Using Key Informants to Evaluate Barriers to Education and Acceptability of the HPV Vaccine in Tanzania: Implications for Cancer Education

Cervical cancer is the third most common cancer globally, with high mortality when left untreated. In sub-Saharan Africa, Tanzania shows higher incidence rates of cervical cancer at 59.1 per 100,000 compared with the global average of 13.1 per 100,000. The HPV vaccine has been shown to successfully reduce HPV infection and is recommended for school-age girls and boys in the USA. Understanding the acceptability of the HPV vaccine and the barriers to vaccination is important for ensuring that HPV vaccination programs are successful. In 2016, Tanzania began school-based HPV vaccination programs in cities and towns surrounding Dar es Salaam, the largest city in Tanzania. Successful implementation of HPV vaccination programs in Dar es Salaam relies on overcoming barriers to vaccination. This study focused on primary school teachers as key informants to assess these barriers. Participants were given a short survey and then asked to participate in focus group sessions. Overall, knowledge of HPV was low, with only 37% of participants having heard of the HPV and only 28.6% having heard of the HPV vaccine. Teachers had a very positive response to the HPV educational sessions. Of the teachers who completed the questionnaires, 100% of them were willing to speak with their school parents about the HPV vaccine and 99% would recommend this vaccine to parents. This study has significant implications for national cancer prevention vaccination programs, not only in Tanzania, but also in other countries starting HPV vaccination as teachers are potentially important advocates for immunization and other childhood health initiatives.

Experiential Learning in Career Development

This manuscript demonstrates the learning experiences of graduate public health students through mentored field research in cancer epidemiology and cancer prevention over the past 13 years. The program has been funded through an R25 grant from the National Cancer Institute (NCI) since 2006 and has supported nearly 200 students from different universities in the USA. Included are data on student recruitment, selection, mentorship, and evaluation of research training in US minority settings as well as foreign countries. Examples of students' learning experiences and life-long skills that shaped students' careers are presented. The insights that fostered the experiential learning idea among key leaders at the NCI Cancer training branch have proven to be sound.

Mentoring in Global Cancer Research Training

This manuscript illustrates general concepts of mentoring in low- and middle-income countries (LMICs). The focus of this manuscript is on public health research based on our experiences with the Cancer Epidemiology Education in Special Populations (CEESP) Program which is further illustrated in this Supplement. While the CEESP Program provides research training in global and US minority settings, this manuscript is focused on the global aspects of the program. We describe the process of selecting students into the CEESP Program, the process of mentoring them, and the preparation of the mentoring sites. We emphasize the review of the CEESP mentors in LMICs and put forward recommendations for enhancing their mentoring skills and disseminating the experience to other US and global institutions interested in global cancer education.

Global Aspects of the Cancer Epidemiology Education in Special Populations (CEESP) Program

This manuscript provides a brief overview of the global aspects of the Cancer Epidemiology Education in Special Populations (CEESP) Program. The overview illustrates program history, aims, progress, evaluation, and dissemination. This manuscript sets the stage for the CEESP manuscripts included in this supplement that illustrate in the program infrastructure, mentoring, the student experiences, and unique features of students for achieving success. In this manuscript, we briefly outline some of the dissemination examples that resulted from utilizing the CEESP infrastructure, as outlined in some of the articles reporting on global research training sites from Egypt, Morocco, Oman, and Tanzania.

Lessons learned, Summary, Challenges, and Recommendations

In this final section, we summarize the different manuscripts included in his Supplement and outline the lessons learned. We also elaborate on the common educational challenges reported in the included articles and the possible recommendations for future global cancer education.

Developing and Maintaining a Global Research Training Infrastructure for Cancer Education

This manuscript illustrates the 20-year process of establishing research sites that have been developed and maintained by the authors in collaboration with oncology colleagues at institutions in low- and middle-income countries. This infrastructure has been created for research training of US public health graduate students over the past 20 years for the Cancer Epidemiology Education in Special Populations (CEESP) Program funded by the US National Cancer Institute (R25 CA112383). We describe the history and resources that were utilized for developing and maintaining the research training infrastructure. We then define the elements needed for selecting and nurturing these global sites for education and research training of students. The elements include data and field resources, patient population, facilities for cancer management, laboratory resources, academic collaborators, and population parameters and cultural characteristics. These elements have also been essential in our US domestic training sites. We then emphasize the strengths and limitations of our global sites. Finally, we elaborate on our learning experience over the past 20 years. We believe that the material provided in this manuscript will serve as a useful toolkit for faculty, mentors, students, and trainees interested developing and/or utilizing research sites for cancer epidemiology and cancer prevention and control research training programs in global settings.

Field Research Experience of Medical Students: Learning and Translation from Global to Underserved US Settings

While most medical schools in the USA provide opportunities for global health experiences, global health education is not included consistently or emphasized adequately in many medical school curricula. The City University of New York Medical School (CSOM) has a mission to educate and train students who are traditionally underrepresented in medicine to practice primary care in medically underserved communities in New York. This manuscript documents the experience of the CSOM in expanding global health education by introducing a new global health cancer training program, partnering with clinicians at the Ocean Road Cancer Institute (ORCI) in Tanzania. This manuscript illustrates the following points: (1) the CSOM curriculum that focuses on community health and social medicine; (2) the process by which students learn by developing research proposals for global cancer; (3) the field research experience and lessons learned; (4) learning about cancer and medicine in a developing country; and (5) lessons learned for translation from global to domestic underserved populations. We also suggest a checklist for future students interested in pursuing global cancer education and research, and recommendations for maximizing learning and career development of students interested in global cancer research and its application to underserved populations in the USA.

Needs for Cancer Education In Oman Based on the Breast Cancer Screening Program

Most breast cancers in Oman are diagnosed at advanced stages and therefore early detection is important. The Oman Cancer Association (OCA) initiated a mobile mammography program in 2009, but no studies have evaluated its impact. This study aimed at estimating the proportion and predictors of OCA-screened women who had repeated mammography (adherence) and the sensitivity and specificity of the program. Demographic, screening, diagnosis, and treatment data of 13,079 women screened in the OCA mammography clinic from 2009 to 2016, and medical records of all breast cancer patients seen at Royal and Sultan Qaboos University hospitals during the same period were retrieved. Logistic regression analysis was conducted to identify predictors of adherence. A total of 8278 screened women over age 42 years (median age of 50 ± 8 years) were included in the study. Only 18% of initially negative screened women were compliant with recommended subsequent screening. Predictors of adherence included age (50-69 years), family history of cancer, family history of breast cancer, and breast self-examination. The overall cancer detection rate was 4.1/1000 screened women. Positive predictive value of screening was 4.7% with a sensitivity rate of 53% and specificity of 92%. This study showed a low mammography adherence among previously screened women. The study revealed low sensitivity, high specificity, and an acceptable cancer detection rate. Future programs should focus on improving data collection of screened women, maintaining the linkage of databases of screening and treatment clinics, and developing guidelines for breast cancer screening in Oman. The recommendations based on the study results should be incorporated into future professional, patient, and public cancer education programs.

Quantifying the under-estimation of cervical Cancer in remote regions of Tanzania

Background

Cervical cancer is the most common cancer among women in Sub-Saharan countries, including Tanzania. While early detection and diagnosis are available in some parts of this large country, radiotherapy has been only available at the Ocean Road Cancer Institute (ORCI), in the capital city of Dar es Salaam and is just starting in a few regions.

