Abstract PD4-04: Psychosocial factors related to interruptions in adjuvant hormonal therapy among women with breast cancer: The breast cancer quality of care study (BQUAL)

Background. Adjuvant hormonal therapy (HT) for hormone-sensitive breast cancer decreases risk of breast cancer recurrence and improves survival. However, some women are non-adherent to this life-saving treatment.

Methods. In a cohort of women recruited at diagnosis of breast cancer in an integrated healthcare system, we investigated factors related to HT interruption (≥90 day gap). Serial interviews were conducted at baseline and during treatment to examine psychological factors as well as sociodemographic factors, tumor characteristics, and treatment factors. A series of multivariate models assessed potential predictors of HT interruptions.

Results. Of the 569 women in our cohort who initiated HT, 137 (24%) interrupted it, including 18 (3%) who did so prior to the first follow-up interview. In a multivariate analysis of clinical and demographic factors, only household income remained associated with HT interruption (OR 0.42, 95%CI 0.24-0.76). At first follow-up, after controlling for income, race and age, lower scores on all quality of life subscales, lower scores on global treatment satisfaction, and poorer scores on the intrusive and avoidant thought subscales of the Impact of Events scale were associated with higher odds of HT interruptions (P<0.001 for all predictors). Scores on social support and on interpersonal processes of care measures were not associated with HT interruptions. However, a higher score on the single question "How often did your doctor speak too fast?" was associated with higher risk of HT interruptions (OR 1.32, p=0.02).

Conclusions: Patients under greater duress and those with lower physical, functional, emotional or social quality of life appeared to be at the highest risk of HT interruption and thus received poorer quality care. A better understanding of psychological factors that can result in poor quality care may pave the way to targeted interventions to improve adherence.

Citation Format: Hershman DL, Kushi LH, Hillyer GC, Coromilis E, Buono D, Lamerato LE, Bovbjerg DH, Mandelblatt8 JS, Tsai W-Y, Jacobson JS, Wright JD, Neugut AI. Psychosocial factors related to interruptions in adjuvant hormonal therapy among women with breast cancer: The breast cancer quality of care study (BQUAL). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr PD4-04.

Socioeconomic and Outdoor Meteorological Determinants of Indoor Temperature and Humidity in New York City Dwellings

BACKGROUND

Numerous mechanisms link outdoor weather and climate conditions to human health. It is likely that many health conditions are more directly affected by indoor rather than outdoor conditions. Yet, the relationship between indoor temperature and humidity conditions to outdoor variability, and the heterogeneity of the relationship among different indoor environments are largely unknown.

METHODS

We use 5-14 day measures of indoor temperature and relative humidity from 327 dwellings in New York City for the years 2008-2011 to investigate the relationship between indoor climate, outdoor meteorological conditions, socioeconomic conditions, and building descriptors. Study households were primarily middle-income and located across the boroughs of Brooklyn, Queens, Bronx, and Manhattan.

RESULTS

Indoor temperatures are positively associated with outdoor temperature during the warm season and study dwellings in higher socioeconomic status neighborhoods are significantly cooler. During the cool season, outdoor temperatures have little effect on indoor temperatures; however, indoor temperatures can range more than 10 °C between dwellings despite similar outdoor temperatures. Apartment buildings tend to be significantly warmer than houses and dwellings on higher floors are also significantly warmer than dwellings on lower floors. Outdoor specific humidity is positively associated with indoor specific and relative humidity, but there is no consistent relationship between outdoor and indoor relative humidity.

CONCLUSIONS

In New York City, the relationship between indoor and outdoor temperature and humidity conditions vary significantly between dwellings. These results can be used to inform studies of health outcomes for which temperature or humidity is an established factor affecting human health and highlights the need for more research on the determinants of indoor climate.

Birth order, atopy, and symptoms of allergy and asthma among inner-city children attending Head Start in New York City

BACKGROUND

In past research, children with older siblings were more likely than others to wheeze at age 2 years, but less likely by age 6 years. Higher infection transmission and a down-regulated allergic immune response as a result of these infections, respectively, were suggested as the causes. However, in a study of children aged 0-3 years in a low-income urban community in New York City, USA, with high asthma prevalence, we observed no birth-order effect.

OBJECTIVE

To evaluate the association between birth order and atopy and respiratory symptoms in 4-year-old children attending Head Start programs in NYC.

METHODS

Respiratory symptoms were assessed by questionnaire for 1005 children (mean age 4.0 years) living in high asthma prevalence neighbourhoods. Serum was collected from a subgroup of the children (n=494) and specific IgE responses to dust mite, cockroach, mouse, and cat allergens were measured.

RESULTS

Prevalence of specific IgE (> or =0.35 IU/mL) did not differ significantly among first (35%), second (35%), and later-born children (28%) (P=0.23). Increasing birth order was associated with increasing prevalence of respiratory symptoms in the prior year, including wheeze (first 20%, second 27%, third or later 35%; P<0.001), being awakened at night by cough (28%, 33%, 38%; P=0.005), emergency department visits (14%, 17%, 21%; P=0.02) and hospitalizations for difficulty breathing (6.1%, 6.6%, 10%; P=0.04). The associations of birth order with respiratory symptoms were statistically significant only for the non-seroatopic children and those without an asthmatic parent.

CONCLUSIONS

Non-seroatopic children with older siblings were more likely than those without older siblings to have respiratory symptoms at age 4 years. Although the stability of these associations over time remains to be determined, the differences in findings between this study and our previous NYC birth cohort study suggest that patterns of asthma development may vary even among low-income populations within the same city.

Asthma, body mass, gender, and Hispanic national origin among 517 preschool children in New York City

BACKGROUND

Striking differences in asthma prevalence have been reported among Hispanic adults and children living in different cities of the USA. Prevalence is highest among those of Puerto Rican and lowest among those of Mexican origin. We hypothesized that body size would mediate this association.

METHODS

Parents of children in New York City Head Start programs completed a questionnaire including demographic factors, health history, a detailed history of respiratory conditions, lifestyle, and home environment. Children's height and weight were measured in home visits. Logistic regression was used to model the association of asthma with body mass index percentile (<85th percentile, gender/age specific vs>or=85th percentile, gender/age specific), national origin, and other factors.

