Screening for skin cancer.

CONTEXT: Malignant melanoma is often lethal, and its incidence in the United States has increased rapidly over the past 2 decades. Nonmelanoma skin cancer is seldom lethal, but, if advanced, can cause severe disfigurement and morbidity. Early detection and treatment of melanoma might reduce mortality, while early detection and treatment of nonmelanoma skin cancer might prevent major disfigurement and to a lesser extent prevent mortality. Current recommendations from professional societies regarding screening for skin cancer vary. OBJECTIVE: To examine published data on the effectiveness of routine screening for skin cancer by a primary care provider, as part of an assessment for the U.S. Preventive Services Task Force. DATA SOURCES: We searched the MEDLINE database for papers published between 1994 and June 1999, using search terms for screening, physical examination, morbidity, and skin neoplasms. For information on accuracy of screening tests, we used the search terms sensitivity and specificity. We identified the most important studies from before 1994 from the Guide to Clinical Preventive Services, second edition, and from high-quality reviews. We used reference lists and expert recommendations to locate additional articles. STUDY SELECTION: Two reviewers independently reviewed a subset of 500 abstracts. Once consistency was established, the remainder were reviewed by one reviewer. We included studies if they contained data on yield of screening, screening tests, risk factors, risk assessment, effectiveness of early detection, or cost effectiveness. DATA EXTRACTION: We abstracted the following descriptive information from full-text published studies of screening and recorded it in an electronic database: type of screening study, study design, setting, population, patient recruitment, screening test description, examiner, advertising targeted at high-risk groups or not targeted, reported risk factors of participants, and procedure for referrals. We also abstracted the yield of screening data including probabilities and numbers of referrals, types of suspected skin cancers, biopsies, confirmed skin cancers, and stages and thickness of skin cancers. For studies that reported test performance, we recorded the definition of a suspicious lesion, the "gold-standard" determination of disease, and the number of true positive, false positive, true negative, and false negative test results. When possible, positive predictive values, likelihood ratios, sensitivity, and specificity were recorded. DATA SYNTHESIS: No randomized or case-control studies have been done that demonstrate that routine screening for melanoma by primary care providers reduces morbidity or mortality. Basal cell carcinoma and squamous cell carcinoma are very common, but detection and treatment in the absence of formal screening are almost always curative. No controlled studies have shown that formal screening programs will improve this already high cure rate. While the efficacy of screening has not been established, the screening procedures themselves are noninvasive, and the follow-up test, skin biopsy, has low morbidity. Five studies from mass screening programs reported the accuracy of skin examination as a screening test. One of these, a prospective study, tracked patients with negative results to determine the number of patients with false-negative results. In this study, the sensitivity of screening for skin cancer was 94% and specificity was 98%. Several recent case-control studies confirm earlier evidence that risk of melanoma rises with the presence of atypical moles and/or many common moles. One well-done prospective study demonstrated that risk assessment by limited physical exam identified a relatively small (<10%) group of primary care patients for more thorough evaluation. CONCLUSIONS: The quality of the evidence addressing the accuracy of routine screening by primary care providers for early detection of melanoma or nonmelanoma skin cancer ranged from poor to fair. We found no studies that assessed the effectiveness of periodic skin examination by a clinician in reducing melanoma mortality. Both self-assessment of risk factors or clinician examination can classify a small proportion of patients as at highest risk for melanoma. Skin cancer screening, perhaps using a risk-assessment technique to identify high-risk patients who are seeing a physician for other reasons, merits additional study as a strategy to address the excess burden of disease in older adults.

Screening for bacterial vaginosis in pregnancy.

