Examining hypertension risk among Black and White breast cancer survivors.

PURPOSE: Breast cancer survivors are at increased risk of cardiovascular dysfunction following their diagnosis; however, hypertension remains underexplored within this context. This retrospective cohort study examined the incidence of hypertension in breast cancer survivors and the association of race with hypertension risk among them. METHODS: Data for this study were abstracted from the electronic health records of women diagnosed with Stages I-III breast cancer. Incident hypertension diagnosis was identified through International Classification of Diseases codes. Bivariate associations were tested using Student's t-test and chi-squared test of independence. Bivariable Cox regression analysis was used to determine demographic and clinical factors that may have been associated with the development of hypertension. RESULTS: A total of 664 women were included. Most women were 50 years of age or younger (52.0%), White (33.0% Black), and received a mastectomy (80.6%). Overall, 45.5% of the cohort developed hypertension. The 1-year hypertension-free survival estimates were 47% (95% confidence interval [CI], 41-54) in Black women and 73% (95% CI, 69-77) in White women (p < 0.0001). Besides race, statistically significant predictors of hypertension included: age greater than 50 (vs. ≤50) (adjusted Hazard Ratio [HR]: 1.40; 95% CI, 1.09-1.80) and residing in a non-metropolitan area (vs. metropolitan) (adjusted HR: 1.60; 95% CI, 1.19-2.16). CONCLUSIONS: This study suggests that breast cancer survivors who are older, Black, or residing in non-metropolitan areas may benefit from added surveillance and hypertension prevention strategies during treatment. Future studies are needed to identify contributors to the observed racial and geographic disparities.

In-situ synthesized V2CTx MXene-based immune tag for the electrochemical detection of Interleukin 6 (IL-6) from breast cancer cells.

Interleukin-6 (IL-6) is a proinflammatory cytokine with a critical role in immune regulation and treatment of many diseases, including breast cancer. Herein, we developed a novel V2CTx MXene-based immunosensor for rapid and accurate IL-6 detection. The chosen substrate was V2CTx, a 2-dimensional (2D) MXene nanomaterial with excellent electronic properties. Prussian blue (Fe4[Fe(CN)6]3), used for its electrochemical properties, and spindle-shaped gold nanoparticles (Au SSNPs), used to combine with antibodies, were in-situ synthesized on the surface of the MXene. The in-situ synthesis ensures a firm chemical connection compared to other tags formed by a less stable physical absorption. Inspired by a sandwich ELISA test, the modified V2CTx tag was captured by the electrode surface with cysteamine to detect the analyte, IL-6, after being attached with a capture antibody (cAb). Benefiting from an increased surface area, an enhanced charge transfer rate, and a firm connection of the tag, this biosensor exhibited excellent analytical performance. The high sensitivity, high selectivity, and wide detection range covering the IL-6 level of both healthy individuals and breast cancer patients were obtained to meet clinical demands. Herein, this V2CTx MXene-based immunosensor is a potential therapeutic and diagnostic point-of-care alternative to routine ELISA IL-6 detection methods.

Use of photo methods in research studies with cancer survivors and their caregivers: a scoping review.

PURPOSE: Photo methods such as photo-elicitation and photovoice have traditionally been implemented as knowledge-generation techniques; however, they have also been conceptualized as tools for community impact and as interventions in and of themselves. We performed a scoping review to document how photo methods have been used in studies of cancer, to describe participant populations, and to identify opportunities for future directions for the use of photo methods in cancer. METHODS: An a priori search strategy was implemented across health-related databases with the following inclusion criteria: (1) study participants were diagnosed with cancer and/or were caregivers of those with cancer; (2) study participants were asked to take and/or respond to photographs as part of the study protocol; (3) articles were published in peer-reviewed journals; (4) articles were written in English. RESULTS: Eighty non-duplicative articles were identified; of these, 30 articles describing 24 individual studies were included for review. All but one (95.8%) of the studies utilized photovoice solely as a knowledge-generation technique without participant outcome measurement or analysis. Across all included studies, participants were largely women with breast cancer; other demographic and cancer-related variables (e.g., race and cancer stage) were not consistently reported. Caregivers were included in 37.5% of studies. CONCLUSION: Photo methods are most frequently used in order to capture qualitative data in cancer populations; however, there are missed opportunities in their lack of use for intervention and systemic change. In addition, inconsistent reporting of demographics and cancer characteristics limits our ability to synthesize these data across studies.

Society of Behavioral Medicine (SBM) position statement: support increased knowledge and efforts to address the financial burden associated with cancer treatment.

