Child-resistant and tamper-resistant packaging: A systematic review to inform tobacco packaging regulation.

OBJECTIVE: We aimed to investigate the effects of special packaging (child-resistant, adult-friendly) and tamper-resistant packaging on health and behavioral outcomes in order to identify research gaps and implications for packaging standards for tobacco products. METHODS: We searched seven databases for keywords related to special and tamper-resistant packaging, consulted experts, and reviewed citations of potentially relevant studies. 733 unique papers were identified. Two coders independently screened each title and abstract for eligibility. They then reviewed the full text of the remaining papers for a second round of eligibility screening. Included studies investigated a causal relationship between type of packaging or packaging regulation and behavioral or health outcomes and had a study population composed of consumers. Studies were excluded on the basis of publication type, if they were not peer-reviewed, and if they had low external validity. Two reviewers independently coded each paper for study and methodological characteristics and limitations. Discrepancies were discussed and resolved. RESULTS: The review included eight studies: four assessing people's ability to access the contents of different packaging types and four evaluating the impact of packaging requirements on health-related outcomes. Child-resistant packaging was generally more difficult to open than non-child-resistant packaging. Child-resistant packaging requirements have been associated with reductions in child mortality. CONCLUSIONS: Child-resistant packaging holds the expectation to reduce tobacco product poisonings among children under six.

Revisiting the Surveillance Epidemiology and End Results Cancer Registry and Medicare Health Outcomes Survey (SEER-MHOS) Linked Data Resource for Patient-Reported Outcomes Research in Older Adults with Cancer.

Researchers and clinicians are increasingly recognizing the value of patient-reported outcome (PRO) data to better characterize people's health and experiences with illness and care. Considering the rising prevalence of cancer in adults aged 65 and older, PRO data are particularly relevant for older adults with cancer, who often require complex cancer care and have additional comorbid conditions. A data linkage between the Surveillance Epidemiology and End Results (SEER) cancer registry and the Medicare Health Outcomes Survey (MHOS) was created through a partnership between the National Cancer Institute and the Centers for Medicare and Medicaid Services that created the opportunity to examine PROs in Medicare Advantage enrollees with and without cancer. The December 2013 linkage of SEER-MHOS data included the linked data for 12 cohorts, bringing the number of individuals in the linked data set to 95,723 with cancer and 1,510,127 without. This article reviews the features of the resource and provides information on some descriptive characteristics of the individuals in the data set (health-related quality of life, body mass index, fall risk management, number of unhealthy days in the past month). Individuals without (n=258,108) and with (n=3,440) cancer (1,311 men with prostate cancer, 982 women with breast cancer, 689 with colorectal cancer, 458 with lung cancer) were included in the current descriptive analysis. Given increasing longevity, advances in effective therapies and earlier detection, and population growth, the number of individuals aged 65 and older with cancer is expected to reach more than 12 million by 2020. SEER-MHOS provides population-level, self-reported, cancer registry-linked data for person-centered surveillance research on this growing population.

Unveiling SEER-CAHPS®: a new data resource for quality of care research.

