Single institution experience of MRI-guided radiotherapy for thoracic tumors and clinical characteristics impacting treatment duty cycle.

Introduction: MRI-guided radiotherapy (MRgRT) allows for direct motion management and real-time radiation treatment plan adaptation. We report our institutional experience using low strength 0.35T MRgRT for thoracic malignancies, and evaluate changes in treatment duty cycle between first and final MRgRT fractions. Methods: All patients with intrathoracic tumors treated with MRgRT were included. The primary reason for MRgRT (adjacent organ at risk [OAR] vs. motion management [MM] vs. other) was recorded. Tumor location was classified as central (within 2cm of tracheobronchial tree) vs. non-central, and further classified by the Expanded HILUS grouping. Gross tumor volume (GTV) motion, planning target volume expansions, dose/fractionation, treatment plan time, and total delivery time were extracted from the treatment planning system. Treatment plan time was defined as the time for beam delivery, including multileaf collimator (MLC) motion, and gantry rotation. Treatment delivery time was defined as the time from beam on to completion of treatment, including treatment plan time and patient respiratory breath holds. Duty cycle was calculated as treatment plan time/treatment delivery time. Duty cycles were compared between first and final fraction using a two-sample t-test. Results: Twenty-seven patients with thoracic tumors (16 non-small cell lung cancer and 11 thoracic metastases) were treated with MRgRT between 12/2021 and 06/2023. Fifteen patients received MRgRT due to OAR and 11 patients received MRgRT for motion management. 11 patients had central tumors and all were treated with MRgRT due to OAR risk. The median dose/fractionation was 50 Gy/5 fractions. For patients treated due to OAR (n=15), 80% had at least 1 adapted fraction during their course of radiotherapy. There was no plan adaptation for patients treated due to motion management (n=11). Mean GTV motion was significantly higher for patients treated due to motion management compared to OAR (16.1mm vs. 6.5mm, p=0.011). Mean duty cycle for fraction 1 was 54.2% compared to 62.1% with final fraction (p=0.004). Mean fraction 1 duty cycle was higher for patients treated due to OAR compared to patients treated for MM (61% vs. 45.0%, p=0.012). Discussion: Duty cycle improved from first fraction to final fraction possibly due to patient familiarity with treatment. Duty cycle was improved for patients treated due to OAR risk, likely due to more central location and thus decreased target motion.

Responding to Food Insecurity and Community Crises through Food Policy Council Partnerships in a Rural Setting.

Food insecurity is a constant struggle for many communities and food needs are often amplified during times of crisis. The objective of this article is to describe the progress in our community food policy council partnership by presenting the elements of success in facilitating policy change and programs that have helped our community in rural Pennsylvania respond to a variety of challenges, including the coronavirus disease 2019 (COVID-19) crisis. We also critically examine ongoing challenges and implications for our work. The elements that have contributed to sustaining our collective work include having a common agenda; collaboration; maintaining independent but mutually supporting member organizational goals; valuing those who are most impacted; and continuous communication. By applying these elements of partnership, the council remains focused on healthy food access, particularly during this COVID-19 crisis and ongoing food-related inequities.

Positive aspects of having had cancer: A mixed-methods analysis of responses from the American Cancer Society Study of Cancer Survivors-II (SCS-II).

OBJECTIVE: This study focused on understanding positive aspects of cancer among a large, national sample of survivors, 2, 5, and 10 years' postcancer diagnosis, who responded to the American Cancer Society Study of Cancer Survivors - II (SCS-II) survey "Please tell us about any positive aspects of having cancer." METHODS: A sequential mixed methods approach examined (1) thematic categories of positive aspects from cancer survivors (n = 5149) and (2) variation in themes by sociodemographics, cancer type, stage of disease, and length of survivorship. RESULTS: Themes comprised 21 positive aspects within Thornton's typology of benefits that cancer survivors attribute to their illness: life perspectives, self, and relationships. New themes pertaining to gratitude and medical support during diagnosis and treatment, health-related changes, follow-up/surveillance, and helping others emerged that are not otherwise included in widely used existing benefit finding cancer scales. Gratitude and appreciation for life were the most frequently endorsed themes. Sociodemographics and stage of disease were associated with positive aspect themes. Themes were not associated with survivor cohorts. CONCLUSIONS: No differences in perceived positive aspects across survivor cohorts suggest that positive aspects of cancer may exist long after diagnosis for many survivors. However, variation across sociodemographics and clinical variables suggests cancer survivors differentially experience positive aspects from their cancer diagnosis. IMPLICATIONS FOR CANCER SURVIVORS: This analysis provides new information about cancer survivors' perceptions of positive aspects from their cancer and factors associated with benefit finding and personal growth. This information can be useful in further refining quality-of-life measures and interventions for cancer survivors.

