AB0786 Self-reported disease burden is greater in spondyloarthritis than in rheumatoid arthritis patients according to multidimensional questionnaire (MDHAQ / RAPID3) scores, despite fewer females, who generally have higher scores on patient questionnaires

Background

Female patients generally have higher scores than males on most items on self-report questionnaires, including MDHAQ/RAPID3 (multi-dimensional health assessment questionnaire/routine assessment of patient index data)1. MDHAQ/RAPID3 was validated in patients with rheumatoid arthritis (RA), but is informative in all diseases studied, including spondyloarthritis (SpA)2. More SpA patients are men than RA patients, suggesting lower scores, but MDHAQ scores are higher in SpA than RA.

Objectives

We compared self-report MDHAQ/RAPID3 scores in RA vs SpA patients according to gender.

Methods

Patients who met classification criteria for RA or SpA (axial SpA and psoriatic arthritis) completed MDHAQ at a routine rheumatology visit. The MDHAQ includes 10 activities for physical function (FN) (8 identical to HAQ), scored 0-3, total 0-30, divided by 3 for a 0-10 score, 3 0-10 visual numeric scales (VNS) for pain (PN), patient global assessment (PATGL), and fatigue (FT), a 60-symptom checklist (ROS60) and a RADAI self-report of painful joints (0-48). RAPID3 is a 0-30 index of FN + PN + PATGL. Means and standard deviations (SDs) of age, education, and 7 MDHAQ scores were computed in patients with RA versus SpA, and in subsets of female versus male patients with either RA or SpA. Unadjusted differences were evaluated using Student’s t and chi-square tests; mean differences were adjusted for age, gender and education using analysis of covariance.

Results

170 patients were studied, 102 with RA and 68 with SpA. 82% of patients with RA and 47% of patients with SpA were female (p<0.001); age and education did not differ between the 2 groups (Table 1). All 7 mean MDHAQ scores analyzed were higher in patients with SpA than in those with RA, although only differences for FN were statistically significant (Table 1). Within both the RA and SpA groups, however, all 7 scores were higher in women than in men, statistically significant for PN, PATGL, RAPID3 and fatigue in RA, and only for fatigue in SpA. In analyses adjusted for gender, FN, PATGL, FT, and RAPID3 were statistically significantly higher in SpA than in RA (Table 1).

Table 1.

Mean differences in the MDHAQ scores between RA and SpA patients.

Total, n=170 patientsRA, n=102SpA, n=68RA: Female(n=84)/Male (n=18)SpA: Female (n=32)/ Male n=36)Mean difference: RA–SpA (95% CIs)UnadjustedMean difference: RA–SpA (95% CIs)Adjusted for age, gender, and educationAge, mean (SD)58.8 (12.2)55.7 (12.2)Gender, female (%)84 (82.4%)32 (47.1%)*Years of education, mean (SD)11.8 (4.3)11.4 (3.7)MDHAQ variables, mean (SD)Physical function (0-10)2.4 (1.8)3.0 (2.1)2.5 (1.8)/ 1.9 (1.6)3.1 (2.0)/ 2.9 (2.2)-0.6 (-1.2, -0.02)-0.7 (-1.3, -0.05)Pain (0-10 VNS)4.5 (2.8)4.9 (3.0)4.8 (2.8)/ 3.3 (2.4)*5.5 (2.9)/ 4.4 (3.0)-0.4 (-1.3, 0.5)-0.8 (-1.7, 0.1)Patient global assessment (0-10 VNS)4.6 (2.8)5.3 (2.9)4.9 (2.8)/ 3.4 (2.6)*5.9 (2.8)/ 4.7 (3.0)-0.6 (-1.5, 0.2)-1.1 (-2.0, -0.2)RAPID3 (0-30)11.6 (6.8)13.3 (7.3)12.3 (6.8)/ 8.5 (6.1)*14.6 (7.2)/ 12.2 (7.3)-1.7 (-3.8, 0.4)-2.7 (-4.9, -0.5)Fatigue (0-10 VNS)4.2 (2.9)4.5 (3.1)4.7 (2.9)/ 2.0 (2.1)*5.5 (3.1)/ 3.6 (2.9)*-0.3 (-1.2, 0.6)-1.0 (-1.9, -0.04)Self-report RADAI painful joint count (0-48)12.4 (11.0)13.4 (11.9)13.2 (11.4)/ 8.6 (8.5)15.6 (13.1)/ 11.5 (10.6)-1.0 (-4.5, 2.4)-2.2 (-5.8, 1.4)60-symptom checklist (0-60)12.6 (10.0)15.2 (10.9)13.3 (10.3)/ 9.4 (7.8)16.0 (10.3)/ 14.6 (11.6)-2.6 (-5.8, 0.6)-2.5 (-5.8, 0.7)

*= p<0.05.

Conclusion

The self-reported disease burden measured by MDHAQ / RAPID3 was higher in patients with SpA than in those with RA, despite having a lower proportion of women, who generally have higher scores on all patient self-report questionnaires, including MDHAQ/RAPID3, within both the RA and SpA groups. Gender differences may lead to underestimation of the greater disease burden in SpA compared to RA.

References

[1]Sokka T. Arthritis Res Therapy. 2009; 11: R7. 2. Castrejon I. Bull Hosp Jt Dis. 2017;75(2):93-100.

Disclosure of Interests

None declared

AB1477 MEDIAN 0-10 PATIENT GLOBAL ASSESSMENT WAS 2.5-5 POINTS HIGHER IN INFLAMMATORY ARTHRITIS PATIENTS POSITIVE VS NEGATIVE FOR FAST4 (FIBROMYALGIA ASSESSMENT SCREENING TOOL) AND/OR MSD2 (MDHAQ DEPRESSION SCREEN): 2 EASILY-SCORED MULTIDIMENSIONAL HEALTH ASSESSMENT QUESTIONNAIRE (MDHAQ) INDICES

Background

Patient global assessment (PATGL) is included in DAS28, CDAI, ASDAS, DAPSA, and other indices to assess rheumatoid arthritis (RA) or spondyloarthropathy (SpA). PATGL reflects inflammatory activity in many patients, but may be elevated by comorbid fibromyalgia (FM) and/or depression (Dep), which are often unrecognized in others, complicating interpretation and use in treat-to-target. A 2-page multidimensional health assessment questionnaire (MDHAQ) includes PATGL and two easily scored cumulative indices, FAST4 (0-4 FM assessment screening tool) and MDS2 (0-2 MDHAQ Dep screen), which agree more than 80% with reference 2011 revised FM criteria, HADS-D and PHQ-9,1-3 and may clarify interpretation of high PATGL and index scores, particularly in busy clinical settings.

Objectives

Analysis of PATGL in patients with RA or SpA according to MDHAQ FAST4 and/or MDS2 positivity (+) or negativity (-).

Methods

MDHAQ was completed at a routine care visit at 3 sites in Australia, Spain, and USA. Medians and interquartile ranges (IQRs) for PATGL were computed for RA and SpA, according to FAST4 + or – and/or MDS2 + or -. Differences between medians of PATGL with 95% confidence intervals (CIs) for FAST4 and/or MDS2 were estimated from median regression models that included FAST4 and MDS2 for each setting, and setting for pooled analyses.

Results

Among 393 RA and 175 SpA patients, 23.0%-32.7% were FAST4+ and 29.4%-36.7% MDS2+, with 41.1% positive for either FAST4 or MDS2 (data not shown). PATGL medians were 4.8-5.0 in all RA and 3.0-6.0 in SpA, 2.0-3.0 in FAST4-/MDS2-, 5.5-6.0 in FAST4-/MDS2+, 7.0-7.5 in FAST4+/MDS2-, and 7.0-8.0 in FAST4+/MDS2+ patients, similar in RA and SpA at 3 settings in 3 continents (Table 1). Adjusted median differences were 3.0–3.5 for FAST4 + vs - (twice the level for FAST4 -, MDS2 -) and 2.0–2.5 for MDS2 + vs - groups (Table 1).

Table 1.

