Impact of the COVID-19 Pandemic on Financial Burden in Those with a Recent History of Cancer

PURPOSE/OBJECTIVE(S)

Cancer is well known to create significant financial burden on patients. The pandemic posed novel financial challenges, potentially worsening financial burden. We hypothesized that the financial burden experienced by participants with a recent history of cancer (HC) during the pandemic would be increased compared to participants without history of cancer (NC).

MATERIALS/METHODS

From June-November 2020, individuals who participated in past Ohio State University (OSU) studies, cancer patients, their caregivers and individuals on OSU community partner listservs were asked to participate in a survey to assess the pandemic's impact on employment and financial concerns (FC). Responses were compiled in a FC score. We wanted to evaluate the impact of a recent cancer diagnosis and treatment, so HC was defined as being diagnosed with cancer within 3 years prior to the survey date. Participants who worked prior to COVID, were matched by propensity score using a 1:2 algorithm to best compare financial burden across HC and NC. Negative binomial multivariable analysis (MVA) was used to compare FC scores of HC to NC, with adjustment for demographic and socioeconomic characteristics. The interaction between HC vs NC and race was examined in MVA.

RESULTS

Of 32,989 contacted individuals, 9,423 (26.8%) completed the survey. Those with a cancer diagnosis >3 years ago, and/or no full-time employment prior to the pandemic were excluded, leaving a sample of 2,703 participants (449 HC and 2,254 NC). The median age was 54 years for HC and 50 years for NC, 83.7% of HC and 80.0% NC had private insurance, and 4.5% of HC and 6.1% of NC had public insurance, 61.7% of HC and 60.2% of NC had income of $75k+ and 6.0% of HC and 7.2% of NC had income of <35k, 5.8% of HC and 5.2% of NC were Black (p<0.01 for all). Given significant differences in baseline characteristics of both groups, a matched pair-analysis of 1218 participants (421 HC and 797 NC) was performed and utilized for remaining analyses. There were no differences between HC and NC in being paid for a full or part-time job (p = 0.15) or job loss (p = 0.47), due to the pandemic. On MVA, HC were less likely to have financial concerns than NC. Black participants had a 1.55 times higher FC score than white participants, and those with an annual household income < $35K and $35K-50K had 1.8 and 1.5 times higher FC score compared to those with income of $75K or higher (p<0.01 for all). When Black HC were compared to Black NC, HC had 1.6 times higher odds of financial concerns (p = 0.02).

CONCLUSION

In this selected population, HC were less likely to have financial concerns than NC, potentially due to difference in baseline characteristics that could not be accounted for in MVA. However, those with total income <$50k and Black participants, particularly Black HC, were the groups most likely to have FC during the pandemic. Further analysis should investigate long-term ramifications of increased FC in these vulnerable groups, particularly when pandemic and cancer-related financial burdens are compounded.

Accessibility and Impact of Telehealth in Rural Populations with a History of Cancer

PURPOSE/OBJECTIVE(S)

After the COVID-19 pandemic, telehealth (TH) has been increasingly utilized in healthcare delivery. We aim to analyze the preference and availability of TH for participants with a history of cancer (HC) and hypothesize HC in rural areas will have lower access to TH compared to metropolitan residents (metro).

MATERIALS/METHODS

From June-November 2020, individuals who had participated in past OSU studies, cancer patients, their nominated caregivers and those on OSU community partner listservs were asked to participate in a survey to understand the pandemic's impacts on healthcare access. A follow-up survey was distributed from March-July 2021. Survey data were merged with information from the OSU James Cancer Registry to confirm history of cancer. Only participants with HC were included in this analysis. Participants were asked demographic questions and questions to assess preferences and accessibility regarding TH. Chi-square tests as well as Wilcoxon Rank Sum Test were used to review the bivariate associations between demographic and TH variables with rural/metro residence.