"It is just another test they want to do": Patient and caregiver understanding of the colonoscopy procedure.

OBJECTIVE: Colonoscopy is a complex procedure that requires bowel preparation, sedation, and has the potential for substantial risk. Given this, we investigated colonoscopy patients' perceived and actual understanding of the procedure. METHODS: Consecutive colonoscopy patients were enrolled and surveyed, with their caregivers, immediately prior to their procedure. Demographics, health literacy, socioeconomic status and perceived risks/benefits were assessed. Thematic analysis was conducted on open-ended responses and a 3-level outcome variable was created to categorize correctness of patients' and caregivers' understanding. Multinomial logistic regression was used to determine predictors of response level. RESULTS: Patients (N=1821) were 77% White, 60% female, and averaged 54 years old; caregivers were demographically similar. Among patients, bivariate analysis revealed that younger age, minority race, and low income, education, and health literacy were associated with incomplete understanding. Multinomial regression revealed that age, education, health literacy, first-time colonoscopy, and perceived risk-benefit difference discriminated among groups. Bivariate and multinomial results for caregivers were similar. CONCLUSION: Patients and caregivers varied on information, understanding and misconceptions about colonoscopy. Implications are discussed for inadequate: 1. informed consent, 2. bowel preparation, and 3. emotional preparation for cancer detection or adverse events. PRACTICE IMPLICATIONS: Attention should be paid to patients' understanding of the purpose, anatomy, and logistics of colonoscopy, preferably prior to bowel preparation.

Current opinion on the role of testosterone in the development of prostate cancer: a dynamic model.

BACKGROUND: Since the landmark study conducted by Huggins and Hodges in 1941, a failure to distinguish between the role of testosterone in prostate cancer development and progression has led to the prevailing opinion that high levels of testosterone increase the risk of prostate cancer. To date, this claim remains unproven. PRESENTATION OF THE HYPOTHESIS: We present a novel dynamic mode of the relationship between testosterone and prostate cancer by hypothesizing that the magnitude of age-related declines in testosterone, rather than a static level of testosterone measured at a single point, may trigger and promote the development of prostate cancer. TESTING THE HYPOTHESIS: Although not easily testable currently, prospective cohort studies with population-representative samples and repeated measurements of testosterone or retrospective cohorts with stored blood samples from different ages are warranted in future to test the hypothesis. IMPLICATIONS OF THE HYPOTHESIS: Our dynamic model can satisfactorily explain the observed age patterns of prostate cancer incidence, the apparent conflicts in epidemiological findings on testosterone and risk of prostate cancer, racial disparities in prostate cancer incidence, risk factors associated with prostate cancer, and the role of testosterone in prostate cancer progression. Our dynamic model may also have implications for testosterone replacement therapy.

Healthy options: a community-based program to address food insecurity.

The objectives of this study are to better understand the lived experience of food insecurity in our community and to examine the impact of a community-based program developed to increase access to local, healthy foods. Participants were given monthly vouchers to spend at local farmers' markets and invited to engage in a variety of community activities. Using a community-based participatory research framework, mixed methods were employed. Survey results suggest that most respondents were satisfied with the program and many increased their fruit and vegetable consumption. However, over 40% of respondents reported a higher level of stress over having enough money to buy nutritious meals at the end of the program. Photovoice results suggest that the program fostered cross-cultural exchanges, and offered opportunities for social networking. Building on the many positive outcomes of the program, community partners are committed to using this research to further develop policy-level solutions to food insecurity.

Pathways to colonoscopy in the South: seeds of health disparities.