Median scores and interquartile ranges for PATGL according to positive or negative FAST4 and/or MDS2

Primary ICD10 diagnosisTotalFAST4 NEG MDS2 NEGFAST4 NEG MDS2 POSFAST4 POS MDS2 NEGFAST4 POS MDS2 POSAdjusted median difference (95% CI) (FAST4 POS – FAST4 NEG)Adjusted median difference (95% CI) (MDS2 POS – MDS2 NEG)Three sites pooledn=518n=305 (58.9%)n=71 (13.7%)n=50 (9.7%)n=92 (17.8%)RA3553.0 (1.0, 5.0)5.5 (3.6, 6.5)7.5 (6.5, 8.5)8.0 (7.0, 9.0)3.5 (2.8, 4.2)2.0 (1.4, 2.6)SpA1632.5 (1.0, 5.0)6.0 (4.0, 6.5)7.3 (6.8, 8.5)8.0 (6.5, 10.0)3.0 (2.1, 3.9)2.5 (1.5, 3.5)Australian=257n=155 (60.3%)n=35 (13.6%)n=22 (8.6%)n=45 (17.5%)RA1823.0 (1.0, 5.0)5.5 (4.5, 6.5)7.5 (7.0, 8.0)8.0 (7.0, 9.0)4.0 (3.0, 5.0)1.5 (0.5, 2.5)SpA752.5 (1.0, 5.0)4.5 (2.0, 6.8)9.0 (7.0, 9.5)8.0 (7.0, 8.5)4.0 (2.2, 5.8)1.0 (-0.8, 2.8)Spainn=169n=90 (53.3%)n=27 (16.0%)n=18 (10.7%)n=34 (20.1%)RA1013.0 (1.0, 4.5)5.5 (3.6, 6.8)6.0 (5.5, 7.0)8.5 (8.0, 8.5)3.0 (2.1, 3.9)2.5 (1.7, 3.3)SpA683.0 (0.8, 5.0)6.5 (6.0, 7.0)7.3 (6.5, 8.0)7.5 (6.5, 10.0)3.0 (1.1, 4.9)2.5 (0.9, 4.1)USAn=92n=60 (65.2%)n=9 (9.8%)n=10 (10.9%)n=13 (14.1%)RA723.0 (1.0, 6.0)6.0 (3.5, 7.0)8.5 (8.0, 9.5)7.0 (7.0, 9.0)5.0 (2.7, 7.3)1.0 (-1.3, 3.3)SpA202.0 (1.0, 4.5)2.0 (1.0, 3.0)7.0 (7.0, 7.0)*8.5 (5.5, 10.0)5.0 (0.5,10.5)0 (-3.3, 3.3)*

NEG = negative, POS = positive, NA=Not available (No patients or the adjusted median differences cannot be estimated due to the small number of patients), *=Only one patient in category.

Conclusion

Median 0-10 PATGL was 2-3-fold higher in 41.1% of RA or SpA patients with positive MDHAQ FM and/or DEP screening indices vs 59% with 2 negative indices. Differences were greater according to FM than Dep. MDHAQ may clarify interpretation of PATGL and indices, including in treat–to–target, using a single, brief, feasible questionnaire in research and busy clinical settings.

References

[1]Schmukler et al. ACR Open Rheumatol. 2019;1:516-25.

[2]Gibson et al, J Rheumatol. 2020;47:761-9.

[3]Morla et al, Arthritis Care & Research. 2021;73:120-9.

Disclosure of Interests

Tengfei Li: None declared, Kathryn Gibson Grant/research support from: Dr. Gibson has received honoraria from UCB, Novartis, and Janssen and grants support from Novartis., Employee of: Dr. Gibson is a part-time employee of Eli Lilly but no financial or other support was received from Eli Lilly in the creation of this abstract., Theodore Pincus: None declared, Juan Schmukler: None declared, Rosa Morlà: None declared, George Luta: None declared

Cancer-Related Cognitive Outcomes Among Older Breast Cancer Survivors in the Thinking and Living With Cancer Study

PURPOSE

To determine treatment and aging-related effects on longitudinal cognitive function in older breast cancer survivors.

METHODS

Newly diagnosed nonmetastatic breast cancer survivors (n = 344) and matched controls without cancer (n = 347) 60 years of age and older without dementia or neurologic disease were recruited between August 2010 and December 2015. Data collection occurred during presystemic treatment/control enrollment and at 12 and 24 months through biospecimens; surveys; self-reported Functional Assessment of Cancer Therapy-Cognitive Function; and neuropsychological tests that measured attention, processing speed, and executive function (APE) and learning and memory (LM). Linear mixed-effects models tested two-way interactions of treatment group (control, chemotherapy with or without hormonal therapy, and hormonal therapy) and time and explored three-way interactions of ApoE (ε4+ v not) by group by time; covariates included baseline age, frailty, race, and cognitive reserve.

RESULTS

Survivors and controls were 60 to 98 years of age, were well educated, and had similar baseline cognitive scores. Treatment was related to longitudinal cognition scores, with survivors who received chemotherapy having increasingly worse APE scores ( P = .05) and those initiating hormonal therapy having lower LM scores at 12 months ( P = .03) than other groups. These group-by-time differences varied by ApoE genotype, where only ε4+ survivors receiving hormone therapy had short-term decreases in adjusted LM scores (three-way interaction P = .03). For APE, the three-way interaction was not significant ( P = .14), but scores were significantly lower for ε4+ survivors exposed to chemotherapy (-0.40; 95% CI, -0.79 to -0.01) at 24 months than ε4+ controls (0.01; 95% CI, 0.16 to 0.18; P < .05). Increasing age was associated with lower baseline scores on all cognitive measures ( P < .001); frailty was associated with baseline APE and self-reported decline ( P < .001).

CONCLUSION

Breast cancer systemic treatment and aging-related phenotypes and genotypes are associated with longitudinal decreases in cognitive function scores in older survivors. These data could inform treatment decision making and survivorship care planning.

Clinical and Psychological Predictors of Switching from Active Surveillance to Active Treatment among Men with Low-Risk Prostate Cancer: the PREPARE Prospective Cohort Study

Numerous observational studies have assessed the clinical predictors of switching from active surveillance (AS) to active treatment (AT), but few have assessed psychological and decisional predictors. In a prospective, comparative effectiveness cohort study of men newly diagnosed with low-risk PCa, we assessed whether psychological and decisional factors predicted switching to AT after adjusting for clinical factors. We conducted pre-treatment telephone interviews (N = 1,139; 69.3% participation) with low-risk PCa patients (PSA &lt; 10, Gleason &lt; 7) and a follow-up assessment 6–10 months post-diagnosis (N = 1057; 93%). Clinical variables were obtained from the medical record. The current analysis included men who were on AS for up to 24 months (N = 515), compared to men on AS for &gt;12 months who switched to AT between 12–24 months (N = 86). In Cox proportional hazard models, we included 2 time-dependent covariates measured between diagnosis and 24-months post-diagnosis: PSA (&lt;4, 4–9.99, 10+) and Gleason score (&lt;7, 7+, no surveillance biopsy). Baseline covariates included age (X = 62.3 (SD = 7.0), first degree relative with PCa (25%), number of positive cores (&lt;2 = 75%), urologist initial treatment recommendation (14% AT). Covariates measured at 6 months included prostate- specific anxiety, decisional satisfaction, decisional uncertainty, and preference for shared vs. independent decisions. The fully adjusted model indicated that switching to an active treatment was more likely among those with a PSA &gt; 10 (HR 5.6, 2.4–13.1), Gleason 7+ (HR 20.2, 12.2–33.4), and the urologist's initial recommendation of AT (HR 2.1, 1.04–4.2). The psychological variables, including preference for making independent treatment decisions (HR 2.7, 1.07–6.9) and concern that disease progression will not be detected (HR 1.5, 0.95–2.4), were independently associated with undergoing AT. After adjusting for clinical evidence of disease progression over the first two years post-diagnosis, men's concerns that disease progression will not be detected and preference for making their own treatment decision each independently predicted undergoing AT. These findings suggest the need to provide information and assistance to men who may be uncertain about remaining on AS, particularly when AS remains clinically indicated.

