Attitudes of primary care physicians toward cancer-prevention trials: a focus group analysis.

PURPOSE: Recruitment of low-income and minority women to cancer-prevention trials requires a joint effort from specialists and primary care providers. We sought to assess primary care providers' attitudes toward participating in cancer-prevention trial recruitment. PROCEDURES: We conducted a focus group with seven Boston-based primary care providers serving low-income and minority women. Providers discussed knowledge, attitudes, and beliefs regarding their role in recruitment to prevention trials. FINDINGS: A qualitative analysis of the focus group transcript revealed nine categories. Three categories related specifically to the primary care physician: 1) the dual role physicians play as advocates for both patient and research; 2) threats to maintaining the primary care relationship; and 3) general philosophy toward prevention. An additional six categories could be subdivided as they apply to the primary care physician, the patient, and the community: 4) trust/commitment; 5) benefits of the research; 6) access to the research; 7) knowledge and recall of the research; 8) influences of media coverage about the research; and 9) cultural sensitivity. CONCLUSIONS: Investigators conducting cancer-prevention trials must address the concerns of primary care physicians to optimize recruitment of subjects- especially low-income and minority women-into trials.

Participation of women in clinical trials of drug therapies: a context for the controversies.

Women's participation in clinical trials, particularly those involving drugs, has been said to be both overrepresented and underrepresented. How can this be? Studies of participation are compared and contrasted to elucidate some reasons for this contradiction. The history of women's participation in clinical trials is chronicled through policies and regulations filled with restrictions. Since 1993, however, the National Institutes of Health has mandated, and the Food and Drug Administration has emphasized, inclusion of women in clinical trials, only to be thwarted by other regulations excluding many women. Gender-specific analyses are required to detect gender differences in effects of pharmaceutical and nonpharmaceutical interventions, but they are seldom performed. The exclusion of women from clinical trials means that women's healthcare is compromised by lack of sex-specific information about dosing of drugs and unique uses of drugs. A database, although currently quite limited, tracks the participation of women in clinical trials funded by federal agencies, industries, and nonprofit groups. Federal regulations have recently changed. Additional changes in access to all phases of clinical trials and enhanced monitoring of clinical trials are recommended.

Breast cancer risk reduction: what do we know and where should we go?

Clinicians should be aware of the advances in breast cancer risk assessment and risk-reduction therapy. The modified Gail model is appropriate for predicting the risk of developing breast cancer within the next 5 years for most women between ages 35 and 75. Tamoxifen has been approved by the U.S. Food and Drug Administration (FDA) for reduction of breast cancer risk in women aged 35 and older who meet the threshold risk for breast cancer. Raloxifene is being compared with tamoxifen in the clinical trial, STAR (a Study of Tamoxifen and Raloxifene), which is now enrolling postmenopausal women aged 35 or older. The risks and benefits of therapy to reduce breast cancer risk are reviewed here. Processes for comparison of risks and benefits and for shared decision making are outlined.

Cancer skills laboratories for medical students: a promising approach for cancer education.

BACKGROUND: Most medical students graduate without the skills necessary to assist patients in cancer control. To address this problem, the authors developed a cancer skills laboratory for second-year medical students. METHODS: The skills laboratory consists of two hours of training, with 15 minutes allotted per station (six to eight students assigned per station). Faculty and fellows lead the stations on prostate cancer, breast cancer, colorectal cancer, skin cancer, counseling for smoking cessation, and a discussion of anti-tobacco advertisements. Students completed pre- and post-laboratory surveys consisting of ten brief questions. RESULTS: Overall, 94% of eligible students in 1997 and 1998 completed the surveys. Using a five-point scale, self-rated skill level increased from 2.12 to 3.83 when all modalities were averaged (p < .001). CONCLUSIONS: Cancer skills laboratories are a promising new means for cancer education.

Risk factors for a decline in upper body function following treatment for early stage breast cancer.

PURPOSE: To identify risk factors for a decline in upper body function following treatment for early stage breast cancer. METHODS: We conducted a cross-sectional observational study of 213 women > 55 years of age newly diagnosed with early stage breast cancer interviewed three to five months following their definitive surgery. Patients were classified as having impaired upper body function related to their breast cancer treatment if: 1) they reported having no difficulty in performing any of three tasks requiring upper body function (pushing or pulling large objects; lifting objects weighing more than 10 pounds; and reaching or extending arms above shoulder level) prior to treatment, but reported that any of these tasks were somewhat or very difficult in the four weeks prior to interview, or 2) they reported that performing any of the three tasks requiring upper body function was somewhat difficult prior to treatment, but reported that any of these tasks were very difficult in the four weeks prior to interview. RESULTS: In multiple logistic regression models, both the extent and type of primary tumor therapy and cardiopulmonary comorbidity were significantly associated with a decline in upper body function following breast cancer treatment. CONCLUSION: Given the critical importance of upper body function in maintaining independent living, clinicians should consider the functional consequences of treatment when they discuss treatment options and post-operative care with older women who have early stage breast cancer.

