Satisfaction with treatment decision-making and treatment regret among Latinas and non-Latina whites with DCIS.

OBJECTIVE: To examine differences in treatment decision-making participation, satisfaction, and regret among Latinas and non-Latina whites with DCIS. METHODS: Survey of Latina and non-Latina white women diagnosed with DCIS. We assessed women's preferences for involvement in decision-making, primary treatment decision maker, and participatory decision-making. We examined primary outcomes of satisfaction with treatment decision-making and treatment regret by ethnic-language group. RESULTS: Among 745 participants (349 Latinas, 396 white) Spanish-speaking Latinas (SSL) had the highest mean preference for involvement in decision-making score and the lowest mean participatory decision-making score and were more likely to defer their final treatment decision to their physicians than English-speaking Latinas or whites (26%, 13%, 18%, p<0.05). SSLs reported lower satisfaction with treatment decision-making (OR 0.4; CI 95%, 0.2-0.8) and expressed more regret than whites (OR 6.2; CI 95%, 3.0-12.4). More participatory decision-making increased the odds of satisfaction (OR 1.5; CI 95%, 1.3-1.8) and decreased the odds of treatment regret (OR 0.8; CI 95%, 0.7-1.0), independent of ethnicity-language. CONCLUSION: Language barriers impede the establishment of decision-making partnerships between Latinas and their physicians, and result in less satisfaction with the decision-making process and more treatment regret. PRACTICE IMPLICATIONS: Use of professional interpreters may address communication-related disparities for these women.

Ductal carcinoma in situ (DCIS): posttreatment follow-up care among Latina and non-Latina White women.

BACKGROUND: There is a lack of information about posttreatment care among patients with ductal carcinoma in situ (DCIS). This study compares posttreatment care by ethnicity-language and physician specialty among Latina and White women with DCIS. METHODS: Latina and White women diagnosed with DCIS between 2002 and 2005 identified through the California Cancer Registry completed a telephone survey in 2006. Main outcomes were breast surveillance, lifestyle counseling, and follow-up physician specialty. KEY RESULTS: Of 742 women (396 White, 349 Latinas), most (90 %) had at least one clinical breast exam (CBE). Among women treated with breast-conserving surgery (BCS; N = 503), 76 % had received at least two mammograms. While 92 % of all women had follow-up with a breast specialist, Spanish-speaking Latinas had the lowest specialist follow-up rates (84 %) of all groups. Lifestyle counseling was low with only 53 % discussing exercise, 43 % weight, and 31 % alcohol in relation to their DCIS. In multivariable analysis, Spanish-speaking Latinas with BCS had lower odds of receiving the recommended mammography screening in the year following treatment compared to Whites (OR 0.5; 95 % CI, 0.2-0.9). Regardless of ethnicity-language, seeing both a specialist and primary care physician increased the odds of mammography screening and CBE (OR 1.6; 95 % CI, 1.2-2.3 and OR 1.9; 95 % CI, 1.3-2.8), as well as having discussions about exercise, weight, and alcohol use, compared to seeing a specialist only. CONCLUSIONS: Most women reported appropriate surveillance after DCIS treatment. However, our results suggest less adequate follow-up for Spanish-speaking Latinas, possibly due to language barriers or insurance access. IMPLICATIONS FOR CANCER SURVIVORS: Follow-up with a primary care provider in addition to a breast specialist increases receipt of appropriate follow-up for all women.

Racial/ethnic differences in use and duration of adjuvant hormonal therapy for breast cancer in the women's health initiative.

