Susan L. Stewart

Addressing the needs of young breast cancer survivors at the 5 year milestone: can a short-term, low intensity intervention produce change?

BackgroundToday, the 5-year relative survival rate for cancer is 65% and there are 10.5 million survivors. The largest group of survivors are those of breast cancer. Reductions in mortality are occurring at a greater rate for women under age 50 at diagnosis than among older women.AimsOur goal was to design a socio-educational intervention for 5-year survivors aged 50 or younger at diagnosis and test the hypotheses that women in the intervention group would show greater improvement than controls with respect to (1) knowledge of breast cancer, its treatment, and long-term health concerns; (2) lifestyle habits (i.e., exercise and diet); and (3) communication with family and physicians.MethodsUsing a randomized controlled trial with a pre-post design, 404 women who were 5xa0years from diagnosis and cancer-free (response rate 54%) were randomly assigned to an intervention or delayed intervention (control) group and were assessed at pre-test (baseline) and 6xa0months later (96% retention). The intervention consisted of three 6-h workshops over a 3xa0month period. Four series of workshops were held at different geographical areas in the greater San Francisco Bay Area. The workshops included activities and information to promote physical, social, emotional, and spiritual well-being. The intervention design was based on findings from focus groups and a survey of 185 cancer-free 5-year survivors that assessed changes since the early months after diagnosis in physical, social, emotional, and spiritual concerns (response rate 73%).ResultsConsistent with our first hypothesis, at post-test, women in the intervention group, on average, had greater knowledge regarding breast cancer, its treatment, and their own future health than did those in the control group (pu2009=u20090.015). Hypothesis 2 was partially supported as women in the intervention group were more likely than the control group to report an increased amount of physical activity (pu2009=u20090.036), but not significant dietary changes. Social support was related to increased self report of physical activity. With the exception of the last series of workshops, the intervention group did not report improved communications with family, friends, and physicians (hypothesis 3).ConclusionsA short-term intervention can affect knowledge levels and physical activity but not diet or communication in the family.Implications for Cancer SurvivorsThe intervention was related to greater knowledge related to breast cancer, and increased report of physical activity. The program was not related to changes in reported diet or family communication.

Dietary assessment in the California Teachers Study: reproducibility and validity

ObjectiveTo evaluate the reproducibility and validity of the food-frequency questionnaire (FFQ) used in the California Teachers Study (CTS) cohort and to use this data to quantify the effects of correcting nutrient-breast cancer relative risks for measurement error.MethodsOne hundred and ninety five CTS cohort members participated in a 10-month dietary validation study that included four 24-h dietary recalls and pre- and post-study FFQs. Shrout–Fleiss intraclass correlations for reproducibility were computed. Under several standard assumptions concerning the correlations of errors in the FFQs and 24-h recalls, we calculated energy-adjusted deattenuated Pearson correlations for validity and tested for differences in validity according to a number of demographic and other risk factors. For each nutrient, we compared the performance of the FFQ versus the 24-h recalls, estimating the number of days of recalls that give equivalent information about true intake as does a single FFQ. Finally, the effects of adjustment for measurement error on risk estimates were evaluated in 44,423 postmenopausal cohort members, 1,544 of whom developed breast cancer during seven years of follow-up. Relative risks (RR) and confidence intervals (CI) were calculated using Cox proportional hazards with and without correction for measurement error.ResultsReproducibility correlations for the nutrients ranged from 0.60 to 0.87. With a few exceptions, validity correlations were reasonably high (range: 0.55–0.85), including rxa0=xa00.74 for alcohol. Performance of the FFQ differed by age for percent of calories from fat and by body mass index and hormone therapy use for alcohol consumption. For most nutrients examined, our FFQ is comparable to two to six recalls for each subject in capturing true intake. In the measurement error-adjusted risk analyses, corrected RRs were within 13% of uncorrected values for all nutrients examined except for linoleic acid. For alcohol consumption the corrected RR (per 20xa0g/1,000xa0kcal/d) was 1.36 (95% CI: 1.03–1.51) compared to the uncorrected estimate of 1.25 (95% CI: 1.10–1.42).ConclusionThe FFQ dietary assessment used in the CTS is reproducible and valid for all nutrients except the unsaturated fatty acids. Correcting relative risk estimates for measurement error resulted in relatively small changes in the associations between the majority of nutrients and the risk of postmenopausal breast cancer.

