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1.  Costs and Outcomes Evaluation of Patient Navigation Following Abnormal Cancer Screening: Evidence from the Patient Navigation Research Program 
Cancer  2013;120(4):570-578.
Navigators can facilitate timely access to cancer services but there are little data on their economic impact.
We conduct a cost-consequence analysis of navigation vs. usual care among 10,521 individuals with abnormal breast, cervix, colorectal or prostate cancer screening results who enrolled in the Patient Navigation Research Program study from January 1 2006 to March 31 2010. Navigation costs included diagnostic evaluation, patient and staff time, materials, and overhead. Consequences or outcomes were time to diagnostic resolution and probability of resolution. Differences in costs and outcomes were evaluated using multi-level, mixed-effects regression adjusting for age, race/ethnicity, language, marital status, insurance, cancer, and site clustering.
Most individuals were minority (70.7%) and un- or publically-insured (72.7%). Diagnostic resolution was higher for navigation vs. usual care at 180 (56.2% vs. 53.8%, p=0.008) and 270 days: 70.0% vs. 68.2%, p<0.001). While there were no differences in average days to resolution (110 vs. 109 days, p=.63), the probability of ever having diagnostic resolution was higher for navigation vs. usual care (84.5% vs. 79.6%, p <0.001). The added cost of navigation vs. usual care was $275 per patient (95% CI $260 – $290, p <0.001). There was no significant difference in stage distribution among the 12.4% of navigated vs. 11% of usual care patients diagnosed with cancer.
Navigation adds costs and modestly increases the probability of diagnostic resolution among patients with abnormal screening tests. Navigation is only likely to be cost-effective if improved resolution translates into earlier cancer stage at diagnosis.
PMCID: PMC3946403  PMID: 24166217
cancer; navigation; cost; outcomes; abnormal cancer screening
2.  Perceived Risk of Breast Cancer among Latinas Attending Community Clinics: Risk Comprehension and Relationship with Mammography Adherence 
Cancer causes & control : CCC  2008;19(10):1373-1382.
To describe breast cancer risk perceptions, determine risk comprehension, and evaluate mammography adherence among Latinas.
Latina women age ≥ 35, primarily from Central and South America, were recruited from community-based clinics to complete in-person interviews (n=450). Risk comprehension was calculated as the difference between numeric perceived risk and Gail risk score. Based on recommended guidelines from the year data were collected (2002), mammography adherence was defined as having a mammogram every one to two years for women ≥ 40 years of age.
Breast cancer risk comprehension was low, as 81% of women overestimated their risk and only 6.9% of women were high risk based on Gail risk scores. Greater cancer worry and younger age were significantly associated with greater perceived risk and risk overestimation. Of women age eligible for mammography (n = 328), 29.0% were non-adherent to screening guidelines. Adherence was associated with older age, (OR = 2.99, 95% CI = 1.76 – 5.09), having insurance (OR = 1.81, 95% CI = 1.03 – 3.17), greater acculturation (OR = 1.18, 95% CI = 1.02 – 1.36), and higher breast cancer knowledge (OR = 2.03, 95% CI = 1.21 – 3.40).
While most Latinas over-estimated their breast cancer risk, older age, having insurance, being more acculturated, and having greater knowledge were associated with greater screening adherence in this Latino population. Perceived risk, risk comprehension, and cancer worry were not associated with adherence. In Latinas, screening interventions should emphasize knowledge and target education efforts at younger, uninsured, and less acculturated mammography-eligible women.
PMCID: PMC4309545  PMID: 18704716
Latina; breast cancer; risk perception; risk comprehension; mammography adherence; acculturation
3.  Personalizing Age of Cancer Screening Cessation Based on Comorbidity: Model estimates of harms and benefits 
Annals of internal medicine  2014;161(2):104-112.
Harms and benefits of cancer screening depend on age and comorbidity, yet reliable estimates are lacking.
To estimate the harms and benefits of cancer screening by age and comorbidity to inform decisions about screening cessation.
Collaborative modeling with seven well-established cancer simulation models and common data on average and comorbidity level-specific life expectancy from SEER-Medicare.
US population.
US cohorts aged 66–90 years in 2010 with average health or one of four comorbidity levels (linked to specific conditions): none, mild, moderate, or severe.
Mammography, prostate-specific antigen testing, or fecal immunochemical testing.
Lifetime cancer deaths prevented and life-years gained (benefits); false-positive tests and overdiagnosed cancers (harms). For each comorbidity level: the age at which harms and benefits of screening were similar to that for individuals with average health undergoing screening at age 74.
