The feasibility of a purpose-renewal intervention after treatment for early stage breast cancer: A brief report.

This feasibility study evaluated the acceptability, implementability, and preliminary efficacy of a brief purpose renewal intervention (the Compass Course) using a one-group pretest-posttest design. Fifteen women who had completed treatment for early-stage breast cancer enrolled in the study. Twelve completed the eight-session group intervention that was designed to help participants identify daily priorities (actual and aspired) that most align with their personal strengths, values, and sources of meaning, that is, their inner compass. The intervention was found to be acceptable and implementable. Preliminary pre- and post-intervention outcomes suggested that participants experienced greater purpose in daily life at posttest but that they did not make demonstrable changes in their activities or roles. Results suggest that the Compass Course was feasible and further study related to purpose renewal for adults with early-stage cancer is warranted.

Predictive value of breast magnetic resonance imaging in detecting mammographically occult contralateral breast cancer: Can we target women more likely to have contralateral breast cancer?

BACKGROUND AND OBJECTIVES: Preoperative breast magnetic resonance imaging (B-MRI) staging in newly diagnosed breast cancer increases detection of synchronous contralateral findings, but may result in false-positive outcomes. This study objective was to identify women more likely of having mammographically occult, MRI detected contralateral breast cancer (CBC). METHODS: We performed a retrospective review of patients who had preoperative B-MRI prior to surgery from 2010 to 2015 and collected patient imaging and clinicopathologic data. Multivariate logistic regression was used to identify predictors of CBC. RESULTS: MRI resulted in contralateral findings in 201 of 1894 patients (10.6%). Overall 3.2% (60 of 1894) had synchronous CBC detected on B-MRI. The majority of CBCs (n = 60) were stage 0 or IA (85.0%), hormone receptor positive (94.9%), human epidermal growth factor receptor 2 (HER2/neu) negative (89.7%), and low/intermediate pathological grade (87.2%). Women more likely to have CBC were older (P < .001), had lobular index cancer (P = .03), and estrogen receptor (ER)+ (P = .027) or progesterone receptor (PR)+ (P = .002) tumors. On multivariate analysis (receiver operating characteristic curve area = 0.75), PR + status (P = .022), and older age (P = .004) were predictive of CBC. CONCLUSIONS: Preoperative MRI is most effective in detecting early stage, hormone receptor-positive CBC in older women.

Clinicopathologic analysis of a large series of microinvasive breast cancers.

Clinical management of microinvasive breast cancer (Tmic) remains controversial. Although metastases are infrequent in Tmic carcinoma patients, surgical treatment typically includes lymph node sampling. The objective of this study was to determine the rate and predictors of lymph node metastases, recurrence, and survival in a large series of Tmic breast carcinomas. Consecutive cases of Tmic were identified within our health care system from 2001 to 2015. We reviewed results of lymph node sampling and other pathologic factors including hormone receptor/HER2 status, associated in situ tumor size/grade, margin status, number of invasive foci, surgical/adjuvant therapies, and recurrence/survival outcomes. In this cohort, 294 Tmic cases were identified with mean follow-up of 4.6 years. Of 260 patients who underwent axillary staging, lymph node metastases were identified in 1.5% (all of which were ductal type). All Tmic cases with positive lymph node metastases had associated DCIS with size > 5 cm (5.3-8.5 cm) compared to a median DCIS tumor size of 2.5 cm (0.2-19.0 cm) for the entire cohort. No lymph node metastases were seen with microinvasive lobular carcinoma. During the follow-up period, there were no regional/distant recurrences or breast cancer-associated deaths in a mean follow-up period of 4.6 years. Two patients developed subsequent ipsilateral breast cancer (DCIS) in a different quadrant than the original Tmic. Clinical behavior of microinvasive breast cancer in this series is similar to DCIS. Lymph node metastases are uncommon and were only seen with ductal type microinvasive carcinoma. Our data suggest limited benefit for routine node sampling and support management of Tmic similar to DCIS, particularly for patients with DCIS < 5 cm in size.

Why Is Cancer Genetic Counseling Underutilized by Women Identified as at Risk for Hereditary Breast Cancer? Patient Perceptions of Barriers Following a Referral Letter.