RESULTS

Of 9,280 who completed the first survey, 7,224 (77.8%) also completed the second survey, and 3,536 were HC (891 rural, 2,645 metro). The median age was 63 years, 63.3% of the participants were women, 89.0% were non-Hispanic white, 15.0% had public health insurance, 53.3% had a college degree or higher, 46.8% of the patients had an income >$75K. In metro areas, more participants were black, had an education of at least a college degree and had higher incomes compared to those in rural areas (p<0.001 for all). Otherwise, there were no differences in patient characteristics between rural and metro HC. When asked TH specific variables, patients in rural areas were less likely to have a smart phone (48.8% vs. 54%), less likely to have internet access (57.8% vs. 62.23%), more likely to be concerned about the cost of internet at home (18% vs. 14.8%), less likely to have participated in video TH visit since the pandemic (27.1% vs. 36.1%) (p<.01 for all). There was no difference in participation in TH by phone, satisfaction with the TH visit, or perception that TH made seeing a provider easier (p>0.05 for all) between rural and metro participants.

CONCLUSION

Participants in rural areas were less likely to have internet access, which may have a role in their decreased engagement with video TH since the pandemic, compared to metro participants. However, there was no difference in use of telephone visits. Video visits are known to allow a more comprehensive evaluation including visual assessments. Although TH options are desirable for those residing further from medical centers, barriers to completion of successful virtual visits have limited more widespread adoption of TH among this patient population. Future efforts to improve care for rural populations should focus on improving disparities in access to quality telecommunication services and expanded connections with rural providers to provide comprehensive care.

Abstract P6-12-02: Racial/ethnic differences in sleep quality and duration among breast cancer survivors: Results from the women's health initiative (WHI)

BACKGROUND: Sleep is a crucial factor for optimal health, but breast cancer survivors often report poor sleep quality. It is estimated 20-70% of survivors have at least one sleep problem, which contribute to quality of life and health differences among survivors. Minority groups tend to have poorer sleep quality and shorter sleep duration than Non-Hispanic Whites (NHW). African-Americans (AA) with breast cancer have a poorer prognosis than NHW for each stage-specific diagnosis and are twice as likely as NHW to report short sleep duration, yet survivor studies are still lacking in AA participants. The purpose of this study was to examine sleep quality and duration patterns before and after cancer diagnosis by race/ethnicity among WHI breast cancer survivors.

METHODS: There were 12,098 postmenopausal women diagnosed with invasive breast cancer after WHI enrollment who were eligible for this secondary analysis. Baseline demographic and clinical characteristics were described. The WHI Insomnia Rating Scale (WHIIRS) was measured at multiple time points pre- and post-diagnosis. A higher WHIIRS scores (0-20 points) indicates greater sleep disturbance and ≥9 points identifies clinical insomnia. A linear mixed model was fit to the WHIIRS sleep quality data to examine if the trend in sleep quality with time changed following a cancer diagnosis. For short (&lt;6hrs) and long (≥9hrs) sleep duration, we fit a logistic regression model with multilevel mixed effects.

RESULTS: The majority of participants were NHW (87.4%), mean age at diagnosis was 70.3 years, and 75% had localized breast cancer at diagnosis. At baseline, 30% of women had insomnia. The lowest average WHIIRS score was 5.6 among Asians, and the highest was 6.6 among American-Indians and NHWs (p=0.02). AAs had the most women sleeping ≤5 hrs/night and NHW had the least (19.6% vs 5.7%, p&lt;0.01). At diagnosis, the average WHIIRS score was 7.2. After diagnosis, sleep quality improved in the overall study population (p=0.03). Short sleep duration ranged from 6% before diagnosis, 9% at diagnosis and 11% after diagnosis (p=0.29). Long sleep duration ranged from 3% before diagnosis, 6% at diagnosis and 15% after diagnosis (p=0.43). There was no difference in sleep quality across race after diagnosis (p=0.53). The probability of short sleep and long sleep after diagnosis did not differ significantly across race (p=0.12, p=0.90), however racial minorities tended to have higher probabilities of short sleep at diagnosis compared to NHWs.

DISCUSSION: Sleep is an appealing area to target for improvement due to the multiple ways it can be treated. With increasing survival rates, there is an emphasis on improving quality of life in survivors. Our results span 20 years pre-diagnosis to 15 years post-diagnosis and are similar to shorter follow-up studies which found most women's sleep problems resolve within a few years of treatment completion. The lack of difference by race was an unexpected finding in another similar longitudinal study, which suggested most differences are seen in cross-sectional sleep studies. This study adds to the literature on longitudinal sleep data, especially to the little data on sleep trajectories in minority breast cancer survivors.

