The next generation of cerebrospinal fluid (CSF)-based molecular diagnostics: Improving sensitivity and actionability in breast and lung cancer patients with CNS involvement

e14502

Background: Liquid biopsy has emerged as a minimally invasive and cost-effective strategy to assess cancer biomarkers without the risk of complications associated with surgical biopsies. Once a tumor has metastasized to the brain, circulating tumor cells (CTCs) and circulating tumor DNA (ctDNA) can be found in the cerebrospinal fluid (CSF). We analyzed CSF samples from patients(pts) with primary lung or breast cancer with either brain (BM) or leptomeningeal metastases (LM). Here we report the analytical and clinical validation of Target Selector CSF assays. Validation testing included pre-analytical and analytical steps. Methods: CSF was collected prospectively from pts with a prior solid tumor diagnosis and suspected BM or LM. CTCs were captured utilizing a primary ten antibody cocktail followed by biotinylated secondary antibodies that bind selectively to CTCs followed by staining with cytokeratin (CK), CD45, streptavidin and DAPI. CTCs were captured in a microfluidic channel,classified as either CK+ or CK-. Cell-free total nucleic acids (cfTNA) was extracted from CSF supernatant and underwent both Target Selector™ single gene and next-generation sequencing (NGS) lung and breast multi-gene testing to assess for molecular alterations. For NGS, data analysis was performed using Torrent Suite with annotation and curation by Ion Reporter and Oncomine Knowledgebase Reporter software. Results: The Target Selector CTC platform assays performed on clinical samples (n = 89) resulted in clinical accuracy = 85.4%, clinical precision (intra-assay, inter-assay, inter-operator, and inter-instrument) = 100% for each measure, clinical sensitivity = 80.0%, clinical specificity = 96.6%, positive predictive value (PPV) = 98%, negative predictive value (NPV) = 70.0%, and analytical specificity = 96.0% (acceptance criteria was 95%) at a limit of detection of 2 CTCs. For molecular analyses, Target Selector™ platform assays resulted in clinical accuracy = 87.4%, clinical sensitivity = 85.2%, clinical specificity = 88.3%, PPV = 76.7%, and NPV = 93.0%. Conclusions: Target Selector is a viable, sensitive, reproducible platform for CTC detection and molecular analysis of CSF samples from patients with breast or lung cancer with CNS metastases especially as the sensitivity of CSF cytology is low and MRI findings can be equivocal. Identifying CTCs and molecular alterations can help characterize both tumor genomic evolution as well as guide treatment following cancer metastasis to the CNS.

Diagnosis of leptomeningeal metastasis (LM) through identification of circulating tumor cells (CTCs) in cerebrospinal fluid (CSF)

3567

Background: Diagnosis of LM from solid tumors can be challenging. The TargetSelector (TS) CTC detection assay has demonstrated highly specific and sensitive CTC capture both for epithelial (CK+) and non-epithelial (CK-) subsets. The assay utilizes a ten-antibody (ab) capture cocktail followed by biotinylated secondary abs that bind to CTCs, enriched in a microfluidic device. TS targeted next-generation sequencing (NGS) assay detects somatic mutations in 12 breast cancer-related genes. The aim was to determine whether TS can improve sensitivity in the diagnosis of LM compared to CSF cytology by lumbar puncture (LP). Methods: CSF was collected prospectively from patients (pts) with a prior solid tumor diagnosis and suspicion of LM. CTCs were isolated from CSF using the TS platform. Cells were stained with cytokeratin (CK), CD45, streptavidin and DAPI. CTCs captured in a microchannel were classified as CK + or -. Peripheral blood samples obtained at time of LP underwent similar CTC analysis. Cell-free total nucleic acids (cfTNA) were extracted from plasma and CSF followed by NGS. Data analysis used the Ion Torrent Suite with annotation and report curation by Ion Reporter and Oncomine Knowledgebase Reporter software respectively. Results: There were 14 pts (13 women and 1 man), median age 56 years (range 32-75) with cancers of the breast (10), lung (1), colon (1), CNS lymphoma (1) or glioma (1). Pts had received a median of 2.5 lines of systemic metastatic therapy (range 0-8). CSF cytology was not sent for 1 pt and TS was not performed for 1 pt. TS and standard cytology had 89% agreement in pts with metastatic breast cancer (MBC, 8/9). Of the 6 pts for whom CTCs were detected in CSF by TS, 3 pts had + cytology (all MBC), 2 pts had - cytology and 1 pt with MBC was not tested by cytology. Of the 3 pts with + CSF by cytology (all MBC), all were detected by TS (Table). Among 5 MBC pts with CTCs present in CSF, ER status was concordant in 2 of 5 (40%). HER2 status was concordant in 3 of 4 (75%) evaluable pts and not determined in 1 pt. Analysis of cfDNA from CSF identified somatic mutations in 3 pts (TP53, PIK3CA, CCND1, respectively). In 1 of 3 pts, the mutation identified in the CSF (PIK3CA) in HR+/HER2- MBC was also identified in the blood. Conclusions: TargetSelector is a viable platform for the detection of breast cancer CTCs in the CSF. NGS performed on CSF samples can identify potentially actionable mutations. [Table: see text]

Morpho-regulation in diverse chicken feather formation: Integrating branching modules and sex hormone-dependent morpho-regulatory modules

Many animals can change the size, shape, texture and color of their regenerated coats in response to different ages, sexes, or seasonal environmental changes. Here, we propose that the feather core branching morphogenesis module can be regulated by sex hormones or other environmental factors to change feather forms, textures or colors, thus generating a large spectrum of complexity for adaptation. We use sexual dimorphisms of the chicken to explore the role of hormones. A long-standing question is whether the sex-dependent feather morphologies are autonomously controlled by the male or female cell types, or extrinsically controlled and reversible. We have recently identified core feather branching molecular modules which control the anterior-posterior (bone morphogenetic orotein [BMP], Wnt gradient), medio-lateral (Retinoic signaling, Gremlin), and proximo-distal (Sprouty, BMP) patterning of feathers. We hypothesize that morpho-regulation, through quantitative modulation of existing parameters, can act on core branching modules to topologically tune the dimension of each parameter during morphogenesis and regeneration. Here, we explore the involvement of hormones in generating sexual dimorphisms using exogenously delivered hormones. Our strategy is to mimic male androgen levels by applying exogenous dihydrotestosterone and aromatase inhibitors to adult females and to mimic female estradiol levels by injecting exogenous estradiol to adult males. We also examine differentially expressed genes in the feathers of wildtype male and female chickens to identify potential downstream modifiers of feather morphogenesis. The data show male and female feather morphology and their color patterns can be modified extrinsically through molting and resetting the stem cell niche during regeneration.