Screening 1000 women with average life expectancy at age 74 for breast cancer resulted in 79–96 (range across models) false-positives, 0.5–0.8 overdiagnosed cancers, and 0.7–0.9 breast cancer deaths prevented. While absolute numbers of harms and benefits differed across cancer sites, the ages at which to cease screening were highly consistent across models and cancer sites when based on harm-benefit ratios comparable to screening average-health individuals at age 74. For individuals with no, mild, moderate, and severe comorbidities, screening until ages of 76, 74, 72, and 66, respectively, resulted in similar harms and benefits as for average-health individuals.
Comorbidity only influenced life expectancy.
Comorbidity is an important determinant of harms and benefits of screening. Estimates of screening benefits and harms by comorbidity can inform discussions between providers and their older patients about personalizing decisions about when to stop cancer screening.
Primary Funding Source
National Cancer Institute at the National Institutes of Health
PMCID: PMC4160041  PMID: 25023249
5.  Cognitive Effects of Cancer and its Treatments at the Intersection of Aging: What do we Know; What do we Need to Know? 
Seminars in oncology  2013;40(6):10.1053/j.seminoncol.2013.09.006.
There is a fairly consistent, albeit non-universal body of research documenting cognitive declines after cancer and its treatments. While few of these studies have included those 65 and older, it is logical to expect that older patients are at risk of cognitive decline. In this paper, we use breast cancer as an exemplar disease for inquiry into the intersection of aging and cognitive effects of cancer and its therapies. There are a striking number of common underlying potential biological risks and pathways for the development of cancer, cancer-related cognitive declines, and aging processes, including the development of a frail phenotype. Candidate shared pathways include changes in hormonal milieu, inflammation, oxidative stress, DNA damage and compromised DNA repair, genetic susceptibility, decreased brain blood flow or disruption of the blood-brain barrier, direct neurotoxicity, decreased telomere length, and cell senescence. There are also similar structure and functional changes seen in brain imaging studies of cancer patients and those seen with “normal” aging and Alzheimer’s disease. Disentangling the role of these overlapping processes is difficult since they require aged animal models and large samples of older human subjects. From what we do know, frailty and its low cognitive reserve seem to be a clinically useful marker of risk for cognitive decline after cancer and its treatments. This and other results from this review suggest the value of geriatric assessments to identify older patients at the highest risk of cognitive decline. Further research is needed to understand the interactions between aging, genetic predisposition, lifestyle factors and frailty phenotypes to best identify the sub-groups of older patients at greatest risk for decline and to develop behavioral and pharmacological interventions targeting this group. We recommend that basic science and population trials be developed specifically for older hosts with intermediate endpoints of relevance to this group, including cognitive function and trajectories of frailty. Clinicians and their older patients can advance the field by active encouragement of and participation in research designed to improve the care and outcomes of the growing population of older cancer patients.
PMCID: PMC3880205  PMID: 24331192
6.  Cost-effectiveness of internet and telephone treatment for smoking cessation: an economic evaluation of The iQUITT Study 
Tobacco control  2012;22(6):e11.
Internet and telephone treatments for smoking cessation can reach large numbers of smokers. There is little research on their costs and the impact of adherence on costs and effects.
To conduct an economic evaluation of The iQUITT Study, a randomised trial comparing Basic Internet, Enhanced Internet and Enhanced Internet plus telephone counselling (‘Phone’) at 3, 6, 12 and 18 months.
We used a payer perspective to evaluate the average and incremental cost per quitter of the three interventions using intention-to-treat analysis of 30-day single-point prevalence and multiple-point prevalence (MPP) abstinence rates. We also examined results based on adherence. Costs included commercial charges for each intervention. Discounting was not included given the short time horizon.
Basic Internet had the lowest cost per quitter at all time points. In the analysis of incremental costs per additional quitter, Enhanced Internet+Phone was the most cost-effective using both single and MPP abstinence metrics. As adherence increased, the cost per quitter dropped across all arms. Costs per quitter were lowest among participants who used the ‘optimal’ level of each intervention, with an average cost per quitter at 3 months of US$7 for Basic Internet, US$164 for Enhanced Internet and US$346 for Enhanced Internet +Phone.
‘Optimal’ adherence to internet and combined internet and telephone interventions yields the highest number of quitters at the lowest cost. Cost-effective means of ensuring adherence to such evidence-based programmes could maximise their population-level impact on smoking prevalence.
PMCID: PMC3626730  PMID: 23010696
7.  Non-initiation and early discontinuation of adjuvant trastuzumab in women with localized HER2-positive breast cancer 
Breast cancer (Tokyo, Japan)  2014;21(6):780-785.
