Health Behavior Differences Between Male and Female U.S. Military Personnel by Sexual Orientation: The Importance of Disaggregating Lesbian, Gay, and Bisexual Groups.

INTRODUCTION: The aims of the study are to identify health-related behaviors associated with sexual orientation among active duty military personnel and to compare those behaviors when lesbian, gay, and bisexual (LGB) groups are aggregated and disaggregated. MATERIALS AND METHODS: We used public data from the 2015 Health-Related Behavior Survey of Active Duty Military Personnel. Binomial logistic regression analyses were used to examine differences between and within heterosexual, same-sex, and bisexual groups as predicted by the following correlates: demographic characteristics, physical activity, substance use, probable mood disorders, unwanted sexual contact, physical abuse, suicidal behaviors, and sexually transmitted infection (STI). RESULTS: In univariate analyses, rates of lifetime unwanted sexual contact and lifetime suicidal ideation were significantly higher for bisexual females compared to other groups. The results of regression analyses differed depending on whether LGB groups were aggregated or disaggregated. Aggregated LGB versus heterosexual model found significant differences with respect to unwanted sexual contact, lifetime suicide attempt, STI, smoking, and marijuana use. Disaggregated models found different patterns of significant correlates, e.g., correlates comparing gays to heterosexual males were STI, sexual contact, lifetime suicide attempt, and age; correlates comparing lesbians to heterosexual females were heavy drinking, probable post-traumatic stress disorder, ever used marijuana, lifetime suicide attempt, lifetime physical abuse, and smoking. CONCLUSION: The findings are consistent with those of previous research showing highest risk for suicidal behaviors and substance abuse among bisexual individuals. We recommend that future studies and clinical care consider LGB sexual identities as heterogeneous groups; otherwise, risks for adverse health behaviors may be overlooked.

Literature Review of Vaginal Stenosis and Dilator Use in Radiation Oncology.

PURPOSE: Guidelines for the care of women undergoing pelvic radiation therapy (RT) recommend vaginal dilator therapy (VDT) to prevent radiation-induced vaginal stenosis (VS); however, no standard protocol exists. This review seeks to update our current state of knowledge concerning VS and VDT in radiation oncology. METHODS AND MATERIALS: A comprehensive literature review (1972-2017) was conducted using search terms "vaginal stenosis," "radiation," and "vaginal dilator." Information was organized by key concepts including VS definition, time course, pathophysiology, risk factors, and interventions. RESULTS: VS is a well-described consequence of pelvic RT, with early manifestations and late changes evolving over several years. Strong risk factors for VS include RT dose and volume of vagina irradiated. Resultant vaginal changes can interfere with sexual function and correlational studies support the use of preventive VDT. The complexity of factors that drive noncompliance with VDT is well recognized. There are no prospective data to guide optimal duration of VDT, and the consistency with which radiation oncologists monitor VS and manage its consequences is unknown. CONCLUSIONS: This review provides information concerning VS definition, pathophysiology, and risk factors and identifies domains of VDT practice that are understudied. Prospective efforts to monitor and measure outcomes of patients who are prescribed VDT are needed to guide practice.

Mental health comorbidities and cost/utilization outcomes in head and neck cancer patients.

PURPOSE: Examine the relationship between mental health comorbidities and health services outcomes in non-elderly adults with head and neck cancer (HNC). DESIGN: Retrospective, cross-sectional. SAMPLE: Non-elderly adults with a primary diagnosis of HNC in U.S. Department of Defense (TRICARE) administrative claims data for fiscal years (FY) 2007-2014. METHODS: Linear regression and generalized linear models were used to examine predictors of reimbursed cost and healthcare utilization, respectively. FINDINGS: On average, there were 2944 HNC patients each year, the majority age 55-64, male, military retirees or family members of retirees, cared for in civilian facilities, and residing in the U.S. southern region. Between FY2007 and FY2014, there were slight increases in prevalence rates for diagnosed depression (12.4%-13.1%), anxiety (8.2%-11.9%), adjustment disorders (3.7%-5.8%), and drug use disorders (10.3%-19.4%), and a slight decrease in alcohol use disorders (12.3%-11.4%). In the cost regression model, depression and anxiety were the seventh and eighth strongest predictors (p < .001), behind hospice use, treatment modalities, chronic physical conditions, and tobacco use. In the utilization regression models, depression, adjustment disorder, and anxiety ranked seventh, ninth, and eleventh as the strongest predictors for the number of ambulatory visits; anxiety, depression and substance use disorder ranked fifth, sixth, and eighth in the model examining predictors of the number of annual hospitalizations; and anxiety and depression ranked fifth and sixth in the model examining predictors of the annual number of bed days. CONCLUSIONS: We found strong evidence that mental health comorbidities impact cost and utilization among HNC patients, independent of other factors. Implications for Psychosocial Providers or Policy: Addressing mental health comorbidities among HNC patients may reduce cost and improve resource efficiency.