Hepatitis B and Hepatocellular Carcinoma Screening Among Asian Americans: Survey of Safety Net Healthcare Providers

BackgroundPhysician patterns of screening for hepatitis B (HBV) and hepatocellular carcinoma (HCC) among Asian Americans are not well described.AimsTo describe HBV and HCC screening practices among providers with large Asian American populations.MethodsProviders within San Francisco’s safety net system were surveyed with respect to HBV and HCC screening practices as well as knowledge, attitudes, and barriers to HCC screening.ResultsAmong the 109 respondents (response ratexa0=xa072%), 62% were aged >40, 65% female, 24% Asian, 87% primary care providers, and 48% had >25% Asian patients. Only 76% had screened >50% of their Asian patients for HBV and 43% had vaccinated >50% of eligible patients against HBV. Although 94% knew Asians were disproportionately affected by HCC, only 79% had screened for HCC in >50% of their Asian patients with chronic hepatitis B (CHB). A majority believed that HCC screening in CHB reduces HCC mortality (70%) and is cost-effective (57%). The most common HCC screening modality was AFP with abdominal ultrasound every 6–12xa0months (63%). Factors associated with HBV screening were familiarity with AASLD guidelines (OR 6.4, 95% CI 1.3–30.1, pxa0=xa00.02) and having vaccinated >50% of eligible patients against HBV (OR 2.2, 95% CI 1.1–4.5, pxa0=xa00.03). Factors associated with HCC screening using abdominal ultrasound every 6–12xa0months were having >25% Asian patients (ORxa0=xa04.5, 95% CI 1.3–15.3, pxa0=xa00.02) and higher HCC knowledge score (ORxa0=xa01.9 per item, 95% CI 1.01–3.6, pxa0=xa00.045).ConclusionsHBV and HCC screening rates and HBV vaccination among Asians from physician report is suboptimal. HCC screening is associated with having more Asian patients and higher provider knowledge. Provider education is essential in increasing rates of HBV and HCC screening among Asian Americans.

Increased RBI abnormalities in human primary prostate cancer following combined androgen blockade

The RB1 proliferation control pathway is a critical determinant of cell cycle progression. Abnormalities of RB1 are found in a variety of cancers, and the association with human prostate cancer (CaP) was examined here.

RACIAL DIFFERENCES IN CLINICALLY LOCALIZED PROSTATE CANCERS OF BLACK AND WHITE MEN

PURPOSEnTumor grade, deoxyribonucleic acid (DNA) ploidy, proliferation, p53 and bcl-2 expression were examined in clinically localized prostate cancers of black and white American men to learn whether these features showed racial differences.nnnMATERIALS AND METHODSnA total of 117 prostate cancers (43 black and 74 white patients) obtained at radical prostatectomy for clinically localized disease were assigned Gleason scores by a single pathologist. Enzymatically dissociated nuclei from archival prostate cancers were examined by DNA flow cytometry using propidium iodide staining and the multicycle program to remove debris and sliced nuclei and to perform cell cycle analysis. For immunostaining after microwave antigen retrieval we used a DO-1/DO-7 monoclonal antibody cocktail for p53 and the clone 124 antibody for bcl-2.nnnRESULTSnSignificantly more black than white men had Gleason score 7 tumors. The DNA ploidy distribution of Gleason 6 or less tumors was similar for both races. As anticipated, the ploidy distribution of higher grade prostate cancer in white men was more abnormal but, unexpectedly, this was not found for higher grade prostate cancer in black men. No significant racial differences were found in S phase fractions, p53 or bcl-2 immunopositivity. However, for prostate cancer in black men there was a significant association between bcl-2 immunopositivity and higher S-phase fractions.nnnCONCLUSIONSnThe aggressive prostate cancers of black men may be characterized by the 2 features of high proliferation and a block to programmed cell death.

