Implementation of a Novel Medical School Multidisciplinary and Interprofessional Oncology Curriculum: a Mixed Method Study.

As the population of patients with cancer and survivors grows, physician knowledge of oncology clinical care and research is increasingly important. Despite this patient population growth, medical students and non-oncology physicians report insufficient oncologic and survivorship care training. First-year students at a single US medical school completing a summer research experience were invited to participate in integrated Scholars in Oncology-Associated Research (SOAR) program. SOAR seeks to broaden students' understanding of multidisciplinary and interprofessional oncology clinical care and research. SOAR consists of three components: structured didactics, multidisciplinary tumor board attendance, and interprofessional shadowing. A mixed-methods approach investigated whether student knowledge improved after SOAR. Thirty-three students enrolled in SOAR (20 in 2015, 13 in 2016) and completed pre-assessments. Twenty-five (75.8%) students completed SOAR and post-assessments. Self-reported understanding of clinical (2[2, 3] vs. 4[4], p < 0.01) and research oncology (2[2, 3] vs. 4[4], p < 0.01) improved after SOAR. Understanding of individual disciplines also significantly improved. When describing clinical oncology, responses written post-SOAR were more comprehensive, averaging 3.7 themes per response vs. 2.8 on pre-assessments (p = 0.03). There were more references to "survivorship" as a component of oncology on post-assessments (0[0.0%] vs. 7[28.0%], p < 0.01) and "screening/prevention" (2[6.1%] vs. 7[28.0%], p = 0.03). Additionally, students more often described cancer care as a continuum on post-assessments (4[12.1%] vs. 11[44.0%], p = 0.01). A structured didactic and experiential introduction to oncology, SOAR, was successfully piloted. SOAR improved participant understanding of oncology and its distinct clinical and research disciplines. Future work will focus on expanding SOAR into a longitudinal oncology curriculum.

Promotion of self-management for post treatment cancer survivors: evaluation of a risk-adapted visit.

PURPOSE: The LIFE Cancer Survivorship Program at NorthShore University HealthSystem provides risk-adapted visits (RAV) facilitated by an oncology nurse during which a survivorship care plan (SCP) is provided and discussed. In this report, we describe and evaluate RAV in promoting individualized health care and self-management during survivorship transition. METHODS: Patients complete a post-RAV questionnaire at their RAV and another ≥1 year after their RAV. RESULTS: One thousand seven hundred thirteen (1713) RAVs, majority for breast cancer, occurred from January 2007 to March 2014. One thousand six hundred fifteen (1615) "day-of" post-RAV questionnaires were completed. Respondents scaled statements as strongly agree/agree/disagree/strongly disagree. Combined strongly agree/agree ratings are 94 % felt more confident in communicating information about their treatments to other health care providers, 90 % felt more comfortable recognizing signs/symptoms to report to providers, and 98 % had a better appreciation for community programs/services. Of 488 respondents (RAV January 2007 to December 2012 n = 1366) to a questionnaire at least 1 year after the RAV, nearly 100 % found SCP useful to summarize medical information, 97 % to reinforce follow-up, 85 % to recognize symptoms of recurrence, 93 % to identify healthy lifestyle practices, 91 % to assist in identifying resources for support, 72 % discussed their SCP with their healthcare provider, and 97 % made at least one positive lifestyle change. CONCLUSIONS: Participation in LIFE RAV following treatment helps survivors to guide future self-care behavior. Data suggest that benefits may persist 1 year after the visit and support the feasibility of a nurse-led RAV to establish a SCP in cancer survivors. IMPLICATIONS FOR CANCER SURVIVORS: Combined provision and discussion of SCPs help survivors construct a useful understanding of their cancer experience and may promote long-term self-management.

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.

Prospective analysis of association between statin use and breast cancer risk in the women's health initiative.

