Validation of Use of Flipped Classroom for Surgery Core Clerkships.

BACKGROUND: The flipped classroom (FC) is an integrated learning paradigm that equips students with self-directed study materials before scheduled meeting times allowing for the deeper application of acquired knowledge with an instructor. There is limited data on the application of FC to clinical undergraduate medical education and particularly as it applies to a surgical clerkship. METHODS: This study is a four-year retrospective study that includes two cohorts of students who matriculated through two training paradigms, traditional classroom (TC) and FC. Information regarding the FC cohort was collected from June 2018 to July 2020 (N=166). A two-year matched historical cohort of students enrolled in the clerkship and taught with the TC paradigm from June 2016 to July 2018 was used for comparison (N=157). The primary aim of this study is to assess the National Board of Medical Examiners (NBME) surgery shelf performance when the FC model is utilized compared to the TC model. This study will validate a prior similar study that had a smaller cohort with different secondary endpoints. Therefore, the secondary aim of this study assesses how teaching style can affect other performance metrics of a rotation (such as clinical performance, quizzes, Objective Structured Clinical Examinations (OSCE), and practicums) and how time was utilized by faculty, staff, and students. RESULTS: There was no difference in overall NBME surgery shelf performance when comparing the FC to the traditional classroom teaching (68.94 vs 70.34, P= 0.1667). Likewise, there was no difference in quiz performance. The FC did allow instructors to spend more time in other clinical components of the curriculum leading to a significant difference in student practicum (84.2 vs 88.26, P = 0.0186) and OSCE grades (87.54 vs 90.58, P <0.0001). CONCLUSION: The surgery NBME shelf performance is not compromised by FC and therefore can be used as an alternative to traditional classroom setting for teaching medical knowledge to surgery clerkship students. In addition, the FC can improve time management for instructors allowing for improved teaching and development in other components of the surgery curriculum.

Spontaneous resolution of gastric perforation caused by an ingested foreign body: a case report.

Foreign body ingestions are commonly seen and are usually uneventful. Very rarely, ingested foreign bodies will cause perforation of the gastrointestinal tract, which can lead to peritonitis, abscesses or fistulation. This is the case of a patient with vague abdominal pain after voluntary ingestion of bleach and an ink pen. The ink pen was found lodged in the gastric antral wall on esophagogastroduodenoscopy. The foreign body spontaneously migrated into the gastric lumen and was successfully removed with endoscopy.

An infrared 3D scanning device as a novel limb volume measurement tool in breast cancer patients.

BACKGROUND: Lymphedema is a common complication of breast cancer treatment that affects one in five breast cancer survivors, yet there is no reliable method to detect lymphedema in the subclinical range. The objective of this study was to determine the feasibility and reliability of using an infrared 3D scanning device (ISD) as a peri-operative limb volume measurement tool. METHODS: Fifteen patients were analyzed based on inclusion criteria. Peri-operative measurements were obtained using tape measure and an ISD. Volumes were calculated using a standard algorithm for tape measure and a custom algorithm for ISD measurements. Linear regression models were used to assess ISD and tape measurement volume and circumference correlation. One-way ANOVA was used to compare change in percent difference at set time points post-operatively (2-3 weeks, 4-6 weeks, and 7-12 weeks) for both ISD and tape measure. t tests for unequal variances with the Bonferroni correction were performed among these groups. RESULTS: There is a positive linear correlation (R2 = 0.8518) between absolute volume measurements by the ISD and tape measure. Analyses over 2-10 weeks post-operatively showed that the ISD was able to detect volume changes in both the unaffected and the affected arm. Furthermore, the affected arm tended to have a greater increase in volume in the majority of patients, indicating these patients could be at risk for lymphedema. CONCLUSIONS: Technology utilizing infrared 3D scanners can reliably measure limb volume pre- and post-treatment similarly to tape measure in a small sample of patients. Further research using 3D scanning technology with a longer follow up is warranted.

A Provocative Molecular Link between Mammographic Density and BRCA1-loss associated TNBC.