Methods

The objective of this study was to compare the observed incidence of cervical cancer for the two remote regions of Mwanza in western Tanzania and Mbeya in southern Tanzania, based on their patients treated at the ORCI from 2011 to 2014. Results: The number patients referred and treated at ORCI were (120 from Mwanza, and 171 from Mbeya, representing 24.6 and 32.8% of the patients histopathologically confirmed in the two sites, respectively. The results showed significant underestimation of cervical cancer in the two regions. The vast majority of patients who were histopathologically-confirmed in their local regions (73.92% from Mwanza and 65.1% from Mbeya), but did not receive the needed radiotherapy treatment at the ORCI. The estimated incidence for the two regions based on the number of patients treated at the ORCI were underestimated by 53.9% for Mwanza and 68.9% for Mbeya.

Conclusions

Local establishment of radiotherapy treatment facilities in remote regions in Tanzania and similar other low-income countries is essential for providing effective treatment and improving survival of diagnosed cervical cancer patients. Linkage between the records of local remote hospitals and the main cancer treatment center in the capital city can also help support the emerging the population-based cancer registry at ORCI.

Changing Incidence of Uterine Cancer in Rural Egypt: Possible Impact of Nutritional and Epidemiologic Transitions

PURPOSE

Uterine cancer is a top-ranking women's cancer worldwide, with wide incidence variations across countries and by rural and urban areas. Hormonal exposures and access to health care vary between rural and urban areas, globally. Egypt has an overall low incidence of uterine cancer but variable rural and urban lifestyles. Are there changes in the incidence of uterine cancer in rural and urban areas in middle-income countries such as Egypt? No previous studies have addressed this question from a well-characterized and validated population-based cancer registry resource in middle-income countries. The aim of this study was to explore the differences in clinical and demographic characteristics of uterine cancer over the period of 1999 to 2010 in rural and urban Gharbiah province, Egypt.

METHODS

Data were abstracted for all 660 patients with uterine cancer included in the Gharbiah Population-based Cancer Registry. Clinical variables included tumor location, histopathologic diagnosis, stage, grade, and treatment. Demographic variables included age, rural or urban residence, parity, and occupation. Crude and age-adjusted incidence rates (IRs) and rate ratios by rural or urban residence were calculated.

RESULTS

No significant differences were observed in most clinical and demographic characteristics between rural and urban patients. The age standardized IR (ASR) was 2.5 times higher in urban than in rural areas (6.9 and 2.8 per 100,000 in urban and rural areas, respectively). The rate ratio showed that the IR in urban areas was 2.46 times the rate in rural areas.

CONCLUSION

This study showed that the disease IR in rural areas has increased in the past decade but is still low compared with the incidence in urban areas in Egypt, which did not show a significant increase in incidence. Nutritional transitions, obesity, and epidemiologic and lifestyle changes toward Westernization may have led to IRs increasing more in rural than in urban areas in Egypt. This pattern of increasing incidence in Egypt, which used to have a low incidence of uterine cancer, may appear in other middle-income countries that experience emerging nutritional and epidemiologic transitions. The rate of uterine cancer in urban areas in Gharbiah is almost similar to the corresponding rates globally. However, the rate in rural areas in this population has increased over the past decade but is still lower than the corresponding global rates. Future studies should examine the etiologic factors related to increasing rates in rural areas and quantify the improvement in rural case finding.

Barriers to Cervical Cancer Screening in Burkina Faso: Needs for Patient and Professional Education

Cervical cancer is among the leading causes of cancer deaths for women in low-income African countries, such as Burkina Faso. Given that cervical cancer is a preventable disease through early detection and vaccination, this study aimed at understanding the barriers to cervical cancer early detection in Ouagadougou, the capital city of Burkina Faso. Women seeking screening and treatment for cervical cancer (n = 351) during the period of May-August 2014, at the Yalgado Ouedraogo University Hospital, were interviewed about their knowledge, attitudes, and practices toward cervical cancer. Interview questions elicited information about sociodemographic of participants, history of screening, knowledge of cervical cancer, and attitudes toward cervical screening. Scores were assigned to responses of questions and knowledge, and tertitles of distributions were used for comparison. A multivariate logistic regression was performed to predict cervical screening. Study participants were relatively young (37.5 ± 10.7 years) and predominately resident of urban areas (83.8 %), and over half had no or less than high school education. Over 90 % of participants had heard about cervical cancer, and about 55 % of them had intermediate-level knowledge of the disease, its screening, and/or risk factors. Knowledge level was lower among rural than urban residents. Predictors of screening included higher level of education (odds ratio (OR) = 2.2; 95 % confidence interval (CI) 1.48-3.23), older age (OR = 1.1; 95 % CI 1.06-1.12), higher socioeconomic standard (SES) (OR = 1.5; 95 % CI 1-2.37), urban residence (OR = 2.0; 95 % CI 1.19-3.25), encouragement for screening by a health care worker (1.98; 95 % CI 1.06-3.69), and employment (OR = 1.9; 95 % CI 1.13-3.11). Low awareness and socioeconomic barriers lead to underutilization of screening services of women. Motivation and education by healthcare workers are important factors for increasing screening rates. Organized patient and professional education programs in gynecologic services are warranted for improving screening in Burkina Faso and other low-resource countries in Africa.

Short- and Long-Term Outcomes of Student Field Research Experiences in Special Populations

Global health education and training of biomedical students in international and minority health research is expending through U.S. academic institutions. This study addresses the short- and long-term outcomes of an NCI-funded R25 short-term summer field research training program. This program is designed for MPH and Ph.D. students in cancer epidemiology and related disciplines, in international and minority settings (special populations) in a recent 7-year period. Positive short-term outcome of 73 students was measured as publishing a manuscript from the field research data and having a job in special populations. Positive long-term outcome was measured as having a post-doc position, being in a doctoral program, and/or employment in special populations at least 3 years from finishing the program. Significant factors associated with both short- and long-term success included resourcefulness of the student and compatibility of personalities and interests between the student and the on-campus and off-campus mentors. Short-term-success of students who conducted international filed research was associated with visits of the on-campus mentor to the field site. Short-term success was also associated with extent of mentorship in the field site and with long-term success. Future studies should investigate how field research sites could enhance careers of students, appropriateness of the sites for specific training competencies, and how to maximize the learning experience of students in international and minority research sites.

Clinical and epidemiologic variations of esophageal cancer in Tanzania

AIM

To estimate the incidence of esophageal cancer (EC) in Kilimanjaro in comparison to other regions in Tanzania.

METHODS

We also examined the clinical, epidemiologic, and geographic distribution of the 1332 EC patients diagnosed and/or treated at Ocean Road Cancer Institute (ORCI) during the period 2006-2013. Medical records were used to abstract patient information on age, sex, residence, smoking status, alcohol consumption, tumor site, histopathologic type of tumor, date and place of diagnosis, and type and date of treatment at ORCI. Regional variation of EC patients was investigated at the level of the 26 administrative regions of Tanzania. Total, age- and sex-specific incidence rates were calculated.

