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1.  Costs, Evidence, and Value in the Medicare Program 
JAMA internal medicine  2013;173(3):227-228.
PMCID: PMC4071606  PMID: 23303388
2.  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
3.  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
4.  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
5.  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
6.  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
7.  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
8.  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
9.  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
10.  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
11.  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
12.  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
13.  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
14.  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
15.  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
16.  Using Simulation Modeling to Inform Strategies to Reduce Breast Cancer Mortality in Black Women in the District of Columbia 
Epidemiology research international  2012;2012(2012):241340.
Black women in the District of Columbia (DC) have the highest breast cancer mortality in the US. Local cancer control planners are interested in how to most efficiently reduce this mortality.
An established simulation model was adapted to reflect the experiences of Black women in DC and estimate the past and future impact of changes in use of screening and adjuvant treatment.
The model estimates that the observed reduction in mortality that occurred from 1975 to 2007 attributable to screening, treatment, and both was 20.2%, 25.7%, and 41.0% respectively. The results suggest that, by 2020, breast cancer mortality among Black women in DC could be reduced by 6% more by initiating screening at age 40 vs. age 50. Screening annually may also reduce mortality to a greater extent than biennially, albeit with a marked increase in false positive screening rates.
This study demonstrates how modeling can provide data to assist local planners as they consider different cancer control policies based on their individual populations.
PMCID: PMC3731168  PMID: 23914301
17.  Patient and Physician Decision Styles and Breast Cancer Chemotherapy Use in Older Women: Cancer and Leukemia Group B Protocol 369901 
Journal of Clinical Oncology  2012;30(21):2609-2614.
Physician and patient decision styles may influence breast cancer care for patients ≥ 65 years (“older”) because there is uncertainty about chemotherapy benefits in this group. We evaluate associations between decision-making styles and actual treatment.
Data were collected from women treated outside of clinical trials for newly diagnosed stage I to III breast cancer (83% response) from January 2004 through April 2011 in 75 cooperative group sites. Physicians completed a one-time mailed survey (91% response), and clinical data were abstracted from charts. Patient decision style was measured on a five-point scale. Oncologists' preference for prescribing chemotherapy was based on standardized vignettes. Regression and multiple imputation were used to assess associations between chemotherapy and other variables.
There were 1,174 women seen by 212 oncologists; 43% of women received chemotherapy. One-third of women preferred to make their own treatment decision. Patient and physician decision styles were independently associated with chemotherapy. Women who preferred less physician input had lower odds of chemotherapy than women who preferred more input (odds ratio [OR] = 0.79 per 1-point change; 95% CI, 0.65 to 0.97; P = .02) after considering covariates. Patients whose oncologists had a high chemotherapy preference had higher odds of receiving chemotherapy (OR = 2.65; 95% CI, 1.80 to 3.89; P < .001) than those who saw oncologists with a low preference.
Physicians' and older patients' decision styles are each associated with breast cancer chemotherapy use. It will be important to re-evaluate the impact of decision styles when there is greater empirical evidence about the benefits and risks of chemotherapy in older patients.
PMCID: PMC3413274  PMID: 22614985
18.  Intervention tailoring for Chinese American women: comparing the effects of two videos on knowledge, attitudes and intentions to obtain a mammogram 
Health Education Research  2012;27(3):523-536.
This study utilized data from an ongoing randomized controlled trial to compare a culturally tailored video promoting positive attitudes toward mammography among Chinese immigrant women to a linguistically appropriate generic video and print media. Intervention development was guided by the Health Belief Model. Five hundred and ninety-two immigrant Chinese Americans from the metropolitan Washington, DC, and New York City areas completed telephone interviews before and after intervention. Changes in knowledge, Eastern views of health care (fatalism and self-care), health beliefs (perceived susceptibility, severity, benefits and barriers) and screening intentions were measured. Results showed that both videos improved screening knowledge, modified Eastern views of health care, reduced perceived barriers and increased screening intentions relative to print media (all P < 0.05). The generic video increased screening intention twice as much as the cultural video, although subgroup analysis showed the increase was only significant in women aged 50–64 years. Only Eastern views of health care were negatively associated with screening intentions after adjusting for all baseline covariates. These data suggest that a theoretically guided linguistically appropriate video that targets women from various ethnic groups is as efficacious in modifying attitudes toward mammography screening as a video that is exclusively tailored for Chinese immigrant women.
PMCID: PMC3337423  PMID: 22327806
19.  The Breast Cancer Quality of Care Study (B-QUAL): A multi-center study to determine causes for non-compliance with breast cancer adjuvant therapy 
The breast journal  2012;18(3):203-213.
