Quality of life of 5–10 year breast cancer survivors diagnosed between age 40 and 49

BACKGROUND: The purpose of this report is to examine the correlates of quality of life (QOL) of a well-defined group of long-term breast cancer survivors diagnosed between the ages of 40 and 49. METHODS: Women were eligible if they were diagnosed with invasive breast cancer or ductal carcinoma in situ 5 to 10 years before June 30, 1998 and were enrolled at Group Health Cooperative, a health maintenance organization in western Washington State. A questionnaire was mailed to 290 women; 216 were included in this analysis. The questionnaire included standardized measures of QOL [e.g., the Cancer Rehabilitation Evaluation System (CARES-SF) and SF-36] as well as general demographic and medical information. ANOVA and logistic regression were used to estimate correlates of self-reported QOL. RESULTS: The mean age at diagnosis was 44.4 years, and the average time since diagnosis was 7.3 years. Women reported high levels of functioning across several standardized QOL scales; mild impairment was found on the CARES-SF Sexual Scale. The presence of breast-related symptoms at survey, use of adjuvant therapy, having lower income, and type of breast surgery were significantly associated with lower QOL 5 to 10 years post-diagnosis on one or more of the scales. CONCLUSIONS: Our results emphasize that younger long-term survivors of breast cancer have a high QOL across several standardized measures. However, the long-term consequences of adjuvant therapy and the management of long-term breast-related symptoms are two areas that may be important for clinicians and women with breast cancer in understanding and optimizing long-term QOL

An ex vivo, assessor blind, randomised, parallel group, comparative efficacy trial of the ovicidal activity of three pediculicides after a single application - melaleuca oil and lavender oil, eucalyptus oil and lemon tea tree oil, and a "suffocation" pediculicide

Background: There are two components to the clinical efficacy of pediculicides: (i) efficacy against the crawling-stages (lousicidal efficacy); and (ii) efficacy against the eggs (ovicidal efficacy). Lousicidal efficacy and ovicidal efficacy are confounded in clinical trials. Here we report on a trial that was specially designed to rank the clinical ovicidal efficacy of pediculicides. Eggs were collected, pre-treatment and post-treatment, from subjects with different types of hair, different coloured hair and hair of different length.Method: Subjects with at least 20 live eggs of Pediculus capitis (head lice) were randomised to one of three treatment-groups: a melaleuca oil (commonly called tea tree oil) and lavender oil pediculicide (TTO/LO); a eucalyptus oil and lemon tea tree oil pediculicide (EO/LTTO); or a "suffocation" pediculicide. Pre-treatment: 10 to 22 live eggs were taken from the head by cutting the single hair with the live egg attached, before the treatment (total of 1,062 eggs). Treatment: The subjects then received a single treatment of one of the three pediculicides, according to the manufacturers' instructions. Post-treatment: 10 to 41 treated live eggs were taken from the head by cutting the single hair with the egg attached (total of 1,183 eggs). Eggs were incubated for 14 days. The proportion of eggs that had hatched after 14 days in the pre-treatment group was compared with the proportion of eggs that hatched in the post-treatment group. The primary outcome measure was % ovicidal efficacy for each of the three pediculicides.Results: 722 subjects were examined for the presence of eggs of head lice. 92 of these subjects were recruited and randomly assigned to: the "suffocation" pediculicide (n = 31); the melaleuca oil and lavender oil pediculicide (n = 31); and the eucalyptus oil and lemon tea tree oil pediculicide (n = 30 subjects). The group treated with eucalyptus oil and lemon tea tree oil had an ovicidal efficacy of 3.3% (SD 16%) whereas the group treated with melaleuca oil and lavender oil had an ovicidal efficacy of 44.4% (SD 23%) and the group treated with the "suffocation" pediculicide had an ovicidal efficacy of 68.3% (SD 38%).Conclusion: Ovicidal efficacy varied substantially among treatments, from 3.3% to 68.3%. The "suffocation" pediculicide and the melaleuca oil and lavender oil pediculicide (TTO/LO) were significantly more ovicidal than eucalyptus oil and lemon tea tree oil pediculicide (EO/LTTO) (P < 0.0001). Ranking: 1. "Suffocation" pediculicide (68.3% efficacy against eggs); 2. Melaleuca oil and lavender oil (44.4%) pediculicide; 3. Eucalyptus oil and lemon tea tree oil (3.3%) pediculicide. The "suffocation" pediculicide and TTO/LO are also highly efficacious against the crawling-stages. Thus, the "suffocation" pediculicide and TTO/LO should be recommended as first line treatments.Trial Registration: The study was listed at the Australian/New Zealand Clinical Trial Registry (ANZCTR): reg. no. 12609000884202