Cost and Healthcare Utilization Among Non-Elderly Head and Neck Cancer Patients in the Military Health System, a Single-Payer Universal Health Care Model.

INTRODUCTION: Examining costs and utilization in a single-payer universal health care system provides information on fiscal and resource burdens associated with head and neck cancer (HNC). Here, we examine trends in the Department of Defense (DoD) HNC population with respect to: (1) reimbursed annual costs and (2) patterns and predictors of health care utilization in military only, civilian only, and both systems of care (mixed model). MATERIALS AND METHODS: A retrospective, cross-sectional study was conducted using TRICARE claims data from fiscal years 2007 through 2014 for reimbursement of ambulatory, inpatient, and pharmacy charges. The study was approved by the Defense Health Agency Office of Privacy and Civil Liberties as exempt from institutional review board full review. The population was all beneficiaries, age 18-64, with a primary ICD-9 diagnosis of HNC, on average, 2,944 HNC cases per year. The outcomes of regression models were total reimbursed health care cost, and counts of ambulatory visits, hospitalizations, and bed days. The predictors were fiscal year, demographic variables, hospice use, type and geographic region of TRICARE enrollment, use of military or civilian care or mixed use, cancer treatment modalities, the number of physical and mental health comorbid conditions, and tobacco use. A priori, null hypotheses were assumed. RESULTS: Per annual average, 61% of the HNC population was age 55-64, and 69% were males. About 6% accessed military facilities only for all health care, 60% accessed civilian only, and 34% accessed both military and civilian facilities. Patients who only accessed military care had earlier stage disease as indicated by rates of single modality treatment and hospice use; military care only and mixed use had similar rates of combination treatment and hospice use. The average cost per patient per year was $14,050 for civilian care only, $13,036 for military care only, and $29,338 for mixed use of both systems. The strongest predictors of higher cost were chemotherapy, radiation therapy, head and neck surgery, hospice care, and mixed-use care. The strongest predictors of health care utilization were chemotherapy, use of hospice, the number of physical and mental health comorbidities, radiation therapy, head and neck surgery, and system of care. CONCLUSIONS: To a single payer, the use of a single system of care exclusively among HNC patients is more cost-effective than use of a mixed-use system. The results suggest an over-utilization of ambulatory care services when both military and civilian care are accessed. Further investigation is needed to assess coordination between systems of care and improved efficiencies with respect to the cost and apparent over-utilization of health care services.

Purchased Behavioral Health Care Received by Military Health System Beneficiaries in Civilian Medical Facilities, 2000-2014.

