"Calling the Spirit Back:" Spiritual Needs Among Great Plains American Indians.

CONTEXT: American Indians (AIs) are disproportionately affected by serious illness such as cancer. Colonization, cultural genocide, and trauma have adversely affected AIs' ability to attain health and well-being, and in many cases led to the loss of the right to practice traditional ceremonies and rituals. Still many AIs describe well-being as being rooted in spirituality. OBJECTIVES: The purpose of this project was to learn about the perspectives of AI cancer survivors, caregivers, and Tribal leaders and healers specific to spirituality while on the cancer journey. METHODS: Qualitative interviews and Indigenous talking circle methodologies were used to explore AIs cancer survivors, caregivers, and Tribal leaders and healers' perspectives on spirituality while on the cancer journey. A data analysis team consisting of AI and non-AI members analyzed the narrative data. RESULTS: Qualitative analysis of interviews and talking circles revealed 4 major themes related to spirituality: the chasm of colonialism, coexistence of Traditional and Christian religions, calling the Spirit back, and prayer as sacred energy. CONCLUSION: It is critical that clinicians caring for AIs with serious illness seek to understand their patients' spiritual beliefs about disease treatment and death and work with them and their families to support quality of life throughout their illness journey. In addition, clinicians must recognize the systemic racism inherent in our healthcare systems, and dismantle cultural clashes and bias for all patients, particularly AIs, who have long suffered from poorer health outcomes.

Breast cancer screening in the era of density notification legislation: summary of 2014 Massachusetts experience and suggestion of an evidence-based management algorithm by multi-disciplinary expert panel.

Stemming from breast density notification legislation in Massachusetts effective 2015, we sought to develop a collaborative evidence-based approach to density notification that could be used by practitioners across the state. Our goal was to develop an evidence-based consensus management algorithm to help patients and health care providers follow best practices to implement a coordinated, evidence-based, cost-effective, sustainable practice and to standardize care in recommendations for supplemental screening. We formed the Massachusetts Breast Risk Education and Assessment Task Force (MA-BREAST) a multi-institutional, multi-disciplinary panel of expert radiologists, surgeons, primary care physicians, and oncologists to develop a collaborative approach to density notification legislation. Using evidence-based data from the Institute for Clinical and Economic Review, the Cochrane review, National Comprehensive Cancer Network guidelines, American Cancer Society recommendations, and American College of Radiology appropriateness criteria, the group collaboratively developed an evidence-based best-practices algorithm. The expert consensus algorithm uses breast density as one element in the risk stratification to determine the need for supplemental screening. Women with dense breasts and otherwise low risk (<15% lifetime risk), do not routinely require supplemental screening per the expert consensus. Women of high risk (>20% lifetime) should consider supplemental screening MRI in addition to routine mammography regardless of breast density. We report the development of the multi-disciplinary collaborative approach to density notification. We propose a risk stratification algorithm to assess personal level of risk to determine the need for supplemental screening for an individual woman.

Effect of practice integration between urologists and radiation oncologists on prostate cancer treatment patterns.

PURPOSE: National attention has focused on whether urology-radiation oncology practice integration, known as integrated prostate cancer centers, contributes to the use of intensity modulated radiation therapy, a common and expensive prostate cancer treatment. MATERIALS AND METHODS: We examined prostate cancer treatment patterns before and after conversion of a urology practice to an integrated prostate cancer center in July 2006. Using the SEER (Statistics, Epidemiology and End Results)-Medicare database, we identified patients 65 years old or older in 1 statewide registry diagnosed with nonmetastatic prostate cancer between 2004 and 2007. We classified patients into 3 groups, including 1--those seen by integrated prostate cancer center physicians (exposure group), 2--those living in the same hospital referral region who were not seen by integrated prostate cancer center physicians (hospital referral region control group) and 3--those living elsewhere in the state (state control group). We compared changes in treatment among the 3 groups, adjusting for patient, clinical and socioeconomic factors. RESULTS: Compared with the 8.1 ppt increase in adjusted intensity modulated radiation therapy use in the state control group, the use of this therapy increased 20.3 ppts (95% CI 13.4, 27.1) in the integrated prostate cancer center group and 19.2 ppts (95% CI 9.6, 28.9) in the hospital referral region control group. Androgen deprivation therapy, for which Medicare reimbursement decreased sharply, similarly decreased in integrated prostate cancer center and hospital referral region controls. Prostatectomy decreased significantly in the integrated prostate cancer center group. CONCLUSIONS: Coincident with the conversion of a urology group practice to an integrated prostate cancer center, we observed an increase in intensity modulated radiation therapy and a decrease in androgen deprivation therapy in patients seen by integrated prostate cancer center physicians and those seen in the surrounding health care market that were not observed in the remainder of the state.