Citation Format: Beverly CM, Naughton M, Foraker R, Pennell M, Young G, Hale L, Crane T, Pan K, Danhauer S, Feliciano E, Paskett E. Racial/ethnic differences in sleep quality and duration among breast cancer survivors: Results from the women's health initiative (WHI) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-12-02.

QOL and Survival Comparisons by Race in Oncology Clinical Trials

BACKGROUND

Significant efforts have been made to increase access and accrual to clinical trials for minority cancer patients (MP). This meta-analysis looked for differences in survival and baseline quality of life (QOL) between MP and non-minority cancer patients (NMP).

MATERIALS AND METHODS

Baseline QOL and overall survival times from 47 clinical trials (6513 patients) conducted at Mayo Clinic Cancer Center/North Central Cancer Treatment Group were utilized. Assessments included Uniscale, Linear Analogue Self Assessment, Symptom Distress Scale (SDS), Profile of Mood States and Functional Assessment of Cancer Therapy - General, each transformed into a 0-100 scale with higher scores indicating better outcomes. This transformation involves subtracting the lowest possible value from the assessment, dividing by the range of the scale (the maximum minus the minimum), and multiplying by 100. Analyses included Fisher's Exact tests, linear regression, Kaplan-Meier curves, and Cox proportional hazards models.

RESULTS

Eight percent of patients self-reported as MP (0.45% American Indian/Alaskan Native, 0.7% Asian, 5% Black/African American, 1.5% Hispanic, 0.1% Native Hawaiian and 0.3% Other). MP had no meaningful deficits relative to non-MP in overall QOL but were slightly worse on FACT-G total score, physical, social/family, functional, and SDS nausea severity. MP with lung, neurological or GI cancers had significantly worse mean scores in nausea (58 vs. 69), sleep problems (34 vs. 54); emotional (53 vs. 74); and social/family (60 vs. 67), respectively. Regression models confirmed these results. After adjusting for disease site, there were no significant differences in survival.

CONCLUSION

MP on these clinical trials indicated small deficits in physical, social, and emotional subscales at baseline compared to NMP. Within cancer sites, MP experienced large deficits for selected QOL domains that bear further attention.

Influence of Personal Exposure to the Cancer of a Loved One on the Breast Cancer Prevention Decisions of High Risk Women

Purpose: To explore the impact of close personal exposure to cancer in a family member or friend in the prevention decisions of women at elevated risk of breast cancer. Methods: 50 semi-structured interviews with women at elevated risk of breast cancer, focusing on perceptions of risk; risk information; consideration of prevention options; decision-making processes and networks, and psychosocial well-being. Transcribed data are analyzed with NVivo 10, using grounded theory methods. Results: Prevention decision making by women who have had close contact with the cancer diagnosis and treatment of a loved one (most often a mother or grandmother, but sometimes a sister, cousin, or close friend) is importantly influenced by these experiences. The process of deciding whether and when to undertake prophylactic mastectomy or oophorectomy, chemoprevention, enhanced surveillance, and/or genetic testing is substantially different in women who have and have not had close personal experience with the cancer of a loved one. Women who have experienced the deaths of one or more loved ones express strong motivation and willingness to undertake definitive interventions; most often this means prophylactic surgery, but this can also include chemoprevention. These women often feel that they are likely to be diagnosed with breast cancer eventually, and seek decisive methods to avoid what they perceive as a life-threatening diagnosis. Women whose loved ones have survived and thrived after a cancer diagnosis are more oriented toward careful surveillance through screening tests and physician checks. These women usually see breast cancer as a challenge they may have to deal with in the future, and they are motivated to set the stage for treatment success by establishing ongoing relationships with highly competent healthcare providers, and by being diagnosed as early as possible. Conclusions: Cancer care has strong effects beyond the cancer patient herself, affecting the decision-making processes and the prevention-related decisions of loved ones as well. Future prevention research for women at elevated risk should consider how their prior experiences with the cancer of friends or family members structure women's expectations of cancer risk, prevention, and outcomes.

Abstract P1-13-02: Benefit/risk of invasive breast cancer adjuvant tamoxifen or aromatase inhibitor use by age, race/ethnicity, and co-morbidity

Background: Older age, minority race/ethnicity, and co-morbidities adversely influence early stage IBC outcome. Further, as AI compared to tamoxifen use has different effects on IBC recurrence and other health outcomes including hip fracture, endometrial cancer, stroke, pulmonary embolism and, perhaps especially, coronary heart disease (CHD), an approach to summarize relative benefit/risk of these agents is needed.