Millions of individuals and their families struggle with both treatment-related and out-of-pocket (OOP) economic repercussions of a cancer diagnosis, an effect increasingly referred to as "financial toxicity." In 2014, the Agency for Healthcare Research and Quality (AHRQ) estimated the total U.S. expenditures for cancer at $87.8 billion dollars with patient OOP costs accounting for $3.9 billion dollars (2014). These figures do not take into account indirect costs, such as those from lost earnings. As a result, financial toxicity can extend well beyond the active treatment phase and have a substantial impact on a household's economic reserve and financial resilience well into the future. Of the 9.5 million U.S. adults aged 50 years and older diagnosed with cancer (2000-2012), 42.2% have depleted their assets at 2 years and 38.2% were financially insolvent in 4 years. Bankruptcy rates are 2.65 times higher among cancer survivors than matched controls. A full 70% of Americans want to have conversations about the costs of care with their health care providers, but only 28% report doing so. Delaying or deferring these conversations can have major financial consequences for patients. According to a polling conducted for the Robert Wood Johnson Foundation (RWJF) by Avalere Health, almost 20% of patients report forgoing care when they have questions about costs. A critical element to achieve this is to have accurate cost information, including health care insurance coverage policies. Specifically, while patients and their families look to their health care providers to help them better navigate the cost implication of their treatment choices, most who are willing to undertake this challenging task need to have accessible and comprehensive (including direct and indirect) cost information to facilitate the discussion.

Skeletal Muscle Mass Loss During Cancer Treatment: Differences by Race and Cancer Site.

OBJECTIVES: To examine skeletal muscle mass change in a racially diverse sample of patients undergoing cancer treatment, determine significant predictors of muscle mass loss, and explore the interaction of race and cancer site. SAMPLE & SETTING: A retrospective analysis was conducted for 212 patients seeking treatment at a university hospital clinic. METHODS & VARIABLES: Skeletal muscle mass index (SMI) was determined by computed tomography at the time of cancer diagnosis and with cancer treatment. RESULTS: One hundred thirty-four patients (63%) had SMI loss with cancer treatment. Race and cancer site were found to be significant predictors of SMI loss. Compared to other racial groups, non-Hispanic Black (NHB) patients had the greatest SMI loss (p < 0.001) with cancer treatment. NHB patients with rectal cancer experienced the greatest SMI loss compared to patients of other races and cancer types. IMPLICATIONS FOR NURSING: To improve survivorship care for patients with cancer, it is essential to develop strategies for assessing and managing skeletal muscle mass loss throughout treatment, particularly for NHB patients with rectal cancer.

Skeletal Muscle Mass Change During Chemotherapy: A Systematic Review and Meta-analysis.

BACKGROUND/AIM: Skeletal muscle mass loss is an emerging concern in oncology. Our systematic review and meta-analysis identified the mean difference in skeletal muscle index pre- to post-chemotherapy and synthesized potential key factors. MATERIALS AND METHODS: We searched primary original research published through October 2019 in four databases: MEDLINE via PubMed, Scopus, CINAHL, and Embase. RESULTS: Fifteen studies were included, 60% published in the past 2 years (2018-2019). Advanced non-small cell lung cancer was the most frequently reported cancer, and overall survival the most often identified key related factor. Mean difference in skeletal muscle index during chemotherapy was 2.72 (95%CI=1.77-3.67, p=0.00), with muscle loss in males (4.52, 95%CI=3.34-5.71, p=0.00) about 1.6 times higher than that in females (2.86, 95%CI=0.81-4.92, p=0.01). CONCLUSION: Oncologists should recognize sex-specific differences in skeletal muscle mass loss during chemotherapy and consider adjusting treatment accordingly.

Association of Insurance Status and Racial Disparities With the Detection of Early-Stage Breast Cancer.