Long-term trajectories of self-reported cognitive function in a cohort of older survivors of breast cancer: CALGB 369901 (Alliance)

BACKGROUND

The number of survivors of breast cancer aged ≥65 years (“older”) is growing, but to the authors' knowledge, little is known regarding the cognitive outcomes of these individuals.

METHODS

A cohort of cognitively intact older survivors with nonmetastatic, invasive breast cancer was recruited from 78 sites from 2004 through 2011; approximately 83.7% of the survivors (1280 survivors) completed baseline assessments. Follow‐up data were collected at 6 months and annually for up to 7 years (median, 4.1 years). Cognitive function was self‐reported using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ‐C30); scores ranged from 0 to 100, with a higher score indicating better function. Group‐based trajectory modeling determined trajectories; women were assigned to a trajectory group based on the highest predicted probability of membership. Multinomial logistic regression evaluated the association between receipt of chemotherapy (with or without hormonal treatment) and trajectory group.

RESULTS

Survivors were aged 65 to 91 years; approximately 41% received chemotherapy. There were 3 cognitive trajectories: “maintained high” (42.3% of survivors); “phase shift” (50.1% of survivors), with scores slightly below but parallel to maintained high; and “accelerated decline” (7.6% of survivors), with the lowest baseline scores and greatest decline (from 71.7 [standard deviation, 19.8] to 58.3 [standard deviation, 21.9]). The adjusted odds of being in the accelerated decline group (vs the maintained high group) were 2.1 times higher (95% confidence interval, 1.3‐3.5) for survivors who received chemotherapy (with or without hormonal therapy) versus those treated with hormonal therapy alone. Greater comorbidity and frailty also were found to be associated with accelerated decline.

CONCLUSIONS

Trajectory group analysis demonstrated that the majority of older survivors maintained good long‐term self‐reported cognitive function, and that only a small subset who were exposed to chemotherapy manifested accelerated cognitive decline. Future research is needed to determine factors that place some older survivors at risk of experiencing cognitive decline. Cancer 2016;122:3555–3563. © 2016 American Cancer Society

Among older survivors of breast cancer who were followed for up to 7 years, approximately 42% reported maintaining high cognitive function, but receipt of chemotherapy (with or without hormonal therapy) appeared to double the odds of being in the group that reported accelerated cognitive decline (vs maintaining high function), compared with receiving hormonal treatment alone. Further research is needed to determine factors that place some older survivors at risk of experiencing cognitive decline.

Motivators and barriers to Latinas' participation in clinical trials: the role of contextual factors

OBJECTIVE

Latinas are underrepresented in clinical trials despite the rise in Hispanic population. This study examines the factors associated with Latinas' willingness to participate in preventive breast cancer randomized clinical trials (RCTs).

METHODS

Women self-identifying as Latina, over age 40, with no prior history of breast cancer were eligible. Using the Behavior Model for Vulnerable Populations, we administered a survey (n=168) to assess predisposing (e.g., knowledge), enabling (e.g., trust) and need factors (e.g., risk perception). Intention to participate was defined using a lenient (maybe, probably or definitely) and a stringent criterion (probably and definitely). Chi-square tests and logistic regression models examined the associations of predisposing, enabling, and need factors with women's intentions to participate in RCTs.

RESULTS

Most participants (74.9%) were monolingual Spanish-speaking immigrants. Most (83.9%) reported willing to participate in clinical trials using the lenient definition (vs. 43.1% under the stringent definition). Using the lenient definition, the odds of willing to participate in RCTs were significantly lower for unmarried women (OR=.25, 95% CI=.08-.79) and those with lower cancer risk perceptions (OR=.20, 95% CI=.06-.63), while being significantly higher for women with lower language acculturation (OR=6.2, 95% CI=1.8-20.9). Using the stringent definition, women who did not endorse a motivation to enroll to help family members (if they had cancer) had significantly lower odds to report intent (OR=.33, 95% CI=.13-.86).

CONCLUSION

Many RCTs may have limited generalizability due to the low representation of minorities. Culturally targeted interventions that address the importance of family for Latinos may ultimately increase their participation in RCTs.

Preliminary Development and Evaluation of an Algorithm to Identify Breast Cancer Chemotherapy Toxicities Using Electronic Medical Records and Administrative Data

PURPOSE

Breast cancer chemotherapy toxicity is not well documented outside of randomized trials. We developed and conducted preliminary evaluation of an algorithm to detect grade 3 and 4 toxicities using electronic data from a large integrated managed care organization.

METHODS

The algorithm used administrative, pharmacy, and electronic data from outpatient, emergency room, and inpatient records of 99 women diagnosed with breast cancer from 2006 to 2009 who underwent chemotherapy. Data were abstracted for 12 months post-treatment initiation (24 months for trastuzumab recipients). An oncology nurse independently blindly reviewed records; these results were the "gold standard." Sensitivity and specificity were calculated for overall toxicity, categories of toxicities, and toxicity by age or regimen. The algorithm was applied to an independent sample of 1,575 patients with breast cancer diagnosed during the study period to estimate prevalence rates.

RESULTS

The overall sensitivity for detecting chemotherapy-related toxicity was 89% (95% CI, 77% to 95%). The highest sensitivity was for identification of hematologic toxicities (97%; 95% CI, 84% to 99%). There were good sensitivities for infectious toxicity, but rates dropped for GI and neurological toxicities. Specificity was high within each category (89% to 99%), but when combined to measure any toxicity, it was lower (70%; 95% CI, 57% to 81%). When applied to an independent chemotherapy sample, the algorithm estimates a 26% rate of hematologic toxicity; rates were higher among patients age ≥ 65 years versus less than 65 years.

CONCLUSIONS

If validated in other samples and health care settings, algorithms to capture toxicity could be useful in comparative and cost-effectiveness evaluations of community practice-delivered treatment.

Cognitive impairment in older patients with breast cancer before systemic therapy: is there an interaction between cancer and comorbidity?

PURPOSE

To determine if older patients with breast cancer have cognitive impairment before systemic therapy.

PATIENTS AND METHODS

Participants were patients with newly diagnosed nonmetastatic breast cancer and matched friend or community controls age > 60 years without prior systemic treatment, dementia, or neurologic disease. Participants completed surveys and a 55-minute battery of 17 neuropsychological tests. Biospecimens were obtained for APOE genotyping, and clinical data were abstracted. Neuropsychological test scores were standardized using control means and standard deviations (SDs) and grouped into five domain z scores. Cognitive impairment was defined as any domain z score two SDs below or ≥ two z scores 1.5 SDs below the control mean. Multivariable analyses evaluated pretreatment differences considering age, race, education, and site; comparisons between patient cases also controlled for surgery.

RESULTS

The 164 patient cases and 182 controls had similar neuropsychological domain scores. However, among patient cases, those with stage II to III cancers had lower executive function compared with those with stage 0 to I disease, after adjustment (P = .05). The odds of impairment were significantly higher among older, nonwhite, less educated women and those with greater comorbidity, after adjustment. Patient case or control status, anxiety, depression, fatigue, and surgery were not associated with impairment. However, there was an interaction between comorbidity and patient case or control status; comorbidity was strongly associated with impairment among patient cases (adjusted odds ratio, 8.77; 95% CI, 2.06 to 37.4; P = .003) but not among controls (P = .97). Only diabetes and cardiovascular disease were associated with impairment among patient cases.

CONCLUSION

There were no overall differences between patients with breast cancer and controls before systemic treatment, but there may be pretreatment cognitive impairment within subgroups of patient cases with greater tumor or comorbidity burden.

Associations among survivorship care plans, experiences of survivorship care, and functioning in older breast cancer survivors: CALGB/Alliance 369901

PURPOSE

Survivorship care plans (SCP) are recommended for all cancer patients and could be especially useful to survivors 65 years and over ("older"). This study examined receipt of SCPs among older breast cancer survivors and whether SCPs were associated with improved patient-reported outcomes.

