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1.  Muscular strength and adiposity as predictors of adulthood cancer mortality in men 
BACKGROUND
We examined the associations between muscular strength, markers of overall and central adiposity and cancer mortality in men.
METHODS
Prospective cohort study including 8,677 men aged 20-82 years followed from 1980 to 2003. Participants were enrolled in The Aerobics Centre Longitudinal Study, the Cooper Clinic in Dallas, Texas, U.S. Muscular strength was quantified by combining 1-repetition maximal measures for leg and bench presses. Adiposity was assessed by body mass index (BMI), percent body fat, and waist circumference.
RESULTS
Cancer death rates per 10,000 person-years adjusted for age and examination year were: 17.5, 11.0, and 10.3 across incremental thirds of muscular strength (P=0.001); 10.9, 13.4, and 20.1 across BMI groups of 18.5-24.9, 25.0-29.9, and ≥30kg/m2, respectively (P=0.008); 11.6 and 17.5 for normal (<25%) and high percent body fat (≥25%), respectively (P=0.006); and 12.2 and 16.7 for normal (≤102 cm) and high waist circumference (>102 cm), respectively (P=0.06). After adjusting for additional potential confounders, hazard ratios (95% confidence intervals) were 1.00 (referent), 0.65 (0.47-0.90), and 0.61 (0.44-0.85) across incremental thirds of muscular strength, respectively (P=0.003 for linear trend). Further adjustment for BMI, percent body fat, waist circumference, or cardiorespiratory fitness had little effect on the association. The associations of BMI, percent body fat, or waist circumference with cancer mortality did not persist after further adjusting for muscular strength (all P≥0.1).
CONCLUSIONS
Higher levels of muscular strength are associated with lower cancer mortality risk in men, independent of clinically established measures of overall and central adiposity, and other potential confounders.
doi:10.1158/1055-9965.EPI-08-1075
PMCID: PMC3762582  PMID: 19366909
Muscular strength; obesity; cancer; cardiorespiratory fitness; resistance exercise
2.  Reducing Colorectal Cancer Incidence and Disparities: Performance and Outcomes of a Screening Colonoscopy Program in South Carolina 
Advances in public health  2014;2014:787282.
This study evaluated the efficiency, effectiveness, and racial disparities reduction potential of Screening Colonoscopies for People Everywhere in South Carolina (SCOPE SC), a state-funded program for indigent persons aged 50–64 years (45–64 years for African American (AA)) with a medical home in community health centers. Patients were referred to existing referral network providers, and the centers were compensated for patient navigation. Data on procedures and patient demographics were analyzed. Of 782 individuals recruited (71.2% AA), 85% (665) completed the procedure (71.1% AA). The adenoma detection rate was 27.8% (males 34.6% and females 25.1%), advanced neoplasm rate 7.7% (including 3 cancers), cecum intubation rate 98.9%, inadequate bowel preparation rate 7.9%, and adverse event rate 0.9%. All indicators met the national quality benchmarks. The adenoma rate of 26.0% among AAs aged 45–49 years was similar to that of older Whites and AAs. We found that patient navigation and a medical home setting resulted in a successful and high-quality screening program. The observed high adenoma rate among younger AAs calls for more research with larger cohorts to evaluate the appropriateness of the current screening guidelines for AAs, given that they suffer 47% higher colorectal cancer mortality than Whites.
doi:10.1155/2014/787282
PMCID: PMC4332847
3.  C-Reactive Protein Levels in African Americans: A Diet and Lifestyle Randomized Community Trial 
Background
Chronic Inflammation is linked to poor lifestyle behaviors and a variety of chronic diseases that are prevalent among African Americans, especially in the southeastern U.S.
Purpose
The goal of the study was to test the effect of a community-based diet, physical activity, and stress reduction intervention conducted in 2009–2012 on reducing serum C-reactive protein (CRP) in overweight and obese African-American adults.
Methods
An RCT intervention was designed jointly by members of African-American churches and academic researchers. In late 2012, regression (i.e., mixed) models were fit that included both intention-to-treat and post hoc analyses conducted to identify important predictors of intervention success. Outcomes were assessed at 3 months and 1 year.
Results
At baseline, the 159 individuals who were recruited in 13 churches and had evaluable outcome data were, on average, obese (BMI=33.1 [±7.1]) and had a mean CRP level of 3.7 (±3.9) mg/L. Reductions were observed in waist-to-hip ratio at 3 months (2%, p=0.03) and 1 year (5%, p<0.01). In female participants attending ≥60% of intervention classes, there was a significant decrease in CRP at 3 months of 0.8 mg/L (p=0.05), but no change after 1 year. No differences were noted in BMI or interleukin-6.
Conclusions
In overweight/obese, but otherwise “healthy,” African-American church members with very high baseline CRP levels, this intervention produced significant reductions in CRP at 3 and 12 months, and in waist-to-hip ratio, which is an important anthropometric predictor of overall risk of inflammation and downstream health effects.