OBJECTIVES: We aimed to highlight sociodemographic differences in how patients access colonoscopy. METHODS: We invited all eligible patients (n = 2500) from 2 academy-affiliated colonoscopy centers in Alachua County, Florida (1 free standing, 1 hospital based), to participate in a precolonoscopy survey (September 2011-October 2013); patients agreeing to participate (n = 1841, response rate = 73.6%) received a $5.00 gift card. RESULTS: We found sociodemographic differences in referral pathway, costs, and reasons associated with obtaining the procedure. Patients with the ideal pathway (referred by their regular doctor for age-appropriate screening) were more likely to be Black (compared with other minorities), male, high income, employed, and older. Having the colonoscopy because of symptoms was associated with being female, younger, and having lower income. We found significant differences for 1 previously underestimated barrier, having a spouse to accompany the patient to the procedure. CONCLUSIONS: Patients' facilitators and barriers to colonoscopy differed by sociodemographics in our study, which implies that interventions based on a single facilitator will not be effective for all subgroups of a population.

Methods of estimating or accounting for neighborhood associations with health using complex survey data.

Reasons for health disparities may include neighborhood-level factors, such as availability of health services, social norms, and environmental determinants, as well as individual-level factors. Investigating health inequalities using nationally or locally representative data often requires an approach that can accommodate a complex sampling design, in which individuals have unequal probabilities of selection into the study. The goal of the present article is to review and compare methods of estimating or accounting for neighborhood influences with complex survey data. We considered 3 types of methods, each generalized for use with complex survey data: ordinary regression, conditional likelihood regression, and generalized linear mixed-model regression. The relative strengths and weaknesses of each method differ from one study to another; we provide an overview of the advantages and disadvantages of each method theoretically, in terms of the nature of the estimable associations and the plausibility of the assumptions required for validity, and also practically, via a simulation study and 2 epidemiologic data analyses. The first analysis addresses determinants of repeat mammography screening use using data from the 2005 National Health Interview Survey. The second analysis addresses disparities in preventive oral health care using data from the 2008 Florida Behavioral Risk Factor Surveillance System Survey.

Potential health impacts of heavy metals on HIV-infected population in USA.

PURPOSE: Noninfectious comorbidities such as cardiovascular diseases have become increasingly prevalent and occur earlier in life in persons with HIV infection. Despite the emerging body of literature linking environmental exposures to chronic disease outcomes in the general population, the impacts of environmental exposures have received little attention in HIV-infected population. The aim of this study is to investigate whether individuals living with HIV have elevated prevalence of heavy metals compared to non-HIV infected individuals in United States. METHODS: We used the National Health and Nutrition Examination Survey (NHANES) 2003-2010 to compare exposures to heavy metals including cadmium, lead, and total mercury in HIV infected and non-HIV infected subjects. RESULTS: In this cross-sectional study, we found that HIV-infected individuals had higher concentrations of all heavy metals than the non-HIV infected group. In a multivariate linear regression model, HIV status was significantly associated with increased blood cadmium (p=0.03) after adjusting for age, sex, race, education, poverty income ratio, and smoking. However, HIV status was not statistically associated with lead or mercury levels after adjusting for the same covariates. CONCLUSIONS: Our findings suggest that HIV-infected patients might be significantly more exposed to cadmium compared to non-HIV infected individuals which could contribute to higher prevalence of chronic diseases among HIV-infected subjects. Further research is warranted to identify sources of exposure and to understand more about specific health outcomes.

The effect of atmospheric particulate matter on survival of breast cancer among US females.

Short-term effects of ambient particulate matter (PM) on cardiopulmonary morbidity and mortality have been consistently documented. However, no study has investigated its long-term effects on breast cancer survival. We selected all female breast cancer cases (n = 255,128) available in the California Surveillance Epidemiology and End Results cancer data. These cases were linked to 1999-2009 California county-level PM daily monitoring data. We examined the effect of PM on breast cancer survival. Results from Kaplan-Meier survival analysis show that female breast cancer cases living in areas with higher levels of PM10 and PM2.5 had a significant shorter survival than those living in areas with lower exposures (p < 0.0001). The results from marginal cox proportional hazards models suggest that exposure to higher PM10 (HR 1.13, 95 % CI 1.02-1.25, per 10 µg/m(3)) or PM2.5 (HR 1.86, 95 % CI 1.12-3.10, per 5 µg/m(3)) was significantly associated with early mortality among female breast cancer cases after adjusting for individual-level covariates such as demographic factors, cancer stage and year diagnosed, and county-level covariates such as socioeconomic status and accessibility to medical resources. Interactions between cancer stage and PM were also observed; the effect of PM on survival was more pronounced among individuals diagnosed with early stage cancers. This study suggests that exposure to high levels of PM may have deleterious effects on the length of survival from breast cancer, particularly among women diagnosed with early stage cancers. The findings from this study warrant further investigation.