METHODS

Three hundred and twenty-eight older women diagnosed with invasive, nonmetastatic breast cancer between 2007-2011 were recruited from 78 cooperative-group sites. Participants completed telephone interviews at baseline and 1-year posttreatment. Regression analyses examined SCP receipt (yes/no) and functioning (EORTC-QLQ-C30), cancer worry, and experiences of survivorship care (care coordination, knowledge).

RESULTS

Only 35% of women received SCPs. For each 1-year increase in age, there was a 5% lower odds of receiving an SCP (odds ratio (OR) = 0.94, 95% confidence interval (CI) 0.91-0.98, p = 0.007). Besides age, no other factor predicted SCPs. SCP receipt was associated with greater knowledge and understanding of requisite follow-up care (p < 0.05); however, functioning was not significantly different among those with vs. without SCPs.

CONCLUSIONS

Receipt of care plans was limited. SCPs improved understanding of breast cancer follow-up care among older survivors, but did not impact functioning one year post-treatment.

IMPLICATIONS FOR CANCER SURVIVORS

To impact functioning and salient needs of the growing cohort of older survivors, survivorship care plans likely should be tailored to geriatric-specific issues. To improve functioning, SCP content should expand to include exercise, nutrition, polypharmacy, social support and management of symptom burden from cancer, and other comorbid conditions. To improve follow-up care for cancer survivors, SCPs should delineate shared care roles between oncology and primary care in managing recurrence surveillance, screening, and cancer sequelae.

Authoritative parenting and cigarette smoking among multiethnic preadolescents: the mediating role of anti-tobacco parenting strategies

INTRODUCTION

Parenting has been shown to affect smoking among children in U.S. majority groups, but less is known about this association among multiethnic urban populations. Our study examines the role of parenting on smoking among a highly diverse sample.

METHODS

Health surveys were collected from eighth graders (N = 459) in 2 low-income urban schools. Structural equation models examined the direct and indirect effects of authoritative parenting on lifetime smoking. A moderated mediation analysis examined whether indirect effects of authoritative parenting vary among racial/ethnic groups.

RESULTS

Authoritative controlling parenting, characterized by limit setting, was positively associated with anti-tobacco parenting. Anti-tobacco parenting was inversely associated with smoking, mediating the relationship between controlling parenting and smoking. There was no evidence that mediation was moderated by race/ethnicity.

CONCLUSIONS

Parent training, which focuses on setting rules and expectations, can be an important and universal element of smoking prevention programs targeted to youth in diverse communities.

A planned, prospective comparison of short-term quality of life outcomes among older patients with breast cancer treated with standard chemotherapy in a randomized clinical trial vs. an observational study: CALGB #49907 and #369901

OBJECTIVES

Patients ≥ 65 years old ("older") are often not included in randomized clinical trials (RCT), but when they are, care in an RCT might improve quality of life (QoL). We conducted a prospective comparison of QoL among older women receiving standard chemotherapy from the same cooperative group physicians in an RCT vs. an observational study ("off-trial").

METHODS

Older women with invasive, non-metastatic breast cancer (n=150 RCT; 530 off-trial) were included. Linear mixed-effects models tested associations between chemotherapy on- vs. off-trial and changes in EORTC (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire) QoL scores over 24 months, controlling for pre-treatment QoL, age, education, tumor factors, comorbidity, and other covariates.

RESULTS

Anthracycline regimens were used by 58% of women treated on-trial vs. 54% of those treated off-trial. Women in the RCT reported an adjusted mean increase of 13.7 points (95% CI 10.2, 17.1) in global QoL at 24 months (vs. mid-treatment), while women treated off-trial had only an adjusted improvement of 7.0 points (95% CI 3.5, 10.4; p=.007 for difference in mean changes). Women in the RCT had significantly greater improvement in emotional function than those treated off-trial, controlling for baseline; they also had greater reductions in therapy side effects and fatigue at 24 months than women off-trial, controlling for covariates.

CONCLUSION

There may be different QoL trajectories for older women undergoing breast cancer chemotherapy on- vs. off-trial. If confirmed, the results suggest that the extra monitoring and communication within an RCT could provide the infrastructure for interventions to address symptoms and improve QoL for the growing older cancer population.

Patient and provider factors associated with colorectal cancer screening in safety net clinics serving low-income, urban immigrant Latinos

BACKGROUND

Latinos have lower colorectal cancer screening rates than Whites.

METHODS

We reviewed a random sample of charts between July 2009 and February 2010 of safety-net clinic of 840 immigrants (50 years and older) from Central and South America receiving care. Logistic regression evaluated associations of ever vs. never screening, patient and physician factors.

RESULTS

Ever screening rates were 24.5%, and only 17% of charts noted a physician screening recommendation. However, the odds of screening were 9.89 times higher (95% CI: 6.25-15.64, p<.001) among patients with a physician recommendation vs. those without, considering covariates. The odds of screening were 0.61 times lower (95% CI: 0.40-0.92, p=.02) in patients with a body mass index ≥ 30 vs. <30.

CONCLUSIONS

While rates were low, determinants of screening were similar in this Latino subgroup to those reported in other Latino and non-Latino populations. Low rates of documented physician screening recommendations may indicate a potential missed opportunity for cancer control in safety-net clinics.

Hospice knowledge and intentions among Latinos using safety-net clinics

BACKGROUND

Hospice use is low in Latinos but we know little about explanations for this pattern.

OBJECTIVE

To describe factors associated with knowledge of and intention to use hospice for cancer care.

METHODS

We conducted a Spanish-language, interviewer-administered cross-sectional survey of 331 Latino immigrants from Central and South America in safety-net clinics. Hospice intentions were measured using a hypothetical scenario. We used logistic regression and multiple imputations to test associations between cultural values, social acculturation, and other variables and knowledge and intentions.

RESULTS

Only 29% knew about hospice and 35% would choose hospice care (once it was defined). Collectivist (group-focused) views (odds ratio [OR] 1.06 per 1-point increase, 95% confidence interval [CI] 1.01-1.12, p=.05), endorsing family-centric values (OR 1.03 per 1-point increase, 95% CI 1.01-1.04, p=.004), and higher education were associated with greater hospice knowledge after considering covariates. Greater social ties were also independently associated with greater knowledge, but knowledge was not related to hospice intentions. Individuals who believed in maintaining secrecy about prognosis were 19% less likely to choose hospice than those who did not endorse secrecy (OR 0.81, 95% CI 0.67-0.99, p = .038). The most socially acculturated individuals were significantly more likely to choose hospice than those with less acculturation (OR 1.19 for each 1-unit increase, 95% CI 10.6-1.34, p = .004).

CONCLUSIONS

Hospice knowledge may be necessary but is not sufficient to increase hospice use among immigrant Latinos. Latino social networks and organizations may provide a natural leverage point for interventions. Interventions to increase hospice use may need to consider culturally related values.

Assessing the awareness of and willingness to participate in cancer clinical trials among immigrant Latinos

Clinical trials are considered the gold standard of evidence about the efficacy of cancer prevention, early detection, and treatment interventions. A paucity of data exists on determinants of clinical trial participation in the growing US Latino population despite poor cancer outcomes in this group. This study seeks to describe correlates of awareness of and willingness to participate in clinical trials among largely Central, North, and South American Latinos using safety-net clinics. Between June 2007 and November 2008, we conducted an interviewer-administered, Spanish-language cross-sectional survey (n = 944). Logistic regression was used to assess effects of health information sources and psychosocial variables on awareness of and intention to participate in clinical trials. Analyses were completed in spring 2010. While only 48% knew what a clinical trial was, when explained, 65% indicated a willingness to participate. Providers were the most common source of health information. Use of Internet for health information, trust in health information, and higher education each independently increased the odds of clinical trial awareness, but obtaining information from providers did not. Contacting the Cancer Information Service and psychosocial factors were each independently associated with intent to join a clinical trial, while demographic factors were not. Information channels such as the Internet may be effective in conveying clinical trial information to Latinos. Providers being cited as the most common source of health information but not being associated with knowledge about or intent to participate in trials suggests a missed opportunity for communication to this population.

