David E. Elkins

Lymphedema of the Arm and Breast in Irradiated Breast Cancer Patients: Risks in an Era of Dramatically Changing Axillary Surgery

Abstract:  The purpose of this study was to assess risk for lymphedema of the breast and arm in radiotherapy patients in an era of less extensive axillary surgery. Breast cancer patients treated for cure were reviewed, with a minimum follow‐up of 1.5 years from the end of treatment. Clinical, surgical, and radiation‐related variables were tested for statistical association with arm and breast lymphedema using regression analyses, t‐tests, and chi‐squared analyses. Between January 1998 and June 2001, 240 women received radiation for localized breast cancer in our center. The incidence of lymphedema of the ipsilateral breast, arm, and combined (breast and arm) was 9.6%, 7.6%, and 1.8%, respectively, with a median follow‐up of 27 months. For breast edema, t‐test and multivariate analysis showed body mass index (BMI) to be significant (p = 0.043, p = 0.0038), as was chi‐squared and multivariate testing for site of tumor in the breast (p = 0.0043, p = 0.0035). For arm edema, t‐test and multivariate analyses showed the number of nodes removed to be significant (p = 0.0040, p = 0.0458); the size of the tumor was also significant by multivariate analyses (p = 0.0027). Tumor size appeared significant because a number of very large cancers failed locally and caused cancer‐related obstructive lymphedema. In our center, even modern, limited level 1–2 axillary dissection and tangential irradiation carries the risk of arm lymphedema that would argue in favor of sentinel node biopsy. For breast edema, disruption of draining lymphatics by surgery and radiation with boost to the upper outer quadrant increased risk, especially for the obese. Fortunately both breast and arm edema benefited from manual lymphatic drainage. 

Quality of Life with Well-Differentiated Thyroid Cancer: Treatment Toxicities and Their Reduction

INTRODUCTION Patients with well-differentiated thyroid cancer have a good prognosis but a significant chance for local recurrence. In the past, limited surgery with postoperative 131I only for extremely high-risk cases or recurrence was not uncommon. As more aggressive surgical and postoperative treatments appear to gain wider acceptance, toxicity and long-term morbidity become more important issues. Our goal is to present the experience of a single institution with emphasis on oral side effects related to 131I as well as acute and chronic symptoms related to this diagnosis and their impact on quality of life. METHODS Fifty-seven patients were followed for a median time of 19.3 months. All patients received therapeutic 131I (mean dose, 154.7 mCi) between January 1, 1996 and August 30, 2002. RESULTS Fifty-four patients (94.7%) were alive at the time of analysis. Sixteen (28.1%) required a second treatment: any sign of persistence resulted in retreatment. Complaints with 131I treatment included altered taste, 26.3%; acute xerostomia, 21.1%; and acute sialoadenitis, 15.8%. Chronic xerostomia occurred in 6 (35.3%) of all patients who received multiple treatments. The incidence of chronic xerostomia was reduced to 1 of 11 (9.1%) with amifostine pretreatment. Other chronic side effects associated with this disease included fatigue 54.4%, weight gain of more than 6 months duration 24.6%, with 12 (27.9%) of those under 60 experiencing an average gain of 2.3 kg from initial diagnosis. CONCLUSION Review of treatment-related symptoms prompted policies to reduce toxicity including amifostine pretreatment for 131I therapy and thyrotropin (synthetic TSH) use in place of iatrogenic hypothyroidism for thyroglobulin testing and scanning.

Validity of the Massachusetts Youth Screening Instrument–2 (MAYSI–2) Scales in Juvenile Justice Settings

High prevalence rates of psychological problems among juvenile offenders underscore the need for effective mental health screening tools in the juvenile justice system. In this study, we evaluated the validity of the Massachusetts Youth Screening Instrument–2 (MAYSI–2) developed by Grisso and Barnum (2001) to identify mental health needs of adolescents in various juvenile justice settings. The sample was 1,192 adolescents (1,082 boys and 110 girls) admitted into Virginia juvenile correction facilities between the dates of July 2004 and June 2006. Analyses revealed higher MAYSI–2 scale scores for girls than for boys and MAYSI–2 scale intercorrelations were similar to those reported in the MAYSI–2 manuals (Grisso & Barnum, 2003, 2006). We also evaluated the concurrent validity of MAYSI–2 scales by examining scale score correlations with related and unrelated extratest variables. Results showed strong convergent validity for several MAYSI–2 scales.