BACKGROUND: Statins are a class of cholesterol-lowering drugs that affect many intracellular pathways that may have implications for chemoprevention against cancer. Epidemiologic data on statins and breast cancer are conflicting. We analyzed updated data from the Women's Health Initiative (WHI) to assess the relationship between statins and breast cancer risk. METHODS: The population included 154,587 postmenopausal women ages 50 to 79 years, with 7,430 pathologically confirmed cases of breast cancer identified over an average of 10.8 (SD, 3.3) years. Information on statins was collected at baseline and years one, three, six, and nine. Self- and interviewer-administered questionnaires were used to collect information on risk factors. Cox proportional hazards regression was used to calculate HRs with 95% confidence intervals (CI) to evaluate the relationship between statin use and cancer risk. Statistical tests were two-sided. RESULTS: Statins were used by 11,584 (7.5%) women at baseline. The annualized rate of breast cancer was 0.42% among statin users and 0.42% among nonusers. The multivariable adjusted HR of breast cancer for users versus nonusers was 0.94 (95% CI, 0.83-1.06). In the multivariable-adjusted, time-dependent model, the HR for simvastatin was 0.87 (95% CI, 0.71-1.07). There was no significant trend by overall duration of use (P value for trend 0.68). There was no effect of tumor stage, grade, or hormone receptor status. CONCLUSION: Overall, statins were not associated with breast cancer risk. IMPACT: Our study is one of the largest prospective observational studies on this topic, and substantially adds to the literature suggesting no relationship between statins and breast cancer risk.

Breast cancer in postmenopausal women after non-melanomatous skin cancer: the Women's Health Initiative observational study.

An increased risk of breast cancer has been reported in patients with non-melanomatous skin cancer (NMSC), but this association has not been studied in a large, multi-geographic population. We utilized data from the Women's Health Initiative observational study to assess whether history of NMSC is associated with breast cancer risk. This analysis included 70,246 postmenopausal White and Hispanic women aged 50-79, in which 4,247 breast cancer cases were identified over a mean (SD) of 11.3 (3.2) years. Baseline information was collected on demographics, medical history, sun exposure, and vitamin D intake. Cox proportional hazards regression was used to calculate hazard ratios (HRs) with 95 % confidence intervals (CIs). The relationship between NMSC and breast cancer was examined as a time-dependent exposure using updated information on NMSC gathered during follow-up visits. All statistical tests were two sided. There were 5,595 women diagnosed with NMSC at study entry. The annualized rate of breast cancer was 0.64 % among women with a history of NMSC and 0.55 % among women with no history of NMSC. The multivariable-adjusted HR for breast cancer among women with a history of NMSC versus no history of NMSC was 1.07 (95 % CI 0.95-1.20, P = 0.27). Further evaluation stratified by tumor characteristics showed an increased risk of lymph node-positive disease, HR = 1.30 (95 % CI 1.01-1.67, P = 0.04), and regional-stage disease, HR = 1.33 (95 % CI 1.05-1.70, P = 0.02), among women with NMSC. There was no significant overall association between NMSC and breast cancer; however, there was an increased risk of more advanced-stage breast cancer which needs further exploration.

Prospective analysis of association between use of statins and melanoma risk in the Women's Health Initiative.

BACKGROUND: Melanoma is the most lethal form of skin cancer, with an estimated 68,130 new cases and 8700 deaths in the United States in 2010. The increasing incidence and high death rate associated with metastatic disease support the need to focus on prevention. The authors used data from the Women's Health Initiative (WHI) to assess whether 3-hydroxy-3 methylglutaryl coenzyme A inhibitors (statins) are associated with a decreased risk of melanoma. METHODS: The study population consisted of 119,726 postmenopausal white women, in which 1099 cases of malignant melanoma were identified over an average (± standard deviation) of 11.6 ± 3.2 years. All diagnoses were confirmed by medical record review and pathology reports. Information on statin use was collected at baseline and during follow-up. Self-administered and interview-administered questionnaires were used to collect information on other risk factors. Cox proportional hazards regression was used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs). Analyses investigated the association of any statin use, type, potency, lipophilic status, and duration of use with melanoma. RESULTS: Statins were used by 8824 women (7.4%) at baseline. The annualized rate of melanoma was 0.09% among statin users and 0.09% among nonusers The multivariable adjusted HR for statin users compared with nonusers was 1.14 (95% CI, 0.91-1.43). There were no significant differences in risk based on statin type, potency, category, duration, or in time-dependent models. CONCLUSIONS: There was no significant association between statin use and melanoma risk among postmenopausal women in the WHI.

