The Global Profile of Breast Cancer: Exploring the Disease Epidemiology among International & Migrant Populations.

Examining the global occurrence and racial disparities in breast cancer is critical to our understanding of the disease etiology. Inflammatory breast cancer (IBC) is a rare and aggressive form of breast cancer, about which very little is known. Given the lack of comparative studies on breast cancer and inflammatory breast cancer on a global scale, this dissertation investigated trends in breast cancer in a population-based cancer registry in Gharbiah, Egypt. Furthermore, we utilized Surveillance, Epidemiology and End Results (SEER) registry data from California, Detroit and New Jersey to evaluate racial disparities in IBC, including among Arab Americans. Finally, this research focused on the lack of standardization in IBC diagnosis by comparing differing criteria for diagnosis to demonstrate the effect of differing criteria on estimating IBC occurrence. The findings from this dissertation demonstrate significant increases in breast cancer incidence in Egypt from 1999-2008, particularly among women 50 years and older; estrogen receptor negative tumors were over represented. These observed trends add to our overall understanding of the etiology of breast cancer and can be used to inform clinicians and policy makers in this region of the world. Furthermore, our research demonstrates that IBC occurrence may be more common among certain minority groups in the United States, including Arab American women. With the significant lack of epidemiologic data on IBC, this study represents important progress toward our understanding of this disease. Finally, our study results suggest for the first time, that the incidence of IBC is likely to be underestimated in the U.S. SEER registry using the current SEER coding guidelines. Emphasis must be placed on the documentation of clinical and pathological characteristics of IBC in the medical record, so that analysis of putative IBC subtypes will be possible and we can further evaluate and come to a consensus on the definition of IBC to be utilized in future research. This dissertation contributes to a better understanding of global heterogeneity in breast cancer and IBC and provides concrete scientific evidence in order to reduce the global burden of this disease.PHDEpidemiological ScienceUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/97974/1/kalamb_1.pd

A Randomized Trial of Realignment Therapy for Treatment of Medial Tibiofemoral Osteoarthritis

Objectives: The objective of this 30-week randomized crossover trial was to determine whether a multi-modal realignment therapy would be successful in relieving pain and improving function among persons with medial tibiofemoral OA. METHODS: We conducted a double blind, randomized crossover trial of a multi-modal realignment therapy for persons with medial tibiofemoral OA. Trial participants met ACR criteria for OA with knee pain, aching or stiffness on most days of the past month and radiographic evidence of a definite osteophyte with predominant medial tibiofemoral OA. We tested two different treatments: A) CONTROL TREATMENT consisting of a neutral knee brace (no valgus angulation), flat unsupportive foot orthoses, and shoes with a flexible midsole; and B) ACTIVE TREATMENT consisting of a valgus knee brace, customized neutral foot orthoses, and shoes designed for motion control. For each subject, the trial lasted 30 weeks, including 12 weeks each of active and control treatment separated by a 6-week washout period. The primary outcome of the linear regression model was change in knee pain and function as assessed by the WOMAC Osteoarthritis Index. RESULTS: 80 participants with medial tibiofemoral OA were randomized. Their mean age was 62 years, mean BMI was 34 kg/m2 and mean WOMAC pain score was 9.2 (0-20 scale). There was no evidence of a carryover effect. The regression model demonstrated that the mean difference in pain between the active and control treatments was -1.82 units (95% confidence interval: -3.05 to -0.60 [p=0.004]) on the WOMAC pain scale, indicating a small, but statistically significant decrease in pain with the multi-modal active treatment. For WOMAC function the realignment intervention had a non-significant effect on function with a -2.90 unit decrease (95% CI -6.60 to 0.79) compared with the control condition (p=0.12). CONCLUSION: Multi-modal realignment therapy decreases pain in persons with medial tibiofemoral OA

A Randomized Trial of Patellofemoral Bracing for Treatment of Patellofemoral Osteoarthritis