BACKGROUND: Five-year breast cancer survival rates are lower among Hispanic and African-American women than among Non-Hispanic White women. Differences in breast cancer treatment likely play a role. Adjuvant hormonal therapies increase overall survival among women with hormone receptor-positive breast cancer. METHODS: We examined racial/ethnic differences in use and duration of adjuvant hormonal therapy among 3,588 postmenopausal women enrolled in the Women's Health Initiative (WHI) Extension Study. Women diagnosed with hormone receptor-positive localized or regional stage breast cancer after study enrollment were surveyed between September 2009 and August 2010 and asked to recall prior use and duration of adjuvant hormonal breast cancer therapy. ORs comparing self-reported use and duration with race/ethnicity (Hispanic, African-American, Asian/Pacific Islander vs. Non-Hispanic White) were estimated using multivariable-adjusted logistic regression. RESULTS: Of the 3,588 women diagnosed from 1994 to 2009; 3,039 (85%) reported any use of adjuvant hormonal therapy, and 67% of women reporting ever-use who were diagnosed before 2005 reported using adjuvant hormonal therapy for the optimal duration of 5 years or more. In adjusted analysis, no statistically significant differences in use or duration by race/ethnicity were observed. CONCLUSIONS: This study did not find significant differences in use or duration of use of adjuvant hormonal therapy by race/ethnicity. IMPACT: Findings should be confirmed in other population-based samples, and potential reasons for discontinuation of therapy across all racial/ethnic groups should be explored. Cancer Epidemiol Biomarkers Prev; 22(3); 365-73. ©2012 AACR.

Quality of life of Latina and Euro-American women with ductal carcinoma in situ.

BACKGROUND: Risk factors for psychosocial distress following a breast cancer diagnosis include younger age, history of depression, inadequate social support, and serious comorbid conditions. Although these quality of life (QOL) concerns have been studied in women with ductal carcinoma in situ (DCIS), Latina women have been understudied. METHODS: Data were from a cross-sectional telephone survey of Latina and Euro-American women with DCIS recruited through a population-based cancer registry. The sample included 396 Euro-American women and 349 Latina women; 156 were interviewed in English and 193 in Spanish, with a median of 2 years after diagnosis. Regression models were created for measures in each of the following four QOL domains: physical, psychological, social, and spiritual. RESULTS: Younger age, no partner, and lower income were related to lower QOL in various domains. Physical comorbidities were associated with lower physical, psychological, and social QOL; lingering effects of surgery and prior depression were associated with lower QOL in all domains. English-speaking and Spanish-speaking Latinas (SSLs) reported higher spiritual QOL, and SSLs reported lower social QOL than Euro-American women. CONCLUSIONS: Despite having lower mortality, women with DCIS are treated with surgery and radiation therapy as if they have invasive cancer, and the aftereffects of treatment can impact their QOL. SSLs are at risk for lower QOL partly because of poverty. However, Latinas' greater spiritual QOL may mitigate some of the psychological and social effects of treatment. IMPLICATIONS: It is important to incorporate these findings into treatment decision making (choice of surgical treatment) and survivorship care (monitoring women with a history of depression or physical comorbidity).

Breast cancer treatment decision-making: are we asking too much of patients?

OBJECTIVE: Physicians are mandated to offer treatment choices to patients, yet not all patients may want the responsibility that entails. We evaluated predisposing factors for, and long-term consequences of, too much and not enough perceived decision-making responsibility among breast cancer patients. DESIGN: Longitudinal assessment, with measurements collected just after surgical treatment (baseline) and 6-month follow-up. PARTICIPANTS: Women with early-stage breast cancer treated surgically at eight NYC hospitals, recruited for a randomized controlled trial of patient assistance to improve receipt of adjuvant treatment. MEASUREMENTS: Using logistic regression, we explored multivariable-adjusted associations between perceived treatment decision-making responsibility and a) baseline knowledge of treatment benefit and b) 6-month decision regret. RESULTS: Of 368 women aged 28-89 years, 72 % reported a "reasonable amount", 21 % "too much", and 7 % "not enough" responsibility for treatment decision-making at baseline. Health literacy problems were most common among those with "not enough" (68 %) and "too much" responsibility (62 %). Only 29 % of women had knowledge of treatment benefits; 40 % experienced 6-month decision regret. In multivariable analysis, women reporting "too much" vs. "reasonable amount" of responsibility had less treatment knowledge ([OR] = 0.44, [95 % CI] = 0.20-0.99; model c = 0.7343;p < 0.01) and more decision regret ([OR] = 2.,91 [95 % CI] = 1.40-6.06; model c = 0.7937;p < 0.001). Findings were similar for women reporting "not enough" responsibility, though not statistically significant. CONCLUSION: Too much perceived responsibility for breast cancer treatment decisions was associated with poor baseline treatment knowledge and 6-month decision regret. Health literacy problems were common, suggesting that health care professionals find alternative ways to communicate with low health literacy patients, enabling them to assume the desired amount of decision-making responsibility, thereby reducing decision regret.