RESULTS

Of 517 children at mean age of 4.0 +/- 0.6 years, 34% met the study criteria for asthma, and 43% were above the 85th percentile. Asthma was strongly associated with non-Mexican national origin, male gender, allergy symptoms, and maternal asthma, and marginally with body size. The odds of asthma among boys of non-Mexican origin was 5.9 times that among boys of Mexican origin [95% confidence interval (CI): 2.9-12.2]; the comparable odds ratio (OR) among girls was 1.8 (95% CI: 0.9-3.6). Body mass was associated with asthma among girls [OR = 2.0 (95% CI: 1.1-3.7)], but not boys [OR = 1.4 (95% CI: 0.8-2.6)].

CONCLUSIONS

The association of asthma with both body mass and national origin was gender-specific among the children in our study. Ours is one of the first studies to report on pediatric asthma in different Hispanic populations in the same city, by gender.

High rates of psychosocial stress among Hispanic breast cancer survivors

9113

Background: Due to early detection and improved treatments, women with breast cancer are living longer. We conducted a survey of attitudes about physical health, psychosocial issues, and health-related behaviors among female breast cancer survivors. Methods: Consecutive women with early-stage breast cancer who were ≥3 months post-completion of primary treatment and had no evidence of residual disease were asked to complete a 127-item self-administered questionnaire assessing physical/emotional health, complementary/alternative medicine use, and employment/financial concerns. Baseline demographic and clinical data were collected, including stage, tumor characteristics, and treatments. Endpoints were differences in responses between Hispanic and white patients on a 5-point scale, or dichotomized for each item. Results: Of 133 respondents, 66 were white and 67 were Hispanic. Their median age was 54 (26–90) years, and their median time since diagnosis was 3 (1–20) years. Compared to whites, Hispanic patients were younger (age <45, 34% vs. 9%, p=0.01), less educated (40% vs. 5% not completing high school, p<0.0001), and more likely to have a yearly household income <$10,000 (58% vs. 7%, p<0.0001). Hispanics were more likely than whites to report depression (31% vs 8%, p=0.0008) and depression-related symptoms and stressors such as: anorexia, pain, financial stress, and infidelity by spouse ( Table 1 ). Hispanics were also more likely to have religious beliefs that helped them cope with cancer. Differences between groups in fatigue, memory loss, and anxiety were not statistically significant. Conclusions: Our study suggests that Hispanic breast cancer survivors may have higher rates of depression and psychosocial stressors than white women. Further research is warranted to assess factors that contribute to depression in cancer survivors, and interventions to diagnose and treat it effectively.

[Table: see text]

No significant financial relationships to disclose.

Cancer incidence and mortality in the Caribbean

21110

Background: Nearly 10% of immigrants to the United States come from the Caribbean region. In this paper, we analyzed incidence and mortality rates of the major cancers in the Bahamas, Barbados, Cuba, the Dominican Republic, Haiti, Jamaica, Puerto Rico, and Trinidad and Tobago, and compared them with US patterns. Methods: We obtained age-standardized, sex-specific cancer incidence and mortality rates for cancers of the bladder, breast, cervix, esophagus, large bowel, liver, lung, pancreas, prostate, and stomach for eight Caribbean countries and the US from the GLOBOCAN program of the International Agency for Research in Cancer (IARC) and for the US population from the Surveillance, Epidemiology, and End Results (SEER) Program of the NCI. Results: GLOBOCAN incidence and mortality rates for the overall US were lower than but correlated with overall SEER rates. Based on GLOBOCAN data, the incidence and mortality rates of cancers of the breast, prostate, large bowel, and lung, and, among males, bladder cancer were lower in the Caribbean countries than the US. Caribbean countries had higher rates of cancers of the cervix, esophagus, liver, and stomach. Haiti had the highest incidence and mortality rates of cervix and liver cancers. Jamaica and Haiti had the highest rates of stomach cancer. Conclusions: Cancer incidence and mortality in the Caribbean generally follow known patterns of association with economic development, infectious agents, and racial/ethnic origin. Studying these patterns and how immigration changes them may yield clues to cancer etiology. A better understanding of cancer incidence and mortality rates may help health policymakers to implement state-of-the-art treatment and preventive services for people of Caribbean descent both in their native countries and in immigrant communities in the US.

[Table: see text]

No significant financial relationships to disclose.

Oral adjuvant treatment choices and local recurrence risk in early stage breast cancer

10625

Background: Among women (W) with early-stage breast cancer (BC) treated with lumpectomy and radiation therapy (RT), those who also receive oral adjuvant therapy (OAT) have a lower risk of local recurrence (LR). The purpose of this study was to evaluate the associations of age (A), race/ethnicity (RE), education (E), socioeconomic status (SS), LR rate, and knowledge about potential side effects (SE) with W’s willingness to receive OAT. Methods: Between 6/05 and 9/05, we asked W with (+) and without (−) BC to participate in an IRB-approved survey. The survey questionnaire presented W with clinical vignettes including information about RT ± 5 years of OAT and the LR and SE associated with treatment options. It then asked W to choose between the treatment options and to rate them, using a time trade-off method, given LR and SE. Results: The distribution of the 161 respondents (55 (+)BC and 106 (−)BC) by A, RE, E, SS is shown in the table below. A and RE were associated with a W’s choice of combined modality treatment (CMT) consisting of RT and OAT, to decrease the risk of LR (p < 0.009 and p < 0.056). Stratified analysis showed an association between CMT and E (p < 0.006) in W (+)BC; A (p < 0.04) and SS (p < 0.04) were associated with CMT choice when SE were described. In W (−) BC, RE (p < 0.02) and SS (p < 0.04) were associated with CMT choice when SE were described. Compared to W who had used oral contraceptive agents (OCA), women who did not use OCA were 45% less likely to trade time to decrease their risk of LR by taking OAT when told about similar SE between OCA and OAT (OR = 0.55, 95% CI 0.28, 1.09), but this association was not statistically significant. Conclusions: W of various A, RE, E and SS who were given information about treatment choices with LR rates chose therapies that gave them the best chance of disease-free survival. For W (+) BC history, level of E significantly influenced the choice to proceed with CMT. A, RE and SS influenced CMT choice when SE were described. W who had used OCA in the past may have been less concerned than others about potential side effects of OAT.