BACKGROUND: Since 1990, the National Cancer Institute (NCI) and Centers for Medicare and Medicaid Services (CMS) have collaborated to create linked data resources to improve our understanding of patterns of care, health care costs, and trends in utilization. However, existing data linkages have not included measures of patient experiences with care. OBJECTIVE: To describe a new resource for quality of care research based on a linkage between the Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS®) patient surveys and the NCI's Surveillance, Epidemiology and End Results (SEER) data. DESIGN: This is an observational study of CAHPS respondents and includes both fee-for-service and Medicare Advantage beneficiaries with and without cancer. The data linkage includes: CAHPS survey data collected between 1998 and 2010 to assess patient reports on multiple aspects of their care, such as access to needed and timely care, doctor communication, as well as patients' global ratings of their personal doctor, specialists, overall health care, and their health plan; SEER registry data (1973-2007) on cancer site, stage, treatment, death information, and patient demographics; and longitudinal Medicare claims data (2002-2011) for fee-for-service beneficiaries on utilization and costs of care. PARTICIPANTS: In total, 150,750 respondents were in the cancer cohort and 571,318 were in the non-cancer cohort. MAIN MEASURES: The data linkage includes SEER data on cancer site, stage, treatment, death information, and patient demographics, in addition to longitudinal data from Medicare claims and information on patient experiences from CAHPS surveys. KEY RESULTS: Sizable proportions of cases from common cancers (e.g., breast, colorectal, prostate) and short-term survival cancers (e.g., pancreas) by time since diagnosis enable comparisons across the cancer care trajectory by MA vs. FFS coverage. CONCLUSIONS: SEER-CAHPS is a valuable resource for information about Medicare beneficiaries' experiences of care across different diagnoses and treatment modalities, and enables comparisons by type of insurance.

Health-related quality of life in older adult survivors of selected cancers: data from the SEER-MHOS linkage.

BACKGROUND: Research on health-related quality of life (HRQOL) among older adult cancer survivors is mostly confined to breast cancer, prostate cancer, colorectal cancer, and lung cancer, which account for 63% of all prevalent cancers. Much less is known about HRQOL in the context of less common cancer sites. METHODS: HRQOL was examined with the 36-Item Short Form Health Survey, version 1, and the Veterans RAND 12-Item Health Survey in patients with selected cancers (kidney cancer, bladder cancer, pancreatic cancer, upper gastrointestinal cancer, cancer of the oral cavity and pharynx, uterine cancer, cervical cancer, thyroid cancer, melanoma, chronic leukemia, non-Hodgkin lymphoma, and multiple myeloma) and in individuals without cancer on the basis of data linked from the Surveillance, Epidemiology, and End Results cancer registry system and the Medicare Health Outcomes Survey. Scale scores, Physical Component Summary (PCS) and Mental Component Summary (MCS) scores, and a utility metric (Short Form 6D/Veterans RAND 6D), adjusted for sociodemographic characteristics and other chronic conditions, were calculated. A 3-point difference in the scale scores and a 2-point difference in the PCS and MCS scores were considered to be minimally important differences. RESULTS: Data from 16,095 cancer survivors and 1,224,549 individuals without a history of cancer were included. The results indicated noteworthy deficits in physical health status. Mental health was comparable, although scores for the Role-Emotional and Social Functioning scales were worse for patients with most types of cancer versus those without cancer. Survivors of multiple myeloma and pancreatic malignancies reported the lowest scores, with their PCS/MCS scores less than those of individuals without cancer by 3 or more points. CONCLUSIONS: HRQOL surveillance efforts revealed poor health outcomes among many older adults and specifically among survivors of multiple myeloma and pancreatic cancer.

Physician roles in the cancer-related follow-up care of cancer survivors.

BACKGROUND AND OBJECTIVES: Information about primary care physicians' (PCPs) and oncologists' involvement in cancer-related follow-up care, and care coordination practices, is lacking but essential to improving cancer survivors' care. This study assesses PCPs' and oncologists' self-reported roles in providing cancer-related follow-up care for survivors who are within 5 years of completing cancer treatment. METHODS: In 2009, the National Cancer Institute and the American Cancer Society conducted a nationally representative survey of PCPs (n=1,014) and medical oncologists (n=1,125) (response rate=57.6%, cooperation rate=65.1%). Mailed questionnaires obtained information on physicians' roles in providing cancer-related follow-up care to early-stage breast and colon cancer survivors, personal and practice characteristics, beliefs about and preferences for follow-up care, and care coordination practices. RESULTS: More than 50% of PCPs reported providing cancer-related follow-up care for survivors, mainly by co-managing with an oncologist. In contrast, more than 70% of oncologists reported fulfilling these roles by providing the care themselves. In adjusted analyses, PCP co-management was associated with specialty, training in late or long-term effects of cancer, higher cancer patient volume, favorable attitudes about PCP care involvement, preference for a shared model of survivorship care, and receipt of treatment summaries from oncologists. Among oncologists, only preference for a shared care model was associated with co-management with PCPs. CONCLUSIONS: PCPs and oncologists differ in their involvement in cancer-related follow-up care of survivors, with co-management more often reported by PCPs than by oncologists. Given anticipated national shortages of PCPs and oncologists, study results suggest that improved communication and coordination between these providers is needed to ensure optimal delivery of follow-up care to cancer survivors.