RESULTS

Male patients 55 years and older had higher incidence of EC than female and younger patients. Of histopathologically-confirmed cases, squamous-cell carcinoma represented 90.9% of histopathologic types of tumors. The administrative regions in the central and eastern parts of Tanzania had higher incidence rates than western regions, specifically administrative regions of Kilimanjaro, Dar es Salaam, and Tanga had the highest rates.

CONCLUSION

Further research should focus on investigating possible etiologic factors for EC in regions with high incidence in Tanzania.

Observed and expected incidence of cervical cancer in lusaka and the southern and Western provinces of Zambia, 2007 to 2012

OBJECTIVES

Cervical cancer is increasing but underestimated in developing countries. We calculated the observed and expected incidence of cervical cancer in Lusaka and Southern and Western provinces of Zambia.

METHODS/MATERIALS

Data for 2007 to 2012 were obtained for the 3 provinces. Data included age, residence, year of diagnosis, marital status, occupation, human immunodeficiency virus (HIV), stage, radiotherapy, and chemotherapy. Expected incidence in Southern and Western provinces was calculated based on observed incidence for Lusaka province, adjusting for HIV.

RESULTS

Crude and age-standardized incidence rates (ASRs) in Lusaka were 2 to 4 times higher than incidence in the other 2 provinces. Lusaka had a rate of 54.1 per 10(5) and ASR of 82.1 per 10(5) in the age group of 15 to 49 years. The Southern province had a rate of 17.1 per 10(5) and ASR of 25.5 per 10(5); the Western province had a rate of 12.3 per 10(5) and ASR rate of 17.2 per 10(5). The observed cervical cancer incidence rates in the Southern and Western provinces were lower than the rate in Lusaka, possibly because of the uncertainty of underreporting/underdiagnosis or actual lower risk for reasons yet unclear. The HIV seroprevalence rates in patients from the 3 provinces were 46% to 93% higher than seroprevalence in the respective general populations.

CONCLUSIONS

Cervical cancer is significantly underestimated in Zambia, and HIV has a significant role in pathogenesis. Future studies should establish methods for case ascertainment and better utilization of hospital- and population-based registries in Zambia and other similar developing countries.

Most women diagnosed with cervical cancer by a visual screening program in Tanzania completed treatment: evidence from a retrospective cohort study

Background

Visual inspection with acetic acid (VIA) to identify and treat pre-cancerous lesions is effective for cervical cancer prevention. Screening programs also facilitate screening and diagnosis of invasive cancers that must be referred for radiation therapy or chemotherapy. This study compared characteristics of women diagnosed with invasive cervical cancer by a VIA screening program who did and did not follow up for treatment and who did and did not complete treatment at the Ocean Road Cancer Institute (ORCI), Dar es Salaam, Tanzania.

Methods

We conducted a retrospective cohort study of ORCI screening referrals from the period November 2002 to June 2011. Women referred for treatment of invasive disease (n = 980) were identified from an existing database of all women attending the screening clinic during this period (n = 20,131) and matched to a dataset of all cervical cancer patients attending ORCI in this period (n = 8,240). Treatment information was abstracted from patient records of women who followed up. Records of a random sample (n = 333) of unscreened patients were reviewed for disease stage.

Results

Of the 980 women referred women, 829 (84.6%) sought treatment. Most of those women (82.8%) completed their prescribed radiation. Lower disease stage, having a skilled occupation, residence in Dar es Salaam, and younger age were independently associated with loss to follow-up. Higher disease stage, residence in Dar es Salaam, older age, and later year of first treatment appointment were independently associated with incomplete treatment among those who followed up. Significantly more screened women had stage 1 disease (14.0%) than unscreened women (7.8%).

Conclusions

Most women referred from the screening clinic completed treatment for their cancer at ORCI. Some of those lost to follow-up may have sought treatment elsewhere. In most cases, the screening clinic appears to facilitate diagnosis and treatment, rather than screening, for women with invasive cervical cancer.

Characterizing inflammatory breast cancer among Arab Americans in the California, Detroit and New Jersey Surveillance, Epidemiology and End Results (SEER) registries (1988-2008)

Introduction

Inflammatory breast cancer (IBC) is characterized by an apparent geographical distribution in incidence, being more common in North Africa than other parts of the world. Despite the rapid growth of immigrants to the United States from Arab nations, little is known about disease patterns among Arab Americans because a racial category is rarely considered for this group. The aim of this study was to advance our understanding of the burden of IBC in Arab ethnic populations by describing the proportion of IBC among different racial groups, including Arab Americans from the Detroit, New Jersey and California Surveillance, Epidemiology and End Results (SEER) registries.

Methods

We utilized a validated Arab surname algorithm to identify women of Arab descent from the SEER registries. Differences in the proportion of IBC out of all breast cancer and IBC characteristics by race and menopausal status were evaluated using chi-square tests for categorical variables, t-tests and ANOVA tests for continuous variables, and log-rank tests for survival data. We modeled the association between race and IBC among all women with breast cancer using hierarchical logistic regression models, adjusting for individual and census tract-level variables.

Results

Statistically significant differences in the proportion of IBC out of all breast cancers by race were evident. In a hierarchical model, adjusting for age, estrogen and progesterone receptor, human epidermal growth receptor 2, registry and census-tract level education, Arab-Americans (OR=1.5, 95% CI=1.2,1.9), Hispanics (OR=1.2, 95% CI=1.1,1.3), Non-Hispanic Blacks (OR=1.3, 95% CI=1.2, 1.4), and American Indians/Alaskans (OR=1.9, 95% CI=1.1, 3.4) had increased odds of IBC, while Asians (OR=0.6, 95% CI=0.6, 0.7) had decreased odds of IBC as compared to Non-Hispanic Whites.

Conclusions

IBC may be more common among certain minority groups, including Arab American women. Understanding the descriptive epidemiology of IBC by race may generate hypotheses about risk factors for this aggressive disease. Future research should focus on etiologic factors that may explain these differences.

Cancer prevention health services research: an emerging field

In October 2009, The University of Texas MD Anderson Cancer Center hosted a symposium, "Future Directions in Cancer Prevention and Control: Workforce Implications for Training, Practice, and Policy." This article summarizes discussions and an Internet and literature review by the symposium's Health Services Infrastructure Working Group. We agree on the need for the recognition of Cancer Prevention Health Services Research (CP-HSR) as a unified research field. With advances in cancer screening and increased emphasis on preventive services under healthcare reform, there is a growing need for investigators with both cancer prevention and HSR expertise to consider the comparative effectiveness of cancer screening methods, the cost-effectiveness of early detection technologies, and the accessibility of preventive care for individuals at risk of cancer. Defining CP-HSR as a field will provide investigators with credibility and will serve to draw more researchers to the field. Increasing funding to train individuals in CP-HSR will be important to help meet the anticipated demand for investigators with this specialized multidisciplinary expertise.

The future of the cancer prevention workforce: why health literacy, advocacy, and stakeholder collaborations matter

In considering the role of the cancer prevention workforce in meeting the nation's future health care needs, it is vital to address the considerable gaps in information, communication, training, professional development, roles, and levels of collaboration among diverse disciplines, stakeholders, and constituencies. As part of an October 2009 symposium at The University of Texas MD Anderson Cancer Center entitled "Future Directions in Cancer Prevention and Control: Workforce Implications for Training, Practice, and Policy," the Health Policy and Advocacy Working Group was convened to discuss barriers to closing these gaps. Three major themes emerged from the group's deliberations and are discussed here: (1) the role of critical health literacy and evidence-based collaborations in cancer prevention education, research, and practice; (2) the implications of health advocacy for policy development and clinical and public health practice; and (3) culturally and linguistically appropriate cancer prevention programs and information within advocacy/workforce collaborations. Mechanisms for addressing these gaps are presented.