One year of trastuzumab therapy is recommended for women with HER2-positive breast cancer ≥1.0 cm in size to increase survival and is considered for women with tumors 0.5–0.9 cm in size. We analyzed compliance with trastuzumab among women with HER2-positive breast cancer in a prospective cohort study. Of 1145 recruited patients with breast cancer, 152 were HER2-positive (13.2 %), of whom 126 had tumors ≥1.0 cm; 110/126 (87.3 %) of these initiated trastuzumab. Non-receipt was associated with older age, better prognosis tumors, and with non-receipt of adjuvant chemotherapy. Of the 110 who initiated treatment, 18 (15 %) did not complete treatment, 15 (83 %) of them because of cardiotoxicity. Of 20 women with tumors 0.5–0.9 cm, 5 (25 %) initiated trastuzumab. Compliance with trastuzumab was very high among those with HER2-positive breast cancer, as was the completion of the recommended therapy.
PMCID: PMC4213210  PMID: 24902664
Trastuzumab; Breast cancer; Adjuvant therapy; Adherence; Early discontinuation; Non-initiation
8.  Disparities in knowledge and willingness to donate research biospecimens: a mixed-methods study in an underserved urban community 
Journal of Community Genetics  2014;5(4):329-336.
Although research involving biospecimens is essential in advancing cancer research, minorities, especially African-Americans, are underrepresented in such research. We conducted a mixed-method (qualitative focus groups among African-Americans and quantitative cross-sectional surveys) study on factors associated with biospecimen knowledge and donation intent in the medically underserved urban communities in Southeast and Southwest Washington, DC. Focus groups were conducted among 41 African-Americans and survey data was available from 302 community residents of different races/ethnicities using convenience sampling. We used logistic regression to model the association between biospecimen knowledge and donation intent with selected sociodemographic variables using survey data. Only 47 % of the participants had knowledge of the different types of biospecimens. In multivariate logistic regression models, male gender, African-American race, and low education levels were significantly associated with lower knowledge about biospecimens. Compared to Whites (79 %), fewer African-Americans (39 %) and Hispanics (57 %) had knowledge of biospecimens but the difference was significant for African-Americans only. Positive intent to donate biospecimens for research was observed among 36 % of the survey respondents. After multivariate adjustment, only biospecimen knowledge was associated with donation intent (odds ratio = 1.91, 95 % confidence interval 1.12, 3.27). Contrary to popular opinion, “mistrust of the medical community” was not the most commonly reported barrier for biospecimen donation among African-Americans. “Not knowing how biospecimens will be used” and “lack of knowledge of biospecimens” were the most common barriers. Our study highlights the importance of education on biospecimens among community residents to increase minority participation in biospecimen research.
Electronic supplementary material
The online version of this article (doi:10.1007/s12687-014-0187-z) contains supplementary material, which is available to authorized users.
PMCID: PMC4159473  PMID: 24771039
Biospecimen; Knowledge; African-American; Disparities
9.  Knowledge and Willingness to Provide Research Biospecimens Among Foreign-born Latinos Using Safety-net Clinics 
Journal of community health  2013;38(4):652-659.
Latinos tend to be under-represented in cancer research and in bio-repositories.
We conducted a Spanish-language, interviewer-administered cross-sectional survey of 331 foreign-born Latinos from Central and South America attending safety-net clinics in order to describe factors associated with knowledge about and intention to provide bio-specimens for research purposes. We used logistic regression and multiple imputation methods to evaluate associations between socio-cultural measures, medical trust, demographics, as well as knowledge about and intentions to provide bio-specimens.
Almost half (47%) of respondents knew what bio-specimens were, and 67% said that they would provide a specimen after being given information about what this involved; this increased to 72% among those with prior knowledge. Controlling for covariates, Latinos with a high school education and above were more likely to know what a bio-specimen was and to say they would provide bio-specimens than were those with lower levels of education (adjusted OR [aOR] 2.85, 95% CI 1.37-5.96; and 3.49, 95% CI 1.41-8.63, p <.01, respectively). Those with greater social integration were more likely to know about bio-specimens than those with less integration (aOR 2.54, 95% CI 1.45-4.46, p=0.001). Higher endorsement of family values was independently associated with intent to give bio-specimens (aOR 1.11, 95% CI 1.02-1.20, p=0.017 per five-point increase in “familism” score). Medical mistrust was not related to intentions to provide specimens.
Our results suggest that interventions to increase willingness to provide bio-specimens could leverage trusted clinics or social networks and should consider individuals’ education and socio-cultural perspectives.
PMCID: PMC3706511  PMID: 23543371
Biospecimens; Latinos; Culture; Research
Cancer  2013;119(14):2541-2548.