Introduction: Behavioral health conditions are a significant concern for the U.S. military and the Military Health System (MHS) because of decreased military readiness and increased health care utilization. Although MHS beneficiaries receive direct care in military treatment facilities, a disproportionate majority of behavioral health treatment is purchased care received in civilian facilities. Yet, limited evidence exists about purchased behavioral health care received by MHS beneficiaries. This longitudinal study (1) estimated the prevalence of purchased behavioral health care and (2) identified patient and visit characteristics predicting receipt of purchased behavioral health care in acute care facilities from 2000 to 2014. Materials and Methods: Medical claims with Major Diagnostic Code 19 (mental disorders/diseases) or 20 (alcohol/drug disorders) as primary diagnoses and TRICARE as the primary/secondary payer were analyzed for MHS beneficiaries (n = 17,943) receiving behavioral health care in civilian acute care facilities from January 1, 2000, to December 31, 2014. The primary dependent variable, receipt of purchased behavioral health care, was modeled for select mental health and substance use disorders from 2000 to 2014 using generalized estimating equations. Patient characteristics included time, age, sex, and race/ethnicity. Visit types included inpatient hospitalization and emergency department (ED). Time was measured in days and visits were assumed to be correlated over time. Behavioral health care was described by both frequency of patients and visit type. The University of South Carolina Institutional Review Board approved this study. Results: From 2000 to 2014, purchased care visits increased significantly for post-traumatic stress disorder, adjustment, anxiety, mood, bipolar, tobacco use, opioid/combination opioid dependence, nondependent cocaine abuse, psychosocial problems, and suicidal ideation among MHS beneficiaries. The majority of care was received for mental health disorders (78.8%) and care was most often received in EDs (56%). Most commonly treated diagnoses included mood, tobacco use, and alcohol use disorders. ED visits were associated with being treated for anxiety (excluding post-traumatic stress disorder; Adjusted odds ratio [AOR]: 9.14 [95% confidence interval (CI): 8.26, 10.12]), alcohol use disorders (AOR = 1.67 [95% CI: 1.53, 1.83]), tobacco use (AOR = 1.16 [95% CI: 1.06, 1.26]), nondependent cocaine abuse (AOR = 5.47 [95% CI: 3.28, 9.12]), nondependent mixed/unspecified drug abuse (AOR = 7.30 [95% CI: 5.11, 10.44]), and psychosis (AOR = 1.38 [95% CI: 1.20, 1.58]). Compared with adults age 60 yr and older, adolescents (ages 12-17 yr), and adults under age 60 yr were more likely to be treated for suicidal ideation, adjustment, mood, bipolar, post-traumatic stress disorder, nondependent cocaine, and mixed/unspecified drug abuse. Adults under age 60 yr also had increased odds of being treated for tobacco use disorders, alcohol use disorders, and opioid/combination opioid dependence compared with adults age 60 yr and older. Conclusions: Over the past 15 yr, purchased behavioral health care received by MHS beneficiaries in acute care facilities increased significantly. MHS beneficiaries received the majority of purchased behavioral health care for mental health disorders and were treated most often in the ED. Receiving behavioral health care in civilian EDs raises questions about access to outpatient behavioral health care and patient-centered care coordination between civilian and military facilities. Given the influx of new Veterans Health Administration users from the MHS, findings have implications for military, veteran, and civilian facilities providing behavioral health care to military and veteran populations.

Perceived Deterrence of Cigarette Use and Smoking Status Among Active Duty Military Personnel.

BACKGROUND: Tobacco use in the military adversely affects fitness, readiness and performance levels, and increases health care costs. In 2011, cigarette use in the military was higher than in the civilian population (24.0% vs. 21.2%). We examined the perceptions of active duty service members with respect to supervisory and military installation determent of cigarette smoking. METHODS: Using the Department of Defense's 2011 Health-Related Behaviors Survey (HRBS) of active duty military personnel (N = 39,877) data, a multivariate logistic regression estimated the association of personnel's perception of leadership discouraging cigarette use with smoking status, controlling for covariates (n = 23,354). RESULTS: Those who perceived their supervisor as "Somewhat" (adjusted odds ratio [AOR] 1.41, 95% confidence interval [CI] [1.29, 1.54]) or "Strongly" (AOR 1.22, 95% CI [1.09, 1.37]) discouraging of cigarette use had higher odds of smoking compared to those who perceived supervisors "Not at all" discouraging use. Odds of currently smoking increased with perceptions of increasing discouragement by installation, from "Somewhat" (AOR 1.64, 95% CI [1.49, 1.80]) to "Strongly discourages" cigarette use (AOR 1.71, 95% CI [1.50, 1.95]). As expected, the strongest correlate of current smoking was having friends who smoke (AOR 13.62, 95% CI [11.53, 16.07]). Other significant covariates in the model focused on current smokers included high risk for alcohol problems, specifically hazardous drinking (AOR 2.57, 95% CI [2.25, 2.93]), harmful drinking (AOR 5.46, 95% CI [3.57, 8.35]), and possible alcohol dependence (AOR 1.43, 95% CI [1.07, 1.91]); being underweight (AOR 1.72, 95% CI [1.19, 2.53]); high anxiety (AOR 1.31, 95% CI [1.18, 1.46]); high anger (AOR 1.20, 95% CI [1.03, 1.39]); and high overall stress (AOR 1.17, 95% CI [1.07, 1.27]). Among the demographic covariates, higher rates of smoking were found in all levels of enlisted military rank, most notably among E1-E4 (AOR 7.22, 95% CI [5.64, 9.21]) and E4-E% (AOR 8.60, 95% CI [6.79, 10.91]); non-Air Force affiliation; longer length of combat experience; males; non-Hispanic whites; married personnel without a spouse present; job classifications in combat, administration, maintenance, or food service; and duty station in the continental United States. Additional analyses found that personnel with high overall stress were less likely to perceive their supervisor (odds ratio 0.67, 95% CI [0.62, 0.73]) and installation (odds ratio 0.69, 95% CI [0.63, 0.76]) as strongly discouraging smoking compared to those with low overall stress. CONCLUSION: Perceived influence of tobacco deterrence by military leadership is associated with smoking behaviors of active duty personnel. Paradoxically, those who perceived the strongest discouragement by military leadership had the highest rates of smoking. We hypothesize that current smokers may have a heightened awareness of antismoking messages and policies, and are more sensitive to threats that impinge upon freedom to smoke or aim to restrict a substance used for stress reduction. Results support military tobacco control efforts extending beyond individual-level approaches. A focus on multilevel influences of health behavior, emphasizing effective leadership, social and environmental changes, is needed to address military smoking behaviors.

