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Background: Pancreatic adenocarcinoma (PC) is a highly lethal malignancy with a survival rate of only 12%. Surveillance is recommended for high-risk individuals (HRIs), but it is not widely adopted. To address this unmet clinical need and drive early diagnosis research, we established the Pancreatic Cancer Early Detection (PRECEDE) Consortium., Methods: PRECEDE is a multi-institutional international collaboration that has undertaken an observational prospective cohort study. Individuals (aged 18-90 years) are enrolled into 1 of 7 cohorts based on family history and pathogenic germline variant (PGV) status. From April 1, 2020, to November 21, 2022, a total of 3,402 participants were enrolled in 1 of 7 study cohorts, with 1,759 (51.7%) meeting criteria for the highest-risk cohort (Cohort 1). Cohort 1 HRIs underwent germline testing and pancreas imaging by MRI/MR-cholangiopancreatography or endoscopic ultrasound., Results: A total of 1,400 participants in Cohort 1 (79.6%) had completed baseline imaging and were subclassified into 3 groups based on familial PC (FPC; n=670), a PGV and FPC (PGV+/FPC+; n=115), and a PGV with a pedigree that does not meet FPC criteria (PGV+/FPC-; n=615). One HRI was diagnosed with stage IIB PC on study entry, and 35.1% of HRIs harbored pancreatic cysts. Increasing age (odds ratio, 1.05; P<.001) and FPC group assignment (odds ratio, 1.57; P<.001; relative to PGV+/FPC-) were independent predictors of harboring a pancreatic cyst., Conclusions: PRECEDE provides infrastructure support to increase access to clinical surveillance for HRIs worldwide, while aiming to drive early PC detection advancements through longitudinal standardized clinical data, imaging, and biospecimen captures. Increased cyst prevalence in HRIs with FPC suggests that FPC may infer distinct biological processes. To enable the development of PC surveillance approaches better tailored to risk category, we recommend adoption of subclassification of HRIs into FPC, PGV+/FPC+, and PGV+/FPC- risk groups by surveillance protocols.

Human papillomavirus (HPV) is a significant health burden and leading cause of virus-induced cancers. However, studies have been hampered due to restricted tropism that makes production and purification of high titer virus problematic. This issue has been overcome by developing alternative HPV production methods such as virus-like particles (VLPs), which are devoid of a native viral genome. Structural studies have been limited in resolution due to the heterogeneity, fragility, and stability of the VLP capsids. The mouse papillomavirus (MmuPV1) presented here has provided the opportunity to study a native papillomavirus in the context of a common laboratory animal. Using cryo EM to solve the structure of MmuPV1, we achieved 3.3 Å resolution with a local symmetry refinement method that defined smaller, symmetry related subparticles. The resulting high-resolution structure allowed us to build the MmuPV1 asymmetric unit for the first time and identify putative L2 density. We also used our program ISECC to quantify capsid flexibility, which revealed that capsomers move as rigid bodies connected by flexible linkers. The MmuPV1 flexibility was comparable to that of a HPV VLP previously characterized. The resulting MmuPV1 structure is a promising step forward in the study of papillomavirus and will provide a framework for continuing biochemical, genetic, and biophysical research for papillomaviruses.

Purpose: To evaluate preferences for and experiences with genetic testing in a diverse cohort of patients with breast cancer identified through population-based registries, with attention to differences by race/ethnicity., Methods: We surveyed women diagnosed with nonmetastatic breast cancer from 2005 to 2007, as reported to the SEER registries of metropolitan Los Angeles and Detroit, about experiences with hereditary risk evaluation. Multivariable models evaluated correlates of a strong desire for genetic testing, unmet need for discussion with a health care professional, and receipt of testing., Results: Among 1,536 patients who completed the survey, 35% expressed strong desire for genetic testing, 28% reported discussing testing with a health care professional, and 19% reported test receipt. Strong desire for testing was more common in younger women, Latinas, and those with family history. Minority patients were significantly more likely to have unmet need for discussion (failure to discuss genetic testing with a health professional when they had a strong desire for testing): odds ratios of 1.68, 2.44, and 7.39 for blacks, English-speaking Latinas, and Spanish-speaking Latinas compared with whites, respectively. Worry in the long-term survivorship period was higher among those with unmet need for discussion (48.7% v 24.9%; P <.001). Patients who received genetic testing were younger, less likely to be black, and more likely to have a family cancer history., Conclusion: Many patients, especially minorities, express a strong desire for genetic testing and may benefit from discussion to clarify risks. Clinicians should discuss genetic risk even with patients they perceive to be at low risk, as this may reduce worry., (© 2015 by American Society of Clinical Oncology.)

Background: While studies suggest most women have little regret regarding their breast cancer treatment decisions immediately following treatment, no studies to date have evaluated how regret may change over time., Objective: To measure the stability of posttreatment decision regret over time among women with breast cancer., Methods: Women diagnosed with breast cancer between August 2005 and May 2007 reported to the Detroit, Michigan, or Los Angeles County Surveillance, Epidemiology, and End Results (SEER) registry and completed surveys at 9 months following diagnosis (time 1) and again approximately 4 years later (time 2). A decision regret scale consisting of 5 items was summed to create 2 decision regret scores at both time 1 and time 2 (range, 0-20). Multivariable linear regression was used to examine change in regret from 9 months to 4 years. Independent variables included surgery type, receipt of reconstruction, and recurrence status at follow-up. The model controlled for demographic and clinical factors., Results: The analytic sample included 1536 women. Mean regret in the overall sample was 4.9 at time 1 and 5.4 at time 2 (P < 0.001). In the multivariable linear model, we found no difference in change in decision regret over time by surgery type. Reporting a new diagnosis of breast cancer at time 2 was associated with a 2.6-point increase in regret over time compared with women without an additional diagnosis (P = 0.003). Receipt of reconstruction was not associated with change in decision regret over time., Conclusions: Decision regret following treatment was low and relatively stable over time for most women. Those facing an additional diagnosis of breast cancer following treatment may be at risk for elevated regret-related distress., (© The Author(s) 2014.)