Associations of serum 25-hydroxyvitamin D with overall and breast cancer-specific mortality in a multiethnic cohort of breast cancer survivors.

PURPOSE: Despite limited evidence on the association of vitamin D with outcomes in breast cancer survivors, some clinicians advise breast cancer patients to use vitamin D supplements. More evidence is needed to inform these recommendations. METHODS: In the Health, Eating, Activity, and Lifestyle study, we examined associations of post-treatment serum concentrations of 25-hydroxyvitamin D (25(OH)D) on overall and breast cancer-specific mortality in 585 breast cancer survivors from western Washington State, New Mexico, and Los Angeles County. 25(OH)D was measured in stored blood collected 2 years post-enrollment. Outcomes were ascertained from the Surveillance, Epidemiology, and End Results registries and medical records. Cox proportional hazards models were fit to assess associations of serum 25(OH)D with overall and breast cancer-specific mortality. RESULTS: After a median follow-up of 9.2 years; 110 women died, including 48 from breast cancer. Standard cut points classified 211 (31.6 %) women as serum 25(OH)D deficient (<20 ng/mL), 189 (32.2 %) as insufficient (20-30 ng/mL), and 185 (36.2 %) as sufficient (>30 ng/mL). Compared to women with deficient 25(OH)D, those in the sufficient ranges had a decreased risk of overall mortality (age-adjusted HR = 0.58; 95 % CI 0.36-0.96); however, multivariate adjustments attenuated the association (HR = 0.90; 95 % CI 0.50-1.61). No association was found between serum 25(OH)D and breast cancer-specific mortality (sufficient: HR = 1.21; 95 % CI 0.52-2.80) in multivariate models. CONCLUSION: In this breast cancer cohort, higher serum 25(OH)D may be associated with improved survival, but results were not statistically significant and must be interpreted with caution. The potential prognostic effect of vitamin D from diet, supplements, or both should be evaluated in future larger studies with additional endpoints from breast cancer patients.

Trends in colorectal cancer test use among vulnerable populations in the United States.

BACKGROUND: Evaluating trends in colorectal cancer (CRC) screening use is critical for understanding screening implementation, and whether population groups targeted for screening are receiving it, consistent with guidelines. This study examines recent national trends in CRC test use, including among vulnerable populations. METHODS: We used the 2000, 2003, 2005, and 2008 National Health Interview Survey to examine national trends in CRC screening use overall and for fecal occult blood test (FOBT), sigmoidoscopy, and colonoscopy. We also assessed trends by race/ethnicity, educational attainment, income, time in the United States, and access to health care. RESULTS: During 2000 to 2008, significant declines in FOBT and sigmoidoscopy use and significant increases in colonoscopy use and in the percentages of adults up-to-date with CRC screening occurred overall and for most population subgroups. Subgroups with consistently lower rates of colonoscopy use and being up-to-date included Hispanics; people with minimal education, low income, or no health insurance; recent immigrants; and those with no usual source of care or physician visits in the past year. Among up-to-date adults, there were few subgroup differences in the type of test by which they were up-to-date (i.e., FOBT, sigmoidoscopy, or colonoscopy). CONCLUSIONS: Although use of CRC screening and colonoscopy increased among U.S. adults, including those from vulnerable populations, 45% of adults aged 50 to 75-or nearly 35 million people-were not up-to-date with screening in 2008. IMPACT: Continued monitoring of CRC screening rates among population subgroups with consistently low utilization is imperative. Improvement in CRC screening rates among all population groups in the United States is still needed.