CONTEXT: Bacterial vaginosis (BV) is a strong independent risk factor for adverse pregnancy outcomes. BV is found in 9% to 23% of pregnant women. Symptoms include vaginal discharge, pruritus, or malodor, but often women with BV are asymptomatic. OBJECTIVES: To determine whether screening and treating pregnant women for BV reduces adverse pregnancy outcomes, as part of an assessment for the U.S. Preventive Services Task Force. DATA SOURCES: Randomized clinical trials of BV treatment in pregnancy that measured pregnancy outcomes were identified from multiple searches in MEDLINE from 1966 to 1999, the Cochrane Controlled Trials Register and Library, and national experts. STUDY SELECTION: All randomized controlled trials of BV treatment in pregnancy that specifically measured pregnancy outcomes. DATA EXTRACTION: The following information was abstracted: study design and blinding, diagnostic methods, antibiotic interventions, timing of antibiotic treatment in pregnancy, criteria for treatment, comorbidities, demographic details, risk factors for preterm delivery such as previous preterm delivery, compliance, rates of spontaneous and total preterm delivery less than 37 weeks and less than 34 weeks, preterm premature rupture of membranes, low birth weight less than 2500 grams, spontaneous abortion, postpartum endometritis, and neonatal sepsis. For each study, we measured the effect of treatment by calculating the difference in the rate of a given pregnancy outcome in the control group minus the treatment group (the absolute risk reduction [ARR]). A stepwise procedure based on the profile likelihood was applied to assess heterogeneity, to pool studies when appropriate, and to calculate the mean and 90% confidence intervals (CIs) for the effect of treatment. DATA SYNTHESIS: Seven randomized controlled trials met inclusion criteria for the meta-analysis. We found no benefit to BV treatment in average-risk women for any pregnancy outcome. Results of studies of high-risk populations, women with previous preterm delivery, were statistically heterogeneous. They clustered into two groups; one showed no benefit (ARR=-0.08, 90% CI=-0.19 to 0.04), whereas the three homogeneous studies showed potential benefit of BV treatment (pooled ARR=0.22; 90% CI=0.13 to 0.31) for preterm delivery before 37 weeks. Four high-risk studies reported results for preterm delivery less than 34 weeks. The pooled estimate showed no benefit (ARR=0.04; 90% CI=-0.02 to 0.09), but variation was noted among individual studies. Two trials of high-risk women found an increase in preterm delivery less than 34 weeks in women who did not have BV but received BV treatment. Comparisons of patient populations, treatment regimens, and study designs did not explain the heterogeneity among studies. CONCLUSIONS: We found no benefit to routine BV screening and treatment. A subgroup of high-risk women may benefit from BV screening and treatment; however, there may be a subgroup for whom BV treatment could increase the occurrence of preterm delivery.

Cancer prevention and early detection.

Advances in the area of cancer prevention and early detection are being made constantly. Basic epidemiologic research continues to provide insight into the impact of carcinogen exposure and the development of cancer. It is exciting to note that the study of Tamoxifen and Raloxifene chemoprevention trial is successfully recruiting women, including minority women, to participate. This large chemoprevention trial is providing much insight into how to recruit and retain women to take a chemoprevention agent to ultimately prevent the development of cancer. Advances also are being made in the knowledge base of how to best detect cancer in asymptomatic people. The best screening tool recommendation for the early detection of colorectal cancer remains controversial. Screening for colorectal cancer, however, is the only way to ultimately decrease the morbidity and mortality associated with the disease. Oncology nurses need to accurately risk for colorectal cancer and provide patients with the necessary information to make an informed choice about the most appropriate screening for their situation. Oncology nurses need to be familiar with new research and advances in cancer prevention and early detection so they can share information with patients and their families.

Factors affecting genetic testing and decisions about prophylactic surgery.