Purpose The number of effective knee osteoarthritis (OA) interventions, especially those tailored to specific compartmental involvement, are small. The objective of this study was to determine the efficacy of a realigning patellofemoral (PF) brace in improving pain and function among persons with symptomatic lateral PF OA. Method We conducted a double blind, randomized crossover trial of a realigning PF brace for persons with lateral PF OA. Participants had lateral PF OA with anterior knee symptoms on most days of the month, lateral PF joint space narrowing, and radiographic evidence of a definite osteophyte in the PF joint. We compared two treatments: (1) Control treatment consisting of a BioSkin Q Brace with patellar realigning strap removed; and (2) Active treatment consisting of a realigning BioSkin Q Brace with the strap applied. For each participant, the trial lasted 18 weeks, including 6 weeks each of active and control treatment period separated by a 6-week washout period. The order of treatments was randomized. The primary outcome was change in knee pain on the visual analog scale (VAS). Secondary outcomes included WOMAC pain, function, and stiffness. An unstructured correlation matrix for observations within participants was used in generalized estimating equation fitting to derive a linear regression model that expressed the relation between the intervention and change in VAS pain. Results 80 participants (63 F) with a mean age and body mass index of 61 years and 28 kg/m2, respectively, were randomized by order of treatment. A model examining the main effects for change in VAS knee pain (0–100) demonstrated no significant treatment effect (−0.68 VAS units, 95% CI: −6.2, 4.8 units, P = 0.81) and no differential carryover effect. There was also no significant difference between active and control treatments for WOMAC pain, function, or stiffness outcomes. Conclusion The effects of a specific realigning PF brace are not of clinical or statistical significance

Using the Technology Acceptance Model to Characterize Barriers and Opportunities of Telemedicine in Rural Populations: Survey and Interview Study

BackgroundHealth care access issues have long plagued rural Americans. One approach to alleviating the challenges and poor health outcomes for rural individuals is through the use of telemedicine, sometimes called telehealth. It is important to understand factors that may be related to telemedicine adoption or nonadoption, particularly in underserved rural settings. ObjectiveThis pilot study examines telemedicine perceptions among rural, underserved populations using the Technology Acceptance Model, which serves as a framework to explore the adoption of telemedicine services by those who have used it. This study also explores the differences between user and nonuser perceptions of telemedicine. MethodsPaper surveys and phone interviews were conducted in rural Northern Lower Michigan. ResultsPerceived usefulness and perceived ease of use explained 91% of the variability in attitude toward telemedicine (R2=0.91; F1,15=73.406; P<.001). Ease of use was a significant predictor (mean 2.36, SD 1.20; P<.001), but usefulness (mean 3.16, SD 0.81; P=.20) was not. Furthermore, there were significant differences in individual perception of telemedicine between users and nonusers. For example, nonusers believed they would receive better care in person (users: mean 3.30, SD 1.22; nonusers: mean 1.91, SD 1.14; F1,32=10.126; P=.003). The quantitative findings were reinforced by the qualitative results from the phone interviews. ConclusionsOverall, the Technology Acceptance Model is an appropriate model to understand the attitudes toward telemedicine that may lead to its adoption by rural Americans

A Comparison of Criteria to Identify Inflammatory Breast Cancer Cases from Medical Records and the Surveillance, Epidemiology and End Results Data base, 2007–2009