[Table: see text]

No significant financial relationships to disclose.

Complementary and alternative medicine in prostate cancer

Prostate cancer patients, like other cancer patients as well as the general population, are increasingly exploring the use of complementary and alternative medicine (CAM). This paper describes the use of CAM in this patient population and the evidence regarding some CAM treatments in the setting of prostate cancer. Some herbal agents and micronutrients have demonstrated biologic activity that may benefit patients with prostate cancer. The clinical effects of these and others and the potential interactions among CAM treatments and with conventional treatment remain an appropriate target for further investigation.

Randomized Trial of Black Cohosh for the Treatment of Hot Flashes Among Women With a History of Breast Cancer

PURPOSE: Most breast cancer survivors experience hot flashes; many use complementary or alternative remedies for these symptoms. We undertook a randomized clinical trial of black cohosh, a widely used herbal remedy for menopausal symptoms, among breast cancer patients.

PATIENTS AND METHODS: Patients diagnosed with breast cancer who had completed their primary treatment were randomly assigned to black cohosh or placebo, stratified on tamoxifen use. At enrollment, patients completed a questionnaire about demographic factors and menopausal symptoms. Before starting to take the pills and at 30 and 60 days, they completed a 4-day hot flash diary. At the final visit, they completed another menopausal symptom questionnaire. Follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels were measured in a subset of patients at the first and final visits.

RESULTS: Of 85 patients (59 on tamoxifen, 26 not on tamoxifen) enrolled in the study, 42 were assigned to treatment and 43 were assigned to placebo; 69 completed all three hot flash diaries. Both treatment and placebo groups reported declines in number and intensity of hot flashes; the differences between the groups were not statistically significant. Both groups also reported improvements in menopausal symptoms that were, for the most part, not significantly different. Changes in blood levels of FSH and LH also did not differ in the two groups.

CONCLUSION: Black cohosh was not significantly more efficacious than placebo against most menopausal symptoms, including number and intensity of hot flashes. Our study illustrates the feasibility and value of standard clinical trial methodology in assessing the efficacy and safety of herbal agents.

Variations in the use of adjuvant chemotherapy for node-positive colon cancer in the elderly: a population-based study

BACKGROUND

Since 1990, the recommended adjuvant therapy for patients with surgically resected node-positive colon cancer has been 5-fluorouracil (5-FU), usually in combination with leucovorin or levamisole. The purpose of this study is to assess the distribution of adjuvant 5-FU treatment in the elderly.

METHODS

The Surveillance, Epidemiology and End Results-Medicare database provides population-based information on cancer patients, representing approximately 14% of the United States population, along with health care utilization data from Medicare claims files. We studied patients with node-positive colon cancer diagnosed between 1992 and 1996 who survived at least 120 days beyond diagnosis (N = 4998).

RESULTS

About 50% of elderly patients received 5-FU within 4 months of diagnosis. The proportion of patients treated with 5-FU increased by about 10% from 1992 to 1996. In a multiple logistic regression model, 5-FU treatment was less likely to be given to older patients (compared with those aged 65-69 years, the odds ratio (OR) [95% CI] was 0.82 [0.67-1.00] for ages 70 to 74 years, 0.47 [0.39-0.57] for ages 75 to 79, 0.17 [0.13-0.20] for ages 80 to 84, and 0.04 [0.03-0.05] for ages 85 to 88 years. Non-Hispanic black patients were less likely to be treated than non-Hispanic white patients (OR 0.46 [0.36-0.59]); patients with more than three positive lymph nodes were more likely to be treated than those with three or less, and those with comorbid conditions were less likely to be treated than those without such conditions.

CONCLUSIONS

Despite its proven efficacy in reducing colon cancer mortality, 5-FU-based chemotherapy is not widely used among apparently eligible patients over age 65. Efforts are needed to ensure that elderly and non-Hispanic black patients receive appropriate treatment.

Effects of a 6-month vitamin intervention on DNA damage in heavy smokers

Because their formation is associated with tumor development in specific tissues, DNA adducts have potential usefulness as intermediate end points in chemoprevention studies. To determine the efficacy of a combination of antioxidant vitamins (vitamins C and E and beta-carotene), a randomized clinical trial was conducted among heavy smokers using DNA damage as the end point. Immunological methods were used to measure polycyclic aromatic hydrocarbon-DNA adducts and oxidative DNA damage (8-oxo or hydroxydeoxyguanosine) in mononuclear and oral cells. A total of 121 subjects were randomized to the 6-month intervention and received either vitamins or placebo. Dropout rates were higher in the placebo than in the vitamin group; 65% of subjects in the vitamin group, but only 47% in the placebo group, provided specimens at 6 months. Plasma levels of all three antioxidants rose significantly in the vitamin group but not in the placebo group. All four measures of DNA damage decreased in both groups; the between-group differences were not statistically significant. These data do not provide clear evidence that antioxidant vitamin intake prevents DNA damage. However, the study demonstrates that DNA damage is a useful end point in chemoprevention trials.

Use of unconventional therapies by children with cancer at an urban medical center

PURPOSE

The aim of this study was to determine the prevalence, modalities, and determinants of use of unconventional therapies among children with cancer receiving conventional treatment at an urban academic medical center in the United States.

PATIENTS AND METHODS

We interviewed the parents of patients and/or patients who were receiving or had received conventional therapy for treatment of childhood cancer. Of 78 patients/ parents asked, 75 consented to the interview, which included demographic factors, life events, and use of unconventional therapies. All participants also consented to the abstraction of chart data for this study.

RESULTS

Overall, 84% of respondents reported the use of one or more unconventional therapies. The most commonly used modalities were changes in diet, nutritional and herbal agents, and mind/body treatments. Most users had tried more than one unconventional modality. No difference in use was seen by cancer diagnosis, race/ethnicity, socio-economic status, or educational attainment of the respondent. Of the therapies used, 50% were not reported to the physicians. Of patients reporting use of an unconventional approach, 85% were concurrently enrolled on clinical trials for primary treatment of their cancer.

CONCLUSIONS

The use of unconventional therapies is highly prevalent among children with cancer and is not associated with demographic or clinical factors or participation in clinical trials. The possibility that an unconventional treatment may interact with a protocol treatment underscores the need for more information about the use of such therapies among all patients.