Trial registration
This study is registered at www.clinicaltrials.gov NCT01760902.
doi:10.1016/j.amepre.2013.05.011
PMCID: PMC3779347  PMID: 24050419
4.  Health Care Information in African-American Churches 
Churches are a trusted resource in African American communities; however, little is known about their presentation of health care information. This study characterized health care information disseminated by 11 African American churches. Content analysis conducted on print media systematically collected over one year used a coding scheme with .77 intercoder reliability. Health care information was identified in 243 items and represented three topics (screening, medical services, health insurance). Screening was the most common topic (n=156), flyers/handouts most often used (n=90), and the church the most common source (n=71). Using chi-square tests, information was assessed over time with health insurance information showing a statistically significant increase (χ2=6.08, p <.05). Study churches provided health care information at varying levels of detail with most coming from church and community publications. Future research should examine additional characteristics of health care information, its presence in other churches and community settings, and how exposure influences behaviors.
doi:10.1353/hpu.2014.0047
PMCID: PMC3998663  PMID: 24509024
consumer health information; health care access; faith-based; African Americans
5.  Examination of wrist and hip actigraphy using a novel sleep estimation procedure ☆ 
Sleep science  2014;7(2):74-81.
Objective
Improving and validating sleep scoring algorithms for actigraphs enhances their usefulness in clinical and research applications. The MTI® device (ActiGraph, Pensacola, FL) had not been previously validated for sleep. The aims were to (1) compare the accuracy of sleep metrics obtained via wrist- and hip-mounted MTI® actigraphs with polysomnographic (PSG) recordings in a sample that included both normal sleepers and individuals with presumed sleep disorders; and (2) develop a novel sleep scoring algorithm using spline regression to improve the correspondence between the actigraphs and PSG.
Methods
Original actigraphy data were amplified and their pattern was estimated using a penalized spline. The magnitude of amplification and the spline were estimated by minimizing the difference in sleep efficiency between wrist- (hip-) actigraphs and PSG recordings. Sleep measures using both the original and spline-modified actigraphy data were compared to PSG using the following: mean sleep summary measures; Spearman rank-order correlations of summary measures; percent of minute-by-minute agreement; sensitivity and specificity; and Bland–Altman plots.
Results
The original wrist actigraphy data showed modest correspondence with PSG, and much less correspondence was found between hip actigraphy and PSG. The spline-modified wrist actigraphy produced better approximations of interclass correlations, sensitivity, and mean sleep summary measures relative to PSG than the original wrist actigraphy data. The spline-modified hip actigraphy provided improved correspondence, but sleep measures were still not representative of PSG.
Discussion
The results indicate that with some refinement, the spline regression method has the potential to improve sleep estimates obtained using wrist actigraphy.
doi:10.1016/j.slsci.2014.09.007
PMCID: PMC4286157  PMID: 25580202
Actigraphy; Polysomnography; Penalized spline
6.  Dietary inflammatory index and inflammatory gene interactions in relation to colorectal cancer risk in the Bellvitge colorectal cancer case–control study 
Genes & Nutrition  2014;10(1):447.
Chronic inflammation is an important factor in colorectal carcinogenesis. However, evidence on the effect of pro-inflammatory and anti-inflammatory foods and nutrients is scarce. Moreover, there are few studies focusing on diet–gene interactions on inflammation and colorectal cancer (CRC). This study was designed to investigate the association between the novel dietary inflammatory index (DII) and CRC and its potential interaction with polymorphisms in inflammatory genes. Data from the Bellvitge Colorectal Cancer Study, a case–control study (424 cases with incident colorectal cancer and 401 hospital-based controls), were used. The DII score for each participant was obtained by multiplying intakes of dietary components from a validated dietary history questionnaire by literature-based dietary inflammatory weights that reflected the inflammatory potential of components. Data from four important single nucleotide polymorphisms located in genes thought to be important in inflammation-associated CRC: i.e., interleukin (IL)-4, IL-6, IL-8, and peroxisome proliferator-activated receptor-γ (PPARG) were analyzed. A direct association was observed between DII score and CRC risk (ORQ4 vs. Q1 1.65, 95 % CI 1.05–2.60, and P trend 0.011). A stronger association was found with colon cancer risk (ORQ4 vs. Q1 2.24, 95 % CI 1.33–3.77, and P trend 0.002) than rectal cancer risk (ORQ4 vs. Q1 1.12, 95 % CI 0.61–2.06, and P trend 0.37). DII score was inversely correlated with SNP rs2243250 in IL-4 among controls, and an interaction was observed with CRC risk. Neither correlation nor interaction was detected for other inflammatory genes. Overall, high-DII diets are associated with increased risk of CRC, particularly for colon cancer, suggesting that dietary-mediated inflammation plays an important role in colorectal carcinogenesis.