Importance: Most women undergoing mastectomy for breast cancer do not undergo breast reconstruction., Objective: To examine correlates of breast reconstruction after mastectomy and to determine if a significant unmet need for reconstruction exists., Design, Setting, and Participants: We used Surveillance, Epidemiology, and End Results registries from Los Angeles, California, and Detroit, Michigan, for rapid case ascertainment to identify a sample of women aged 20 to 79 years diagnosed as having ductal carcinoma in situ or stages I to III invasive breast cancer. Black and Latina women were oversampled to ensure adequate representation of racial/ethnic minorities. Eligible participants were able to complete a survey in English or Spanish. Of 3252 women sent the initial survey a median of 9 months after diagnosis, 2290 completed it. Those who remained disease free were surveyed 4 years later to determine the frequency of immediate and delayed reconstruction and patient attitudes toward the procedure; 1536 completed the follow-up survey. The 485 who remained disease free at follow-up underwent analysis., Exposures: Disease-free survival of breast cancer., Main Outcomes and Measures: Breast reconstruction at any time after mastectomy and patient satisfaction with different aspects of the reconstruction decision-making process., Results: Response rates in the initial and follow-up surveys were 73.1% and 67.7%, respectively (overall, 49.4%). Of 485 patients reporting mastectomy at the initial survey and remaining disease free, 24.8% underwent immediate and 16.8% underwent delayed reconstruction (total, 41.6%). Factors significantly associated with not undergoing reconstruction were black race (adjusted odds ratio [AOR], 2.16 [95% CI, 1.11-4.20]; P = .004), lower educational level (AOR, 4.49 [95% CI, 2.31-8.72]; P < .001), increased age (AOR in 10-year increments, 2.53 [95% CI, 1.77-3.61]; P < .001), major comorbidity (AOR, 2.27 [95% CI, 1.01-5.11]; P = .048), and chemotherapy (AOR, 1.82 [95% CI, 0.99-3.31]; P = .05). Only 13.3% of women were dissatisfied with the reconstruction decision-making process, but dissatisfaction was higher among nonwhite patients in the sample (AOR, 2.87 [95% CI, 1.27-6.51]; P = .03). The most common patient-reported reasons for not having reconstruction were the desire to avoid additional surgery (48.5%) and the belief that it was not important (33.8%), but 36.3% expressed fear of implants. Reasons for avoiding reconstruction and systems barriers to care varied by race; barriers were more common among nonwhite participants. Residual demand for reconstruction at 4 years was low, with only 30 of 263 who did not undergo reconstruction still considering the procedure., Conclusions and Relevance: Reconstruction rates largely reflect patient demand; most patients are satisfied with the decision-making process about reconstruction. Specific approaches are needed to address lingering patient-level and system factors with a negative effect on reconstruction among minority women.

Background: Many women with early-stage breast cancer are working at the time of diagnosis and survive without disease recurrence. The short-term impact of chemotherapy receipt on employment has been demonstrated, but the long-term impact merits further research., Methods: The authors conducted a longitudinal multicenter cohort study of women diagnosed with nonmetastatic breast cancer between 2005 and 2007, as reported to the population-based Los Angeles and Detroit Surveillance, Epidemiology, and End Results program registries. Of 3133 individuals who were sent surveys, 2290 (73%) completed a baseline survey soon after diagnosis and of these, 1536 (67%) completed a 4-year follow-up questionnaire., Results: Of the 1026 patients aged < 65 years at the time of diagnosis whose breast cancer did not recur and who responded to both surveys, 746 (76%) worked for pay before diagnosis. Of these, 236 (30%) were no longer working at the time of the follow-up survey. Women who received chemotherapy as part of their initial treatment were less likely to be working at the time of the follow-up survey (38% vs 27%; P = .003). Chemotherapy receipt at the time of diagnosis (odds ratio, 1.4; P = .04) was found to be independently associated with unemployment during survivorship in a multivariable model. Many women who were not employed during the survivorship period wanted to work: 50% reported that it was important for them to work and 31% were actively seeking work., Conclusions: Unemployment among survivors of breast cancer 4 years after diagnosis is often undesired and appears to be related to the receipt of chemotherapy during initial treatment. These findings should be considered when patients decide whether to receive adjuvant chemotherapy, particularly when the expected benefit is low., (© 2014 American Cancer Society.)