Both of the articles reviewed here as well as the references, suggest that very little is actually known about the impact of many aspects of genetic testing. How decision are made about genetic testing in people who do not have cancer, how the results of testing are used used to guide care, and ultimately how people adjust to prophylactic surgery, which is the most effective form of prevention currently available to those who do have a mutation are not completely clear. This has many implications for practice in general. Oncology nurses who build relationships with those diagnosed with cancer and their families may be one of the best groups of professionals to provide the education and counseling individuals and families need prior to making any decision about genetic testing. Just as many responses to cancer exist, so do many responses to finding out the results of mutation status. Oncology nurses are challenged to help facilitate adjustment to learning that one carries a mutation that significantly increases risk of developing cancer. More nursing research needs to be conducted on how to facilitate this adjustment. Dealing with the unknown can be a frightening experience. Little is known about the long-term effectiveness of prophylactic mastectomy and oophorectomy in unaffected mutation-positive individuals. Most of what is known is based on retrospective review. Nurses are challenged to interpret this information, along with its inherent strengths and weaknesses, to individuals so they can make the best possible decisions. The psychosocial needs of those who undergo prophylactic surgery are not clearly understood. Surgery can have many psychological outcomes, and how individuals adjust to these changes is not clear. More nursing research is needed not only to understand these needs but also to design interventions to facilitate and improve adjustment to not only the information that one is mutation positive but also to prophylactic surgery. People who do not have cancer but have a high risk for cancer because of their genetic background need comprehensive and consistent care by knowledgeable healthcare providers. Although these individuals have not been diagnosed with cancer, they have complex psychosocial needs related to their family history and the decisions being made about prevention strategies. Oncology nurses can help fill this gap in care and provide the necessary support these individuals need.

Application of carcinogenesis theory to primary prevention.

PURPOSE/OBJECTIVES: To apply current cancer development theory to concepts of and interventions for cancer prevention. DATA SOURCES: Current medical and nursing literature. DATA SYNTHESIS: Carcinogenesis is a complex process that is only partially understood. The information that is available supports efforts to control the disease. However, the lack of detailed understanding limits attempts to alter the course of cancer. CONCLUSION: The understanding that cancer is the result of cumulative genetic errors can be used to direct oncology nursing interventions to prevent the disease. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses should be aware of the various factors that influence cancer development to prescribe primary prevention measures. Nurses also must be aware that efforts to understand carcinogenesis and exploit that knowledge are ongoing. Awareness of advances in the understanding of cancer development are keys to appropriate patient care.

The role of the nurse in developing cancer screening programs.

PURPOSE/OBJECTIVE: To describe and provide an overview of the role that nurses can play in developing cancer screening programs. DATA SOURCES: Published articles, book chapters, and clinical experience. DATA SYNTHESIS: Many approaches and considerations are available for developing cancer screening programs. Planning considerations include needs assessment, patient-education strategies, funding, recruitment issues, follow-up strategies, staffing, policy development, and evaluation. An understanding of these considerations may lead to more effective cancer screening programs. CONCLUSIONS: Nurses can play an integral role in the development and management of cancer screening programs. Careful program planning may enhance this process. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses need to consider a wide range of issues when developing cancer screening programs, including the purpose of the program, how the program will be implemented, the population being served, and the potential impact on individuals being served.

Information needs regarding menopause. Results from a survey of women receiving cancer prevention and detection services.

Women often have questions related to menopause and hormone replacement therapy (HRT). A brochure entitled Understanding Menopause and Beyond was developed to address these issues. The purpose of this study was (a) to formally evaluate the relevance and utility of a brochure in understanding menopause and related health concerns and (b) to describe women's information needs at menopause. This descriptive study was conducted using a self-administered survey with a convenience sample of 200 pre-, peri-, and postmenopausal women attending a cancer screening center. On the basis of survey results, the topics most likely to be discussed with a health care provider were the risks and benefits of HRT and bone mineral density testing. The topics most frequently cited in the brochure that women previously did not know or understand were the questions to ask and the information to share with a health care provider and the risk factors for osteoporosis. The most important and informative sections of the brochure were those describing the risk factors for osteoporosis, the questions to ask and the information to share with a health care provider, and the risks and benefits of HRT. It was concluded that women have information needs regarding menopause not only related to the potential cancer risks, but also about related health issues such as osteoporosis, cardiovascular health, and emotional health. Furthermore, a targeted brochure can be effective in addressing these information needs. Oncology nurses who provide cancer screening and education services frequently receive questions about the safety and efficacy of HRT and other questions related to menopause. They therefore are uniquely qualified to address these concerns with their patients.