Importance: Compared with non-Hispanic white women, racial/ethnic minority women receive a diagnosis of breast cancer at a more advanced stage and have higher morbidity and mortality with breast cancer diagnosis. Access to care with adequate insurance may be associated with earlier diagnosis, expedited treatment, and improved prognosis. Objective: To examine the extent to which insurance is associated with access to timely breast cancer diagnosis and breast cancer stage differences among a large, diverse population of US patients with breast cancer. Design, Setting, and Participants: This retrospective, cross-sectional population-based study used data from the Surveillance, Epidemiology, and End Results Program on 177 075 women aged 40 to 64 years who received a diagnosis of stage I to III breast cancer between January 1, 2010, and December 31, 2016. Statistical analysis was performed from August 1, 2017, to October 1, 2019. Main Outcomes and Measures: The primary outcome was the risk of having a more advanced stage of breast cancer at diagnosis (ie, stage III vs stages I and II). Mediation analyses were conducted to determine associations of race/ethnicity and proportion of observed differences mediated by health insurance status with earlier stage of diagnosis. Results: A total of 177 075 women (mean [SD] age, 53.5 [6.8] years; 148 124 insured and 28 951 uninsured or receiving Medicaid) were included in the study. A higher proportion of women either receiving Medicaid or who were uninsured received a diagnosis of locally advanced breast cancer (stage III) compared with women with health insurance (20% vs 11%). In multivariable models, non-Hispanic black (odds ratio [OR], 1.46 [95% CI, 1.40-1.53]), American Indian or Alaskan Native (OR, 1.31 [95% CI, 1.07-1.61]) and Hispanic (OR, 1.35 [95% CI, 1.30-1.42]) women had higher odds of receiving a diagnosis of locally advanced disease (stage III) compared with non-Hispanic white women. When adjusting for health insurance and other socioeconomic factors, associations between race/ethnicity and risk of locally advanced breast cancer were attenuated (non-Hispanic black: OR, 1.29 [95% CI, 1.23-1.35]; American Indian or Alaskan Native: OR, 1.11 [95% CI, 0.91-1.35]; Hispanic: OR, 1.17 [95% CI, 1.12-1.22]). Nearly half (45%-47%) of racial differences in the risk of locally advanced disease were mediated by health insurance. Conclusions and Relevance: This study's findings suggest that nearly half of the observed racial/ethnic disparities in higher stage at breast cancer diagnosis are mediated by health insurance coverage.

Care Coordination for Breast Cancer Survivors in Urban Underserved Communities: Will Treatment Summaries and Survivorship Care Plans Be Enough?

BACKGROUND: Few studies have examined cancer care coordination at federally qualified health centers (FHQCs). The Commission on Cancer's (CoC) standard 3.3, i.e., treatment summaries and survivorship care plans (TS-SCPs), is aimed at improving communication between cancer specialists and primary care providers (PCPs) across all healthcare systems. Whether this will improve care at FQHCs is unclear. We sought to understand breast cancer care coordination at FQHCs before the stepwise implementation of standard 3.3. METHODS: In 2014, we conducted a retrospective chart review at five Chicago FQHCs. We used ICD-9 codes to identify 109 breast cancer cases diagnosed within 5 years of the chart review. We examined charts for (1) external cancer records, (2) PCP documentation of breast cancer histories, and (3) documentation of PCP engagement in cancer-relevant follow-up care. RESULTS: Less than 50% of the charts had PCP documentation of more than one area of cancer-relevant follow-up care. Availability of external records did not increase PCP engagement in cancer-relevant follow-up care. Instead, PCPs who documented information about their patient's breast cancer treatments also documented more cancer-relevant follow-up care. CONCLUSION: Before the stepwise implementation of TS-SCPs, less than 50% of the charts had PCP documentation of more than one area of cancer-related follow-up care. The TS-SCP is designed to facilitate care coordination between specialists and PCPs through increased communication. Our results suggest the availability of external cancer information did not necessarily translate into care delivery. This suggests communication of information alone is insufficient.

Intensive Surveillance with Biannual Dynamic Contrast-Enhanced Magnetic Resonance Imaging Downstages Breast Cancer in BRCA1 Mutation Carriers.

PURPOSE: To establish a cohort of high-risk women undergoing intensive surveillance for breast cancer.Experimental Design: We performed dynamic contrast-enhanced MRI every 6 months in conjunction with annual mammography (MG). Eligible participants had a cumulative lifetime breast cancer risk ≥20% and/or tested positive for a pathogenic mutation in a known breast cancer susceptibility gene. RESULTS: Between 2004 and 2016, we prospectively enrolled 295 women, including 157 mutation carriers (75 BRCA1, 61 BRCA2); participants' mean age at entry was 43.3 years. Seventeen cancers were later diagnosed: 4 ductal carcinoma in situ (DCIS) and 13 early-stage invasive breast cancers. Fifteen cancers occurred in mutation carriers (11 BRCA1, 3 BRCA2, 1 CDH1). Median size of the invasive cancers was 0.61 cm. No patients had lymph node metastasis at time of diagnosis, and no interval invasive cancers occurred. The sensitivity of biannual MRI alone was 88.2% and annual MG plus biannual MRI was 94.1%. The cancer detection rate of biannual MRI alone was 0.7% per 100 screening episodes, which is similar to the cancer detection rate of 0.7% per 100 screening episodes for annual MG plus biannual MRI. The number of recalls and biopsies needed to detect one cancer by biannual MRI were 2.8 and 1.7 in BRCA1 carriers, 12.0 and 8.0 in BRCA2 carriers, and 11.7 and 5.0 in non-BRCA1/2 carriers, respectively. CONCLUSIONS: Biannual MRI performed well for early detection of invasive breast cancer in genomically stratified high-risk women. No benefit was associated with annual MG screening plus biannual MRI screening.See related commentary by Kuhl and Schrading, p. 1693.