Career development needs assessment in cancer prevention and control: focus on research in minority and international settings

This study was conducted as a needs assessment to inform the development of an educational program designed to provide mentorship and skills supporting careers in cancer research, with a focus on domestic minority populations and international settings. The objectives were to determine: (1) the level of interest among trainees in careers in cancer research and (2) preferences and constraints constituted by potential components, features, and duration of the proposed extramural training program. The target populations were participants and directors of federal training programs in cancer research, specifically (1) trainees in the NCI-K01, K07, and K08 programs, as well as the Department of Defense (DoD) Breast and Prostate Control Programs and (2) PIs of NCI R25 training programs and federally designated Comprehensive Cancer Centers. We developed, piloted, and administered electronically a survey to elicit perspectives of trainees' career development needs and preferences. Response rates from each training group exceeded 65%, with the exception of the K08 trainees (49%). The proportion of cancer research trainees who are interested in careers that include research on US minority groups was 70% of K01 trainees, 72% of K07 trainees, 45% of K08 trainees, and 75% of DoD trainees. A substantial percent of these trainees indicated their plans also include cancer research in international settings: 60% of K01s; 50% of K07s, 42% of K08s, and 87% of DoD trainees. Trainees identified substantial interest in a program that would provide the following: mentoring, manuscript writing skills, collaborative research in special populations, financial support, and focused modular courses. This study offers encouraging evidence of interest which focused in extramural education to augment skills facilitating cancer-related research in special populations.

Association between a functional polymorphism (-1195T>C) in the IGFBP5 promoter and head and neck cancer risk

BACKGROUND

To the best of our knowledge, no studies to date have evaluated roles of insulin-like growth factor binding protein 5 (IGFBP5) polymorphisms in risk of squamous cell carcinoma of the head and neck (SCCHN).

METHODS

A hospital-based study of 1082 patients with SCCHN and 1120 cancer-free controls was performed to investigate associations between 2 functional polymorphisms, -1195T>C and -709G>C, in the IGFBP5 promoter region and SCCHN risk.

RESULTS

We demonstrated that the transcription factor, activator protein 1 (AP-1), differentially bound to T or C variants at -1195 in the promoter to regulate the IGFBP5 promoter activity and that the C variant genotypes were associated with deferential risk of late-stage SCCHN, compared to the TT genotype, particularly for human papillomavirus (HPV)-unrelated sites (adjusted odds ratio [OR], 2.21; 95% confidence interval [CI], 1.19-4.11 for CC vs TT).

CONCLUSION

The IGFBP5 -1195T>C polymorphism is functional and may potentially be a biomarker for susceptibility to late-stage SCCHN.

Genetic variations of the PI3K-AKT-mTOR pathway and clinical outcome in muscle invasive and metastatic bladder cancer patients

The phosphoinositide-3 kinase (PI3K)-AKT- mammalian target of rapamycin (mTOR) pathway is an important cellular pathway controlling cell growth, tumorigenesis, cell invasion and drug response. We hypothesized that genetic variations in the PI3K-AKT-mTOR pathway may affect the survival in muscle invasive and metastatic bladder cancer (MiM-BC) patients. We conducted a follow-up study of 319 MiM-BC patients to systematically evaluate 289 single-nucleotide polymorphisms (SNPs) of 20 genes in the PI3K-AKT-mTOR pathway as predicators of survival. In multivariate Cox regression, AKT2 rs3730050, PIK3R1 rs10515074 and RAPTOR rs9906827 were significantly associated with survival. In combined analysis, we found a cumulative effect of these three SNPs on survival. With the increasing number of unfavorable genotypes, there was a significant trend of higher risk of death in multivariate Cox regression (P for trend <0.001) and shorter median survival time in Kaplan-Meier estimates (P log rank <0.001). This is the first study to evaluate the role of germ line genetic variations in the PI3K-AKT-mTOR pathway genes as predictors of MiM-BC clinical outcomes. These findings warrant further replication in independent populations and may provide information on disease management and development of target therapies.

Research training of students in minority and international settings: lessons learned from cancer epidemiology education in special populations

This article describes the development and evaluation of an NCI-sponsored short-term summer cancer research education program. The study questions examined: the feasibility of conducting a cancer education program in special populations at multiple US and international field sites for masters students; the merit and worth that students and faculty attribute to the program; and students' scholarly and cancer-related career outcomes. Developing a new curriculum, increasing the pool of mentors, utilizing and increasing the number of field sites, and program dissemination were also evaluated. Evidence of the program's success included students' completion of field experiences at multiple sites and their subsequent 70% project-related publication rate, with 79% of trainees reporting themselves as likely to pursue future cancer-related careers. Evaluation-guided future plans for the program include implementing faculty development to further enhance the program outcomes.

Genetic variations in PI3K-AKT-mTOR pathway and bladder cancer risk

Genetic variations in phosphoinositide-3 kinase (PI3K)-AKT-mammalian target of rapamycin (mTOR) pathway may affect critical cellular functions and increase an individual's cancer risk. We systematically evaluate 231 single-nucleotide polymorphisms (SNPs) in 19 genes in the PI3K-AKT-mTOR signaling pathway as predictors of bladder cancer risk. In individual SNP analysis, four SNPs in regulatory associated protein of mTOR (RAPTOR) remained significant after correcting for multiple testing: rs11653499 [odds ratio (OR): 1.79, 95% confidence interval (CI): 1.24-2.60, P = 0.002], rs7211818 (OR: 2.13, 95% CI: 1.35-3.36, P = 0.001), rs7212142 (OR: 1.57, 95% CI: 1.19-2.07, P = 0.002) and rs9674559 (OR: 2.05, 95% CI: 1.31-3.21, P = 0.002), among which rs7211818 and rs9674559 are within the same haplotype block. In haplotype analysis, compared with the most common haplotypes, haplotype containing the rs7212142 wild-type allele showed a protective effect of bladder cancer (OR: 0.83, 95% CI: 0.70-0.97). In contrast, the haplotype containing the rs7211818 variant allele showed a 1.32-fold elevated bladder cancer risk (95% CI: 1.09-1.60). In combined analysis of three independent significant RAPTOR SNPs (rs11653499, rs7211818 and rs7212142), a significant trend was observed for increased risk with an increase in the number of unfavorable genotypes (P for trend <0.001). Compared with the subjects without any of the unfavorable genotypes, those carrying all three unfavorable genotypes showed a 2.22-fold (95% CI: 1.33-3.71) increased bladder cancer risk. This is the first study to evaluate the role of germ line genetic variations in PI3K-AKT-mTOR pathway as cancer susceptibility factors that will help us identify high-risk individuals for bladder cancer.