Principles of cancer prevention and early detection.

Oncology nurses are becoming involved more frequently in answering questions regarding cancer prevention and detection. This article includes a discussion of basic underlying principles of cancer prevention and detection, including types of prevention, frequently used epidemiologic terms, validity assessments of cancer screening tests, and strategies for risk assessment. An understanding of basic principles related to cancer prevention and detection is necessary to provide information and patient education that is accurate and beneficial to patients and their families. With this background information, oncology nurses can help develop programs for cancer prevention and control.

Screening for second cancers and osteoporosis in long-term survivors.

PURPOSE: The purpose of this preliminary study was to describe the extent to which healthcare providers recommend the screening strategies for early detection described by the American Cancer Society (ACS), for breast, gynecologic, and colorectal cancer, and by the National Osteoporosis Foundation (NOF), for osteoporosis, to women who are long-term survivors of breast, ovarian, or endometrial cancer. DESCRIPTION OF THE STUDY: A four-part survey was developed for this study, with the first three parts based on the ACS guidelines for breast, gynecologic, and colorectal cancer screening and the NOF guidelines for osteoporosis screening. The fourth part related to personal characteristics, setting, knowledge, and perceptions of the nurses surveyed. A random sample of outpatient nurses was obtained from the Oncology Nursing Society. Of 668 nurses, 321 (48%) responded (Oncology Certified Nurse (OCN) 68.1%; Advanced Oncology Certified Nurse (AOCN) 16.6%). RESULTS: The most consistently performed screenings that were reported were mammogram (range 74.2-87.7%), professional breast examination (range 73.9-83.7%), and Pap test and pelvic examination (range 61.8-85.2%). The least frequently performed screenings are flexible sigmoidoscopy/colonoscopy (range 20.2-27.7%), bone mineral density testing (range 16.9-19.0%), and height measurement (range 22.5-28.3%). Less than one third of survivors are offered counseling on strategies to promote bone health. CLINICAL IMPLICATIONS: Knowledge of factors associated with osteoporosis and the use of screening strategies for second malignancies in survivors of breast, ovarian, and endometrial cancers can be used to implement activities such as patient education and clinical practice protocols that will increase the use of current screening recommendations.

Cancer risk assessment: conceptual considerations for clinical practice.

PURPOSE/OBJECTIVES: To review current information on the types and components of risk assessment and associated considerations for clinical practice and education. DATA SOURCES: Published articles, book chapters, and clinical experience. DATA SYNTHESIS: Cancer risk assessment is a clinical process that is integral to cancer screening. Cancer risk assessment includes obtaining information about cancer risk factors and selecting the best means to communicate this information to individual patients. Ethical, psychosocial, and clinical factors are considerations. A comprehensive tool to provide consistency in documenting risk factors as part of a comprehensive cancer risk assessment is included. CONCLUSIONS: Nurses can conduct and interpret cancer risk assessments. Consideration of conceptual issues of risk assessment may enhance this process. IMPLICATIONS FOR NURSING PRACTICE: When implementing cancer risk assessments into cancer screening programs, nurses need to consider the purpose of conducting the risk assessment, how the information will be interpreted to the population being served, and the potential impact on an individual patient.

Osteoporosis: a concern for cancer survivors.

