Development and Evaluation of a Training Program for Community-Based Participatory Research in Breast Cancer.

This paper describes the development and feasibility of the Community Based Research Infrastructure to Better Science (CRIBS) training. The goal of this training program was to help new or existing community-academic teams to build strong partnerships and successfully develop together fundable research projects focused on breast cancer environmental causes and disparities. A comprehensive mixed-methods participatory approach was utilized to assess the training. Twenty-two community-academic teams applied for the training program; twelve teams were enrolled. All teams completed the training and subsequently submitted research applications for funding. All components of the training received high ratings and positive qualitative comments. Self-rated competency in all of the learning domains increased during the training. Four (33%) of teams were successful in their first attempt to garner research funding, and six (50%) were eventually successful. The evaluation of CRIBS found it to have successfully achieved all four goals of the training: (1) Twelve new CBPR (community-based participatory research) teams, (2) improved knowledge about CBPR and science, (3) twelve submitted grant proposals in the first year, and (4) six (50%) successfully funded research projects.

Lip tenting: a simple technique for better lip enhancement.

Lip augmentation is practiced with increasing frequency by cosmetic practitioners using a variety of different filling substances. Often the result is less than optimal, with a duckbill lip that only serves to discourage other patients from asking for lip enhancement. The authors will present a simple technique to enhance or augment the lip by injecting almost vertically from the white roll, rather than injecting parallel to the lip contour. This fashion of lip enhancement is called "lip tenting." It is a simple way to have optimal control over both shape and volume in enhancement, especially in patients with asymmetrical lips, lip pockets and in those who require correction from previous suboptimal lip augmentation. Moreover, the aesthetic result obtained by this technique is a more natural appearance of the lip than frequently achieved using conventional methods.

Nodule formation following lip augmentation using porcine collagen-derived filler.

In 2006, a novel, porcine-derived collagen filler (Evolence) was introduced to the Canadian aesthetic market. Evolence, unlike bovine-derived collagen, does not require skin testing and was marketed as an alternative to hyaluronic acid based fillers for augmentation of the lip and facial defects. The authors injected the lips of 20 female patients with the Evolence filler for the purposes of lip enhancement and/or augmentation. Sixteen of the 20 patients (80%) experienced multiple lip nodules despite firmly molding the product immediately after injection. Many of these nodules required further treatment. Some nodules regressed over many months, but some nodules were still quite visible in 6 patients over 1 year later. Given this direct clinical experience, it is the authors' conclusion that the Evolence filler should not be injected into the lips due to the high incidence of nodule formation.

Breast cancer in limited-resource countries: health care systems and public policy.

As the largest cancer killer of women around the globe, breast cancer adversely impacts countries at all levels of economic development. Despite major advances in the early detection, diagnosis, and treatment of breast cancer, health care ministries face multitiered challenges to create and support health care programs that can improve breast cancer outcomes. In addition to the financial and organizational problems inherent in any health care system, breast health programs are hindered by a lack of recognition of cancer as a public health priority, trained health care personnel shortages and migration, public and health care provider educational deficits, and social barriers that impede patient entry into early detection and cancer treatment programs. No perfect health care system exists, even in the wealthiest countries. Based on inevitable economic and practical constraints, all health care systems are compelled to make trade-offs among four factors: access to care, scope of service, quality of care, and cost containment. Given these trade-offs, guidelines can define stratified approaches by which economically realistic incremental improvements can be sequentially implemented within the context of resource constraints to improve breast health care. Disease-specific "vertical" programs warrant "horizontal" integration with existing health care systems in limited-resource countries. The Breast Health Global Initiative (BHGI) Health Care Systems and Public Policy Panel defined a stratified framework outlining recommended breast health care interventions for each of four incremental levels of resources (basic, limited, enhanced, and maximal). Reallocation of existing resources and integration of a breast health care program with existing programs and infrastructure can potentially improve outcomes in a cost-sensitive manner. This adaptable framework can be used as a tool by policymakers for program planning and research design to make best use of available resources to improve breast health care in a given limited-resource setting.

Integrated primary and mental health care: evaluating a nurse-managed center for clients with serious and persistent mental illness.

Nurse-managed centers have been at the forefront of providing ambulatory care alternatives for underserved populations lacking access to care. Following this model, the Center for Integrated Health Care of the College of Nursing at the University of Illinois in Chicago delivers primary and mental health care services to a population of people with serious and persistent mental illness. The authors' experience illustrates the many rewards and challenges that nurse-managed centers face. This article describes their center's model of integrated care, examines selected performance indicators, and discusses the implications, opportunities, and challenges ahead.

Rehabilitation of children with traumatic brain injury: descriptive analysis of a nationwide sample using the WeeFIM.