Electronic supplementary material
The online version of this article (doi:10.1007/s12263-014-0447-x) contains supplementary material, which is available to authorized users.
doi:10.1007/s12263-014-0447-x
PMCID: PMC4259879  PMID: 25488145
Dietary inflammatory index; Colorectal cancer; Inflammatory genes; Case–control study
7.  Case-control study of the PERIOD3 clock gene length polymorphism and colorectal adenoma formation 
Oncology Reports  2014;33(2):935-941.
Clock genes are expressed in a self-perpetuating, circadian pattern in virtually every tissue including the human gastrointestinal tract. They coordinate cellular processes critical for tumor development, including cell proliferation, DNA damage response and apoptosis. Circadian rhythm disturbances have been associated with an increased risk for colon cancer and other cancers. This mechanism has not been elucidated, yet may involve dysregulation of the ‘period’ (PER) clock genes, which have tumor suppressor properties. A variable number tandem repeat (VNTR) in the PERIOD3 (PER3) gene has been associated with sleep disorders, differences in diurnal hormone secretion, and increased premenopausal breast cancer risk. Susceptibility related to PER3 has not been examined in conjunction with adenomatous polyps. This exploratory case-control study was the first to test the hypothesis that the 5-repeat PER3 VNTR sequence is associated with increased odds of adenoma formation. Information on demographics, medical history, occupation and lifestyle was collected prior to colonoscopy. Cases (n=49) were individuals with at least one histopathologically confirmed adenoma. Controls (n=97) included patients with normal findings or hyperplastic polyps not requiring enhanced surveillance. Unconditional multiple logistic regression was used to calculate odds ratios (ORs) with 95% confidence intervals (CIs), after adjusting for potential confounding. Adenomas were detected in 34% of participants. Cases were more likely to possess the 5-repeat PER3 genotype relative to controls (4/5 OR, 2.1; 95% CI, 0.9–4.8; 5/5 OR, 5.1; 95% CI, 1.4–18.1; 4/5+5/5 OR, 2.5; 95% CI, 1.7–5.4). Examination of the Oncomine microarray database indicated lower PERIOD gene expression in adenomas relative to adjacent normal tissue. Results suggest a need for follow-up in a larger sample.
doi:10.3892/or.2014.3667
PMCID: PMC4306271  PMID: 25501848
adenoma; clock gene; circadian rhythm; colorectal cancer; variable number tandem repeat
8.  All-Cause, Cardiovascular, and Cancer Mortality Rates in Postmenopausal White, Black, Hispanic, and Asian Women With and Without Diabetes in the United States 
American Journal of Epidemiology  2013;178(10):1533-1541.
Using data from the Women's Health Initiative (1993–2009; n = 158,833 participants, of whom 84.1% were white, 9.2% were black, 4.1% were Hispanic, and 2.6% were Asian), we compared all-cause, cardiovascular, and cancer mortality rates in white, black, Hispanic, and Asian postmenopausal women with and without diabetes. Cox proportional hazard models were used for the comparison from which hazard ratios and 95% confidence intervals were computed. Within each racial/ethnic subgroup, women with diabetes had an approximately 2–3 times higher risk of all-cause, cardiovascular, and cancer mortality than did those without diabetes. However, the hazard ratios for mortality outcomes were not significantly different between racial/ethnic subgroups. Population attributable risk percentages (PARPs) take into account both the prevalence of diabetes and hazard ratios. For all-cause mortality, whites had the lowest PARP (11.1, 95% confidence interval (CI): 10.1, 12.1), followed by Asians (12.9, 95% CI: 4.7, 20.9), blacks (19.4, 95% CI: 15.0, 23.7), and Hispanics (23.2, 95% CI: 14.8, 31.2). To our knowledge, the present study is the first to show that hazard ratios for mortality outcomes were not significantly different between racial/ethnic subgroups when stratified by diabetes status. Because of the “amplifying” effect of diabetes prevalence, efforts to reduce racial/ethnic disparities in the rate of death from diabetes should focus on prevention of diabetes.
doi:10.1093/aje/kwt177
PMCID: PMC3888272  PMID: 24045960
diabetes; health disparities; menopause; mortality; obesity; women's health
9.  A Randomized Controlled Trial of Mindfulness-Based Stress Reduction for Women With Early-Stage Breast Cancer Receiving Radiotherapy 
Integrative cancer therapies  2013;12(5):404-413.
Purpose
To testthe relative effectiveness of a mindfulness-based stress reduction program (MBSR) compared with a nutrition education intervention (NEP) and usual care (UC) in women with newly diagnosed early-stage breast cancer (BrCA) undergoing radiotherapy.
Methods
Datawere available from a randomized controlled trialof 172 women, 20 to 65 years old, with stage I or II BrCA. Data from women completing the 8-week MBSR program plus 3 additional sessions focuses on special needs associated with BrCA were compared to women receiving attention control NEP and UC. Follow-up was performed at 3 post-intervention points: 4 months, and 1 and 2 years. Standardized, validated self-administered questionnaires were used to assess psychosocial variables. Descriptive analyses compared women by randomization assignment. Regression analyses, incorporating both intention-to-treat and post hoc multivariable approaches, were used to control for potential confounding variables.