US breast cancer mortality is declining but thousands of women still die each year.
Two established simulation models examine 6 strategies that include increased screening and/or treatment or elimination of obesity vs. continuation of current patterns. The models use common national data on incidence and obesity prevalence, competing causes of death, mammography characteristics, treatment effects and survival/cure. Parameters are modified based on obesity (defined as BMI ≥ 30kg/m2). Outcomes are presented for the year 2025 among women age 25+ and include numbers of cases, deaths, mammograms and false positives; age-adjusted incidence and mortality; breast cancer mortality reduction and deaths averted; and probability of dying of breast cancer.
If current patterns continue, the models project that there would be about 50,100–57,400 (range across models) annual breast cancer deaths in 2025. If 90% of women were screened annually from ages 40–54 and biennially from ages 55–99 (or death) then 5,100–6,100 fewer deaths would occur vs. current patterns, but incidence, mammograms and false-positives increase. If all women receive indicated systemic treatment (with no screening change) then 11,400–14,500 more deaths would be averted vs. current patterns, but increased toxicity could occur. If 100% receive screening plus indicated therapy, there would be 18,100–20,400 fewer deaths. Eliminating obesity yields 3,300–5,700 fewer breast cancer deaths vs. continuation of current obesity levels.
Maximal reductions in breast cancer deaths could be achieved through optimizing treatment use, followed by increasing screening use and obesity prevention.
PMCID: PMC3700651  PMID: 23625540
Simulation; Modeling; Breast Cancer; Treatment; Mammography; Obesity
11.  Costs, Evidence, and Value in the Medicare Program 
JAMA internal medicine  2013;173(3):227-228.
PMCID: PMC4071606  PMID: 23303388
12.  Narrowing Racial Gaps in Breast Cancer Chemotherapy Initiation: The Role of the Patient-Provider Relationship 
Chemotherapy improves breast cancer survival but is underused more often in black than in white women. We examined associations between patient-physician relationships and chemotherapy initiation and timeliness of initiation among black and white patients.
Women with primary invasive, non-metastatic breast cancer were recruited via hospitals (in Washington, DC and Detroit) and community outreach between July 2006 and April 2011. Data were collected via telephone interviews and medical records. Logistic regression models evaluated associations between chemotherapy initiation and independent variables. Since there were race interactions, analyses were race-stratified. Factors associated with time from surgery to chemotherapy initiation and delay of ≥ 90 days were evaluated with linear and logistic regressions, respectively.
Among eligible women, 82.8% were interviewed and 359 (90.9%)of those had complete data. The odds of initiating chemotherapy were 3.26 times (95% CI: 1.51, 7.06) higher among black women reporting greater communication with physicians (vs. lesser), after considering covariates. In contrast, the odds of starting chemotherapy were lower for white women reporting greater communication (vs. lesser) (adjusted OR .22, 95% CI: .07, .73). The opposing direction of associations was also seen among the sub-set of black and white women with definitive clinical indications for chemotherapy. Among those initiating treatment, black women had longer mean time to the start of chemotherapy than whites (71.8 days vs. 55.0 days, p= .005), but race was not significant after considering trust in oncologists, where initiation time decreased as trust increased, controlling for covariates. Black women were also more likely to delay ≥ 90 days than whites (27% vs. 8.3%; p=.024), but this was not significant after considering religiosity.
The patient-physician dyad and sociocultural factors may represent leverage points to improve chemotherapy patterns in black women.
PMCID: PMC3662254  PMID: 23588954
chemotherapy initiation; disparities; patient-provider communication
13.  Racial Disparities in Posttraumatic Stress After Diagnosis of Localized Breast Cancer: The BQUAL Study 
Little is known about the development of posttraumatic stress disorder (PTSD) over time among women diagnosed with breast cancer. This study examines changes in PTSD symptoms in the first 6 months after diagnosis and assesses racial/ethnic differences in PTSD symptomatology over time.
We recruited women with newly diagnosed breast cancer, stages I to III, from three sites in the United States. Three telephone interviews were conducted: baseline at about 2 to 3 months after diagnosis, first follow-up at 4 months after diagnosis, and second follow-up at 6 months after diagnosis. We measured traumatic stress in each interview using the Impact of Events Scale; recorded sociodemographic, tumor, and treatment factors; and used generalized estimating equations and polytomous logistic regression modeling to examine the associations between variables of interest and PTSD.