Adjusting for confounding by neighborhood using generalized linear mixed models and complex survey data.

When investigating health disparities, it can be of interest to explore whether adjustment for socioeconomic factors at the neighborhood level can account for, or even reverse, an unadjusted difference. Recently, we proposed new methods to adjust the effect of an individual-level covariate for confounding by unmeasured neighborhood-level covariates using complex survey data and a generalization of conditional likelihood methods. Generalized linear mixed models (GLMMs) are a popular alternative to conditional likelihood methods in many circumstances. Therefore, in the present article, we propose and investigate a new adaptation of GLMMs for complex survey data that achieves the same goal of adjusting for confounding by unmeasured neighborhood-level covariates. With the new GLMM approach, one must correctly model the expectation of the unmeasured neighborhood-level effect as a function of the individual-level covariates. We demonstrate using simulations that even if that model is correct, census data on the individual-level covariates are sometimes required for consistent estimation of the effect of the individual-level covariate. We apply the new methods to investigate disparities in recency of dental cleaning, treated as an ordinal outcome, using data from the 2008 Florida Behavioral Risk Factor Surveillance System (BRFSS) survey. We operationalize neighborhood as zip code and merge the BRFSS data with census data on ZIP Code Tabulated Areas to incorporate census data on the individual-level covariates. We compare the new results to our previous analysis, which used conditional likelihood methods. We find that the results are qualitatively similar.

Conditional pseudolikelihood methods for clustered ordinal, multinomial, or count outcomes with complex survey data.

In order to adjust individual-level covariate effects for confounding due to unmeasured neighborhood characteristics, we have recently developed conditional pseudolikelihood methods to estimate the parameters of a proportional odds model for clustered ordinal outcomes with complex survey data. The methods require sampling design joint probabilities for each within-neighborhood pair. In the present article, we develop a similar methodology for a baseline category logit model for clustered multinomial outcomes and for a loglinear model for clustered count outcomes. All of the estimators and asymptotic sampling distributions we present can be conveniently computed using standard logistic regression software for complex survey data, such as sas proc surveylogistic. We demonstrate validity of the methods theoretically and also empirically by using simulations. We apply the new method for clustered multinomial outcomes to data from the 2008 Florida Behavioral Risk Factor Surveillance System survey in order to investigate disparities in frequency of dental cleaning both unadjusted and adjusted for confounding by neighborhood.

Adjusting for confounding by neighborhood using a proportional odds model and complex survey data.

In social epidemiology, an individual's neighborhood is considered to be an important determinant of health behaviors, mediators, and outcomes. Consequently, when investigating health disparities, researchers may wish to adjust for confounding by unmeasured neighborhood factors, such as local availability of health facilities or cultural predispositions. With a simple random sample and a binary outcome, a conditional logistic regression analysis that treats individuals within a neighborhood as a matched set is a natural method to use. The authors present a generalization of this method for ordinal outcomes and complex sampling designs. The method is based on a proportional odds model and is very simple to program using standard software such as SAS PROC SURVEYLOGISTIC (SAS Institute Inc., Cary, North Carolina). The authors applied the method to analyze racial/ethnic differences in dental preventative care, using 2008 Florida Behavioral Risk Factor Surveillance System survey data. The ordinal outcome represented time since last dental cleaning, and the authors adjusted for individual-level confounding by gender, age, education, and health insurance coverage. The authors compared results with and without additional adjustment for confounding by neighborhood, operationalized as zip code. The authors found that adjustment for confounding by neighborhood greatly affected the results in this example.

Area-level socioeconomic position and repeat mammography screening use: results from the 2005 National Health Interview Survey.

BACKGROUND: Despite a considerable number of studies describing the relationship between area-level socioeconomic conditions and mammography screening, definitive conclusions have yet to be drawn. The aim of this study was to examine the relationship between area-level socioeconomic position (SEP) and repeat mammography screening, using nationwide U.S. census SEP data linked to a nationally representative sample of women who participated in the 2005 National Health Interview Survey (NHIS). METHODS: An area-level SEP index using 2000 U.S. census tract data was constructed and categorized into quartiles, including information on unemployment, poverty, housing values, annual family income, education, and occupation. Repeat mammography utilization (dichotomous variable) was defined as having three mammograms over the course of 6 years (24-month interval), which must have included a recent mammogram (in past 2 years). Results were obtained by ordinary multivariable logistic regression for survey data. Women ages 46 to 79 years (n = 7,352) were included in the analysis. RESULTS: In a model adjusted for sociodemographics, health care factors, and known correlates of mammography screening, women living in more disadvantaged areas had lower odds of engaging in repeat mammography than women living in the most advantaged areas [OR comparing quartile 4 (most disadvantaged) to quartile 1 (most advantaged) = 0.63; 95% confidence interval, 0.50-0.80]. CONCLUSION: The results of this nationwide study support the hypothesis that area-level SEP is independently associated with mammography utilization. IMPACT: These findings underscore the importance of addressing area-level social inequalities, if uptake of mammography screening guidelines is to be realized across all social strata.