Screening Colonoscopy in the US: Attitudes and Practices of Primary Care Physicians

BACKGROUND: Rising colorectal cancer (CRC) screening rates in the last decade are attributable almost entirely to increased colonoscopy use. Little is known about factors driving the increase, but primary care physicians (PCPs) play a central role in CRC screening delivery. OBJECTIVE: Explore PCP attitudes toward screening colonoscopy and their associations with CRC screening practice patterns. DESIGN: Cross-sectional analysis of data from a nationally representative survey conducted in 2006-2007. PARTICIPANTS: 1,266 family physicians, general practitioners, general internists, and obstetrician-gynecologists. MAIN MEASURES: Physician-reported changes in the volume of screening tests ordered, performed or supervised in the past 3 years, attitudes toward colonoscopy, the influence of evidence and perceived norms on their recommendations, challenges to screening, and practice characteristics. RESULTS: The cooperation rate (excludes physicians without valid contact information) was 75%; 28% reported their volume of FOBT ordering had increased substantially or somewhat, and the majority (53%) reported their sigmoidoscopy volume decreased either substantially or somewhat. A majority (73%) reported that colonoscopy volume increased somewhat or substantially. The majority (86%) strongly agreed that colonoscopy was the best of the available CRC screening tests; 69% thought it was readily available for their patients; 59% strongly or somewhat agreed that they might be sued if they did not offer colonoscopy to their patients. All three attitudes were significantly related to substantial increases in colonoscopy ordering. CONCLUSIONS: PCPs report greatly increased colonoscopy recommendation relative to other screening tests, and highly favorable attitudes about colonoscopy. Greater emphasis is needed on informed decision-making with patients about preferences for test options

Pressing ahead: developing and testing of new measures in implementation science

Measurement forms the foundation of any scientific field; yet, systematic reviews reveal that many available measures of implementation context, process, and outcomes lack reliability or validity. An urgent need exists for psychometrically strong measures in implementation science; without them, the field cannot produce cumulative knowledge about implementation barriers, facilitators, processes, or generate sound evidence about which implementation strategies work best, when, and for whom. In this panel session, three researchers reported on their efforts to develop and test new measures of constructs featured in the Consolidated Framework for Implementation Research (CFIR). Maria Fernandez described the work of the CDC/NCI-funded Cancer Prevention and Control Research Network to create measures for seven constructs in the inner-setting domain of CFIR and assess the psychometric properties of those measures using data from a multi-state sample of community health centers. Shuting Liang reported on the Network’s effort to develop and assess measures of selected constructs in other CFIR domains and discussed the inter-relationships of these constructs at both the individual and clinic level of analysis. Sara Jacobs explored in two different study contexts the psychometric properties of, and measurement issues associated with, a new theory-based measure of implementation climate. Building on the presentations, Stephen Taplin moderated a discussion between panelists and participants about the role of theory in measurement, the challenges of adapting existing measures, the implications of item-wording choices, the effects of context on measurement properties, and the measurement of organization-level constructs using individual-level data. Participants learned about new measures they could use in their own research; in addition, they engaged in dialogue about needs, opportunities, challenges, and recommended practices in measurement in implementation scienc