Development and Validation of an Instrument for Measuring Attitudes and Beliefs about Complementary and Alternative Medicine (CAM) Use among Cancer Patients.

Despite cancer patients' extensive use of complementary and alternative medicine (CAM), validated instruments to measure attitudes, and beliefs predictive of CAM use are lacking. We aimed at developing and validating an instrument, attitudes and beliefs about CAM (ABCAM). The 15-item instrument was developed using the theory of planned behavior (TPB) as a framework. The literature review, qualitative interviews, expert content review, and cognitive interviews were used to develop the instrument, which was then administered to 317 outpatient oncology patients. The ABCAM was best represented as a 3-factor structure: expected benefits, perceived barriers, and subjective norms related to CAM use by cancer patients. These domains had Eigenvalues of 4.79, 2.37, and 1.43, and together explained over 57.2% of the variance. The 4-item expected benefits, 7-item perceived barriers, and 4-item subjective norms domain scores, each had an acceptable internal consistency (Cronbach's alpha) of 0.91, 0.76, and 0.75, respectively. As expected, CAM users had higher expected benefits, lower perceived barriers, and more positive subjective norms (all P < 0.001) than those who did not use CAM. Our study provides the initial evidence that the ABCAM instrument produced reliable and valid scores that measured attitudes and beliefs related to CAM use among cancer patients.

Acupuncture for hot flashes: decision making by breast cancer survivors.

PURPOSE: Hot flashes (HFs) are a particularly common and distressing symptom among breast cancer survivors (BCSs). Given its low rate of side effects, acupuncture shows promise as a therapeutic approach for HFs, but little is known about BCS's decision making about the use of acupuncture. This study seeks to identify attitudes and beliefs about using acupuncture for HFs by BCSs. METHODS: Using the Theory of Planned Behavior (TPB) as a conceptual framework, we conducted semistructured interviews among women with stage I-III breast cancer who had finished primary treatment and were currently experiencing HFs. Interviews were taped, transcribed, and coded. We used a modified grounded theory approach to analyze the data. RESULTS: Twenty-five BCSs (13 whites/12 African American) participated in the study. Respondents stated that their intended use of acupuncture for HFs would be dependent on (1) expected therapeutic effects (eg, pain relief, energy); (2) practical concerns (eg, fear of needles, practitioner experience, time commitment); and (3) source of decision support/validation (eg, family members, physicians, self). Although constructs in the TPB accounted for many decision factors, respondents identified 2 major themes outside of the TPB: (1) viewing acupuncture as a natural alternative to medications, and (2) assessing the degree of HFs as bothersome enough in the context of other medical comorbidities to trigger the need for therapy. CONCLUSION: BCSs expressed varied expected therapeutic benefits, practical concerns, and decision support, emphasizing the "natural appeal" and symptom appraisal as key determinants when using acupuncture for HFs. Incorporating these factors in counseling BCSs may promote patient-centered communication, leading to improved hot flash management and quality of life.

De qi: Chinese acupuncture patients' experiences and beliefs regarding acupuncture needling sensation--an exploratory survey.

INTRODUCTION: While de qi, the acupuncture needling sensation, has been considered as an important component of acupuncture, little is known of the acupuncture patient's experience and beliefs about de qi in clinical settings. The aim of this study was to describe Chinese acupuncture patients' perceived sensations of, and beliefs about, acupuncture needling. METHODS: We developed a questionnaire and conducted a survey study at two time periods among 200 subjects at six outpatient acupuncture clinics in Beijing, China. RESULTS: Respondents were 55% female and had a mean age of 41 years. The most common types of needling sensations reported by subjects were the terms 'distended' (94%), 'sore' (81%), 'electric' (81%) and 'numb' (78%). Eighty-nine percent of subjects reported that the needling sensation travelled away from the puncturing points or travelled among the needling points. Eighty-two percent of subjects believed that the needling sensation was very important for acupuncture treatment, and 68% further indicated that the stronger the needling sensation, the more effective the therapy. Eighty-one percent of subjects found the acupuncture process to be very comfortable and relaxing. CONCLUSION: Chinese acupuncture patients described the common characteristics of de qi and its migratory nature. The sensations were believed to be important in producing clinical efficacy by most patients. Measuring the sensations described as de qi in future prospective studies will help us understand the degree to which this phenomenon has an effect on the physiological outcome and clinical response to acupuncture. There appears to be a limit to the number of sensations that can be discriminated by each individual patient, and further development of the questionnaire is planned.

Acupuncture expectancy scale: development and preliminary validation in China.