Of 1139 participants, 23% reported symptoms consistent with a diagnosis of PTSD at baseline, 16.5% at first follow-up, and 12.6% at the second follow-up. Persistent PTSD was observed among 12.1% participants, as defined by having PTSD at two consecutive interviews. Among participants without PTSD at baseline, 6.6% developed PTSD at the first follow-up interview. Younger age at diagnosis, being black (odds ratio [OR] = 1.48 vs white, 95% confidence interval [CI] =1.04 to 2.10), and being Asian (OR = 1.69 vs white, 95% CI = 1.10 to 2.59) were associated with PTSD.
Nearly one-quarter of women newly diagnosed with breast cancer reported symptoms consistent with PTSD shortly after diagnosis, with increased risk among black and Asian women. Early identification of PTSD may present an opportunity to provide interventions to manage symptoms.
PMCID: PMC3627645  PMID: 23434900
14.  Screening Outcomes in Older US Women Undergoing Multiple Mammograms in Community Practice: Does Interval, Age, or Comorbidity Score Affect Tumor Characteristics or False Positive Rates? 
Uncertainty exists about the appropriate use of screening mammography among older women because comorbid illnesses may diminish the benefit of screening. We examined the risk of adverse tumor characteristics and false positive rates according to screening interval, age, and comorbidity.
From January 1999 to December 2006, data were collected prospectively on 2993 older women with breast cancer and 137 949 older women without breast cancer who underwent mammography at facilities that participated in a data linkage between the Breast Cancer Surveillance Consortium and Medicare claims. Women were aged 66 to 89 years at study entry to allow for measurement of 1 year of preexisting illnesses. We used logistic regression analyses to calculate the odds of advanced (IIb, III, IV) stage, large (>20 millimeters) tumors, and 10-year cumulative probability of false-positive mammography by screening frequency (1 vs 2 years), age, and comorbidity score. The comorbidity score was derived using the Klabunde approximation of the Charlson score. All statistical tests were two-sided.
Adverse tumor characteristics did not differ statistically significantly by comorbidity, age, or interval. Cumulative probability of a false-positive mammography result was higher among annual screeners than biennial screeners irrespective of comorbidity: 48.0% (95% confidence interval [CI] = 46.1% to 49.9%) of annual screeners aged 66 to 74 years had a false-positive result compared with 29.0% (95% CI = 28.1% to 29.9%) of biennial screeners.
Women aged 66 to 89 years who undergo biennial screening mammography have similar risk of advanced-stage disease and lower cumulative risk of a false-positive recommendation than annual screeners, regardless of comorbidity.
PMCID: PMC3589257  PMID: 23385442
15.  Cognitive function in older women with breast cancer treated with standard chemotherapy and capecitabine on Cancer and Leukemia Group B 49907 
Cognitive changes in older women receiving chemotherapy are poorly understood. We examined self-reported cognitive function for older women who received adjuvant chemotherapy on Cancer and Leukemia Group B (CALGB) 49907. CALGB 49907 randomized 633 women aged ≥65 with stage I–III breast cancer to standard adjuvant chemotherapy (cyclophosphamide–methotrexate–5-fluoro-uracil or doxorubicin–cyclophosphamide) versus capecitabine. We examined self-reported cognitive function in 297 women (CALGB 361002) who enrolled on the quality of life substudy and had no gross impairment on cognitive screening. Women were evaluated using an 18-item instrument at six time points (baseline through 24 months). At each time point for each patient, we calculated a cognitive function score (CFS) defined as the mean response of items 1–18 and defined impairment as a score >1.5 standard deviations above the overall average baseline score. Differences in scores by patient characteristics were evaluated using a Kruskal–Wallis test. A linear mixed-effects model was used to assess CFSs by treatment over time. Among 297 women, the median age was 71.5 (range 65–85) and 73 % had performance status of 0. Baseline depression and fatigue were reported in 6 and 14 % of patients, respectively. The average CFS at baseline was 2.08 (corresponding to “normal ability”), and baseline cognitive function did not differ by treatment regimen (p = 0.350). Over 24 months, women reported minimal changes at each time point and insignificant differences by treatment arm were observed. In a healthy group of older women, chemotherapy was not associated with longitudinal changes in self-reported cognitive function.
PMCID: PMC3920483  PMID: 23681403
Cognitive function; Older women; Breast cancer; Age
16.  A planned, prospective comparison of short-term quality of life outcomes among older breast cancer patients treated with standard chemotherapy in a randomized clinical trial vs. an observational study: CALGB #49907 and #369901✰ 
Journal of geriatric oncology  2013;4(4):353-361.
Patients ≥65 years old (“older”) are often not included in randomized clinical trials (RCT), but when they are, care in an RCT might improve quality of life (QoL). We conducted a prospective comparison of QoL among older women receiving standard chemotherapy from the same cooperative group physicians in an RCT vs. an observational study (“off-trial”).