Efficacy of a Weight Loss Intervention for African American Breast Cancer Survivors.

Purpose African American women with breast cancer have higher cancer-specific and overall mortality rates. Obesity is common among African American women and contributes to breast cancer progression and numerous chronic conditions. Weight loss interventions among breast cancer survivors positively affect weight, behavior, biomarkers, and psychosocial outcomes, yet few target African Americans. This article examines the effects of Moving Forward, a weight loss intervention for African American breast cancer survivors (AABCS) on weight, body composition, and behavior. Patients and Methods Early-stage (I-III) AABCS were randomly assigned to a 6-month interventionist-guided (n = 125) or self-guided (n = 121) weight loss program supporting behavioral changes to promote a 5% weight loss. Anthropometric, body composition, and behavioral data were collected at baseline, postintervention (6 months), and follow-up (12 months). Descriptive statistics and mixed models analyses assessed differences between groups over time. Results Mean (± standard deviation) age, and body mass index were 57.5 (± 10.1) years and 36.1 (± 6.2) kg/m2, respectively, and 82% had stage I or II breast cancer. Both groups lost weight. Mean and percentage of weight loss were greater in the guided versus self-guided group (at 6 months: 3.5 kg v 1.3kg; P < .001; 3.6% v 1.4%; P < .001, respectively; at 12 months: 2.7 kg v 1.6 kg; P < .05; 2.6% v 1.6%; P < .05, respectively); 44% in the guided group and 19% in the self-guided group met the 5% goal. Body composition and behavioral changes were also greater in the interventionist-guided group at both time points. Conclusion The study supports the efficacy of a community-based interventionist-guided weight loss program targeting AABCS. Although mean weight loss did not reach the targeted 5%, the mean loss of > 3% at 6 months is associated with improved health outcomes. Affordable, accessible health promotion programs represent a critical resource for AABCS.

The Breast-Thyroid Cancer Link: A Systematic Review and Meta-analysis.

Rates of thyroid cancer in women with a history of breast cancer are higher than expected. Similarly, rates of breast cancer in those with a history of thyroid cancer are increased. Explanations for these associations include detection bias, shared hormonal risk factors, treatment effect, and genetic susceptibility. With increasing numbers of breast and thyroid cancer survivors, clinicians should be particularly cognizant of this association. Here, we perform a systematic review and meta-analysis of the literature utilizing PubMed and Scopus search engines to identify all publications studying the incidence of breast cancer as a secondary malignancy following a diagnosis of thyroid cancer or thyroid cancer following a diagnosis of breast cancer. This demonstrated an increased risk of thyroid cancer as a secondary malignancy following breast cancer [OR = 1.55; 95% confidence interval (CI), 1.44-1.67] and an increased risk of breast cancer as a secondary malignancy following thyroid cancer (OR = 1.18; 95% CI, 1.09-1.26). There is a clear increase in the odds of developing either thyroid or breast cancer as a secondary malignancy after diagnosis with the other. Here, we review this association and current hypothesis as to the cause of this correlation.

Medical Student Knowledge of Oncology and Related Disciplines: a Targeted Needs Assessment.