Triple-negative breast cancer (TNBC) is a highly aggressive form of breast cancer that has a high mortality rate and disproportionately affects young African American (AA) women who carry mutations in the BRCA1 gene. Approximately 80% of breast cancers which develop in BRCA1-mutant carriers will have TNBC and the molecular mechanism facilitating tumor development is unclear. Our earlier work suggested Ubc9 to play a critical role in BRCA1 loss mediated TNBC cell migration and metastasis. Collagen is one of the major components of the stromal extracellular matrix (ECM) network that influences tissue density. Its re-organization act as a scaffold aiding cancer cells to migrate causing metastasis. Ubc9 is known to increase the production of collagen, a key component of fibroglandular breast tissue, as well as tumorigenesis. Our work is based on the hypothesis that loss of BRCA1 in women with high breast density causes abnormal Ubc9 levels which upregulates collagen, fibronectin and inhibits SIRT1, ß-catenin expression facilitating TNBC. We tested this hypothesis by studying the expression of total collagen, fibronectin, Ubc9, SIRT1, ß-catenin in BRCA1 mutant TNBC cells and tumor sample derived from patient with dense breasts using immunofluorescence, immunohistochemistry, and collagen assay. Our results suggest for the first time that mutation or loss of BRCA1 function in women with fibrocystic breasts can lead to over expression of Ubc9, induction of collagen and; fibronectin, inhibition of SIRT1 and nuclear accumulation of ß-catenin which could contribute to TNBC development. This network will aid not only in the identification of potential mechanism-based biomarkers that could detect disease early, but also enforce preventive measures that could reduce the risk for TNBC in women with high MD thus reducing the mortality associated with these cancers to achieve health equity.

Estimating the Reliability and Validity of the Upper Extremity Functional Index in Women After Breast Cancer Surgery.

BACKGROUND: Activity limitations as well as impairments such as pain, numbness, limitation of shoulder range of motion, and weakness are common and well documented during and after treatment for breast cancer. There is limited information regarding the measurement properties of patient-reported outcome measures of upper extremity activity limitation in this population. This study examined the reliability and validity of the Upper Extremity Functional Index (UEFI) in patients after surgery for breast cancer. PATIENTS AND METHODS: Measures of function, shoulder flexion range of motion, and pain were obtained for 53 women before and 2 weeks after surgery for breast cancer. To estimate UEFI test-retest reliability, a convenience sample of 20 patients was assessed on a second occasion within 48 hours of their 2-week postsurgery assessment. Convergent and discriminant construct validation methods were applied by examining correlations between UEFI scores and change scores with those of the shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH), Functional Assessment of Cancer Therapy-Breast (FACT-B) +4 items, shoulder flexion range, and pain. RESULTS: UEFI test-retest reliability was estimated to be 0.87 (95% confidence interval, 0.69, 0.94), and the standard error of measurement was 4.8 (95% confidence interval, 3.7, 7.1) scale points. The 90% confidence interval for a given UEFI score was ±7.9 and minimal detectable change at 90% confidence (MDC90) was ±11.1 points. UEFI correlations with the QuickDASH (cross-sectional -0.79 and longitudinal -0.62) were greater than with the FACT-B+4 and impairment measures. CONCLUSION: These results support and guide the use of the UEFI in patients after breast cancer surgery.

A novel Ubc9 -dependent pathway regulates SIRT1- ER-α Axis and BRCA1-associated TNBC lung metastasis.

Triple negative breast cancer (TNBC) is a heterogeneous disease and has a higher rate of recurrence and distant metastasis. African-American (AA) women have a higher frequency of BRCA1 mutations and TNBC compared to other populations. Basal-like tumors have a higher rate of brain, lung and distant nodal metastasis more than other TNBC subtypes, contributing to higher mortality rate. Our previous work suggested Ubc9, a SUMO E2-conjugating enzyme to induce proliferation and migration of BRCA1-incompetent TNBC cells and TNBC cell lines established from the pleural effusion metastasis of a woman with TNBC. To understand the downstream signaling axis involved in distant metastasis we have used clinically relevant BRCA1 mutant and lung metastatic TNBC cell lines and our results show deregulated expression of caveolin-1, VEGF and SIRT1 in these cells compared to normal mammary epithelial cells by immunofluorescence analysis. We observed SIRT1 to be induced by wild type BRCA1a and BRCA1a I26A mutant unlike the disease associated Ubc9 binding mutants in TNBC cells. Knock down of Ubc9 induced SIRT1 expression in TNBC and ER-α expression in breast cancer cells. This is the first report demonstrating a role for Ubc9 in repressing both SIRT1 and ER-α expression in BRCA1 associated TNBC cells. It also suggests that the BARD-dependent E3 Ubiquitin ligase and HR (homologous recombination) activity of BRCA1 may not be required for inducing SIRT1 expression. Our results suggest for the first time that in BRCA1 mutant TNBC Ubc9-mediated induction of VEGF, inhibition of caveolin-1, SIRT1 and ER-α expression as a novel molecular mechanism underlying TNBC EMT (epithelial mesenchymal transition) leading to lung metastasis with pleural effusion. Drugs that target Ubc9 to both induce SIRT1 and ER-α or using SIRT1 agonists in combination with chemotherapy can be used as a promising targeted therapeutic approach for treating basal-like metastatic BRCA1-linked TNBC thus reducing the mortality in patients with TNBC.