OBJECTIVE: To describe functional capability at admission and discharge of children with traumatic brain injury (TBI) in rehabilitation settings. DESIGN: Descriptive analysis. SETTING: Inpatient pediatric rehabilitation hospitals in the United States. PARTICIPANTS: Children (N=3815) in 56 pediatric inpatient rehabilitation facilities who were discharged during 1999 to 2001. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Admission and discharge WeeFIM scores. RESULTS: Admission and discharge WeeFIM scores correlated positively with age at admission, time from injury to rehabilitation admission, and length of stay (LOS). Higher admission WeeFIM scores correlated with shorter LOS, shorter time from injury to admission to rehabilitation, and higher discharge WeeFIM scores. CONCLUSIONS: Children with TBI demonstrated significant improvement in functional measures during rehabilitation. Discharge function and LOS correlated with admission severity, with children who had higher functional status and shorter time between injury and rehabilitation care having higher discharge function and shorter LOS.

American Society of Clinical Oncology technology assessment on the use of aromatase inhibitors as adjuvant therapy for postmenopausal women with hormone receptor-positive breast cancer: status report 2004.

PURPOSE: To update the 2003 American Society of Clinical Oncology technology assessment on adjuvant use of aromatase inhibitors. RECOMMENDATIONS: Based on results from multiple large randomized trials, adjuvant therapy for postmenopausal women with hormone receptor-positive breast cancer should include an aromatase inhibitor in order to lower the risk of tumor recurrence. Neither the optimal timing nor duration of aromatase inhibitor therapy is established. Aromatase inhibitors are appropriate as initial treatment for women with contraindications to tamoxifen. For all other postmenopausal women, treatment options include 5 years of aromatase inhibitors treatment or sequential therapy consisting of tamoxifen (for either 2 to 3 years or 5 years) followed by aromatase inhibitors for 2 to 3, or 5 years. Patients intolerant of aromatase inhibitors should receive tamoxifen. There are no data on the use of tamoxifen after an aromatase inhibitor in the adjuvant setting. Women with hormone receptor-negative tumors should not receive adjuvant endocrine therapy. The role of other biomarkers such as progesterone receptor and HER2 status in selecting optimal endocrine therapy remains controversial. Aromatase inhibitors are contraindicated in premenopausal women; there are limited data concerning their role in women with treatment-related amenorrhea. The side effect profiles of tamoxifen and aromatase inhibitors differ. The late consequences of aromatase inhibitor therapy, including osteoporosis, are not well characterized. CONCLUSION: The Panel believes that optimal adjuvant hormonal therapy for a postmenopausal woman with receptor-positive breast cancer includes an aromatase inhibitor as initial therapy or after treatment with tamoxifen. Women with breast cancer and their physicians must weigh the risks and benefits of all therapeutic options.

Center for Integrated Health Care: primary and mental health care for people with severe and persistent mental illnesses.

The Center for Integrated Health Care capitalizes on the abilities, drive, and autonomy of advanced practice nurses, resulting in an exciting, timely academic nursing center exemplar. People with severe and persistent mental illnesses receive care that is targeted specifically to a population with chronic mental illnesses and tailored to the unique individual by integrating primary and mental health care. This Center is a partnership between Thresholds, a psychosocial rehabilitation center, staff and University of Illinois at Chicago, College of Nursing faculty. The Center's goals are to provide quality care, support teaching and learning for nursing and other health professional learners, and generate new knowledge related to the integration of mental and physical health care. To achieve long-term sustainability, the Center must partner with a federally qualified health center.

Overview of breast health care guidelines for countries with limited resources.

Among women around the globe, breast cancer is both the most common cancer and the leading cause of cancer-related death. Women in economically disadvantaged countries have a lower incidence of breast cancer, but poorer survival rates for the disease relative to women in affluent countries. Evidence suggests that breast cancer mortality can be reduced if resources are applied to the problem in a systematic way. The purpose of the Global Summit Consensus Conference was to begin a process to develop guidelines for improving breast health care in countries with limited resources-those with either low- or medium-level resources based on World Health Organization (WHO) criteria. Breast cancer experts and patient advocates representing 17 countries and 9 world regions participated in the conference. They reviewed the existing breast health guidelines, which generally assume unlimited resources. Individual panels then discussed and debated how limited resources can best be applied to improve three areas of breast health care--early detection, diagnosis, and treatment--and how to integrate these areas in building a breast health care program. The panelists unanimously agreed on the guiding principle that all women have the right to access to health care. They also agreed that collecting data on breast cancer is imperative for deciding how best to apply resources and for measuring progress. The panelists acknowledged the considerable challenges in implementing breast health care programs when resources are limited, as well as the need to build a program that is specific to each country's unique situation. The panelists noted that the development of centralized, specialized cancer centers may be a cost-effective way to deliver breast cancer care to some women when it is not possible to deliver such care to women nationwide. In countries with limited resources, at least half of the women have advanced or metastatic breast cancer at the time of diagnosis. Because advanced breast cancer has the poorest survival rate and is the most resource intensive to treat, measures to reduce the stage at diagnosis are likely to have the greatest overall benefit in terms of both survival and costs. Women should have access to diagnosis and treatment if efforts are undertaken to improve early detection of breast cancer. The panels' findings outline specific steps for prioritizing the use of limited resources to decrease the impact of breast cancer around the globe.

Early detection of breast cancer in countries with limited resources.