Family history information comprises an important tool in identifying and referring patients at risk for hereditary breast and ovarian cancer (HBOC) to cancer genetic counseling. Despite recommendations and support provided by numerous professional organizations, cancer genetic counseling services are underutilized by atrisk patients. This study aimed to: (1) determine the rate of genetic counseling utilization following a referral letter, (2) characterize factors (barriers and supports) which influenced uptake of services, and (3) identify potential strategies for increasing utilization. This study evaluated the uptake of cancer genetic counseling among 603 screening mammography patients identified as having an increased risk for HBOC based on National Comprehensive Cancer Network (NCCN) guidelines. At risk individuals and their primary care providers were mailed a referral letter recommending genetic counseling. Three focus groups (N = 24) were conducted to identify responses to receiving a letter recommending genetic counseling, barriers to seeking genetic counseling, and facilitating factors to utilizing these services. Participant responses were qualitatively analyzed using thematic and cross case analysis. Within one year, 50/603 (8 %) of the identified at-risk women completed a genetic counseling appointment. Participant-perceived barriers which influenced their decision not to seek genetic counseling included lack of relevance and utility, limited knowledge about genetic counseling, concerns about the genetic counseling process, and concerns about cost and insurance coverage. Participant-perceived facilitating factors which would support a decision to seek genetic counseling included greater awareness and education about genetic counseling services when receiving a referral, and improved follow up and guidance from their provider. Findings from this study support the need for patient and primary care provider education, and improved provider-patient communication to increase uptake of genetic counseling services.

Serum Markers of Bone Turnover and Angiogenesis in Patients With Bisphosphonate-Related Osteonecrosis of the Jaw After Discontinuation of Long-Term Intravenous Bisphosphonate Therapy.

PURPOSE: To analyze serum markers of bone turnover, angiogenesis, endocrine function, and inflammation in patients with bisphosphonate-related osteonecrosis of the jaw (BRONJ) who discontinued long-term intravenous bisphosphonate (BP) therapy. PATIENTS AND METHODS: Serum samples were obtained from 25 BRONJ patients who had discontinued long-term intravenous BP therapy for an average of 11.4 ± 8.7 months and 48 non-BRONJ controls who continued receiving intravenous BP therapy. Samples were analyzed for total alkaline phosphatase, bone-specific alkaline phosphatase, osteocalcin, C-telopeptide, vascular endothelial growth factor, triiodothyronine, thyroxine, thyroid-stimulating hormone, 25-hydroxyvitamin D, and C-reactive protein. RESULTS: The mean number of BP infusions was significantly higher in BRONJ patients compared with controls (38.4 ± 26.3 infusions vs 18.8 ± 7.2 infusions, P < .0001); however, the duration of BP therapy was not significantly different between the groups (P = .23). Overall, there were no significant differences in any of the markers between BRONJ patients and controls (all P values ≥ .16). In a subgroup analysis that matched BRONJ patients and controls according to mean age and number of BP infusions (10 BRONJ patients and 48 controls), log10 vascular endothelial growth factor (2.9 ± 0.4 pg/mL vs 2.4 ± 0.4 pg/mL, P < .001) and C-reactive protein (34 ± 26 mg/L vs 13 ± 8 mg/L, P < .01) levels were significantly higher in BRONJ patients compared with controls. Within BRONJ patients, none of the serum markers were correlated with duration of BP discontinuation. CONCLUSIONS: Levels of bone turnover and endocrine markers in BRONJ patients who discontinue long-term intravenous BP therapy are similar to those in non-BRONJ controls receiving intravenous BP therapy. However, levels of angiogenesis and inflammation markers are higher in BRONJ patients who discontinue long-term intravenous BP therapy. The prolonged skeletal half-life of BPs may suppress bone turnover markers in BRONJ patients for several years after discontinuation of intravenous BP therapy, suggesting an extended effect on bone homeostasis.

Radon testing and mitigation: an intervention in a primary care setting.

Radon is the second leading cause of lung cancer and it is recommended that all homes be tested for radon. Written surveys completed by 692 patients at two primary care clinics in the Minneapolis, MN, area revealed that only 24.7 % had ever tested their home. Testing rate was higher with greater income and education level and in homes without someone who smokes. Of participants whose homes had not been tested, 250 were enrolled in an intervention that included printed information on radon, a coupon for a discounted testing kit, and encouragement by their primary care provider to test. Follow-up indicated minimal effect of this intervention, with only 14.4 % of these participants testing during the ensuing year. Future studies should assess a stronger intervention, perhaps over multiple visits, and providing test kits on site. Targeting patients who smoke may be an effective use of resources.