Older women with invasive, non-metastatic breast cancer (n = 150 RCT; 530 off-trial) were included. Linear mixed-effects models tested associations between chemotherapy on- vs. off-trial and changes in EORTC (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire) QoL scores over 24 months, controlling for pre-treatment QoL, age, education, tumor factors, comorbidity, and other covariates.
Anthracycline regimens were used by 58% of women treated on-trial vs. 54% of those treated off-trial. Women in the RCT reported an adjusted mean increase of 13.7 points (95% CI 10.2, 17.1) in global QoL at 24 months (vs. mid-treatment), while women treated off-trial had only an adjusted improvement of 7.0 points (95% CI 3.5, 10.4; p = .007 for difference in mean changes). Women in the RCT had significantly greater improvement in emotional function than those treated off-trial, controlling for baseline; they also had greater reductions in therapy side effects and fatigue at 24 months than women off-trial, controlling for covariates.
There may be different QoL trajectories for older women undergoing breast cancer chemotherapy on- vs. off-trial. If confirmed, the results suggest that the extra monitoring and communication within an RCT could provide the infrastructure for interventions to address symptoms and improve QoL for the growing older cancer population.
PMCID: PMC3910230  PMID: 24472479
Older patients; Breast cancer; Chemotherapy; Quality of Life; Randomized clinical trials; Observational studies
17.  Interpersonal Influences and Attitudes about Adjuvant Therapy Treatment Decisions among Early Stage Breast Cancer Patients: An Examination of Differences by Age and Race/Ethnicity in the BQUAL Study 
Patients are increasingly involved in cancer treatment decisions and yet little research has explored factors that may affect patient attitudes and beliefs about their therapeutic choices. This paper examines psychosocial factors (e.g., attitudes, social support), provider-related factors (e.g., communication, trust), and treatment considerations in a prospective study of a sample of early stage breast cancer patients eligible for chemotherapy and/or hormonal therapy (BQUAL cohort). The data comes from a multi-site cohort study of white, black, Hispanic, and Asian non-metastatic breast cancer patients recruited in New York City, Northern California, and Detroit Michigan. Baseline surveys were conducted over the telephone between 2006 and 2010 among a total of 1145 women. Most participants were white (68%), had more than a high school education (76%), and were diagnosed with stage I disease (51%). The majority of women reported discussing chemotherapy and hormonal therapy with their doctor (90% and 83% respectively); these discussions primarily took place with medical oncologists. Nearly a quarter of women reported that the treatment decision was difficult and the majority were accompanied to the doctor (76%) and involved a friend or family member in the decision (54%). Positive considerations (e.g., beliefs about treatment reducing risk of recurrence) were important in making treatment decisions. Participants preferred a shared decision-making style, but results suggested that there is room for improvement in terms of actual patient involvement in the decision and provider communication, particularly among black patients. Patients 65 years and older reported fewer provider discussions of chemotherapy, poorer patient-provider communication, higher rates of being assisted by family members in making the decision, and more negative attitudes and beliefs towards treatment.
PMCID: PMC3563273  PMID: 23263696
adjuvant therapy; breast cancer; treatment decisions; quality of care; racial disparities
18.  Influence of Study Features and Methods on Overdiagnosis Estimates in Breast and Prostate Cancer Screening 
Annals of internal medicine  2013;158(11):831-838.
Knowledge of the likelihood that a screen-detected cancer case has been overdiagnosed is vitally important for treatment decision making and screening policy development. An overdiagnosed case is an excess case detected because of cancer screening. Estimates of the frequency of overdiagnosis in breast and prostate cancer screening are highly variable across studies. In this article we identify features of overdiagnosis studies that influence results and illustrate their impact using published studies. We first consider different ways to define and measure overdiagnosis. We then examine contextual features and how they affect overdiagnosis estimates. Finally, we discuss the effect of estimation approach. Many studies use excess incidence under screening as a proxy for overdiagnosis. Others use statistical models to make inferences about lead time or natural history and then derive the corresponding fraction of cases that are overdiagnosed. We conclude with a list of questions that readers of overdiagnosis studies can use to evaluate the validity and relevance of published estimates and recommend that authors of publications quantifying overdiagnosis provide information about these features of their studies.
PMCID: PMC3733533  PMID: 23732716
19.  Patient and Provider Factors Associated with Colorectal Cancer Screening in Safety Net Clinics Serving Low-income, Urban Immigrant Latinos 
Journal of health care for the poor and underserved  2012;23(3):10.1353/hpu.2012.0109.
Latinos have lower colorectal cancer screening rates than Whites.