OBJECTIVE: Expectancy has been shown to affect the response to psychological and medical interventions; however, the lack of validated measure of expectancy in the setting of acupuncture limits the quantitative evaluation of the effects of expectancy on clinical response to acupuncture therapy. We seek to develop and validate an instrument that measures patients' expected response from acupuncture. SETTING/DESIGN: We developed the acupuncture expectancy scale by eliciting items from patients and then conducted a survey study in two phases to test the reliability and validity of the instrument among 200 subjects at six outpatient acupuncture clinics in Beijing, China. RESULTS: Our final scale consisted of four items measuring the expectation of improvement of illness, enhanced coping, increased vitality, and symptom alleviation as a result of acupuncture therapy. Scores of acupuncture expectancy scales ranged from four to 20, with a median of 17, and 21% at the maximum score. No item had over 5% missing data. Internal consistency (Cronbach's alpha coefficient) was .82. Principal components analysis revealed one general component accounting for 64% of the variance. Expectancy of response was positively correlated with selected questions of perceived efficacy (0.44), satisfaction (0.49), and confidence in prescribed acupuncture therapy (0.51), all with P < .001. CONCLUSION: We developed a simple four-item instrument with valid and reliable score that measures expectancy about acupuncture therapy and correlates to subject reported response. The reliability and validity of acupuncture expectancy scale score needs to be tested in other types of populations. Incorporating this instrument in clinical trials can evaluate the role of expectancy as part of the complex social-behavioral component of acupuncture therapy.

Decrease in racial disparities in the staging evaluation for prostate cancer after publication of staging guidelines.

PURPOSE: We compared how men with incident prostate cancer were staged before and after the 1995 publication of National Comprehensive Cancer Network, American Urological Association and American College of Radiology staging guidelines, and determined whether there were racial differences in the staging evaluation. MATERIALS AND METHODS: We performed a retrospective cohort study of the use of bone scan and pelvic imaging (pelvic computerized tomography or magnetic resonance imaging) in 96,986 men with incident prostate cancer from 1991 to 1994 compared to 1995 to 1999 from Surveillance, Epidemiology and End Results-Medicare linked data files. RESULTS: During 1991 to 1994 bone scan was done in 83.1% and 73.7% of men who would and would not have met guideline criteria for staging, respectively. From 1995 to 1999 bone scan use decreased slightly in men who met guideline criteria (74.4%) but it decreased substantially in men who did not meet guideline criteria (55.2%). Between 1991 to 1994 and 1995 to 1999 rates of pelvic imaging increased for men who did and decreased for men who did not meet guideline criteria for staging (45.5% to 57.2% and 48.4% to 41.5%, respectively). On multivariate analysis in men who did not meet guideline criteria there was no change in the association between the use of staging tests and race from 1991 to 1994, to 1995 to 1999. However, of men who met guideline criteria for staging black men were less likely to undergo bone scan and less likely to undergo pelvic imaging than white men diagnosed in 1991 to 1994 but this racial difference was not seen during 1995 to 1999. CONCLUSIONS: Using a population based cohort this study reveals a decrease in racial disparity and an increase in evidence based use of staging tests in men with incident prostate cancer in the period after the publication of National Comprehensive Cancer Network, American Urological Association and American College of Radiology guidelines.

Use of complementary and alternative medicine and prayer among a national sample of cancer survivors compared to other populations without cancer.

OBJECTIVES: Extensive use of complementary and alternative medicine (CAM) among cancer survivors has been described in literature, but the rate has not previously been compared to other groups in a true population sample. METHODS: We performed a cross-sectional study using data from the 2002 National Health Interview Survey to determine the prevalence of CAM and prayer for health (PFH) use among cancer survivors and compared the rates of such use among cancer survivors with the US general and other chronic diseased populations while controlling for key socio-demographic factors. RESULTS: Among 31,044 adult survey respondents, 1904 had a prior cancer diagnosis, of whom 40% reported CAM and 62% reported PFH use during the year before the survey. The top three CAM modalities were herbs (20%), deep breathing (14%) and meditation (9%). Controlling for other factors, cancer survivors used more CAM than the general population (adjusted odds ratio [OR] 1.36, 95% confidence interval [CI] 1.20-1.53), but similar to those with chronic symptomatic illness (p=0.5). Cancer survivors used PFH more than the general population (OR 1.87, 95% CI 1.66-2.10) and all other groups (p<0.001). The greater CAM and PFH use by cancer survivors was seen in both recent and distant diagnoses (>10 years). CONCLUSION: A previous cancer diagnosis is associated with a modest increase in CAM use compared with the general population but similar to other chronic symptomatic illnesses; however, cancer survivors are more likely to pray for health than all other populations. Exploring CAM and prayer use in clinical settings may help clinicians better understand the needs of their patients.