Health-related quality of life in rural cancer survivors compared with their urban counterparts: a systematic review.

PURPOSE: We conducted a systematic review to describe health-related quality of life (HRQOL) in rural cancer survivors (RCS), and compare HRQOL between RCS and urban cancer survivors (UCS). METHOD: We searched Medline, Embase, CINAHL Plus, and PsycINFO for studies with HRQOL in adult cancer survivors living in rural, regional, remote, and urban areas, who had completed definitive primary cancer treatment, without evidence of residual disease. Where available, we used normative and clinically important values to ascribe meaning to HRQOL data. FINDINGS: Fifteen studies (16 papers) were included. Most were from the US (n = 8) and reported on breast cancer survivors (n = 9). Six HRQOL instruments, collecting data across 16 domains, were used. Three instruments were specific to the survivorship phase. Normative and clinical data were available for 12 studies. Compared with normative populations, RCS had clinically worse physical HRQOL (6/12 studies), better social/family (5/7), and functional (3/6) HRQOL, and there were no differences in emotional or/mental HRQOL (9/12). In six studies with rural-urban comparator groups and normative and clinically important data, RCS and UCS had clinically worse physical (3/6 and 2/6, respectively) and better social/family (3/4 and 2/4 studies, respectively) HRQOL than normative populations. Functional HRQOL was better in RCS (2/4 studies) than UCS and normative populations. In 3/6 studies, there were no clinical differences in emotional or/mental HRQOL between RCS, UCS, and normative populations. CONCLUSION: Overall, HRQOL is not clearly better or worse in RCS than UCS. Future research should include different tumor types, rural residents, and survivorship-specific HRQOL instruments.

Consumer and clinician perspectives on personalising breast cancer prevention information.

BACKGROUND: Personalised prevention of breast cancer has focused on women at very high risk, yet most breast cancers occur in women at average, or moderately increased risk (≤moderate risk). OBJECTIVES: To determine; 1) interest of women at ≤ moderate risk (consumers) in personalised information about breast cancer risk; 2) familial cancer clinicians' (FCCs) perspective on managing women at ≤ moderate risk, and; 3) both consumers' and FCCs reactions to iPrevent, a personalised breast cancer risk assessment and risk management decision support tool. METHODS: Seven focus groups on breast cancer risk were conducted with 49 participants; 27 consumers and 22 FCCs. Data were analysed thematically. RESULTS: Consumers reported some misconceptions, low trust in primary care practitioners for breast cancer prevention advice and frustration that they often lacked tailored advice about breast cancer risk. They expressed interest in receiving personalised risk information using iPrevent. FCCs reported an inadequate workforce to advise women at ≤ moderate risk and reacted positively to the potential of iPrevent to assist. CONCLUSIONS: While highlighting a potential role for iPrevent, several outstanding issues remain. For personalised prevention of breast cancer to extend beyond women at high risk, we must harness women's interest in receiving tailored information about breast cancer prevention and identify a workforce willing to advise women.

Identifying people at higher risk of melanoma across the U.K.: a primary-care-based electronic survey.

BACKGROUND: Melanoma incidence is rising rapidly worldwide among white populations. Defining higher-risk populations using risk prediction models may help targeted screening and early detection approaches. OBJECTIVES: To assess the feasibility of identifying people at higher risk of melanoma using the Williams self-assessed clinical risk estimation model in U.K. primary care. METHODS: We recruited participants from the waiting rooms of 22 general practices covering a total population of > 240 000 in three U.K. regions: Eastern England, North East Scotland and North Wales. Participants completed an electronic questionnaire using tablet computers. The main outcome was the mean melanoma risk score using the Williams melanoma risk model. RESULTS: Of 9004 people approached, 7742 (86%) completed the electronic questionnaire. The mean melanoma risk score for the 7566 eligible participants was 17·15 ± 8·51, with small regional differences [lower in England compared with Scotland (P = 0·001) and Wales (P < 0·001), mainly due to greater freckling and childhood sunburn among Scottish and Welsh participants]. After weighting to the age and sex distribution, different potential cut-offs would allow between 4% and 20% of the population to be identified as higher risk, and those groups would contain 30% and 60%, respectively of those likely to develop melanoma. CONCLUSIONS: Collecting data on the melanoma risk profile of the general population in U.K. primary care is both feasible and acceptable for patients in a general practice setting, and provides opportunities for new methods of real-time risk assessment and risk stratified cancer interventions.