Interest in genetic testing for modest changes in breast cancer risk: implications for SNP testing

BACKGROUND

Advances in genomics may eventually lead to 'personalized genetic medicine,' yet the clinical utility of predictive testing for modest changes in risk is unclear. We explored interest in genetic testing for genes related to modest changes in breast cancer risk in women at moderate to high risk for breast cancer.

METHODS

Women (n = 105) with a negative breast biopsy and ≥1 relative with breast or ovarian cancer completed telephone surveys. We measured demographic and psychosocial variables and, following presentation of hypothetical scenarios of genetic tests for lower-penetrance breast cancer gene mutations, assessed interest in willingness to pay for and comprehension of test results. We used logistic regression models with generalized estimating equations to evaluate combinations of risk level, cost and behavioral modifiers.

RESULTS

Many women (77%) reported 'definite' interest in genetic testing, with greater interest in tests that conveyed more risk and cost less. Behavioral modifiers of risk (taking a vitamin; diet/exercise), having a regular physician, greater perceived benefits of genetic testing, and greater cancer worry also influenced interest. Most participants (63%) did not understand relative vs. absolute risk. Women with less understanding reported more cancer worry and greater willingness to pay for testing.

CONCLUSION

Interest in genetic testing for mutations related to modest changes in risk was high, modified by both test and psychosocial factors. Findings highlight the need for education about benefits and risks of testing for mutations that convey modest changes in risk, particularly given the current lack of clinical validity/utility and availability of direct-to-consumer genetic testing.

One in four people may develop symptomatic hip osteoarthritis in his or her lifetime

OBJECTIVE

To estimate the lifetime risk of symptomatic hip osteoarthritis (OA).

DESIGN

We analyzed data from the Johnston County Osteoarthritis Project [a longitudinal population-based study of OA in North Carolina, United States (n=3068)]. The weighted baseline sample comprised 18% blacks and 54% women, and the mean age was 63 years (range=45-93). Symptomatic hip OA was defined as a Kellgren-Lawrence (K-L) radiographic score of ≥ 2 (anterior-posterior pelvis X-rays) and pain, aching or stiffness on most days, or groin pain, in the same hip. Lifetime risk, defined as the proportion who developed symptomatic hip OA in at least one hip by age 85, among people who live to age 85, was modeled using logistic regression with repeated measures (through generalized estimating equations).

RESULTS

Lifetime risk of symptomatic hip OA was 25.3% [95% confidence interval (CI)=21.3-29.3]. Lifetime risk was similar by sex, race, highest educational attainment, and hip injury history. We studied lifetime risk by body mass index (BMI) in three forms: at age 18; at baseline and follow-up; and at age 18, baseline and follow-up and found no differences in estimates.

CONCLUSION

The burden of symptomatic hip OA is substantial with one in four people developing this condition by age 85. The similar race-specific estimates suggest that racial disparities in total hip replacements are not attributable to differences in disease occurrence. Despite increasing evidence that obesity predicts an increased risk of both hip OA and joint replacement, we found no association between BMI and lifetime risk.

Breast cancer adjuvant chemotherapy decisions in older women: the role of patient preference and interactions with physicians

PURPOSE

Breast cancer chemotherapy decisions in patients > or = 65 years old (older) are complex because of comorbidity, toxicity, and limited data on patient preference. We examined relationships between preferences and chemotherapy use.

METHODS

Older women (n = 934) diagnosed with invasive (> or = 1 cm), nonmetastatic breast cancer from 2004 to 2008 were recruited from 53 cooperative group sites. Data were collected from patient interviews (87% complete), physician survey (93% complete), and charts. Logistic regression and multiple imputation methods were used to assess associations between chemotherapy and independent variables. Chemotherapy use was also evaluated according to the following two groups: indicated (estrogen receptor [ER] negative and/or node positive) and possibly indicated (ER positive and node negative).

RESULTS

Mean patient age was 73 years (range, 65 to 100 years). Unadjusted chemotherapy rates were 69% in the indicated group and 16% in the possibly indicated group. Women who would choose chemotherapy for an increase in survival of < or = 12 months had 3.9 times (95% CI, 2.4 to 6.3 times; P < .001) higher odds of receiving chemotherapy than women with lower preferences, controlling for covariates. Stronger preferences were seen when chemotherapy could be indicated (odds ratio [OR] = 7.7; 95% CI, 3.8 to 16; P < .001) than when treatment might be possibly indicated (OR = 1.9; 95% CI, 1.0 to 3.8; P = .06). Higher patient rating of provider communication was also related to chemotherapy use in the possibly indicated group (OR = 1.9 per 5-point increase in communication score; 95% CI, 1.4 to 2.8; P < .001) but not in the indicated group (P = .15).

CONCLUSION

Older women's preferences and communication with providers are important correlates of chemotherapy use, especially when benefits are more equivocal.

Patient preference as a determinant of breast cancer adjuvant chemotherapy use in older women: CALGB #369901

9544

Background: Decisions about use of breast cancer chemotherapy in women 65 and older (“older”) can be complex due to comorbidity, uncertain efficacy and limited data on patient preference. Methods: Older women diagnosed with invasive, non-metastatic breast cancer between 2004 and 2008 were recruited from 53 CALGB sites for an observational study of preferences and chemotherapy use. Data on preferences and other factors were collected from patient interviews and clinical data were abstracted from charts. Generalized estimating equation regression was used to assess associations between chart-reported chemotherapy and independent variables; associations were also evaluated in 2 subgroups: “chemotherapy indicated” (estrogen receptor [ER] negative and/or node positive) and “consider chemotherapy” (ER positive and node negative). Results: Among 935 eligible women registered, 815 (87.2%) completed interviews. The mean age of the cohort was 73 years (range 65–100); 38% were node positive, 82% were ER positive and all had tumors ≥ 1 cm (44% were AJCC stage 1, 44% stage 2 and 12% stage 3). Based on ER and nodal status, chemotherapy was “indicated” for 47% and could be “considered” for 53%. Crude chemotherapy rates were 70% in the “indicated” group and 17% in the “considered” group, for an overall rate of 42%. Women who would choose chemotherapy for an increase in survival of ≤12 months were 4.1 times (95% CI 2.5–6.7, p<.0001) more likely to receive chemotherapy than women who would only choose chemotherapy if it added more than 12 months, controlling for age, tumor factors, comorbidity and other covariates. Stronger preferences were seen among women with “indications” for chemotherapy (OR 7.9, 95% CI 3.7–17.0, p<.001) than in those where treatment might be “considered” (OR 1.8, 95% CI 0.9–3.4, p=.08). Higher patient rating of communication with providers was independently related to a decision to use chemotherapy among women where chemotherapy could be “considered” but not among those where chemotherapy was “indicated”. Conclusions: Beyond clinical indications, older women's preferences and communication with providers are important correlates of chemotherapy use.

[Table: see text]

Prevalence of hip symptoms and radiographic and symptomatic hip osteoarthritis in African Americans and Caucasians: the Johnston County Osteoarthritis Project

OBJECTIVE

To report contemporary estimates of the prevalence of hip-related osteoarthritis (OA) outcomes in African Americans and Caucasians aged>or=45 years.

METHODS

Weighted prevalence estimates and their corresponding 95% confidence intervals for hip symptoms, radiographic hip OA, symptomatic hip OA, and severe radiographic hip OA were calculated using SUDAAN for age, race, and sex subgroups among 3068 participants (33% African Americans, 38% men) in the baseline examination (1991-97) of The Johnston County Osteoarthritis Project, a population-based study of OA in North Carolina. Radiographic hip OA was defined as Kellgren-Lawrence radiographic grade>or=2, moderate/severe radiographic hip OA as grades 3 and 4, and symptomatic hip OA as hip symptoms in a hip with radiographic OA.

RESULTS

Hip symptoms were present in 36%; 28% had radiographic hip OA; nearly 10% had symptomatic hip OA; and 2.5% had moderate/severe radiographic hip OA. Prevalence of all 4 outcomes was higher in older individuals; most outcomes were higher for women and African Americans.

CONCLUSION

African Americans in this population do not have a lower prevalence of hip-related OA outcomes as previous studies suggested. Increasing public and health system awareness of the relatively high prevalence of these outcomes, which can be disabling, may help to decrease their effects and ultimately prevent them.