Results
A subset of 120 women underwent radiotherapy; 77 completed treatment prior to the study, and 40 had radiotherapy during the MBSR intervention. Women who actively received radiotherapy (art) while participating in the MBSR intervention (MBSR-art) experienced a significant (P < .05) improvement in 16 psychosocial variables compared with the NEP-art, UC-art, or both at 4 months. These included health-related, BrCA-specific quality of life and psychosocial coping, which were the primary outcomes, and secondary measures, including meaningfulness, helplessness, cognitive avoidance, depression, paranoid ideation, hostility, anxiety, global severity, anxious preoccupation, and emotional control.
Conclusions
MBSR appears to facilitate psychosocial adjustment in BrCA patients receiving radiotherapy, suggesting applicability for MBSR as adjunctive therapy in oncological practice.
doi:10.1177/1534735412473640
PMCID: PMC3758444  PMID: 23362338
mindfulness-based stress reduction program; breast cancer; quality of life; psychosocial intervention; radiotherapy; radiation therapy
10.  Comparing Farmers’ Market Revenue Trends Before and After the Implementation of a Monetary Incentive for Recipients of Food Assistance 
Introduction
We examined the influence of an intervention to increase fruit and vegetable purchases at farmers’ markets for recipients of food assistance, Shop N Save (SNS), on revenue trends at a farmers’ market located at a federally qualified health center (FQHC) in rural South Carolina. We compared revenue trends for 20 weeks before the intervention (2011) and 20 weeks after (2012).
Methods
SNS provided one $5 monetary incentive per week to customers spending $5 or more in food assistance at the farmers’ market. SNS was available to any farmers’ market customer using Supplemental Nutrition Assistance Program (SNAP), Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and/or Senior or WIC Farmers’ Market Nutrition Program (FMNP) vouchers. Sales receipts were recorded for each transaction at the farmers’ market to document payment type and the cost of the purchase. All SNS participants completed a one-time enrollment survey.
Results
A total of 336 customers self-enrolled in SNS from June through October 2012. Most SNS participants were female, African American, and patients at the FQHC. In total, the use of all forms of food assistance (SNAP, WIC, and FMNP) at the farmers’ market increased significantly after the intervention (from 10% before, to 25% after, P = .003). Senior FMNP vouchers and SNAP usage increased the most.
Conclusion
Interventions that provide incentives to recipients of food assistance programs at farmers’ markets are a viable strategy for increasing food assistance usage and revenue.
doi:10.5888/pcd11.130347
PMCID: PMC4032058  PMID: 24854238
11.  Innovative and Community-Driven Communication Practices of the South Carolina Cancer Prevention and Control Research Network 
The South Carolina Cancer Prevention and Control Research Network (SC-CPCRN) is 1 of 10 networks funded by the Centers for Disease Control and Prevention and the National Cancer Institute (NCI) that works to reduce cancer-related health disparities. In partnership with federally qualified health centers and community stakeholders, the SC-CPCRN uses evidence-based approaches (eg, NCI Research-tested Intervention Programs) to disseminate and implement cancer prevention and control messages, programs, and interventions. We describe the innovative stakeholder- and community-driven communication efforts conducted by the SC-CPCRN to improve overall health and reduce cancer-related health disparities among high-risk and disparate populations in South Carolina. We describe how our communication efforts are aligned with 5 core values recommended for dissemination and implementation science: 1) rigor and relevance, 2) efficiency and speed, 3) collaboration, 4) improved capacity, and 5) cumulative knowledge.
doi:10.5888/pcd11.140151
PMCID: PMC4112920  PMID: 25058673
12.  Factors Related to Coronary Heart Disease Risk Among Men: Validation of the Framingham Risk Score 
Introduction
Coronary heart disease (CHD) remains a leading cause of death in the United States. The Framingham Risk Score (FRS) was developed to help clinicians in determining their patients’ CHD risk. We hypothesize that the FRS will be significantly predictive of CHD events among men in the Aerobics Center Longitudinal Study (ACLS) population.
Methods
Our study consisted of 34,557 men who attended the Cooper Clinic in Dallas, Texas, for a baseline clinical examination from 1972 through 2002. CHD events included self-reported myocardial infarction or revascularization or death due to CHD. During the 12-year follow-up 587 CHD events occurred. Multivariable-adjusted hazard ratios generated from ACLS analysis were compared with the application of FRS to the Framingham Heart Study (FHS).
Results
The ACLS cohort produced similar hazard ratios to the FHS. The adjusted Cox proportional hazard model revealed that men with total cholesterol of 280 mg/dL or greater were 2.21 (95% confidence interval (CI), 1.59–3.09) times more likely to have a CHD event than men with total cholesterol from 160 through 199mg/dL; men with diabetes were 1.63 (95% CI, 1.35–1.98) times more likely to experience a CHD event than men without diabetes.