Head and neck cancer screening among 4611 tobacco users older than forty years.

We implemented screening for squamous cell carcinomas of the oral cavity, pharynx, and larynx with symptom assessment and systematic inspection of the oral mucosa by primary care practitioners at health care sites serving inner-city residents of Boston; 4611 tobacco users older than 40 years were screened, and 313 with specific criteria were referred to otolaryngology for diagnostic evaluations. In these screened patients, the prevalence of oral mucosal lesions was almost 13% and prevalence of persistent hoarseness was more than 11%. Although the identification of these cancers was rare (nearly 3%), abnormal findings were seen in more than 70% of referred patients. These clinical and histologic diagnoses are described. We have documented the range of pathologic conditions in high-risk patients screened for upper aerodigestive tract malignancy.

The epidemiology of AL and AA amyloidosis.

The limited available epidemiological information on AL amyloidosis suggests that there may be differences between population-based studies and case series data with respect to variables such as age and racial patterns. Much more work in this area is required before specific aetiologic hypotheses can be tested. Most available data to approximate the epidemiology of AA amyloidosis are derived from autopsies. Most patients with AA amyloidosis die from causes other than amyloidosis, therefore mortality data based on death certificates is of limited value in AA amyloidosis. Case ascertainment in autopsy studies may be difficult due to the frequent lack of adequate histological controls. Establishment of registries for both AL and AA amyloidosis would facilitate epidemiological research in these disorders.

A multidisciplinary educational program to promote head and neck cancer screening.

An educational program to promote screening through primary health care for the squamous cell cancers of the buccal cavity, pharynx, and larynx as developed and implemented, and its impact on screening was documented. Providers of care for high-risk patients at seven inner-city health care sites in Boston were identified and targeted for training. Of the 327 providers who were targeted for training from December 1986 through June 1989, 261 (80%) attended educational sessions. Screening exams were documented on an average of 14.7 patients per targeted provider through December 1989. The educational program was associated with a large increase in documented screening for these cancers, compared with baseline rates. Several adaptations in the program were required, including a demonstration of efficient screening to address the concerns of these providers about time constraints. Variations in the quantity and quality of documented screening among health care sites were noted.

Social environment and social support.

Research on the relevance of social support to cancer has been plentiful since the first American Cancer Society workshop on methodological issues in behavioral and psychosocial science. Nonetheless, critical shortcomings continue to characterize the attempt empirically to establish such things as the extent to which social support predicts adjustment to cancer diagnosis and treatment. Prominent among these is the failure to adequately address large elements of the social structure, such as social class and urbanization, and to investigate how they shape the well being of persons with or at risk for cancer and their caregivers. We recommend that more psychosocial research on the link between social support and cancer be conducted within populations beset by poverty and without adequate access to health care. Funding is needed for the training and maintenance of multidisciplinary and multicultural teams of researchers working within community-based organizations and hospitals serving the underserved.

Advances in screening protocols for the detection of early bladder cancer.

Bladder cancer screening faces several obstacles, including low yield, numerous false-positive results, and the absence of a single effective screening test. We present a model of a screening program that (1) targets an occupational cohort exposed to a putative carcinogen, to increase the detection of disease, (2) uses four screening tests in parallel to maximize case detection, and (3) defines a diagnostic protocol that minimizes the number of invasive procedures by utilizing both flexible and rigid cystoscopy. In a hypothetical cohort of 1000 men aged 45 to 74 years potentially exposed to a bladder carcinogen, the model would find eight of the nine detectable cancers, with a sensitivity of 89% and a specificity of 78%. In addition, the model allows the sensitivities, specificities, and predictive values of the individual screening tests to be compared and evaluated in a single cohort.

Years of potential life lost: another indicator of the impact of cutaneous malignant melanoma on society.