In oncology, quality of care is a major issue for patients and providers. Significant variations in care, including non-receipt of adjuvant systemic therapy, non-adherence to therapy, and/or early discontinuation of therapy, occur frequently and may impact survival. Reasons for these variations are not well understood, but may play a role in the prominent disparity in breast cancer survival between blacks and whites. Since May 2006, the Breast Cancer Quality of Care Study (B-QUAL) has recruited 1158 women with non-metastatic breast cancer from several centers across the country, with completed data on 1057 participants to date. Detailed information on demographic, behavioral, biomedical, and emotional factors related to chemotherapy use was collected on each participant at baseline and at two follow-up interviews during the first 6 months. In addition, for women with ER+ tumors, further questionnaires were completed every 6 months regarding hormonal therapy use. Each participant was also asked to provide a DNA sample, and to allow medical record review. We surveyed physicians providing care to the study participants regarding attitudes toward adjuvant treatment. The mean age of participants was 58 years (SD 11.6), and 15% (n=160) were black. The majority had an annual household income <$90,000 (n=683), had college education or higher (n=802), 55.9% were married, and 57.9% were not currently employed. Seventy-six percent had hormone-receptor-positive tumors, 49.9% initiated chemotherapy and 82.7% started hormonal therapy. Blacks differed significantly from women of other races with regard to income (p <.0001), education (p=0.0005), hormone receptor status (p=0.02), and tumor grade (p=0.0002). The main endpoints of the study are non-initiation of chemotherapy or hormonal therapy, non-adherence to therapy and early discontinuation of therapy. Treatment and outcomes will be compared on the 15% of participants who are black versus other participants. The B-QUAL Study will be a rich ongoing source of information regarding reasons for differences in receipt of both adjuvant chemotherapy and hormonal therapy. This information may be useful in planning interventions to improve quality of care.
PMCID: PMC3519420  PMID: 22487337
Quality of care; adjuvant therapy; adherence; breast cancer; persistence; early discontinuation; racial disparities
20.  Computational Modeling and Multilevel Cancer Control Interventions 
This chapter presents an overview of computational modeling as a tool for multilevel cancer care and intervention research. Model-based analyses have been conducted at various “beneath the skin” or biological scales as well as at various “above the skin” or socioecological levels of cancer care delivery. We review the basic elements of computational modeling and illustrate its applications in four cancer control intervention areas: tobacco use, colorectal cancer screening, cervical cancer screening, and racial disparities in access to breast cancer care. Most of these models have examined cancer processes and outcomes at only one or two levels. We suggest ways these models can be expanded to consider interactions involving three or more levels. Looking forward, a number of methodological, structural, and communication barriers must be overcome to create useful computational models of multilevel cancer interventions and population health.
PMCID: PMC3482961  PMID: 22623597
21.  Cultural Views, Language Ability, and Mammography Use in Chinese American Women 
Mammography screening rates among Chinese American women have been reported to be low. This study examines whether and how culture views and language ability influence mammography adherence in this mostly immigrant population. Asymptomatic Chinese American women (n = 466) aged 50 and older, recruited from the Washington, D.C. area, completed a telephone interview. Regular mammography was defined as having two mammograms at age-appropriate recommended intervals. Cultural views were assessed by 30 items, and language ability measured women’s ability in reading, writing, speaking, and listening to English. After controlling for risk perception, worry, physician recommendation, family encouragement, and access barriers, women holding a more Chinese/Eastern cultural view were significantly less likely to have had regular mammograms than those having a Western cultural view. English ability was positively associated with mammography adherence. The authors’ results imply that culturally sensitive and language-appropriate educational interventions are likely to improve mammography adherence in this population.
PMCID: PMC3577419  PMID: 19233947
breast cancer screening; culture; minority health
22.  “The Worst Thing About Hospice Is That They Talk About Death”: Contrasting Hospice Decisions and Experience among Immigrant Central and South American Latinos to US-born White, Non-Latino Cancer Caregivers 
Palliative medicine  2010;24(4):427-434.
Hospice care is promoted as a model for improving end of life care and decreasing burden on caregivers. However, hospice use is low in Latinos and little is known about how Latinos make hospice decisions and experience hospice once enrolled. We used qualitative methods to conduct in-depth interviews and focus groups with 15 Latino bereaved hospice family caregivers and 15 White Non-Latino bereaved hospice family caregivers to describe hospice experiences and evaluate whether cultural factors affected the experience. We identified differences in decision-making and caregiving experience that were influenced by culture. For example, cultural values of denial, secrecy about prognosis and a collective, family-centered system influenced hospice decisions and experience in Latinos but not Non-Latinos. This study identifies a significant dilemma; that is, how to discuss hospice with a patient and family who prefer not to discuss a terminal prognosis. Future research is needed to extend these preliminary results; such results may be useful for designing interventions to improve end of life care and caregiving in Latinos.