Efficacy of prednisone 1-4 mg/day in patients with rheumatoid arthritis: a randomised, double-blind, placebo controlled withdrawal clinical trial

Objective:

A randomised double-blind placebo controlled withdrawal clinical trial of prednisone versus placebo in patients with rheumatoid arthritis (RA), treated in usual clinical care with 1–4 mg/day prednisone, withdrawn to the same dose of 1 mg prednisone or identical placebo tablets.

Methods:

All patients were from one academic setting and all trial visits were conducted in usual clinical care. Patients were taking stable doses of 1–4 mg prednisone with stable clinical status, documented quantitatively by patient questionnaire scores. The protocol included three phases: (1) equivalence: 1–4 study prednisone 1 mg tablets taken for 12 weeks to ascertain their efficacy compared with the patient’s usual tablets before randomisation; (2) transfer: substitution of a 1 mg prednisone or identical placebo tablet every 4 weeks (over 0–12 weeks) to the same number as baseline prednisone; (3) comparison: observation over 24 subsequent weeks taking the same number of either placebo or prednisone tablets as at baseline. The primary outcome was withdrawal due to patient-reported lack of efficacy versus continuation in the trial for 24 weeks.

Results:

Thirty-one patients were randomised, 15 to prednisone and 16 to placebo, with three administrative discontinuations. In “intent-to-treat” analyses, 3/15 prednisone and 11/16 placebo participants withdrew (p = 0.03). Among participants eligible for the primary outcome, 3/13 prednisone and 11/15 placebo participants withdrew for lack of efficacy (p = 0.02). No meaningful adverse events were reported, as anticipated.

Conclusion:

Efficacy of 1–4 mg prednisone was documented. Evidence of statistically significant differences with only 31 patients may suggest a robust treatment effect.

Lifetime risk of symptomatic knee osteoarthritis

OBJECTIVE

To estimate the lifetime risk of symptomatic knee osteoarthritis (OA), overall and stratified by sex, race, education, history of knee injury, and body mass index (BMI).

METHODS

The lifetime risk of symptomatic OA in at least 1 knee was estimated from logistic regression models with generalized estimating equations among 3,068 participants of the Johnston County Osteoarthritis Project, a longitudinal study of black and white women and men age >or=45 years living in rural North Carolina. Radiographic, sociodemographic, and symptomatic knee data measured at baseline (1990-1997) and first followup (1999-2003) were analyzed.

RESULTS

The lifetime risk of symptomatic knee OA was 44.7% (95% confidence interval [95% CI] 40.0-49.3%). Cohort members with history of a knee injury had a lifetime risk of 56.8% (95% CI 48.4-65.2%). Lifetime risk rose with increasing BMI, with a risk of 2 in 3 among those who were obese.

CONCLUSION

Nearly half of the adults in Johnston County will develop symptomatic knee OA by age 85 years, with lifetime risk highest among obese persons. These current high risks in Johnston County may suggest similar risks in the general US population, especially given the increase in 2 major risk factors for knee OA, aging, and obesity. This underscores the immediate need for greater use of clinical and public health interventions, especially those that address weight loss and self-management, to reduce the impact of having knee OA.

Interpretation of serum C-reactive protein (CRP) levels for cardiovascular disease risk is complicated by race, pulmonary disease, body mass index, gender, and osteoarthritis

OBJECTIVE

High-sensitivity C-reactive protein (hsCRP) in serum is used as a marker of risk for cardiovascular disease (CVD); however CRP is a non-specific acute phase reactant. We evaluated the association between hsCRP concentrations and the most common form of arthritis, osteoarthritis (OA), and assessed the applicability of hsCRP for CVD risk prediction.

METHODS

Participants (n=662) were selected from the population-based Johnston County Osteoarthritis Project, using stratified simple random sampling to achieve balance according to radiographic knee OA status, ethnic group, gender, and age group. The presence and severity of knee and hip OA were determined radiographically. CVD risk was estimated by hsCRP concentration and independently with the Framingham risk algorithm.

RESULTS

Serum natural log-transformed hsCRP (ln hsCRP) was higher in African-Americans (P<0.0001) and women (P<0.0001), was higher in participants who had chronic pulmonary disease (P=0.01), hypertension (P<0.0001), or used pain medications (P=0.004), and correlated with body mass index (BMI) (r=0.40, P<0.0001) and waist circumference (r=0.33, P<0.0001), but not with age, CVD, or current smoking. Ln hsCRP was strongly positively associated with all definitions of radiographic OA (rOA; P<0.0001), but this association was not independent of BMI. Although 183 participants reported no CVD and were classified as low risk by the Framingham CVD score, 61% of them were classified as moderate or high risk for CVD using hsCRP; this proportion designated high risk for CVD on the basis of hsCRP consisted primarily of women (P<0.05) and individuals with OA (P<0.01).

CONCLUSIONS

The pathogenic significance of hsCRP elevations in this subgroup is unclear. Serum hsCRP for predicting risk of CVD is confounded by obesity, ethnicity, gender and comorbidities.

Prevalence of knee symptoms and radiographic and symptomatic knee osteoarthritis in African Americans and Caucasians: the Johnston County Osteoarthritis Project

OBJECTIVE

To report contemporary estimates of the prevalence of knee-related osteoarthritis (OA) outcomes in African Americans and Caucasians aged > or = 45 years.

METHODS

Weighted prevalence estimates for knee symptoms, radiographic knee OA, symptomatic knee OA, and severe radiographic knee OA were calculated for age, ethnic, and sex subgroups, in 3018 participants (33% African Americans, 38% men) in the baseline examination (1991-97) of The Johnston County Osteoarthritis Project, a population-based study of OA in North Carolina. Radiographic knee OA was defined as Kellgren-Lawrence radiographic grade > or = 2, severe radiographic knee OA as grades 3 and 4, and symptomatic knee OA as knee symptoms in a knee with radiographic OA.

RESULTS

Knee symptoms were present in 43%, 28% had radiographic knee OA, 16% had symptomatic knee OA, and 8% had severe radiographic knee OA. Prevalence was higher in older individuals and women. African Americans had slightly higher prevalence of knee symptoms, radiographic knee OA, and symptomatic knee OA, but significantly higher prevalence of severe radiographic knee OA compared to Caucasians.

CONCLUSION

Policy should be directed to increasing education of the public and the medical community about the high prevalence of these conditions, especially in these subgroups, to decrease their impact and ultimately prevent them.

Identification of an urinary metabolite profile associated with osteoarthritis

OBJECTIVE

Osteoarthritis (OA) is one of the most common diseases among the elderly. The main characteristic is the progressive destruction of articular cartilage. We lack quantitative and sensitive biomarkers for OA to detect changes in the joints in an early stage of the disease. In this study, we investigated whether a urinary metabolite profile could be found that could serve as a diagnostic biomarker for OA in humans. We also compared the profile we obtained previously in the guinea pig spontaneous OA model.

METHODS

Urine samples of 92 participants (47 non-OA controls and 45 individuals with radiographic OA of the knees or hips) were selected from the Johnston County Osteoarthritis Project (North Carolina, USA). Participants ranged in age from 60 to 84 years. Samples were measured by 1H nuclear magnetic resonance spectroscopy (NMR) with subsequent principal component discriminant analysis and partial least squares regression analysis.

RESULTS

Differences were observed between urine NMR spectra of OA cases and controls (P<0.001 for both male and female subjects). A metabolite profile could be determined which was strongly associated with OA. This profile largely resembled the profile previously identified for guinea pigs with OA (approximately 40 out of the approximately 125 signals of the human profile were present in the guinea pig profile as well). A correlation was found between the metabolite profile and radiographic OA severity (R2 = 0.82 (male); R2 = 0.93 (female)).

CONCLUSION

This study showed that a urine metabolite profile may serve as a novel discriminating biomarker of OA.

Serum hyaluronan levels and radiographic knee and hip osteoarthritis in African Americans and Caucasians in the Johnston County Osteoarthritis Project

OBJECTIVE

Serum hyaluronan (HA) has been proposed as a potential biomarker of osteoarthritis (OA). We examined associations between serum HA and radiographic OA in an ethnically diverse, population-based sample.