Decision analysis of tamoxifen for the prevention of invasive breast cancer

PURPOSE

The recent Breast Cancer Prevention Trial has shown that tamoxifen may prevent invasive breast cancer. We used a Markov model to estimate the long-term effects of chemoprevention with tamoxifen on survival, quality-adjusted survival, and health care costs.

METHODS

We used a hypothetical cohort of women with breast-cancer risk similar to that of participants in the Breast Cancer Prevention Trial, and a computer-based decision analysis (Markov model and 500 Monte Carlo simulations) to model the outcomes of interest. Survival calculations were from Surveillance, Epidemiology, and End-Results (SEER) data; preference ratings from a time trade-off questionnaire administered to a group of average-risk women; and cost estimates from the Group Health Cooperative of Puget Sound and the Health Care Financing Administration. We obtained utility measures for quality-adjustment by administering a time trade-off questionnaire to a group of community-based women.

RESULTS

Use of tamoxifen prolonged the average survival of cohort members by 69 days (95% probability interval [PI] 27 to 117) for those who started use at age 35 years; 40 days (95% PI 16 to 67) for those who started use at age 50 years; and 27 days (95% PI 14 to 40) for those who started use at age 60 years. Tamoxifen extended quality-adjusted survival by 38 days (95% PI 0.1 to 82) at age 35, 25 days (95% PI 0 to 50) at age 50, and 22 days (95% PI 5 to 39) days at age 60. Chemoprevention with tamoxifen cost $46,619 (95% PI $27,928 to $98,796) per life year life saved for women who started at age 35; for women over age 50, it cost more than $50,000 per life year saved.

DISCUSSION

Tamoxifen use may improve long-term survival and quality-adjusted survival among women who are at increased risk of breast cancer, but this benefit diminishes with age. Tamoxifen is cost-effective in comparison with other cancer treatment strategies for younger women only.

Research on complementary/alternative medicine for patients with breast cancer: a review of the biomedical literature

PURPOSE

This article reviews English-language articles published in the biomedical literature from 1980 to 1997 that reported results of clinical research on complementary and alternative medical treatments (CAM) of interest to patients with breast cancer.

METHODS

We searched 12 electronic databases and the bibliographies of the retrieved papers, review articles, and books on CAM and breast cancer. The retrieved articles were grouped by end point: breast cancer (eg, tumor size, survival), disease-related symptoms, side effects of treatment, and immune function. Within each end point, we organized the articles by modality and assessed study design, findings, and qualitative aspects.

RESULTS

Of the more than 1,000 citations retrieved, 51 fit our criteria for review. Of the articles reviewed, 17 were randomized clinical trials; three of these were trials of cancer-directed interventions, two of which involved the same treatment (melatonin). Seven articles described observational studies, and the remainder were reports of phase I or II trials. Relatively few CAM modalities reportedly used by many breast cancer patients were mentioned in articles retrieved by this process. Most articles had shortcomings.

CONCLUSION

Although many studies had encouraging results, none showed definitively that a CAM treatment altered disease progression in patients with breast cancer. Several modalities seemed to improve other outcomes (eg, acupuncture for nausea, pressure treatments for lymphedema). If CAM studies are well-founded, well-designed, and meticulously conducted, and their hypotheses, methods, and results are reported clearly and candidly, research in this controversial area should acquire credibility both in the scientific community and among advocates of unconventional medicine.

Prevention with tamoxifen or other hormones versus prophylactic surgery in BRCA1/2-positive women: a decision analysis

PURPOSE

Recent randomized controlled trials have shown that tamoxifen and raloxifene may prevent invasive breast cancer. This decision analysis study compares the outcomes of chemoprevention with tamoxifen, raloxifene, or oral contraceptives with the outcomes of prophylactic surgery among women with high-risk BRCA1/2 mutations.

PATIENTS AND METHODS

We used a simulated cohort of 30-year-old women who tested positive for BRCA1/2 mutations and constructed a Markov model with Monte Carlo simulations, incorporating cumulative breast and ovarian cancer incidence rates from the literature and survival figures from SEER data. We assumed that prophylactic surgery reduces ovarian cancer risk by 45% and breast cancer risk by 90%, that tamoxifen reduces invasive breast cancer risk by 49%, and that raloxifene has similar efficacy and safety in premenopausal and postmenopausal women. We used data obtained from high-risk women by a time trade-off questionnaire to calculate quality-adjusted life-years. We based our cost estimates for hospital and ambulatory care on Health Care Financing Administration payments, the SEER-HCFA database, and the Pharmacy Fundamental Reference.

RESULTS

In our model, a 30-year-old BRCA1/2+ woman could prolong survival by 0.9 years (95% probability interval, 0.4-1.2 years) by having bilateral oophorectomy, 3.4 years (2.7-3.7 years) by having bilateral mastectomy, and 4.3 years (3.6-4.6 years) by having both procedures instead of surveillance alone. Chemoprevention with tamoxifen and raloxifene increased survival by 1.6 years (1.0-2.1 years) and 2.2 years (1.3-2.8 years), respectively. Chemoprevention yielded more quality-adjusted life-years than did prophylactic surgery, even when treatment was delayed to age 40 or 50 years. All these procedures were cost-effective or cost-saving compared with surveillance alone.

DISCUSSION

Our model suggests that although surgery may yield more substantial survival and cost benefits, quality of life issues may make chemoprevention a more attractive option for young women at high genetic risk.

Safety and costs of treating neutropenic fever in an outpatient setting

PURPOSE

The purpose of this study is to analyze the safety of outpatient treatment for cancer patients with chemotherapy-induced neutropenic fever in a community hospital setting and to compare the costs of outpatient treatment with those of inpatient treatment for such patients.

PATIENTS AND METHODS

We reviewed charts and charges for 32 consecutive patients initially treated for neutropenic fever with broad-spectrum antibiotics in the offices of Hematology/Oncology Associates (HOA) at the Bennett Cancer Center in the Stamford Hospital January 1997-June 1998. We also reviewed charts and charges for eight consecutive HOA patients with neutropenic fever who met the criteria for outpatient treatment but were initially hospitalized for other reasons during this period. We compared these two groups with respect to mean nadir absolute neutrophil count (ANC), mean number of days when ANC < 1,000 cells cu mm, and mean number of days of intravenous antibiotic treatment. We compared costs for ambulatory and hospital care of the two groups using Health Care Financing Administration (HCFA) payments in 1998 as a proxy for costs.