[Exoprosthetic Replacement of the Upper Extremity]

During the last years, the prosthetic replacement in upper limb amputees has undergone different developments. The use of new nerve surgical concepts improved the control strategies tremendously, especially for high-level amputees. Technological innovation in the field of pattern recognition enables the control of multifunctional myoelectric hand prostheses in a natural and intuitive manner. However, the different levels of amputation pose different challenges for the therapeutic team which concern not only the prosthetic attachment; also the expected functional outcome of prosthetic limb replacement differs greatly between the individual levels of amputation. Therefore, especially in partial hand amputations the indication for prosthetic fitting has to be evaluated critically, as these patients may benefit more from biologic reconstructive concepts. The value of the upper extremity, in particular of the hand, is undisputable and, as such represents the driving force for the technological and surgical developments within the exoprosthetic replacement. This article discusses the possibilities and limitations of exoprosthetic limb replacement on the different amputation levels and explores new developments.

[Prosthetic reconstruction of the upper extremity]

BACKGROUND

Prosthetic replacement after amputation or loss of function of the upper extremity has gained therapeutic value over the last years. The control of upper arm prostheses has been refined by the use of selective nerve transfers, and the indication for prosthetic replacement has been expanded.

OBJECTIVES

Overview regarding surgical, therapeutic and prosthetic options in upper extremity amputations or their loss of function.

METHODS

Selective literature research including the authors' own experience in everyday clinical practice, as well as a review of medical records.

RESULTS

Selective nerve transfers of the amputated nerves of the brachial plexus to the remaining stump muscles can create up to six myosignals for intuitive and simultaneous control of the different prosthetic joints. This way, an efficient and harmonious control of the prosthetic device is possible without the need to change between the different control levels. The prosthetic replacement, with consequent elective amputation, represents a new approach in the functional reconstruction of the upper extremity, especially in patients with a functionless hand after massive soft tissue or nerve damage.

Abstract P2-01-10: Immunocytochemistry staining for estrogen and progesterone receptor in circulating tumor cells: Concordance between primary and metastatic tumors

Introduction: Estrogen (ER) and progesterone receptor (PR)) status is recommended by immunohistochemistry (IHC) and is considered standard practice for selection of treatment options in all breast cancer patients. Because biopsy is not often feasible in every patient presenting with recurrent and/or metastatic disease, circulating tumor cells (CTCs) offer an attractive alternative source of tumor tissue for determining ER/PR status. In addition, CTCs enable monitoring for more effective course of treatment.

Experimental Design: Twenty ml of peripheral blood was collected prospectively from 34 patients diagnosed with late stage metastatic/recurrent breast cancer. CTCs were isolated using the microfluidic OncoCEE platform. A cocktail of antibodies was utilized for CTC capture, and detection was accomplished with an expanded anti-cytokeratin (CK) cocktail mixture and anti-CD45. ER/PR protein expression was assessed by immunocytochemistry (ICC) on CK+/CD45- CTCs captured directly within the microchannel and then compared to IHC performed on the primary and/or metastatic tumor.

Results: CK+/CD45−/DAPI+ cells were detected in 22 of 34 (65%) patients with late stage breast cancer and assessed for ER/PR immunocytochemistry. Among the 22 cases with one or more CTCs, a concordance of 75% (15/20) and 90% (9/10) in ER/PR status between primary and metastatic tumor was observed, respectively. An overall concordance of 86% (19/22) was achieved. Five cases were discordant based on primary tissue alone; however, two of these cases are concordant when compared to the metastatic biopsy. Thus, only three cases were found to be discordant: all three were positive by IHC on the primary and/or metastatic tumor but negative by CTCs and all three had relatively low numbers of CTCs detected.

Conclusions: There is significant heterogeneity of ER/PR protein expression in CTCs and primary/metastatic tumor biopsy. In addition, hormonal status may change over time due to therapy. ER/PR ICC on CTCs using the OncoCEE platform is shown to be feasible, with high concordance (86%) as compared to primary and/or metastatic biopsy (by IHC). The significance of heterogeneity at the ER/PR protein level in CTCs related to the prognosis and predictive response to anti-estrogen therapy needs further evaluation in larger prospective clinical trials.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-01-10.

P1-07-13: Efficiency of a Laboratory Developed HER2 FISH Test on Circulating Tumor Cells

INTRODUCTION: Most circulating tumor cell (CTC) platforms rely on EpCAM for capture and cytokeratin (CK) for detection. However, an important population of cells that are CK-negative (i.e. cells with epithelial-mesenchymal transition (EMT) phenotype) will be missed. We report a new strategy to efficiently isolate a more heterogeneous population of CTCs using an antibody cocktail.

METHODS: In the first prospective study, blood (20 mL) was collected from 89 patients diagnosed with various late stage metastatic/recurrent cancers (breast, CRC, lung, prostate) following IRB approval. PBMCs were incubated with either EpCAM alone or a mixture of 10 capture antibodies to target both epithelial and mesenchymal cells. CTCs were subsequently captured in the OncoCEE™ channels and detected with cytokeratin (CK) and CD45. A second prospective IRB approved study involving 54 patients diagnosed with late stage metastatic/recurrent breast cancer was performed using similar detection strategies (CK cocktail mixture and anti-CD45) with the addition of HER2 FISH to determine amplification status among captured CK+/CD45- and CK-/CD45-cells.

RESULTS: In the first study, overall detection of CK+ cells was 83% with EpCAM alone and 93% with antibody cocktail. In addition, a median of 0.4 CK+ cells/mL and 1.0 CK+ cells/mL was observed using EpCAM and antibody cocktail, respectively. In the second study, CK+/CD45- cells were detected in 43 of 54 cases (80%). Among the 43 cases in which CK+/CD45- cells were detected, high concordance (93%) in HER2 status between primary tumor and CTCs was observed with HER2 amplification noted in both CK+/CD45- (50%) and CK-/CD45- (50%) cells.

CONCLUSIONS: We have developed a novel and robust method for CTC enumeration that utilizes a cocktail of antibodies for the detection of a heterogeneous (CK+ and CK-) population of CTCs. Our findings suggest an important population of CK- cells is being missed by current stain criteria in breast cancer patients. Data also demonstrate that recovery of CTCs from peripheral blood using the OncoCEE™ platform is efficient and suitable for FISH-based laboratory testing.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-07-13.

P5-01-08: Immunocytochemistry Staining of Estrogen Receptor in Circulating Tumor Cells as Compared to Primary Tumor

Introduction: Estrogen receptor (ER) status in all breast cancer patients is recommended by immunohistochemistry (IHC) and is considered standard practice for selection of treatment options. However, the analytical sensitivity of IHC in detecting low levels of ER is often poor and likely due to methodological variation. Because biopsy is not often feasible in all patients presenting with recurrent and/or metastatic breast disease, circulating tumor cells (CTCs) offer an attractive alternative source of tumor tissue for determining ER status and can be monitored more readily to enable a more effective course of treatment.