Assessment of vulvar discomfort with sexual activity among women in the United States.

BACKGROUND: Multidimensional self-report measures of sexual function for women do not include the assessment of vulvar discomfort, limiting our understanding of its prevalence. In an effort to improve the measurement of patient-reported health, the National Institutes of Health funded the creation of the Patient Reported Outcomes Measurement Information System (PROMIS). This included the development of the PROMIS Sexual Function and Satisfaction measure, and version 2.0 of the Sexual Function and Satisfaction measure included 2 scales to measure vulvar discomfort with sexual activity. OBJECTIVES: The objectives of the study were to describe the development of 2 self-reported measures of vulvar discomfort with sexual activity, describe the relationships between these scales and scales for lubrication and vaginal discomfort, and report the prevalence of vulvar discomfort with sexual activity in a large, nationally representative sample of US women. STUDY DESIGN: We followed PROMIS measure development standards, including qualitative development work with patients and clinicians and psychometric evaluation of candidate items based on item response theory, in a probability sample of 1686 English-speaking US adult women. We tested 16 candidate items on vulvar discomfort. We present descriptive statistics for these items, correlation coefficients among the vulvar and vaginal scales, and mean PROMIS scores with 95% confidence intervals separately by menopausal status for the 1046 women who reported sexual activity in the past 30 days. RESULTS: Based on the psychometric evaluation of the candidate items, we created 2 separate 4 item scales, one to measure labial discomfort and pain and one to measure clitoral discomfort and pain. Additional items not included in the scales assess pain quality, numbness, and bleeding. The correlations between the lubrication, vaginal discomfort, and the 2 vulvar discomfort measures ranged from 0.46 to 0.77, suggesting that these measures represent related yet distinct concepts. In our nationally representative sample, 1 in 5 US women endorsed some degree of vulvar discomfort with sexual activity in the past 30 days. Menopausal status was associated with lower lubrication and higher vaginal discomfort but not with vulvar discomfort. CONCLUSION: The PROMIS Vulvar Discomfort with Sexual Activity-Labial and Vulvar Discomfort with Sexual Activity-Clitoral scales are publicly available for use in research and clinical settings. There is limited overlap between vulvar discomfort and lubrication or vaginal discomfort. The importance of measuring vulvar discomfort as part of a comprehensive assessment of sexual function is underscored by its prevalence.

Development and Initial Validation of the PROMIS(®) Sexual Function and Satisfaction Measures Version 2.0.

INTRODUCTION: The Patient-Reported Outcomes Measurement Information System (PROMIS)(®) Sexual Function and Satisfaction measure (SexFS) version 1.0 was developed with cancer populations. There is a need to expand the SexFS and provide evidence of its validity in diverse populations. AIM: The aim of this study was to describe the development of the SexFS v2.0 and present preliminary evidence for its validity. METHODS: Development built on version 1.0, plus additional review of extant items, discussions with 15 clinical experts, 11 patient focus groups (including individuals with diabetes, heart disease, anxiety, depression, and/or are lesbian, gay, bisexual, or aged 65 or older), 48 cognitive interviews, and psychometric evaluation in a random sample of U.S. adults plus an oversample for specific sexual problems (2281 men, 1686 women). We examined differential item functioning (DIF) by gender and sexual activity. We examined convergent and known-groups validity. RESULTS: The final set of domains includes 11 scored scales (interest in sexual activity, lubrication, vaginal discomfort, clitoral discomfort, labial discomfort, erectile function, orgasm ability, orgasm pleasure, oral dryness, oral discomfort, satisfaction), and six nonscored item pools (screeners, sexual activities, anal discomfort, therapeutic aids, factors interfering with sexual satisfaction, bother). Domains from version 1.0 were reevaluated and improved. Domains considered applicable across gender and sexual activity status, namely interest, orgasm, and satisfaction, were found to have significant DIF. We identified subsets of items in each domain that provided consistent measurement across these important respondent groups. Convergent and known-groups validity was supported. CONCLUSIONS: The SexFS version 2.0 has several improvements and enhancements over version 1.0 and other extant measures, including expanded evidence for validity, scores centered around norms for sexually active U.S. adults, new domains, and a final set of items applicable for both men and women and those sexually active with a partner and without. The SexFS is customizable, allowing users to select relevant domains and items for their study.

