Findings from 752,081 clinical breast examinations reported to a national screening program from 1995 through 1998.

BACKGROUND AND METHODS: Mammography programs have received extensive study, but little is known about the outcome of clinical breast examinations (CBEs) performed in community settings. Consequently, we analyzed data from the National Breast and Cervical Cancer Early Detection Program on CBEs provided to low-income women from 1995 through 1998 and determined the percentage of CBEs considered to be abnormal, suspicious for cancer; the rates of cancer detection; and the sensitivity, specificity, and positive predictive value of CBEs. RESULTS: We analyzed data from 752081 CBEs and found that 6.9% of all CBEs were coded abnormal, suspicious for cancer, and that 5.0 cancers were detected per 1000 examinations (95% confidence interval [CI] = 4.9-5.2). The values observed for sensitivity (58.8%) and specificity (93.4%) were comparable to those reported for the CBE component of clinical trials. The observed positive predictive value was 4.3%. About 74% of all records also reported mammography results. The cancer-detection rate among records reporting an abnormal CBE and normal mammography was 7.4 cancers per 1000 records (95% CI = 6. 3-8.4). When the CBE was normal but the mammography was abnormal, the rate was 42.0 cancers per 1000 records (95% CI = 39.9-44.1). When both CBE and mammography results were abnormal, the rate was 170.3 cancers per 1000 records (95% CI = 162.7-177.9). Cancer detection could not be attributed entirely to CBE or mammography on 38% of the records in the latter subset because the tests were performed on the same day. CONCLUSION: CBEs performed in community-based screening programs can detect breast cancers as effectively as CBEs performed in clinical trials and may modestly improve early-detection campaigns.

Implementing recommendations for the early detection of breast and cervical cancer among low-income women.

SCOPE OF THE PROBLEM: Among U.S. women, breast cancer is the most commonly diagnosed cancer and remains second only to lung cancer as a cause of cancer-related mortality. The American Cancer Society (ACS) estimates that 182,800 new cases of female breast cancer and 41,200 deaths from breast cancer will occur in 2000. Since the 1950s, the incidence of invasive cervical cancer and mortality from this disease have decreased substantially; much of the decline is attributed to widespread use of the Papanicolaou (Pap) test. ACS estimates that 12,800 new cases of invasive cervical cancer will be diagnosed, and 4,600 deaths from this disease will occur in the United States in 2000. ETIOLOGIC FACTORS: The risk for breast cancer increases with advancing age; other risk factors include personal or family history of breast cancer, certain benign breast diseases, early age at menarche, late age at menopause, white race, nulliparity, and igher socioeconomic status. Risk factors for cervical cancer include certain human papilloma virus infections, early age at first intercourse, multiple male sex partners, a history of sexually transmitted diseases, and low socioeconomic status. Black, Hispanic, or American Indian racial/ethnic background is considered a risk factor because cervical cancer detection and death rates are higher among these women. RECOMMENDATIONS FOR PREVENTION: Because studies of the etiology of breast cancer have failed to identify feasible primary prevention strategies suitable for use in the general population, reducing mortality from breast cancer through early detection has become a high priority. The potential for reducing death rates from breast cancer is contingent on increasing mammography screening rates and subsequently detecting the disease at an early stage--when more treatment options are available and survival rates are higher. Effective control of cervical cancer depends primarily on early detection of precancerous lesions through use of the Papanicolaou test, followed by timely evaluation and treatment. Thus, the intended outcome of cervical cancer screening differs from that of breast cancer screening. In 1991, the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) was implemented to increase breast and cervical cancer screening among uninsured, low-income women. RESEARCH AGENDA: To support recommended priority activities for NBCCEDP, CDC has developed a research agenda comprising six priorities. These six priorities are a) determining effective strategies to communicate changes in NBCCEDP policy to cancer screening providers and women enrolled in the program; b) identifying effective strategies to increase the proportion of enrolled women who complete routine breast and cervical cancer rescreening according to NBCCEDP policy; c) identifying effective strategies to increase NBCCEDP enrollment among eligible women who have never received breast or cervical cancerscreening; d) evaluating variations in clinical practice patterns among providers of NBCCEDP screening services; e) determining optimal models for providing case-management services to women in NBCCEDP who have an abnormal screening result, precancerous breast or cervical lesion, or a diagnosis of cancer; and f) conducting economic analyses to determine costs of providing screening services in NBCCEDP. CONCLUSION: The NBCCEDP, through federal, state, territorial, and tribal governments, in collaboration with national and community-based organizations, has increased access to breast and cervical cancer screening among low-income and uninsured women. This initiative enabled the United States to make substantial progress toward achieving the Healthy People 2000 objectives for breast and cervical cancer control among racial/ethnic minorities and persons who are medically underserved. A continuing challenge for the future is to increase national commitment to providing screening services for all eligible uninsured women to ultimately reduce morbidity and mortality from breast and cervical cancer.

