Patient-reported treatment toxicity and adverse events in Black and White women receiving chemotherapy for early breast cancer.

PURPOSE: It is not known whether chemotherapy-related symptom experiences differ between Black and White women with early breast cancer (Stage I-III) receiving current chemotherapy regimens and, in turn, influences dose delay, dose reduction, early treatment discontinuation, or hospitalization. METHODS: Patients self-reported their race and provided symptom reports for 17 major side effects throughout chemotherapy. Toxicity and adverse events were analyzed separately for anthracycline and non-anthracycline regimens. Fisher's exact tests and two-sample t-tests compared baseline patient characteristics. Modified Poisson regression estimated relative risks of moderate, severe, or very severe (MSVS) symptom severity, and chemotherapy-related adverse events.Please check and confirm that the authors and their respective affiliations have been correctly identified and amend if necessary.no changes RESULTS: In 294 patients accrued between 2014 and 2020, mean age was 58 (SD13) and 23% were Black. For anthracycline-based regimens, the only significant difference in MSVS symptoms was in lymphedema (41% Black vs 20% White, p = .04) after controlling for axillary surgery. For non-anthracycline regimens, the only significant difference was MSVS peripheral neuropathy (41% Blacks vs. 23% White) after controlling for taxane type (p = .05) and diabetes (p = .05). For all other symptoms, severity scores were similar. Dose reduction differed significantly for non-anthracycline regimens (49% Black vs. 25% White, p = .01), but not for anthracycline regimens or in dose delay, early treatment discontinuation, or hospitalization for either regimen. CONCLUSION: Except for lymphedema and peripheral neuropathy, Black and White patients reported similar symptom severity during adjuvant chemotherapy. Dose reductions in Black patients were more common for non-anthracycline regimens. In this sample, there were minimal differences in patient-reported symptoms and other adverse outcomes in Black versus White patients.

On the front line of HIV virological monitoring: barriers and facilitators from a provider perspective in resource-limited settings.

Scale-up of viral load (VL) monitoring for HIV-infected patients on antiretroviral therapy (ART) is a priority in many resource-limited settings, and ART providers are critical to effective program implementation. We explored provider-perceived barriers and facilitators of VL monitoring. We interviewed all providers (n = 17) engaged in a public health evaluation of dried blood spots for VL monitoring at five ART clinics in Malawi. All ART clinics were housed within district hospitals. We grouped themes at patient, provider, facility, system, and policy levels. Providers emphasized their desire for improved ART monitoring strategies, and frustration in response to restrictive policies for determining which patients were eligible to receive VL monitoring. Although many providers pled for expansion of monitoring to include all persons on ART, regardless of time on ART, the most salient provider-perceived barrier to VL monitoring implementation was the pressure of work associated with monitoring activities. The work burden was exacerbated by inefficient data management systems, highlighting a critical interaction between provider-, facility-, and system-level factors. Lack of integration between laboratory and clinical systems complicated the process for alerting providers when results were available, and these communication gaps were intensified by poor facility connectivity. Centralized second-line ART distribution was also noted as a barrier: providers reported that the time and expenses required for patients to collect second-line ART frequently obstructed referral. However, provider empowerment emerged as an unexpected facilitator of VL monitoring. For many providers, this was the first time they used an objective marker of ART response to guide clinical management. Providers' knowledge of a patient's virological status increased confidence in adherence counseling and clinical decision-making. Results from our study provide unique insight into provider perceptions of VL monitoring and indicate the importance of policies responsive to individual and environmental challenges of VL monitoring program implementation. Findings may inform scale-up by helping policy-makers identify strategies to improve feasibility and sustainability of VL monitoring.

Gonadotropin-releasing hormone agonist overuse: urologists' response to reimbursement and characteristics associated with persistent overuse.

BACKGROUND: Medicare reimbursement cuts have been associated with declining gonadotropin-releasing hormone (GnRH) agonist overuse in localized prostate cancer. Medical school affiliation and foreign training have been associated with persistent overuse. However, physician-level prescribing changes and the practice type of persistent overusers have not been examined. We sought to describe physician-level changes in GnRH agonist overuse and test the association of time in practice and solo practice type with GnRH agonist overuse. METHODS: We matched American Medical Association physician data for 2138 urologists to Surveillance, Epidemiology and End Result-Medicare data for 12,943 men diagnosed with early-stage and lower-grade adenocarcinoma of the prostate between 2000 and 2007. We conducted a population-based, retrospective study using multilevel modeling to control for patient and provider characteristics. RESULTS: Three distinct patterns of GnRH agonist overuse were observed. Urologists' time in practice was not associated with GnRH agonist overuse (odds ratio (OR) 0.89; 95% confidence interval (CI): 0.75-1.05). However, solo practice type (OR 1.65; 95% CI: 1.34-2.02), medical school affiliation (OR 0.65; 95% CI: 0.55-0.77) and patient race were. Compared with non-Hispanic whites, non-Hispanic blacks (OR 1.76; 95% CI: 1.37-2.27), Hispanics (OR 1.41; 95% CI: 1.12-1.79) and men of 'other' race (OR 1.44; 95% CI: 1.04-1.99) had greater odds of receiving unnecessary GnRH agonists. CONCLUSIONS: GnRH agonist overuse remains high among some urologists who may be professionally isolated and difficult to reach. These urologists treat more vulnerable populations, which may contribute to health disparities in prostate cancer treatment quality. Nonetheless, these findings provide guidance to develop interventions to address overuse in prostate cancer.