Self-Reported Sexual Function Measures Administered to Female Cancer Patients: A Systematic Review, 2008-2014.

A systematic review was conducted to identify and characterize self-reported sexual function (SF) measures administered to women with a history of cancer. Using 2009 PRISMA guidelines, we searched electronic bibliographic databases for quantitative studies published January 2008-September 2014 that used a self-reported measure of SF, or a quality of life (QOL) measure that contained at least 1 item pertaining to SF. Of 1,487 articles initially identified, 171 were retained. The studies originated in 36 different countries with 23% from US-based authors. Most studies focused on women treated for breast, gynecologic, or colorectal cancer. About 70% of the articles examined SF as the primary focus; the remaining examined QOL, menopausal symptoms, or compared treatment modalities. We identified 37 measures that assessed at least one domain of SF, eight of which were dedicated SF measures developed with cancer patients. Almost one third of the studies used EORTC QLQ modules to assess SF, and another third used the Female Sexual Function Inventory. There were few commonalities among studies, though nearly all demonstrated worse SF after cancer treatment or compared to healthy controls. QOL measures are better suited to screening while dedicated SF questionnaires provide data for more in depth assessment. This systematic review will assist oncology clinicians and researchers in their selection of measures of SF and encourage integration of this quality of life domain in patient care.

Development and Validation of a Single-Item Screener for Self-Reporting Sexual Problems in U.S. Adults.

BACKGROUND: Brief self-assessment of sexual problems in a clinical context has the potential to improve care for patients through the ability to track trends in sexual problems over time and facilitate patient-provider communication about this important topic. However, instruments designed for research are typically too long to be practical in clinical practice. OBJECTIVE: To develop and validate a single-item self-report clinical screener that would capture common sexual problems and concerns for men and women. DESIGN: We created three candidate screener items, refined them through cognitive interviews, and administered them to a large sample. We compared the prevalence of responses to each item and explored the discrepancies between items. We evaluated the construct validity of the items by comparing them to scores on the Patient-Reported Outcomes Measurement Information System® Sexual Function and Satisfaction (PROMIS® SexFS) measure. PARTICIPANTS: Local patients participated in two rounds of cognitive interviews (n = 7 and n = 11). A probability-based random sample of U.S. adults comprised the item-testing sample (n = 3517). MAIN MEASURES: The items were as follows: 1) a yes/no item on any sexual problems or concerns ("general screener"), 2) a yes/no item on problems experienced for 3 months or more during the past 12 months, with a list of examples ("long list screener"), and 3) an item identical to the long list screener except that examples appeared individually as response options and respondents could check all that applied ("checklist screener"). KEY RESULTS: All of the screeners tested showed evidence for basic validity and had minimal missing data. Percentages of women and men endorsing the screeners were 10 % and 15 % (general); 20 % and 17 % (long list); and 38 % and 30 % (checklist), respectively. Participants who endorsed the screeners had lower function compared to those who did not endorse them. CONCLUSIONS: We recommend the checklist screener for its specificity and ability to identify specific problems associated with decreased sexual function.

Prevalence, health care utilization, and costs of fibromyalgia, irritable bowel, and chronic fatigue syndromes in the military health system, 2006-2010.

OBJECTIVE: We compared prevalence, health care utilization, and costs over time for nonelderly adults diagnosed with fibromyalgia syndrome (FMS), irritable bowel syndrome (IBS), and chronic fatigue syndrome (CFS) in relation to timing of federal approvals for FMS drugs. DATA SOURCE: We used military health care claims from October 2006 to September 2010. STUDY DESIGN/ANALYSIS: Retrospective, multiple-year comparisons were conducted using trend analyses, and time series regression-based generalized linear models. RESULTS: Over 5 years, FMS prevalence rates increased from 0.307% to 0.522%, whereas IBS and CFS prevalence rates remained stable. The largest increase in FMS prevalence occurred between 2007 and 2008. Health care utilization was higher for FMS cases compared to IBS and CFS cases. Over 5 years, the total cost for FMS-related care increased $163.2 million, whereas IBS costs increased $14.9 million and CFS cost increased $3.7 million. Between 2006 and 2010, total pharmacy cost for FMS cases increased from $55 million ($3,641/person) to $96.3 million ($3,557/person). CONCLUSION: Although cause and effect cannot be established, the advent of federally approved drugs for FMS in concert with pharmaceutical industry marketing of these drugs coincide with the observed changes in prevalence, health care utilization, and costs of FMS relative to IBS and CFS.