Conclusion
The FRS significantly predicts CHD events in the ACLS cohort. To the best of our knowledge, this is the first report of a large, single-center cohort study to validate the FRS by using extensive laboratory and clinical measurements.
doi:10.5888/pcd11.140045
PMCID: PMC4133511  PMID: 25121352
13.  Relations of Depressive Symptoms and Antidepressant Use to Body Mass Index and Selected Biomarkers for Diabetes and Cardiovascular Disease 
American journal of public health  2013;103(8):e34-e43.
Objectives
We investigated whether depressive symptoms and antidepressant use are associated with biomarkers for glucose dysregulation and inflammation, body mass index (BMI), and waist circumference.
Methods
Postmenopausal women were recruited into the Women’s Health Initiative from 1993 to 1998, and data were collected at regular intervals through 2005. We used multiple linear regression models to examine whether depressive symptoms and antidepressant use are associated with BMI, waist circumference, and biomarkers.
Results
Analysis of data from 71 809 women who completed all relevant baseline and year 3 assessments showed that both elevated depressive symptoms and antidepressant use were significantly associated with higher BMI and waist circumference. Among 1950 women, elevated depressive symptoms were significantly associated with increased insulin levels and measures of insulin resistance. Analyses of baseline data from 2242 women showed that both elevated depressive symptoms and antidepressant use were associated with higher C-reactive protein levels.
Conclusions
Monitoring body habitus and other biomarkers among women with elevated depression symptoms or taking antidepressant medication may be prudent to prevent diabetes and cardiovascular disease.
doi:10.2105/AJPH.2013.301394
PMCID: PMC3791588  PMID: 23763394
14.  Intersection of identities. Food, role, and the African–American pastor☆ 
Appetite  2013;67:44-52.
African–American pastors can foster health-related innovations as gatekeepers and advocates within their churches. Personal experiences with food and health likely influence their support of such programs. Identities or meanings attached to societal roles have been shown to motivate individuals’ attitudes and behaviors. Understanding role and eating identities of African–American pastors may have important implications for participation in faith-based health promotion programs. This study aimed to describe the eating and pastoral identities of African–American pastors, explore intersections between these identities, and highlight implications for nutrition programs. In-depth interviews with 30 African–American pastors were audio-recorded and transcribed verbatim. Data were analyzed using theory-guided and grounded-theory approaches. Pastors described affinity across one or more dimensions including healthy, picky, meat, and over-eater identities. In describing themselves as pastors, the dimensions pastor’s heart, teacher, motivator, and role model emerged. Pastors who described themselves as healthy eaters were more likely to see themselves as role models. Pastors with healthier eating identities and more complex pastoral identities described greater support for health programming while unhealthy, picky, and over-eaters did not. These findings provide guidance for understanding eating and role identities among pastors and should be considered when designing and implementing faith-based programs.
doi:10.1016/j.appet.2013.03.007
PMCID: PMC3758249  PMID: 23538172
Identity; Diet; Role; Faith-based programs; African American; Pastors
15.  Angiotensin Receptor Blockers and Risk of Prostate Cancer among United States Veterans 
Journal of clinical pharmacology  2013;53(7):773-778.
Objectives
To address concerns regarding increased risk of prostate cancer (PrCA) among Angiotensin Receptor Blocker users, we used national retrospective data from the Department of Veterans Affairs (VA) through the Veterans Affairs Informatics and Computing Infrastructure (VINCI).
Methods
We identified a total of 543,824 unique Veterans who were classified into either ARB treated or not-treated in 1:15 ratio. The two groups were balanced using inverse probability of treatment weights. A double-robust cox-proportional hazards model was used to estimate the hazard ratio for PrCA incidence. To evaluate for a potential Gleason score stage migration we conducted weighted Cochrane-Armitage test.
Results
Post weighting, the rates of PrCA in treated and not-treated groups were 506 (1.5%) and 8,269 (1.6%), respectively; representing a hazard ratio of (0.91, p-value 0.049). There was no significant difference in Gleason scores between the two groups.