Sociodemographic characteristics, health beliefs, and the accuracy of cancer knowledge

BACKGROUND

Recent studies have found that knowledge about cancer prevention and treatment differs across ethnic and socioeconomic status (SES) backgrounds, which could directly impact our decisions to engage in protective health behaviors. In this study, we examined sociodemographic-based differences in cancer knowledge and health beliefs and examined differences in the accuracy of the cancer knowledge based on health beliefs.

METHODS

Cross-sectional surveys were conducted between July 1995 and March 2004 on adult, healthy, cancer-free control participants (N = 2074; 50% male) enrolled into a molecular epidemiological case-control study. Most were non-Hispanic white, 14% were African American, and 8% were Hispanic. Participants were personally interviewed on 6 items assessing health beliefs and 10 items assessing cancer knowledge.

RESULTS

Unadjusted differences in cancer knowledge were observed by gender, age, ethnicity, household income, educational attainment, and smoking status. After adjusting for the other sociodemographic characteristics, women had more accurate knowledge than men, the accuracy of knowledge increased with higher educational attainment and annual household income, and never smokers had more accurate knowledge than ever smokers (P < .01 for all). Moreover, accurate cancer knowledge was associated with protective health beliefs; eg, the belief that changing health habits was worthwhile was associated with more accurate knowledge.

CONCLUSIONS

Results emphasize the need to develop health education programs that enhance cancer knowledge among individuals of low SES and foster protective health beliefs.

Genotypes and haplotypes of ERCC1 and ERCC2/XPD genes predict levels of benzo[a]pyrene diol epoxide-induced DNA adducts in cultured primary lymphocytes from healthy individuals: a genotype-phenotype correlation analysis

Benzo[a]pyrene diol epoxide (BPDE)-induced DNA adducts are a risk factor for tobacco-related cancers. Excision repair cross-complementing complementation group 1 (ERCC1) and excision repair cross-complementing complementation group 2/xeroderma pigmentosum D (ERCC2/XPD) participate in the nucleotide excision repair (NER) pathway that removes BPDE-DNA adducts; however, few studies have provided population-based evidence for this association. Therefore, we assayed for levels of in vitro BPDE-induced DNA adducts and genotypes of single-nucleotide polymorphisms (SNPs) of the NER genes ERCC1 (rs3212986 and rs11615) and ERCC2/XPD (rs13181, rs1799793 and rs238406) in 707 healthy non-Hispanic whites. The linear trend test of increased adduct values in never to former to current smokers was statistically significant (P(trend) = 0.0107). The median DNA adduct levels for the ERCC2 rs1799793 GG, GA and AA genotypes were 23, 29 and 30, respectively (P(trend) = 0.057), but this trend was not observed for other SNPs. After adjustment for covariates, adduct values larger than the median value were significantly associated with the genotypes ERCC1 rs3212986TT [odds ratio (OR) = 1.89, 95% confidence interval (CI) = 1.03-3.48] and ERCC2/XPD rs238406AA (OR = 0.64, 95% CI = 0.41-0.99) and rs238406CA (OR = 0.63, 95% CI = 0.45-0.89) compared with their corresponding wild-type homozygous genotypes. The results of haplotype analysis further suggested that haplotypes CAC and CGA of ERCC2/XPD, TC of ERCC1 and CACTC of ERCC2/XPD and ERCC1 were significantly associated with high levels of DNA adducts compared with their most common haplotypes. Our findings suggest that the genotypes and haplotypes of ERCC1 and ERCC2/XPD may have an effect on in vitro BPDE-induced DNA adduct levels.

Works-in-progress: guiding junior scientists through career development applications

BACKGROUND

Career development awards are important to the professional careers of many junior scientists. Designed to launch researchers as independent scientists earlier in their careers, such grants release them from full schedules of teaching and clinical service, protecting their time for research and publishing. Yet few know how best to embark on this crucial endeavor.

METHODS

We pilot tested a faculty-facilitated, biweekly working group for postdoctoral fellows and junior faculty preparing career development applications. Based on their needs and interests, sessions included didactic activities, structured panel discussions, identification of resources, and individual guidance. For those unable to attend regularly, e-mail kept them informed of information shared and lessons learned, as summarized by participants on a rotating basis.

RESULTS

Although success in terms of funded applications is yet unknown, preliminary evaluation suggests high satisfaction among the participants.

CONCLUSIONS

Ultimately, if successful, a low-cost, easy-to-administer working group approach such as this can add great value to any training program.

Time course of the renal functional response to partial nephrectomy: measurements in conscious rats

Previous investigations into the functional responses of the surviving nephrons following reductions in renal mass have been performed largely in anaesthetized animals and have taken little account of how the compensatory changes develop with time. The present study has assessed a method for determining glomerular filtration rate (GFR) in unrestrained, uncatheterized, conscious rats (plasma disappearance of (99m)Tc-diethylenetriamene pentaacetic acid (DTPA)) and has used this method to document the time course of the changes in GFR over a 32 day period following uninephrectomy or 5/6 nephrectomy. Concurrent measurements of excretion rates and of the clearance of lithium (the latter being an index of end-proximal fluid delivery) provided information on changes in overall tubular function and segmental reabsorption. After uninephrectomy, the GFR of the remaining kidney (compared with that of a single kidney of sham-operated animals) increased maximally (by approximately 50%) within 8 days; after 5/6 nephrectomy, the increase in the GFR of the remnant kidney was maximal (at approximately 300%) within 16 days. Overall excretion rates of sodium and potassium were well maintained in partially nephrectomized animals throughout the period of study, while the excretion of water increased (by approximately 30% after uninephrectomy and by approximately 120% after 5/6 nephrectomy), partly as a result of the compensatory increases in GFR but mainly as a consequence of moderate (after uninephrectomy) or marked (after 5/6 nephrectomy) reductions in fractional reabsorption. During the early period after 5/6 nephrectomy, potassium excretion sometimes exceeded the filtered load, indicating net secretion. Lithium clearance data indicated that the changes in tubular function after 5/6 nephrectomy include a reduction in fractional reabsorption in the proximal tubule, whereas after uninephrectomy any such effect on the proximal tubule is minor and transient.

MDM2 gene promoter polymorphisms and risk of lung cancer: a case-control analysis

The MDM2 protein negatively regulates p53 expression level in modulating DNA repair, cell-cycle control, cell growth and apoptosis. Polymorphisms in the promoter region of the MDM2 gene have been shown to alter protein expression and may, thus, play a role in carcinogenesis. To test our hypothesis that the MDM2 promoter polymorphisms are associated with risk of lung cancer, we conducted a hospital-based, case-control study of 1026 non-Hispanic white patients newly diagnosed with lung cancer and 1145 cancer-free controls who were frequency-matched by age (+/-5 years), sex, ethnicity and smoking status. We genotyped for the MDM2 promoter G2580T (also called SNP309) and G2164A polymorphisms that have a minor allele frequency >0.05. The distributions of the MDM2-2580G variant allele and genotypes were significantly less common among the cases than among the controls (P = 0.038 and 0.045, respectively), but this was not evident for MDM2-2164G (P = 0.865 and 0.614, respectively). Compared with the MDM2-2580TT genotype, the MDM2-2580G variant genotypes were associated with a decreased risk of lung cancer [odds ratio = 0.81 and 95% confidence interval = 0.67-0.98 for GT, 0.83 (0.63-1.08) for GG, and 0.81 (0.68-0.97) for the combined GT/GG genotype]. However, no significant association was observed between the MDM2-2164G variant genotypes and lung cancer risk. Our results suggest that the MDM2-2580G allele may be a marker of reduced genetic susceptibility to lung cancer in the non-Hispanic white population, a finding that seems to contradict previous reports.