Importance: The growing rate of contralateral prophylactic mastectomy (CPM) among women diagnosed as having breast cancer has raised concerns about potential for overtreatment. Yet, there are few large survey studies of factors that affect women's decisions for this surgical treatment option., Objective: To determine factors associated with the use of CPM in a population-based sample of patients with breast cancer., Design, Setting, and Participants: A longitudinal survey of 2290 women newly diagnosed as having breast cancer who reported to the Detroit and Los Angeles Surveillance, Epidemiology, and End Results registries from June 1, 2005, to February 1, 2007, and again 4 years later (June 2009 to February 2010) merged with Surveillance, Epidemiology, and End Results registry data (n = 1536). Multinomial logistic regression was used to evaluate factors associated with type of surgery. Primary independent variables included clinical indications for CPM (genetic mutation and/or strong family history), diagnostic magnetic resonance imaging, and patient extent of worry about recurrence at the time of treatment decision making., Main Outcomes and Measures: Type of surgery received from patient self-report, categorized as CPM, unilateral mastectomy, or breast conservation surgery., Results: Of the 1447 women in the analytic sample, 18.9% strongly considered CPM and 7.6% received it. Of those who strongly considered CPM, 32.2% received CPM, while 45.8% received unilateral mastectomy and 22.8% received breast conservation surgery (BCS). The majority of patients (68.9%) who received CPM had no major genetic or familial risk factors for contralateral disease. Multivariate regression showed that receipt of CPM (vs either unilateral mastectomy or breast conservation surgery) was significantly associated with genetic testing (positive or negative) (vs UM, relative risk ratio [RRR]: 10.48; 95% CI, 3.61-3.48 and vs BCS, RRR: 19.10; 95% CI, 5.67-56.41; P < .001), a strong family history of breast or ovarian cancer (vs UM, RRR: 5.19; 95% CI, 2.34-11.56 and vs BCS, RRR: 4.24; 95% CI, 1.80-9.88; P = .001), receipt of magnetic resonance imaging (vs UM RRR: 2.07; 95% CI, 1.21-3.52 and vs BCS, RRR: 2.14; 95% CI, 1.28-3.58; P = .001), higher education (vs UM, RRR: 5.04; 95% CI, 2.37-10.71 and vs BCS, RRR: 4.38; 95% CI, 2.07-9.29; P < .001), and greater worry about recurrence (vs UM, RRR: 2.81; 95% CI, 1.14-6.88 and vs BCS, RRR: 4.24; 95% CI, 1.80-9.98; P = .001)., Conclusions and Relevance: Many women considered CPM and a substantial number received it, although few had a clinically significant risk of contralateral breast cancer. Receipt of magnetic resonance imaging at diagnosis contributed to receipt of CPM. Worry about recurrence appeared to drive decisions for CPM although the procedure has not been shown to reduce recurrence risk. More research is needed about the underlying factors driving the use of CPM.

Purpose: This study investigated factors associated with declines in emotional well-being (EWB) over time in breast cancer survivors., Methods: Women with breast cancer (Stages I-III) residing in Los Angeles, CA, or Detroit, MI, and reported to the Surveillance, Epidemiology, and End Results registries between June 2005 and February 2007 completed surveys at 9 months and 4 years after diagnosis. EWB was measured by the Functional Assessment of Cancer Treatment-Breast. Using a stress coping framework, logistic regression models assessed associations between personal, social, and clinical correlates, appraisal (e.g., worry about recurrence) and coping factors (e.g., emotional support) to EWB declines., Results: Among eligible women who completed primary breast cancer treatment, 772 completed both surveys, and 192 (24.9 %) experienced EWB declines over time. Women with past or current depression were more likely to report EWB decline (p < 0.01). Survivors who perceived they did not receive enough information about risk of breast cancer recurrence during primary treatment were more likely to have EWB decline (OR 0.53, 95 % CI 0.32-0.87). Greater perceived likelihood of recurrence (OR 1.95, 95 % CI 1.01-5.29) and increased worry about recurrence (OR 1.38, 95 % CI 1.10-1.72) were associated with EWB decline. Higher spirituality beliefs and practices were associated with EWB decline., Conclusions: A considerable number of breast cancer patients report emotional well-being declines over time. Early identification of women who are vulnerable, such as women with past depression, is crucial to improve quality of care. Women would benefit from education about cancer recurrence and tailored strategies to manage worry about recurrence over time., Implication for Cancer Survivors: Understanding actual risk of recurrence and managing worry about recurrence is important for cancer survivors. Emotional concerns are common for individuals with cancer so survivors should feel free to reach out and discuss such concerns with providers well into the survivorship period.

To describe which providers provide breast cancer survivorship care, we conducted a longitudinal survey of nonmetastatic breast cancer patients identified by the SEER registries of Los Angeles and Detroit. Multinomial logistic regression examined the adjusted odds of surgeon compared with a medical oncologist follow-up or primary care provider compared with medical oncologist follow-up, adjusting for age, race/ethnicity, insurance, tumor stage, receipt of chemotherapy, endocrine therapy use, and visit to a medical oncologist at the time of diagnosis. Results were weighted to account for sample selection and nonresponse. 844 women had invasive disease and received chemotherapy or endocrine therapy. 65.2 % reported medical oncologists as their main care provider at 4 years, followed by PCP/other physicians (24.3 %) and surgeons (10.5 %). Black women were more likely to receive their follow-up care from surgeons (OR 2.47, 95 % CI 1.16-5.27) or PCP/other physicians (OR 2.62, 95 % CI 1.47-4.65) than medical oncologists. Latinas were more likely to report PCP/other physician follow-up than medical oncologists (OR 2.33, 95 % CI 1.15-4.73). Compared with privately insured women, Medicaid recipients were more likely to report PCP/other physician follow-up (OR 2.52, 95 % CI 1.24-5.15). Women taking endocrine therapy 4 years after diagnosis were less likely to report surgeons or PCP/other physicians as their primary provider of breast cancer follow-up care. Different survivorship care patterns emerge on race/ethnicity and insurance status. Interventions are needed to inform patients and providers on the recommended sources of breast cancer follow-up.