Risk factors for delayed immunization in a random sample of 1163 children from Oregon and Washington.

Despite extensive study of vaccine safety and decades of effort to immunize infants and toddlers, little is known about the comprehensiveness of vaccine coverage in US children younger than 2 years of age. Provider and parent data from a population-based sample of 1163 children from two states were analyzed to assess coverage rates at three ages and to evaluate characteristics of children and their families that predict failure to immunize on schedule. Overall, 78% of the children had received their first dose of diphtheria and tetanus toxoids with pertussis vaccine (DTP) and their first dose of oral poliovirus (OPV) by 92 days of age. Similarly, 77% had received their third dose of DTP and their second dose of OPV by their first birthday. However, by their second birthday only 60% had received the full series of four doses of DTP, three doses of OPV, and one dose of the measles, mumps, and rubella vaccines. When considered singly, several variables including child birth order, family income, maternal education, and marital status significantly predicted failure to immunize on schedule. In multivariate logistic models, only birth order and maternal education consistently predicted vaccine status at each of the three ages. Compared with first-born children, those who were later-born were 1.7 times more likely to be incompletely immunized at 2 years of age (95% confidence interval: 1.2, 2.3). Children of more educated mothers were significantly less likely to be underimmunized at all ages.(ABSTRACT TRUNCATED AT 250 WORDS)

Cigarette smoking cessation and alcohol treatment.

Cigarette smoking is common among problem drinkers and recovering alcoholics but most cessation research has not addressed this special population of smokers. Confidential survey data were collected from over 700 alcoholism counselors and medical personnel in residential and outpatient chemical dependency units (CDUs) in Nebraska to identify the quit smoking method these experts recommend and to assess their personal experiences with smoking cessation. A total of 334 respondents (45% of the group) self-identified as a recovering alcoholic, 51 (7%) as a problem drinker, and 350 (48%) as having no history of alcohol problems. Over 63% of all respondents were former or current smokers. The most frequently recommended quitting methods for people still in treatment for alcohol problems were relying on a support group (69%), adhering to Alcoholics Anonymous (AA) principles (64%), and quitting "cold turkey" (45%). In an adjusted logistic regression model, quitting "cold turkey" and relying on the principles of AA significantly increased a respondent's odds of personally becoming a successful tobacco quitter. We conclude that many recovering alcoholics and problem drinkers can successfully quit smoking and should be encouraged to use abstinence coping skills learned in alcohol treatment.

Effect of smoking cessation counseling on recovery from alcoholism: findings from a randomized community intervention trial.

AIMS: To assess the effects of a smoking cessation program for recovering alcoholics on use of alcohol, tobacco and illicit drugs after discharge from residential treatment. DESIGN AND SETTING: A randomized community intervention trial design was employed in which 12 residential drug treatment centers in Iowa, Kansas and Nebraska were matched and then randomly assigned to the intervention or control condition. PARTICIPANTS: Approximately 50 adult residents (inpatients) from each site were followed for 12 months after treatment discharge. INTERVENTION: Participating residents in the six intervention centers received a 4-part, individually tailored, smoking cessation program while those in the six control sites received usual care. FINDINGS: Both moderate and heavy drinking rates were reduced in the intervention group. Intervention site participants were significantly more likely than controls to report alcohol abstinence at both the 6-month (OR = 1.59, 95%CI: 1.09-2.35) and 12-month assessment (OR = 1.84, 95%CI: 1.28-2.92). Illicit drug use rates were comparable. Effect of the intervention on tobacco quit rates was not statistically significant. CONCLUSIONS: Counseling alcoholics in treatment to quit smoking does not jeopardize the alcohol recovery process. However, low-intensity tobacco interventions are unlikely to yield high tobacco quit rates.