Inflammatory breast cancer ( IBC ) is a relatively rare and extremely aggressive form of breast cancer that is diagnosed clinically. Standardization of clinical diagnoses is challenging, both nationally and internationally; moreover, IBC coding definitions used by registries have changed over time. This study aimed to compare diagnostic factors of IBC reported in a U.S. Surveillance, Epidemiology, and End Results ( SEER ) registry to clinical criteria found in the medical records of all invasive breast cancer cases at a single institution. We conducted a medical record review of all female invasive breast cancers ( n  = 915) seen at an NCI‐designated comprehensive cancer center in Detroit from 2007 to 2009. IBC cases were identified based on the presence of the main clinical characteristics of the disease (erythema, edema, peau d'orange). We compared the proportion of IBC out of all breast cancers, using these clinical criteria and the standard SEER IBC codes. In the reviewed cases, the clinical criteria identified significantly more IBC cases ( n  = 74, 8.1%) than the standard IBC SEER definition ( n  = 19, 2.1%; p < 0.0001). No IBC cases were identified in the cancer center records using the SEER pathologic coding, which requires the diagnosis of inflammatory carcinoma on the pathology report, a notation that is rarely made. Emphasis must be placed on the documentation of clinical and pathologic characteristics of IBC in the medical record, so that analysis of putative IBC subtypes will be possible. Our results indicate the need for a consensus on the definition of IBC to be utilized in future research.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/106657/1/tbj12234.pd

Rural patient and provider perceptions of telehealth implemented during the COVID-19 pandemic

Abstract Background Understanding perceptions of telehealth  implementation from patients and providers can improve the utility and sustainability of these programs, particularly in under-resourced rural settings. The purpose of this study was to evaluate both patient and provider perceptions of telehealth visits in a large rural healthcare system during the COVID-19 pandemic. To promote sustainability of telehealth approaches, we also assessed whether the percentage of missed appointments differed between in-person and telehealth visits. Methods Using anonymous surveys, we evaluated patient preferences and satisfaction with telehealth visits from November 2020 -March 2021 and assessed perceptions of telehealth efficiency and value among rural providers from September–October 2020. We examined whether telehealth perceptions differed according to patients’ age, educational attainment, insurance status, and distance to clinical site and providers’ age and length of time practicing medicine using ANOVA test. We also examined whether the percentage of missed appointments differed between in-person and telehealth visits at a family practice clinic within the rural healthcare system from April to September 2020 using a Chi-square test. Results Over 73% of rural patients had favorable perceptions of telehealth visits, and satisfaction was generally higher among younger patients. Patients reported difficulty with scheduling follow-up appointments, lack of personal contact and technology challenges as common barriers. Over 80% of the 219 providers responding to the survey reported that telehealth added value to their practice, while 36.6% agreed that telehealth visits are more efficient than in-person visits. Perception of telehealth value and efficiency did not differ by provider age (p = 0.67 and p = 0.67, respectively) or time in practice (p = 0.53 and p = 0.44, respectively). Technology challenges for the patient (91.3%) and provider (45.1%) were commonly reported. The percentage of missed appointments was slightly higher for telehealth visits compared to in-person visits, but the difference was not statistically significant (8.7% vs. 8.0%; p = 0.39). Conclusions Telehealth perceptions were generally favorable among rural patients and providers, although satisfaction was lower among older patients and providers. Our findings suggest that telehealth approaches may add value and efficiency to rural clinical practice. However, technology issues for both patients and providers and gaps in care coordination need to be addressed to promote sustainability of telehealth approaches in rural practice

Tobacco Cessation Motivations, Preferences, and Barriers Among Rural Smokers: Implications for Optimizing Referrals in Clinical Practice

Introduction: Rural‒urban smoking disparities have widened in recent years because smoking prevalence reductions have been experienced disproportionately among urban adults. Tobacco cessation programs that work in urban settings may not be reaching rural smokers or may need tailoring to be effective. Identifying smoking cessation preferences and barriers among rural smokers can facilitate the implementation of acceptable programs to address rural smoking-related disparities. Thus, the aim of this study was to examine tobacco cessation motivations, preferences, and barriers among rural smokers and to assess smokers’ likelihood to use various types of tobacco cessation programs. Methods: Using a cross-sectional study design, we distributed a self-administered survey to 100 smokers during regularly scheduled healthcare appointments at 3 rural Michigan practices from June to August 2019. We examined differences in participant characteristics by the readiness to quit using chi-square/Fisher's exact tests and described cessation motivations, preferences, and barriers to tobacco cessation among rural smokers. Results: Participants reporting readiness to quit were less likely to have smoking allowed in their home (31.7% vs. 75.0%; p=0.003) and had a higher prevalence of anxiety (62.1% vs. 6.3%; p=0.0001) and depression (49.2% vs. 18.8%; p=0.04) than those not ready to quit. Preferences were higher for nicotine replacement medications and reward-based approaches, with only 10% of participants being likely to use telephone-based quitlines. Conclusions: These findings suggest that provider referrals to nicotine replacement medications and reward-based approaches can be used to enhance tobacco cessation among rural smokers