RESULTS

Of 32 patients with neutropenic fever initially treated in the outpatient setting, only four required hospitalization. No patients in either group died in connection with neutropenic fever. Although outpatients received an average of 3.6 days and inpatients only 2.5 days of antibiotic treatment, outpatient treatment was significantly less costly than inpatient treatment.

CONCLUSION

In a community hospital setting most cancer patients with neutropenic fever who meet certain criteria can be safely, effectively, and inexpensively treated as outpatients.

Research on complementary and alternative therapies for cancer: issues and methodological considerations

Recent evidence suggests that at least one cancer patient in three uses some form of complementary and alternative medicine (CAM). We conducted a review of the published research on the efficacy of these treatments for breast cancer, which resulted in some observations about the current state of research and guidelines for future research. Although many of the papers reported encouraging results, the preponderance of phase I and II trials and other limitations precluded definitive conclusions about the efficacy of the treatments reported in these studies. A growing institutional base in this country has begun to facilitate improved research on CAM for cancer, yet many gaps remain. For example, there are no published reports of clinical trials or observational studies with survival endpoints for treatment agents used by many cancer patients. Clinical trials of a few CAM treatments are now in progress, but the results will not be available for several years. More complex and customized treatments may require innovative study designs and practitioner-investigator collaborations. Given the mounting evidence that CAM treatments are biologically active as well as widely used, CAM research may affect cancer outcomes.

The quality of life associated with prophylactic treatments for women with BRCA1/2 mutations

PURPOSE

This study was conducted to obtain and compare the preferences assigned to cancer states and prevention measures by women who had breast cancer, were at high risk for breast cancer, or had neither condition.

PATIENTS AND METHODS

We administered a time trade-off questionnaire to 21 breast cancer patients, 28 women with a personal history of multiple breast biopsies or a family history of breast cancer, and 135 women without these conditions (the reference group). We stratified the reference group into two groups aged 20 to 32 years and 33 to 50 years, respectively.

RESULTS

All four groups assigned higher preference to breast cancer than to ovarian cancer. Both reference groups preferred using a tamoxifen-like drug to having mastectomy or oophorectomy for cancer prevention; the high-risk and breast cancer groups did not. None of the four groups had a preference between prophylactic mastectomy and breast cancer. All the groups were willing to subtract more years from their life expectancy to protect offspring from genetic risk than to protect themselves. Reference group members in the 33- to 50-year age range had lower mean ratings than the breast cancer group for almost all the health states, and breast cancer patients were less willing than other respondents to trade time for health. Most of these differences were not statistically significant. The high-risk group was similar to the older reference group in time trade-off ratings.

DISCUSSION

The time trade-off-based preferences of healthy women may be used to predict the treatment preferences of women with BRCA1/2 mutations. Obtaining healthy women's ratings of treatment outcomes may help health care policy makers envision the consequences of the difficult choices that high-risk women face.

Benefits and costs of screening Ashkenazi Jewish women for BRCA1 and BRCA2

PURPOSE

To determine the survival benefit and cost-effectiveness of screening Ashkenazi Jewish women for three specific BRCA1/2 gene mutations.

METHODS

We used a Markov model and Monte Carlo analysis to estimate the survival benefit and cost-effectiveness of screening for three specific mutations in a population in which their prevalence is 2.5% and the associated cancer risks are 56% for breast cancer and 16% for ovarian cancer. We assumed that the sensitivity and specificity of the test were 98% and 99%, respectively, that bilateral prophylactic oophorectomy would reduce ovarian cancer risk by 45%, and that bilateral prophylactic mastectomy would reduce breast cancer risk by 90%. We used Medicare payment data for treatment costs and Surveillance, Epidemiology, and End Results data for cancer survival.

RESULTS

Our model suggests that genetic screening of this population could prolong average nondiscounted survival by 38 days (95% probability interval, 22 to 57 days) for combined surgery, 33 days (95% probability interval, 18 to 43 days) for mastectomy, 11 days (95% probability interval, 4 to 25 days) for oophorectomy, and 6 days (95% probability interval, 3 to 8 days) for surveillance. The respective cost-effectiveness ratios per life-year saved, with a discount rate of 3%, are $20,717, $29,970, $72,780, and $134,273.

CONCLUSION

In this Ashkenazi Jewish population, with a high prevalence of BRCA1/2 mutations, genetic screening may significantly increase average survival and, depending on costs and screening/treatment strategies, may be cost-effective by the standards of accepted cancer screening tests. According to our model, screening is cost-effective only if all women who test positive undergo prophylactic surgery. These estimates require confirmation through prospective observational studies and clinical trials.

Association between coronary heart disease and cancers of the breast, prostate, and colon

Coronary heart disease (CHD) and cancers of the breast, prostate, and colon are more common in industrialized countries than in the developing world, and to some degree, these conditions appear to share risk factors. To investigate whether there is an association between these cancers and a prior history of CHD, a hospital-based case-control study was conducted at Columbia-Presbyterian Medical Center in New York. The study was based on 252 breast cancer cases, 256 colorectal cancer cases, and 322 benign surgical controls, all of whom underwent biopsy or surgery between January 1989 and December 1992, and on 319 prostate cancer cases and 189 benign prostatic hypertrophy controls diagnosed between January 1984 and December 1986 (prior to widespread use of prostate-specific antigen screening). Medical records were reviewed on each, focusing on the preoperative anesthesia and surgical clearances. No association was found between a history of CHD and breast or colorectal cancer, but an elevated risk was found for prostate cancer (odds ratio, 2.00; 95% confidence interval, 1.18-3.39), using unconditional logistic regression with adjustment for appropriate confounders. No association was found between cigarette smoking and any of the three cancers. Aspirin use was protective for colorectal cancer (odds ratio, 0.35; 95% confidence interval, 0.17-0.73) but had no association with breast or prostate cancer. The study suggests that individuals with CHD are at elevated risk for prostate cancer but not breast or colorectal cancer. Etiological risk factors associated with CHD should be investigated with regard to prostate cancer. Patients with CHD may represent a high-risk group for prostate cancer and potential future targets for prostate cancer screening interventions.