Issues in biomedical research: what do Hispanics think?

OBJECTIVE: To examine barriers and facilitators of biomedical research participation among Hispanics in a rural community in Washington State. METHODS: Questionnaires addressed socio-demographics, health care access, and barriers and facilitators of participation in biomedical studies. This is a descriptive analysis of the findings. RESULTS: Barriers include the need to care for family members (82%), fear of having to pay for research treatments (74%), cultural beliefs (65%), lack of time (75%) and trust (71%), and the degree of hassle (73%). Facilitators include having a friend/relative with the disease being researched (80%) and monetary compensation (73%). CONCLUSION: Researchers should be mindful of these facilitators and barriers when recruiting for biomedical research studies.

Racial and ethnic differences in adjuvant hormonal therapy use.

BACKGROUND: In the United States, 5-year breast cancer survival is highest among Asian American women, followed by non-Hispanic white, Hispanic, and African American women. Breast cancer treatment disparities may play a role. We examined racial/ethnic differences in adjuvant hormonal therapy use among women aged 18-64 years, diagnosed with hormone receptor-positive breast cancer, using data collected by the Northern California Breast Cancer Family Registry (NC-BCFR), and explored changes in use over time. METHODS: Odds ratios (OR) comparing self-reported ever-use by race/ethnicity (African American, Hispanic, non-Hispanic white vs. Asian American) were estimated using multivariable adjusted logistic regression. Analyses were stratified by recruitment phase (phase I, diagnosed January 1995-September 1998, phase II, diagnosed October 1998-April 2003) and genetic susceptibility, as cases with increased genetic susceptibility were oversampled. RESULTS: Among 1385 women (731 phase I, 654 phase II), no significant racial/ethnic differences in use were observed among phase I or phase II cases. However, among phase I cases with no susceptibility indicators, African American and non-Hispanic white women were less likely than Asian American women to use hormonal therapy (OR 0.20, 95% confidence interval [CI]0.06-0.60; OR 0.40, CI 0.17-0.94, respectively). No racial/ethnic differences in use were observed among women with 1+ susceptibility indicators from either recruitment phase. CONCLUSIONS: Racial/ethnic differences in adjuvant hormonal therapy use were limited to earlier diagnosis years (phase I) and were attenuated over time. Findings should be confirmed in other populations but indicate that in this population, treatment disparities between African American and Asian American women narrowed over time as adjuvant hormonal treatments became more commonly prescribed.

Improving knowledge and screening for colorectal cancer among Hispanics: overcoming barriers through a PROMOTORA-led home-based educational intervention.

In the U.S., nearly 67 % of Hispanics ages 50 and older report that they have never had a screening colonoscopy. Barriers to screening include cost, lack of health insurance, anticipation of pain, embarrassment, mistrust of medical/healthcare systems and institutions, a fatalistic belief system, as well as fear and lack of knowledge regarding cancer survival. These barriers are significantly more problematic among Hispanics who are poor and those who live in underserved rural and border communities. This study addressed barriers by using promotoras and a home-based educational intervention to improve knowledge of cancer and screening for colorectal cancer (CRC) among Hispanics in Yakima Valley, Washington. Study participants attended a promotora led home-based educational intervention consisting of home-health parties (HHPs) and completed baseline and follow-up surveys on general cancer knowledge and knowledge specific to CRC and related screening practices. Results suggest increase in knowledge of cancer and participation in screening for CRC. Promotora facilitated home-based interventions offer culturally appropriate ways to reach Hispanics in rural and other underserved communities to reduce barriers and improve access to CRC and other cancer screenings.

Racial/ethnic differences in initiation of adjuvant hormonal therapy among women with hormone receptor-positive breast cancer.