Prospective analysis of association between use of statins or other lipid-lowering agents and colorectal cancer risk.

PURPOSE: To determine whether 3-hydroxy-3-methylglutaryl coenzyme A inhibitors (statins) are associated with a decreased risk of colorectal cancer. METHODS: The population included 159,219 postmenopausal women enrolled in the Women's Health Initiative in which 2000 pathologically confirmed cases of colorectal cancer were identified during an average of 10.7 (S.D. 2.9) years. Information on statins was collected at baseline and years 1, 3, 6, and 9. Self- and interviewer-administered questionnaires were used to collect information on other risk factors. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated by the use of Cox proportional hazards regression to evaluate the relationship between statin use and risk. Statistical tests were two-sided. RESULTS: Statins were used by 12,030 (7.6%) women at baseline. The annualized colorectal cancer rate was 0.13% among users and 0.12% among nonusers. The multivariable adjusted HR for users versus nonusers was 0.99 (95% confidence interval [CI], 0.83-1.20, p = .95), and 0.79 (95% CI, 0.56-1.11) for users of ≥3 years. In the multivariable adjusted time-dependent model, the HR for lovastatin was 0.62 (95% CI, 0.39-0.99). There was no effect of tumor location, stage or grade. CONCLUSIONS: There was a reduction in colorectal cancer risk associated with lovastatin and a nonsignificant association with longer duration of use.

Intentional weight loss and risk of lymphohematopoietic cancers.

OBJECTIVES: We hypothesized that intentional weight loss may be associated with development of lymphohematopoietic cancers, based on observations of immune suppression following weight loss in short-term studies. METHODS: At the baseline of the Women's Health Initiative Observational Study (1994-1998), participants reported information about intentional weight loss episodes in the past 20 years. We estimated hazard ratios (HRs) and 95% confidence intervals (CIs) among 81,219 women for associations between past intentional weight loss and risk of developing non-Hodgkin lymphoma (NHL), leukemia, and multiple myeloma during an average 9.9 years of follow-up. RESULTS: The risk of NHL was associated with having lost a large maximum amount of weight (> or =50 pounds, HR = 1.68, 95% CI 1.13-2.50). NHL risk also varied by the frequency of intentional weight loss; women had increased risk if they lost 50 pounds or more > or =3 times (HR = 1.97, 95% CI 0.93-4.16; p trend by frequency = 0.09) or 20-49 pounds > or =3 times (HR = 1.55, 95% CI 1.00-2.40; p trend = 0.05), but there was no risk associated with smaller amounts of weight loss (10-19 pounds > or =3 times, HR = 0.78, 95% CI 0.46-1.33). These associations persisted with adjustment for body mass index at different ages. We observed non-significant associations of similar magnitude for multiple myeloma, but past intentional weight loss episodes were not associated with leukemia. CONCLUSION: Further assessment of intentional weight loss as a possible risk factor for lymphomas may provide insight into the etiology of these cancers.

Incident invasive breast cancer, geographic location of residence, and reported average time spent outside.

There have been reports of greater breast cancer incidence and mortality at northern compared with southern latitudes postulated to be related to vitamin D exposure. Among 71,662 participants in the Women's Health Initiative Observational Study (WHIOS) free of cancer at baseline (1993-1998), associations were explored between incident invasive postmenopausal breast cancer (n = 2,535), over approximately 8.6 years follow-up, and the following: (a) region of residence at birth, age 15 years, age 35 years; (b) region of residence at WHIOS baseline; and (c) clinic center solar irradiance. Hazard ratios and 95% confidence intervals (CI) for breast cancer were estimated after adjustment for individual level confounders. There was no difference in breast cancer risk by region of earlier life, baseline residence, or solar irradiance measured in Langelys (gm-cal) per cm(2). There was an observed 15% decreased risk among women residing in areas of low versus high solar irradiance measured in Watts per m(2) (95% CI, 2-26%). However, the associated P(trend) of 0.20 was not significant. Conversely, women who reported spending on average <30 minutes versus >2 hours outside in daylight year round at WHIOS year 4 follow-up (n = 46,926), had a 20% (95% CI, 2-41%; P(trend) = 0.001) increased risk of breast cancer. In conclusion, region of residence and geographic solar irradiance are not consistently related to risk of breast cancer and may not be sufficient proxy measures for sunlight/vitamin D exposure. The observed association between time spent outside and breast cancer risk support the hypothesis that vitamin D may protect against breast cancer.