Recovering staff and smoking in chemical dependency programs in rural Nebraska.

The problem of cigarette smoking among those who are recovering from alcohol dependence is becoming more apparent as chemical dependency units (CDUs) are beginning to restrict smoking for clients and staff and more actively encourage nicotine abstinence. To date, little is known about effective smoking cessation techniques for people with a history of alcohol problems. To obtain new data, a survey of personal experiences with smoking cessation and professional recommendations about nicotine dependence was administered to 124 recovering treatment professionals in CDUs in rural Nebraska. Among the 99 staff with a history of smoking, 81 (80%) had tried to quit smoking and 38 were former smokers at the time of the survey. Quitting "cold turkey" was the most popular smoking cessation method. Reliance on AA principles was second. The results suggest that recovering staff can successfully quit smoking by applying their professional practice guidelines for alcohol treatment to their personal problems with tobacco.

Feasibility of smoking cessation counseling by phone with alcohol treatment center graduates.

Several studies have tested the effectiveness of telephone counseling as a smoking cessation intervention, but few have addressed its application with the special population of smokers who are also problem drinkers or recovering alcoholics. Two hundred and eighty-eight male and female subjects were recruited from six residential alcohol treatment programs in Nebraska, Iowa, and Kansas to receive three postreatment telephone calls based on the stages of change model. Most subjects (71%) participated in at least one telephone counseling session, but only 38% participated in all three. Those who completed of session were significantly (p < .01) more likely to have advanced one stage of change in their readiness to quit smoking and to report having quit smoking for at least 24 hours since leaving treatment (p < .01). Stage-based telephone counseling appears to be a feasible approach to addressing smoking cessation among recovering alcoholics, with a modest positive effect on subsequent tobacco use.

The double triumph: sustained sobriety and successful cigarette smoking cessation.

Conventional practice wisdom has long shielded alcohol treatment center clients from social and medical pressures to quit smoking. But, recent findings of increased cancer risk are forcing a re-examination of traditional practices. Detailed case histories of 14 recovering alcoholics who successfully quit smoking suggest the feasibility of cessation efforts even in the face of severe substance abuse histories.

Nicotine addiction counseling for chemically dependent patients.

A total of 771 professionals employed in alcohol treatment programs in Nebraska were surveyed to determine whether their personal alcohol and tobacco use status or characteristics of their treatment programs were related to whether they provided nicotine addiction counseling. About a third of respondents agreed that clients in active treatment should be urged to quit smoking. Compared with respondents who had never smoked, current smokers were one-half to one-third as likely to provide such counseling. Greater knowledge of the effects of nicotine addiction and employment in programs that provided nicotine addiction education or treatment increased the odds of counselors' providing nicotine counseling. Counselors' alcohol use status was not associated with nicotine counseling practices.

Depression screening scores during residential drug treatment and risk of drug use after discharge.

Depression is a highly prevalent disorder among patients in residential drug treatment, and the prognosis for recovery from chemical dependency among depressed persons is uncertain. This report presents one-year follow-up data on alcohol, cocaine, and marijuana use among patients who completed the Center for Epidemiologic Studies Depression Scale (CES-D) during their inpatient stay in one of 12 residential treatment programs in the Midwest. At 12-month follow-up, CES-D scores in the depressed range were significantly associated with risk of relapse for alcohol and marijuana use, but not for cocaine use.

Urging the alcoholic client to quit smoking cigarettes.

Cigarette smoking is highly correlated with alcohol abuse. Yet information regarding smoking cessation for alcoholics is largely absent. To begin addressing this gap, 311 alcohol treatment professionals staffing 23 inpatient facilities in Washington state reviewed a list of 8 different time points, including "never," at which an alcohol-involved adult could be urged to quit smoking cigarettes. Respondents first selected those time points at which they favored and then those at which they personally encouraged smoking cessation. One year after the onset of sobriety emerged as the preferred time point. Responses were analyzed according to the treatment staff's self-reported alcohol and smoking status. Staff who described themselves as alcoholics and smokers were significantly less likely than nonalcoholic-nonsmokers to urge smoking cessation efforts.