Mortality after breast cancer diagnosis is known to vary by race/ethnicity even after adjustment for differences in tumor characteristics. As adjuvant hormonal therapy decreases risk of recurrence and increases overall survival among women with hormone receptor-positive tumors, treatment disparities may play a role. We explored racial/ethnic differences in initiation of adjuvant hormonal therapy, defined as two or more prescriptions for tamoxifen or aromatase inhibitor filled within the first year after diagnosis of hormone receptor-positive localized or regional-stage breast cancer. The sample included women diagnosed with breast cancer enrolled in Kaiser Permanente Northern California (KPNC). Odds ratios [OR] and 95% confidence intervals [CI] compared initiation by race/ethnicity (Hispanic, African American, Chinese, Japanese, Filipino, and South Asian vs. non-Hispanic White [NHW]) using logistic regression. Covariates included age and year of diagnosis, area-level socioeconomic status, co-morbidities, tumor stage, histology, grade, breast cancer surgery, radiation and chemotherapy use. Our sample included 13,753 women aged 20-79 years, diagnosed between 1996 and 2007, and 70% initiated adjuvant hormonal therapy. In multivariable analysis, Hispanic and Chinese women were less likely than NHW women to initiate adjuvant hormonal therapy ([OR] = 0.82; [CI] 0.71-0.96 and [OR] = 0.78; [CI] 0.63-0.98, respectively). Within an equal access, insured population, lower levels of initiation of adjuvant hormonal therapy were found for Hispanic and Chinese women. Findings need to be confirmed in other insured populations and the reasons for under-initiation among these groups need to be explored.

Adjuvant hormonal therapy use among women with ductal carcinoma in situ.

OBJECTIVE: In the absence of consistent guidelines for the use of adjuvant hormonal therapy (HT) in treating ductal carcinoma in situ (DCIS), our purpose was to explore a variety of factors associated with discussion, use, and discontinuation of this therapy for DCIS, including patient, tumor, and treatment-related characteristics and physician-patient communication factors. METHODS: We identified women from eight California Cancer Registry regions diagnosed with DCIS from 2002 through 2005, aged ≥18 years, of Latina or non-Latina white race/ethnicity. A total of 744 women were interviewed an average of 24 months postdiagnosis about whether they had (1) discussed with a physician, (2) used, and (3) discontinued adjuvant HT. RESULTS: Although 83% of women discussed adjuvant HT with a physician, 47% used adjuvant HT, and 23% of users reported discontinuation by a median of 11 months. In multivariable adjusted analyses, Latina Spanish speakers were less likely than white women to discuss therapy (odds ratio [OR] 0.36, 95% confidence interval [CI] 0.18-0.69) and more likely to discontinue therapy (OR 2.67, 95% CI 1.05-6.81). Seeing an oncologist for follow-up care was associated with discussion (OR 5.10, 95% CI 3.14-8.28) and use of therapy (OR 4.20, 95% CI 2.05-8.61). Similarly, physician recommendation that treatment was necessary vs. optional was positively associated with use (OR 11.2, 95% CI 6.50-19.4) and inversely associated with discontinuation (OR 0.38, 95% CI 0.19-0.73). CONCLUSIONS: Physician recommendation is an important factor associated with use and discontinuation of adjuvant HT for DCIS. Differences in discussion and discontinuation of therapy according to patient characteristics, particularly ethnicity/language, suggest challenges to physician-patient communication about adjuvant HT across a language barrier.

Educating Hispanic women about breast cancer prevention: evaluation of a home-based promotora-led intervention.

OBJECTIVES: Trained community health promoters (i.e., promotoras) conducted home-based group educational interventions (home health parties) to educate Hispanic women from the Lower Yakima Valley of Washington state about breast cancer and mammography screening. METHODS: Women aged 40-79 participating in the parties completed baseline and follow-up surveys 6 months postintervention (n = 70). Changes in general cancer knowledge, breast cancer screening practices, and intentions to be screened among participants from baseline to follow-up were measured using McNemar's test for marginal homogeneity to evaluate the effectiveness of the parties. RESULTS: The average age of the sample was 50.0 years (standard deviation [SD] 10.0), 84% reported less than an eighth grade education, and 54% were covered by the state's Basic Health Care Plan. Significant changes between baseline and follow-up were observed with respect to (1) believing that risk of cancer could not be reduced (41% vs. 15%, respectively, p = 0.001), (2) ever having a mammogram (83% vs. 91%, p = 0.014), (3) discussing a mammogram with a doctor (37% vs. 67%, p < 0.001), and (4) intending to have a mammogram within the next few months among women who did not report having a mammogram between baseline and follow-up (61% vs. 81%, p = 0.046). CONCLUSIONS: Participation in home-based group educational interventions delivered by promotoras may be associated with improved breast cancer screening practices among Hispanic women.