Experimental Design: Twenty ml of peripheral blood was collected prospectively from # patients diagnosed with late stage metastatic/recurrent breast cancer. CTCs were isolated using the microfluidic OncoCEE™ platform. A cocktail of antibodies was utilized for CTC capture and detection with an expanded anti-cytokeratin (CK) cocktail mixture and anti-CD45. ER protein expression was assessed by immunocytochemistry (ICC) on the cells captured within the microchannels and compared to IHC performed on the primary tumor.

Results: CK+/CD45- cells were detected in 23 of 27 cases (85%). Among the 23 cases in which CK+ cells were detected, only moderate concordance (16/23; 70%) in ER status between primary tumor and CTCs was observed.

Conclusions: There is significant heterogeneity between ER protein expression in CTCs and primary tumor. ER ICC on CTCs from peripheral blood using the OncoCEE™ platform is shown to be feasible but the comparison likely compromised by lack of tumor staging at the time of blood draw. Given that IHC was in some cases performed 5–10 years pre-blood draw and that tumors have the potential to convert, ER status only moderately correlates to the IHC status in the primary tumor. The significance of heterogeneity at the ER protein level in CTCs ascertaining to the prognosis and predictive response to anti-estrogen therapy needs further evaluation in larger prospective clinical trials.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-01-08.

P4-06-04: Detection of HER2 Gene Amplification in Circulating Tumor Cells and Disseminated Tumor Cells by Fluorescence In Situ Hybridization Using OncoCEE™

BACKGROUND: The status of HER2 gene amplification in circulating tumor cells (CTCs) and disseminated tumor cells (DTCs) might provide useful information for monitoring response to trastuzumab therapy, and may provide a basis for consideration of trastuzumab in patients with HER2 negative primary tumors who have HER2 positive CTCs and/or DTCs. The majority of techniques utilized for detection of minimal residual disease are limited in their ability to allow detailed phenotypic and genotypic evaluation of the cells. We report the utility of a microfluidic platform (OncoCEE™,Biocept, San Diego) for detecting HER2 gene amplification in CTCs and DTCs in patients with non-metastatic breast cancer.

METHODS: Peripheral blood (10ml) and bone marrow (BM) (1-2ml) were collected from patients with clinical stage I-III breast cancer in acid citrate dextrose solution (BD, Franklin Lakes, NJ) and anti-clumping reagent (OncoCEE-Sure™). Mononuclear cells were recovered using a Percoll density gradient method, incubated with a mixture of 10 primary capture antibodies (Abs), introduced into CEE™ microchannels, stained with fluorescent anti cytokeratin (CK) and CD45 abs and finally processed for fluorescence in situ hybridization (FISH) using probes specific to centromere 17 (spectrum green) and HER2 (spectrum arrange). The ratio of HER2:CEP17 >2.2 in any CK+/CD45- and CK-/CD45- cell was regarded as positive for HER2 gene amplification.

RESULTS: Peripheral blood and/or BM from 78 patients (65 BM; 70 blood; 57 matched blood and BM) with T1NO (39), T1N1 (8), T2N0 (12), T2N1 (2), T2N2 (1), T2N3 (3), T3N0 (2), T3N1 (2), T3N2 (1), T4N0(5), T4N1 (3), with HER2+ (n=12) and HER2− (n=58) primary invasive breast tumors were studied. The 12 patients with HER2+ primary tumors had HER2+ DTCs in 3/12 (25%) and HER2+ CTCs in 1/9 (11%) cases respectively. HER2+ DTCs and HER2+ CTCs occurred in 12/55 (24%) and in 4/63 (6%) of the patients with HER2− primary breast tumors. HER2+ CTCs and DTCs occurred simultaneously in only 2 patients and in either blood (3) or BM (13) in the remaining patients.

CONCLUSION: 1. The cell enrichment and extraction microfluidic technology (OncoCEE™) provides a sensitive platform for evaluation of HER2 gene amplification of CTCs and DTCs.

2. HER2+ primary tumors were associated with either HER2+ CTCs or DTCs in 25% of the patients.

3. HER2+ CTCs or DTCs occurred in 28% of patients with HER2−primary tumor.

4. Discordant HER2 status was contributed mainly by HER2+ DTCs occurring in HER2 - primary tumors.

5. The clinical significance of evaluating the status of HER2 gene amplification in CTCs and DTCs in the management of patients with breast cancer needs to be evaluated prospectively in larger clinical trials.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-06-04.

Abstract 319: Comparison of fluorescence in situ hybridization of estrogen receptor genetic locus with protein expression in invasive breast carcinoma

INTRODUCTION: Evaluation of estrogen receptor (ESR1) status is recommended in all breast cancer patients and is generally performed using immunohistochemistry (IHC). However, the analytical sensitivity of IHC in detecting low levels of ESR1 amplification is often poor and likely due to methodological variation. Though FISH (fluorescent in-situ hybridization) has been proposed as an alternative approach for detection of ESR1 gain, results have been controversial with few studies evaluating concordance between FISH and IHC. In this study, we describe the performance of FISH using an ESR1 probe and correlation of the results with IHC for ESR protein expression.

METHODS: FISH and IHC for ESR1 was performed on adjacent sections of formalin fixed paraffin embedded tumor sections from 32 patients with invasive breast cancer enrolled for treatment at MD Anderson Cancer Center. For FISH, pretreatment of the slides with the paraffin pretreatment kit III (Abbott Laboratories) was performed followed by incubation using the ESR1/Cen6 probe set (Zytovision). The number of fluorescent signals for each the ESR1 and centromere 6 were counted in a minimum of 200 non-overlapping, intact nuclei. Nuclei were characterized as normal (two signals for each locus), monosomy (one signal for ER and two signals for the centromere) or trisomy (three signals for ER and two signals for the centromere). IHC on primary tumor tissue sections was carried out in a Bond-maX machine (Leica Microsystems) with primary ER antibody (clone 6F11, Novocastra) at dilution of 1:35 and antigen retrieval using citrate buffer. Nuclear positivity in the tumor cells was expressed as percentage and categorized as negative, low positive or positive based on nuclear staining of 0%, 1-10% and >10% respectively.

RESULTS: Of the 32 samples that were successful for both FISH and IHC, a comparison was made to determine concordance of FISH signals to ER IHC results. We calculated the percentage of cells having ≫3 ESR1 signals and those that contained <2 ESR1 signals in all 32 cases. Based on a FISH percentage cutoff of 2.0, cases could be classified into three groups: negative (n=7), equivocal (n=8) and amplified (n=10) with seven cases being discordant when compared to IHC results. The p-value for the ratio of ER negative to ER positive cohort was found to be statistically significant (p=0.026). Based on these criteria we observe a concordance of 75% between the two technologies.