Years of potential life lost (YPLL) is an indicator of premature mortality that complements traditional incidence and mortality rates and that facilitates comparisons among different cancers. We calculated YPLL from cutaneous melanoma and 11 other cancers routinely recorded and tracked by Surveillance, Epidemiology and End Results (SEER). YPLL from cutaneous melanoma ranked eighth for persons younger than 65 years of age and fourth for those 20 to 49 years of age. An average of 17.1 YPLL per death were due to melanoma, one of the highest rates for adult-onset cancers. The results of our study, the first to apply YPLL to cutaneous melanoma, emphasize the disproportionate impact of this cancer on young and middle-aged adults and reemphasize the importance of this cancer as a public health priority.

Use of health services before diagnosis of head and neck cancer among Boston residents.

One hundred thirty incident cases of head and neck cancer in Boston between September 1, 1985, and March 31, 1988, provided interview or medical record review data on the use of health services in the 24 months preceding the diagnosis of cancer. One hundred twenty-four subjects were able to recall whether and how often they visited health care sites in this period, reporting a median number of 10.5 visits; 94% recalled at least one visit. Eighty-nine medical record reviews indicated a median of seven visits. For the most part, these visits were to providers whom subjects considered their regular source of care--sources that provided care in a broad range of locations. These data support a strategy of integrating screening for head and neck cancers into existing health care services.

Evaluation of melanoma/skin cancer screening in Massachusetts. Preliminary results.

Although screening for melanoma/skin cancer is theoretically of value, few data are available to evaluate its effectiveness or the value of a visual exam by a dermatologist as a cancer screening tool. From the 2560 persons screened for melanoma/skin cancer in Massachusetts in 1986 and 1987, the authors followed the positive screenees to determine their final diagnosis. The authors obtained information on 85% of these persons, and found nine malignant melanomas, 91 non-melanoma skin cancers, 39 dysplastic nevi, and three congenital nevi. The sensitivity of the visual exam by a dermatologist was 89% to 97% and the predictive value positive was 35% to 75% for skin cancer. The authors conclude that the yield of screening is equivalent to that of other major cancer screening efforts and that the sensitivity and predictive value of the visual examination by the dermatologist is appropriate for a cancer screening tool.

Screening for melanoma/skin cancer: theoretic and practical considerations.

There is increasing national interest concerning strategies for the early detection of melanoma/skin cancer. Screening has been implemented on a national scale in an effort to decrease morbidity and mortality from this disease; however, many crucial questions about the proper methods and ultimate value of screening remain unanswered. In this review we apply the scientific principles of cancer screening to dermatology, address the theoretic and practical challenges of cancer screening in terms of melanoma/skin cancer, analyze existing data on skin cancer screening, and identify issues that require future research.

Screening for cancer by residents in an internal medicine program.

A study was conducted by the authors to explore screening for cancer by internal medicine residents in a primary care clinic. The charts of 151 patients over 40 years of age followed by residents in the outpatient clinic of an innercity hospital were reviewed for documentation of screening on initial evaluation or on follow-up within 12 months of the initial visit. The residents were unaware of the chart review, and cancer screening had received no special emphasis in their training program. Screening was more frequently performed on male patients than female patients: smoking history (61 percent of males, 34 percent of females); alcohol history (64 percent of males, 26 percent of females); occupational history (48 percent of males, 15 percent of females); and testing for hidden blood in stools (73 percent of males, 41 percent of females). Breast examination and Pap smears were done on 33 percent and 29 percent of the women patients, respectively, with women residents performing them slightly more frequently than male residents. This low rate of cancer risk screening suggests the need for intensive education of residents on the potential for cancer prevention through early detection.

The efficient workup of suspected lung cancer.

The triage process of patients with suspected cancer of the lung is reviewed, paying particular attention to areas of inefficiency and delay. Most patients with suspected lung cancer are inoperable and can be triaged on presentation. The efficient workup involves confirmation of diagnosis and simultaneous determination of stage and operative status. The physician should search for common sites of metastatic spread, with pragmatic use of biopsies and scans. From the outset, the physician should also pay special attention to the patient's functional status, attitude toward possible surgery, and cardiopulmonary status, with the goal of quickly directing each patient to proper therapy.

Thymoma and the nephrotic syndrome: a report of a case.

A 48-year-old male presented with the nephrotic syndrome 3 years after resection and irradiation of a thymoma. Renal biopsy revealed membranous glomerulonephritis by electron microscopy. IgA, IgG, and C3 deposition were present in the glomerular basement membrane by immunofluorescence. There was no evidence of other autoimmune diseases or causes of the membranous glomerulonephritis. He has continued to have proteinuria and edema 1 year later.