Family history of colorectal adenomatous polyps and increased risk for colorectal cancer

BACKGROUND

The risk for colorectal cancer among family members of patients with colorectal cancer is well established, but the risk among family members of patients with colorectal adenomas is less well established.

OBJECTIVE

To examine the risk for colorectal cancer among first-degree relatives of patients with adenoma compared with that among first-degree relatives of controls without adenoma.

DESIGN

Reconstructed cohort study.

SETTING

Three university-based colonoscopy practices in New York City.

PATIENTS

1554 first-degree relatives of 244 patients with newly diagnosed adenomas and 2173 first-degree relatives of 362 endoscopically normal controls.

MEASUREMENTS

Structured interviews were used to obtain family history. Adjusted relative risks (RR) were estimated from Cox proportional hazards regression models.

RESULTS

The risk for colorectal cancer was elevated (RR, 1.74 [95% CI, 1.24 to 2.45]) among first-degree relatives of patients with newly diagnosed adenomas compared with the risk among first-degree relatives of controls. This increased risk was the same for parents (RR, 1.58 [CI, 1.07 to 2.34]) and siblings (RR, 1.58 [CI, 0.81 to 3.08]). First-degree relatives of patients with adenomas did not have elevated risk for other cancers. The risk for colorectal cancer among family members increased with decreasing age at diagnosis of adenoma in probands. Among first-degree relatives of patients who were 50 years of age or younger when the adenoma was diagnosed, the risk was more than four times greater (RR, 4.36 [CI, 2.24 to 8.51]) than that among first-degree relatives of patients who were older than 60 years of age when the adenoma was diagnosed.

CONCLUSIONS

First-degree relatives of patients with newly diagnosed adenomas, particularly of patients who are 50 years of age or younger at diagnosis, are at increased risk for colorectal cancer and should undergo screening similar to that recommended for relatives of patients with colorectal cancer.

The epidemiology of cancer of the small bowel

Despite its anatomical location between two regions of high cancer risk, the small bowel rarely develops a malignant tumor. However, in recent years, small bowel cancer incidence rates have begun to rise. The purpose of this review is to explore the descriptive and analytic epidemiology of small bowel cancer for those factors that protect this organ and those factors associated with loss of this protection. Within the small intestine, the sites at the highest risk are the duodenum, for adenocarcinomas, and the ileum, for carcinoids and lymphomas. In industrialized countries, small bowel cancers are predominantly adenocarcinomas; in developing countries, lymphomas are much more common. The incidence of small bowel cancer rises with age and has generally been higher among males than among females. The risk factors for small bowel cancer include dietary factors similar to those implicated in large bowel cancer, cigarette smoking, alcohol intake, and other medical conditions, including Crohn's disease, familial adenomatous polyposis, cholecystectomy, peptic ulcer disease, and cystic fibrosis. The protective factors may include rapid cell turnover, a general absence of bacteria, an alkaline environment, and low levels of activating enzymes of precarcinogens. Adenocarcinomas of the small and large bowel are similar in risk factors and geographic distribution but not in recent time trends; colorectal cancer incidence rates in the United States have been falling since the mid-1980s. Small bowel lymphoma may be associated with infectious agents, such as HIV. Given the differences in anatomic and geographic location among histological subtypes, much may be learned from well-designed, histology-specific epidemiological and genetic studies of cancer of the small bowel.

Prevalence and incidence of colorectal adenomas and cancer in asymptomatic persons

The prevalence of colorectal adenomatous polyps varies widely from country to country and is highly correlated with colorectal cancer incidence rates in each country. The prevalence of adenomas reported in older studies was based on autopsy findings and is higher than that in more recent studies based on endoscopy findings. Among asymptomatic, average-risk patients, adenoma prevalence averages approximately 10% in sigmoidoscopy studies and more than 25% in colonoscopy studies, whereas the prevalence of colorectal cancer among these patients is less than 1%. The cumulative incidence of new adenomas within 3 years after normal endoscopy averages about 7% by flexible sigmoidoscopy and 27% by colonoscopy.

Epidemiology of gastrointestinal polyps

Associations between polyps and cancer of the gastrointestinal tract have been fully documented for adenomatous polyps and cancer of the large bowel. The geographic, gender, and age distribution of colorectal adenomas parallels that of colorectal cancer incidence, and individuals with a history of adenomas are at increased risk for metachronous adenomas and cancer. Observational studies of risk factors for incident adenomas have found elevated risk associated with dietary variables including: high fat, low fiber, and low vegetable intake; family history; obesity; smoking; and other exposures, some of which also are associated with cancer. Dietary intervention trials with adenoma recurrence as an endpoint, however, have had little success. Screening with polypectomy has proved effective in reducing cancer incidence and may change the epidemiology of colorectal cancer.

Recurrent adenomatous polyps and body mass index

Interest in risk factors for the recurrence of adenomatous polyps derives from the use of recurrent adenomas as surrogate end points in longitudinal studies of invasive colorectal cancer. In this case-control study, the effect of increased body mass index (BMI) on the risk of recurrent adenomas was investigated. Subjects consisted of patients seen at three colonoscopy practices in New York City, all of whom had a previous history of adenomas. On index colonoscopy, recurrent cases had an adenoma, whereas controls were normal. Men and women were analyzed separately, with different logistic models developed using backward elimination from a full model containing the covariates age at diagnosis, age-at-highest-weight, pack-years of smoking, activity level, energy intake, and fat and fiber intake. Men in the upper quartiles of BMI were found to be at greater risk of recurrent adenomas. In a model which controlled for age at diagnosis, age-at-highest-weight, activity level, pack-years of smoking and kilocalories, the estimated odds ratios were 2.2, 1.9 and 1.9 respectively for the second, third and fourth quartiles compared to the first quartile. Only the estimate for the second quartile was found to be statistically significant. No effect was observed for women, even in a model which controlled for age at diagnosis, age-at-highest-weight, pack-years and total fat. Obesity may play a role in adenoma recurrence. Confirmation of this finding would have important implications for possible prevention strategies in the future.