CONCLUSION:

1. There is a significant heterogeneity between the gene amplification status and protein overexpression of ESR1.

2. The gene status of ESR1 ranges from negative, equivocal and amplified in both ER negative and ER immunopositive cases.

3. The significance of heterogeneity at the ESR1 gene locus in ascertaining the prognosis and predictive response to antiestrogen therapy needs further evaluation in larger prospective clinical trials.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 319. doi:10.1158/1538-7445.AM2011-319

Abstract LB-310: FISH-based determination of HER2 status in circulating tumor cells isolated with the microfluidic CEE™ platform

Purpose: Determination of HER2 status by immunohistochemistry (IHC) and fluorescent in-situ hybridization (FISH) in patients with breast cancer is considered standard practice for selection of treatment options. Though patients presenting with recurrent and/or metastatic disease are often re-evaluated for HER2, biopsy is not often feasible. Thus, circulating tumor cells (CTCs) are an attractive alternative source of tumor tissue for determining HER2 status to enable a more effective course of treatment.

Experimental Design: Twenty to thirty ml of peripheral blood was collected prospectively from 54 patients diagnosed with late stage metastatic/recurrent breast cancer. CTCs were isolated using the microfluidic CEE™ platform. CTC capture was achieved using a cocktail of capture antibodies, followed by detection with an expanded anti-cytokeratin (CK) cocktail mixture and anti-CD45. HER2 amplification was subsequently assessed by FISH on captured CK+/CD45− and CK−/CD45− cells.

Results: CK+/CD45− cells were detected in 43 of 54 cases (80%). Among the 43 cases in which CK+ cells were detected, high concordance (93%) in HER2 status between primary tumor (by IHC and FISH) and CTCs (by FISH) was observed. An overall sensitivity of 95% and a specificity of 92% were obtained using the OncoCEE-BR™ assay.

Conclusions: Recovery of CTCs from peripheral blood using the CEE™ platform is shown to be efficient and suitable for FISH-based testing. In addition, HER2 FISH on recovered CTCs is proven to be sensitive and accurate.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr LB-310. doi:10.1158/1538-7445.AM2011-LB-310

Promoting sun safety among zoo visitors

BACKGROUND

Each year, millions of children visit zoological parks, where they are exposed to long bouts of ultraviolet radiation (UVR). We conducted a study in the winter and replicated it in the summer to evaluate an intervention for reducing UVR exposure during the zoo visit.

METHODS

Each study used a nonequivalent control group design: one zoological site received the intervention and a second received evaluation only. Key outcome measures consisted of observed prevalence of hat use by exiting children (N = 8,721 and 8,524, respectively, in winter and summer studies) and purchase rates of sunscreen and hats in zoo gift shops. Intervention consisted of tip sheets for parents, children's activities, prompts, and discounts off the price of sunscreen and sun-protective hats.

RESULTS

In the summer study, sales of both sunscreen and target hats increased significantly at the intervention site relative to the control site, whereas in the winter study, only sunscreen sales at the intervention site had a significant (relative) increase. Children's hat use increased significantly at the intervention site, but only in the winter study.

CONCLUSIONS

The multicomponent program was effective in promoting purchases of sun-safe items, but its impact on children's hat use was inconclusive.

Compliance with federal and state legislation by indoor tanning facilities in San Diego

BACKGROUND

The prevalence rates of both skin cancers and indoor tanning among the US population are high and have increased substantially in recent years. Low compliance by indoor tanning facilities with safety regulations may place consumers at greater risk of skin and ocular damage.

OBJECTIVE

This study quantified the level of compliance by indoor tanning facilities with selected federal and state regulations and recommendations.

METHODS

Tanning facilities (N = 54) in San Diego County, California, were visited by a confederate posing as a prospective customer. Compliance with 13 regulations/recommendations were assessed by either direct query or observation of the presence/absence of signs and warning labels. Operators' responses to 5 risk-based questions also were noted.

RESULTS

No facility complied with all 13 regulations/recommendations. Compliance with 3 protective eyewear regulations was high (89%-100%). In contrast, compliance with maximum tanning frequency recommendations (approximately 6%) and parental consent regulations (approximately 43%) was disturbingly low.

CONCLUSION

The investigators recommend instituting mandatory, comprehensive training for operators, as well as systematic compliance monitoring with enforcement of penalties for noncompliance.

Confidence intervals for the risk ratio under cluster sampling based on the beta-binomial model

In cohort studies, the risk ratio (RR) is one of the most commonly used epidemiologic indices to quantify the effect of a suspected risk factor on the probability of developing a disease. When we employ cluster sampling to collect data, an interval estimator that does not account for the intraclass correlation between subjects within clusters is likely inappropriate. In application of the beta-binomial model to account for the intraclass correlation, we develop four asymptotic interval estimators of the RR, which are direct extensions of some recently developed estimators for independent binomial sampling. We then use Monte Carlo simulation to evaluate the finite-sample performance of these four interval estimators in a variety of situations. We find that the estimator using the logarithmic transformation generally performs well and is preferable to the other three estimators in most of the situations considered here. Finally, we include an example from a study of an educational intervention with emphasis on behaviour change to illustrate the use of the estimators developed in this paper.

Patient reminder letters to promote annual mammograms: a randomized controlled trial

BACKGROUND

This study assessed the effects of a reminder letter from a physician (relative to a mammography facility letter or no letter) on appointment compliance among women 50-74 years of age due for an annual screening mammogram.

METHODS

A total of 1,562 women were randomly as signed to the groups. Each Group 1 subject received a reminder letter from her physician, each Group 2 subject received a reminder letter from her mammography facility, and Group 3 served as a control group.

RESULTS

The return rates for Groups 1, 2, and 3 were 47.7, 46.6, and 28.3%, respectively; the overall difference was significant using a chi(2) analysis (P < 0.001). Bonferroni pairwise comparisons indicated no difference between Groups 1 and 2 but significant differences (P < 0.001) between Group 3 and the other two groups. Logistic regression indicated that relative to Group 3, the adjusted odds of returning for Groups 1 and 2 were 2.37 and 2.24, respectively.

CONCLUSIONS

Mammography providers and their patients likely will benefit from in-reach reminder systems. Physicians who do not use reminder systems should refer their patients to facilities that use these systems.