Electronic Messages Increase Hepatitis B Screening in At-Risk Asian American Patients: A Randomized, Controlled Trial

BackgroundHepatitis B (HBV) induced hepatocellular carcinoma is the greatest cancer health disparity affecting Asian Americans, but the prevalence of screening to detect HBV is suboptimal.AimsOur aims were to determine the effectiveness of electronic health record (EHR) prompts to increase ordering of HBV tests among primary care providers (PCPs) within an academic health system.MethodsWe conducted a randomized, controlled trial between April and June 2011 among 76 PCPs caring for 175 outpatient adults with Chinese or Vietnamese surnames, with appointments with providers and no history of HBV testing. Providers were randomized to either receive an EHR prompt for HBV testing prior to patients’ appointments or usual care. Primary outcomes were the proportion of patients (1) whose physician ordered a HBsAg test and (2) who completed testing. Secondary outcomes were (A) test results and (B) whether the physicians followed-up on the results.ResultsHBsAg tests were ordered for 36/88 (40.9xa0%) of the intervention patients and 1/87 (1.1xa0%) of the control patients [χ2 (dfxa0=xa01)xa0=xa041.48, pxa0<xa00.001]. Thirty intervention patients (34.1xa0%) and no control patients completed the HBsAg test [χ2 (dfxa0=xa01)xa0=xa035.80, pxa0<xa00.001]. Four (13.3xa0%) of the completed tests were HBsAg-positive, 14 (46.7xa0%) were immune, and 12 (40xa0%) were unprotected from HBV. Two HBsAg-positive patients were referred to specialists, and 3 unprotected patients were vaccinated for HBV.ConclusionsEHR-based provider prompts significantly increased HBV testing in Chinese and Vietnamese patients when compared to “usual care.” EHR prompts are a promising intervention that could significantly increase screening for HBV.

Development and implementation of an Internet-based survivorship care program for cancer survivors treated with hematopoietic stem cell transplantation.

IntroductionThe Internet provides a widely accessible modality for meeting survivorship care needs of cancer survivors. In this paper, we describe the development and implementation of an Internet site designed as a base from which to conduct a randomized controlled trial to meet psycho-educational needs of hematopoietic stem cell transplantation (HSCT) survivors.MethodsA cross-disciplinary team designed, wrote content, and programmed an Internet site for online study registration, consent, assessment, and study implementation. All survivors who were 3–18xa0years after HSCT for hematologic malignancy and treated at one transplant center were approached by mail for participation. All study activities could be conducted without study staff contact. However, participants had options for phone or email contact with study staff as desired.ResultsOf 1,775 participants approached for the study, 775 (58% of those eligible) consented and completed baseline assessment. Mean age was 51.7 (SD, 12.5; age range, 18–79xa0years), with 56% male. Fifty-seven percent required staff contact one or more times; a majority were for minor technical issues or delays in completion of enrollment or baseline assessment.Discussions/conclusionsThis study demonstrated the potential for providing Internet-based survivorship care to long-term survivors of HSCT. Although building a survivorship Internet site requires a team with diverse expertise, once built, these resources can be implemented rapidly with large numbers of survivors.Implications for cancer survivorsWhile Internet-based services will not meet all the needs of cancer survivors, this methodology represents an important modality for augmenting onsite clinical services as a method for meeting psycho-educational, information, and resource needs of cancer survivors.

Quality of Life in Long-Term Cancer Survivors

Due to improved diagnosis and treatment, 59% of persons diagnosed with cancer today will survive their disease for at least 5 years from the time of diagnosis.1 Overall, it is currently estimated that over 9.6 million persons living in the United States are cancer survivors.1 While there is a growing body of literature on the physical, psychological, and social difficulties of survivors2; fewer studies focus on persons who are long-term, that is, 5-year survivors.3–6 According to SEER (surveillance, epidemiology, and end results) data,7 the percentage of persons who have survived more than 5 years after being diagnosed with cancer has increased over the past two decades. For men, large gains in cancer survival rates (more than 10%) were seen in cancers of the prostate, colon, and kidney, and non-Hodgkin lymphoma, melanoma, and leukemia. Modest gains (5–10%) were found for cancers of the bladder, stomach, liver, brain, and esophagus. For women, large gains in cancer survival rates were seen for colon, kidney, and breast cancers and non-Hodgkin lymphoma. Modest gains were found for bladder, oral cavity, stomach, brain, esophageal, and ovarian cancers and melanoma and leukemia. Limited survival improvement was noted in adults diagnosed with cancers of the lung, pancreas, and liver, cancer that are often characterized by late stage at diagnosis and relatively limited survival rates even when diagnosed at a localized stage. There was also little or no gain in several cancers with generally high survival rates, including larynx, thyroid, and uterine cancers. Survival statistics in the United States still favor the more affluent and Euro-American population; the survival rate of non-Euro-Americans has been estimated to be 5–15% lower.8,9