Cosmesis with Bilateral Mammoreduction for Conservative Breast Cancer Treatment

Abstract:  Over 7 years, 57 women with breast cancer underwent lumpectomy and bilateral mammoreduction. Physical complaints about large or lax breast shape were the predominate rationale. Two patients were immediately lost to follow‐up, 55 patients remained and were followed every 3 months for an average of 1.6 years. This is the largest series traceable by computer and literature search. Chart review and patient examination in this retrospective review were utilized as the basis for data within the article. Collated notes from patients’ doctors were assessed, as well as documented patient responses to the procedure. Pictures without head/face for identifiers were taken of the patients. Chart data were collected by clinicians, but were reviewed blindly by a statistician. The overall control and cosmesis rates as well as alleviation of heavy breast problems were noted. Only 6% of women had fair to poor cosmetic results; the majority (82%) had excellent to good results. Women with very large breasts or markedly relaxed breast tissue of concern to the patients proved optimal candidates for lumpectomy of cancer and bilateral mammoreduction in the conservative treatment of these cancers. There was a significant reduction in the physical complaints of the patients as well. For women with very pendulous or extremely large breasts, lumpectomy and bilateral mammoreduction may prove to be the optimal course of action.

Incremental Validity of the MMPI-2 Content Scales in a Psychiatric Sample

The current study replicated and expanded previous investigations that focused on the incremental contribution of the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) content scales. The MMPI-2 and the Symptom Checklist-90-Revised (SCL-90-R) were administered to 597 adult psychiatric patients (289 females, 308 males) receiving inpatient treatment. In addition, clinical psychologists provided ratings on each of these patients with the Brief Psychiatric Rating Scale (BPRS) and the Global Assessment Scale (GAS). A series of hierarchical stepwise multiple regression analyses were conducted with MMPI-2 basic and content scales as the independent variables and SCL-90-R, BPRS, and GAS variables as the dependent criteria. Similar to Findings by Ben-Porath, McCully, and Almagor, MMPI-2 content scales were shown to add incrementally to the prediction of variance on self-report measures; the current study also revealed significant relationships to clinician-rater criteria. Implications of the present findings for test interpretation procedures and future research are presented and discussed.

Impact of race on breast cancer in lower socioeconomic status women.

Abstract:  Lower socioeconomic status and lack of access to care are often implicated as plausible causes for African American women to present with later stage breast cancer than Caucasian women. Our objective is to determine if racial differences are present in newly diagnosed breast cancer in women of equivalent socioeconomic status. A retrospective review of prospectively gathered data from women with newly diagnosed breast cancer was performed. All women presented to the indigent (uninsured and below the poverty line) breast clinic for evaluation and treatment of their breast pathology. Data pertaining to epidemiologic factors, diagnosis, pathology, and treatment were collected. The data were analyzed by chi‐squared and tailed t‐tests. Between March 2002 and May 2004, 52 women (African American = 36, Caucasian = 16) were diagnosed with breast cancer at our clinic. The median age for both groups at presentation was 56.6 years. The staging assessment based on the pathologic size of the tumor was also equivalent between African American and Caucasian women at 2.29 cm and 2.21 cm, respectively. Metastatic lymph node involvement occurred in 14 women (African American = 7, Caucasian = 7), with 19.4% African American and 43.8% Caucasian being node positive (p = 0.068). In fact, there were no statistically significant differences between the races for menarche, menopause, body mass index (BMI), duration of symptoms before presentation, type of diagnostic biopsy or surgery chosen, histology, receptor status, utilization of chemotherapy and radiation, and length of follow‐up. The only statistical differences found were in the age of the first live birth (African American = 19, Caucasian = 22; p = 0.028), the use of ultrasound in initial evaluation of a breast mass (less use in African American; p = 0.012), and utilization of sentinel lymph node biopsy (Caucasian = 75%, African American = 42%; p = 0.026). Breast cancer in African American women traditionally presents at a more advanced stage and with poor prognostic features. However, when matched for lower socioeconomic status, racial disparities essentially disappear.