An Electronic Health Record Tool Increases Genetic Counseling Referral of Individuals at Hereditary Cancer Risk: An Intervention Study.

INTRODUCTION: There is widespread under-identification of individuals at hereditary cancer risk despite national guidelines calling for screening. We evaluated the utilization of a tool embedded in the electronic health record (EHR) to assist primary care providers in screening patients for cancer genetic counseling referral. METHODS: We designed BestPractice Advisories linked to a Genetic Cancer Screening Tool (GCST) in EpicCare Ambulatory. The GCST identifies individuals for evaluation for BRCA1/2, Lynch syndrome, and other risk mutations due to personal and family history. We tested the tool in a 7-week intervention in adult wellness visits at two clinics, one urban and one rural. RESULTS: Out of 687 eligible patients, the screening survey was completed for 469 (67%), and of these, 150 (32%) screened positive for a personal and/or family history meeting genetic counseling referral criteria. Of individuals screening positive, a referral order was placed for 20 (13%). GCST screen-positive rate varied by patient gender but not race or age. Referral rate varied by provider and clinic but was not significantly affected by patient demographics. In the previous year over an equivalent date range, 0.1% of wellness visits (1 of 1,086) led to a referral, and this rate increased to 2.1% (22 of 1,062) during the intervention. The proportion of providers referring patients also increased, from 3.8% (1 of 26) to 42.3% (11 of 26). DISCUSSION/CONCLUSION: Genetic counseling referral of individuals at hereditary cancer risk was increased by use of an EHR-integrated tool. These findings add evidence for the benefit of clinical decision support for cancer genetic risk screening in primary care.

Preliminary Efficacy of an Occupation-Oriented Purpose in Life Intervention After Breast Cancer.

Background. Purpose in life is important to health and well-being; purpose disruption often goes unidentified after breast cancer. Purpose. To evaluate the efficacy of a purpose renewal intervention and utility of a screening question for identifying people with purpose-related distress. Method. In this prospective pretest-posttest study, participants with breast cancer received an 8-session purpose renewal group intervention (n = 35). Participants completed standardized measures of meaning and purpose at pretest, posttest, and two-month follow-up and a forced-choice Purpose Status Question (PSQ) at pretest. Findings. Participants made statistically significant pretest-to-posttest and pretest-to-follow-up improvements. The PSQ demonstrated construct validity: 40% of participants lacked purpose direction at pretest and this subgroup made significantly greater improvements than participants who reported purpose direction at pretest. Implications. The PSQ warrants further study as a screener to identify people with purpose-related distress. Many breast cancer survivors may benefit from a purpose in life intervention; a subgroup may benefit more.

Cognitive Dysfunction: Feasibility of a Brief Intervention to Help Breast Cancer Survivors.

BACKGROUND: Many cancer survivors experience cancer-related cognitive dysfunction (CRCD), which is believed to be the result of multiple contributing biologic, situational, and personal factors. Efficacious, clinically implementable interventions addressing the multifactorial nature of CRCD are needed. OBJECTIVES: This study evaluated the feasibility of an intervention to help breast cancer survivors mitigate the effects of modifiable factors that contribute to CRCD and improve cognitive functioning. METHODS: A single-group pre-/post-test design was used. Treatment fidelity was tracked to evaluate implementability; attendance rates, experience surveys, and homework engagement were used to characterize acceptability. Pre- and post-test cognitive functioning, stress, fatigue, and mood were measured to evaluate preliminary efficacy. FINDINGS: The intervention was implementable and acceptable to participants. Participants made statistically significant improvements.

Effects of Germline Pathogenic Variants, Cancer Subtypes, Tumor-related Characteristics, and Pregnancy-associated Diagnosis on Outcomes.