Methods: Incidence rates for health outcomes by age and race/ethnicity, absent AI or tamoxifen use, were obtained from the placebo arms of the three primary Women's Health Initiative clinical prevention trials (n = 33,072). AI and tamoxifen effects on IBC distant recurrence (relative risk [PR] 0.82) were estimated from a meta-analysis of the ATAC and Big-1-98 trial results (n = 14,149) and on other health outcomes from published meta-analysis of side effects in seven AI vs tamoxifen trials (n = 30,023); RR of 1.47 for hip fracture, 0.34 for endometrial cancer, 0.84 for stroke, 0.55 for pulmonary embolism, 1.26 for CHD (Amir et al JNCI 2011;103:1299). Following the methodology of Freedman et al (JCO 2011;29:2327), mortality weights were assigned health outcomes (5 year mortality risk of 0.2 for MI, 0.8 for IBC distant recurrence, etc) to assess net all cause mortality benefit/risk for AI compared to tamoxifen by recurrence risk, age (decade), race/ethnicity, hysterectomy (yes/no) and, in separate analyses, in women with diabetes and in women with cardiovascular disease [CVD] history.

Results: In these analyses, clinical outcome of women with early stage IBC was unfavorable (more deaths per 1000 women/years) with tamoxifen compared to AI adjuvant use regardless of age, race/ethnicity, diabetes or CVD history even with 10-year distant recurrence risk of only 10%. AI superiority was substantially greater in women with a uterus and, in exploratory analyses, when assuming a CVD relative risk for AI use of 1.0, rather than a CHD relative risk of 1.26 used in all other analyses, as the AI CHDrisk elevation is controversial. The net benefit of AI compared to tamoxifen influence on clinical outcomes are described in a series of tables to be presented which quantify benefit/risk in particular women groups. The example below illustrates the excess number of deaths/1000 woman years for tamoxifen vs. AI by recurrence risk, age, and hysterectomy status.

 Excess Number of Deaths per 1000 women/year for Tamoxifen Compared to AI Tamoxifen vs. AI (with uterus)Tamoxifen vs. AI (without uterus)10-year Distant Recurrence (%)Age GroupAge Group 50-59y60-69y70-79y50-59y60-69y70-79y1015120620010211111030326382375278287286

For a 60-69 year old woman with a uterus at 30% 10 year recurrence risk, there would be 382 more deaths per 1000 women/yr for tamoxifen vs. AI use. With prior hysterectomy, there would still be 287 more deaths for tamoxifen use.

Conclusion: We developed an index to quantify the benefit risk for adjuvant AI vs. tamoxifen use. Even assessing a RR of 1.26 for CHD for AI use, tamoxifen compared to AI use had unfavorable outcome in all examined groups. This index can complement clinical evaluation in comparing use of these two adjuvant therapy approaches in women of different ages and racial/ethnic groups.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-13-02.

Abstract PD08-09: Impact of a Telephone-Based Exercise Intervention on Physical Activity Behaviors and Fitness in a Cooperative Group Setting

Observational studies have demonstrated a 30-50% lower risk of disease-specific and overall mortality in physically active breast and colorectal cancer patients as compared to sedentary individuals. However, there have been no randomized trials looking at the impact of physical activity on cancer outcomes, and the optimal design of such a trial is not yet well-defined. The Active After Cancer Trial (AACT) is a multicenter feasibility study designed to evaluate the ability of a telephone-based intervention to increase physical activity in patients with breast and colorectal cancer. Methods: Sedentary (reporting less than 60 minutes/week of recreational activity) individuals with stage I-III breast or colorectal cancer were eligible for enrollment after completion of all adjuvant chemotherapy and radiation. Participants were randomized 1:1 to a centralized telephone coaching intervention, with a target goal of 180 minutes/week of physical activity, or to a usual care control group. Intervention participants received an average of 10 telephone contacts over 16-weeks. Initial calls focused upon building self-efficacy and later calls concentrated upon relapse prevention and maintenance of exercise behaviors. Participants underwent assessment of physical activity behaviors (7-Day Physical Activity Recall), fitness (6-Minute Walk Test), physical functioning (EORTC QLQ C-30), fatigue (FACIT) and exercise self-efficacy at baseline and 16 weeks after enrollment.