Predicting risk of breast cancer in postmenopausal women by hormone receptor status.

BACKGROUND: Strategies for estrogen receptor (ER)-positive breast cancer risk reduction in postmenopausal women require screening of large populations to identify those with potential benefit. We evaluated and attempted to improve the performance of the Breast Cancer Risk Assessment Tool (i.e., the Gail model) for estimating invasive breast cancer risk by receptor status in postmenopausal women. METHODS: In The Women's Health Initiative cohort, breast cancer risk estimates from the Gail model and models incorporating additional or fewer risk factors and 5-year incidence of ER-positive and ER-negative invasive breast cancers were determined and compared by use of receiver operating characteristics and area under the curve (AUC) statistics. All statistical tests were two-sided. RESULTS: Among 147,916 eligible women, 3236 were diagnosed with invasive breast cancer. The overall AUC for the Gail model was 0.58 (95% confidence interval [CI]=0.56 to 0.60). The Gail model underestimated 5-year invasive breast cancer incidence by approximately 20% (P<.001), mostly among those with a low estimated risk. Discriminatory performance was better for the risk of ER-positive cancer (AUC = 0.60, 95% CI = 0.58 to 0.62) than for the risk of ER-negative cancer (AUC = 0.50, 95% CI = 0.45 to 0.54). Age and age at menopause were statistically significantly associated with ER-positive but not ER-negative cancers (P=.05 and P=.04 for heterogeneity, respectively). For ER-positive cancers, no additional risk factors substantially improved the Gail model prediction. However, a simpler model that included only age, breast cancer in first-degree relatives, and previous breast biopsy examination performed similarly for ER-positive breast cancer prediction (AUC=0.58, 95% CI= 0.56 to 0.60); postmenopausal women who were 55 years or older with either a previous breast biopsy examination or a family history of breast cancer had a 5-year breast cancer risk of 1.8% or higher. CONCLUSIONS: In postmenopausal women, the Gail model identified populations at increased risk for ER-positive but not ER-negative breast cancers. A model with fewer variables appears to provide a simpler approach for screening for breast cancer risk.

Daily coffee consumption and prevalence of nonmelanoma skin cancer in Caucasian women.

The purpose of this study was to assess the relationship between daily coffee consumption and nonmelanoma skin cancer. This study was a cross-sectional analysis of women enrolled in the Women's Health Initiative Observational Study (n=93 676). As nearly all cases of self-reported nonmelanoma skin cancer occurred among Caucasian women (97.8%), we focused our analyses on this group. Compared with nondrinkers, women drinking only caffeinated coffee on a daily basis had a 10.8% lower prevalence of nonmelanoma skin cancer. Consumption of six or more cups of caffeinated coffee per day was associated with a 36% reduction in nonmelanoma skin cancer. After adjusting for various demographic and life style variables, daily consumption of six or more cups was associated with a 30% reduced prevalence of nonmelanoma skin cancer. In contrast to caffeinated coffee, daily consumption of decaffeinated coffee was not associated with a significant change in self-reported nonmelanoma skin cancer for Caucasian women. Daily caffeinated coffee consumption was associated with a dose-related decreased prevalence of nonmelanoma skin cancer in Caucasian women.

Cutaneous melanoma in postmenopausal women after nonmelanoma skin carcinoma: the Women's Health Initiative Observational Study.

