larger than 2 cm than were whites. Invasive breast cancers with both lymph node involvement and systemic metastases were more prevalent in African American than in white women. CONCLUSION: These results suggest that even in health care settings that provide access to routine screening, African American women are more likely to have their breast cancers diagnosed accidentally and at more advanced stages than their white counterparts.

Communicating breast cancer risk: patient perceptions of provider discussions.

This study investigated the relationship between breast cancer risk communication delivered by providers and patient knowledge, perceptions, and screening practices. Telephone interviews were conducted with 141 African American (n = 71) and white (n = 70) first-degree relatives of breast cancer patients who received medical services at 2 university medical centers in North Carolina during 1994-95. Multiple items assessed subjects' reports of discussions with providers about family history and personal risk, knowledge of breast cancer risk factors, risk perceptions, breast cancer concerns, and screening practices. African American (AA) women were less likely than white women to report being informed of their increased personal risk of breast cancer because of family history. After controlling for education level, AA women aged > or = 50 years were less likely than white women to have ever had a mammogram. Both AA and white women who discussed family history and risk with their providers were significantly more likely to have had a mammogram within the past 2 years. Although these discussions seemed to increase participants' perceived risk of developing breast cancer, they did not promote knowledge of risk factors or increase levels of cancer concern. Study results indicate that provider discussions about family history and personal risk, accompanied by increases in risk perception, promote patient compliance with screening goals. Findings suggest that accurate knowledge about specific breast cancer risk factors may not be necessary to achieve screening compliance. However, additional studies are needed to investigate the relationship between knowledge of breast cancer risk factors and the adoption of behaviors associated with reducing breast cancer risk.