Results: One hundred and twenty-one patients were enrolled through 10 Cancer and Leukemia Group B (CALGB) institutions; 100 patients had breast cancer and 21 had colorectal cancer. Average age was 54.3, 74% of patients had received chemotherapy and mean time since completion of adjuvant treatment was 24 months. Participants randomized to the exercise group experienced significant improvements in fitness and physical functioning as compared to controls.

Table. Baseline measures and change (post-minus pre) scores in intervention and control patients (±SD)

Intervention participants also reported a doubling in minutes of weekly physical activity, but this was not a significant increase compared to controls.

Conclusions: Sedentary breast and colorectal cancer survivors can be enrolled in a physical activity intervention. A centralized telephone coaching intervention successfully increased fitness and physical functioning, although self-reported exercise time was not significantly changed. A large-scale clinical trial within the co-operative groups is feasible.

Extending the patient navigator research program from Harlem to the nation

6096

Background: Low-income persons face barriers when attempting to seek cancer diagnostics tests and treatment. In 1990, Harold Freeman implemented a novel patient navigator program for women with abnormal mammograms, resulting in earlier presentations and better survival. Identified barriers included lack of insurance, poor social support, coping styles, health beliefs such as fatalism, and poor health literacy skills. Single-site navigator programs have been subsequently implemented. Building on these experiences, the National Cancer Institute is supporting navigator programs at 9 sites. Methods: At 9 sites, the skill set of the navigators, community partnerships, target patient populations were reviewed for information regarding cancer type, number of patients seen, and navigator type. Common data elements include time to diagnosis and time to initiation of treatment, navigation costs, cost-effectiveness of the intervention (in order to address sustainability), and navigation satisfaction. Results: See Table . Conclusions: While programs such as the Breast and Cervical Cancer Treatment Act, the Department of Veterans Affairs, and the Indian Health Board provide financial support to pay for diagnostic/treatment services, the Patient Navigator Research Program will provide medical, social, and psychosocial services for 5,295 patients with positive breast cancer screens, 3,528 patients with positive cervical cancer screens, 5,507 patients with colorectal cancer screens, and 1,167 patients with prostate cancer screens. Diversity of sites, navigator skill sets, patient eligibility, sociodemographics, and study design in conjunction with common data elements, outcomes, and analytic plans will allow us to assess the efficacy and costs of a range of navigation programs.

[Table: see text]

No significant financial relationships to disclose.

Meat intake and the recurrence of colorectal adenomas

A large multicenter randomized controlled trial was re-assessed to check whether meat intake and a reduction in its consumption are associated with recurrence of adenomatous polyps of the large bowel, which are precursors of most colorectal malignancies. All subjects (n = 1905; 958 interventions and 947 controls) had one or more histologically confirmed colorectal adenomas removed during a colonoscopy within 6 months before randomization. The subjects were followed-up for approximately 4 years after randomization and a colonoscopy for detecting adenomas was conducted at the 1st and 4th year after randomization. Dietary variables were assessed at baseline (T0) and in conjunction with annual visits at the end of the 1st (T1), 2nd (T2), 3rd (T3) and 4th (T4) years. Odds ratios using logistic regression models for meat variables were estimated based on the average intake at T0, T1, T2, T3 and T4 (prior to the T4 colonoscopy) as well as change (T0-T4) in intake. In the intervention group, the total reduction in median intake of red meat from T0 to T4 was observed by the end of 1st year itself (30 and 31% for men and women, respectively). The analysis provide no evidence to suggest that lower intake or reduction in total and in red meat consumption during a period of 4 years reduces the risk of adenoma recurrence (including multiple or advanced adenoma), whereas the data suggest that high intake of fish is associated with lower risk of adenoma recurrence.

Hormone replacement therapy and colorectal adenoma recurrence among women in the Polyp Prevention Trial

BACKGROUND

Epidemiologic studies have suggested that estrogen may protect against the development of colorectal cancers and adenomatous polyps. We conducted a prospective study to evaluate the association between hormone replacement therapy (HRT) and adenoma recurrence among perimenopausal and postmenopausal women participating in the Polyp Prevention Trial, a randomized dietary intervention study of individuals with colorectal adenomas.

