Armin D. Weinberg

Genetic Testing and Cancer Risk Management Recommendations by Physicians for At-Risk Relatives

Purpose: Sequence-based cancer susceptibility testing results are described as negative, deleterious mutation or variant of uncertain significance. We studied the impact of different types of test results on clinical decision making.Methods: Practicing physicians from five specialties in Texas completed an online case-based survey (n = 225). Respondents were asked to make genetic testing and management recommendations for healthy at-risk relatives of patients with cancer.Results: When the patient carried a deleterious BRCA1 mutation or variant of uncertain significance, 98% and 82% of physicians, respectively, recommended testing of at-risk relatives (P < 0.0001). In both situations, comprehensive BRCA1/2 analysis was selected most with a corresponding 9-fold increase in unnecessary genetic testing costs. There was no difference in physicians with (n = 81) or without (n = 144) prior BRCA1/2 testing experience (P = 0.3869). Cancer risk management recommendations were most intense for the relative with a deleterious mutation compared with variant of uncertain significance, negative, or no testing with 63%, 13%, 5%, and 2%, respectively, recommending oophorectomy (P < 0.0001).Conclusions: Independent of experience, or specialty, physicians chose more comprehensive testing for healthy relatives than current guidelines recommend. In contrast, management decisions demonstrated the uncertainty associated with a variant of uncertain significance. Utilization of genetic professionals and education of physicians on family-centered genetic testing may improve efficacy and substantially reduce costs.

Breast cancer screening: Racial/ethnic differences in behaviors and beliefs

Racial/ethnic differences in breast cancer screening behaviors and beliefs were examined in 259 asymptomatic women, 50 years old or older, who participated in a no-cost worksite breast cancer screening program. Hispanics were more likely than African Americans to report having had mammography in the past year. Caucasians and Hispanics were more likely than African Americans to report having had a clinical breast examination in the past year. African Americans to report having had a clinical breast examination in the past year. African Americans and Hispanics were more likely to practice monthly breast self-examination than were Caucasians. African Americans were more likely to report cancer-related fears and worries as barriers to mammography, whereas Caucasians were more likely to report being too busy, inconvenience, and procrastination as barriers. African Americans also were more likely to evaluate their physicians and other health professionals positively than were Caucasians. These results suggest a need to make a special effort to address cancer-related fears as barriers to screening among African Americans, and time-related barriers to screening among Caucasians.

Early detection of skin cancer: Racial/ethnic differences in behaviors and attitudes

Data from 384 individuals participating in a worksite skin cancer screening program were used to assess racial/ethnic differences in attitudes toward and practice of prevention and early detection of skin cancer. Caucasians and Hispanics were more likely than African Americans to report having used a sunscreen during the past year. Caucasians performed skin self-examination more frequently than Hispanics, but African Americans did not differ in their frequency of skin self-examination from the other two groups. African Americans and Hispanics reported that they would be less likely than Caucasians to seek immediate follow-up care for suspicious skin lesions. Both similarities and differences were found in a variety of health belief variables across the three groups. These findings suggest a need for intensified efforts at primary and secondary prevention of skin cancer among African Americans.

Pitfalls in Interpreting Prostate Specific Antigen Velocity

PURPOSE The concept of prostate specific antigen (PSA) velocity as an improved marker for prostate cancer detection is intriguing. However, before this concept is applied to individual patients several confounding parameters must be addressed. We determined the variability of serum PSA levels in men without prostate cancer. MATERIALS AND METHODS We reviewed data from a prostate cancer screening program, and determined inter-assay and individual variability of the serum PSA values for a 2-year followup period in 265 men clinically free of prostate cancer. RESULTS Our average inter-assay coefficient of variation was 7.5%. Therefore, we considered only PSA changes exceeding +/- 15% as significant. Fluctuations in serum PSA occurred in 78% of the men during the observation period, and 12.5% had at least a single PSA increase exceeding 0.75 ng/ml. per year. Fluctuations were noted throughout the entire range of serum PSA levels but became progressively larger with an increasing mean PSA. CONCLUSIONS The inter-assay variability must be considered when interpreting PSA velocity. Individual fluctuations in serum PSA dictate an observation period of at least 2 years before PSA velocity is considered abnormal.

The State of School Heart Health Education: A Review of the Literature

The evidence and presence of modifiable risk factors asso ciated with heart disease has heightened interest among health educators in developing prevention oriented programs. In an attempt to assist in planning future curriculum efforts and research in this area a literature re view was conducted. It is presented and organized within the following three major categories: 1. incidence of cardiovascular risk factors (in the school age population); 2. need for health education (the status of adoles cent health and problems of motivation); and 3. evaluations of current heart projects (knowledge, attitudes and behavioral outcomes). A few clas sic articles were included: the primary literature reviewed was that of the past 10 years. The following conclusions were drawn: 1. there is a need to be concerned about the cardiovascular health of young people; 2. the need for educational programs about proven methods of prevention is well documented; 3. studies have found that adolescents do not have suf ficient knowledge upon which to make healthful decisions related to pre venting cardiovascular disease; 4. research has demonstrated that well de signed programs can be effective in increasing health knowledge and pro moting positive attitudes; 5. some programs have encouraged behavioral change; 6. most programs ha ve proven too expensive to become integral components of the curricula; and 7. further educational research must be conducted so that health education might by the end of this decade play a significant role in the reduction of the morbidity and mortality inflicted by cardiovascular disease.