A national survey of sun safety activities at U.S. zoos

Skin cancer incidence in the United States has increased. Exposure to ultraviolet radiation (UVR) is a major risk factor for skin cancer. Every year, millions of children with their families visit outdoor leisure facilities such as zoos where overexposure to UVR may occur. This study was conducted to assess the proportion of U.S. zoos that provided sun safety activities during the summer of 1998 and their willingness to incorporate skin cancer prevention strategies at their facility in the future. A 56 item self-administered questionnaire was mailed to 140 zoos accredited by the American Zoo and Aquarium Association. A follow-up telephone survey was also conducted with 33 mail non-respondents. The response rate was 97% (N = 136). Results revealed that in the summer of 1998, only 5% of zoos provided sun safety recommendations to visitors and 25% of zoos provided recommendations to their employees. The recommendations made most often to visitors and employees were to use sunscreen and wear protective clothing. Eighty-five percent of zoos indicated interest in providing sun safety activities at their facilities in the future. The next step will be to design environmentally appropriate sun safety programs for zoos and to encourage zoos to implement these programs.

Rates and correlates of discomfort associated with mammography

PURPOSE

To explore the rates and correlates of discomfort at mammography in asymptomatic women aged 50-74 years from six San Diego, Calif, mammography facilities.

MATERIALS AND METHODS

Subjects (N = 1,800) completed a 43-item telephone interview approximately 3 weeks after screening mammography. Bivariate associations between variables were analyzed with chi(2) analysis. Logistic regression was used to assess the independent predictors of discomfort at mammography while controlling for all other factors.

RESULTS

Nine hundred thirty-three (52%) women reported moderate to extreme discomfort at mammography. Discomfort was not related to the intention to undergo future mammography (P =.95). Factors that were significantly associated with discomfort in multivariate analyses were facility (P <.001), satisfaction with care (P <.04), and perception of the technologist's "roughness" (P <.001).

CONCLUSION

Discomfort, although not related to the intention to undergo future mammography, had a relatively high incidence.

Ultraviolet radiation exposure in children: a review of measurement strategies

Rates of skin cancer in the U.S. are high and have been increasing rapidly. Recommendations for primary prevention focus on the reduction of ultraviolet radiation (UVR) exposure, especially in childhood. Valid, reliable strategies are needed to measure UVR exposure in children, to document baseline levels, and to assess intervention impact. This article reviews strategies reported in observational and intervention studies and considers their potential usefulness for application with children. The strategies include verbal report (by self or parent), direct observation, visual inspection, ultraviolet (UV) sensitive film, the Erythema Meter, the spectrophotometer, and the colorimeter. Each strategy is described along several dimensions, including ease of use, cost, and whether it is suitable for measuring acute and cumulative exposure. The review describes the existing validity and reliability data and points out a need for further research assessing the reliability and validity of most of these measures. Additionally, suggestions for matching strategies with measurement and intervention objectives are presented.

Skin cancer prevention counseling by pharmacists: specific outcomes of an intervention trial

The purpose of this study was to evaluate the effects of an intervention on pharmacists' behaviors, knowledge, and attitudes related to skin cancer prevention counseling. Fifty-four pharmacy sites (N = 178 pharmacists) were randomly assigned to the intervention or control condition. Intervention consisted of video-based training, prompts installed in the pharmacy to promote pharmacist-patient discussions on the topic, and group-based feedback on previous week's counseling rates. Outcomes were measured using a mailed survey. The proportion of patients counseled at post-test was significantly higher among intervention subjects, adjusting for pretest values. Similar results were found for pharmacists' skin cancer knowledge and self-rated expertise, but not for counseling-related attitudes. The intervention was successful. If implemented on a wide scale, large segments of the U.S. population would be exposed to skin cancer prevention advice.

Project Salsa: development and institutionalization of a nutritional health promotion project in a Latino community

PURPOSE

Project Salsa was a community-based effort seeking to promote health through nutritional behavior change in a Latino community of San Diego, California. The purpose of this article is to report on program factors related to long-term institutionalization of Project Salsa interventions.

DESIGN

Project Salsa was a demonstration rather than an experimental project. To ensure maximum sensitivity to the needs and values of the community, Project Salsa began with an extensive health needs assessment, including development of an advisory council, telephone survey, archival research, and key informant interviews.

SETTING

Project Salsa interventions took place in San Ysidro, California, located near the U.S.-Mexico border adjacent to Tijuana from 1987 to 1992.

SUBJECTS

The intervention community had 14,500 residents, of which nearly 83% were Latino.

INTERVENTIONS

Interventions included coronary heart disease risk factor screenings, meal preparation classes, newspaper columns, point-of-purchase education, school health and cafeteria programs, and breast-feeding promotion.

MEASURES

Institutionalization of intervention components.

RESULTS

Two of the interventions, the risk factor screenings and school health programs, are still in operation 4 years after the end of project funding.

CONCLUSIONS

Four factors common to institutionalized components are presented in the paper.

Promoting skin cancer prevention counseling by pharmacists

OBJECTIVES

This study evaluated the effects of an intervention on rates of skin cancer prevention counseling by pharmacists.

METHODS

Fifty-four pharmacies were randomly assigned to intervention or control conditions. Intervention consisted of training, feedback, and prompts. Counseling rates before and after the intervention were obtained from study confederates.

RESULTS

At pretest, the proportions of control and intervention sites providing counseling at least once were 7.4% and 0%, respectively (NS). At posttest, these proportions were 3.7% and 66.7%, respectively (P < .001).

CONCLUSIONS

The results indicated that the intervention was successful and that pharmacists can play an important role in educating the public about skin cancer prevention strategies.

Misleading nutrition claims on cracker packages prior to and following implementation of the Nutrition Labeling and Education Act of 1990

OBJECTIVES

This study compared patterns in selected health claims on snack cracker packaging and fat content prior to and following enforcement of the Nutrition Labeling and Education Act of 1990 (NLEA).

METHODS

Through observations at supermarkets in 1991 and 1995, the prevalence on packages of health claims that consumers associate with heart disease prevention was evaluated. The fat content of each product also was recorded. Criteria for potentially misleading claims were developed.

RESULTS

Analysis of both cross-sectional data and products that were available in both years showed that fat content, as well as the number of products containing target claims, had significantly decreased by 1995. The prevalence of potentially misleading claims also declined significantly, from 77% in 1991 to 49% in 1995.

CONCLUSIONS

Although the data regarding the changes from 1991 to 1995 are encouraging, the prevalence of potentially misleading health claims for this food category continues to be high.

Solar protection behaviors among outdoor workers

Due to the lack of information regarding how US workers protect themselves from ultraviolet radiation, this study explored solar protection behaviors among three groups of outdoor workers. This cross-sectional research involved two separate studies. Study 1 consisted of observations of 312 outdoor workers, and Study 2 was a paper and pencil survey (n = 240). For each data set, occupational groups were compared on ultraviolet radiation protection. Observational data indicated that 50.4% of the workers had adequate protection. Across occupational groups, the ranking from highest to lowest levels of protection was consistent for both data sets. Face and lower arms were consistently the least protected sites. The pattern of findings suggests the importance of assessing protection of individual body sites, as well as composite protection.