METHODS

We used a questionnaire and interviews to collect detailed information, at baseline and at each of four annual study visits, from 620 women regarding hormone use, menopausal status, diet, alcohol consumption, and other risk factors. Adenoma recurrence was ascertained by complete colonoscopy at baseline and after 1 and 4 years. Logistic regression models were used to evaluate the association between hormone use and adenoma recurrence after adjusting for intervention group and for age and body mass index at baseline. All statistical tests were two-sided.

RESULTS

Adenomas recurred in 200 women. There was no overall association between adenoma recurrence and either overall hormone use (odds ratio [OR] = 1.01; 95% confidence interval [CI] = 0.70 to 1.45), combined estrogen and progestin use (OR = 0.94; 95% CI = 0.57 to 1.56), or unopposed estrogen use (OR = 1.04; 95% CI = 0.68 to 1.59). HRT use was associated with a reduction in risk for recurrence of distal adenomas (OR = 0.56; 95% CI = 0.32 to 1.00) and a statistically nonsignificant increase in risk for recurrence of proximal adenomas (OR = 1.39; 95% CI = 0.85 to 2.26). We observed a statistically significant interaction between the HRT-adenoma recurrence association and age (P =.02). HRT was associated with a 40% reduced risk of adenoma recurrence among women older than 62 years (OR = 0.58; 95% CI = 0.35 to 0.97) but with an increased risk among women younger than 62 years (OR = 1.99; 95% CI = 1.11 to 3.55).

CONCLUSIONS

HRT was not associated with a reduced risk for overall adenoma recurrence in this trial cohort, although there was a suggestion of an age interaction. The effect of age on the association needs to be confirmed in other adenoma recurrence trials.

Implementation of a 4-y, high-fiber, high-fruit-and-vegetable, low-fat dietary intervention: results of dietary changes in the Polyp Prevention Trial

BACKGROUND

The Polyp Prevention Trial (PPT) was a multicenter randomized clinical trial designed to determine the effects of a high-fiber (4.30 g/MJ), high-fruit-and-vegetable (0.84 servings/MJ), low-fat (20% of energy from fat) diet on the recurrence of adenomatous polyps in the large bowel.

OBJECTIVE

Our goal was to determine whether the PPT intervention plan could effect change in 3 dietary goals and to examine the intervention's effect on the intake of other food groups and nutrients.

DESIGN

Participants with large-bowel adenomatous polyps diagnosed in the past 6 mo were randomly assigned to either the intervention (n = 1037) or the control (n = 1042) group and remained in the trial for 4 y. Three dietary assessment instruments were used to measure dietary change: food-frequency questionnaires (in 100% of the sample), 4-d food records (in a 20% random cohort), and 24-h dietary recalls (in a 10% random sample).

RESULTS

Intervention participants made and sustained significant changes in all PPT goals as measured by the dietary assessment instruments; the control participants' intakes remained essentially the same throughout the trial. The absolute differences between the intervention and control groups over the 4-y period were 9.7% of energy from fat (95% CI: 9.0%, 10.3%), 1.65 g dietary fiber/MJ (95% CI: 1.53, 1.74), and 0.27 servings of fruit and vegetables/MJ (95% CI: 0.25, 0.29). Intervention participants also reported significant changes in the intake of other nutrients and food groups. The intervention group also had significantly higher serum carotenoid concentrations and lower body weights than did the control group.

CONCLUSION

Motivated, free-living individuals, given appropriate support, can make and sustain major dietary changes over a 4-y period.

Use of vitamins, minerals, and nutritional supplements by participants in a chemoprevention trial

BACKGROUND

The growing use of vitamins, minerals, and nutritional supplements has the potential to influence the design and interpretation of randomized controlled trials of chemopreventive agents. To the extent that these complementary agents are effective, they could limit the ability of trials to demonstrate an effect of the agents under study.

METHODS

During the course of a colorectal neoplasia chemoprevention trial using aspirin in a group of colorectal carcinoma survivors, the authors obtained information on the use of vitamins, minerals, and supplements at baseline and every 6 months. The information from 622 study participants was categorized and enumerated.

RESULTS

One or more supplements were used at some time by 341 (55%) subjects. Among those who took supplements, 66% took more than 1 and 13% took 5 or more. The mean number of supplements taken was 2.6 (1.7 standard deviation). Vitamins were the most commonly used (49%), followed by minerals (22%), botanicals (13%), and others (5%). Among the vitamins, the most frequently used were multivitamins (38% of subjects), vitamin C (18%), and vitamin E (22%). Calcium (16%) was the most frequent mineral. Among users, there were no differences in supplement use by age or gender.