Dietary fiber is associated with circulating concentrations of C-reactive protein in breast cancer survivors: the HEAL study.

Inflammation is a suspected risk factor for breast cancer and its subsequent prognosis. The extent to which dietary and lifestyle factors might influence inflammation is important to examine. Specifically, dietary fiber may reduce systemic inflammation, but this relationship has not been examined among breast cancer survivors. We examined associations between dietary fiber and serum concentrations of C-reactive protein (CRP) and serum amyloid A (SAA), among 698 female breast cancer survivors from the Health, Eating, Activity, and Lifestyle (HEAL) Study. Data are from interviews and clinical visits conducted 24-months post-study enrollment. Multivariate-adjusted linear regression estimated associations of total, soluble, and insoluble fiber with serum concentrations of CRP and SAA. Logistic regression estimated the odds of elevated CRP (defined as >3.0 mg/l) across tertiles of dietary fiber intake. Mean total dietary fiber intake was 13.9 ± 6.4 g/day. Mean CRP and SAA were 3.32 ± 3.66 and 7.73 ± 10.23 mg/l, respectively. We observed a multivariate-adjusted inverse association between total dietary fiber intake and CRP concentrations (ß, -0.029; 95% CI, -0.049, -0.008). Results for insoluble fiber were similar (ß, -0.039; 95% CI, -0.064, -0.013). Among survivors who consumed >15.5 g/day of insoluble dietary fiber, a 49% reduction in the likelihood of having elevated CRP concentrations (OR, 0.51; 95% CI, 0.27, 0.95) was observed compared to those who consumed <5.4 g/day (P = 0.053). Our results suggest that diets high in fiber may benefit breast cancer survivors via reductions in systemic inflammation; elevated inflammation may be prognostic for reduced survival.

Dietary fiber, carbohydrates, glycemic index, and glycemic load in relation to breast cancer prognosis in the HEAL cohort.

BACKGROUND: Dietary intake of fiber, carbohydrate, glycemic index (GI), and glycemic load (GL) may influence breast cancer survival, but consistent and convincing evidence is lacking. METHODS: We investigated associations of dietary fiber, carbohydrates, GI, and GL with breast cancer prognosis among n = 688 stage 0 to IIIA breast cancer survivors in the Health, Eating, Activity, and Lifestyle (HEAL) study. Premenopausal and postmenopausal women from Western Washington State, Los Angeles County, and New Mexico participated. Usual diet was assessed with a food frequency questionnaire. Total mortality, breast cancer mortality, nonfatal recurrence, and second occurrence data were obtained from SEER (Surveillance, Epidemiology, and End Results) registries and medical records. Cox proportional hazards regression estimated multivariate-adjusted hazard ratios and 95% confidence intervals (CI). RESULTS: During a median of 6.7 years follow-up after diagnosis, n = 106 total deaths, n = 83 breast cancer-specific deaths, and n = 82 nonfatal recurrences were confirmed. We observed an inverse association between fiber intake and mortality. Multivariate-adjusted hazard rate ratios (HRR) comparing high to low intake were 0.53 (95% CI 0.23-1.23) and 0.75 (95% CI 0.43-1.31). A threshold effect was observed whereby no additional benefit was observed for intakes of 9 g/d or more. Fiber intake was suggestively inversely associated with breast cancer-specific mortality (HRR = 0.68, 95% CI 0.27-1.70) and risk of nonfatal recurrence or second occurrence (HRR = 0.68, 95% CI 0.27-1.70), but results were not statistically significant. CONCLUSION: Dietary fiber was associated with a nonsignificant inverse association with breast cancer events and total mortality. Further studies to assess and confirm this relationship are needed in order to offer effective dietary strategies for breast cancer patients. IMPACT: Increasing dietary fiber may an effective lifestyle modification strategy for breast cancer survivors.