BACKGROUND: Although breast cancer (BC) is uncommon in women age ≤ 35 years, women in this age group may have more aggressive cancer subtypes and high-risk pathogenic variants (HRPVs). Higher recurrence and mortality rates in young patients may be related to differences in tumor biology, pathologic mutation status, or treatment. The purpose of this study was to evaluate germline mutation status and other factors that affect recurrence-free survival (RFS) and overall survival (OS) in young women with BC. MATERIALS AND METHODS: This was a retrospective study of women diagnosed with BC at age ≤ 35 years at Allina Health System from 2000 through 2017 (n = 306). Information was collected on germline mutation status, tumor characteristics (grade, hormone receptor, and human epidermal growth factor receptor 2), molecular subtype, pregnancy-associated cancers, and treatment. Survival analyses using Kaplan-Meier curves were conducted for RFS and OS. RESULTS: With mean follow-up of 6.5 years, OS was 87.0% for invasive cancers, RFS was 84.7%; 69% obtained genetic testing, and 26.9% had HRPVs. There were no differences in RFS or OS between patients with HRPV versus unknown/low/moderate risk variants. Recurrence analysis showed increased recurrence rates in luminal B-like cancers followed by triple negative and human epidermal growth factor receptor 2-positive cancers (P = .041). Pregnancy-associated BC diagnoses, angiolymphatic invasion, and tumor stage were associated with reduced OS. In spite of young age at diagnosis, nearly one-third of patients did not receive germline genetic testing. CONCLUSIONS: Similar survival patterns were found between women with HRPV versus no known mutations. Luminal B-like subtype, pregnancy-associated BC, angiolymphatic invasion, and cancer stage were associated with reduced OS.

HER2 Testing Characteristics Can Predict Residual Cancer Burden following Neoadjuvant Chemotherapy in HER2-Positive Breast Cancer.

OBJECTIVES: The response to HER2-targeted neoadjuvant chemotherapy (NAC) in HER2-positive (+) breast cancer can be quantified using residual cancer burden (RCB) pathologic evaluation to predict relapse free/overall survival. However, more information is needed to characterize the relationship between patterns of HER2 testing results and response to NAC. We evaluated clinicopathologic characteristics associated with RCB categories in HER2+ patients who underwent HER2-directed NAC. METHODS: A retrospective chart review was conducted with Stage I-III HER2+ breast cancer cases following NAC and surgical resection. HER2 immunohistochemistry (IHC) staining and fluorescence in situ hybridization (FISH), histologic/clinical characteristics, hormone receptor status, and RCB scores (RCB-0, RCB-I, RCB-II, and RCB-III) were evaluated. RESULTS: 64/151 (42.4%) patients with HER2+ disease had pathologic complete response (pCR). Tumors with suboptimal response (RCB-II and RCB-III) were more likely to demonstrate less than 100% HER2 IHC 3+ staining (p < 0.0001), lower HER2 FISH copies (p < 0.0001), and lower HER2/CEP17 ratios (p = 0.0015) compared to RCB-I and RCB-II responses. Estrogen receptor classification using ≥10% versus ≥1% staining showed greater association with higher RCB categories. CONCLUSIONS: HER2+ characteristics show differing response to therapy despite all being categorized as positive; tumors with less than 100% IHC 3+ staining, lower HER2 FISH copies, and lower HER2/CEP17 ratios resulted in higher RCB scores.

HER2 Testing: Insights From Pathologists' Perspective on Technically Challenging HER2 FISH Cases.

OBJECTIVE: College of American Pathologists and the American Society of Clinical Oncology guidelines provide straightforward criteria for HER2 interpretation in breast carcinomas; however, a subset of cases present unusual diagnostic dilemmas. MATERIALS AND METHODS: Ten challenging HER2 fluorescence in situ hybridization (FISH) cases were selected for analysis. The study included a variety of problematic cases such as those with discordant immunohistochemistry (IHC) and FISH results, cases with high intratumoral variability in HER2 copy number, a case with a highly amplified clone in 5% to 10% of the tumor sample, and a case with tumor cells containing tightly clumped HER2 signals. Six high volume HER2 FISH laboratories performed and interpreted HER2 FISH (adding HER2 IHC if necessary). Interpretation strategies were discussed. RESULTS: There was 100% concordance between laboratories in 4/10 cases. Tumors with increased intratumoral variability (tumors with high variability in HER2 copy number per cell but which otherwise do not fulfill College of American Pathologists and the American Society of Clinical Oncology criteria for heterogeneity) exhibited 100% concordance in 3/4 cases, but 1 case had only 50% agreement. Low positive HER2 cases (group 1 cases with <6 average HER2 copies/cell) had 1 laboratory disagreeing with the majority in 4/4 cases, and this was the only category with discordance between IHC and FISH methodologies. All laboratories identified the case with heterogeneity and interpreted it as positive. Five of the 6 laboratories interpreted the case with tightly clustered HER2 signals as positive. CONCLUSIONS: This study offers specific observations and interpretation strategies that laboratories can use when confronted with difficult HER 2 cases. It then highlights communication strategies a laboratory may use to discuss these unusual HER2 results with the clinical team.