We reviewed a random sample of charts between July 2009 and February 2010 of safety-net clinic of 840 immigrants (50 years and older) from Central and South America receiving care. Logistic regression evaluated associations of ever vs. never screening, patient and physician factors.
Ever screening rates were 24.5%, and only 17% of charts noted a physician screening recommendation. However, the odds of screening were 9.89 times higher (95% CI: 6.25–15.64, p<.001) among patients with a physician recommendation vs. those without, considering covariates. The odds of screening were 0.61 times lower (95% CI: 0.40–0.92, p=.02) in patients with a body mass index ≥ 30 vs. <30.
While rates were low, determinants of screening were similar in this Latino subgroup to those reported in other Latino and non-Latino populations. Low rates of documented physician screening recommendations may indicate a potential missed opportunity for cancer control in safety-net clinics.
PMCID: PMC3824152  PMID: 24212154
Latinos; colorectal cancer; screening; immigrants; obesity
20.  Noninitiation of Adjuvant Chemotherapy in Women With Localized Breast Cancer: The Breast Cancer Quality of Care Study 
Journal of Clinical Oncology  2012;30(31):3800-3809.
For some women, adjuvant chemotherapy for nonmetastatic breast cancer decreases recurrences and increases survival; however, patient-physician decisions regarding chemotherapy receipt can be influenced by medical and nonmedical factors.
Patients and Methods
We used a prospective cohort design and multivariate modeling to investigate factors related to noninitiation of chemotherapy among women with newly diagnosed breast cancer recruited from three US sites. We interviewed patients at baseline and during treatment on sociodemographic, tumor, and treatment decision-making factors. Patients were categorized according to National Comprehensive Cancer Network guidelines as those for whom chemotherapy was definitely indicated, clinically discretionary, or discretionary based on age greater than 70 years.
Of 1,145 patients recruited, chemotherapy was clinically indicated for 392 patients, clinically discretionary for 459 patients, discretionary because of age for 169 patients, and not indicated for 93 patients; data were insufficient for 32 patients. Chemotherapy rates were 90% for those in whom chemotherapy was clinically indicated, 36% for those in whom it was discretionary because of clinical factors, and 19% for those in whom it was discretionary based on age greater than 70 years. Nonreceipt of chemotherapy was associated with older age, more negative beliefs about treatment efficacy, less positive beliefs about chemotherapy, and more concern about adverse effects. In the two discretionary groups, clinical predictors of worse outcome (greater tumor size, positive nodes, worse grade, and estrogen receptor– and progesterone receptor–negative status) were associated with increased chemotherapy initiation.
Utilization of adjuvant chemotherapy was most common among patients who, based on clinical criteria, would most likely benefit from it, patients with more positive than negative beliefs regarding treatment efficacy, and patients with few concerns about adverse effects.
PMCID: PMC3478575  PMID: 23008305
21.  Results of a randomized controlled trial testing the efficacy of a culturally-targeted and a generic video on mammography screening among Chinese-American immigrants 
Research comparing the effects of culturally-targeted and generic but linguistically appropriate intervention programs is limited. We conducted a randomized controlled trial comparing the efficacy of a culturally-targeted video, a generic video, and a fact sheet (control) in promoting mammography screening among Chinese-American immigrants.
We randomized 664 Chinese-American women from the Washington, DC and New York City areas who were >40 years and non-adherent to annual mammography screening guidelines to three study arms (each with ~221 women). The outcome was self-reported mammography screening six months post intervention. Measures of knowledge, Eastern cultural views, and health beliefs were administered before and after the intervention.
The culturally-targeted video, the generic video, and the fact sheet increased mammography utilization by 40.3%, 38.5%, and 31.1% from baseline, respectively. A significant intervention effect was observed only in one subgroup: The culturally-targeted video significantly increased mammography screening among low-acculturated women over the fact sheet (OR=1.70, 95% CI=1.04, 2.78). Overall, women who obtained a mammogram during the follow-up period reported significantly fewer barriers to screening after intervention than those who had not obtained screening. Both of the video groups reported fewer barriers after intervention than the control group.
Both theoretically-guided videos increased the likelihood of mammography use to a similar extent. Cultural targeting was only effective for low-acculturated women. Both videos reduced perceived barriers to screening and consequently increased screening behavior.
The results of this study provide empirical evidence on the efficacy of cultural targeting for minority immigrants.
PMCID: PMC3542829  PMID: 22971901
Cultural targeting; Video intervention; Mammography screening; Chinese Americans; Randomized controlled trial
22.  Through the Lens of Culture: Quality of Life Among Latina Breast Cancer Survivors 
Latinas have lower quality of life than Caucasian cancer survivors but we know little about factors associated with quality of life in this growing population.