Implementing the Prospective Surveillance Model (PSM) of Rehabilitation for Breast Cancer Patients with 1-Year Postoperative Follow-up, a Prospective, Observational Study.

BACKGROUND: The Prospective Surveillance Model (PSM) of rehabilitation for patients with breast cancer aims for early identification, treatment, and support of physical impairments postoperatively. The purpose of this study was to describe the incidence of impairments during the first postoperative year and the differences between the patients requiring rehabilitation intervention versus those not requiring intervention. METHODS: A total of 120 patients were enrolled. Impairment measures included: pain, range of motion, and self-reported measures of function using the Upper Extremity Functional Index (UEFI) and Quick Disability of the Arm, Shoulder and Hand (QuickDASH) questionnaires. These measures were performed at designated intervals during the first postoperative year. All patients received exercise and education, and patients with identified impairments underwent individualized rehabilitation intervention. Clinical factors associated with need for intervention were determined using univariate analysis. RESULTS: Thirty-six patients required rehabilitation intervention. There were no statistically significant differences between intervention and no-intervention groups for body mass index, breast surgery type, reconstruction type, or radiotherapy. Statistically significant differences were found between intervention and no-intervention groups in early postoperative UEFI, QuickDASH, pain scores, age, number of lymph nodes removed [9.3 (intervention) vs. 5.6 (no-intervention)], axillary surgery type, chemotherapy, and breast cancer stage. CONCLUSIONS: Survivorship practitioners should have heightened awareness for rehabilitation intervention in patients with greater axillary surgery and burden of disease. Patients with more activity restriction and lower levels of function in the early postoperative period may benefit from rehabilitation intervention. Future studies should focus on implementing a screening tool to identify patients in need of rehabilitation referral.

Excising Additional Margins at Initial Breast-Conserving Surgery (BCS) Reduces the Need for Re-excision in a Predominantly African American Population: A Report of a Randomized Prospective Study in a Public Hospital.

BACKGROUND: Margin status is an important prognostic factor for local recurrence after breast conserving surgery (BCS) for breast cancer. We designed a prospective randomized trial to evaluate the effect of shave margins on positive margins and locoregional recurrence (LRR). METHODS: Patients were randomized to BCS or BCS with resection of 5 additional margins (BCS + M). Tumor margins were classified as negative [>2 mm for ductal carcinoma in situ (DCIS); >1 mm for invasive carcinoma] based on guidelines at the time of accrual. RESULTS: A total of 75 patients with stage 0-III breast cancer (76 samples) were randomized, mean age 59.6 years with median follow-up 39.5 months. Overall, 21 patients (27.6 %) had positive margins: 14 had undergone BCS and 7 BCS + M (p = 0.005). Of the 21 patients with positive margins, 19 had DCIS on final pathology (OR 7.56; 95 % CI 1.52-37.51).All patients with positive margins were offered re-excision; 11 had negative final margins after re-excision surgery. Overall, 6 patients (8.3 %) developed LRR with recurrence being more common in the BCS group when compared with the BCS + M group (17.2 vs 2.3 %; p = 0.025). CONCLUSIONS: Taking additional cavity shave margins at the time of initial excision resulted in a reduction in positive margin rate, a decrease in return to operating room for re-excision, and lower LRR.

Phyllodes tumors in African American women.