Cost-effectiveness of strategies to enhance mammography use

OBJECTIVE. To estimate the cost-effectiveness of three strategies to increase breast cancer screening with mammography (reminder postcard, reminder telephone call, and motivational telephone call). DESIGN. Cost accounting for each strategy followed by cost-effectiveness analysis. DATA SOURCE FOR EFFECTIVENESS. Randomized trial of three strategies conducted at Group Health Cooperative of Puget Sound (GHC). TARGET POPULATION. Women 50 to 79 years of age who were enrolled in GHC&apos;s breast cancer screening program who did not schedule screening mammography within 2 months after it was recommended by letter. PERSPECTIVE. Health plan. OUTCOME MEASURE. Marginal cost-effectiveness of each additional woman screened. RESULTS OF BASE-CASE ANALYSIS. Because of its high cost (about $26 per call) and intermediate effectiveness, the motivational call was the least cost-effective strategy. If it was assumed that 50$22 per woman screened versus $92 for the reminder call. Among women with no previous mammography, the marginal cost-effectiveness for the postcard was$70 versus $100 for the reminder call. RESULTS OF SENSITIVITY ANALYSIS. Among women with no previous mammography, the choice between the reminder postcard and the reminder call was sensitive to assumptions about the percentage of women expected to receive mammography in the absence of other promotional strategies. CONCLUSIONS. A simple reminder postcard is the most cost-effective way to increase mammography. Choices about how to promote mammography will ultimately depend on plan values and willingness to invest in promotional strategies that increase participation at higher unit costs. F or women 50 to 69 years of age, evidence clearly supports the effectiveness of mammography as a breast cancer screening tool. Randomized trials have demonstrated that mammographic screening in this age group can decrease breast cancer mortality rates by approximately 25% to 30% within 5 or 6 years. 1 Breast cancer mortality rates have decreased since 1990, perhaps in part because of widespread screening. 2-4 These benefits highlight the need to increase awareness and promotion of mammography. With the growth of managed care in the United States, the opportunity to use the health plan to promote mammography as a breast cancer screening tool has increased. However, health plans face the challenge of finding cost-effective ways to increase women&apos;s participation in screening programs. This paper is available at ecp.acponline.org. • • • Health benefits are sufficient incentive for health plans to find ways to increase participation, but the health care market also prompts plans to improve delivery of all preventive services. So-called &quot;report cards,&quot; such as the Health Plan Employer Data Information Set (HEDIS) measures produced by the National Committee on Quality Assurance, include mammography participation in women 52 to 69 years of age as one of the elements on which managed health plans are evaluated. Many health insurance purchasers will not contract with plans that fail to meet HEDIS or other report card standards. Little research exists on the costs associated with alternative strategies for breast cancer screening recruitment. Most cost analyses have focused on the value of mammographic screening, and the results of these studies have contributed to widespread adoption of such screening for women 50 years of age and older. 5 The National Cancer Institute, the American Cancer Society, the U.S. Preventive Services Task Force, and other groups in the United States and other countries recommend screening mammography for women in this age group, in part because of demonstrated reductions in mortality rate. In this paper, we use the results of a recent randomized trial 8 to examine the cost-effectiveness of three strategies to encourage participation in mammographic screening (reminder postcard, reminder telephone call, and motivational telephone call). Methods Overview We report the estimated cost-effectiveness of alternative strategies to increase mammography use in women 50 to 79 years of age. Our data are based on a recent trial conducted at Group Health Cooperative of Puget Sound (GHC). Our goal was to provide health plans with information about the cost-effectiveness of a reminder postcard, reminder telephone call, and motivational telephone call in increasing enrollees&apos; participation in screening programs. The outcome of interest, based on the anticipated needs of health plan decision makers, was the marginal or incremental cost per participant screened for each promotional strategy. Setting Our analysis is from the perspective of GHC, a mixedmodel HMO serving more than 500,000 enrollees in western Washington State. In terms of ethnicity and socioeconomic status, the GHC population is similar to the communities in which it provides care. 5 Although GHC has an ongoing breast cancer screening program, we did not consider the fixed costs associated with developing and maintaining this program in our analysis. Effectiveness: The Randomized Trial Effectiveness data for our analysis were based on a randomized trial 8 that evaluated alternative strategies to improve participation in GHC&apos;s breast cancer screening program. Participants were recruited for the trial from a random sample of 11,570 women aged 50 to 79 years who were due to receive mammography in GHC&apos;s breast cancer screening program. 214 Descriptive data on the women in each intervention group are given in Cost: Accounting Methods Overview Cost assignment for each strategy is based on the project team&apos;s report of resources used to deliver the intervention. Our cost model includes any office space or equipment from GHC&apos;s screening program that was used but not paid for by the trial. GHC allowed the research team to use some existing screening program resources (e.g., office space, telephones, computers) without charge. However, we estimated the overhead expenses needed for each intervention group by assuming that the health plan incurred all of the additional expenditures required to implement each promotional strategy. Dollar values for resources used in the trial were 1998 local market costs for personnel, office space, furnishings, and equipment. We do not use GHC&apos;s costs because they may reflect idiosyncrasies of GHC&apos;s pur- chasing or human resource policies. The cost model includes all personnel, hardware, and material necessary to implement and conduct the promotional strategies, except building and maintaining the screening program information system. Total costs for each fixed and variable resource used in each strategy were allocated on a per-participant basis. Average fixed cost elements necessary for each promotional strategy, such as office space, telephone lines, and computers, were allocated to all women randomly assigned to that strategy. Reminder Postcard Costs for the postcard group include development of the text used on the postcard as well as its design, production, and mailing. Production and mailing costs are based on bulk mailing charges, and we assume that all relevant personal information for eligible women was available from the existing health plan database. Costs included an analyst (to abstract screening program information on eligible women), equipment, and office space needed to complete these tasks. Reminder and Motivational Telephone Calls The most significant variable cost in both telephonebased strategies was time spent on the telephone. Callers in both telephone groups collected data on the length of the telephone calls, and costs were allocated on the basis of average cost per minute of contact time. Staff deliver