Breast conserving surgery versus mastectomy: the influence of comorbidities on choice of surgical operation in the Department of Defense health care system.

BACKGROUND: Studies on the effect of comorbidities on breast cancer operation have been limited and inconsistent. This study investigated whether pre-existing comorbidities influenced breast cancer surgical operation in an equal access health care system. METHODS: This study was based on linked Department of Defense cancer registry and medical claims data. The study subjects were patients diagnosed with stage I to III breast cancer during 2001 to 2007. Logistic regression was used to determine if comorbidity was associated with operation type and time between diagnosis and operation. RESULTS: Breast cancer patients with comorbidities were more likely to receive mastectomy (odds ratio [OR] = 1.27; 95% confidence interval [CI], 1.14 to 1.42) than breast conserving surgery plus radiation. Patients with comorbidities were also more likely to delay having operation than those without comorbidities (OR = 1.27; 95% CI, 1.14 to 1.41). CONCLUSIONS: In an equal access health care system, comorbidity was associated with having a mastectomy and with a delay in undergoing operation.

Development of the NIH PROMIS ® Sexual Function and Satisfaction measures in patients with cancer.

INTRODUCTION: We describe the development and validation of the Patient-Reported Outcomes Measurement Information System(®) Sexual Function and Satisfaction (PROMIS(®) SexFS; National Institutes of Health) measures, version 1.0, for cancer populations. AIM: To develop a customizable self-report measure of sexual function and satisfaction as part of the U.S. National Institutes of Health PROMIS Network. METHODS: Our multidisciplinary working group followed a comprehensive protocol for developing psychometrically robust patient-reported outcome measures including qualitative (scale development) and quantitative (psychometric evaluation) development. We performed an extensive literature review, conducted 16 focus groups with cancer patients and multiple discussions with clinicians, and evaluated candidate items in cognitive testing with patients. We administered items to 819 cancer patients. Items were calibrated using item-response theory and evaluated for reliability and validity. MAIN OUTCOME MEASURES: The PROMIS SexFS measures, version 1.0, include 81 items in 11 domains: Interest in Sexual Activity, Lubrication, Vaginal Discomfort, Erectile Function, Global Satisfaction with Sex Life, Orgasm, Anal Discomfort, Therapeutic Aids, Sexual Activities, Interfering Factors, and Screener Questions. RESULTS: In addition to content validity (patients indicate that items cover important aspects of their experiences) and face validity (patients indicate that items measure sexual function and satisfaction), the measure shows evidence for discriminant validity (domains discriminate between groups expected to be different) and convergent validity (strong correlations between scores on PROMIS and scores on conceptually similar older measures of sexual function), as well as favorable test-retest reliability among people not expected to change (interclass correlations from two administrations of the instrument, 1 month apart). CONCLUSIONS: The PROMIS SexFS offers researchers a reliable and valid set of tools to measure self-reported sexual function and satisfaction among diverse men and women. The measures are customizable; researchers can select the relevant domains and items comprising those domains for their study.

Quality of cancer survivorship care in the military health system (TRICARE).

PURPOSE: Following the acute phase of treatment, national guidelines recommend cancer survivors have routine contact with health care providers and undergo basic ancillary testing while avoiding high-cost imaging (HCI). We conducted this study to determine how frequently breast, prostate, and colorectal cancer survivors received recommended follow-up care and HCI tests during the survivorship period. METHODS: Using administrative data from TRICARE beneficiaries, we identified a cohort of patients who were treated for breast, prostate, or colorectal cancer between October 2005 and March 2007. These patients were then followed through September 2010. During the 3 years after initial treatment, we determined how frequently survivors received all minimum recommended survivorship care as defined by national guidelines and underwent HCI tests and if these outcomes varied by geographic region. RESULTS: Overall, 3148 patients underwent treatment for breast (n = 1630), prostate (n = 1173), or colorectal (n = 345) cancer. Sixty-five percent received all minimum recommended care over 3 years (breast = 74.1%, prostate = 65.3%, colorectal = 25.5%). During the 3-year period, 74.1% of breast cancer survivors received a mammogram each year, whereas 69.1% of colorectal cancer survivors had at least 1 colonoscopy. Sixty-four percent had at least 1 HCI study during the 3-year period (positron emission tomography = 10.9%, computer tomography = 48.8%, magnetic resonance imaging = 36.6%) at a cost of $3.5 million. Substantial state-level variation was noted for both outcomes. DISCUSSION: Some cancer survivors do not receive recommended care following initial treatment while frequently undergoing HCI. The existing geographic variation in quality and imaging utilization suggests that improvements to cancer survivorship care are possible.