Conclusions
We found a small, but statistically significant, reduction in the incidence of clinically detected PrCA among patients assigned to receive ARB with no countervailing effect on degree of differentiation (as indicated by Gleason score). Findings from this study support FDA’s recent conclusion that ARB use does not increase risk of incident PrCA.
doi:10.1002/jcph.98
PMCID: PMC3768141  PMID: 23686462
Angiotensin Receptor Blockers; Prostate Cancer; Department of Veterans Affairs; Inverse Probability of Treatment Weight; Propensity Score; Survival analysis; Cancer Registry; Drug Safety
16.  Creating a Cadre of Junior Investigators to Address the Challenges of Cancer-Related Health Disparities: Lessons Learned from the Community Networks Program 
Community-based participatory research (CBPR) initiatives such as the National Cancer Institute’s Community Networks Program (CNP) (2005–2010) often emphasize training of junior investigators from underrepresented backgrounds to address health disparities. From July to October 2010, a convenience sample of 80 participants from the 25 CNP national sites completed our 45-item, web-based survey on the training and mentoring of junior investigators. This study assessed the academic productivity and CBPR-related experiences of the CNP junior investigators (n=37). Those from underrepresented backgrounds reported giving more presentations in non-academic settings (9 vs. 4 in last 5 years, p=0.01), having more co-authored publications (8 vs. 3 in last 5 years, p=0.01), and spending more time on CBPR-related activities than their non-underrepresented counterparts. Regardless of background, junior investigators shared similar levels of satisfaction with their mentors and CBPR experiences. This study provides support for the success of the CNP’s training program, especially effort directed at underrepresented investigators.
doi:10.1007/s13187-012-0361-0
PMCID: PMC3407323  PMID: 22528636
17.  Outcome Evaluation of a State Comprehensive Cancer Control Plan: Laying the Foundation 
Context
Rigorous outcome evaluation is essential to monitor progress toward achieving goals and objectives in comprehensive cancer control plans (CCCPs).
Objective
This report describes a systematic approach for an initial outcome evaluation of a CCCP.
Design
Using the Centers for Disease Control and Prevention evaluation framework, the evaluation focused on (1) organizing cancer plan objectives by anatomic site and risk factors, (2) rating each according to clarity and data availability, (3) the subsequent evaluation of clearly stated objectives with available outcome data, and (4) mapping allocation of implementation grants for local cancer control back to the CCCP objectives.
Setting
South Carolina.
Main Outcome Measures
Evaluation outcomes included (1) a detailed account of CCCP objectives by topic area, (2) a systematic rating of level of clarity and availability of data to measure CCCP objectives, (3) a systematic assessment of attainment of measurable objectives, and (4) a summary of how cancer control grant funds were allocated and mapped to CCCP objectives.
Results
A system was developed to evaluate the extent to which cancer plan objectives were measurable as written with data available for monitoring. Twenty-one of 64 objectives (33%) in the South Carolina's CCCP were measurable as written with data available. Of the 21 clear and measurable objectives, 38% were not met, 38% were partially met, and 24% were met. Grant allocations were summarized across CCCP chapters, revealing that prevention and early detection were the most heavily funded CCCP areas.
Conclusions
This evaluation highlights a practical, rigorous approach for generating evidence required to monitor progress, enhance planning efforts, and recommend improvements to a CCCP.
doi:10.1097/PHH.0b013e31825d208c
PMCID: PMC3777627  PMID: 23381113
cancer control; cancer prevention; program evaluation; state cancer plan
18.  African American Men’s and Women’s Perceptions of Clinical Trials Research: Focusing on Prostate Cancer among a High-Risk Population in the South 
Journal of health care for the poor and underserved  2013;24(4):10.1353/hpu.2013.0187.
While African Americans are at significantly higher risk for developing certain cancers, they also have low rates of participation in cancer research, particularly clinical trials. This study assessed both African American men’s and African American women’s (1) knowledge of and participation in cancer-related clinical research and (2) barriers to and motivations for participating in clinical research. Data were collected from a total of 81 participants. Phase I of this research consisted of qualitative focus groups (all 81 participants). Phase II included quantitative pre/post survey data from an education program (56 participants). Findings from the study revealed that African American men and women had poor knowledge about clinical trials and the informed consent process, limited experience in participating in clinical trials, and they feared and mistrusted cancer research. Participants identified incentives, assurance of safety, knowledge and awareness, and benefiting others as motivators to participate in clinical trials research.
doi:10.1353/hpu.2013.0187
PMCID: PMC3818250  PMID: 24185170
African Americans; clinical trials; cancer research; participation; barriers; motivators
19.  Determinants of Racial/Ethnic Disparities in Incidence of Diabetes in Postmenopausal Women in the U.S. 
Diabetes Care  2012;35(11):2226-2234.
OBJECTIVE
To examine determinants of racial/ethnic differences in diabetes incidence among postmenopausal women participating in the Women’s Health Initiative.
RESEARCH DESIGN AND METHODS
Data on race/ethnicity, baseline diabetes prevalence, and incident diabetes were obtained from 158,833 women recruited from 1993–1998 and followed through August 2009. The relationship between race/ethnicity, other potential risk factors, and the risk of incident diabetes was estimated using Cox proportional hazards models from which hazard ratios (HRs) and 95% CIs were computed.