A population-based assessment of specialty physician involvement in cancer clinical trials.

BACKGROUND: Clinical trials are critical for evaluating new cancer therapies, but few adult patients participate in them. Physicians have an important role in facilitating patient participation in clinical trials. We examined the characteristics of specialty physicians who participate in clinical trials by enrolling or referring patients, the types of trials in which they participate, and factors associated with physicians who report greater involvement in clinical trials. METHODS: We analyzed data from the Cancer Care Outcomes Research and Surveillance Consortium. The study included 1533 specialty physicians who cared for colorectal and lung cancer patients (496 medical oncologists, 228 radiation oncologists, and 809 surgeons) and completed a survey conducted during 2005-2006 (response rate = 61.0%). Descriptive statistics were used to characterize physicians' personal and practice characteristics, and regression models were used to examine associations between these characteristics and physician participation in clinical trials. All statistical tests were two-sided. RESULTS: A total of 87.8% of medical oncologists, 66.1% of radiation oncologists, and 35.0% of surgeons reported referring or enrolling one or more patients in clinical trials during the previous 12 months. The mean number of patients referred or enrolled by these physicians was 17.2 (95% confidence interval [CI] = 15.5 to 18.9) for medical oncologists, 9.5 (95% CI = 7.7 to 11.3) for radiation oncologists, and 12.2 (95% CI = 9.8 to 14.6) for surgeons (P < .001). Specialty type, involvement in teaching, and affiliation with a Community Clinical Oncology Program (CCOP) and/or a National Cancer Institute-designated cancer center were associated with physician trial participation and enrolling more patients (all Ps < .05). Two-thirds of physicians with a CCOP or National Cancer Institute-designated cancer center affiliation reported participating in trials. CONCLUSIONS: Features of specialty physicians' practice environments are associated with their trial participation, but many physicians at CCOPs and cancer centers do not participate.

Serum vitamin D and breast density in breast cancer survivors.

BACKGROUND: Vitamin D influences cellular proliferation and proliferation-related breast tissue characteristics, such as mammographic breast density. Little is known about vitamin D status, assessed by serum 25-hydroxyvitamin D [25(OH)D], and its relationship to breast density in breast cancer survivors. METHODS: Participants were 426 postmenopausal breast cancer survivors from the Health, Eating, Activity, and Lifestyle Study. Women from New Mexico, Los Angeles, and western Washington were enrolled postdiagnosis. Data for this report are from an examination conducted 24 months postenrollment. Participants completed health-related questionnaires, gave fasting blood samples, and completed height and weight measurements. Serum [25(OH)D] was assayed by radioimmunoabsorbant assay. Breast dense area and percent density were measured from postdiagnosis-digitized mammograms. Multivariate linear regression tested associations of serum [25(OH)D] with mammographic breast density measures. RESULTS: Of the 426 participants, 22.8% were African-American, 11.3% were Hispanic, and 62.8% were non-Hispanic white. We observed no associations of serum [25(OH)D] with either breast density or breast dense area. Among women with vitamin D deficiency (serum [25(OH)D], <16.0 ng/mL; n = 103), mean percent breast density was 8.0%, and among those with sufficient status (n = 99; serum [25(OH)D], > or = 32.0 ng/mL), mean percent density was 8.5%. Breast dense area averaged 27.2 and 26.2 cm2 for women with vitamin D deficiency and sufficiency, respectively. CONCLUSION: Data from this multiethnic cohort of breast cancer survivors do not support the hypothesis that serum vitamin D, [25(OH)D], is associated with breast density in cancer survivors.

The role of primary care physicians in cancer care.