Efforts to adjust for confounding by neighborhood using complex survey data.

In social epidemiology, one often considers neighborhood or contextual effects on health outcomes, in addition to effects of individual exposures. This paper is concerned with the estimation of an individual exposure effect in the presence of confounding by neighborhood effects, motivated by an analysis of National Health Interview Survey (NHIS) data. In the analysis, we operationalize neighborhood as the secondary sampling unit of the survey, which consists of small groups of neighboring census blocks. Thus the neighborhoods are sampled with unequal probabilities, as are individuals within neighborhoods. We develop and compare several approaches for the analysis of the effect of dichotomized individual-level education on the receipt of adequate mammography screening. In the analysis, neighborhood effects are likely to confound the individual effects, due to such factors as differential availability of health services and differential neighborhood culture. The approaches can be grouped into three broad classes: ordinary logistic regression for survey data, with either no effect or a fixed effect for each cluster; conditional logistic regression extended for survey data; and generalized linear mixed model (GLMM) regression for survey data. Standard use of GLMMs with small clusters fails to adjust for confounding by cluster (e.g. neighborhood); this motivated us to develop an adaptation. We use theory, simulation, and analyses of the NHIS data to compare and contrast all of these methods. One conclusion is that all of the methods perform poorly when the sampling bias is strong; more research and new methods are clearly needed.

Neighborhood- and individual-level socioeconomic variation in perceptions of racial discrimination.

OBJECTIVE: In approaching the study of racial discrimination and health, the neighborhood- and individual-level antecedents of perceived discrimination need further exploration. We investigated the relationship between neighborhood- and individual-level socioeconomic position (SEP), neighborhood racial composition, and perceived racial discrimination in a cohort of African-American and White women age 40-79 from Connecticut, USA. DESIGN: The logistic regression analysis included 1249 women (39% African-American and 61% White). Neighborhood-level SEP and racial composition were determined using 1990 census tract information. Individual-level SEP indicators included income, education, and occupation. Perceived racial discrimination was measured as lifetime experience in seven situations. RESULTS: For African-American women, living in the most disadvantaged neighborhoods was associated with fewer reports of racial discrimination (odds ratio (OR) 0.44; 95% confidence interval (CI) 0.26, 0.75), with results attenuated after adjustment for individual-level SEP (OR 0.54, CI: 0.29, 1.03), and additional adjustment for neighborhood racial composition (OR 0.70, CI: 0.30, 1.63). African-American women with 12 years of education or less were less likely to report racial discrimination, compared with women with more than 12 years of education (OR 0.57, CI: 0.33, 0.98 (12 years); OR 0.51, CI: 0.26, 0.99 (less than 12 years)) in the fully adjusted model. For White women, neither neighborhood-level SEP nor individual-level SEP was associated with perceived racial discrimination. CONCLUSION: Individual- and neighborhood-level SEP may be important in understanding how racial discrimination is perceived, reported, processed, and how it may influence health. In order to fully assess the role of racism in future studies, inclusion of additional dimensions of discrimination may be warranted.

Associations of serum concentrations of organochlorine pesticides with breast cancer and prostate cancer in U.S. adults.