Changes in short-term health-related quality of life in women undergoing gynecologic oncologic laparotomy: an associated factor analysis.

PURPOSE: The primary purpose of this study is to evaluate health-related quality of life (HR-QOL) of gynecologic cancer patients undergoing laparotomy. METHODS: Women who underwent laparotomy by gynecologic cancer completed the European Organization for Research and Treatment of Cancer (EORTC) Quality of life questionnaires (QLQ-C30 and QLQ-OV28) presurgery and at 1 month. RESULTS: Of the 181 women studied between January 2007 and March 2008, 116 women (64.1%) had ovarian cancer, 27 (14.9%) had cervical cancer, and 29 (16.0%) had endometrial cancer. By 1 month post-surgery, there was a significant decrease in HR-QOL on the global, abdominal/gastrointestinal (GI) score, body image, chemotherapy side effects, and other single items of the OV28 questionnaire, as well as on physical, role and social functioning, fatigue, nausea and vomiting, pain, insomnia, constipation, appetite loss, and financial difficulties items on C30 questionnaires. Emotional functioning on C30 questionnaires was significantly improved 1 month after surgery. The majority of these items persisted 1 month after surgery only in patients with ovarian cancer. Abdominal/GI score on OV28 questionnaires as well as role and physical functioning on C30 questionnaires were significantly lower between baseline and postsurgical HR-QOL in women with other gynecologic malignancies. CONCLUSION: The results suggest a significant impact of HR-QOL among gynecologic cancer patients 1 month after laparotomy, particularly among those with ovarian cancer.

Patient experiences with communication about sex during and after treatment for cancer.

OBJECTIVE: We studied patients' experiences with oncology providers regarding communication about sexual issues during and after treatment for cancer. METHODS: During development of the Patient-Reported Outcomes Measurement Information System (PROMIS(®)) Sexual Function measure, we collected focus group and survey data on communication with oncology professionals about sexual problems. We conducted 16 focus groups with patients and survivors (n = 109) and analyzed the discussions for major themes, including experiences discussing sex during oncology visits. During testing of the PROMIS Sexual Function measure, we assessed experiences discussing sexual problems with oncology professionals (n = 819) and measured bivariate associations between asking for information from clinicians and sexual function and satisfaction with sex life. RESULTS: Most patients and survivors (74%) thought that discussions with oncology professionals about sexual problems were important, but whether they had ever received information about sexual function from a provider varied by cancer type (23% lung, 29% breast, 39% colorectal, and 79% prostate). Those who had asked an oncology professional about sexual problems had significantly greater interest in sexual activity as well as more sexual dysfunction. CONCLUSIONS: Sexual problems are a widespread concern among patients and survivors, but there is much variation in experiences of communication about sexual issues, and many patients do not receive the information they need from their oncology providers. There are large differences in sexual function between patients who do and do not ask providers about sexual problems. Sexual health has yet to be fully integrated into oncology care, even for cancers involving sex organs.

Sexual functioning along the cancer continuum: focus group results from the Patient-Reported Outcomes Measurement Information System (PROMIS®).

OBJECTIVE: Cancer and treatments for cancer affect specific aspects of sexual functioning and intimacy; however, limited qualitative work has been done in diverse cancer populations. As part of an effort to improve measurement of self-reported sexual functioning, we explored the scope and importance of sexual functioning and intimacy to patients across cancer sites and along the continuum of care. METHODS: We conducted 16 diagnosis- and sex-specific focus groups with patients recruited from the Duke University tumor registry and oncology/hematology clinics (N=109). A trained note taker produced field notes summarizing the discussions. An independent auditor verified field notes against written transcripts. The content of the discussions was analyzed for major themes by two independent coders. RESULTS: Across all cancers, the most commonly discussed cancer- or treatment-related effects on sexual functioning and intimacy were fatigue, treatment-related hair loss, weight gain and organ loss or scarring. Additional barriers were unique to particular diagnoses, such as shortness of breath in lung cancer, gastrointestinal problems in colorectal cancers and incontinence in prostate cancer. Sexual functioning and intimacy were considered important to quality of life. While most effects of cancer were considered negative, many participants identified improvements to intimacy after cancer. CONCLUSION: Overall evaluations of satisfaction with sex life did not always correspond to specific aspects of functioning (e.g. erectile dysfunction), presenting a challenge to researchers aiming to measure sexual functioning as an outcome. Health-care providers should not assume that level of sexual impairment determines sexual satisfaction and should explore cancer patients' sexual concerns directly.