RESULTS
Participants were aged 63 years on average at baseline. The racial/ethnic distribution was 84.1% non-Hispanic white, 9.2% non-Hispanic black, 4.1% Hispanic, and 2.6% Asian. After an average of 10.4 years of follow-up, compared with whites and adjusting for potential confounders, the HRs for incident diabetes were 1.55 for blacks (95% CI 1.47–1.63), 1.67 for Hispanics (1.54–1.81), and 1.86 for Asians (1.68–2.06). Whites, blacks, and Hispanics with all factors (i.e., weight, physical activity, dietary quality, and smoking) in the low-risk category had 60, 69, and 63% lower risk for incident diabetes. Although contributions of different risk factors varied slightly by race/ethnicity, most findings were similar across groups, and women who had both a healthy weight and were in the highest tertile of physical activity had less than one-third the risk of diabetes compared with obese and inactive women.
CONCLUSIONS
Despite large racial/ethnic differences in diabetes incidence, most variability could be attributed to lifestyle factors. Our findings show that the majority of diabetes cases are preventable, and risk reduction strategies can be effectively applied to all racial/ethnic groups.
doi:10.2337/dc12-0412
PMCID: PMC3476929  PMID: 22833490
20.  Written and Spoken Narratives about Health and Cancer Decision Making: A Novel Application of Photovoice 
Health promotion practice  2012;14(6):10.1177/1524839912465749.
Photovoice is a community-based participatory research method that researchers have used to identify and address individual and community health needs. We developed an abbreviated photovoice project to serve as a supplement to a National Cancer Institute (NCI)-funded pilot study focusing on prostate cancer (PrCA) that was set in a faith-based African-American community in South Carolina. We used photovoice for three reasons: (1) to enhance communication between study participants and researchers; (2) to empower African-American men and women to examine their health decisions through photographs; and 3) to better understand how participants from this community make health-related decisions. The 15 individuals participating in the photovoice project were asked to photograph aspects of their community that informed their health-related decisions. Participants provided written and oral narratives to describe the images in a small sample of photographs. Four primary themes emerged in participants’ photographs and narratives: 1) food choices; 2) physical activity practices; 3) community environment and access to care; and 4) influences of spirituality and nature on health. Although written and audio-recorded narratives were similar in content, the audio-recorded responses were more descriptive and emotional. Results suggest that incorporating audio-recorded narratives in community photovoice presentations may have a greater impact than written narratives on health promotion and decision-making and policy-makers due to an increased level of detail and personalization. In conclusion, photovoice strengthened the parent study and empowered participants by making them more aware of factors influencing their health decisions.
doi:10.1177/1524839912465749
PMCID: PMC3580129  PMID: 23171652
community-based participatory research; African American; health decision making; photography; qualitative analysis
21.  The effects of mindfulness-based stress reduction on psychosocial outcomes and quality of life in early-stage breast cancer patients: a randomized trial 
The aim of this study was determine the effectiveness of a mindfulness-based stress-reduction (MBSR) program on quality of life (QOL) and psychosocial outcomes in women with early-stage breast cancer, using a three-arm randomized controlled clinical trial (RCT). This RCT consisting of 172 women, aged 20–65 with stage I or II breast cancer consisted of the 8-week MBSR, which was compared to a nutrition education program (NEP) and usual supportive care (UC). Follow-up was performed at three post-intervention points: 4 months, 1, and 2 years. Standardized, validated self-administered questionnaires were adopted to assess psychosocial variables. Statistical analysis included descriptive and regression analyses incorporating both intention-to-treat and post hoc multivariable approaches of the 163 women with complete data at baseline, those who were randomized to MBSR experienced a significant improvement in the primary measures of QOL and coping outcomes compared to the NEP, UC, or both, including the spirituality subscale of the FACT-B as well as dealing with illness scale increases in active behavioral coping and active cognitive coping. Secondary outcome improvements resulting in significant between-group contrasts favoring the MBSR group at 4 months included meaningfulness, depression, paranoid ideation, hostility, anxiety, unhappiness, and emotional control. Results tended to decline at 12 months and even more at 24 months, though at all times, they were as robust in women with lower expectation of effect as in those with higher expectation. The MBSR intervention appears to benefit psychosocial adjustment in cancer patients, over and above the effects of usual care or a credible control condition. The universality of effects across levels of expectation indicates a potential to utilize this stress reduction approach as complementary therapy in oncologic practice.
doi:10.1007/s10549-011-1738-1
PMCID: PMC3784652  PMID: 21901389
Mindfulness-based stress reduction program; Quality of life; Psychosocial factors; Expectancy; Breast cancer psychosocial intervention
22.  A prospective study of cardiorespiratory fitness and breast cancer mortality 
Purpose
Physical activity may protect against breast cancer. Few prospective studies have evaluated breast cancer mortality in relation to cardiorespiratory fitness, an objective marker of physiologic response to physical activity habits.
Methods
We examined the association between cardiorespiratory fitness and risk of death from breast cancer in the Aerobics Center Longitudinal Study. Women (N=14,811), aged 20 to 83 years with no prior breast cancer history, received a preventive medical examination at the Cooper Clinic in Dallas, TX, between 1970 and 2001. Mortality surveillance was completed through December 31, 2003. Cardiorespiratory fitness was quantified as maximal treadmill exercise test duration and was categorized for analysis as low (lowest 20% of exercise duration), moderate (middle 40%), and high (upper 40%). At baseline, all participants were able to complete the exercise test to at least 85% of their age-predicted maximal heart rate.