Cancer risk assessment tools in primary care: a systematic review of randomized controlled trials.

PURPOSE: We conducted this review to identify published randomized controlled trials (RCTs) of cancer risk assessment tools used in primary care and to determine their impact on clinical utility (clinicians), screening uptake (patients), and psychosocial outcomes (patients). METHODS: We searched EMBASE, PubMed and the Cochrane databases for RCTs of cancer risk assessment tools in primary care up to May 2014. Only studies set in primary care, with patients eligible for screening, and English-language articles were included. RESULTS: The review included 11 trials of 7 risk tools. The trials were heterogeneous with respect to type of tool that was used, type(s) of cancer assessed, and outcomes measured. Evidence suggested risk tools improved patient risk perception, knowledge, and screening intentions, but not necessarily screening behavior. Overall, uptake of a tool was greater if initiated by patients, if used by a dedicated clinician, and when combined with decision support. There was no increase in cancer worry. Health promotion messages within the tool had positive effects on behavior change. Trials were limited by low-recruitment uptake, and the heterogeneity of the findings necessitated a narrative review rather than a meta-analysis. CONCLUSIONS: Risk tools may increase intentions to have cancer screening, but additional interventions at the clinician or health system levels may be needed to increase risk-appropriate cancer screening behavior.

Implementing a QCancer risk tool into general practice consultations: an exploratory study using simulated consultations with Australian general practitioners.

BACKGROUND: Reducing diagnostic delays in primary care by improving the assessment of symptoms associated with cancer could have significant impacts on cancer outcomes. Symptom risk assessment tools could improve the diagnostic assessment of patients with symptoms suggestive of cancer in primary care. We aimed to explore the use of a cancer risk tool, which implements the QCancer model, in consultations and its potential impact on clinical decision making. METHODS: We implemented an exploratory 'action design' method with 15 general practitioners (GPs) from Victoria, Australia. General practitioners applied the risk tool in simulated consultations, conducted semi-structured interviews based on the normalisation process theory and explored issues relating to implementation of the tool. RESULTS: The risk tool was perceived as being potentially useful for patients with complex histories. More experienced GPs were distrustful of the risk output, especially when it conflicted with their clinical judgement. Variable interpretation of symptoms meant that there was significant variation in risk assessment. When a risk output was high, GPs were confronted with numerical risk outputs creating challenges in consultation. CONCLUSIONS: Significant barriers to implementing electronic cancer risk assessment tools in consultation could limit their uptake. These relate not only to the design and integration of the tool but also to variation in interpretation of clinical histories, and therefore variable risk outputs and strong beliefs in personal clinical intuition.

Smartphone applications for melanoma detection by community, patient and generalist clinician users: a review.

Smartphone health applications ('apps') are widely available but experts remain cautious about their utility and safety. We reviewed currently available apps for the detection of melanoma (July 2014), aimed at general community, patient and generalist clinician users. A proforma was used to extract and assess each app that met the inclusion criteria, and we undertook content analysis to evaluate their content and the evidence applied in their development. Thirty-nine apps were identified with the majority available only for Apple users. Over half (n = 22) provided information or education about melanoma, ultraviolet radiation exposure prevention advice, and skin self-examination strategies, mainly using the ABCDE (A, Asymmetry; B, Border; C, Colour; D, Diameter; E, Evolving) method. Half (n = 19) helped users take and store images of their skin lesions either for review by a dermatologist or for self-monitoring to identify change, an important predictor of melanoma; a similar number (n = 18) used reminders to help users monitor their skin lesions. A few (n = 9) offered expert review of images. Four apps provided a risk assessment to patients about the probability that a lesion was malignant or benign, and one app calculated users' future risk of melanoma. None of the apps appeared to have been validated for diagnostic accuracy or utility using established research methods. Smartphone apps for detecting melanoma by nonspecialist users have a range of functions including information, education, classification, risk assessment and monitoring change. Despite their potential usefulness, and while clinicians may choose to use apps that provide information to educate their patients, apps for melanoma detection require further validation of their utility and safety.

Family history questionnaires designed for clinical use: a systematic review.