Training chemical dependency counselors to treat nicotine dependence.

To test the effectiveness of providing chemical dependency (CD) staff with a knowledge-and-skills-building workshop on treatment of nicotine dependence, we employed a nested cross-sectional design with six outpatient CD programs in Nebraska (3 intervention, 3 control sites). Data on tobacco counseling provided by CD staff were obtained by telephone from sequential samples of smokers currently receiving alcohol treatment at each participating site. Intervention site clients with clinic visits after the staff training workshop were no more likely than intervention-site clients with clinic visits before the workshop to report having been counseled about their smoking (OR = 0.95, 95% confidence interval (CI): 0.74-1.21). However, control-site clients were significantly more likely to report having been counseled about smoking during the second half of the study (OR = 2.15, 95% CI: 1.49-3.08), even though staff training was not provided at control sites until data collection had been completed. These findings suggest that in some alcohol treatment programs simple monitoring of staff counseling practices may be sufficient to increase the frequency of attention to tobacco. In others, more intensive efforts might be needed to shift CD staff toward more consistent treatment of nicotine dependence.

Alcohol and tobacco use in the Minnesota Heart Health Program.

Correlations between alcohol intake and cigarette smoking have been extensively documented. Prospective data on the relationship between smoking and alcohol remain quite limited. The Minnesota Heart Health Program (MHHP) collected such data as part of a 10-year research and demonstration project intended to reduce the prevalence of heart disease. The study involved six communities, three that received intervention and three, comparison. The current analyses focused upon baseline relationships and longitudinal changes in alcohol and tobacco use. Contrary to prediction, those who quit smoking were no more likely than continuing smokers to reduce alcohol intake. Furthermore, alcohol intake at baseline did not predict smoking status at follow-up. Gender differences were found in a number of comparisons. Further study is needed of changes in smoking and drinking patterns over time in the general population.

Cigarette smoking cessation attempts by recovering alcoholics.

Survey data on the smoking cessation experiences of 77 recovering alcoholics are reported. A comparison of successful and unsuccessful quitters addressed questions about optimal timing of cessation efforts, relative severity of alcohol and tobacco abuse histories, and the impact of cessation efforts on the maintenance of sobriety. Findings suggest that recovering alcoholics can successfully quit smoking without jeopardizing sobriety but that individuals with more severe substance abuse histories may be less successful. Although successful quitters tended to wait longer before attempting cessation, a comparison of the two groups was not statistically significant.

Self-control skills for preventing smoking.

This study evaluated the effects of self-control skills intervention to prevent smoking with middle school subjects. Informed and consenting subjects were pretested, then by school were randomly divided into three conditions: experimental, placebo, and test-only control. Experimental condition subjects received self-control skills intervention covering self-instruction, self-reinforcement, problem solving, and interpersonal communication. Placebo condition subjects received a discussion-oriented intervention employing health education methods to prevent smoking. Results at 15-month follow-up indicated that self-control and placebo condition subjects, relative to control condition subjects, improved more on measures of health knowledge and nonsmoking intentions. Self-control skills subjects had better 15-month follow-up scores than subjects in the other two conditions on measures of communication, self-instruction, self-praise, cigarette refusals, and noncompliance to smoke. Self-control condition subjects reported less weekly cigarette smoking compared with placebo and control condition subjects at final follow-up.

Tobacco cessation with patients recovering from alcohol and other substance abuse.

This article focuses on the problem of tobacco cessation in the patient recovering from alcohol or other substance abuse. The authors review the epidemiology of the problem, specific health risks to this population from continued tobacco use, and recent research findings that address previous treatment concerns. Recommendations for counseling by physicians are made. These include an algorithm for determining the patient's stage of readiness for making a quit attempt, specific counseling tasks based on the patients stage, and motivational counseling strategies aimed at increasing the patients motivation to quit.

Prevalence of morphologic defects in spermatozoa from beef bulls.