Bilingual staff conducted interviews with a national cross-sectional sample of 264 Latina breast cancer survivors. Quality of life was measured using the Functional Assessment of Cancer Therapy-Breast (FACT-B). Regression models evaluated associations between culture, social and medical context and overall quality of life and its subdomains.
Latina survivors were 1-5 years post-diagnosis and reported a lower mean quality of life score compared to other published reports of non-Latina survivors (M=105; SD=19.4 on the FACT-B). Culturally-based feelings of breast cancer-related stigma and shame were consistently related to lower overall quality of life and lower well-being in each quality of life domain. Social and medical contextual factors were independently related to quality of life; together cultural, social and medical context factors uniquely accounted for 62% of the explained model variance of overall quality of life (Adjusted R2=0.53, P<.001). Similar relationships were seen for quality of life subdomains in which cultural, social and medical contextual variables independently contributed to the overall variance of each final model: physical well-being (Adjusted R2=0.23, P <.001), social well-being (Adjusted R2=0.51, P<.001), emotional well-being (Adjusted R2=0.28, P<.001), functional well-being (Adjusted R2=0.41, P<.001) and additional breast concerns (Adjusted R2=0.40, P<.001).
Efforts to improve Latinas’ survivorship experiences should consider cultural, social and medical contextual factors to close existing quality of life gaps between Latinas and other survivors.
PMCID: PMC3547364  PMID: 23085764
Breast cancer; survivorship; Latinos; quality of life
23.  Hospice Knowledge and Intentions among Latinos Using Safety-Net Clinics 
Journal of Palliative Medicine  2012;15(9):984-990.
Hospice use is low in Latinos but we know little about explanations for this pattern.
To describe factors associated with knowledge of and intention to use hospice for cancer care.
We conducted a Spanish-language, interviewer-administered cross-sectional survey of 331 Latino immigrants from Central and South America in safety-net clinics. Hospice intentions were measured using a hypothetical scenario. We used logistic regression and multiple imputations to test associations between cultural values, social acculturation, and other variables and knowledge and intentions.
Only 29% knew about hospice and 35% would choose hospice care (once it was defined). Collectivist (group-focused) views (odds ratio [OR] 1.06 per 1-point increase, 95% confidence interval [CI] 1.01-1.12, p=.05), endorsing family-centric values (OR 1.03 per 1-point increase, 95% CI 1.01-1.04, p=.004), and higher education were associated with greater hospice knowledge after considering covariates. Greater social ties were also independently associated with greater knowledge, but knowledge was not related to hospice intentions. Individuals who believed in maintaining secrecy about prognosis were 19% less likely to choose hospice than those who did not endorse secrecy (OR 0.81, 95% CI 0.67-0.99, p=.038). The most socially acculturated individuals were significantly more likely to choose hospice than those with less acculturation (OR 1.19 for each 1-unit increase, 95% CI 10.6-1.34, p=.004).
Hospice knowledge may be necessary but is not sufficient to increase hospice use among immigrant Latinos. Latino social networks and organizations may provide a natural leverage point for interventions. Interventions to increase hospice use may need to consider culturally related values.
PMCID: PMC3422069  PMID: 22731515
24.  To screen or not to screen older women for breast cancer: a conundrum 
PMCID: PMC3745823  PMID: 23718292
false-positive results; life expectancy-based screening; overdiagnosis; risk-based screening; screening frequency; screening mammography
25.  A survey of breast cancer physicians regarding patient involvement in breast cancer treatment decisions 
Breast (Edinburgh, Scotland)  2012;22(4):548-554.
Shared breast cancer treatment decision-making between patients and physicians increases patient treatment satisfaction and compliance and is influenced by physician-related factors. Attitudes and behaviors about patient involvement in breast cancer treatment decisions and treatment-related communication were assessed by specialty among breast cancer physicians of women enrolled in the Breast Cancer Quality of Care Study (BQUAL).
Of 275 BQUAL physicians identified, 50.0% responded to the survey. Most physicians spend 46–60 min with the patient during the initial consult visit and 51.5% report that the treatment decision is made in one visit. Oncologists spend more time with new breast cancer patients during the initial consult (p = 0.021), and find it more difficult to handle their own feelings than breast surgeons (p = <0.001).
Breast surgeons and oncologists share similar attitudes and behaviors related to patient involvement in treatment decision-making, yet oncologists report more difficulty managing their own feelings during the decision-making process.
PMCID: PMC3640652  PMID: 23107518
Breast cancer; Treatment decision-making; Physician survey; Patient participation

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