Impact of a Biospecimen Collection Seminar on Willingness to Donate Biospecimens among Chinese Americans: Results from a Randomized, Controlled Community-Based Trial

Background: Biospecimen collection from diverse populations can advance cancer disparities research, but is currently underrepresented. Methods: We partnered with a community-based clinic serving Cantonese-speaking Chinese Americans to develop and revise an educational seminar on biospecimen collection. Through a randomized controlled trial (n = 395), the intervention seminar was compared with a control seminar (cancer prevention) on change in willingness to donate biospecimens. Results: At baseline, many were willing to donate a biospecimen (saliva, urine, hair, toenails, blood, unused cancerous tissue) whether healthy or hypothetically had cancer. Also, many would donate because future generations would benefit, and few had concerns about donation. In logistic regression analyses, there was an intervention effect for willingness to donate: urine if had cancer [OR, 2.2; 95% confidence interval (CI), 1.3–3.7], toenails if healthy (OR, 2.1; 95% CI, 1.4–3.2) or had cancer (OR, 2.3; 95% CI, 2.0–2.7), hair if healthy (OR, 1.8; 95% CI, 1.3–2.5) or had cancer (OR, 2.8; 95% CI, 1.9–4.0), and unused cancerous tissue (OR, 1.8; 95% CI, 1.2–2.9). There was also an intervention effect for donating because future generations would benefit (OR, 2.0; 95% CI, 1.4–3.0), and this attitude was a strong independent predictor for willingness to donate all biospecimens, whether healthy or had cancer (OR, 2.9–4.2). Conclusion: Cantonese-speaking Chinese American participants of an educational seminar on biospecimen collection showed greater increases in willingness to donate biospecimens and donating for the benefit of future generations, than participants who attended a control seminar. Impact: Donating for the benefit of future generations is a theme that should be incorporated in messages that encourage biospecimen donation for Chinese Americans. See all articles in this CEBP Focus section, “Community Network Program Centers.” Cancer Epidemiol Biomarkers Prev; 23(3); 392–401. ©2014 AACR.

Cluster-randomized trial to increase hepatitis B testing among Koreans in Los Angeles

Background: In the United States, Korean immigrants experience a disproportionately high burden of chronic hepatitis B (HBV) viral infection and associated liver cancer compared with the general population. However, despite clear clinical guidelines, HBV serologic testing among Koreans remains persistently suboptimal. Methods: We conducted a cluster-randomized trial to evaluate a church-based small group intervention to improve HBV testing among Koreans in Los Angeles. Fifty-two Korean churches, stratified by size (small, medium, large) and location (Koreatown versus other), were randomized to intervention or control conditions. Intervention church participants attended a single-session small-group discussion on liver cancer and HBV testing, and control church participants attended a similar session on physical activity and nutrition. Outcome data consisted of self-reported HBV testing obtained via 6-month telephone follow-up interviews. Results: We recruited 1,123 individuals, 18 to 64 years of age, across the 52 churches. Ninety-two percent of the sample attended the assigned intervention session and 86% completed the 6-month follow-up. Sample characteristics included were as follows: mean age 46 years, 65% female, 97% born in Korea, 69% completed some college, and 43% insured. In an intent-to-treat analysis, the intervention produced a statistically significant effect (OR = 4.9, P < 0.001), with 19% of intervention and 6% of control group participants reporting a HBV test. Conclusion: Our intervention was successful in achieving a large and robust effect in a population at high risk of HBV infection and sequelae. Impact: The intervention was fairly resource efficient and thus has high potential for replication in other high-risk Asian groups. Cancer Epidemiol Biomarkers Prev; 24(9); 1341–9. ©2015 AACR.