Cancer screening practices among racially and ethnically diverse breast cancer survivors: results from the 2001 and 2003 California health interview survey.

INTRODUCTION: Women treated for breast cancer are at increased risk for developing second or new cancers. This study examined behavioral and health care utilization practices associated with screening behaviors for mammography, Papanicolaou (Pap), home fecal occult blood test (FOBT) and endoscopy (flexible sigmoidoscopy, colonoscopy, proctoscopy) among racially and ethnically diverse female breast cancer survivors (BCS) and women without a cancer history. METHODS: Data from the 2001 and 2003 California Health Interview Survey (CHIS), a random-digit dial population-based survey of adult respondents was used to examine self-reported screening practices of BCS (n = 1,502) and women without a cancer history (n = 31,911). RESULTS: Compared to women without a cancer history, BCS reported more recent screening for all tests. Among BCS, Hispanics reported lowest screening for routine mammography (84.2% versus 68.9%; P < 0.05) but highest screening for Pap test (95.4% versus 85.4%; P > 0.01). White and Asian BCS reported more endoscopic examinations (58.9% versus 46.5%; P < 0.001; 61.2% versus 38.4%; P < 0.05) than the comparison population. After adjustment for demographic, socioeconomic, and health status differences, screening rates for BCS showed higher mammography use (odds ratio [OR] 1.97; 95% confidence interval [95% CI] 1.58-2.46), Pap test (OR 1.44; 95% CI 1.22-1.70), and endoscopic use (OR 1.35; 95% CI 1.16-1.58), but not higher for FOBT. CONCLUSIONS: Even though BCS generally had higher cancer screening rates than women without a cancer history, racial/ethnic differences exist among the type of test received. Narrowing these differences is essential to lessen disparities. IMPLICATIONS FOR CANCER SURVIVORS: The need for screening guidelines for BCS remains a high priority. Survivors would benefit from the frequency of screening for all cancers post-treatment.

Using cognitive interviews to evaluate items for measuring sexual functioning across cancer populations: improvements and remaining challenges.

PURPOSE: One goal of the Patient-Reported Outcomes Measurement Information System (PROMIS) is to develop a measure of sexual functioning that broadens the definition of sexual activity and incorporates items that reflect constructs identified as important by patients with cancer. We describe how cognitive interviews improved the quality of the items and discuss remaining challenges to assessing sexual functioning in research with cancer populations. METHODS: We conducted 39 cognitive interviews of patients with cancer and survivors on the topic of sexual experience. Each of the 83 candidate items was seen by 5-24 participants. Participants included both men and women and varied by cancer type, treatment trajectory, race, and literacy level. Significantly revised items were retested in subsequent interviews. RESULTS: Cognitive interviews provided useful feedback about the relevance, sensitivity, appropriateness, and clarity of the items. Participants identified broad terms (e.g., "sex life") to assess sexual experience and exposed the challenges of measuring sexual functioning consistently, considering both adjusted and unadjusted sexual experiences. CONCLUSIONS: Cognitive interviews were critical for item refinement in the development of the PROMIS measure of sexual function. Efforts are underway to validate the measure in larger cancer populations.

U.S. Latino population composition change and comprehensive cancer centers.

BACKGROUND: We describe a typology characterizing population trends of U.S. Latinos/Hispanics from 1990 to 2000 with respect to National Cancer Institute-designated comprehensive cancer centers (CCCs) and corresponding consolidated metropolitan statistical or metropolitan statistical areas (CMSA/MSAs). METHODS: Using U.S. Census Bureau data, we constructed population pyramids to analyze population growth and composition for each CMSA/MSA with a CCC. RESULTS: We identified four types of population growth and composition: Type I--Very Fast and Unstable; Type II--Fast and Unstable; Type III--Somewhat Fast and Stable; Type IV--Slow and Stable. CONCLUSIONS: The CCCs in areas with Types I and II population growth face the greatest challenges because of the lack of infrastructure for reaching medically underserved Latinos. In contrast, CCCs in areas with Types III and IV population growth may have significant infrastructure but must quickly develop interventions to reach and provide access to aging Latinos to reduce health disparities in cancer mortality and morbidity.