PURPOSE/OBJECTIVES: To describe the risk factors, prevention, diagnosis, management, and impact of osteoporosis on the lives of women who have survived breast and endometrial cancer. DATA SOURCES: Journal articles, selected textbooks, prescribing information, and conference proceedings. DATA SYNTHESIS: Women who have not been able to have estrogen-replacement therapy (including women who have survived breast and endometrial cancer) are at higher risk for developing osteoporosis. Osteoporosis is associated with significant medical costs and can have a detrimental effect on long-term quality of life (QOL) as well as increased mortality. Recently, significant advances have been made in the ability to detect and manage osteoporosis. CONCLUSIONS: Thorough assessment, appropriate evaluation, and treatment of osteoporosis can reduce the complications of this condition and ultimately improve the QOL for women surviving cancer. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses should include assessment of risk for osteoporosis into their practice. Education about the prevention of osteoporosis should be included with other wellness education. Women at higher risk for the development of osteoporosis should be referred for a diagnostic evaluation. Oncology nurses can provide women with osteoporosis with education about treatment as well as psychosocial support.

Case in point. Counseling about hormone replacement therapy.

Mrs. S's case demonstrates the dilemmas that many women face at menopause regarding HRT. No clear answer to her question exists. Oncology nurses need to help women understand that taking HRT is a decision that is best made after carefully weighing the risks and benefits of therapy. Mrs. S needs to realize that she has some risk factors for heart disease, osteoporosis, breast cancer, and uterine cancer. Depending on her motivation, Mrs. S can modify some of the risk factors (e.g., reducing her weight and cholesterol). Smoking cessation also would reduce her risk for heart disease and, to a lesser extent, osteoporosis. Although her risk for developing breast cancer is higher than for a woman without a family history of breast cancer, she only has one relative who was older when she developed breast cancer. This risk factor in itself probably would not be enough to advise her against taking HRT. Additional testing may offer some clarification. If her breasts are difficult to examine or her mammograms are difficult to interpret, Mrs. S may feel that the risk of missing breast cancer early is too high to justify taking HRT. An abnormal endometrial biopsy also may make Mrs. S decide against taking HRT. BMD testing might help to better assess her risk for osteoporosis. If some bone loss has occurred before menopause, she may want to give more consideration to taking HRT or medications such as alendronate sodium to reduce her risk for an osteoporotic fracture. Women need to understand that, often, no best answer is available to the question of whether or not to take HRT. With every decision comes some consequences. An understanding of risk factors and ways to maximize cardiovascular, breast, endometrial, and bone health are important factors to consider when making an informed decision. Clearly, this is an area where oncology nurses can provide tremendous patient education and support to women making decisions about HRT.

Exploring the psychosocial meaning of recurrent cancer: a descriptive study.

Many persons diagnosed with malignancy will experience one or more recurrences of malignancy. Little is known about the psychosocial meaning of recurrent cancer. Using Lazarus and Folkman's model of stress, appraisal and coping, the two purposes of this descriptive study were to (a) describe the meaning of a recurrence of cancer to the patient and (b) to explore if the patient perceives the diagnosis of recurrence as being different from the initial diagnosis of cancer. Purposeful sampling for persons with recent recurrent malignancy produced a sample (n = 20). Subjects completed an unstructured, indepth interview. The meaning of the recurrence was influenced by prior cancer-related experiences of the subjects and dominated by death and death-related concerns. Differences from the initial diagnosis included a deeper awareness of the significance of the "cancer diagnosis".

Presentation of nursing diagnosis content in fundamentals of nursing textbooks.

The technique and rationale for the use of nursing diagnosis generally are introduced early in the undergraduate curriculum. The three purposes of this descriptive study were to describe the general characteristics and presentation of content on nursing diagnosis in fundamentals of nursing textbooks; describe how the content from the theoretical chapter(s) in nursing diagnosis is carried through in the clinical chapters; and describe how content on diagnostic errors is presented. Although most of the textbooks presented content on nursing diagnosis in a similar fashion, the clinical chapters of the books did not follow the same pattern. Content on diagnostic errors was inconsistent. Educators may find this an effective methodology for reviewing textbooks.