A qualitative investigation of cancer survivorship experiences among rural Hispanics.

Cancer survivorship experiences were explored among Hispanic men and women with cancer and family members of cancer survivors, recruited from two rural Washington communities in the Lower Yakima Valley. Five focus groups were conducted from February 2006 to October 2007 with 31 women and 10 men. Disbelief, fear, sadness, strength, courage, faith, and hope were common reactions to diagnosis. Concerns about family/children, losing medical coupons, and feelings of depression/isolation were identified as challenges faced after diagnosis. Participants identified smoking and environmental exposures as causes of cancer, but many believed operating on tumors caused cancer to spread. Participants used conventional treatments but identified herbal/natural remedies as cures. Most participants reported negative experiences with physicians and believed their community would benefit from language-appropriate information regarding prevention and treatment. The importance of linking survivors through support groups was emphasized and information elicited from sessions has been used to organize survivor support groups in these two communities.

A group-randomized tobacco trial among 30 Pacific Northwest colleges: results from the Campus Health Action on Tobacco study.

INTRODUCTION: We conducted a group-randomized trial to increase smoking cessation and decrease smoking onset and prevalence in 30 colleges and universities in the Pacific Northwest. METHODS: Random samples of students, oversampling for freshmen, were drawn from the participating colleges; students completed a questionnaire that included seven major areas of tobacco policies and behavior. Following this baseline, the colleges were randomized to intervention or control. Three interventionists developed Campus Advisory Boards in the 15 intervention colleges and facilitated intervention activities. The freshmen cohort was resurveyed 1 and 2 years after the baseline. Two-years postrandomization, new cross-sectional samples were drawn, and students were surveyed. RESULTS: At follow-up, we found no significant overall differences between intervention and control schools when examining smoking cessation, prevalence, or onset. There was a significant decrease in prevalence in private independent colleges, a significant increase in cessation among rural schools, and a decrease in smoking onset in urban schools. DISCUSSION: Intervention in this college population had mixed results. More work is needed to determine how best to reach this population of smokers.

Type 2 diabetes among rural Hispanics in Washington State: perspectives from community stakeholders.

During February-March 2006, elicitation interviews were conducted with 23 community stakeholders in the Yakima Valley, Washington State, to examine concerns about diabetes and to obtain recommendations for how to address concerns among Hispanics in this rural community. Using a snowball approach, stakeholders were identified from organizations providing care and outreach for Hispanics with diabetes. Interviews were guided by a social ecology approach and were conducted as part of a larger parent study using principles of community-based participatory research. Audiotaped interviews were transcribed and then coded by three staff members who identified common themes independently before meeting to reach consensus. Stakeholders represented health care delivery or social service organizations, churches, or local radio stations. Diabetes was perceived as an important problem among community members, who often underwent delayed diagnosis of the disease. Lack of disease knowledge, access to appropriate information or services, health insurance, and personal responsibility were perceived as barriers. Stakeholders recommended using exiting organizations and businesses as intervention channels, promoting cultural sensitivity of health professionals and volunteers, creating and distributing appropriate information, and organizing activities to promote awareness and disease management. Recommendations have informed the design of community interventions to lessen the impact of diabetes in the Yakima Valley.

Workplace exposures and protective practices of Hispanic warehouse workers.

BACKGROUND: This study was undertaken to assess workplace hazards and protective practices among Hispanic men and women working post-harvest in asparagus, apple and pear packaging warehouses. METHODS: Three focus groups were conducted in July 2003 with 25 workers (20 women, 5 men) recruited from communities in the Yakima Valley, Washington. Focus group content informed the design of an in-person structured interview administered to 50 additional warehouse workers from August to November 2006. RESULTS: Focus group participants reported difficult working conditions, exposure to chemicals, adverse health effects and use of work and home protective practices to minimize exposures for themselves and their families. Structured interview participants reported few workplace exposures to chemicals although many reported engaging in workplace and home protective practices. DISCUSSION: Findings from this research can direct initial efforts to determine if and how interventions for warehouse workers may be designed to protect against hazardous workplace exposures.