Effects of exercise vs bisphosphonates on bone mineral density in breast cancer patients receiving chemotherapy.

Chemotherapy for breast cancer causes early-onset menopause for most women older than age 40 and is associated with accelerated bone loss. The primary objective of this study was to compare the effects of intravenous (IV) zoledronic acid versus prescribed physical activity (PA) on changes in bone mineral density (BMD) for women between the ages of 40 and 55 years receiving chemotherapy for breast cancer. A randomized controlled trial of 62 patients with breast cancer during chemotherapy compared IV zoledronic acid and oral calcium/vitamin D (ZO group) versus a PA program and oral calcium/vitamin D (PA group). ZO group participants received zoledronic acid IV every 3 months for 5 treatments. PA group participants were enrolled in a home-based exercise program and received motivational counseling, pedometers, and exercise tapes. BMD measurements from dual-energy x-ray absorptiometry (DEXA) scanning were completed at baseline and at 12 months. BMD significantly decreased in the PA group but not in the ZO group. Although spine, total hip, and total body BMD increased in the ZO group by 1.6%, 0.8%, and 0.8%, respectively, BMD decreased in the PA group by 6.0%, 3.4%, and 3.3%, respectively (P values < 0.0001 for all group comparisons). Zoledronic acid protected patients with breast cancer against bone loss during initial treatment, whereas home-based PA interventions were less effective in preventing bone loss.

Bisphosphonate-related osteonecrosis of the jaw: clinical features, risk factors, management, and treatment outcomes of 26 patients.

PURPOSE: To report the clinical features, risk factors, management, and treatment outcomes of nitrogen-containing bisphosphonate (n-BIS)-related osteonecrosis of the jaw (BRONJ). PATIENTS AND METHODS: Patients with suspected BRONJ were referred to the School of Dentistry for evaluation and treatment. RESULTS: A total of 26 patients (9 men and 17 women, mean age 64 years) were diagnosed with BRONJ. Of the 26 patients, 23 had received n-BIS therapy for cancer and 3 for osteoporosis. BRONJ lesions were noted more frequently in the mandible and in the posterior sextants. Of the 26 patients, 16 had developed BRONJ after dentoalveolar procedures, and 10 had developed it spontaneously. The mean interval to development of BRONJ was shorter in the patients with cancer receiving intravenous n-BIS than in the patients with osteoporosis receiving oral n-BIS (37.1 versus 77.7 months, P = .02). Using the American Association of Oral and Maxillofacial Surgeons staging system, 2 patients were diagnosed with stage I lesions, 19 with stage II, and 5 with stage III lesions. The initial management of BRONJ was nonsurgical, with debridement performed at subsequent visits, if needed. The BRONJ lesions healed completely in 4 patients, healed partially in 8, remained stable in 7, and progressed in 7. The spontaneous lesions responded favorably to BRONJ management compared with lesions that developed after dentoalveolar procedures (P = .01). No significant difference was found in response to BRONJ management between patients who had continued or discontinued n-BIS therapy after the BRONJ diagnosis (P = .54). CONCLUSIONS: Long-term n-BIS therapy and recent dental procedures are consistent findings in patients with BRONJ. Spontaneous BRONJ lesions respond favorably to current BRONJ treatment strategies.

Views of primary care providers on follow-up care of cancer patients.

BACKGROUND AND OBJECTIVES: Primary care providers (PCPs) are often involved in the care of cancer survivors. This study asked PCPs about their role in the follow-up care of breast and colorectal cancer patients and elicited opinions on improving the transfer of care from oncologists to PCPs. METHODS: A total of 175 PCPs in a large health care system with an electronic medical record system were mailed a questionnaire that addressed (1) their comfort and confidence regarding surveillance for cancer recurrence, (2) when patients should be seen in primary care, (3) evaluation of the transfer of care, (4) potential problems with that process, and (5) suggestions for improving that process. RESULTS: The response rate was 75.4%. Overall, 52% were comfortable having responsibility for surveillance of cancer recurrence, and 43% were confident they are following standard guidelines for cancer recurrence. Both of the aforementioned measures increased with years of practice. More than half rated the current transfer of care from oncologist to PCP as fair or poor. The most common problems identified were uncertainty regarding the type (62.6% for breast, 56.5% for colorectal), frequency (72.5%, 66.4%), and duration (74.8%, 67.2%) of surveillance testing. CONCLUSIONS: Levels of comfort, confidence, and satisfaction were generally low. PCPs need more specific guidance regarding surveillance for cancer recurrence.