CONCLUSIONS

Supplement use was common among colorectal carcinoma survivors enrolled in a prevention trial. Investigators should record the information on supplement use so that the possible impact of the supplements on trial endpoints can be evaluated. It may be necessary to increase the size of studies if many of the subjects take potentially effective supplements.

Phase I clinical study of fish oil fatty acid capsules for patients with cancer cachexia: cancer and leukemia group B study 9473

The purpose of this study was to determine the maximum tolerated dose and dose-limiting toxicities of fish oil fatty acid capsules containing omega-3 fatty acid ethyl esters. Twenty-two patients with neoplastic disease not amenable to curative therapy who had lost 2% of body weight over a previous 1 month time period were given an escalating dose of fish oil fatty acids. The maximum tolerated dose was found to be 0.3 g/kg per day of this preparation. This means that a 70-kg patient can generally tolerate up to 21 1-g capsules/day containing 13.1 g of eicosapentaenoic acid + docosahexaenoic acid, the two major omega-3 fatty acids. Dose-limiting toxicity was gastrointestinal, mainly diarrhea, and a poorly described toxicity designated as "unable to tolerate in esophagus or stomach." A patient with chronic lymphocytic leukemia taking the fish oil provided an unusual opportunity to perform a detailed biochemical study of the effect of fish oil capsules on the lipids of malignant cells at several sequential time points in treatment. Studies of the malignant lymphocytes, serum, and whole blood of this one patient revealed an increase in eicosapentaenoic acid, the major component of the fish oil capsules, during fish oil capsule treatment. This study provides a scientific basis for the selection of omega-3 fatty acid doses for future studies in cancer. The maximum tolerated dose found is considerably higher than anticipated from published studies of many human diseases. The observation of a modification of the lipids of leukemic cells, serum, and blood in a patient with chronic leukemia provides a biochemical basis for a possible effect of fish oil supplements on cancer cachexia and tumor growth.

Colon cancer treatment in rural North and South Carolina

The purpose of this study was to determine the degree to which colon cancer treatment in rural North and South Carolina in 1991 and 1996 conformed to national treatment recommendations. Data came from medical records of colon cancer patients residing in rural North and South Carolina. The National Cancer Institute's Physician Data Query (PDQ) database was used to define state-of-the-art care and to categorize receipt of primary and/or adjuvant treatment. Changes in treatment over time, location, and stage and bivariate relationships between treatment and selected covariates were assessed with chi-square and Fisher's exact tests. Regression was used to control for possible interactions between patient and/or disease characteristics and treatment. The majority of colon cancer cases received primary therapy as suggested by the PDQ which was not significantly related to other factors examined. There was variation in provision of adjuvant therapy. Stage III patients received adjuvant therapy significantly more often than did stage II patients (p </= 0.01). Receipt of appropriate adjuvant therapy among stage III patients was significantly associated with younger patient age and white race (p </= 0.05). Rural colon cancer patients are likely to receive primary therapy as recommended by the PDQ, but may be less likely to receive suggested adjuvant therapy. Further understanding of variations in the rate of adjuvant therapy for colon cancer is needed to ensure appropriate treatment regimens are obtained for rural colon cancer patients.

Rural breast cancer treatment: evidence from the Reaching Communities for Cancer Care (REACH) project

BACKGROUND

Research shows that rural populations are more likely than their urban counterparts to be diagnosed with late-stage cancer, but less is known about appropriateness of cancer treatment in rural locations after diagnosis. The objective of this analysis was to assess the degree to which rural breast cancer treatment was received in concordance with national recommendations.

METHODS

Data came from 251 stage I and II breast cancer patients residing in rural North Carolina. State-of-the-art care was defined using the National Cancer Institute's (NCI) physician data query (PDQ) database, and cases were categorized into appropriate primary and/or adjuvant treatment. Chi-square and Fishers' exact tests were used to assess changes in appropriate treatment over time (1991-1996) and between stage. Multiple logistic regression was used to determine whether any patient or disease characteristics were associated with receipt of appropriate treatment.