Preventive services in a Medicare managed care environment

The results of a four year demonstration project of preventive services for Medicare managed care enrollees suggest that health promotion programs can impact health behaviors and outcomes. The study provided selected preventive services to 1,800 Medicare enrollees in a managed care environment. Participants were randomly assigned to control and experimental groups with the experimental group receiving an intervention service package and the control group usual care. The results included enhanced health behavior practices, lower depression, and higher immunization rates among those individuals in the experimental group. This study suggests that selected preventive services can be provided in a managed care environment to Medicare enrollees with likely positive health status and utilization outcomes.

Skin cancer prevention education: a national survey of YMCAs

High skin cancer incidence and mortality rates have created a need for skin cancer prevention education. Children are an important target for this education, as overexposure to sun and sunburns at an early age have been linked to the development of skin cancer. This study identified the prevalence of skin cancer prevention education and the need for this education at YMCA swim classes. This study also assessed the feasibility of implementing Project SUNWISE, an existing skin cancer prevention curriculum, developed for YMCA swim classes. A 51-item survey was mailed to Aquatics Directors at all YMCAs with outdoor pools. Based on a 63% response rate (N = 208), only 28% of YMCAs thought the children in their swim classes were adequately protected from the sun, and only 28% offered skin protection or sun safety education in swim classes. Only 50% of YMCAs trained their swim instructors on skin cancer prevention. While 91% of YMCAs had one or more sun protection items near the pool (e.g., sunscreen, umbrella, covered area), 93% of YMCAs saw the need for additional protection. The majority of YMCAs (95%) were willing to incorporate a skin cancer prevention education curriculum, similar to Project SUNWISE, into their swim classes. This study emphasized the need for more skin cancer prevention education programs targeting children and examined the correlates of skin cancer prevention education at YMCAs. Geographic region, percent of possible sunshine, and ultraviolet radiation were significantly associated with the skin cancer prevention education program status at the YMCAs.

Reducing ultraviolet radiation exposure in children

BACKGROUND

Project SUNWISE evaluated the effectiveness of a multicomponent intervention in reducing children's ultraviolet radiation (UVR) exposure.

METHODS

Across four YMCAs, 48 aquatics classes (N = 169 children, mean age = 7) were randomly assigned to either the intervention or the control condition. The 6-week intervention included a UVR reduction curriculum presented at poolside by aquatics instructors and home-based activities for children and their parents. Outcome measures were (a) tanness-associated skin color dimensions assessed with a colorimeter, (b) specific daily solar protection behaviors of children as reported by parents, and (c) general solar protection behaviors.

RESULTS

Controlling for intraclass clustering in all analyses, at posttest, no statistically significant between-group differences were found in tanness, daily solar protection scores, or general sunscreen use. The intervention group showed significantly greater general hat use relative to controls.

CONCLUSIONS

The intervention failed to impact most of the outcome measures. Supplementing the behavior-focused intervention package with environmental supports may be warranted.

Assessing children's ultraviolet radiation exposure: the use of parental recall via telephone interviews

OBJECTIVES

This study evaluated the validity of a parental report measure of children's solar protection behaviors.

METHODS

Fifty-eight children had skin color assessed twice with a colorimeter. Between measurement sessions, parents were interviewed by telephone to assess children's indoor-outdoor status and solar protection across 40 hourly intervals.

RESULTS

Parental report of child's indoor-outdoor status was significantly correlated with the colorimeter values, whereas the use of sunscreen and protective clothing was not.

CONCLUSIONS

This measure was feasible for assessing ultraviolet exposure in young children. The component that assessed the number of intervals spent outdoors evidenced predictive validity.

Educating the public about skin cancer prevention: a role for pharmacists

OBJECTIVES

The incidence of skin cancer is increasing at an alarming rate. This study aimed to assess pharmacists' willingness to counsel patients about skin cancer and factors which are predictive of this.

METHODS

A 30 item survey assessing skin cancer prevention counselling attitudes and behaviours, personal skin cancer prevention behaviours, and willingness to counsel on skin cancer prevention, was mailed to 300 randomly selected San Diego County pharmacists.

RESULTS

Data obtained from 128 pharmacists (43% response rate) indicated that the incidence of skin cancer prevention counselling was very low, with over one-third stating that they never counsel patients on this topic. Of those that did counsel, the percentage of patients counselled on skin cancer prevention was below 5%. Bivariate analyses indicated that pharmacists who counselled on this topic differed from those that did not on knowledge of skin cancer, attitudes and beliefs about counselling patients, pharmacy setting, services offered by their pharmacies, and their personal sun protective behaviours. Multivariate analysis indicated that two variables independently predicted skin cancer prevention counselling; whether the pharmacy where the respondent was employed offered this service, and attitude about counselling. Over 90% of respondents reported they were willing to counsel patients on skin cancer prevention and other health-related topics.

CONCLUSIONS

Future studies should focus on skin cancer prevention counselling barriers and environmental prompts encouraging this type of interaction between pharmacists and patients.

Assessing children's ultraviolet radiation exposure: the potential usefulness of a colorimeter

OBJECTIVES

This study evaluated the colorimeter as an objective measure of children's ultraviolet (UV) radiation exposure.

METHODS

Fifty-eight children, ages 6 to 9 years, attended two summer measurement sessions, with 46 attending a subsequent winter session.

RESULTS

Comparisons between summer sessions for the L* scale showed that only the upper arm significantly changed in the tanner direction, while b* scale values indicated significant tanning for all body sites. All exposed body sites changed significantly in the less tan direction between summer and winter measurements.

CONCLUSIONS

Using colorimeters to objectively measure children's UV exposure has potential applications for skin cancer prevention programs.

A survey of recreational sun exposure of residents of San Diego, California

The incidence of skin cancer in San Diego is one of the highest in the nation. Research has documented that excessive unprotected exposure to ultraviolet (UV) radiation over time significantly increases a person's risk for developing various types of skin cancer. Our study investigated the amount of sun exposure and the practice of sun protection among San Diegans and examined factors thought to be associated with these behaviors. In April 1994, a random sample of 864 San Diego residents was surveyed by telephone. Because most survey questions specifically asked about sun exposure and sun protection when tanning versus recreating, the analyses were presented separately for recreators (i.e., those who spent time in the sun during the hours of 8:00 am and 6:00 pm for recreation last summer; n = 786) and tanners (i.e., those who spent at least 10% of their time in the sun to get a tan last summer; n = 464), a subset of recreators. Study results indicated that on average, 27% of the tanners' time in the sun last summer was spent getting a tan, and tanners reported using sunscreen about 50% of the time on both their face and body. In terms of sun protection while recreating, survey respondents reported using sunscreen on their face approximately 40% of the time compared to approximately 30% of the time on their body. Correlates of sun exposure and sun protection for both tanners and recreators included demographic characteristics, susceptibility factors, attitudes, and knowledge. The findings from this study support the need for education on skin cancer prevention. The practical implications of these findings are discussed in terms of appropriate community skin cancer prevention interventions. Medical Subject Headings (MeSH): skin cancer, sunlight, behavior.