Photovoice as a social process of critical consciousness

The reluctance of some communities to participate in research and researchers' lack of penetration into the community are major stumbling blocks to successful community-based approaches. The authors'purpose is to determine how a photovoice project in a lower income, African American, urban community was able to generate a social process that resulted in active grassroots participation in a community-campus partnership. Through this partnership initiative, the authors asked neighborhood residents to take photographs of things in the community of which they were proud and the things they wanted to change, and to tell the story of why these were important. The authors used strategies from visual anthropology to analyze the 54 photographs, stories, and dialogue produced. Their analysis identified three distinct levels of cognitive-emotional interpretations that moved participants out of helplessness toward authentic engagement and participation. The authors discuss implications and lessons learned for community-based participatory research.

Effects of a Preschool Staff Intervention on Children's Sun Protection: Outcomes of Sun Protection Is Fun!

The preschool is an important yet understudied setting for sun-protection interventions. This study evaluates the effects of Sun Protection is Fun! (SPF) on preschool staff behavioral and psychosocial outcomes related to protecting children from sun exposure. Twenty preschools participated in a 2-year, group-randomized trial to evaluate SPF, a behavioral intervention grounded in social cognitive theory and designed to be more extensive than previous preschool sun-protection interventions. The staff intervention included training, a video, newsletters, a curriculum, and sunscreen. Cross-sectional samples of staff completed surveys at baseline ( N= 245), a 12month intervention assessment ( N = 192), and a 24-month intervention assessment ( N = 225). At the 12-month and 24-month assessments, significant behavioral effects were seen for use of sunscreen, protective clothing, and shade. Knowledge, self-efficacy, and norms were among the psychosocial variables most affected by the intervention. This study demonstrates that the SPF intervention is effective in improving staff outcomes related to children's sun protection.

Knowledge gained after a brief CME module on breast cancer diagnosis

BACKGROUND

In developing countries, continuing medical education (CME) is lacking and physicians' knowledge of cancer control may also be lacking.

METHOD

We evaluated knowledge of 144 primary care physicians in Egypt and 50 in Tunisia regarding breast cancer (BC) and inflammatory BC (IBC) in particular. We invited the physicians to pretesting, presentation of an educational module, and post-testing.

RESULTS

We found significant improvement in knowledge about risk factors for IBC and BC, importance of early detection and clinical examination, and referral of IBC cases. The variables that were independently associated with improved BC knowledge, were rural practice location, being a female physician, and greater numbers of BC patients seen in the last year. CONCLUSION. We developed and evaluated a CME module to improve BC diagnostic knowledge of primary care physicians in developing countries. The evaluation showed that physicians most lacking in this knowledge had the greatest gains. With the anticipated adoption of this module in Egypt and Tunisia, we expect to see more appropriate referrals to cancer centers. These results could guide future oncology CME for physicians in developing countries.

Creating tomorrow's leaders in cancer prevention: a novel interdisciplinary career development program in cancer genetics research

OBJECTIVE

To prepare oncology, genetics and molecular medicine professionals for basic, translational and epidemiological cancer genetics research through advanced training in a novel specialized cancer genetics career development program (CGCDP).

METHODS

Established in 2001, the City of Hope CGCDP is the only program in the NCI R25T portfolio focused on interdisciplinary training of oncologists and geneticists as cancer genetics and cancer prevention research program leaders. Program infrastructure, curriculum, recruitment strategies, implementation, evaluation and outcome are described.

RESULTS

During the initial four-year period, twelve highly qualified health care professionals were recruited for cancer genetics academic, experiential, and research training. All trainees presented abstracts, published peer-reviewed journal articles, and/or were awarded cancer genetics research grants. Most are now in academic/research venues, following a cancer genetics research career trajectory.

CONCLUSION

The CGCDP is an NIH-funded program that has successfully trained doctoral and mid-level professionals in cancer genetics research. Program graduates are addressing the burden of cancer by translating cancer genetics investigations into individual risk assessment tools and effective cancer screening and prevention interventions.

Allostatic load and health disparities: a theoretical orientation

Eliminating racial and ethnic health disparities requires restructuring the biomedical models that have focused on the individual as the level of analysis and emphasized the parts rather than the whole. A recently developed understanding of human physiology and adaptive regulation, constructs of allostasis and allostatic load, provides a theoretical orientation that needs to be explored. Thus, the purpose of this article is to present an orientation of allostasis and allostatic load as a theoretical framework for exploring health disparities. This article will (a) present a general background on the evolution of relevant physiologic theories, (b) offer the general theoretical definitions and explanations of allostasis, allostatic load, and mediation processes, (c) examine empirical evidence for the constructs, and (d) discuss the implications of this orientation for health disparities research.

Increased plasma levels of angiogenin and the risk of bladder carcinoma: from initiation ot recurrence

BACKGROUND

Angiogenesis is a well known prerequisite for tumor growth and metastasis. It is believed that angiogenin initiates cell migration and aids cell proliferation. Based on this, the authors hypothesized that individuals who had increased plasma levels of angiogenin were at an elevated risk for carcinoma of the urinary bladder.

METHODS

In this ongoing case-control study, the authors used an enzyme-linked immunosorbent assay to compare plasma levels of angiogenin in 209 patients with bladder carcinoma and in 208 healthy control participants who were matched according to age (+/- 5 years), gender, and ethnicity.

RESULTS

The mean plasma angiogenin concentration was significantly higher in patients compared with controls (343.2 ng/mL vs. 308.0 ng/mL, respectively; P < 0.01). High plasma angiogenin levels were associated with a two-fold increased risk for bladder carcinoma. Moreover, in patients who had superficial bladder carcinoma, plasma angiogenin levels were significantly higher among those who had recurrent disease than in those who were without recurrence (P < 0.01). Similarly, patients who had superficial bladder carcinoma with higher angiogenin levels had a shorter recurrence-free survival than patients who had lower angiogenin levels (P < 0.01). Finally, elevated angiogenin levels were associated with an increased recurrence risk, with hazard ratio of 2.85.

CONCLUSIONS

The results of this study demonstrated that the plasma levels of angiogenin were significantly higher in patients who had bladder carcinoma compared with healthy control participants and in patients with superficial bladder carcinoma who had recurrent disease compared with patients who were without recurrence. Therefore, an elevated plasma level of angiogenin may serve as a novel predictor for the risk of bladder carcinoma.

An intervention for parents to promote preschool children's sun protection: effects of Sun Protection is Fun!

BACKGROUND

Young children are an important focus of sun-protection efforts, but there has been relatively little study of sun-protection interventions developed for preschool-aged children and their parents. This paper reports on the evaluation of Sun Protection is Fun! (S.P.F.), designed to improve parents' practices and psychosocial outcomes related to protecting preschool children from sun exposure.

METHODS

A group-randomized trial was conducted in 20 preschools to evaluate the S.P.F. parent intervention that included a video, newsletters, and handbooks. A separate, on-site intervention for preschool staff aimed to create a preschool climate that encouraged parents' sun protection for their children. Cross-sectional samples of parents completed surveys at baseline (n = 384), 12 months (n = 640), and 24 months (n = 694).