BACKGROUND: The family medical history is an important risk factor for several common chronic diseases but challenges remain in efficiently identifying individuals at increased risk. Family history questionnaires (FHQs) may have an important role in primary care as a screening tool to support tailored disease prevention. AIMS: To systematically review studies reporting on the use and outcomes of FHQs in a clinical setting. METHODS: Studies were identified through electronic searches of Medline, EMBASE, CINAHL, PsychInfo, and Google Scholar until December 2007. Due to the heterogeneity of the included papers, formal synthesis was not possible. We therefore developed a taxonomy based on the principal objectives and design of each study. RESULTS: A plethora of FHQs were identified but few had been formally evaluated. Forty-four publications were reviewed. Sixteen papers met our inclusion criteria reporting 14 different FHQs. The majority of FHQs focused on 1 or more cancers. Twelve papers reported on the evaluation of a FHQ in a non-referred population, predominantly in primary care practice. Four papers reported a formal validation of a FHQ against a reference standard, demonstrating reasonable accuracy. Six further papers showed that a FHQ can be used to identify populations at increased risk of cancer, many of whom had not been previously identified. Two papers found a positive impact of using a FHQ on subsequent cancer screening, and a further 3 found no significant psychological long-term harm associated with their use. CONCLUSIONS: Despite the abundance of available FHQs, few have been formally evaluated. Several short single-cancer specific FHQs exist, but there are no simple, short generic FHQs suitable for use in primary care practice. FHQs can be used to obtain reasonably accurate family history information and to identify populations at increased disease risk. They have been shown to have a positive impact on cancer screening and are not associated with long-term psychological harm.

The defined-contribution plan: the next generation of healthcare financing.

In response to rising health insurance premiums, many purchasers of coverage are evaluating the possibility of implementing defined-contribution health insurance plans. Under a defined-contribution plan, employers or the government pay a specified portion of the premium, and the consumer chooses a plan from a menu of options, paying the balance of the premium based on their plan selection. A shift to a defined-contribution model will have far-reaching implications for consumers, employer and government purchasers, payers, and providers. Providers will face changes in consumption patterns and the need to develop a brand image, market their strengths directly to consumers, educate consumers about their services and pricing, and reconfigure infrastructures to be able to respond efficiently to consumer demands.

Survival probability in ovarian clear cell adenocarcinoma.

OBJECTIVE: The aim of this study was to evaluate the 5-year survival probability (SP) of patients treated for ovarian clear cell adenocarcinoma (OCCA) at a single tertiary institution and to compare it to the 5-year SP of patients with other histologic subtypes of epithelial ovarian cancer. METHODS: Sixty-four patients with pure OCCA treated at the Cleveland Clinic Foundation from 1981 to 1996 were retrospectively identified and clinical information was abstracted. All histologic materials were reviewed by a single gynecologic pathologist. SP was calculated by the Kaplan-Meier method. SPs for OCCA patients were compared to that of other high-grade epithelial ovarian cancer patients in the gynecologic tumor registry. Cox proportional hazards modeling was used to identify varibles associated with decreased SP. RESULTS: The FIGO stages of OCCA study patients were Stage I, 31 (50%), Stage II, 6 (10%), Stage III, 17 (27%), and Stage IV, 8 (13%) (2 patients unstaged). Forty-four patients had no gross residual cancer at the completion of initial surgery while 9 patients had 1 cm residual. Forty-five (73%) received postoperative chemotherapy. The median follow-up for surviving patients is 97 months (range 38 to 209 months). The overall 5-year SP of OCCA patients is 50% with limited disease (Stages I and II) patients having a 5-year SP of 72% versus 17% 5-year SP in patients with advanced disease (P < 0.001). FIGO stage was most predictive of outcome. The overall 5-year SP of OCCA patients (50%) differed significantly (P < 0.05) from that of other ovarian cancer registry patients (30%). OCCA patients with limited cancer survived similarly to registry patients (72 vs 72%) as did patients with advanced OCCA compared with registry patients (17 vs 22%). CONCLUSIONS: When controlled for grade and stage, the overall survival with OCCA is identical to that of other high-grade epithelial ovarian cancers. Factors that account for the better overall survival of OCCA patients are more favorable disease stage, younger age, and improved debulking status.

Plasmacytoma of the ovary: a case report and literature review.

BACKGROUND: Ovarian plasmacytomas are a unique and unusual presentation of extramedullary plasmacytomas (EMP). A report of the seventh such case is presented with review of the previous six cases. METHODS: Surgical and medical staging were performed on the present case. The literature is reviewed. RESULTS: EMP involving the ovary is usually large at the time of presentation, more likely involving the left side, and without evidence of disseminated disease. As in other plasma cell dyscrasia, IgG paraprotein is more frequently involved. CONCLUSION: Adjuvant treatment for ovarian plasmacytomas is not clearly established; however, if complete surgical resection is achieved and no evidence of multiple myeloma is found, observation should be strongly considered.