Utility of Oncotype DX Risk Assessment in Patients With Invasive Lobular Carcinoma.

INTRODUCTION/BACKGROUND: Oncotype DX (Genomic Health, Redwood City, CA) uses reverse transcriptase polymerase chain reaction analysis to measure tumor gene expression for determining recurrence risk (RR) and guiding chemotherapy decisions for breast cancer patients. Invasive lobular carcinoma (ILC) is a histologic subtype that has not been the focus of prior studies validating Oncotype DX. The study purpose was to develop a model using histologic tumor characteristics to predict uniformly low Oncotype DX Recurrence Scores (RS) in ILC. PATIENTS AND METHODS: ILC cases in our pathology database with Oncotype DX testing were identified. Histologic tumor characteristics, immunohistochemical (IHC) of estrogen receptor (ER)/progesterone receptor (PgR) percent, HER2, E-cadherin expression, and Ki-67 levels were obtained for cases. Discriminant analysis was used to test the hypothesis that tumors classified as lower/higher risk based on Oncotype DX RS would differ significantly on a linear combination of variables. RESULTS: From 2006 - 2014, 158 cases of ILC having Oncotype DX testing were identified; 90 low risk (RS < 18), 66 intermediate risk (RS 18 - 30) and 2 high risk (RS > 30). Discriminant analysis showed that PgR% followed by Ki-67 provided the greatest contribution to discern low versus elevated RS. A subset of 57 cases (∼36%) with predicted probabilities > 86% for either low or high RS yielded 96.5% correct classification, 92.3% sensitivity, and 97.7% specificity. CONCLUSION: Our analytical model may be useful in predicting lower RR in patients with ILC. If validated, this provides a faster and less expensive alternative to Oncotype DX testing in certain patients with ILC.

Surgical Outcomes of Lobular Neoplasia Diagnosed in Core Biopsy: Prospective Study of 316 Cases.

BACKGROUND: Management recommendations for lobular neoplasia (LN) including lobular carcinoma-in-situ (LCIS) and atypical lobular hyperplasia (ALH) diagnosed in core biopsies (CB) are controversial. Our aim was to prospectively identify a subset of patients who do not require subsequent surgical excision (SE). PATIENTS AND METHODS: All patients diagnosed with LN on CB were enrolled and referred for SE. Cases with coexistent ductal carcinoma-in-situ or invasive carcinoma were excluded. Cases with coexistent ductal atypia (LN-DA) and LCIS variants (LN-V) were separated from pure classic LN (LN-C). Dedicated breast pathologists and radiologists reviewed cases with careful imaging/pathology correlation. RESULTS: Of 13,772 total percutaneous breast CB procedures, 302 of 370 patients diagnosed with LN underwent SE. Upgrade to carcinoma was present in 3.5% (8/228) LN-C, 26.7% LN-V (4/15), and 28.3% LN-DA (15/53). Calcifications were the imaging target for 180 (79%) of 228 LN-C cases; 7 were associated with upgrade (3.9%). Upgrades were rare for mass lesions (1/32) and magnetic resonance imaging-targeted lesions (0/14). Upgrades were similar for ALH and LCIS (3.4% vs. 4.5%). During postsurgical follow-up (mean, 34.5 months), 6.5% LN-C patients developed carcinoma in either breast. CONCLUSION: Although LN with nonclassic morphology or with associated ductal atypia requires SE, this can be avoided in LN-C diagnosed on CB targeting calcifications when careful imaging/pathology correlation is applied. Until larger numbers are studied, excising LN-C diagnosed as masses or magnetic resonance imaging-detected lesions may be prudent. Regardless of their selection for surgical management, LN patients need close surveillance in view of their long-term risk of breast cancer.

Interventions to prevent loss of bone mineral density in women receiving chemotherapy for breast cancer.