BACKGROUND: Organochlorine (OC) pesticides are a group of environmental endocrine disruptors that may be associated with an increased risk for hormone-related cancers including cancers of the breast and prostate. However, epidemiologic evidence is limited and inconsistent. OBJECTIVES AND METHODS: We used 1999-2004 National Health and Nutrition Examination Survey data to examine associations between serum concentrations of OC pesticides and prostate and breast cancers. RESULTS: After adjustment for other covariates, serum concentrations of beta-hexachlorocyclohexane (HCH) (p for trend = 0.02), trans-nonachlor (p for trend = 0.002), and dieldrin (p for trend = 0.04) were significantly associated with the risk of prevalent prostate cancer. Adjusted odds ratios for the second and third tertiles of detectable values were 1.46 [95% confidence interval (CI), 0.52-4.13] and 3.36 (95% CI, 1.24-9.10) for beta-HCH; 5.84 (95% CI, 1.06-32.2) and 14.1 (95% CI, 2.55-77.9) for trans-nonachlor; and 1.06 (95% CI, 0.30-3.73) and 2.74 (95% CI, 1.01-7.49) for dieldrin compared with concentrations in the lowest tertile or below the limit of detection. However, there was no positive association between serum concentrations of OC pesticides and breast cancer prevalence. CONCLUSION: Although further study is necessary to confirm these findings, these results suggest that OC pesticide exposures may have a significant effect on cancer risk. Efforts to reduce worldwide OC use are warranted.

Screening mammography: a cross-sectional study to compare characteristics of women aged 40 and older from the deep South who are current, overdue, and never screeners.

PURPOSE: We sought to identify unique barriers and facilitators to breast cancer screening participation among women aged 40 and older from Mississippi who were categorized as current, overdue, and never screeners. METHODS: Cross-sectional data from a 2003 population-based survey with 987 women aged 40 and older were analyzed. Chi-square analysis and multinomial logistic regression examined how factors organized under the guidance of the Model of Health Services Utilization were associated with mammography screening status. RESULTS: Nearly one in four women was overdue or had never had a mammogram. Enabling factors, including poor access to care (no annual checkups, no health insurance) and to health information, lack of social support for screening, and competing needs, were significantly associated with being both overdue and never screeners. Pertaining to factors unique to each screening group, women were more likely to be overdue when they had no usual source of health care and believed that treatment was worse than the disease. In turn, women were more likely to be never screeners when they were African American, lacked a provider recommendation for screening, and held the fatalistic view that not much could be done to prevent breast cancer. CONCLUSION: Similar and unique factors impact utilization of mammography screening services among women. Those factors could inform efforts to increase screening rates.

Association between exposure to alkylbenzenes and cardiovascular disease among National Health and Nutrition Examination Survey (NHANES) participants.

Numerous studies have demonstrated that air pollution is associated with an increased risk of mortality and morbidity due to cardiovascular disease (CVD). Alkylbenzenes are ubiquitous in outdoor and indoor air environments. Yet few studies have evaluated the potential links between exposures to alkylbenzenes and CVD independent of tobacco smoking. In this study, we used the 1999-2004 National Health and Nutrition Examination Survey (NHANES) to examine the relationship between alkylbenzenes (toluene, styrene, ethylbenzene, and the xylenes) and CVD prevalence. All five alkylbenzenes suggested linear trends. Subjects in higher exposure categories of blood alkylbenzenes had higher prevalence of CVD, as compared to subjects in the reference group, of below the limit of detection (LOD) and less than the 50th percentile in the case of toluene and styrene. For the remainder of the alkylbenzes, similar statistically significant associations were observed. Further studies are needed to explore associations between these highly prevalent pollutants and CVD.

The potential of survivorship care plans in primary care follow-up of minority breast cancer patients.

BACKGROUND: When the clinical care of minority breast cancer survivors is transferred from oncology settings to primary care, quality of care may be compromised if their primary care providers do not have adequate cancer treatment records and follow-up care guidelines. Survivorship care plans (SCPs) given to survivors before they transition to primary care settings are designed to improve the transfer of this information. This study examined these issues in a sample of minority breast cancer survivors. DESIGN: During four focus groups with minority breast cancer survivors, data were collected about the types of information survivors remember receiving from their oncologists about follow-up health care needs. Survivors were also asked their opinions on the value and content of a survivorship care plan. RESULTS: Minority breast cancer survivors received variable amounts of information about their cancer treatments. They were dissatisfied with the amount of information they received on cancer-related side-effects, including race-specific information. The American Society of Clinical Oncology's breast cancer survivorship care plan was viewed as important, but too highly technical and limited in information on side-effects and self-care approaches. CONCLUSIONS: Survivorship care plans may help increase information transfer from oncologists to patients and primary care providers, but the content of care plans needs to be adapted to minority patients' concerns. Primary care physicians may be challenged by survivors to explain recommended surveillance guidelines and to respond to untreated physical and psychosocial problems.