Reproductive risk factors for colorectal adenomatous polyps (New York City, NY, United States)

Events of reproductive life, such as parity and age at menarche, have been found in some but not all studies to be associated with risk for colorectal cancer in females. Because adenomatous polyps (adenomas) are precursors of colorectal cancer, we investigated whether reproductive variables were associated with colorectal adenomas. We conducted a case-control study among patients examined in three colonoscopy practices in New York City (NY, United States) from 1986 to 1988. Adenoma cases (n = 128) were defined as women who had an adenoma detected at the index colonoscopy with no history of inflammatory bowel disease, adenomas, or cancer. Controls (n = 283) were women with a normal index colonoscopy and no history of inflammatory bowel disease, adenomas, or cancer. The adjusted odds ratio (OR) for the association of early menarche (age less than 13 years) with adenomas was 0.6 (95 percent confidence interval = 0.4-0.9). Parity, history of spontaneous or induced abortion, infertility, type of menopause, age at menopause, use of oral contraceptives, and use of menopausal hormone replacement therapy were not associated statistically significantly with adenoma risk, although some possible trends were observed. Our findings do not implicate reproductive events, nulliparity, or overexposure to estrogens or to menstrual cycles as mechanisms of increased risk for colorectal neoplasia.

An above-knee prosthesis with a system of energy recovery: a technical note

Knee flexion to 24 degrees during early stance transforms kinetic energy into potential energy of a total center of mass (TCM) position. Flexion is controlled by the musculoligamentous apparatus. Reproduction of such flexion in a new single-axis prosthesis knee unit has minimized the metabolic energy cost to the patient by a more favorable use of gravity acting upon the prosthetic segments and the body as well as of inertia. Potential energy is stored in the spring shock absorber of the knee unit. The coefficient of energy recovery increased by 30% in comparison with a conventional above-knee prosthesis. Energy costs to the patient decrease an average of 35% during gait with the new prosthesis. The same amount of unloading during walking is typical of an intact limb. The knee unit mechanism has a link set on the axle, thus providing two joints with a common axis: a) the main joint for knee flexion to 70 degrees during swing phase and flexion to 135 degrees during sitting; b) the second joint for bending at the beginning of stance phase. Compared with conventional units, gait with the new unit displays several functional advantages: 1) normal knee kinematics with movement of a TCM along a trajectory that contributes to an easy rollover of the foot and smooth and continuous translation of the body; 2) shock absorption during early stance prevents impact from the anterior brim of the socket; 3) at mid-stance, the increase of the TCM position accumulates potential energy that results in a significant increase of the push-off force; 4) during rapid gait, the unit provides adequate resistance to knee flexion; 5) location of the joint axis in front of the line of gravity loads the prosthesis in standing, making possible unimpeded carrying of the prosthesis over the support, the lengths of the prosthetic and the intact limb being equal; in addition, it facilitates flexion before the beginning of the swing phase. Production of the units began in 1992.

Coronary artery disease and colorectal neoplasia

PURPOSE

This study was designed to determine whether patients with coronary artery disease are at elevated risk for colorectal neoplasia.

METHODS

A case-control study was conducted among consecutive patients in three colonoscopy practices in New York City from 1986 to 1988. All study participants completed an interview questionnaire covering demographics, diet, environmental and behavioral exposures, family and personal medical history, and other variables. For the present study, 298 newly diagnosed colorectal adenoma cases and 107 incident cancer cases were compared with 507 colonoscoped controls without colorectal neoplasia or other significant findings on colonoscopy. Data on history of coronary artery disease (angina and/or heart attack) were obtained solely from the study participants' questionnaire responses.

RESULTS

No association was observed between angina, heart attack, or either and colorectal adenomas in males. However, prior coronary artery disease was found to be associated with colorectal cancer in males more than 60 years of age and with colorectal adenomas in females aged 50 years or younger.

CONCLUSION

Men with coronary artery disease may be at elevated risk for subsequent colorectal cancer. Young women with coronary artery disease also may be at elevated risk for colorectal neoplasia.

The limitations of breast cancer screening for first-degree relatives of breast cancer patients

Bitter controversy surrounds the recommendation of mammographic breast-cancer screening for women aged 40 and 49 years of average risk. This paper considers the case for screening women in their 40s with higher risk, specifically women who have one or more first-degree relatives with breast cancer. A review of the literature and of current knowledge suggests that screening such women is more cost-effective, in the sense of having a higher yield per mammogram and better predictive value, than screening women of average risk in this age group. However, there is no evidence that screening is more efficacious in reducing mortality in this subgroup than in other women in their 40s.

Incidence and recurrence rates of colorectal adenomas: a prospective study

BACKGROUND/AIMS

The frequency of colorectal adenomas, the precursor lesions for most cases of colorectal carcinoma, has been generally measured as prevalence rates of adenomas at autopsy or colonoscopy. The aim of this study was to estimate the incidence rate of adenomas and compare it with the adenoma recurrence rate.

METHODS

Data on colonoscopies performed in three New York City practices were collected prospectively. The cumulative rate of adenoma diagnosis on repeat colonoscopy was calculated for patients with no abnormalities on index colonoscopy ("incidence" rate) and for patients with adenomas on the index colonoscopy ("recurrence" rate).

RESULTS

The cumulative incidence rate of adenomas at 36 months was 16%, and the cumulative recurrence rate at 36 months was 42% (P < 0.004). The recurrence rate was higher in patients with multiple adenomas than in those with a single adenoma on index colonoscopy, although the increase was not statistically significant.

CONCLUSIONS

Although the recurrence rate has always been assumed to be elevated, this study is the first to compare the recurrence rate of adenomas with the incidence rate directly and to show that the recurrence rate is indeed elevated.

