Characteristics and Outcomes for Secondary Breast Cancer in Childhood, Adolescent, and Young Adult Cancer Survivors Treated with Radiation.

BACKGROUND: Radiotherapy is used to treat many adolescent and young adult (AYA) and childhood cancer patients and is a risk factor for secondary breast cancer. While premenopausal breast cancer is inherently more aggressive, no studies to date have evaluated the characteristics and breast cancer-specific survival (BCSS) of premenopausal secondary breast cancer after radiotherapy in AYA and childhood cancer survivors. METHODS: Female patients ages 12 to 50 diagnosed with primary breast cancer from 1988 to 2014 (n = 107,751) were obtained from the California Cancer Registry and compared with similar aged patients with secondary breast cancer who were treated with radiotherapy for their primary tumor (n = 1,147) from ages 12 to 39. We examined BCSS using multivariable Cox proportional hazards regression. RESULTS: The secondary breast cancer cohort was more likely to be Hispanic or Black, be 35 to 45 years of age, have earlier stage tumors, be higher grade, have no lymph node involvement, and be hormone receptor negative. All women showed worse BCSS for large tumor size, lymph node involvement, and hormone receptor-negative status. BCSS was worse for women with secondary breast cancer both overall (hazard ratio, 1.98; 95% confidence interval, 1.77-2.23) and in all subgroups considered. Associations were most pronounced in Hispanics, Asian/Pacific Islanders, and younger women, as well as those with earlier stage, lymph node-negative, and hormone receptor-positive disease. CONCLUSIONS: BCSS is significantly decreased among all survivors of childhood and AYA cancer treated with radiotherapy that develop a secondary breast cancer, including women with good prognostic features. IMPACT: Therefore, we may need to consider alternative and even more aggressive treatment in what were considered low-risk populations previously.

A model for rural oncology.

Small rural hospitals in the United States have had challenging issues developing sustainable oncology programs. This is a report on the development of a successful rural oncology program. In 2006, the Tahoe Forest Health System in Truckee, CA, a remote mountain resort town, started a cancer program that was focused on addressing patient and family fears that are common to all cancer patients but more frightening in the rural setting. Four years later, it is a thriving program with significant community support, a creative academic affiliation, and a central focus of the future of the hospital. The Tahoe Forest Cancer Center developed a sustainable model for high quality cancer care that overcomes geographic, cultural and financial barriers. This structure may serve as a model for national rural health care.

"Teaching as a Competency": competencies for medical educators.

Most medical faculty receive little or no training about how to be effective teachers, even when they assume major educational leadership roles. To identify the competencies required of an effective teacher in medical education, the authors developed a comprehensive conceptual model. After conducting a literature search, the authors met at a two-day conference (2006) with 16 medical and nonmedical educators from 10 different U.S. and Canadian organizations and developed an initial draft of the "Teaching as a Competency" conceptual model. Conference participants used the physician competencies (from the Accreditation Council for Graduate Medical Education [ACGME]) and the roles (from the Royal College's Canadian Medical Education Directives for Specialists [CanMEDS]) to define critical skills for medical educators. The authors then refined this initial framework through national/regional conference presentations (2007, 2008), an additional literature review, and expert input. Four core values grounded this framework: learner engagement, learner-centeredness, adaptability, and self-reflection. The authors identified six core competencies, based on the ACGME competencies framework: medical (or content) knowledge; learner- centeredness; interpersonal and communication skills; professionalism and role modeling; practice-based reflection; and systems-based practice. They also included four specialized competencies for educators with additional programmatic roles: program design/implementation, evaluation/scholarship, leadership, and mentorship. The authors then cross-referenced the competencies with educator roles, drawing from CanMEDS, to recognize role-specific skills. The authors have explored their framework's strengths, limitations, and applications, which include targeted faculty development, evaluation, and resource allocation. The Teaching as a Competency framework promotes a culture of effective teaching and learning.

Patient desires: a model for assessment of patient preferences for care of severe or terminal illness.

OBJECTIVE: Patient-centered care is better achieved through a comprehensive understanding of patients' preferences for how they want to live their life and how they want to influence their own death. Though much has been written on identifying goals of care, it is often difficult for clinicians to articulate patient goals to guide care planning. We explored the literature on patient's preferences for their care in chronic or life-limiting illness to develop a model for assessment of patient perspectives. We then illustrated our model with composite patients from our clinics and we provide questions to guide patient discussion. METHODS: We searched MEDLINE from 1986 to 2004 for primary research articles that relate primarily to a patient's preferences for his or her care. We reviewed over 3500 titles, abstracts, and research papers. Hundreds of articles described patients' quality of life, health status, or satisfaction. We excluded consensus guidelines, non-English papers, reviews, and articles focused on medical professional perspectives. Forty-eight studies focused primarily on patient preferences. Using an iterative process, we identified unique issues and broader themes in patients' desires for their care. RESULTS: Studies focused on patients with cancer, those in hospice or those with terminal disease. Three domains emerged: patient feelings about disease, feelings about suffering, and feelings about the circumstances of death. Attention was given to the differences between patients in terms of the strength and persistence of feelings in each domain. SIGNIFICANCE OF RESULTS: Based on existing data, there are three fundamental domains of patient perspective that influence preferences for care. These domains can be assessed by the care team to guide the development of a plan of care and to identify areas of conflict. Our review identifies gaps in the end-of-life literature and areas for future work in patient preferences.