BACKGROUND: The demand for oncology services in the United States (US) is increasing, whereas a shortage of oncologists looms. There is the need for a better understanding of the involvement of primary care physicians (PCPs) in cancer care. OBJECTIVE: To characterize the role of PCPs in cancer care, compare it with that of oncologists, and identify factors explaining greater PCP involvement in cancer care. DESIGN: National survey of physicians caring for cancer patients conducted by the Cancer Care Outcomes Research and Surveillance Consortium. PARTICIPANTS: 1694 PCPs; 1621 oncologists. MEASUREMENTS: Questionnaires mailed during 2005 and 2006 examined the participation of physicians in 12 aspects of care for cancer patients. MAIN RESULTS: Over 90% of PCPs fulfilled general medical care roles for patients with cancer such as managing comorbid conditions, chronic pain, or depression; establishing do-not-resuscitate status; and referring patients to hospice. Oncologists were less involved in these roles. Determining the treatment preferences of individual patients and deciding on the use of surgery were the only cancer care roles in which > or =50% of PCPs participated. Twenty-two percent of PCPs reported no direct involvement in cancer care roles while 19% reported heavy involvement. PCPs who were aged > or =50 years, were internists or geriatricians, taught medical students, saw more cancer patients, or experienced referral barriers fulfilled more roles. Rural practice location was not associated with greater PCP involvement in cancer care. CONCLUSIONS: PCPs across the US have an active role in cancer patient management. Determining the optimal interface between PCPs and oncologists in delivering and coordinating cancer care is an important area for future research.

Comorbidities, therapy, and newly diagnosed conditions for women with early stage breast cancer.

PURPOSE: To describe comorbidities in breast cancer patients at diagnosis and examine factors associated with self-reported comorbidities 30 months post-diagnosis. METHODS: Nine hundred forty one of 1,171 women had a medical record abstract and a follow-up survey in the Health, Eating, Activity and Lifestyle Study. RESULTS: We compared our breast cancer cohort to a contemporaneous nationally-representative sample of age, race/ethnicity and education matched women without cancer (n = 865). Breast cancer patients did not have substantially more comorbidities than women without breast cancer. Women with a hospital record of congestive heart failure significantly less often received chemotherapy or radiation following breast conserving surgery. In multivariate analysis, women who received chemotherapy alone (OR = 3.2; 95% CI: 1.5-6.8), chemotherapy plus radiation (OR = 1.9; 95% CI: 1.02-3.7) or radiation plus tamoxifen (OR = 1.9; 95% CI: 1.1-3.2) were significantly more likely to report at least one new comorbid condition following breast cancer diagnosis than women who received no chemotherapy, tamoxifen or radiation. Overall, women who received adjuvant therapy were more likely to have new comorbidities. CONCLUSIONS: Comorbidities were not substantially different in breast cancer patients than the non-cancer matched controls. Future research should focus on efforts to minimize comorbidities related to chemotherapy and other combination therapy.

A health services research agenda for cellular, molecular and genomic technologies in cancer care.

BACKGROUND: In recent decades, extensive resources have been invested to develop cellular, molecular and genomic technologies with clinical applications that span the continuum of cancer care. METHODS: In December 2006, the National Cancer Institute sponsored the first workshop to uniquely examine the state of health services research on cancer-related cellular, molecular and genomic technologies and identify challenges and priorities for expanding the evidence base on their effectiveness in routine care. RESULTS: This article summarizes the workshop outcomes, which included development of a comprehensive research agenda that incorporates health and safety endpoints, utilization patterns, patient and provider preferences, quality of care and access, disparities, economics and decision modeling, trends in cancer outcomes, and health-related quality of life among target populations. CONCLUSIONS: Ultimately, the successful adoption of useful technologies will depend on understanding and influencing the patient, provider, health care system and societal factors that contribute to their uptake and effectiveness in 'real-world' settings.

Role of religiosity and spirituality in complementary and alternative medicine use among cancer survivors in California.