An assessment of mucosal immunisation in protection against Streptococcus equi ('Strangles') infections in horses.

The ability of mucosally administered antigen to provide protection against Streptococcus equi ('Strangles') infections in horses was examined. First, an enzyme linked immunosorbent assay (ELISA) was developed to detect the immune status of horses to S. equi. This assay was used to select Strangles-naive horses for the study and also to monitor their response to immunisation. Potential vaccine candidates were: (a) orally administered paraformaldehyde killed S. equi; (b) intraperitoneally (IP) administered paraformaldehyde killed S. equi in a non-inflammatory adjuvant; (c) orally administered live avirulent S. equi; (d) orally administered microencapsulated streptococcal M protein. The latter three preparations were first assessed in a rat model, using rate of lung bacterial clearance following intratracheal inoculation of live virulent bacteria as an indication of efficacy. Candidates (a) and (b) were then assessed in an equine model. IP immunisation of horses was shown to effectively induce production of specific antibody in mucosal and systemic sites. Four weeks after initial immunisation, horses were challenged intranasally with live virulent S. equi. Both groups of immunised horses demonstrated partial protection following vaccination. Of the IP immunised horses, only two out of four developed clinical signs of Strangles following live challenge. The orally immunised horses all developed submandibular abscesses containing S. equi. However, none of the immunised horses became as ill as the control horses in terms of fever, anorexia, loss of condition and general malaise.

Whole-blood platelet aggregation predicts in vitro and in vivo primary hemostatic function in the elderly.

Increased platelet aggregation is associated with higher coronary artery disease mortality. Enhanced platelet aggregation in platelet-rich plasma has also been described in the elderly. To define age-related changes in primary hemostasis, we studied 37 elderly and 31 young blood donors. There were no significant age-related differences in whole-blood platelet aggregation, platelet adherence and thrombus formation on human umbilical artery segments, or bleeding time. Plasma fibrinogen was significantly higher in elderly men and women, whereas activated factor VII was elevated only in elderly women. Collagen-induced platelet aggregation was significantly correlated with platelet adherence to the subendothelium in elderly (r = .488, P = .002) but not in young donors. Accordingly, collagen-induced platelet aggregation showed a significant inverse correlation with bleeding time only in the elderly (r = -.401, P = .014). Arachidonic acid-induced platelet aggregation was significantly associated with platelet adherence to the subendothelium (r = .658, P = .003) and bleeding time (r = -.540, P = .021) only in elderly men. In young donors, ADP-induced platelet aggregation was significantly correlated with platelet adherence to the thrombogenic adventitial surface (r = .395, P = .031); in the elderly this association only approached significance (r = .315, P = .058). Whole-blood platelet aggregation in response to collagen and arachidonic acid may be more useful in predicting primary hemostatic function in the elderly than in the young. Furthermore, in the elderly, the correlation between platelet aggregation in whole blood and platelet-arterial wall interactions in vitro and in vivo may contribute to the ability of this test to predict coronary risk.

Sex differences in platelet adherence to subendothelium: relationship to platelet function tests and hematologic variables.

Men have significantly more atherosclerotic disease than women. Platelet-mediated thrombosis plays a role in the initiation of myocardial infarction and stroke. Citrated whole blood from male and female donors was perfused through an annular system over everted human umbilical artery segments. Comparisons were made between platelet adherence and thrombus formation on subendothelium, platelet aggregation in citrated whole blood, hematologic variables, and the bleeding time. Platelet spreading and adherence were approximately 22% greater with male blood (P < 0.001), whereas thrombus formation on subendothelium and collagen- and arachidonic acid-induced platelet aggregation did not show sex-related differences. Platelet aggregation with adenosine diphosphate was greater in women, related to their lower hematocrit values. By contrast, in women hematocrit values showed a slight but significant positive correlation with platelet adherence on subendothelium. Fibrinogen was significantly correlated with collagen- and adenosine-diphosphate-induced platelet aggregation and with platelet adherence, spreading, and thrombus formation on subendothelium. The mean bleeding time was slightly longer in women than in men (P = 0.118). Platelet aggregation was not associated with the bleeding time except for collagen-induced platelet aggregation in males; the latter was significantly correlated with platelet adherence and spreading in both sexes, while arachidonic acid-induced platelet aggregation predicted platelet adherence and spreading in males. Male blood shows enhanced primary hemostatic activity; this may predispose men to atherosclerosis.