Despite increasing numbers of cancer survivors, non-oncology physicians report discomfort and little training regarding oncologic and survivorship care. This pilot study assesses medical student comfort with medical oncology, surgical oncology, radiation oncology, hospice/palliative medicine, and survivorship care. A survey was developed with input from specialists in various fields of oncologic care at a National Cancer Institute-designated comprehensive cancer center. The survey included respondent demographics, reports of experience with oncology, comfort ratings with oncologic care, and five clinical vignettes. Responses were yes/no, multiple choice, Likert scale, or free response. The survey was distributed via email to medical students (MS1-4) at two US medical schools. The 105 respondents were 34 MS1s (32 %), 15 MS2s and MD/PhDs (14 %), 26 MS3s (25 %), and 30 MS4s (29 %). Medical oncology, surgical oncology, and hospice/palliative medicine demonstrated a significant trend for increased comfort from MS1 to MS4, but radiation oncology and survivorship care did not. MS3s and MS4s reported the least experience with survivorship care and radiation oncology. In the clinical vignettes, students performed the worst on the long-term chemotherapy toxicity and hospice/palliative medicine questions. Medical students report learning about components of oncologic care, but lack overall comfort with oncologic care. Medical students also fail to develop an increased self-assessed level of comfort with radiation oncology and survivorship care. These pilot results support development of a formalized multidisciplinary medical school oncology curriculum at these two institutions. An expanded national survey is being developed to confirm these preliminary findings.

Long-term results of radiation therapy oncology group 9903: a randomized phase 3 trial to assess the effect of erythropoietin on local-regional control in anemic patients treated with radiation therapy for squamous cell carcinoma of the head and neck.

PURPOSE: This paper reports long-term results of RTOG 9903, to determine whether the addition of erythropoietin (EPO) would improve the outcomes of radiation therapy (RT) in mildly to moderately anemic patients with head and neck squamous cell carcinoma (HNSCCa). METHODS AND MATERIALS: The trial included HNSCCa patients treated with definitive RT. Patients with stage III or IV disease received concomitant chemoradiation therapy or accelerated fractionation. Pretreatment hemoglobin levels were required to be between 9.0 and 13.5 g/dL (12.5 g/dL for females). EPO, 40,000 U, was administered weekly starting 7 to 10 days before RT was initiated in the RT + EPO arm. RESULTS: A total of 141 of 148 enrolled patients were evaluable. The baseline median hemoglobin level was 12.1 g/dL. In the RT + EPO arm, the mean hemoglobin level at 4 weeks increased by 1.66 g/dL, whereas it decreased by 0.24 g/dL in the RT arm. With a median follow-up of 7.95 years (range: 1.66-10.08 years) for surviving patients and 3.33 years for all patients (range: 0.03-10.08 years), the 5-year estimate of local-regional failure was 46.2% versus 39.4% (P=.42), local-regional progression-free survival was 31.5% versus 37.6% (P=.20), and overall survival was 36.9% versus 38.2% (P=.54) for the RT + EPO and RT arms, respectively. Late toxicity was not different between the 2 arms. CONCLUSIONS: This long-term analysis confirmed that despite the ability of EPO to raise hemoglobin levels in anemic patients with HNSCCa, it did not improve outcomes when added to RT. The possibility of a detrimental effect of EPO could not be ruled out.

Hormone replacement therapy and breast cancer: heterogeneous risks by race, weight, and breast density.

BACKGROUND: Although studies have demonstrated a positive association between hormone replacement therapy (HRT) and breast cancer risk, this association may vary by patient factors. METHODS: We analyzed 1642824 screening mammograms with 9300 breast cancer cases in postmenopausal women aged 45 years or older derived from the Breast Cancer Surveillance Consortium, a longitudinal registry of mammography screening in the United States. Multiple imputation methods were used to accommodate missing data for HRT use (14%) and other covariables. We performed logistic regression to estimate odds ratios (ORs) for breast cancer associated with HRT use within strata of race/ethnicity, age, body mass index (BMI), and breast density, with two-way interaction terms between HRT use and each key covariable of interest. P values for assessing possible interactions were computed from Wald z statistics. All statistical tests were two-sided. RESULTS: HRT use was associated with greater than 20% increased risk in white (OR = 1.21; 95% CI = 1.14 to 1.28), Asian (OR = 1.58; 95% CI = 1.18 to 2.11), and Hispanic women (OR = 1.35; 95% CI = 1.09 to 1.67) but not black women (OR = 0.91; 95% CI = 0.72 to 1.14; P interaction = .04). In women with low/normal BMI and extremely dense breasts, HRT use was associated with the highest breast cancer risk (OR = 1.49; 95% CI = 1.21 to 1.83), compared with nonusers. In overweight/obese women with less-dense breasts, no excess risk was associated with HRT use (adjusted ORs = 0.96 to 1.03). CONCLUSIONS: The impact of HRT use on breast cancer risk varies according to race/ethnicity, BMI, and breast density. This risk stratification could help in advising HRT use for the relief of menopausal symptoms.

Factors associated with compliance to adjuvant hormone therapy in Black and White women with breast cancer.