Accuracy of self-reported breast cancer among women undergoing mammography

This study estimated the sensitivity and specificity of self-reported breast cancer and their associations with patient factors and pathologic findings using data from the Breast Cancer Surveillance Consortium

Teams and Teamwork During a Cancer Diagnosis: Interdependency Within and Between Teams

This article discusses the care process among three groups (primary care, radiology, and surgery) aiding a 57-year-old woman during her screening mammography and diagnosis of breast cancer. This is the first in a series of articles exploring principles and topics relevant to teams guiding clinicians involved in cancer care. The challenges demonstrated in this case illustrate how clinicians work within and between groups to deliver this first phase of cancer care. The case helps demonstrate the differences between groups and teams. Focusing on the patient and the overall process of care coordination can help move groups toward becoming teams who deliver better care by identifying and managing goals, roles, and interdependent care tasks. Care providers and researchers can use the case to consider their own work and essential aspects of teamwork needed to improve care, patient outcomes, and the evidence that supports each

International variation in management of screen-detected ductal carcinoma in situ of the breast.

BACKGROUND: Ductal carcinoma in situ (DCIS) incidence has grown with the implementation of screening and its detection varies across International Cancer Screening Network (ICSN) countries. The aim of this survey is to describe the management of screen-detected DCIS in ICSN countries and to evaluate the potential for treatment related morbidity. METHODS: We sought screen-detected DCIS data from the ICSN countries identified during 2004-2008. We adopted standardised data collection forms and analysis and explored DCIS diagnosis and treatment processes ranging from pre-operative diagnosis to type of surgery and radiotherapy. RESULTS: Twelve countries contributed data from a total of 15 screening programmes, all from Europe except the United States of America and Japan. Among women aged 50-69years, 7,176,050 screening tests and 5324 screen-detected DCIS were reported. From 21% to 93% of DCIS had a pre-operative diagnosis (PO); 67-90% of DCIS received breast conservation surgery (BCS), and in 41-100% of the cases this was followed by radiotherapy; 6.4-59% received sentinel lymph node biopsy (SLNB) only and 0.8-49% axillary dissection (ALND) with 0.6% (range by programmes 0-8.1%) being node positive. Among BCS patients 35% received SLNB only and 4.8% received ALND. Starting in 2006, PO and SLNB use increased while ALND remained stable. SLNB and ALND were associated with larger size and higher grade DCIS lesions. CONCLUSIONS: Variation in DCIS management among screened women is wide and includes lymph node surgery beyond what is currently recommended. This indicates the presence of varying levels of overtreatment and the potential for its reduction