METHODS

Participants were selected from the Johnston County Osteoarthritis Project, using stratified simple random sampling to achieve balance according to radiographic knee OA status, ethnic group, sex, and age group. Serum HA was measured by enzyme-linked immunosorbent assay. Radiographic OA variables included knee OA, knee OA laterality, knee OA severity, concomitant knee and hip OA, and total number of OA-affected knee and hip joints. Analysis of covariance was used to assess differences in mean serum levels of natural log-transformed HA (ln serum HA) between groups, adjusting for ethnicity, sex, age, body mass index (BMI), and self-reported comorbidities.

RESULTS

Levels of ln serum HA were positively associated with all definitions of radiographic OA (P < 0.0001). Levels of ln serum HA were higher in Caucasians (P = 0.0094) and in men (P = 0.0038) and were moderately correlated with age (r = 0.35, P < 0.0001). The associations with radiographic OA, ethnicity, sex, and age remained statistically significant after adjustment (P < 0.0045). There were no interactions between ethnicity and the other covariates.

CONCLUSION

These cross-sectional data support a role for serum HA as a biomarker of radiographic OA. The variations in levels of serum HA attributable to ethnicity, sex, and age were not explained by radiographic OA, BMI, or comorbidities. The lack of strong confounding between serum HA and comorbidities further supports a role for serum HA as a potential biomarker.

A case-control study of serum tocopherol levels and the alpha- to gamma-tocopherol ratio in radiographic knee osteoarthritis: the Johnston County Osteoarthritis Project

Tocopherols are lipid-soluble antioxidants that may protect against some conditions of aging. The authors examined associations between radiographic knee osteoarthritis and serum levels of alpha-, delta-, and gamma-tocopherol and the alpha:gamma-tocopherol ratio in African-American and White adults from the Johnston County Osteoarthritis Project (North Carolina, 1991-1997). Two hundred cases with radiographic knee osteoarthritis (Kellgren-Lawrence grades > or = 2) and 200 controls (Kellgren-Lawrence grade 0) were randomly selected and matched by age, ethnicity, and sex. Serum tocopherol levels were measured by high performance liquid chromatography. Conditional logistic regression was used to estimate associations between radiographic knee osteoarthritis and tertiles of each tocopherol measure, independent of confounders. Persons in the highest tertile of the alpha:gamma-tocopherol ratio had half the odds of radiographic knee osteoarthritis as those in the lowest tertile (adjusted odds ratio = 0.5, 95% confidence interval: 0.2, 1.2). This inverse association occurred in all ethnic and sex subgroups, significantly in African Americans and men. Radiographic knee osteoarthritis was inversely associated with serum alpha-tocopherol in African Americans and men, positively associated with serum gamma-tocopherol in men, and unassociated with serum delta-tocopherol. Associations between radiographic knee osteoarthritis and tocopherol isoforms are complex and may vary by ethnicity and sex.

Ethnic and sex differences in serum levels of cartilage oligomeric matrix protein: the Johnston County Osteoarthritis Project

OBJECTIVE

Previous descriptions of potential biomarkers of osteoarthritis (OA) have been limited to Caucasians. In the present study, we examined associations between serum levels of cartilage oligomeric matrix protein (COMP) and ethnicity (African American or Caucasian) and sex in the Johnston County Osteoarthritis Project, a population-based study of OA in rural North Carolina.

METHODS

All African Americans and a randomly selected sample of Caucasians who had available sera and either no radiographic evidence of knee or hip OA according to the Kellgren/Lawrence (K/L) system (K/L grade 0) or radiographic evidence of knee OA (K/L grade 2 or higher) were included. Serum COMP levels were quantified by sandwich enzyme-linked immunosorbent assay, using monoclonal antibodies 16-F12 and 17-C10. Linear regression models were used to assess relationships between serum levels of natural log-transformed COMP (ln COMP) and ethnicity and sex, controlling for age, height, body mass index (BMI), radiographic OA, and the presence of other symptomatic joints. Radiographic OA was defined in separate models as the presence, severity, and laterality of radiographic knee OA, the co-occurrence of radiographic knee and hip OA, and the number of knees and hips with radiographic OA.

RESULTS

The 769 subjects in the study sample had a mean +/- SD age of 62 +/- 10.3 years. Levels of ln COMP were associated with age, BMI, and all definitions of radiographic OA (P = 0.0001), and varied by ethnicity and sex. In adjusted models, ln COMP was higher in African American women than in Caucasian women (P = 0.003) and higher in Caucasian men than Caucasian women (P = 0.0001). There were no statistically significant differences in serum ln COMP levels between African American men and women.

CONCLUSION

Serum COMP levels vary by ethnicity and sex. These factors should be considered in the derivation of standards using this, and possibly other, potential biomarkers of OA.

Serum cartilage oligomeric matrix protein and clinical signs and symptoms of potential pre-radiographic hip and knee pathology

OBJECTIVE

To examine the cross-sectional relationship between serum cartilage oligomeric matrix protein (COMP) and hip and knee clinical signs and symptoms in a sample of adults without radiographic hip or knee osteoarthritis (OA).

DESIGN

A total of 145 persons with available sera and no evidence of radiographic hip or knee OA (Kellgren-Lawrence grade 0) were randomly selected from the Caucasian participants of the Johnston County Osteoarthritis Project. COMP was quantified by a competitive ELISA assay with a monoclonal antibody 17-C10. Hip and knee clinical signs and symptoms were assessed by physical examination and interview, and their associations with Ln COMP analysed with general linear models.

RESULTS

After adjustment for age, gender, body mass index (BMI), and other symptomatic joints, mean Ln COMP was statistically significantly higher among persons with hip-related clinical signs (P=0.018), among those with hip-related symptoms (P=0.046), and among individuals meeting American College of Rheumatology clinical criteria for hip OA (P=0.021). There were no statistically significant associations between any of the knee-related clinical signs and symptoms and Ln COMP.

CONCLUSION

Serum COMP may be useful as a biomarker of pre-radiographic hip joint pathology; its utility as a biomarker of pre-radiographic knee joint pathology is unclear.

Serum carotenoids and radiographic knee osteoarthritis: the Johnston County Osteoarthritis Project

OBJECTIVE

Antioxidant intake has been associated with less progression of radiographic knee osteoarthritis (OA), but studies of carotenoid biomarkers and OA have not been done. We examined associations between serum concentrations of nine naturally occurring carotenoids and radiographic knee OA.

DESIGN

The study design was matched case-control. Sera were analysed by high-performance liquid chromatography for nine carotenoids: lutein, zeaxanthin, alpha- and beta-cryptoxanthin, trans- and cis-lycopene, alpha-carotene, and trans- and cis-beta-carotene. Conditional logistic regression was used to estimate the association between tertiles of each carotenoid and radiographic knee OA, independent of body mass index, education, serum cholesterol, and the other carotenoids.

SETTING

Johnston County, North Carolina, United States of America.

SUBJECTS

Two-hundred cases with radiographic knee OA (Kellgren-Lawrence grades > or = 2) and 200 controls (Kellgren-Lawrence grade = 0) were randomly selected from the Johnston County Osteoarthritis Project, and were matched on age, gender and race.

RESULTS

Participants with serum levels of lutein or beta-cryptoxanthin in the highest tertile were approximately 70% less likely to have knee OA than controls (odds ratio (OR) [95% confidence interval (CI)] = 0.28 [0.11, 0.73] and 0.36 [0.14, 0.95], respectively). Those in the highest tertile of trans-beta-carotene (OR = 6.40 [1.86, 22.1]) and zeaxanthin (OR = 3.06 [1.19, 7.85]) were more likely to have knee OA.

CONCLUSIONS

While certain carotenoids may protect against knee OA, others may increase the odds of knee OA. Further study of carotenoids and knee OA are warranted before clinical recommendations about these substances and knee OA can be made.