BACKGROUND: Phyllodes is a rare tumor accounting for less than 1% of all breast neoplasms. Studies defining clinical predictors of malignant phyllodes (MP) are rare and inconsistent. Furthermore, MP occurrence in African American (AA) women has never been analyzed. This study will delineate clinical and pathologic features in AA patients that may reasonably predict the probability of malignancy. METHODS: A retrospective study of clinical records was carried out for 50 AA patients diagnosed with phyllodes tumors (PT) and treated between 1982 and 2012. Patients' charts were analyzed regarding demographics, pathology findings, and treatment. RESULTS: The diagnosis of benign disease was made in 40 (78%), borderline in 3 (6%), and malignancy in 7 (14%) patients; however, 1 patient (2%) had mixed phyllodes with ductal carcinoma in situ. The mean age was significantly different for patients with benign disease (33 years) compared with those with malignancy (54 years; P < .001). The average tumor size was twice as large (11.8 vs 4.1 cm; P = .029) and mitoses were higher with 50% of MPs having greater than 5 per 10 high power fields. Although rare, nodal metastasis, ulceration, and multicentric disease occurred only in MP. CONCLUSIONS: Among AA patients with phyllodes tumors, those with malignant tumors were older and had larger tumors and higher mitotic indices than those with benign disease. AA patients also displayed some of the more rare features of advanced disease and presented with malignancy near the highest reported frequency.

Triple Negative Breast Cancer - An Overview.

Triple Negative Breast Cancer (TNBC) is a heterogeneous disease that based on immunohistochemistry (IHC) is estrogen receptor (ER) negative, progesterone receptor (PR) negative and human epidermal growth factor receptor 2 (HER2) negative. TNBC is typically observed in young AA women and Hispanic women who carry a mutation in the BRCA1 gene. TNBC is characterized by a distinct molecular profile, aggressive nature and lack of targeted therapies. The purpose of this article is to review the current and future novel signalling pathways as therapeutic approaches to TNBC. Recent Identification of a new BRCA1 trafficking pathway holds promise in the future for the development of targeted therapies for TNBC.

BRCA1 proteins regulate growth of ovarian cancer cells by tethering Ubc9.

Mutation in the BRCA1 gene is associated with increased risk for hereditary breast and ovarian cancers. In sporadic ovarian tumors, BRCA1 dysfunction is thought to be common. BRCA1 is a nuclear-cytoplasm shuttling protein. Our group has previously reported that BRCA1 proteins, unlike K109R and cancer-predisposing mutant C61G BRCA1 proteins, bind the sole SUMO E2-conjugating enzyme Ubc9. In this study, we examined the result of altered Ubc9 binding and knockdown on the sub-cellular localization and growth inhibitory function of BRCA1 proteins in ovarian cancer cells. Using live imaging of YFP, RFP-tagged BRCA1 and BRCA1a proteins, our results show enhanced cytoplasmic localization of K109R and C61G mutant BRCA1 proteins in ES-2, NIHOVCAR3 and UWB 1.289 ovarian cancer cells. Down-regulation of Ubc9 in ovarian cancer cells using Ubc9 siRNA resulted in cytoplasmic localization of BRCA1 and BRCA1a proteins. These mutant BRCA1a proteins were impaired in their capacity to inhibit growth of ES-2 ovarian cancer cells. Several ovarian cancer cells, including a BRCA1-null ovarian cancer cell line, showed higher levels of expression of Ubc9. This is the first study demonstrating the physiological link between loss of Ubc9 binding and loss of growth suppression of disease-associated mutant BRCA1a proteins in ovarian cancer cells. BRCA1, by turning off or on Ubc9 binding, regulates growth of ovarian cancers.

Pseudoangiomatous stromal hyperplasia (PASH) of the breast: a series of 24 patients.

Pseudoangiomatous stromal hyperplasia (PASH) is a benign mesenchymal proliferative lesion of the breast. In 2005, only 109 cases had been reported since its initial description in 1986 by Vuitch et al. Our 24 cases represent one of the largest series to be reported from a single institution. We retrospectively reviewed data from 2004 to 2010 of patients diagnosed with PASH by surgical excision or image-guided biopsy. All pathological specimens were reviewed by a single pathologist. The samples were stained for estrogen and progesterone receptors (ER and PR), CD34, and the lymphatic marker D2-40. All but one of 24 (96%) patients presented with breast masses either on imaging or clinically. Fourteen of the 24 patients (58%) were diagnosed on surgical excision, 10 (42%) diagnosed with core needle biopsy, and five (20%) were diagnosed using both techniques. The tumors ranged in size from 0.3 cm to 7.0 cm. All women except two were premenopausal or perimenopausal at diagnosis. Nineteen samples were available for hormonal receptor staining and of these 18 of 19 (95%) were ER or PR positive. PASH was diagnosed in two men, a transgender male on hormones and the other with gynecomastia. The patients' ages ranged from 18 to 86 years old. In addition to PASH other benign histopathological findings include stromal fibrosis and atypical ductal or lobular hyperplasia. Imaging revealed no distinguishing feature for PASH with benign histology. One patient had synchronous ductal carcinoma in-situ (DCIS). Patients were treated with local excision or observation. This study suggests that PASH is primarily a diagnosis of premenopausal and perimenopausal women. Our series supports a hormonal basis for its development due to the positive staining for hormonal receptors. Management is conservative surgery for larger masses with careful observation being an option in patients not at high risk for breast cancer.