Annual return rates to mammography facilities by women age 50 and older

Data were collected at multiple mammography facilities to determine the use of inreach strategies for asymptomatic women age 50 and older and the annual return rates for screening by this age group. Interviews with 26 facility managers indicated that the majority use a reminder strategy. Using chart audits in a subset (n = 10) of the facilities of 475 randomly-selected patients, the return rate in 1991 (of patients seen in 1990) averaged 41% within 18 months after the 1990 appointment. Those data suggest that mammography providers, as well as the women they serve, could benefit from interventions to encourage annual mammograms.

Breast self-examination: knowledge and practices of Hispanic women in two southwestern metropolitan areas

The breast self-examination (BSE) practices of 1,453 Hispanic women in Phoenix, Arizona and San Diego, California were the focus of this study. Variables proposed as factors that influence the frequency and proficiency of BSE were demographic variables, particularly language and level of acculturation, having been taught BSE by a health professional, and experience with the disease. Results indicate that even though the majority of the women at both the Phoenix (78.1%) and San Diego (83.7%) sites had been taught BSE by a professional and most women in Phoenix (62.5%) and San Diego (63.4%) reported performing BSE within the past month, only 0.7% of the women at both sites were found to be proficient in the technique of BSE. Further, results indicate that language and acculturation were correlated with whether or not a woman performed BSE. These findings suggest that BSE education classes must provide information and techniques that promote proficiency in BSE, and must be designed to meet the unique needs of Hispanic women, particularly those of low acculturation levels.

Facility-based inreach strategies to promote annual mammograms

Mammography facilities frequently use inreach strategies, such as reminders, to encourage annual returns by asymptomatic women 50 years of age and older. We describe three pilot studies that systematically compared various strategies. In each study, patients seen for a screening mammogram during a specified period were randomly assigned to a novel reminder condition or a comparison condition one year later, and return rates were monitored. In study 1, return rates for subjects receiving a standard mailed reminder (36%) and subjects receiving a mailed reminder plus incentive (32%) were similar. In study 2, return rates for subjects receiving a mailed reminder (44%) and subjects receiving a phoned reminder (48%) also were similar. However, study 3 focused on a mailed reminder on the referring physician's letterhead sent by the mammography facility versus no reminder, and a significant increase in return rates resulted (47% versus 19%). We present the implications of this pattern of findings and discuss the need for a larger trial of the physician-endorsed reminder.

Changes in health behaviors of older adults: the San Diego Medicare Preventive Health Project

BACKGROUND

This study presents behavioral outcomes at 1-year follow-up from a preventive services intervention trial with Medicare beneficiaries.

METHODS

The health promotion package consisted of goal setting and counseling based on a health risk appraisal and a series of eight educational sessions. All subjects completed a health risk appraisal questionnaire immediately prior to the intervention and 1 year later; this served as the dependent measure.

RESULTS

Results indicated that there were significant, positive changes in intervention subjects in activity level and selected nutrition behaviors relative to control subjects. The strengths and weaknesses of a broad-based approach to intervention are discussed.

Evaluation of a worksite mammography program

We implemented a one-year program to promote mammography for employees at one campus of a state university system; a second campus served as a comparison site. Measurement cohorts, who were surveyed immediately before and after the intervention, had been randomly selected at each site; all of the subjects had insurance coverage that included mammographic screening. The intervention consisted of print media, on-site workshops, and incentive drawings. Results indicated that mammography rates increased significantly at both sites, for both those 40-49 years of age and for those > or = 50 years of age. The rate increases for the 40- to 49-year-old age group at the intervention and control sites were 17.6% and 13.6%, respectively, and, for the > or = 50-year-old age group, 11.9% and 6.3%. However, the differential changes in rates between the sites were not significant for either age category. The intervention was perceived positively by the intervention site cohort, and participation in the various components was encouraging. We present suggestions for future research on this topic.

The effects of an instructional audiotape on breast self-examination proficiency

This study evaluated the effects of a refresher instructional audiotape on breast self-examination (BSE) proficiency 6 months after BSE had been trained to criteria. Subjects (n = 54), who were undergraduate women, were trained in group sessions to perform BSE competently. Subjects were randomly assigned to one of two "maintenance" groups: tape or no tape. Tape-group subjects received a BSE tape at the end of their training session. Subjects in both groups received monthly mailed prompts. At 6 months posttraining, subjects were videotaped in a clinic environment while performing BSE and 10 components of the exam subsequently were evaluated. The results indicated that tape-group subjects showed significantly better performance than controls on four components, including amount of breast area examined. The tape had no effect on BSE frequency. The tape strategy may be valuable in maintaining proficiency once BSE is trained.

Predictors of participation in a school-based anti-tobacco activism program

This study investigated the predictors of participation in a school-based, anti-tobacco activism program. Subjects in this study consisted of 7th grade students participating in the intervention component of Project S.H.O.U.T., a tobacco use prevention program in San Diego County, California. In the activism component, a newsletter containing an activism contest was distributed to each student. Small prizes were awarded to contest winners at each school. "Activism" included letter and petition writing, anti-tobacco poster contests, merchant education, peer surveys and magazine subscription cards. A total of 170 students participated in the activities, with 81.1 percent participating two or more times. Of those who participated, 59 percent were female and 60 percent were White, non-Hispanic. Two sets of logistic analyses were conducted. Variables such as SES, gender, ethnicity, friends' tobacco use and parental tobacco use were used to predict participation in activism activities. The choice of variables was intended to provide information regarding activism participation in reference to known tobacco risk factors. Results of the first analysis indicated that students with a higher SES, and in an urban vs. rural location were more likely to participate in the activism activities. The second analysis used the same set of characteristics to predict "ever-use" of tobacco. Results of this analysis indicated that male gender, low grades, White, non-Hispanic ethnicity, friends' and parents' tobacco use were positively associated with tobacco experimentation.

Income allowance policies of state Medicaid agencies as work incentives or disincentives for ICF/MR residents

Results of a survey of six Midwestern states demonstrated that although some state Medicaid agencies have had work incentive policies for ICF/MR residents for some time, others continue to utilize policies that are a disincentive to work. Policy changes toward employment incentives in state Medicaid agencies should improve work opportunities for workers with mental retardation at little expense to the government.