Breast cancer is commonly diagnosed at late stages in countries with limited resources. Efforts aimed at early detection can reduce the stage at diagnosis, potentially improving the odds of survival and cure, and enabling simpler and more cost-effective treatment. Early detection of breast cancer entails both early diagnosis in symptomatic women and screening in asymptomatic women. Key prerequisites for early detection are ensuring that women are supported in seeking care and that they have access to appropriate, affordable diagnostic tests and treatment. We therefore propose the following sequential action plan: 1) promote the empowerment of women to obtain health care, 2) develop infrastructure for the diagnosis and treatment of breast cancer, 3) begin early detection efforts through breast cancer education and awareness, and 4) when resources permit, expand early detection efforts to include mammographic screening. Public education and awareness can promote earlier diagnosis, and these goals can be achieved in simple and cost-effective ways, such as dissemination of messages through mass media. All women have the right to education about breast cancer, but it must be culturally appropriate and targeted and tailored to the specific population. When resources become available for screening, they should be invested in screening mammography, as it is the only modality that has thus far been shown to reduce breast cancer mortality. Clinical breast examination (CBE) and breast self-examination (BSE) are important components of routine breast care in countries with access to mammography and are important for general breast health education in all countries. However, the evidence does not support the use of CBE and BSE as lifesaving screening methods at this time, recognizing that data from countries with very limited resource are lacking. When widespread screening is not possible, screening can begin in an institution, city, or region, or by targeting screening to women at highest risk. A pilot program can be an ideal way to define the best approach to screening. To succeed, early detection efforts must include the health care providers with whom women have contact; these providers may be physicians, nurses, midwives, traditional healers, or others. There are tremendous differences among and within countries, and a program to promote early detection must be tailored to each country's unique situation.

The history of breast cancer advocacy.

There have been four key steps in the advent of breast cancer advocacy: priming the market, engaging consumers, establishing political advocacy, and taking the advocacy mainstream. Breast cancer was surrounded by secrecy until the 1980s, when brave individuals such as former First Ladies Betty Ford and Nancy Reagan, and founder of the Susan G. Komen Foundation, Nancy Brinker (Susan Komen's sister), began speaking publicly about the personal impact of the disease, which increased awareness of breast cancer and made it more acceptable to talk about it openly. At the same time, statistics about breast cancer were presented in new ways that the public could understand. Public health advocates played a key role in the second step, engaging consumers, when they established guidelines in the 1980s that encouraged women to perform breast self-examinations (BSEs) and have screening mammograms and clinical breast examinations (CBEs). Other events that helped engage consumers were increased media coverage of breast cancer issues, the founding of the Komen Race for the Cure in 1983, and the establishment of other programs that both educated the public and raised funds. Funds from these efforts enabled advocates to hold educational forums and produce educational materials in different media and tailored to different audiences and to become active in the funding of research. The third step, political action, became possible when breast cancer advocates joined together in the 1980s and 1990s to work toward legislative, regulatory, and funding changes, such as passage of the Mammography Quality Standards Act and increased funding for the National Cancer Institute. These efforts contributed to a more than quadrupling of federal funding for breast cancer research in the 1990s. Going mainstream, the final step in the advocacy process, entailed establishing a solid base of support to ensure that the message about breast cancer stays strong and fresh. This has been achieved by engaging the business, government, and scientific communities as partners in advocacy.

American Society of Clinical Oncology technology assessment on the use of aromatase inhibitors as adjuvant therapy for women with hormone receptor-positive breast cancer: status report 2002.

OBJECTIVE: To conduct an evidence-based technology assessment to determine whether the routine use of anastrozole or any of the aromatase inhibitors in the adjuvant breast cancer setting is appropriate for broad-based conventional use in clinical practice. POTENTIAL INTERVENTIONS: Anastrozole, letrozole, and exemestane. OUTCOMES: Outcomes of interest include breast cancer incidence, breast cancer-specific survival, overall survival, and net health benefit. EVIDENCE: A comprehensive, formal literature review was conducted for relevant topics and is detailed in the text. Testimony was collected from invited experts and interested parties. The American Society of Clinical Oncology (ASCO)-prescribed technology assessment procedure was followed. BENEFITS/HARMS: The ASCO panel recognizes that a woman and her physician's decision regarding adjuvant hormonal therapy is complex and will depend on the importance and weight attributed to information regarding both cancer and non-cancer-related risks and benefits. CONCLUSION: The panel was influenced by the compelling, extensive, and long-term data available on tamoxifen. Overall, the panel considers the results of the Arimidex (anastrozole) or Tamoxifen Alone or in Combination (ATAC) trial and the extensive supporting data to be very promising but insufficient to change the standard practice at this time (May 2002). A 5-year course of adjuvant tamoxifen remains the standard therapy for women with hormone receptor-positive breast cancer. The panel recommends that physicians discuss the available information with patients, and, in making a decision, acknowledge that treatment approaches can change over time. Individual health care providers and their patients will need to come to their own conclusions, with careful consideration of all of the available data. (Specific questions addressed by the panel are summarized in Appendix 3.) VALIDATION: The conclusions of the panel were endorsed by the ASCO Health Services Research Committee and the ASCO Board of Directors.