Information exchange and decision making in the treatment of Latina and white women with ductal carcinoma in situ.

The natural history of ductal carcinoma in situ (DCIS) is largely unknown, and its optimal treatment remains controversial. Using semi-structured interviews, this study compared 18 White and 16 Latina women's understanding of their DCIS diagnosis, treatment decision-making processes, and satisfaction with care. Ethnic differences were observed in cognitive and emotional responses to DCIS, with White women generally reporting a better understanding of their diagnosis and treatment, and Latinas reporting more distress. Regardless of ethnicity, women with DCIS preferred that physicians discuss treatment options and attend to their informational and emotional needs. Satisfaction was associated with adequate information, expediency of care, and physicians' sensitivity to patients' emotional needs.

Understanding Latino adolescent risk behaviors: parental and peer influences.

OBJECTIVE: To assess baseline factors associated with having ever drunk alcohol, smoked, and having had sex two years later among a sample of Latino adolescents. DESIGN: In a prospective cohort study, Latino adolescents completed telephone surveys assessing demographic information and health-enhancing and -compromising behaviors, administered 3 times (baseline, T2, and T3) during a two-year period. SETTING: Students were recruited between 1997 and 1998, from four middle schools within three Los Angeles school districts. PARTICIPANTS: Latino adolescents in 7th and 8th grade, from any of the four middle schools, whose parents provided written permission for them to participate in a telephone health behavior survey. MAIN OUTCOME MEASURES: Self-report of ever drank alcohol, ever smoked cigarettes, ever had sex by T3. RESULTS: Being more acculturated, engaging in risky behaviors, valuing independence, and having friends who had ever smoked at baseline were positively associated with having ever drunk alcohol and having ever smoked by T3. Parents' negative reactions to risky and unhealthy behaviors were protective against drinking and smoking. Working at a paid job and having parents with a high school education or higher were associated with drinking alcohol by T3. Older age at baseline was positively associated with having sex, while receiving good grades and valuing religion were protective against having sex. CONCLUSIONS: Findings reveal that both parents and peers are important influences on adolescent risk behaviors and suggest that interventions for adolescents to prevent such behaviors should involve peers and parents.

Lifestyle behavior counseling for women patients among a sample of California physicians.

BACKGROUND: Physical inactivity, poor diet, excessive alcohol consumption, and smoking are modifiable risk factors associated with development of chronic diseases. Although the prevalence of diseases associated with these detrimental lifestyle behaviors is high among women in the United States, they may not receive adequate counseling from physicians. METHODS: To predict physicians' lifestyle counseling practices, we assessed personal, professional, and health behavior characteristics from responses to a self-administered survey of breast cancer risk reduction practices. Subjects were California physicians identified through AMA Masterfile, in family practice, internal medicine, or obstetrics/gynecology, who were asked to report the percentages of women patients they counseled on physical activity, diet, alcohol, and smoking. RESULTS: Of 1647 eligible physicians, 822 (50.0%) responded. Fifty-six percent reported counseling at least 75% of patients about physical activity, 54.6% about diet, and 44.8% about alcohol. More than three quarters (78.7%) counseled at least 75% of patients about smoking. In logistic regression analyses, woman gender, family practice, and internal medicine specialties emerged as significant predictors of counseling for all lifestyle behaviors. Older age was associated with dietary and alcohol counseling. Race/ethnicity was associated only with smoking counseling, and country of medical school was associated with counseling for physical activity and smoking. Sources of new medical knowledge emerged as predictors for all types of counseling, whereas physicians' own level of physical activity only predicted counseling about physical activity. CONCLUSIONS: Physicians' personal, professional, practice, and health behavior characteristics were associated with reported lifestyle counseling of women patients. Results reveal important directions for future physician-based interventions to improve counseling.