Objective: The study aimed to characterize cancer-related concerns among women with a new diagnosis of gynecological cancer from a developmental life stage perspective. The study compared the degree of cancer-related concern between young women (45 years or younger), middle age women (46-64 years), and older women (65 years or older)., Materials/methods: Data from women (N = 243) with a condition diagnosed as primary gynecological cancer who were participating in a randomized control trial were analyzed. Women completed a measure that assessed the degree of concern in 12 cancer-related domains (physical functioning, cancer treatment, emotional functioning, sexual functioning, disease progression/death, own well-being, partner well-being, relationship with spouse/partner, body image, relationship with others, employment, and finances). Multivariate comparisons were made between the 3 age groups on the cancer-related concerns., Results: There were age group differences in overall cancer-related concern and specific cancer-related domains. Young women reported the greatest cancer-related concern (P < 0.001). They reported greater concern over emotional functioning (P < 0.001) and sexual functioning (P < 0.001) compared to the middle- and older-age groups. Older women reported less concern over the impact of cancer on finances (P = 007). There were no differences between age groups in concern over physical impairment, cancer treatment, disease progression/death, own well-being, partner well-being, relationship with spouse/partner, body image, and relationship with others., Conclusions: Age may play an important role in the impact of a gynecological cancer diagnosis in domains of functioning, specifically emotional functioning, sexual functioning, and finances. Other cancer-related areas may represent more universal degree of impact. Professionals may benefit from considering the impact of cancer from a developmental life stage perspective.

Purpose/objectives: To characterize the perspectives of partners (husbands or significant others) of patients with breast cancer in the treatment decision-making process and to evaluate racial and ethnic differences in decision outcomes., Design: A cross-sectional survey., Setting: Los Angeles, CA, and Detroit, MI., Sample: 517 partners of a population-based sample of patients with breast cancer four years post-treatment., Methods: A self-administered mailed questionnaire. Chi-square tests and logistic regression were used to assess associations between race and ethnicity and decision outcomes., Main Research Variables: Decision regret and three elements of the decision process: information received, actual involvement, and desired involvement., Findings: Most partners reported receiving sufficient information (77%), being involved in treatment decisions (74%), and having sufficient involvement (73%). Less-acculturated Hispanic partners were more likely than their Caucasian counterparts to report high decision regret (45% versus 14%, p<0.001). Factors significantly associated (p<0.05) with high decision regret were insufficient receipt of treatment information, low involvement in decision making, and a desire for more involvement., Conclusions: Partners were generally positive regarding their perspectives about participating in the breast cancer treatment decision-making process. However, less acculturated Hispanic partners were most vulnerable to decision regret. In addition, high decision regret was associated with modifiable elements of the decision-making process., Implications for Nursing: Attention should be paid to ensuring racial and ethnic minority partners are sufficiently involved in breast cancer treatment decisions and receive decision support.

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.

Background: While randomized controlled trials represent the highest level of evidence we can generate in comparative effectiveness research, there are clinical scenarios where this type of study design is not feasible. The Comparative Effectiveness Analyses of Surgery and Radiation in localized prostate cancer (CEASAR) study is an observational study designed to compare the effectiveness and harms of different treatments for localized prostate cancer, a clinical scenario in which randomized controlled trials have been difficult to execute and, when completed, have been difficult to generalize to the population at large., Methods: CEASAR employs a population-based, prospective cohort study design, using tumor registries as cohort inception tools. The primary outcome is quality of life after treatment, measured by validated instruments. Risk adjustment is facilitated by capture of traditional and nontraditional confounders before treatment and by propensity score analysis., Results: We have accrued a diverse, representative cohort of 3691 men in the USA with clinically localized prostate cancer. Half of the men invited to participate enrolled, and 86% of patients who enrolled have completed the 6-month survey., Conclusion: Challenging comparative effectiveness research questions can be addressed using well-designed observational studies. The CEASAR study provides an opportunity to determine what treatments work best, for which patients, and in whose hands.

Adjuvant endocrine therapy for breast cancer reduces recurrence and improves survival rates. Many patients never start treatment or discontinue prematurely. A better understanding of factors associated with endocrine therapy initiation and persistence could inform practitioners how to support patients. We analyzed data from a longitudinal study of 2,268 women diagnosed with breast cancer and reported to the Metropolitan Detroit and Los Angeles SEER cancer registries in 2005-2007. Patients were surveyed approximately both 9 months and 4 years after diagnosis. At the 4-year mark, patients were asked if they had initiated endocrine therapy, terminated therapy, or were currently taking therapy (defined as persistence). Multivariable logistic regression models examined factors associated with initiation and persistence. Of the 743 patients eligible for endocrine therapy, 80 (10.8 %) never initiated therapy, 112 (15.1 %) started therapy but discontinued prematurely, and 551 (74.2 %) continued use at the second time point. Compared with whites, Latinas (OR 2.80, 95 % CI 1.08-7.23) and black women (OR 3.63, 95 % CI 1.22-10.78) were more likely to initiate therapy. Other factors associated with initiation included worry about recurrence (OR 3.54, 95 % CI 1.31-9.56) and inadequate information about side effects (OR 0.24, 95 % CI 0.10-0.55). Factors associated with persistence included two or more medications taken weekly (OR 4.19, 95 % CI 2.28-7.68) and increased age (OR 0.98, 95 % CI 0.95-0.99). Enhanced patient education about potential side effects and the effectiveness of adjuvant endocrine therapy in improving outcomes may improve initiation and persistence rates and optimize breast cancer survival.