Characterizing inflammatory breast cancer among Arab Americans in the California, Detroit and New Jersey Surveillance, Epidemiology and End Results (SEER) registries (1988–2008)

Introduction: Inflammatory breast cancer (IBC) is characterized by an apparent geographical distribution in incidence, being more common in North Africa than other parts of the world. Despite the rapid growth of immigrants to the United States from Arab nations, little is known about disease patterns among Arab Americans because a racial category is rarely considered for this group. The aim of this study was to advance our understanding of the burden of IBC in Arab ethnic populations by describing the proportion of IBC among different racial groups, including Arab Americans from the Detroit, New Jersey and California Surveillance, Epidemiology and End Results (SEER) registries.Methods: We utilized a validated Arab surname algorithm to identify women of Arab descent from the SEER registries. Differences in the proportion of IBC out of all breast cancer and IBC characteristics by race and menopausal status were evaluated using chi-square tests for categorical variables, t-tests and ANOVA tests for continuous variables, and log-rank tests for survival data. We modeled the association between race and IBC among all women with breast cancer using hierarchical logistic regression models, adjusting for individual and census tract-level variables.Results: Statistically significant differences in the proportion of IBC out of all breast cancers by race were evident. In a hierarchical model, adjusting for age, estrogen and progesterone receptor, human epidermal growth receptor 2, registry and census-tract level education, Arab-Americans (OR=1.5, 95% CI=1.2,1.9), Hispanics (OR=1.2, 95% CI=1.1,1.3), Non-Hispanic Blacks (OR=1.3, 95% CI=1.2, 1.4), and American Indians/Alaskans (OR=1.9, 95% CI=1.1, 3.4) had increased odds of IBC, while Asians (OR=0.6, 95% CI=0.6, 0.7) had decreased odds of IBC as compared to Non-Hispanic Whites.Conclusions: IBC may be more common among certain minority groups, including Arab American women. Understanding the descriptive epidemiology of IBC by race may generate hypotheses about risk factors for this aggressive disease. Future research should focus on etiologic factors that may explain these differences

Implementation of Physical Activity Programs for Rural Cancer Survivors: Challenges and Opportunities

Physical activity after cancer diagnosis has been consistently associated with improvements in quality of life and prognosis. However, few cancer survivors meet physical activity recommendations, and adherence is even lower among those living in rural settings. The purpose of this quasi-experimental study was to evaluate the implementation of a clinic-based physical activity program for cancer survivors at a rural community oncology setting. We also examined changes in quality-of-life measures among 24 cancer survivors participating in the physical activity program and described challenges and opportunities to optimize future implementation efforts in rural settings. Significant pre- to post-program improvements in fatigue (5.5 to 6.8; p = 0.03), constipation (7.7 to 9.0; p = 0.02), pain (6.7 to 8.0; p = 0.007), and sleep quality (p = 0.008) were observed. Participants also reported improved nausea, stamina, depression, stress, and overall physical health after participation in the physical activity program, although the differences were not statistically significant (all p-values &gt; 0.13). However, the reach of the physical activity program was limited, with only 0.59% of cancer survivors participating. Fidelity to the physical activity program was relatively high, with 72.7% of survivors participating in at least five classes. Our findings suggest that physical activity programs in oncological settings may need tailoring to effectively reach rural cancer survivors