A randomized, double-blind, crossover clinical trial of diclofenac plus misoprostol versus acetaminophen in patients with osteoarthritis of the hip or knee

OBJECTIVE

To perform a randomized, double-blind, crossover clinical trial of diclofenac + misoprostol versus acetaminophen in ambulatory patients with osteoarthritis of the hip or knee.

METHODS

Patients in 12 ambulatory care settings were eligible if they were age >40 years and if they had Kellgren/Lawrence radiographic grade 2-4 osteoarthritis of the knee or hip and a score of > or =30 mm on a 100-mm visual analog pain scale. Patients were randomized to one of two groups, 75 mg diclofenac + 200 microg misoprostol twice daily or 1,000 mg acetaminophen 4 times daily (each for 6 weeks), and were then crossed over to the other treatment for 6 weeks. A placebo was included in each treatment regimen to enable double blinding. The primary outcome measures were the Western Ontario and McMaster Universities Osteoarthritis Index and the visual analog pain scale of the Multidimensional Health Assessment Questionnaire. Safety was assessed using a standard form to review adverse events.

RESULTS

We enrolled 227 patients, of whom 218 provided data for the first treatment period and 181 provided data for both treatment periods. Significantly higher levels of improvement in the primary outcomes were seen for diclofenac + misoprostol than for acetaminophen (P < 0.001). Adverse events were more common when patients took diclofenac + misoprostol (P = 0.046). Diclofenac + misoprostol was rated as "better" or "much better" by 57% of the 174 patients who provided such ratings for both treatment periods, while acetaminophen was rated as "better" or "much better" by 20% of these patients, and 22% reported no difference (P < 0.001). Differences favoring diclofenac + misoprostol over acetaminophen were greater in patients with more severe osteoarthritis according to baseline pain scores, radiographs, or number of involved joints.

CONCLUSION

Patients with osteoarthritis of the hip or knee had significantly greater improvements in pain scores over 6 weeks with diclofenac + misoprostol than with acetaminophen, although patients with mild osteoarthritis had similar improvements with both drugs. Acetaminophen was associated with fewer adverse events.

Serum cartilage oligomeric matrix protein reflects osteoarthritis presence and severity: the Johnston County Osteoarthritis Project

OBJECTIVE

To characterize serum cartilage oligomeric matrix protein (COMP) levels by age and gender for a radiographically defined population free of hip and knee osteoarthritis (OA), and to examine the potential utility of COMP as a diagnostic biomarker for knee OA.

METHODS

Serum samples and knee and hip radiographs were obtained at a baseline evaluation as part of the Johnston County Osteoarthritis Project, a population-based study of OA in rural North Carolina. A total of 291 Caucasian participants were randomly selected for COMP analysis, 143 patients with radiographic knee OA (Kellgren/Lawrence [K/L] grade > or = 2) and 148 controls with neither hip nor knee OA (K/L grade 0), evenly distributed by age and gender. COMP was quantified by competitive enzyme-linked immunosorbent assay with monoclonal antibody 17-C10. The natural log-transformed COMP data were analyzed using general linear models.

RESULTS

Serum COMP levels were significantly elevated (P = 0.0001) in the age > or = 65 group (mean +/- SD 1,302.1 +/- 496.7 ng/ml) versus the age 45-54 and age 55-64 groups (1,058.1 +/- 432.4 and 1,038.6 +/- 313.3, respectively). Serum COMP levels of the OA group were significantly higher than those of the control group (1,208.57 +/- 487.47 ng/ml versus 1,061.83 +/- 370.58 ng/ml; P = 0.0093). Serum COMP levels also increased significantly with knee OA K/L grade (P = 0.0047), knee OA laterality (P = 0.0043), and number of knee and hip joints involved (P = 0.0001). There was no significant difference in serum COMP levels by gender or obesity.

CONCLUSION

We demonstrate that in a population-based sample, serum COMP levels can distinguish an OA-affected subgroup from an unaffected subgroup and can reflect disease severity and multiple joint involvement in OA.

An application of methods for clustered binary responses to a cardiovascular study with small sample size

This paper discusses statistical methods for a cardiovascular study in which each of eight animals had a dichotomous outcome observed for each of several treatments. There were five treatments in all: shunt, control, two doses of a test drug for potentially causing an unfavorable cardiovascular event, and a combination of the test drug and a counteracting agent. Exact conditional methods were used through LogXact, a statistical software for exact logistic regression and an alternative framework for performing a large class of nonparametric tests performed by StatXact. The results agreed reasonably with asymptotic methods even though the sample size was small.

Knee pain and knee osteoarthritis severity in self-reported task specific disability: the Johnston County Osteoarthritis Project

OBJECTIVE

To evaluate the contributions of radiographic knee osteoarthritis (OA) and knee pain severity to self-reported disability performing upper and lower extremity tasks in a rural, population based sample.

METHODS

Data from 1192 African-American and Caucasian participants in the Johnston County Osteoarthritis Project were analyzed with multiple logistic regression to examine the roles of Kellgren-Lawrence radiographic knee OA grade and knee pain severity in self-reported difficulty performing 20 activities of the Health Assessment Questionnaire. Potential confounders included age, sex, race, marital status, education, and body mass index.

RESULTS

Forty-three percent reported difficulty performing at least one task. Mild knee pain was independently associated with difficulty performing 16 upper and lower extremity tasks, and moderate/severe knee pain with all 20 tasks, with little change after adjustment (p < 0.0001). In contrast, mild radiographic knee OA was associated with difficulty in only 4 mobility and transfer tasks: climbing 5 steps, taking a tub bath, getting in/out of a car, and performing chores. Moderate/severe radiographic knee OA was associated with difficulty in 17 of 20 tasks (in 10 of 17, p < 0.0001), except lifting a cup, opening car doors, and turning faucets. However, no associations between radiographic knee OA and difficulty were statistically significant after adjustment for knee pain and the above factors.

CONCLUSION

Knee pain severity was the strongest risk factor for self-reported difficulty performing tasks of upper and lower extremity function. Future studies of disability should include data on knee pain severity.

Ethnic differences in self-reported functional status in the rural south: the Johnston County Osteoarthritis Project

OBJECTIVE

We examined ethnic differences in self-reported functional status in a rural, population-based sample in North Carolina.

METHODS

Data from 1,197 African-American and Caucasian participants, aged 45 and older, in the Johnston County Osteoarthritis Project were analyzed using multiple logistic regression to examine differences in difficulty performing tasks of the Health Assessment Questionnaire (HAQ) and in risk factor profiles associated with difficulty.

RESULTS

Forty-three percent reported difficulty in one or more HAQ tasks. African-Americans were more likely than Caucasians to report difficulty performing 3 tasks (P < 0.04); these differences were minimal after adjustment for confounders. For some tasks, risk factor profiles included body mass index in African-Americans only, and age and female gender more often in Caucasians. Low educational attainment was part of the risk factor profile for walking in African-Americans.

CONCLUSIONS

Differences in proportions of African-Americans and Caucasians reporting difficulty in performance of HAQ tasks were minimal, but risk factor profiles for difficulty appeared to vary by ethnicity.

Self-reported functional status in osteoarthritis of the knee in a rural southern community: the role of sociodemographic factors, obesity, and knee pain

OBJECTIVE

This study examined the roles of sociodemographic factors (age, race, gender, education, marital status), obesity, and severity of radiographic knee osteoarthritis (OA) and knee pain on self-reported functional status.

METHODS

The sample included 1,272 African-American and Caucasian individuals, aged 45 years or older, from the Johnston County Osteoarthritis Project. Analysis of variance was used to assess variation in mean Health Assessment Questionnaire (HAQ) scores by the above variables.

RESULTS

Mean HAQ scores differed by severity of radiographic knee OA and knee pain, obesity, and all demographic factors (P < 0.0001), except race. Only age, female sex, obesity, and knee pain severity were independent effects (P < 0.0009). Disability associated with knee pain varied by both radiographic knee OA severity and obesity.

CONCLUSIONS

Knee pain severity was more important than radiographic knee OA severity in determining disability. Obesity was independently associated with disability and compounded disability from knee pain. Studies of disability in knee OA should include assessment of obesity, severity of radiographic knee OA, and severity of knee pain, as well as their interactions.