Objective: This cross sectional study aimed to characterize fears of recurrence among women newly diagnosed with gynecologic cancer. The study also evaluated models predicting the impact of recurrence fears on psychological distress through social and cognitive variables., Methods: Women (N=150) who participated in a randomized clinical trial comparing a coping and communication intervention to a supportive counseling intervention to usual care completed baseline surveys that were utilized for the study. The survey included the Concerns about Recurrence Scale (CARS), Beck Depression Inventory (BDI), Impact of Event Scale (IES), and measures of social (holding back from sharing concerns and negative responses from family and friends) and cognitive (positive reappraisal, efficacy appraisal, and self-esteem appraisal) variables. Medical data was obtained via medical chart review., Results: Moderate-to-high levels of recurrence fears were reported by 47% of the women. Younger age (p<.01) and functional impairment (p<.01) correlated with greater recurrence fears. A social-cognitive model of fear of recurrence and psychological distress was supported. Mediation analyses indicated, that as a set, the social and cognitive variables mediated the association between fear of recurrence and both depression and cancer-specific distress. Holding back and self-esteem showed the strongest mediating effects., Conclusion: Fears of recurrence are prevalent among women newly diagnosed with gynecologic cancer. Social and cognitive factors play a role in women's adaptation to fears and impact overall psychological adjustment. These factors may be appropriate targets for intervention., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background and Purpose: While variation in breast cancer quality indicators has been studied, to date there have been no studies examining the degree of surgeon-level variation in patient-reported outcomes. The purpose of this study is to examine surgeon-level variation in patient appraisals of their breast cancer care experiences., Methods: Survey responses and clinical data from breast cancer patients reported to Detroit and Los Angeles Surveillance, Epidemiology and End Results registries from 6/2005 to 2/2007 were merged with attending surgeon surveys (1,780 patients, 291 surgeons). Primary outcomes were patient reports of access to care, care coordination, and decision satisfaction. Random-effects models examined variation due to individual surgeons for these three outcomes., Results: Mean values on each patient-reported outcome scale were high. The amount of variation attributable to individual surgeons in the unconditional models was low to modest: 5.4% for access to care, 3.3% for care coordination, and 7.5% for decision satisfaction. Few factors were independently associated with patient reports of better access to or coordination of care, but less-acculturated Latina patients had lower decision satisfaction., Conclusions: Patients reported generally positive experiences with their breast cancer treatment, though we found disparities in decision satisfaction. Individual surgeons did not substantively explain the variation in any of the patient-reported outcomes.

Purpose: Disparities in receipt of adjuvant chemotherapy may contribute to higher breast cancer fatality rates among black and Hispanic women compared with non-Hispanic whites. We investigated factors associated with receipt of chemotherapy in a diverse population-based sample., Patients and Methods: Women diagnosed with breast cancer between August 2005 and May 2007 (N = 3,252) and reported to the Detroit, Michigan, or Los Angeles County Surveillance, Epidemiology, and End Results (SEER) registry were recruited to complete a survey. Multivariable analyses examined factors associated with chemotherapy receipt., Results: The survey was sent to 3,133 patients; 2,290 completed a survey (73.1%), and 1,403 of these patients were included in the analytic sample. In multivariable models, disease characteristics were significantly associated with the likelihood of receiving chemotherapy. Low-acculturated Hispanics were more likely to receive chemotherapy than non-Hispanic whites (odds ratio [OR], 2.00; 95% CI, 1.31 to 3.04), as were high-acculturated Hispanics (OR, 1.43; 95% CI, 1.03 to 1.98). Black women were less likely to receive chemotherapy than non-Hispanic whites, but the difference was not significant (OR, 0.83; 95% CI, 0.64 to 1.08). Increasing age (even in women age < 50 years) and Medicaid insurance were associated with lower rates of chemotherapy receipt., Conclusion: In this population-based sample, disease characteristics were strongly associated with receipt of chemotherapy, indicating that clinical benefit guides most treatment decisions. We found no compelling evidence that black women and Hispanics receive chemotherapy at lower rates. Interventions that address chemotherapy use rates according to age and insurance status may improve quality of systemic treatment.

Background: The national obesity epidemic is contributing to an increased proportion of overweight and obese breast cancer patients. The authors' purpose was to determine whether patterns of use and outcomes of reconstruction differed among obese and nonobese patients., Methods: The authors performed a 5-year follow-up survey of mastectomy-treated breast cancer patients from the Los Angeles and Detroit Surveillance, Epidemiology and End Results Cancer Registries (response rate, 59 percent). Patients were divided into three body mass index categories: normal weight (body mass index<25 kg/m), overweight (25 to 30 kg/m), and obese (>30 kg/m). Outcomes of interest were receipt of reconstruction, type and timing of reconstruction, access barriers, and satisfaction. Chi-square and t tests were used for analysis. Logistic regression was used to identify predictors of autologous reconstruction., Results: Of 374 mastectomy-treated patients, receipt of reconstruction did not vary by body mass index (53 percent normal weight, 48 percent overweight, and 45 percent obese; p=0.43). Receipt did vary by type of reconstruction: significantly more obese patients received transverse rectus abdominis musculocutaneous flaps compared with normal weight patients (53 percent versus 26 percent; p=0.01). No specific access barriers to reconstruction were identified. Patient satisfaction with surgical decision-making and surgical outcomes was similar across body mass index categories., Conclusions: Obese compared with normal weight breast cancer patients have similar use of breast reconstruction, are more likely to receive an autologous procedure, and report similar satisfaction with surgical outcomes. Future efforts should be directed at decreasing the surgical risk in this challenging patient population., Clinical Question/level of Evidence: Therapeutic, II.