OBJECTIVES: Cancer survivors often turn to religion, spirituality, and complementary and alternative medicine (CAM) because they perceive these areas as being more holistic and patient-centered than conventional medicine. Because increased religiosity and spirituality have been found to be associated with higher CAM use in the general population, it was hypothesized that these factors would be important predictors of CAM use in cancer survivors. DESIGN AND SUBJECTS: The study included a subsample of 1844 people with cancer or a history of cancer from the 2003 California Health Interview Survey of CAM, a cross-sectional survey of a population-based sample of adults in California. Prevalence and predictors of religious/spiritual forms of CAM (R/S CAM) and nonreligious/nonspiritual forms of CAM (non-R/S CAM) were compared. Multivariate logistic regression was used to identify the predictors of R/S CAM and non-R/S CAM. RESULTS: Nearly two thirds of participants reported using at least 1 type of R/S CAM, and 85% reported ever using non-R/S CAM. The majority of cancer survivors reported that they were very/moderately religious or spiritual. Both religiosity and spirituality were strongly related to non-R/S CAM use, but in opposite directions. Very or moderately religious cancer survivors were less likely (odds ratio=0.30; 95% confidence interval, 0.12-0.40) than nonreligious cancer survivors to use non-R/S CAM. In contrast, very or moderately spiritual cancer survivors were more likely (odds ratio=2.42; 95% confidence interval, 1.16-6.02) than nonspiritual cancer survivors to use non-R/S CAM. CONCLUSIONS: The use of R/S CAM and non-R/S CAM is very high in cancer survivors. It may be helpful for clinicians to ascertain their patients' use of these types of CAM to integrate all forms of care used to managing their cancer.

Overview of the SEER--Medicare Health Outcomes Survey linked dataset.

The Surveillance, Epidemiology, and End Results (SEER)--Medicare Health Outcomes Survey (MHOS) links cancer registry data with survey data from Medicare managed care enrollees. The linked file includes clinical information about the cancer with self-reported data about symptoms, functional status and health-related quality of life (HRQOL) for Medicare managed care enrollees. This article provides a description of the SEER-MHOS data as a tool to study cancer among Medicare enrollees. In order to highlight the strengths of the database, we also present some descriptive statistics from the database.

Vitamin D insufficiency in a multiethnic cohort of breast cancer survivors.

BACKGROUND: Little is known about vitamin D status in breast cancer survivors. This issue is important because vitamin D influences pathways related to carcinogenesis. OBJECTIVE: The objective of this report was to describe and understand vitamin D status in a breast cancer survivor cohort. DESIGN: Data are from the Health, Eating, Activity, and Lifestyle study. With the use of a cross-sectional design, we examined serum concentrations of 25-hydroxyvitamin D [25(OH)D] in 790 breast cancer survivors from western Washington state, New Mexico, and Los Angeles County. Cancer treatment data were obtained from Surveillance, Epidemiology, and End Results registries and medical records. Fasting blood, anthropometry, and lifestyle habits were collected after diagnosis and treatment. We examined distributions of 25(OH)D by race-ethnicity, season, geography, and clinical characteristics. Multivariate regression tested associations between 25(OH)D and stage of disease. RESULTS: Five hundred ninety-seven (75.6%) of the women had low serum 25(OH)D, suggesting vitamin D insufficiency or frank deficiency. The overall mean (+/-SD) was 24.8 +/- 10.4 ng/mL, but it was lower for African Americans (18.1 +/- 8.7 ng/mL) and Hispanics (22.1 +/- 9.2 ng/mL). Women with localized (n = 424) or regional (n = 182) breast cancer had lower serum 25(OH)D than did women with in situ disease (n = 184) (P = 0.05 and P = 0.03, respectively). Multivariate regression models controlled for age, body mass index (in kg/m(2)), race-ethnicity, geography, season, physical activity, diet, and cancer treatments showed that stage of disease independently predicted serum 25(OH)D (P = 0.02). CONCLUSIONS: In these breast cancer survivors, the prevalence of vitamin D insufficiency was high. Clinicians might consider monitoring vitamin D status in breast cancer patients, together with appropriate treatments, if necessary.

Dietary supplement use in individuals living with cancer and other chronic conditions: a population-based study.