PMCID: PMC3570252  PMID: 20507867
Hospice; Latino; End of Life; Cancer; Caregiving; Communication
23.  Information Channels Associated with Awareness of Human Papillomavirus Infections and Vaccination among Latino Immigrants from Safety Net Clinics 
We report on information channels associated with awareness about human papillomavirus (HPV) among immigrant Central and South American Latinos.
We conducted a survey of 1334 Latino ≥21 years attending safety-net clinics in 2007–2008. Logistic regression analyses evaluated associations with HPV awareness.
Forty-eight percent were aware of HPV infection and 40% were aware of the vaccine. Spanish television (38%) and providers (23%) were the primary HPV information sources. Infection awareness was associated with internet use (OR 1.47; 95% CI 1.10–1.96) and self-efficacy to find health information (OR 1.19; 95% CI 1.08–1.30). Vaccine awareness was associated with media use for health information (OR 1.27; 95% CI 1.09–1.49) and internet use (OR 1.59; 95% CI 1.18–2.13).
Although Spanish television has reached this low HPV awareness group, there may be missed opportunities for education by providers. Television and the internet may also be effective channels for future interventions.
PMCID: PMC3567193  PMID: 22089978
Human Papillomavirus; Latinos; Cervical Cancer; Health Communication; Vaccine
24.  Assessing the awareness of and willingness to participate in cancer clinical trials among immigrant Latinos 
Journal of community health  2012;37(2):335-343.
There is a paucity of data on determinants of clinical trial participation in the growing and diverse US Latino population. We describe correlates of awareness of and willingness to participate in clinical trials among Central and South American Latinos using safety net clinics.
We conducted an interviewer administered, Spanish language cross-sectional survey (n=944). Logistic regression was used to assess effects of health information sources and psychosocial variables on awareness of clinical trials and intention to participate in clinical trials.
While only 48% knew what a clinical trial was, when explained, 65% indicated a willingness to participate in a trial. Providers were the most common source of general health information. Use of Internet for health information (OR = 2.33, 95% CI 1.63, 3.34, p = .001), trust in health information (OR = 1.33, 1.12, 1.58 for each one unit increase, p = .001) and higher education each independently increased the odds of clinical trial awareness, but obtaining information from providers did not. Contacting the Cancer Information Service (OR = 2.49, 95% CI 1.01, 6.14, p = .05) and psychosocial factors (e.g., greater worry, higher self-efficacy and trust in information) were each independently associated with intent to join a clinical trial but demographic factors were not.
Several information channels, including the Internet and telephone call centers appear to be effective in conveying information about clinical trials. While providers were cited as the most common source of health information, this source was not associated with clinical trial knowledge or intent to participate in trials suggesting a missed opportunity for communication to this immigrant Latino population.
PMCID: PMC3567194  PMID: 21805372
Clinical trial awareness; clinical trial participation; Latinos; mass media
25.  Non-initiation of adjuvant hormonal therapy in women with hormone receptor positive breast cancer: The Breast Cancer Quality of Care Study (B-QUAL) 
Adjuvant hormonal therapy for non-metastatic hormone receptor (HR)-positive breast cancer decreases risk of breast cancer recurrence and increases survival. However, some women do not initiate this life-saving treatment.
We used a prospective cohort design to investigate factors related to non-initiation of hormonal therapy among women with newly diagnosed, non-metastatic hormone receptor positive breast cancer recruited from three U.S. sites. Serial interviews were conducted at baseline and during treatment to examine sociodemographic factors, tumor characteristics, and treatment decision-making factors. Multivariate modeling assessed associations between variables of interest and hormonal therapy initiation.
Of 1050 breast cancer patients recruited, 725 (69%) had HR-positive breast cancer, of whom 87 (12.0%) based on self-report and 122 (16.8%) based on medical record/pharmacy fill rates did not initiate hormonal therapy. In a multivariable analysis, non-initiation of hormonal therapy, defined by medical record/pharmacy, was associated with having greater negative beliefs about efficacy of treatment (OR 1.42, 95%CI 1.18-1.70). Non-initiation was less likely in those who found the quality of patient/physician communication to be higher (OR 0.96, 95%CI 0.93-0.99), the hormonal therapy treatment decision an easy one to make (OR 0.45, 95% CI 0.23-0.90) or neither easy nor difficult (OR 0.34, 95%CI 0.20-0.58); and had more positive beliefs about hormonal therapy efficacy (OR 0.40, 95%CI 0.34-0.62).
Factors influencing non-initiation of adjuvant hormonal therapy are complex and influenced by patient beliefs regarding treatment efficacy and side effects. Educational interventions to women about the benefits of hormonal therapy may decrease negative beliefs and increase hormone therapy initiation.
PMCID: PMC3561459  PMID: 22527111

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