Mary Beth Mercer

Computer Program to Assist in Making Decisions About Adjuvant Therapy for Women With Early Breast Cancer

PURPOSE The goal of the computer program Adjuvant! is to allow health professionals and their patients with early breast cancer to make more informed decisions about adjuvant therapy. METHODS Actuarial analysis was used to project outcomes of patients with and without adjuvant therapy based on estimates of prognosis largely derived from Surveillance, Epidemiology, and End-Results data and estimates of the efficacy of adjuvant therapy based on the 1998 overviews of randomized trials of adjuvant therapy. These estimates can be refined using the Prognostic Factor Impact Calculator, which uses a Bayesian method to make adjustments based on relative risks conferred and prevalence of positive test results. RESULTS From the entries of patient information (age, menopausal status, comorbidity estimate) and tumor staging and characteristics (tumor size, number of positive axillary nodes, estrogen receptor status), baseline prognostic estimates are made. Estimates for the efficacy of endocrine therapy (5 years of tamoxifen) and of polychemotherapy (cyclophosphamide/methotrexate/fluorouracil-like regimens, or anthracycline-based therapy, or therapy based on both an anthracycline and a taxane) can then be used to project outcomes presented in both numerical and graphical formats. Outcomes for overall survival and disease-free survival and the improvement seen in clinical trials, are reasonably modeled by Adjuvant!, although an ideal validation for all patient subsets with all treatment options is not possible. Additional speculative estimates of years of remaining life expectancy and long-term survival curves can also be produced. Help files supply general information about breast cancer. The programs Internet links supply national treatment guidelines, cooperative group trial options, and other related information. CONCLUSION The computer program Adjuvant! can play practical and educational roles in clinical settings.

Outcomes of a randomized community-level HIV prevention intervention for women living in 18 low-income housing developments

OBJECTIVES Women in impoverished inner-city neighborhoods are at high risk for contracting HIV. A randomized, multisite community-level HIV prevention trial was undertaken with women living in 18 low-income housing developments in 5 US cities. METHODS Baseline and 12-month follow-up population risk characteristics were assessed by surveying 690 women at both time points. In the 9 intervention condition housing developments, a community-level intervention was undertaken that included HIV risk reduction workshops and community HIV prevention events implemented by women who were popular opinion leaders among their peers. RESULTS The proportion of women in the intervention developments who had any unprotected intercourse in the past 2 months declined from 50% to 37.6%, and the percentage of womens acts of intercourse protected by condoms increased from 30.2% to 47.2%. Among women exposed to intervention activities, the mean frequency of unprotected acts of intercourse in the past 2 months tended to be lower at follow-up (mean = 4.0) than at baseline (mean = 6.0). These changes were corroborated by changes in other risk indicators. CONCLUSIONS Community-level interventions that involve and engage women in neighborhood-based HIV prevention activities can bring about reductions in high-risk sexual behaviors.

Public Policy, Public Opinion, and Consent for Organ Donation

Medical advances in transplantation techniques have driven an exponential increase in the demand for transplantable organs. Unfortunately, policy efforts to bolster the organ supply have been less than effective, failing to provide a stopgap for ever-increasing numbers of patients who await organ transplantation. The number of registrations on waiting lists exceeded 65,245 in early 1999, a 325% increase over the 20,000 that existed 11 years earlier in 1988. Regrettably, more than 4,000 patients die each year while awaiting transplantation.

A National Study of Physician Recommendations to Initiate and Discontinue Growth Hormone for Short Stature

OBJECTIVES: Overall growth hormone (GH) use depends on decisions to both initiate treatment and continue treatment. The determinants of both are unclear. We studied how physicians decided to begin GH in idiopathic short stature and how, after an initial course of treatment, they decided to continue, intensify (increase the dose), or terminate treatment. METHODS: We used a national census study of 727 pediatric endocrinologists involving a structured questionnaires with a factorial experimental design. Main outcome measures were GH recommendations for previously untreated children and those children who were treated with GH for 1 year. RESULTS: The response rate was 90%. In previously untreated children, recommendations to initiate GH were consistent with guidelines and also influenced by family preferences and physician attitudes (P < .001). In children treated with GH, recommendations on whether to continue GH were influenced by the growth response to therapy (P < .01) but were divided regarding course of action. With identical growth responses to treatment, physician decisions diverged (intensify versus discontinue GH) and were driven by independent, nonphysiologic, and contextual factors (eg, physician attitudes, family preferences, and GH-initiation recommendation; each P < .001). Together, attitudinal and contextual factors exerted more influence on continuation decisions than did the growth response to therapy. CONCLUSIONS: Physician decisions to initiate GH are largely consistent with evidence-based medicine. However, decisions about continuing GH vary and are strongly influenced by factors other than response to treatment. With a potential market of 500 000 US children and costs exceeding

Patient, physician, and consumer drivers: referrals for short stature and access to specialty drugs.

10 billion per year, changes in GH use may depend on potentially modifiable physician attitudes and family preferences as much as physiologic evidence.

Predictors of condom use and human immunodeficiency virus test seeking among women living in inner-city public housing developments.

Background:Candidates for specialty drugs, the fastest growing and costliest pharmaceuticals, typically originate with primary care referrals. However, little is known about what drives such referrals—especially for large populations such as short, otherwise normal children (idiopathic short stature). Recent expanded approval of growth hormone (GH) makes more than 585,000 US children eligible for such treatment, potentially costing over

HIV risk behaviors among women living in low-income, inner-city housing developments.

11 billion/y. Methods:To quantify the relative impact of patient physiological indicators, physician characteristics, and consumer preferences on referrals to endocrinologists (and potential access to GH) for short children, a national study of 1268 randomly selected US pediatricians was conducted, based on a full factorial experimental design in a structured survey. Results:While patient indicators (height, growth pattern) influenced referrals (P < 0.001), consumer drivers (family concern) and physician attitudes had almost as great an impact—especially for children with less severe growth impairment (P < 0.001). Physician belief that short stature impairs emotional well-being and physician characteristics (female, older, shorter, beliefs about drug company information) increased referrals (P < 0.03–0.001)—independent of growth parameters. Conclusions:Referral recommendations that create the pool of candidates for the specialty drug GH are heavily swayed by physician characteristics and consumer preferences, particularly in the absence of compelling physiological evidence. This makes most of children with short stature strikingly susceptible to nonphysiological influences on referrals that render them candidates for this specialty drug. Only 1 additional referral per US pediatrician would likely increase GH costs by over

Families' understanding of brain death.

100 million/y.

The reasons families donate organs for transplantation: implications for policy and practice.

Background and Objectives: To examine prevalence and predictors of condom use and human immunodeficiency virus (HIV) test seeking among women living in inner‐city housing developments. Study Design: Between April and June 1994, 671 women living in low‐income housing developments in five cities in the United States completed an anonymous self‐report questionnaire eliciting information on acquired immune deficiency syndrome (AIDS) risk behavior and characteristics indicative of risk. Results: Most participants were women of color who were economically disadvantaged. Fifteen percent reported multiple sex partners, and 30% of women with one sex partner believed he had sex with someone else in the past year. Predictors of condom use included increased rates of safe‐sex negotiation, stronger risk reduction intentions, absence of condom barrier beliefs, and multiple sex partners. Women tested for HIV in the past year were younger, perceived themselves to be at risk for HIV infection, reported more conversations with other women about AIDS concerns, and had condoms readily available. Conclusions: HIV public health prevention interventions are urgently needed for women who live in low‐income urban housing developments.