Breast and cervical cancer screening in older women: the San Diego Medicare Preventive Health Project

BACKGROUND. This study presents rates and correlates of cancer screening, including mammography, clinical breast exam, breast self-examination, and Pap tests, in older women. Age was the predictor of main interest. RESULTS. Among a sample of female Medicare beneficiaries ages 65 and older, who were members of a health maintenance organization, there was a significant, inverse relationship between age and mammography adherence, while controlling for health status, physician utilization, education, and income. The proportions of subjects ages 65-74 and 75+ never having had a mammogram were 17 and 32%, respectively, and the proportions having had annual mammograms were 40 and 28%, respectively. Pap test frequency showed a trend toward an inverse relationship with age, controlling for demographic and health-related variables. In the youngest age group (65-69), 52% had annual Pap tests, whereas in the oldest group (80+), only 36% had annual Pap tests. Age did not predict frequency of clinical breast exam, and the relationship of age to breast self-examination was inconclusive. The role of the physician in promoting cancer screening is discussed.

Evaluation of a media-based mammography program

Reports indicate that only 15%-20% of women 50 years of age and older have had a mammogram. To promote screening mammography, the San Diego County Unit of the American Cancer Society sponsored a community-wide program that featured (1) discounted mammograms through participating clinics, (2) program promotion through television news, and (3) availability of a phone bank for obtaining referrals for mammography. Pre- and postintervention random sample phone surveys indicated that women's intentions to obtain a mammogram increased significantly after the media campaign, particularly in those aware of the program. Women's intentions after the media campaign predicted mammography compliance in the following year. A total of 3,102 women received mammograms directly through the program, with a "suspicious finding" rate of 4%. Participant satisfaction with the program was high.

Mammography knowledge and intentions among insured women

METHOD. A survey was conducted among 1,113 randomly selected insured state university employees to evaluate knowledge of the American Cancer Society mammography guidelines, awareness of insurance coverage for screening mammograms, previous guideline adherence, and future mammography intentions.

RESULTS

The survey, which included two mailings with follow-up phone cells of nonresponders, had a refusal rate of 6%. Respondents were relatively more likely to know the guideline for older age groups; 77% knew the guidelines for women 50+. Over one-third of the responders were not aware that their insurance policy covered screening mammograms. For women who had never had a mammogram, insurance knowledge was significantly related to intentions to have a mammogram in the future. Previous screening adherence, as well as future intentions, was positively related to the age of the respondent. The results are contrasted with those of previous studies, and the implications for the content of future breast cancer screening campaigns are discussed.

The effects of co-worker-delivered prompts on breast self-examination frequency

In this study, we evaluated the efficacy of co-worker-delivered reminders to perform breast self-examination (BSE). Before participating in a BSE training workshop, subjects (n = 36) were randomly assigned in pairs (of co-workers who registered together) to one of two experimental conditions: contract or control. Subjects in the contract condition, after discussing specific prompting strategies as part of a "buddy system" in their workshop, contracted to prompt their designated peers at least once a month for six months following the workshop. In addition, subjects in both conditions received mailed prompts monthly. We assessed BSE adherence and prompting behaviors in retrospective interviews. Results indicated that subjects in both conditions significantly increased BSE frequency above pre-workshop levels. However, the magnitude of this increase did not differ between conditions. A process evaluation indicated that the control group pairs were similar to the contract group pairs in their prompting behavior.

The effects of social demand on breast self-examination self-report

The measurement of breast self-examination (BSE) adherence typically relies on verbal self-report. These studies systematically manipulated social demand within a face-to-face interview and examined the effects on self-reported BSE frequency. In Study 1, subjects (n = 37) received either a high-demand or a low-demand preface prior to being asked about BSE practice over the past year. Study 2 (n = 89) was a replication, with the addition of a no-preface (control) condition. Results from Study 1 indicated that although the conditions were comparable on demographic and breast cancer/BSE knowledge variables, the high-demand condition reported a significantly higher number of BSEs than the low-demand condition. An attenuation of this pattern was found in Study 2, with the control condition reporting a frequency between the low demand's and the high demand's reported frequencies. The implications for BSE intervention and prevalence research are discussed.

Long-term smoking status of cardiac patients following symptom-specific cessation advice

Although physicians routinely advise postcardiac event patients to stop smoking, the effect of a modified advice format targeting specific health concerns has not been investigated. Also, no studies of cessation advice with cardiac patients have used biochemical verification of self-reported abstinence. The present study included 48 veterans with a history of smoking and cardiac problems; of these, 31 were smoking and 17 were abstinent at initial assessment. Alveolar carbon monoxide (COa) levels served to: (1) augment cessation advice by demonstrating smoking risks and cessation benefits specific to cardiac patients and (2) verify self-report. At 12 months followup, following cessation advice, 18% of the abstinent subjects had resumed smoking while none of the smokers had become abstinent. Those who maintained abstinence significantly increased their estimates of the contribution of smoking to their cardiac problems whereas those who continued to smoke showed no change.

Promoting mammography appointment making

Compliance with screening mammography recommendations is low. Consequently, a community-wide program offering $50 mammograms at 29 radiology facilities was implemented. The program was promoted on a local TV news show and women 35 years and older were instructed to call a referral phone bank. If the caller met eligibility criteria, she received an information packet that assigned her to one of the facilities; it was her responsibility to schedule the appointment. At one facility, a strategy to increase compliance was piloted using a controlled design. Of the 96 subjects assigned to that clinic, 47 received an incentive coupon combined with a prompt in addition to the information packet and 49 received no coupon. The coupon was redeemable for a nutrition information kit when the subject appeared at her appointment. Results indicated that the incentive group had a significantly higher rate of appointment making than the control group (81 vs. 59%). Of subjects in both groups who made appointments, nearly 100% kept them. The intervention appeared to be cost-effective with a self-referred sample.

Community-based health promotion: a survey of churches, labor unions, supermarkets, and restaurants

A telephone survey of randomly-sampled churches, labor unions, supermarkets and restaurants was conducted in San Diego, California to determine the level of health promotion activities offered for members and customers. Nearly two-thirds of the churches offered health promotion programs, the bulk of which were single educational sessions. A similar proportion of labor unions reported programs, and most of them consisted of the distribution of materials and single-session group meetings. About one-third of the supermarkets reported activities, with most of these being the distribution of brochures. Similarly, about one-third of restaurants reported programs, which primarily consisted of the enforcement of no-smoking regulations. Very few organizations evaluated programs or desired assistance from health professionals. It was concluded that while secular health promotion programs are common and are available to many people, their quality and effectiveness are unknown. These findings present a challenge for public health professionals and agencies.