RESULTS

Most (81-90%) of the breast cancer cases received the appropriate primary therapy (mastectomy or lumpectomy followed by radiation therapy); of these, the majority received a mastectomy (66-72%). Fewer women received adjuvant therapy as recommended (27-61%), although significantly more stage II than stage I cases did so (p < or = 0.05). Regression showed that stage and estrogen-receptor (ER) status were associated with appropriate therapy.

CONCLUSIONS

The findings suggest that there exist deviations from NCI established treatment recommendations among rural breast cancer patients. More research is needed to develop better methods for dissemination of state-of-the-art cancer information to rural physicians and patients, and to understand how treatment decisions are made.

Is colonoscopy needed for the nonadvanced adenoma found on sigmoidoscopy? The Polyp Prevention Trial

BACKGROUND & AIMS

The need for colonoscopy when small tubular adenomas with low-grade dysplasia are found on sigmoidoscopy is uncertain. The aim of this study was to examine the prevalence and characteristics of proximal adenomas in patients with distal adenomas.

METHODS

We studied 981 subjects with distal adenomas found on the index colonoscopy before randomization in the Polyp Prevention Trial.

RESULTS

Four hundred sixty patients (46.9%) had >/=1 distal adenoma that was pathologically advanced (villous component, high-grade dysplasia, or >/=1 cm); 21.5% (211 of 981) had any proximal adenoma; and 4.3% (42 of 981) (95% confidence interval [CI], 3.0-5.5) had an advanced proximal adenoma. A greater percentage of patients with an advanced distal adenoma (5.9%) (95% CI, 3.7-8.0) had an advanced proximal adenoma compared with those with a nonadvanced distal adenoma (2.9%) (95% CI, 1.4-4.3) (OR, 2.1; 95% CI, 1.1-4.3; P = 0.03). Not performing a colonoscopy in patients with a nonadvanced distal adenoma would have missed 36% (15 of 42) of the advanced proximal adenomas.

CONCLUSIONS

Patients with an advanced distal adenoma are twice as likely to have an advanced proximal adenoma as patients with a nonadvanced distal adenoma. However, eschewing a colonoscopy in patients with a nonadvanced distal adenoma would result in not detecting a sizeable percentage of the prevalent advanced proximal adenomas. These data support performance of a colonoscopy in patients with a nonadvanced distal adenoma. Confirmation of these results in asymptomatic subjects undergoing screening sigmoidoscopy is advisable.

The polyp prevention trial II: dietary intervention program and participant baseline dietary characteristics

The Polyp Prevention Trial (PPT) is a multicenter randomized controlled trial to evaluate whether a low-fat, high-dietary fiber, high-fruit and -vegetable eating pattern will reduce the recurrence of adenomatous polyps of the large bowel. Men and women who had one or more adenomas removed recently were randomized into either the intervention (n = 1037) or control (n = 1042) arms. Food frequency questionnaire data indicate that PPT participants at the beginning of the trial consumed 36.8% of total energy from fat, 9.7 g of dietary fiber/1000 kcal, and 3.8 daily servings of fruits and vegetables. Baseline dietary characteristics, including intake of fat, fiber, and fruits and vegetables, as well as other macro- and micronutrients, were similar in the two study groups. The intervention participants receive extensive dietary and behavioral counseling to achieve the PPT dietary goals of 20% of total energy from fat, 18 g/1000 kcal of dietary fiber, and 5-8 daily servings (depending on total caloric intake) of fruits and vegetables. Control participants do not receive such counseling and are expected to continue their usual intake. Dietary intake in both groups is mentioned annually using a 4-day food record (also completed at 6 months by intervention participants only) and a food frequency questionnaire, with a 10% random sample of participants completing an annual unscheduled 24-h telephone recall. Blood specimens are drawn and analyzed annually for lipids and carotenoids. This article provides details on the rationale and design of the PPT dietary intervention program and describes the participant baseline dietary intake data characteristics.

Characteristics of men reporting for prostate cancer screening

A survey to determine demographics, prostate cancer screening practices, and prostate cancer-related knowledge and beliefs was administered to over 1,700 participants at five sites during Prostate Cancer Awareness Week (1991) screening events. Findings are presented by site since significant differences in demographics existed. Results suggest that screenings conducted at the major medical centers attract primarily white males, a number of whom already practice adequate secondary prevention. Thus, if optimal benefit is sought through mass prostate cancer screening, innovative strategies to reach populations that are currently underserved and at risk are necessary.