OBJECTIVE: To determine the overall prevalence of morphologic defects in spermatozoa from beef bulls and to determine whether prevalence varies with the age of the bull. DESIGN: Cross-sectional observational study. ANIMALS: 2,497 beef bulls that were evaluated for breeding soundness in 1994 by 29 practicing veterinarians in a 5-state geographic region. PROCEDURE: Slides of spermatozoa from each bull were made and submitted by practicing veterinarians for morphologic evaluation. One hundred spermatozoa per slide were examined, and each was classified as having 1 of 9 morphologic defects or as normal. RESULTS: 63% of bulls evaluated were 10 to 12 months old, and 20% were 13 to 18 months old. A mean of 70.6% of spermatozoa was classified as normal. Most common defects were proximal droplets (8.4%), distal midpiece reflexes (6.7%), separated heads (5.5%), and distal droplets (3.8%). Other defects were seen < 2% of the time. Bulls 10 to 12 months of age had a higher prevalence of proximal and distal droplet defects than older bulls. CLINICAL IMPLICATIONS: Practitioners conducting breeding soundness evaluations in beef bulls must be aware of common spermatozoal defects. Bulls that are evaluated at a young age will have more defects than older bulls and should be reevaluated, particularly for those defects for which prevalence decreases with age.

Nicotine dependence and alcoholism epidemiology and treatment.

Nicotine dependence in alcohol-involved adults is a long-ignored treatment problem. The absence of its discussion in the literature is difficult to defend in light of medical and epidemiological data on the cost and prevalence of this dual addition. Most descriptive studies of alcohol abusers published in the past 20 years have reported tobacco use rates of at least 90%. There is a crucial need to educate treatment professionals and their clients about the additional health risks associated with joint nicotine dependence and alcoholism. Historically, certain barriers to active intervention have existed in drug abuse treatment facilities, including (1) concerns that urging clients to quit smoking might have an adverse effect on their maintenance of sobriety, (2) a tendency to minimize the strength and severity of nicotine addition, (3) a lack of informative data on how best to treat smoking in recovering alcoholics, and (4) financial issues related to marketing and insurance compensation. Recent data obtained from recovering alcoholics who have tried to quit smoking and anecdotal reports from alcoholism treatment centers that have begun addressing nicotine addiction are now challenging these barriers. Education, role modeling, environmental control, and development of staff expertise can be incorporated into standard alcoholism treatment programs to jointly treat these paired addictions.

Nicotine dependence and alcoholism epidemiology and treatment.

Nicotine dependence in alcohol-involved adults is a long-ignored treatment problem. The absence of its discussion in the literature is difficult to defend in light of medical and epidemiological data on the cost and prevalence of this dual addiction. Most descriptive studies of alcohol abusers published in the past 20 years have reported tobacco use rates of at least 90%. There is a crucial need to educate treatment professionals and their clients about the additional health risks associated with joint nicotine dependence and alcoholism. Historically, certain barriers to active intervention have existed in drug abuse treatment facilities, including (1) concerns that urging clients to quit smoking might have an adverse effect on their maintenance of sobriety, (2) a tendency to minimize the strength and severity of nicotine addiction, (3) a lack of informative data on how best to treat smoking in recovering alcoholics, and (4) financial issues related to marketing and insurance compensation. Recent data obtained from recovering alcoholics who have tried to quit smoking and anecdotal reports from alcoholism treatment centers that have begun addressing nicotine addiction are now challenging these barriers. Education, role modeling, environmental control, and development of staff expertise can be incorporated into standard alcoholism treatment programs to jointly treat these paired addictions.

Factors that may discourage annual mammography among low-income women with access to free mammograms: a study using multi-ethnic, multiracial focus groups.

Age-eligible women enrolled in the National Breast and Cervical Cancer Early Detection Program can obtain free or low-cost mammograms annually, but many do not routinely complete rescreening. This study investigated the rescreening behavior of low-income women by conducting 8 focus groups in Texas with enrollees who had access to free mammograms. Concerns mentioned in the focus groups included fear of radiation, anxiety that the test might not find a cancer that was there, and worries that cancer might be detected. In all groups, some women mentioned the embarrassment, discomfort, or pain they experienced during a prior mammogram, although no one indicated they would refuse to have another mammogram because of these concerns. Findings highlight the useful insights that can be obtained from focus groups and underscore the need for more research on aspects of the experience of mammography that may affect rescreening.