BACKGROUND: Studies have demonstrated lower rates of breast cancer survival for Black versus White women. Factors implicated include later stages at diagnosis, differences in tumor biology, and lower compliance rates to adjuvant hormone therapy (AHT) among Black women with hormone sensitive breast cancer. We examined factors associated with compliance to AHT among Black and White women with invasive breast cancer. METHODS: Women with estrogen receptor positive (ER+), non-metastatic breast cancer were identified by the cancer registry at the University of Chicago Hospital and asked to complete a mail-in survey. Compliance was defined by self-reported adherence to AHT ≥80% at the time of the survey plus medical record verification of persistence (completion of 5 years of AHT). Logistic regression was used to determine factors associated with compliance to AHT. RESULTS: 197 (135 White and 62 Black) women were included in the analysis. 97.4% of patients reported adherence to therapy. 87.4% were found to be persistent to therapy. Overall compliance was 87.7% with no statistically significant racial difference seen (87.9% in White and 87.0% in Black, P = 0.87). For both Black and White women, compliance was strongly associated with both perceived importance of AHT (OR =2.1, 95% CI:1.21-3.68,P = 0.009) and the value placed on their doctor's opinion about the importance of AHT (OR = 4.80, 95% CI: 2.03-11.4, P < 0.001). CONCLUSIONS: In our cohort of Black and White women, perceived importance of AHT and the degree to which they valued their doctor's opinion correlated with overall compliance. This suggests that Black and White women consider similar factors in their decision to take AHT.

The expanding use of third-generation aromatase inhibitors: what the general internist needs to know.

BACKGROUND: Breast cancer patients represent the largest group of adult cancer survivors in the US. Most breast cancers in women 50 years of age and older are hormone receptor positive. Third generation aromatase inhibitors (AIs) are the newest class of drugs used in treating hormone responsive breast cancer. It is often during start of adjuvant hormone therapy that the breast cancer patient establishes (or reestablishes) close follow-up with their general internist. OBJECTIVE: Given the large numbers of breast cancer patients in the US and the increasing use of third generation AI's, general internists will need to have a clear understanding of these drugs including their benefits and potential harms. Currently there are three third generation aromatase inhibitors FDA approved for use in the US. All have been shown to be superior to tamoxifen in disease free survival (DFS) in the treatment of both metastatic and early breast cancers. RESULTS: While the data on side effects is limited, AI (compared to tamoxifen) may result in higher rates of osteoporosis and fractures, more arthralgias, and increased vaginal dryness and dysparuenia. Limited information on their effects on the cardiovascular system and neuro-cognitive function are also available. Patient's receiving adjuvant hormone therapy are generally considered disease free or disease stable and require less intensive monitoring by their breast cancer specialist. CONCLUSIONS: In situations where patients experience significant negative side effects from AI therapy, discussions to discontinue treatment (and switch to an alternative endocrine therapy) should involve the cancer specialist and take into consideration the patient's risk for breast cancer recurrence and the impact of therapy on their quality of life. In some cases, patients may choose to never initiate AI treatment. In other cases, patients may choose to prematurely discontinue therapy even if therapy is well tolerated. In both settings increased knowledge by the general internists will likely facilitate discussions of risks versus benefits of therapy and possibly improve compliance to adjuvant hormone therapy.

Cancer survivorship care: exploring the role of the general internist.

According to the National Cancer Institute (NCI), cancer survivorship encompasses the "physical, psychosocial, and economic issues of cancer from diagnosis until the end of life." Today, one in 30 Americans are cancer survivors. Almost two-thirds have at least one chronic health condition. As the numbers of cancer survivors increase, cancer itself can be viewed as a chronic medical condition. This paper illustrates some of the challenges faced by cancer survivors. We discuss the limitations of current models of survivorship care, including shared care. In addition, we explore how the American Board of Internal Medicine's previously proposed credential of Comprehensive Care Internist could serve to define and integrate the complex needs of adult cancer survivors with the skills and talents of general internists.

Modifiable risk factors for the primary prevention of heart disease in women.

Coronary heart disease is the leading cause of death in women older than 50. This article will discuss the role of modifiable risk factors for the primary prevention of heart disease in women, including hypertension, smoking, obesity, and exercise. We will also address what is known about the role of psychological factors in the development of heart disease in women. Cholesterol and diabetes are discussed only in the context of obesity because both are addressed elsewhere in this issue. Finally, this article will review the evidence on the use of low-dose aspirin and antioxidants in the primary prevention of heart disease in women.