An Evaluation of the Usefulness of the MMPI-2 F(p) Scale

The Minnesota Multiphasic Personality Inventory-2 (MMPI-2) F(p) scale was developed by Arbisi and Ben-Porath (1995) by identification of 27 items endorsed by fewer than 20% of individuals in both normal and psychiatric samples. The F(p) scale was designed for applications in settings characterized by high base rates of serious psychopathology, such as psychiatric inpatient units, and is proposed as a useful scale in discriminating overreported protocols from those produced by patients with serious psychopathology. In this study we investigated the characteristics of this scale in a sample of 617 psychiatric inpatients who responded to the MMPI-2 under standard conditions, and 203 overreported protocols derived in research studies conducted with normal adult participants instructed to simulate various forms of serious psychopathology. Results of this study are consistent with prior reports of a relatively low frequency of item endorsement for F(p) scale items in psychiatric samples, and intercorrelations between the F(p) scale and the MMPI-2 basic clinical scales in clinical samples that are generally lower than those produced between either F or Fb and the basic clinical scales. However, this intercorrelational pattern between F(p) and the MMPI-2 basic scales was not as consistent for the overreported sample. Additionally, the F(p) scale appears to be effective in discriminating overreported from accurate MMPI-2 protocols, with some evidence that the optimal cutting scores for this and other MMPI-2 infrequency scales may differ as a function of gender. Finally, these findings do not show clear evidence of improved group prediction derived from the use of the F(p) scale in contrast to results obtainable through the use of the MMPI-2 F scale.

Identification of Random Responding on the MMPI-A

Although substantial research literature on the effects of random responding on the MMPI-2 exists, there is very limited data available on this issue with the MMPI-A. The purpose of this study was to evaluate the utility of selected MMPI-A validity scales in detecting differences in response patterns between protocols produced by 354 adolescents assessed in clinical settings and a group of 354 randomly produced MMPI-A protocols. Results indicate that MMPI-A validity and basic clinical scales differ significantly between random and clinical groups and that MMPI-A validity Scales F, F1, F2, and VRIN appear to be most useful in correctly identifying protocols from actual clinical participants versus randomly generated response patterns. Findings are discussed in terms of the dramatic effects of the sample base rate for random responding on overall classification accuracy results. Furthermore, it was noted that the optimal cutting scores for MMPI-A Scales F, F1, F2, and VRIN were largely consistent with interpretive recommendations found in the test manual (Butcher et al., 1992) when the relative frequency of random response protocols to clinical protocols was evaluated at a ratio of 1:10. Finally, future recommendations for evaluation of the F1-F2 difference score and the TRIN scale are offered in terms of the most relevant research designs to evaluate these measures.

Evaluation of an MMPI--a short form: implications for adaptive testing.

Efforts to develop a viable short form of the MMPI (Hathaway & McKinley, 1943) span more than 50 years, with more recent attempts to significantly shorten the item pool focused on the use of adaptive computerized test administration. In this article, we report some psychometric properties of an MMPI-Adolescent version (MMPI-A; Butcher et al., 1992) short form based on administration of the first 150 items of this test instrument. We report results for both the MMPI-A normative sample of 1,620 adolescents and a clinical sample of 565 adolescents in a variety of treatment settings. We summarize results for the MMPI-A basic scales in terms of Pearson product-moment correlations generated between full administration and short-form administration formats and mean T score elevations for the basic scales generated by each approach. In this investigation, we also examined single-scale and 2-point congruences found for the MMPI-A basic clinical scales as derived from standard and short-form administrations. We present the relative strengths and weaknesses of the MMPI-A short form and discuss the findings in terms of implications for attempts to shorten the item pool through the use of computerized adaptive assessment approaches.

Psychometric Properties of the Minnesota Multiphasic Personality Inventory–Adolescent (MMPI–A) Clinical, Content, and Supplementary Scales in a Forensic Sample

In this study, we evaluated the internal psychometric properties and external correlates of scores on the Clinical, Content, and Supplementary scales in a forensic sample of 496 adolescents (315 boys and 181 girls) who were court-ordered to receive psychological evaluations. We examined Cronbachs alpha coefficients, scale intercorrelation matrices, and frequencies of scale elevations. Further, we found varying degrees of support for the convergent and discriminant validity of scores on the MMPI–A (Butcher et al., 1992) Clinical, Content, and Supplementary scales. This study adds to the body of literature establishing the utility of the MMPI–A in forensic evaluations.