Exposure of red spruce seedlings to acid mist: importance of droplet composition just prior to drying periods

Two-year-old red spruce (Picea rubens Sarg.), raised from seed collected at five locations from Maine to North Carolina, were exposed in a greenhouse to either sulphuric or nitric acid mist (median pH 2-85). Exposures were performed three times a day, four days a week over an eleven-week period during the growing season. Each exposure consisted of 4 h of misting followed by a 3.75 h drying period. Immediately before each drying period, acidic droplets were either left to dry directly on the foliage or were removed by a 15 min deionized water (diw) rinse. When sulphuric acid droplets dried directly on the foliage, visible injury developed and to a lesser degree the same was true for nitric acid. When acidic droplets were replaced with dim before each drying period, foliar injury did not develop despite misting for hundreds of hours at pH values well within the range that has caused visible injury in previous experiments. When acidic droplets dried directly on foliage, needle dry weight was reduced, but differences between sulphuric and nitric acid exposure were not found. No treatment effects were found on terminal shoot length. Treatment responses among seedlings from different seed resources were similar, with greater variation found within provenances than between provenances. We conclude that the composition of liquid on foliage at the end of wet deposition events and the processes occurring during drying periods are important factors in determining the response of red spruce to acidic cloudwater.

Fatherhood and distal adenomas of the large bowel: a study of male self-defense officials in Japan

Parity has been studied extensively as a risk factor for colorectal cancer but has not been definitively shown to be associated with altered risk. In a few studies, risk of colorectal cancer in childless men has been compared to risk in men with children, but results have not been consistent. We analyzed the association of fatherhood with risk of colorectal adenomas in male self-defense officials (ages 49-55) in Japan. The study participants received a preretirement health examination including flexible sigmoidoscopy at Self-Defense Forces hospitals in Japan from January 1991 through December 1992. The examinations identified 265 cases with rectal or sigmoid adenomas and 1480 controls with normal examinations up to 60 cm from the anus. Data on marital status, number of children, long-term work assignment away from wife and children, and other lifestyle variables were obtained by means of a self-administered questionnaire prior to physical examination. Multiple logistic regression analysis assessed the risk of adenomas in relation to number of children, marital status, long-term work assignment away from family, and military rank, with adjustment for cigarette smoking, alcohol intake, dietary variables, body mass index, and recreational physical activity. In this relatively homogeneous group, more than 98% of both cases and controls were currently married, and more than 93% had children. The adjusted odds ratio for the association of adenomas with fatherhood was 0.4 (95% confidence interval, 0.2-0.8). Marital status and work assignment away from the family were not associated with adenoma risk. These findings suggest that colorectal adenomas and perhaps cancer risk may be associated with childlessness in men.

Cigarette smoking and other behavioral risk factors for recurrence of colorectal adenomatous polyps (New York City, NY, USA)

Adenomatous polyps (hereinafter referred to as adenomas) are known precursors of colorectal cancer. Cigarette smoking has been associated with adenomas but not with colorectal cancer, while alcohol and fat intake have been associated with both adenomas and cancer in some studies. Approximately 30 percent of patients with resected adenomas develop another adenoma within three years. This case-control study explores the association of cigarette smoking with adenoma recurrence. Between April 1986 and March 1988, we administered a questionnaire to colonoscoped patients aged 35 to 84 years in three New York City (NY, USA) practices. We compared 186 recurrent polyp cases (130 males, 56 females) and 330 controls (187 males, 143 females) who had a history of polypectomy but normal follow-up colonoscopy, by cigarette-smoking pack-years adjusted for possible confounders. Risk for a metachronous or recurrent adenoma was significantly greater in the highest quartile of smokers than in never-smokers among both men (odds ratio [OR] = 1.8, 95 percent confidence interval [CI] = 1.0-3.4) and women (OR = 3.6, CI = 1.7-7.6). Adjustment for time since smoking cessation reduced risk only slightly, as did adjustment for dietary fat intake, which itself remained significant. No association was found between alcohol intake and risk of recurrence. Cigarette smokers appear to have an elevated risk of adenoma recurrence that is not eliminated entirely by smoking cessation. Intervention trials that use adenoma recurrence as an endpoint should take smoking into account.

Colorectal cancer: detection, treatment, and rehabilitation

In the United States, colorectal cancer is the second most common cause of cancer mortality after lung cancer. However, incidence and mortality rates have been falling, reflecting improvements in primary prevention, early detection, and treatment. This article reviews the major advances in the understanding and management of colorectal cancer.

Gender and colorectal cancer

Studies of gender differences in colorectal cancer have shown temporal shifts in incidence and site distribution which can be attributed, in part, to environmental and behavioural factors. In high-risk populations, rectal cancer and left-sided colon cancer have been more frequent in older men, whereas right-sided colon cancer has been more commonly found in older women. Among known associations with reduced colorectal cancer risk, women appear to ingest more dietary fibre, seem to benefit more from physical activity and body mass, and consume less alcohol. Although these differences may contribute to the risk differential, hormonal events during reproductive years also appear to affect women's risk at older age. The interactions of sex hormone metabolism and nutrition, including dietary fibre, in colorectal carcinogenesis provide a rewarding field for investigation.

Effect of fertilizer on the growth of radish plants exposed to simulated acidic rain containing different sulfate to nitrate ratios

Two successive experiments were performed in the greenhouse to test the hypothesis that plant response to the amounts and ratios of sulfuric and nitric acids in rain is affected by the amount of fertilizer added to the growing medium. Radish plants, grown with different levels of N?P?K fertilizer, were given ten 1-h exposures over a 3-week period to simulate acidic rain at pH values from 2.6 to 5.0 and sulfate to nitrate mass ratios from 0.3 to 7.5. Increased acidity of simulated rain reduced plant growth, with a greater depression of hypocotyl mass than shoot mass. The reverse growth response occurred with increased supply of fertilizer: plant biomass rose with a larger increase in shoot mass than hypocotyl mass. In one experiment, plants that received a greater supply of fertilizer exhibited more obvious reductions in growth of hoots at the higher levels of acidity of simulated rain. There were no significant effects of sulfate to nitrate ratios in simulated rain on plant growth, nor any effect of this ratio on the response of shoots and hypocotyls to acidity of simulated rain. Addition of fertilizer had no effect on plant response to sulfate to nitrate ratios. These results do not support the hypothesis that nutrient-deficient plants are either more or less responsive to sulfate and nitrate in rain than plants grown with optimal supplies of nutrients. They support previous results indicating no effects of sulfate to nitrate ratio in simulated acidic rain on plant growth. The results also suggest that the greatest risk of harmful effects on vegetation may come from the combination of high sulfate and high acidity in rainfall.