RESULTS

S.P.F. demonstrated significant effects on parents' sun-avoidance strategies at 12 months (P < .05) and sunscreen use at 24 months (P < .05). There were significant intervention effects on parents' sun-protection knowledge (P < .001), perceived norms of teachers' sunscreen use (P < .001), sunscreen impediments (P < .05), and sunscreen expectancies (P < .05) at 12 months. Parents' perceived norms of teacher sunscreen use were significantly improved at 24 months (P < .001).

CONCLUSIONS

More intense intervention strategies may need to complement take-home materials to result in greater effects on parents' sun protection for their children.

Genetic polymorphisms of p21 are associated with risk of squamous cell carcinoma of the head and neck

The p21 (Waf1/Cip1/CDKN1A) protein regulates the transition from the G1 to the S phase and has an important role in modulating cell-cycle control, apoptosis and cell growth. Two polymorphisms of the p21 gene at codon 31 (p21 C98A, dbSNP rs1801270) and at the 3' untranslated region (p21 T70C, dbSNP rs1059234) may have an effect on the protein function and may thus play a role in the development of cancer. We hypothesized that these two p21 polymorphisms are associated with the risk of squamous cell carcinoma of the head and neck (SCCHN). We tested this hypothesis in a hospital-based case-control study of 712 patients newly diagnosed with SCCHN and 1222 cancer-free controls who were frequency-matched by age, sex and ethnicity. All subjects were non-Hispanic whites. Our results showed that the variant alleles and genotypes were more common among cases than among controls (P < 0.001 and P = 0.013 for p21C70T, and P < 0.001 and P = 0.035 for p21C98A, respectively). Compared with the p21 70CC genotype, there was a significantly greater risk of SCCHN associated with the variant p21 70TC [odds ratio (OR) = 1.47, 95% confidence interval (CI) = 1.12-1.93] and combined p21 70TC/TT (OR = 1.49, 95% CI = 1.14-1.95) genotypes. Similarly, compared with the p21 98CC genotype, there was also a significantly greater SCCHN risk associated with the variant p21 98AC (OR = 1.32, 95% CI = 1.00-1.73) and combined p21 98AC/AA (OR = 1.37, 95% CI = 1.05-1.79) genotypes. When these two polymorphisms were evaluated together by the number of risk alleles, there was a significant increase in SCCHN risk that was dependent on the number of risk alleles (P(trend) = 0.001). Our results suggest that the presence of these two p21 polymorphisms may be a marker of genetic susceptibility to SCCHN.

Polymorphisms in XPD Exons 10 and 23 and Bladder Cancer Risk

INTRODUCTION

The nucleotide excision repair gene, xeroderma pigmentosum complementation group D (XPD), has been hypothesized to have a role in cancer risk, but results from prior molecular epidemiologic studies and genotype-phenotype analyses are conflicting.

MATERIALS AND METHODS

We examined the frequency of the XPD Asp312Asn polymorphism in exon 10 and the XPD Lys751Gln polymorphism in exon 23 in 505 incident bladder cancer cases and 486 healthy controls.

RESULTS

Overall, the XPD exon 10 and 23 genotypes were not associated with bladder cancer risk, after adjusting for age, sex, ethnicity, and smoking status. A gender-specific role was evident that showed an increased risk for women, but not for men, associated with the variant genotypes for both exons. For example, when the exon 23 variant allele genotypes were combined (Lys/Gln + Gln/Gln), there was an increased bladder cancer risk in women [odds ratio (OR), 1.69; 95% confidence interval (95% CI), 1.12-2.58] but not in men (OR, 0.99; 95% CI, 0.79-1.24; P(interaction) = 0.041; OR, 1.62; 95% CI, 1.02-2.58). There was also a gene-smoking interaction that showed the variant alleles for either exon or the combination of both increase the risk of bladder cancer for light and heavy smokers. For exon 23 (P(interaction) = 0.057; OR, 1.21; 95% CI, 0.99-1.47), heavy smokers (> or = 20 pack-years) who carried the exon 23 variant allele genotypes had an OR of 4.13 (95% CI, 2.53-6.73), whereas heavy smokers with the wild-type genotypes were at lower risk (OR, 3.55; 95% CI, 2.19-5.75). Moderate smokers (1-19 pack-years) with the variant allele genotypes had an OR of 1.54 (95% CI, 0.94-2.53), whereas moderate smokers with the wild-type genotypes had an OR of 1.12 (95% CI, 0.63-1.98).

CONCLUSIONS

Although we did not observe main effects associated with the XPD genotypes, these results do suggest the variant allele genotypes were associated with increased bladder cancer risk in women and smokers with statistically significant interactions in the exon 23 polymorphism. Although there is biological plausibility, these novel findings for gender and smoking should be interpreted with caution upon confirmation in larger studies.

p73 G4C14-to-A4T14 polymorphism and risk of lung cancer

Genetic variants in genes controlling cellular processes such as cell cycle, DNA repair, and apoptosis may modulate lung cancer risk. p73 has some p53-like activity and plays an important role in modulating these processes. The noncoding region of exon 2 of the p73 gene has two polymorphisms that are in complete linkage disequilibrium with one another, which may alter translation efficiency of the p73 protein. To test the hypothesis that this p73 polymorphism plays a role in the etiology of lung cancer, we conducted a hospital-based case-control study of 1054 patients newly diagnosed with lung cancer and 1139 cancer-free controls and evaluated the association between the p73 variant AT allele and risk of lung cancer. Cancer-free controls were frequency matched to the cases by age (+/-5 years), sex, and smoking status, and all subjects were non-Hispanic whites. The variant AT allele and genotypes were more common among the cases than among the controls (P = 0.0007 and P < 0.001, respectively). Compared with the GC/GC genotype, the variant GC/AT and AT/AT genotypes were associated with a statistically significantly increased risk for lung cancer [adjusted odds ratio (OR) = 1.32, 95% confidence interval (CI), 1.10-1.59 and OR = 1.54, 95% CI, 1.05-2.26, respectively] in an allele dose-effect relationship (trend test: P < 0.001). The risk associated with the AT allele (GC/AT+AT/AT) was more pronounced in younger (</=50 years) individuals (OR = 1.53, 95% CI, 1.00-2.37), men (OR = 1.61, 95% CI, 1.26-2.06), light smokers (OR = 1.58, 95% CI, 1.17-2.14), and squamous cell lung carcinoma (OR = 1.79, 95% CI, 1.32-2.42). These results suggest that this p73 polymorphism may be a marker for susceptibility to lung cancer.

The Black-White Perception Gap and Health Disparities Research

Reducing and eliminating racial and ethnic health disparities has become a national research priority. This research agenda requires new research frameworks that encompass the social determinants of health and the translation pathways of these social contexts into physiological morbidity. Within these sociobiological research frameworks, identity and emotions are seen as crucial links in the causal pathways from stressors to biological responses. In this country, the lived social reality of African American individuals is experienced through the color of their skin. Their identity is bound with the racial inequities of our society. It has been suggested that the emotions of anger and frustration resulting from this institutionalized racial discrimination are an emotional causative pathway to the pathophysiology contributing to the health disparities experienced by African Americans. However, as much as we espouse the concept of cultural competency in health care, until recently, there has been very little honest dialogue about how race and racism influences health. This article will explore the Black-White cultural perception gap and attempt to provide insight on the relationship to African American health and implications for health disparities research.