Improving on national quality indicators of breast cancer care in a large public hospital as a means to decrease disparities for African American women.

BACKGROUND: In April 2007, the National Quality Forum (NQF) endorsed the first nationally recognized hospital-based performance measures for stage I, II, and III breast cancer. The purpose of this study was to document compliance with the 3 NQF breast quality indicators during 2 time intervals in a metropolitan public hospital. MATERIALS AND METHODS: Tumor registry and medical records were used to identify patient demographics and treatments before (2005-2006) and after (2008) implementations in 2007 as a result of the NQF audit. Program changes included: hiring a dedicated medical oncology nurse practitioner, requiring the radiation oncology case manager to attend weekly multidisciplinary conferences, educating Patient Navigators of the importance of multimodal care, and providing support groups for patients addressing importance of completion of all treatment options. RESULTS: A total of 213 female patients were diagnosed with and treated for stage I, II, or III breast cancer in 2005-2006 and 2008. Of these, 189 (89%) were African American (AA) women. Also, 70 patients of 86 (81.3%) received radiation therapy, 60 of 77 (77.9%) received or were considered for adjuvant chemotherapy, and 124 of 144 (86.1%) for hormonal therapy according to NQF indicators. After 2007, patients receiving radiation therapy increased from 75.8 to 95.8%. Patients receiving or considered for adjuvant chemotherapy or hormonal therapy increased from 73.7 to 93.7% and from 84.1 to 90.0%, respectively. CONCLUSIONS: NQF breast cancer indicators provided a mechanism to improve compliance of multimodal treatment in our center. Raising awareness of these indicators in the multidisciplinary conference, hiring dedicated personnel, and educating patients has led to major improvements in breast cancer care.

Using National Quality Forum breast cancer indicators to measure quality of care for patients in an AVON comprehensive breast center.

In April 2007, the National Quality Forum (NQF) endorsed the first nationally recognized hospital-based performance measures for quality of care for breast cancer. The aim of this study was to measure quality of care at our AVON Center for Breast Care (AVONCBC) using these indicators. We retrospectively reviewed tumor registry and medical records of females under age 70 diagnosed with breast cancer in years 2005-2006. For patients diagnosed with hormone receptor negative breast cancer, 22 of 29 (75.9%) and 28 of 32 (87.5%) were considered for or received chemotherapy in 2005 and 2006, respectively. Of those patients, 21 of 29 (72.4%) and 24 of 32 (75.0%) were considered for or received chemotherapy within the NQF 4-month period. For patients undergoing breast conserving surgery (BCS), 20 of 23 (86.9%) in 2005 and 37 of 39 (94.9%) in 2006 were referred for adjuvant radiation therapy. The proportion of patients who received radiation therapy within 1 year of diagnosis was 18 of 23 (78.2%) and 29 of 39 (74.4%) for diagnosis years 2005 and 2006, respectively. The vast majority of patients in our AVONCBC are referred to medical and/or radiation oncology for adjunctive therapy and about three-fourths receive treatment compliant with the NQF QI. To increase our compliance rate, we are developing methods to improve access to the multiple disciplines in our AVONCBC. Using the NQF indicators serves to assess hospital performance at a systems-level and as a useful method for tracking cancer quality of care.

Effects of an outreach and internal navigation program on breast cancer diagnosis in an urban cancer center with a large African-American population.

BACKGROUND: Compared with white women, African-American (AA) women who are diagnosed with breast cancer experience an excess in mortality. To improve outcomes, the authors implemented community education and outreach initiatives in their cancer center, at affiliated primary care sites, and in the surrounding communities. They then assessed the effectiveness of these outreach initiatives and internal patient navigation on stage of diagnosis. METHODS: This cross-sectional study was an analysis of all women with breast cancer who were diagnosed and/or treated in the years from 2001 through 2004. The outreach initiatives were implemented in 2001; 125 trained Community Health Advocates (CHAs) provided educational programs to the community, and Patient Navigators communicated directly with patients to encourage screening, diagnostic procedures, and treatment. RESULTS: In total, 487 patients were diagnosed/treated from 2001 through 2004. Since 2001, there were 1148 community interventions by CHAs with an estimated program attendance of >10,000 participants. In the interval from 2001 through 2004, the proportion of stage 0 (in situ) breast cancers increased from 12.4% (n = 14) to 25.8% (n = 33; P < .005), and there was a decline in stage IV invasive breast cancers from 16.8% (n = 19) to 9.4% (n = 12; P < .05). CONCLUSIONS: The outreach initiatives and internal patient navigation appear to have improved stage at diagnosis. To determine whether specific patients presented earlier as a result of specific community outreach initiatives, prospective work is underway to measure the effects of these interventions on potential stage migration. Similarly, prospective data are being collected to determine whether Patient Navigators influence treatment and appointment adherence as well as the underlying reasons for barriers to specific interventions in this underserved minority population.