Purpose: To assess whether radiation oncologists and surgeons differ in their attitudes regarding the local management of breast cancer, and to examine coordination of care between these specialists., Methods and Materials: We surveyed attending surgeons and radiation oncologists who treated a population-based sample of patients diagnosed with breast cancer in metropolitan Detroit and Los Angeles. We identified 419 surgeons, of whom 318 (76%) responded, and 160 radiation oncologists, of whom 117 (73%) responded. We assessed demographic, professional, and practice characteristics; challenges to coordinated care; and attitudes toward management in three scenarios., Results: 92.1% of surgeons and 94.8% of radiation oncologists indicated access to a multidisciplinary tumor board. Nevertheless, the most commonly identified challenge to radiation oncologists, cited by 27.9%, was failure of other providers to include them in the treatment decision process early enough. Nearly half the surgeons (49.7%) stated that few or almost none of the breast cancer patients they saw in the past 12 months had consulted with a radiation oncologist before undergoing definitive surgery. Surgeons and radiation oncologists differed in their recommendations in management scenarios. Radiation oncologists were more likely to favor radiation than were surgeons for a patient with 3/20 lymph nodes undergoing mastectomy (p = 0.03); surgeons were more likely to favor more widely clear margins after breast conservation than were radiation oncologists (p = 0.001)., Conclusions: Despite the widespread availability of tumor boards, a substantial minority of radiation oncologists indicated other providers failed to include them in the breast cancer treatment decision-making process early enough. Earlier inclusion of radiation oncologists may influence patient decisions, and interventions to facilitate this should be considered., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Surveillance, Epidemiology, and End Results (SEER) registry data have been used to suggest underuse and disparities in receipt of radiotherapy. Prior studies have cautioned that SEER may underascertain radiotherapy but lacked adequate representation to assess whether underascertainment varies by geography or patient sociodemographic characteristics. The authors sought to determine rates and correlates of underascertainment of radiotherapy in recent SEER data., Methods: The authors evaluated data from 2290 survey respondents with nonmetastatic breast cancer, aged 20 to 79 years, diagnosed from June of 2005 to February 2007 in Detroit and Los Angeles and reported to SEER registries (73% response rate). Survey responses regarding treatment and sociodemographic factors were merged with SEER data. The authors compared radiotherapy receipt as reported by patients versus SEER records. The authors then assessed correlates of radiotherapy underascertainment in SEER., Results: Of 1292 patients who reported receiving radiotherapy, 273 were coded as not receiving radiotherapy in SEER (underascertained). Underascertainment was more common in Los Angeles than in Detroit (32.0% vs 11.25%, P < .001). On multivariate analysis, radiotherapy underascertainment was significantly associated in each registry (Los Angeles, Detroit) with stage (P = .008, P = .026), income (P < .001, P = .050), mastectomy receipt (P < .001, P < .001), chemotherapy receipt (P < .001, P = .045), and diagnosis at a hospital that was not accredited by the American College of Surgeons (P < .001, P < .001). In Los Angeles, additional significant variables included younger age (P < .001), nonprivate insurance (P < .001), and delayed receipt of radiotherapy (P < .001)., Conclusions: SEER registry data as currently collected may not be an appropriate source for documentation of rates of radiotherapy receipt or investigation of geographic variation in the radiation treatment of breast cancer., (Copyright © 2011 American Cancer Society.)

Purpose: In this era of rapidly evolving clinical knowledge, clinicians need to be aware of current research and how it might affect their practice. The Internet is a widely available, under-assessed tool for providing this information. In this two-phase pilot study, a novel Web site (www.cansortsurgeons.org) was developed to specifically disseminate relevant clinical information to community breast oncology surgeons., Methods: The first phase targeted a sample of community surgeons identified from Surveillance, Epidemiology, and End Results catchment areas in Los Angeles, CA and Detroit, MI. The second phase broadened availability by linking the site through the American College of Surgeons (ACoS) Commission on Cancer (CoC) homepage. An eight-question, Web-based survey was used to obtain feedback regarding the Web site's utility and potential application to clinical practice. Journal continuing medical education credit was also offered through ACoS., Results: For phase 1, of the 315 community surgeons invited to view the site, 114 (36%) participated in the study and 98 (86%) responded to the survey. Overall, there was a strongly supportive response, with 79 (81%) recommending the site to other clinicians. For phase 2, of the 516 site hits, 411 came from the ACoS site. Only 10 individuals completed the survey during this phase, but all positively endorsed the utility of the site., Conclusion: The implication for clinical practice is that the Internet is a useful tool for providing relevant clinical research to providers. In the future, this could be tailored to an individual's needs, aiding synthesis and, hopefully, improving the quality of clinical care.

Background: Postmastectomy breast reconstruction is an important component of breast cancer care, but few receive it at the time of the mastectomy. Virtually nothing is known about receipt of reconstruction after initial cancer therapy and why treatment might be delayed., Materials and Methods: A 5-year follow-up survey was mailed to a population-based cohort of mastectomy-treated breast cancer patients who were initially surveyed at time of diagnosis in 2002 and reported to the Los Angeles and Detroit SEER registries (N = 645, response rate 60%). Outcomes were receipt of reconstruction (immediate [IR], delayed [DR], or none) and patient appraisal of their treatment decisions., Results: About one-third (35.9%) had IR, 11.5% had DR, and 52.6% had no reconstruction. One-third delayed reconstruction because they focused more on other cancer interventions, and nearly half were concerned about surgical complications and interference with cancer surveillance. Two-thirds of those with no reconstruction said that the procedure was not important to them. A large proportion of all patients were satisfied with their reconstruction decision-making (89.4% IR, 78.4% DR, 80.4% no reconstruction, P = NS). However, only 59.3% of those with no reconstruction felt that they were adequately informed about their reconstructive options (vs 82.7% IR and 78.4% DR, P < .01)., Conclusions: There was modest uptake of breast reconstruction after initial cancer treatment. Factors associated with delayed reconstruction were primarily related to uncertainty about the procedure, concern about cancer surveillance, and low priority. Those without reconstruction demonstrated significant informational needs, which should be addressed with future research efforts.