BACKGROUND: An elevated risk for cutaneous melanoma has been reported in individuals with nonmelanoma skin carcinoma (NMSC), but to the authors' knowledge, this association has not been prospectively studied in a large, multigeographic population of postmenopausal women. METHODS: The association between NMSC and the incidence of cutaneous melanoma was assessed in the Women's Health Initiative Observational Study involving 67,030 non-Hispanic white postmenopausal women ages 50-79 years and who were free of prior other cancers at baseline. Cancer history, demographics, and previous and current risk exposures were determined by questionnaires at baseline and follow-up. Participants' reports of incident cutaneous melanoma collected annually were confirmed by physician review of medical records. Cox proportional hazards analyses were used to assess the relation of prior NMSC with incident cutaneous melanoma. RESULTS: In age-adjusted analysis, women with a history of NMSC but no other malignancy (n = 5552) were found to be 2.41 times more likely to develop cutaneous melanoma over a mean 6.5 years compared with women who had no history of NMSC (95% confidence interval [95% CI], 1.82-3.20). In a multivariate analysis, women with a history of NMSC and no other cancer history at baseline were 1.70 times more likely to develop cutaneous melanoma compared with women without NMSC (95% CI, 1.18-2.44). CONCLUSION: The results of the current study provide evidence and further defines the magnitude of increased risk for cutaneous melanoma in postmenopausal non-Hispanic white women with a history of NMSC.

Estrogen plus progestin and colorectal cancer in postmenopausal women.

BACKGROUND: Although the Women's Health Initiative (WHI) trial of estrogen plus progestin in postmenopausal women identified more overall health risks than benefits among women in the hormone group, the use of estrogen plus progestin was associated with a significant decrease in the risk of colorectal cancer. We analyzed features of the colorectal cancers that developed and their relation to the characteristics of the participants. METHODS: In the WHI trial, 16,608 postmenopausal women who were 50 to 79 years of age and had an intact uterus were randomly assigned to a combination of conjugated equine estrogens (0.625 mg per day) plus medroxyprogesterone acetate (2.5 mg per day) or placebo. The main outcome measures were the incidence, stages, and types of colorectal cancer, as determined by blinded central adjudication. RESULTS: There were 43 invasive colorectal cancers in the hormone group and 72 in the placebo group (hazard ratio, 0.56; 95 percent confidence interval, 0.38 to 0.81; P=0.003). The invasive colorectal cancers in the hormone group were similar in histologic features and grade to those in the placebo group but with a greater number of positive lymph nodes (mean +/-SD, 3.2+/-4.1 vs. 0.8+/-1.7; P=0.002) and were more advanced (regional or metastatic disease, 76.2 percent vs. 48.5 percent; P=0.004). In exploratory analyses, women in the hormone group with antecedent vaginal bleeding had colorectal cancers with a greater number of positive nodes than women in the hormone group who did not have vaginal bleeding (3.8+/-4.3 vs. 0.7+/-1.5 nodes, P=0.006). CONCLUSIONS: Relatively short-term use of estrogen plus progestin was associated with a decreased risk of colorectal cancer. However, colorectal cancers in women who took estrogen plus progestin were diagnosed at a more advanced stage than those in women who took placebo.

Association of nonmelanoma skin cancer with second malignancy.

BACKGROUND: Heightened risks of second cancers have been reported in patients with nonmelanoma cancer of the skin (NMSC), but this association has not been studied in a large, ethnically diverse, multigeographic population. METHODS: This cross-sectional study assessed the association of NMSC with another malignancy in the Women's Health Initiative Observational Study, a study that was conducted in 40 communities throughout the U.S. and involved 93,676 postmenopausal women ages 50-79 years. Cancer history, demographics, and previous and current risk exposures were determined by questionnaire at a baseline examination. Logistic regression was used to assess the association (odds ratio) of a history of NMSC with a history of other (non-NMSC) cancers controlling for age and potential confounding factors. Complete cancer data were available in 92,658 women. RESULTS: In age-adjusted analyses, women with a history of NMSC (n = 7554 women) were 2.30 times as likely to report a history of another cancer, other than NMSC, compared with women who had no history of NMSC (95% confidence interval [95% CI], 2.18-2.44). In a subgroup analysis, black women with NMSC had 7.46 times the odds (95% CI, 3.08-18.0) of reporting a second malignancy compared with black women without NMSC. CONCLUSIONS: This study provides additional evidence of an association between NMSC and another malignancy in a large, multiethnic population.