OBJECTIVE: Cancer survivors are increasingly turning to complementary and alternative medicine (CAM) to manage short- and long-term treatment sequelae. Population-based data on relative use of dietary supplements among cancer survivors compared to those without a cancer history is lacking. Our objective was to compare supplement use among those with and without cancer and among those with and without other chronic conditions, and to identify correlates of supplement use by cancer status. DESIGN: Cross-sectional, population-based survey of participants in the 2003 CAM supplement to the 2001 California Health Interview Survey. SUBJECTS: Participants reporting a cancer diagnosis on the 2001 California Health Interview Survey or newly reported diagnosis on the 2003 survey (n=1,844) plus a random oversampling of racial/ethnic minorities (n=7,343). MEASURES: Self-reported use of a multivitamin and 27 vitamins, minerals, herbs, and other natural products during the preceding 12 months. STATISTICAL ANALYSES: Logistic regression analyses were performed with control for potential confounders. RESULTS: Adults with cancer or other chronic conditions had higher prevalence of supplement use than those reporting no illness. The independent effect of cancer was associated with vitamin use, whereas living with other chronic conditions was associated with all types of supplement use, except multivitamins. Correlates of supplement use were similar between cancer survivors and cancer-free individuals-being a woman, advancing age, and greater physical activity, fruit and vegetable intake, and other CAM use. Among cancer survivors, non-Hispanic whites had the lowest prevalence of herbal supplement use. CONCLUSIONS: These results indicate that having a chronic medical condition is the major factor associated with supplement use. A diagnosis of cancer, by itself, does not have an independent effect on supplement use. This suggests that most supplement use among cancer survivors is directed at dealing with or preventing the exacerbation of a comorbid condition. Consumers and health professionals should be aware that there is limited information on the effects of dietary supplements taken concurrently with prescription and other over-the-counter medications.

Religious and spiritual practices and identification among individuals living with cancer and other chronic disease.

Religion and spirituality in the context of health care are poorly understood, particularly for individuals with chronic illness. Using data from the 2003 Complementary and Alternative Medicine supplement to the 2001 California Health Interview Survey, we examined whether cancer survivors (n = 1,777) and individuals with other chronic illnesses (n = 4,784) were either more likely to identify themselves as religious and spiritual or more likely to use religious and spiritual practices for health purposes than individuals with no disease (n = 2,342). We observed that cancer survivors and individuals with chronic illnesses were more likely than those with no disease to use religious and spiritual prayer and healing practices. Individuals with chronic diseases were not inherently more likely to identify themselves as religious than were healthy individuals and were only slightly more likely to identify themselves as spiritual. These findings indicate that individuals with cancer and other chronic illnesses may be using religious and spiritual practices as a way to cope with their illness. Future research should continue to examine whether and how religious and spiritual practices are used as complementary or alternative medicine, and health care professionals should ask their patients about such use.

The use of complementary and alternative medicine among california adults with and without cancer.

This article examines the extent and correlates of complementary and alternative medicine (CAM) use among a population-based sample of California adults that is highly diverse in terms of sociodemographic characteristics and health status. As a follow-up to a state-wide health survey of 55,428 people, 9187 respondents were interviewed by phone regarding their use of 11 different types of CAM providers, special diets, dietary supplements, mind-body interventions, self-prayer and support groups. The sample included all participants in the initial survey who reported a diagnosis of cancer, all the non-white respondents, as well as a random sample of all the white respondents. The relation of CAM use to the respondents' demographic characteristics and health status is assessed. CAM use among Californians is generally high, and the demographic factors associated with high rates of CAM use are the same in California as have been found in other studies. Those reporting a diagnosis of cancer and those who report other chronic health problems indicate a similar level of visits to CAM providers. However, those with cancer are less likely to report using special diets, and more likely to report using support groups and prayer. Health status, gender, ethnicity and education have an independent impact upon CAM use among those who are healthy as well as those who report suffering from chronic health problems, although the precise relation varies by the type of CAM used.