Results
A total of 68 breast cancer deaths occurred during follow-up (mean=16 years). Age-adjusted breast cancer mortality rates per 10,000 woman-years were 4.4, 3.2, and 1.8 for low, moderate, and high cardiorespiratory fitness groups, respectively (trend P = 0.008). After further controlling for body mass index, smoking, drinking, chronic conditions, abnormal exercise electrocardiogram responses, family history of breast cancer, oral contraceptive use, and estrogen use, hazard ratios (95% CI) for breast cancer mortality across incremental cardiorespiratory fitness categories were 1.00 (referent), 0.67 (0.35–1.26), 0.45 (0.22–0.95); trend P = 0.04.
Conclusions
These results indicate that cardiorespiratory fitness is associated with a reduced risk of dying from breast cancer in women.
doi:10.1249/MSS.0b013e31818edac7
PMCID: PMC3774121  PMID: 19276861
Epidemiology; Prevention; Death from breast cancer; Physical activity
23.  Mentholated cigarettes and smoking-related cancers revisited: An ecologic examination 
The US Food and Drug Administration is assessing whether menthol should be banned as an additive to cigarettes. An important part of this determination concerns the health effects of mentholated relative to non-mentholated cigarettes. We examined the ecologic association between sales of mentholated cigarettes for the period 1950–2007, menthol preference by race and sex, and incidence rates of four tobacco-related cancers during 1973–2007. Total sales of mentholated cigarettes (market share) increased from about 3% in 1950 to slightly less than 30% in 1980 and remained fairly stable thereafter. Additional data show consistently that, compared to White smokers, Black smokers favor mentholated cigarettes by roughly a 3-fold margin. Differences in the incidence of lung cancer, squamous cell cancer of the esophagus, oropharyngeal cancer, and laryngeal cancer by race and sex and trends over a 35-year period, during which menthol sales were relatively stable and during which Black smokers were much more likely to smoke mentholated cigarettes compared to Whites, are not consistent with a large contribution of menthol, over and above the effect of smoking per se.
doi:10.1016/j.yrtph.2012.03.002
PMCID: PMC3773183  PMID: 22429780
Mentholated cigarettes; Sales; Prevalence; Esophageal cancer; Lung cancer; Oropharyngeal cancer; Laryngeal cancer; Ecologic study
24.  Urbanicity Affects Blood Pressure and Heart Rate Reactivity to a Speech Stressor in Cameroon 
Ethnicity & disease  2010;20(3):251-256.
Objective
To examine the interactive influence of urbanicity on cardiovascular reactivity to speech stressors among 103 urban and 93 rural Cameroonians.
Method
Heart rate, systolic, and diastolic blood pressure (HR, SBP, and DBP) changes from baseline were assessed during a speech preparation period, speech stressor task, and post-speech recovery period.
Results
After adjusting for income, age, BMI, and sex, urban subjects showed greater diastolic reactivity to the pre-speech and speech conditions than to recovery. Urban subjects also showed greater reactivity to the speech stressor than to other conditions. Urban subjects showed greater HR reactivity to the speech stressor. Rural subjects showed greater diastolic reactivity to the pre-speech and speech stressor and less recovery.
Conclusion
Urbanicity affects blood pressure and heart rate differently for urban and rural Cameroonians. It also affects recovery from stressors. More exploration into the influence of urbanization on hypertension risk factors in developing countries is warranted. (Ethn Dis. 2010;20:251–256)
PMCID: PMC3773215  PMID: 20828098
Heart Rate; Blood Pressure; Urban; Cameroon
25.  Assessing the Influence of Health Literacy on HIV-Positive Women’s Cervical Cancer Prevention Knowledge and Behaviors 
Women living with HIV (WLH) bear a disproportionate burden of cervical cancer and may face challenges understanding health information. The purpose of this study was to assess the influence of health literacy on WLH cervical cancer screening knowledge and behaviors. WLH were recruited from clinic- and community-based settings in the southeastern USA. The majority of women completing a questionnaire assessing factors related to cervical cancer were African American (90 %). About 38 % of women reported low health literacy. Compared to women with high health literacy, these women were more likely to report having had ≥2 Pap tests during the year after HIV diagnosis (p=0.02), and less likely to have had a Pap test <1 year previously (p=0.05). There was no difference in cervical cancer or human papillomavirus knowledge among those with low versus high health literacy. Results revealed mixed finding on the influence of health literacy on screening knowledge and behaviors.
doi:10.1007/s13187-013-0470-4
PMCID: PMC3769692  PMID: 23564430
Health literacy; HIV-positive women; Cervical cancer

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