Association between the V109G Polymorphism of the p27 Gene and the Risk and Progression of Oral Squamous Cell Carcinoma

PURPOSE

Abnormalities in p27 may alter cell cycle delay required for DNA repair after exposure to carcinogens. A coding exon 1 polymorphism at codon 109 (T-->G) in p27 was identified and thought to have an effect on the functions of its protein. We hypothesized that this p27 T109G polymorphism is associated with squamous cell carcinoma of the head and neck (SCCHN) risk.

EXPERIMENTAL DESIGN

We tested this hypothesis in a hospital-based case-control study of 713 patients newly diagnosed with SCCHN and 1224 cancer-free controls frequency matched to the cases by age (+/-5 years), sex, and smoking status. All subjects were non-Hispanic whites. We genotyped for this p27 variant using genomic DNA from each subject.

RESULTS

Compared with the p27 109VV variant, the p27 109GG variant was associated with a nonsignificantly increased risk of SCCHN [crude odds ratio (OR) = 1.29; 95% confidence interval (CI) = 0.88-1.90; adjusted OR = 1.20; 95% CI = 0.81-1.77], but the risk was statistically significant among men (adjusted OR = 1.55, 95% CI = 1.00-2.42), current alcohol users (adjusted OR = 1.68, 95% CI = 1.01-2.82), and patients with oral cavity cancer (adjusted OR = 1.77, 95% CI = 1.03-3.04). The p27 109GG variant was also associated with oral tumor overall stage, suggesting that it may play a role in tumor progression.

CONCLUSIONS

Our findings suggest that the p27 109GG variant genotype may not play a major role in the etiology of SCCHN but may be associated with an increased risk in at-risk subgroups or subsets of SCCHN, particularly oral cavity cancer and possibly tumor progression. Larger studies with oral squamous cell carcinoma are needed to verify these findings.

Association of a p73 exon 2 G4C14-to-A4T14 polymorphism with risk of squamous cell carcinoma of the head and neck

p73, a novel p53 homolog, has some p53-like activity and plays an important role in modulating cell-cycle control, apoptosis and cell growth. p73 regulates differentiation of head and neck squamous epithelium, and changes in p73 may lead to the development of squamous cell carcinoma of the head and neck (SCCHN). Two linked non-coding exon 2 polymorphisms (designated as G4C14-to-A4T14) were identified recently but their functional relevance is unknown. We hypothesized that this p73 polymorphism plays a role in the etiology of SCCHN. Therefore, in this hospital-based case-control study of 708 patients newly diagnosed with SCCHN and 1229 cancer-free controls, we evaluated the association between the p73 AT variant allele and risk of SCCHN. The controls were frequency-matched to the cases by age (+/-5 years), sex and smoking status, and all subjects were non-Hispanic whites. Our results showed that the frequencies of variant AT allele and genotypes were more common in the cases than in the controls (P = 0.029 and P = 0.009, respectively). Compared with the GC/GC genotype, the variant genotypes (GC/AT + AT/AT) were associated with a statistically significantly increased risk for SCCHN [odds ratio (OR) = 1.33, 95% confidence interval (CI) = 1.10-1.60]. Further stratification analyses by age, sex, smoking and alcohol status and by cancer sites within the head and neck region indicated that this significantly increased risk was more pronounced in younger (< or =50 years) individuals (adjusted OR = 1.70; 95% CI, 1.19-2.43), women (1.61; 1.09-2.37), current smokers (1.77; 1.25-2.51) and patients with oral cancer (1.54; 1.15-2.07). Our results suggest that this p73 polymorphism may be a risk marker for genetic susceptibility to SCCHN.

Social capital, health, and health disparities

PURPOSE

To synthesize the empirical evidence that links social capital to population health with the aim of identifying implications for health disparities research.

METHODS

A literature search of PubMed and CINAHL databases from January 1990 to June 2002 was done using the search term "social capital." In addition, tables of contents of applicable journals from January 1997 to June 2002 were searched. Reference lists were examined for additional empirical and theoretical articles related to social capital and health. Eighty-four articles were retrieved for review and 19 articles met inclusion criteria.

FINDINGS

Although most reseachers concluded that their findings supported an association between social capital and health, all research was descriptive, without conceptual development. This gap resulted in (a) lack of distinction of the concept as an attribute of a geographic space or as an individual attribute, (b) problematic use of operational variables, and (c) limited theoretical exploration of causal linkage. These deficits limit the usefulness of the concept for health disparities research.

CONCLUSIONS

The lack of conceptual development diminishes the usefulness of social capital as a variable for public health research. However, the empirical evidence is sufficient to warrant further work to advance the concept in relation to population health and health disparities.

A qualitative study of head and neck cancer

The findings presented contribute to quality of life (QOL) research by highlighting the significance of factors affecting the communication by patients with primary-stage squamous cell carcinoma of the head and neck cancer (SCCHN) of their experiences of suffering after treatment to their clinicians. Qualitative research methodology based on open-ended interviews with 18 survivors of American Joint Committee on Cancer primary stage I and II SCCHN were used. The interviews were transcribed verbatim and thematically analyzed. Three important themes emerged: (1). a diminished self (2). fears of addiction, and (3). hopelessness and the loss of meaning in life after SCCHN. The findings indicate that SCCHN patients under-report their experiences mainly due to fear. As a consequence, and perhaps due to a failure on the part of clinicians and patients to adequately address such fears, SCCHN patients may experience greater psychological morbidity, becoming increasingly fatalistic about biomedicine's ability to restore them to health after cancer despite being "cured", or to relieve related symptoms. This qualitative study provides a perspective as to why such under-reporting occurs, thereby potentially enhancing clinician-patient communication and the QOL of SCCHN patients who present with curable disease.

Communicating suffering in primary stage head and neck cancer*

The findings presented in this discussion seek to make a contribution to quality of life (QOL) research, by highlighting the import of factors affecting the communication of primary stage head and neck cancer patient's experiences of suffering after treatments by their clinicians. Qualitative research methodology based on open-ended interviews with 18 survivors of American Joint Committee on Cancer (AJCC) Stage I and Stage II, squamous cell carcinoma of the head and neck (SCCHN) were used. The interviews were transcribed verbatim and thematically analysed. In this preliminary analysis, three important themes emerged: (1) a self diminished by cancer; (2) the fear of addiction to pain medications; and (3) hopelessness and the loss of meaning in life after SCCHN. Our present findings indicate that SCCHN patients understand their experiences of cancer and under-report their experiences of suffering mainly because of fear. These include fears of: being further diminished by SCCHN, fears of addiction, and an inability to cope with the additional losses associated with SCCHN. As a consequence, and perhaps, because of a failure the part of clinicians and patients to adequately address these fears, SCCHN patients may also experience greater psychological morbidity, becoming fatalistic about biomedicine's ability to restore them to health after cancer, or related symptoms, including pain, despite being 'cured.' This study provides a perspective on why this under-reporting occurs, thereby potentially enhancing clinician-patient communication and the QOL of SCCHN patients who present with curable disease.