Loss of bone mineral density (BMD) is a significant problem for women receiving breast cancer treatment. The purpose of this article is to present the state of the knowledge on BMD loss and analyze interventions to prevent BMD loss in women receiving breast cancer treatment. The data sources include primary research reports, review articles, and book chapters. With increased numbers of breast cancer survivors, BMD loss experienced with treatment is a significanthealth concern because of risks of osteoporosis and bone fractures. These long-term treatment effects may significantly impact patients' long-term morbitity and mortality. BMD screening as well as an assessment of physical activity and dietary history should be conducted with women undergoing breast cancer treatment. Bisphosphonates are effective in preventing BMD loss, and other interventions such as physical activity and dietary interventions need further testing. Oncology nurses are ideal candidates for implementing interventions to prevent BMD loss because of their understanding of cancer treatments, knowledge of health-related behaviors, and ability to teach patients about the positive health benefits of lifestyle changes.

The effects of mammographic detection and comorbidity on the survival of older women with breast cancer.

OBJECTIVES: To determine an upper age limit or quantifiable level of comorbidity that would render mammography screening ineffectual in decreasing mortality in women aged 65 and older. DESIGN: Retrospective cohort study. SETTING: Upper midwestern United States. PARTICIPANTS: Five thousand one hundred eighty-six predominantly Caucasian women aged 65 to 101 diagnosed with invasive breast cancer from 1986 through 1994. Data were obtained from The Upper Midwest Tumor Registry System, a regional consortium database in Minnesota, North Dakota, and South Dakota. MEASUREMENTS: Relative risks (RRs) of death were computed for patients with mammographically detected tumors, stratified by age and comorbidity. Survival analysis was performed, stratified by level of comorbidity and method of tumor detection. RESULTS: Patients with mammographically detected tumors and no comorbidity experienced significantly lower RRs of death in every age group (range P <.001 to P =.039). Women with mammographically detected tumors and mild to moderate comorbidity had RRs of death as follows: age 65 to 69 (RR = 0.32, 95% confidence interval (CI) = 0.15-0.69), age 70 to 74, (RR = 0.45, 95% CI = 0.22-0.91); age 75 to 79 (RR = 0.47, 95% CI = 0.25-0.88), age 80 and older (RR = 0.52, 95% CI = 0.33-0.80). Women with severe or multiple comorbidities experienced no improvement in survival with mammographically detected tumors. CONCLUSIONS: Mammographic detection of breast cancer may be associated with a significantly decreased risk of death for older women of all ages, even for women with mild to moderate levels of comorbidity, but for older women with severe or multiple comorbidities, mammography is not associated with improvement in overall survival.

A nurse-based pilot program to reduce cardiovascular risk factors in a primary care setting.

OBJECTIVE: To evaluate the effectiveness of a nurse-based cardiovascular disease (CVD) risk factor reduction program among patients at a primary care outpatient clinic. STUDY DESIGN: Preintervention and postintervention longitudinal, prospective pilot study to evaluate patients' achievement of CVD risk factor reduction. PATIENTS AND METHODS: A total of 436 patients at a primary care clinic in suburban Minneapolis, Minnesota, were enrolled in 2 years; 286 patients were followed up with additional visits. The nurse intervention included comprehensive CVD risk assessment, patient education, and counseling. Algorithms guided the development of individualized care plans based on laboratory test values, blood pressure readings, tobacco use, and history of cardiovascular events. Physicians were consulted for serious changes in patients' medical conditions or for medication changes. Three measures were compared from baseline to the end of the program: blood pressure, low-density lipoprotein cholesterol levels, and tobacco use. RESULTS: Statistically significant reductions were achieved from baseline to the final nurse visit in systolic blood pressure (from 155.8 to 143.4 mm Hg), diastolic blood pressure (from 94.4 to 84.0 mm Hg), and dyslipidemia (low-density lipoprotein cholesterol, from 4.15 to 3.80 mmol/L [from 160 to 147 mg/dL]) (P < .001 for all). Of the 40 tobacco users who participated in the program, 12 discontinued use (30%). CONCLUSIONS: This pilot study provides preliminary evidence of the effectiveness of a nurse-based CVD risk reduction program. Further study is needed to target high-risk patients and to compare results in the nurse intervention group with those in patients receiving usual care.