Background: Worry about recurrence (worry) is a persistent concern of breast cancer survivors. Little is known about whether race/ethnicity or healthcare experiences are associated with worry., Methods: Women with nonmetastatic breast cancer diagnosed from June 2005 to February 2007 and reported to Detroit or Los Angeles Surveillance, Epidemiology, and End Results registries were surveyed (mean 9 months postdiagnosis); 2290 responded (73%). Latinas and African Americans were oversampled. A worry scale was constructed as the mean score of 3 items (on 5-point Likert, higher = more worry): worry about cancer returning to the same breast, occurring in the other breast, or spreading to other parts of the body. Race/ethnicity categories were white, African American, and Latina (categorized into low vs high acculturation). The worry scale was regressed on sociodemographics, clinical/treatment, and healthcare experience factors (eg, care coordination collapsed into low, medium, high)., Results: Low acculturated Latinas reported more worry and African Americans less worry than whites (P < .001). Other factors independently associated with more worry were younger age, being employed, more pain and fatigue, and radiation (Ps < .05). With all factors in the model, less worry was associated (all Ps < .05) with greater ease of understanding information (2.89, 2.99, 2.81 for low, medium, high), better symptom management (3.19, 2.89, 2.87 for low, medium, high), and more coordinated care (3.36, 2.94, 2.82 for low, medium, high). Race/ethnicity remained significant controlling for all factors (P < .001)., Conclusions: Less acculturated Latina breast cancer patients are vulnerable to high levels of worry. Interventions that improve information exchange, symptom management, and coordinating care hold promise in reducing worry., (Copyright © 2011 American Cancer Society.)

Objective: To identify factors associated with perceptions of care coordination in a diverse sample of breast cancer patients., Methods: Breast cancer patients reported to the metropolitan SEER registries of Detroit or Los Angeles from 6/05 to 2/07 were surveyed after diagnosis (N=2268, RR=72.4%). Outcomes were two dichotomous measures reflecting patient appraisal of care coordination during their treatment experience. Primary independent variables were race/ethnicity (white, African American, Latina-high acculturated, Latina-low acculturated) and health literacy (low, moderate, high). Logistic regression was used to evaluate factors associated with both measures of care coordination., Results: 2148 subjects were included in the analytic dataset. 16.4% of women perceived low care coordination and 12.5% reported low satisfaction. Race/ethnicity was not significantly associated with care coordination. Women with low subjective health literacy were 3-4 times as likely as those with high health literacy to perceive low care coordination and low satisfaction with care coordination (OR=3.88; 95% CI: 2.78-5.41; OR=3.19 95% CI: 2.25-4.52, respectively)., Conclusions: Many breast cancer patients positively appraised their care coordination, but patients with low health literacy perceived low care coordination., Practice Implications: Providers should be aware of the health literacy deficits that may contribute to their patients' attitudes towards their breast cancer care coordination., (Published by Elsevier Ireland Ltd.)

Background: Preclinical data suggest that bisphosphonates exhibit antitumor activity. However, clinical studies indicated conflicting results. In this study, we compared the overall survival (OS) of postmenopausal patients with nonmetastatic invasive breast cancer who received any of the second-generation nitrogen-containing bisphosphonates for osteopenia or osteoporosis, with the survival of those who did not., Patients and Methods: We conducted a retrospective study at the Wayne State University/Karmanos Cancer institute (KCI) in Detroit, Michigan and extracted data from the Metropolitan Detroit Cancer Surveillance System (MDCSS), a Surveillance, Epidemiology and End Results (SEER) registry. Patients > 50 years of age with stage I, II, or III invasive breast cancer between the years 2000 through 2003 were included. Information regarding medications was extracted from the patients' medical records., Results: A total of 696 women with stage I-III breast cancer were included. Ninety-seven women (14%) used nitrogen-containing bisphosphonates. The difference in OS between bisphosphonate users and nonusers was not statistically significant (P = .32) at 3 years. After adjusting for differences between the groups in age, stage of disease, hormone receptor status, endocrine therapy, vitamin D, and calcium use, there was a marginally significant (P = .07) difference in survival; bisphosphonate users had poorer survival than nonusers., Conclusion: Our results indicate that the use of nitrogen-containing bisphosphonates is not associated with improved OS in patients with nonmetastatic breast cancer, even after adjusting for known prognostic factors, but with a marginally worse OS. Further research is awaited to clarify the role of bisphosphonates in the adjuvant setting.

Background: Concerns about the use of mastectomy and breast reconstruction for breast cancer have motivated interest in surgeon's influence on the variation in receipt of these procedures., Objectives: To evaluate the influence of surgeons on variations in the receipt of mastectomy and breast reconstruction for patients recently diagnosed with breast cancer., Methods: Attending surgeons (n = 419) of a population-based sample of breast cancer patients diagnosed in Detroit and Los Angeles during June 2005 to February 2007 (n = 2290) were surveyed. Respondent surgeons (n = 291) and patients (n = 1780) were linked. Random-effects models examined the amount of variation due to surgeon for surgical treatment. Covariates included patient clinical and demographic factors and surgeon demographics, breast cancer specialization, patient management process measures, and attitudes about treatment., Results: Surgeons explained a modest amount of the variation in receipt of mastectomy (4%) after controlling for patient clinical and sociodemographic factors but a greater amount for reconstruction (16%). Variation in treatment rates across surgeons for a common patient case was much wider for reconstruction (median, 29%; 5th-95th percentile, 9%-65%) then for mastectomy (median, 18%; 5th-95th percentile, 8% and 35%). Surgeon factors did not explain between-surgeon variation in receipt of treatment. For reconstruction, 1 surgeon factor (tendency to discuss treatment plans with a plastic surgeon prior to surgery) explained a substantial amount of the between-surgeon variation (31%)., Conclusion: Surgeons have largely adopted a consistent approach to the initial surgery options. By contrast, the wider between-surgeon variation in receipt of breast reconstruction suggests more variation in how these decisions are made in clinical practice.