High prevalence of triple-negative tumors in an urban cancer center.

BACKGROUND: A disparate proportion of breast cancer deaths occur among young women, those of African-American (AA) ancestry, and particularly young AA women. Estrogen receptors (ER), progesterone receptors (PR), and human epidermal growth factor receptor-2 (HER-2) are key clinically informative biomarkers. The triple-negative (ER-/PR-/HER-2-) tumor subgroup is intrinsically resistant to treatment and portends a poor prognosis. Age, race, and socioeconomic status have been associated with triple-negative tumors (TNT). In the current study, the authors investigated breast cancer subgroups among patients in an urban cancer center serving a multiracial, low socioeconomic population. METHODS: This case series analyzed female invasive breast cancers diagnosed and/or treated between 2003 and 2004 in the AVON Comprehensive Breast Center at Grady Hospital in Atlanta, Georgia. Data were obtained from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program, and augmented by the hospital registry and pathology reports. Statistical analyses utilized frequency distributions and logistic regression. RESULTS: Of 190 breast cancers; 167 (88%) were diagnosed among AA and 23 (12%) were diagnosed among non-AA women. The median age at diagnosis in the 2 groups was 58 years and 57 years, respectively. TNT prevalence was found to differ by race (29.3% among AA women and 13.0% among non-AA women; P = .010). Differences persisted after adjustment for age and stage (odds ratio [OR] of 3.1; 95%confidence interval [95% CI], 0.8-11.6). The majority of recurrences (40.0%) occurred among women with TNT, who were also most likely to experience a fatal event (OR of 3.7; 95%CI, 1.1-13.0). CONCLUSIONS: Despite a similarity in their age at diagnosis, AA women in our urban cancer center presented with a higher prevalence of TNT and TNT was found to predict the poorest outcomes. Institutional interactive breast conferences and intervention/navigation programs could help to dispel breast cancer disparities and improve outcomes.

Abnormal mammogram follow-up: do community lay health advocates make a difference?

This pilot study evaluates a community lay health advocate (CLHA) intervention in promoting follow-up for abnormal mammograms among African American women. A controlled trial was implemented at an urban hospital in Atlanta, with 48 women in a CLHA intervention group and 35 in a usual care group. Participants were 25 or older and had an abnormal mammogram between March 25, 2002, and May 2, 2003. Intervention group women received CLHA support including encouragement of timely abnormal mammogram follow-up, reminders of follow-up appointments, identification and removal of barriers to follow-up, and accompaniment to follow-up appointments. Women in the intervention group were significantly more likely to keep their first abnormal mammogram follow-up appointment, all of their scheduled follow-up appointments, and their biopsy or fine needle aspiration appointment. CLHAs are effective in promoting abnormal mammogram followup among African American women and may be an important resource in reducing racial disparities in breast cancer mortality.

Effects of HIV-1 Nef, a cytotoxic viral protein, on the growth of primary colorectal cancer.

Colorectal cancer is the third leading cause of cancer deaths in American men and women. We describe the cytotoxic use of HIV-1 Nef protein and a cytotoxic peptide identified within the HIV-1 Nef structure in targeting human cancer cells in vitro and in vivo in a human xenograft model. A human colorectal tumor was implanted and propagated in the subcutaneous tissue of SCID mice. The mice were injected biweekly with the Nef apoptotic peptide. The tumor treated with Nef peptide underwent significant growth inhibition by as much as 300 percent when compared to the control (untreated) tumors. The Nef peptides were found to have an apoptotic effect on the human colon tumor similar to the effect seen on CD4 cells when the viral protein is secreted by the HIV-1 virus infected cells. The evidence from the xenograft mouse model suggests that the Nef peptides can be used to inhibit human colorectal cancer growth.