Is there a role for survivorship care plans in advanced cancer?

PURPOSE: The Institute of Medicine (2006) has recommended that cancer survivors completing treatment receive a survivorship care plan (SCP). The survivorship needs in advanced cancer have been overlooked and understudied. The potential role of SCPs for survivors with advanced or metastatic cancer is unknown and was explored in this study. METHODS: We conducted two focus groups of survivors with advanced or metastatic cancer. Participants reviewed a sample JourneyForward™ SCP modified for advanced cancer. Sessions were audiotaped and transcribed; transcripts and field notes were evaluated using inductive content analysis. RESULTS: Sixteen survivors with metastatic cancer participated: 12 (75 %) were female, 15 (94 %) were white, and median age was 66 (range 55-80); 9 participants had breast cancer, 4 colon, 2 prostate, and 1 ovarian cancer. Participants believed that an SCP would be most helpful after initial diagnosis and treatment, but not as helpful once the cancer progressed. They thought a "cancer care plan" focusing solely on the current management would be better to concisely summarize the treatment plan and time frame for the next segment of care for those with advanced cancer. Most participants endorsed the need to have written information to reinforce verbal information received during medical visits since it was difficult to remember information provided. Participants expected their oncologist to assume primary responsibility for coordination of the care plan, but anticipated an important supportive role for primary care providers. To this end, they emphasized the need for better communication between providers. CONCLUSIONS: A cancer care plan developed by the oncologist, similar to an SCP but more focused on current management, may be more useful for survivors with advanced cancer. Exploring this topic in larger groups of more diverse survivors with advanced cancer will help to elucidate the details a written plan of care should contain, and how to promote effective coordination between oncology and primary care providers. IMPLICATIONS FOR CANCER SURVIVORS: There are many transitions of care along the cancer journey. A written plan of care, similar to an SCP, may be useful for survivors with advanced cancer.

Sertraline and norsertraline levels in three breastfed infants.

BACKGROUND: In assessing the safety of medication use in breastfeeding, it is important to know whether the drug used by the mother will be present in the breastfed infant. Compared with data for tricyclic antidepressants (TCAs), which have generally not been found in the plasma of breastfed infants, there are few data on the use of serotonin selective reuptake inhibitors (SSRIs) in breastfeeding. This poses a dilemma for breastfeeding women and their treating clinicians, because of the enhanced tolerability of SSRIs compared with TCAs, and because some patients do not respond well to TCAs. METHOD: Sertraline and norsertraline plasma concentrations were measured in three breastfeeding mother-infant pairs. Maternal and infant plasma samples were drawn a few minutes apart. Two of the infants had an additional sample assayed without contemporaneous maternal samples examined. Drug assay was by high-performance liquid chromatography. Limit of reproducible quantifiability was 2 ng/mL, and limit of detectability was 1 ng/mL. RESULTS: Maternal sertraline dose ranged from 50 to 100 mg/day. All infant plasma samples showed low levels (< 2 ng/mL) of either sertraline and norsertraline or norsertraline alone. Breastfeeding was continued, and the infants have shown no adverse effects on short-term follow-up. CONCLUSION: These data suggest that sertraline and/or its almost inactive metabolite may be present at very low concentrations in the plasma of breastfed infants. No adverse effects were noted in the infants. Limitations of the findings and possible implications for the use of sertraline during breastfeeding are discussed.

Prevention of recurrent postpartum major depression.

OBJECTIVE: Postpartum depression affects between 10 and 15 percent of new mothers. These mothers are apprehensive about recurrence after later births. This study tested the efficacy of antidepressant medication administered during the postpartum period to prevent a recurrence of postpartum depression among women who had suffered a previous episode. METHODS: An open clinical trial was conducted at a university-based outpatient clinic treating pregnant and postpartum women with mood disorders. Study participants were 23 pregnant women who had at least one previous postpartum episode that fit DSM-III-R criteria for nonbipolar major depression without psychotic features. Postpartum monitoring for recurrence of depressive symptoms was compared with postpartum monitoring plus postbirth treatment with either the medication that had been effective for the previous episode or nortriptyline. The first dose was given within 24 hours of birth. The authors assessed recurrence of postpartum major depression by psychiatric examination and use of the Inventory to Diagnose Depression, a reliable self-report instrument. RESULTS: A significantly greater proportion of the women who elected monitoring alone (62.5 percent) suffered recurrence of major depression compared with the women who received monitoring plus medication (6.7 percent) (p = .0086). CONCLUSIONS: Prophylactic antidepressant treatment reduced the recurrence of postpartum major depression.

Tricyclic dose requirements across pregnancy.

In a series of eight pregnant women, the authors found that the doses of tricyclic antidepressants required to achieve remission of symptoms and adequate serum levels increased during the second half of pregnancy. During the final trimester, the mean dose required was 1.6 times the mean dose required when the patients were not pregnant.