Anxiety in medical situations and chemotherapy‐related problems among cancer patients

Relationships between anxiety in medical situations and age, gender, duration of illness, and communication problems with friends or relatives were examined in a heterogeneous sample of 117 adult cancer patients. The relationships between the same demographic, medical, and psychosocial variables and chemotherapy-related problems in a subsample of 79 patients receiving chemotherapy also were examined. Results indicated that females and patients who reported more communication problems with friends or relatives reported more anxiety in medical situations. Female patients and patients who reported more communication problems with friends or relatives also reported more chemotherapy-related problems. Duration of illness was not related significantly to either dependent measure. Clinical implications of these results are discussed.

Adjuvant chemotherapy for stage III colon cancer in the oldest old: Results beyond clinical guidelines

Randomized trials demonstrating the benefits of chemotherapy in patients with American Joint Committee on Cancer stage III colon cancer underrepresent persons aged ≥ 75 years. The generalizability of these studies to a growing elderly population remains unknown.

Demographic, psychosocial, and objective risk factors related to perceived risk of skin cancer

BACKGROUND AND METHODS The present study examined the ways in which demographic, psychosocial, and objective risk factors were related to perceived risk of skin cancer among 384 hospital employees who participated in a screening program. It was hypothesized that pyschosocial risk factors would account for a significant portion of the variance in risk perception beyond that accounted for by the other risk factors. RESULTS The risk factors accounted for approximately 44% of the variance in risk perception. Psychosocial risk factors accounted for a statistically significant portion of the variance in risk perception beyond that accounted for by other risk factors. Worry, family history of skin cancer, and race/ethnicity were most strongly related to perceived risk. CONCLUSIONS Results are discussed in terms of the need for educational programs that emphasize the relationship between level of risk and skin cancer and provide specific information regarding steps that can be taken to prevent skin cancer.

Cancer Clinical Trials Accrual: Missed Opportunities to Address Disparities and Missed Opportunities to Improve Outcomes for All

Stewart et al. 1 have implemented a clever strategy for documenting the underrepresentation of racial/ethnic minorities and older patients in surgical oncology clinical trials. Their approach involved calculation of an ‘‘enrollment fraction’’ (EF) for various subsets of the American cancer patient population. Individual EFs were computed as the ratio of National Cancer Institute (NCI)-generated data on cooperative group clinical trial accrual compared with Surveillance, Epidemiology, and End Results Program-derived cancer incidence data. The disappointing (but not necessarily surprising) results from these analyses demonstrated that EFs were substantially lower for African American, Hispanic/Latino American, and Asian/Pacific Islander cancer patients (0.48%, 0.54%, and 0.59%, respectively) when compared with white Americans (0.72%). Cancer patients age 75 years and older had an EF of 0.14%, in contrast to an EF of 1.8% for patients aged 21 to 54, and 0.91% for those aged 55 and 64. Race/ethnicity- and age-related disparities in surgical oncology clinical trial accrual are potent examples of inequities the current American health care system. The clinical trial mechanism represents the most powerful weapon that the oncology community possesses in the effort to improve the standard of care as well as survivorship for cancer patients. Diet, comorbidities, lifestyle/culture, and socioeconomic resources are all features that vary between and

Application of cancer prevention knowledge: A longitudinal follow‐up study of medical students

Measuring the clinical application of knowledge and skills acquired in specific medical school courses is a critical part of curriculum evaluation. Second-year Cancer Prevention Course (CPC) students and a comparison group were surveyed by questionnaires, cognitively tested, and a subsample participated in in-depth interviews. The 6-month and 18-month follow-up interviews indicated that more CPC students practiced prevention in their clinical rotations than did the comparison group. Direct, one-on-one access to patients during clinical training was an important mediating factor in the practice of prevention skills. In addition, a behavioral intent inventory showed that CPC students, in their future careers, intend to perform certain specific cancer prevention activities more than others. Long-term retained knowledge (75% correct) stabilized at levels significantly higher (p less than .001) than baseline test scores prior to the Cancer Prevention Course. At the time of the two follow-up exams of cognitive knowledge, the comparison group of students was able to do no better than had the CPC students at baseline before the course. Positive beliefs about cancer prevention improved over the study period. More than twice as many cancer course students attended subsequent optional lectures and reported optional reading on cancer prevention topics than did the comparison group. Overall, the study showed a lasting effect of the elective course in cancer prevention, in terms of tested knowledge, and self-reported measures of attitudes, beliefs, practice of prevention in clinical rotations, and intent to apply prevention in future practice.