Purpose: To use patient self-report to provide more valid estimates of whether radiotherapy (RT) is underutilized than possible with registry data, as well as to evaluate for disparities and the influence of preferences and provider interactions., Methods: We considered 2,260 survey respondents who had nonmetastatic breast cancer, were age 20 to 79 years, were diagnosed between July 2005 and February 2007 in Detroit and Los Angeles, and reported to Surveillance, Epidemiology and End Results (SEER) registries (72% response rate). Survey responses were merged with SEER data. We assessed rates and correlates of RT receipt among all patients with invasive cancer receiving breast-conserving surgery (BCS) and among patients undergoing mastectomy with indications for RT (ie, positive lymph nodes or T3-4 tumors)., Results: Among 904 patients undergoing BCS with strong indications for RT, 95.4% received RT, and 77.6% received RT among the 135 patients undergoing mastectomy with strong indications (P < .001). Among 114 patients undergoing BCS with weaker indications (ie, elderly) for RT, 80.0% received treatment, and 47.5% received RT among the 164 patients undergoing mastectomy with weaker indications (T1N1, T2N1, or T3N0 disease; P < .001). On multivariate analysis, surgery type (P < .001), indication strength (P < .001), age (P = .005), comorbidity (P < .001), income (P = .03), patient desire to avoid RT (P < .001), level of surgeon involvement in decision to have radiation (P < .001), and SEER site (P < .001) were significantly associated with likelihood of RT receipt., Conclusion: RT receipt was consistently high across sociodemographic subgroups after BCS but was lower after mastectomy, even among patients with strong indications for treatment, in whom clinical benefit is similar. Surgeon involvement had a strong influence on RT receipt.

Objectives: The Institute of Medicine has called for more coordinated cancer care models that correspond to initiatives led by cancer providers and professional organizations. These initiatives parallel those underway to integrate the management of patients with chronic conditions., Methods: We developed 5 breast cancer patient and practice management process measures based on the Chronic Care Model. We then performed a survey to evaluate patterns and correlates of these measures among attending surgeons of a population-based sample of patients diagnosed with breast cancer between June 2005 and February 2007 in Los Angeles and Detroit (N = 312; response rate, 75.9%)., Results: Surgeon practice specialization varied markedly with about half of the surgeons devoting 15% or less of their total practice to breast cancer, whereas 16.2% of surgeons devoted 50% or more. There was also large variation in the extent of the use of patient and practice management processes with most surgeons reporting low use. Patient and practice management process measures were positively associated with greater levels of surgeon specialization and the presence of a teaching program. Cancer program status was weakly associated with patient and practice management processes., Conclusion: Low uptake of patient and practice management processes among surgeons who treat breast cancer patients may indicate that surgeons are not convinced that these processes matter, or that there are logistical and cost barriers to implementation. More research is needed to understand how large variations in patient and practice management processes might affect the quality of care for patients with breast cancer.

Purpose: There is concern that minority women have limited access to breast reconstruction. We described patterns of use, experiences with clinicians, and patients' satisfaction with treatment decisions for women of different race/ethnicities., Methods: A total of 3,252 patients with breast cancer from Los Angeles and Detroit Surveillance, Epidemiology, and End Results registries were surveyed near the time of diagnosis (n = 2,260, response rate 72.2%). The primary outcomes were receipt of reconstruction, access to information about reconstruction, and decisional satisfaction. The primary independent variable was race/ethnicity (white, African American [AA], highly acculturated Latina [Latina-high], and less acculturated Latina [Latina-low]). Control variables included other sociodemographic and clinical factors. chi(2) and multivariate logistic regression were used for the analyses., Results: Receipt of reconstruction varied significantly by patient race/ethnicity-40.9% of whites, 33.5% of AAs, 41.2% of Latina-high, and only 13.5% of Latina-low (P < .001)-and persisted when we controlled for demographic and clinical factors. Minority women were significantly less likely than whites to see a plastic surgeon before initial surgery and were more likely to desire more information about reconstruction (17.0% of whites v 27.0% of AAs, 30.0% of Latina-high, and 55.9% of Latina-low; P < .001). Decisional satisfaction was lowest among minority women without reconstruction (P < .001)., Conclusion: Minority women, particularly less acculturated Latinas, had low receipt of breast reconstruction, which may be related to limited information about the procedure and less access to plastic surgeons. Greater desire for information and lower satisfaction with surgical decisions among these patients motivate greater attention to treatment support for these patients.

Context: There is concern that mastectomy is overused in the United States., Objectives: To evaluate the association of patient-reported initial recommendations by surgeons and those given when a second opinion was sought with receipt of initial mastectomy; and to assess the use of mastectomy after attempted breast-conserving surgery (BCS)., Design, Setting, and Patients: A survey of women aged 20 to 79 years with intraductal or stage I and II breast cancer diagnosed between June 2005 and February 2007 and reported to the National Cancer Institute's Surveillance, Epidemiology, and End Results registries for the metropolitan areas of Los Angeles, California, and Detroit, Michigan. Patients were identified using rapid case ascertainment, and Latinas and blacks were oversampled. Of 3133 patients sent surveys, 2290 responded (73.1%). A mailed survey was completed by 96.5% of respondents and 3.5% completed a telephone survey. The final sample included 1984 female patients (502 Latinas, 529 blacks, and 953 non-Hispanic white or other)., Main Outcome Measures: The rate of initial mastectomy and the perceived reason for its use (surgeon recommendation, patient driven, medical contraindication) and the rate of mastectomy after attempted BCS., Results: Of the 1984 patients, 1468 had BCS as an initial surgical therapy (75.4%) and 460 had initial mastectomy, including 13.4% following surgeon recommendation and 8.8% based on patient preference. Approximately 20% of patients (n = 378) sought a second opinion; this was more common for those patients advised by their initial surgeon to undergo mastectomy (33.4%) than for those advised to have BCS (15.6%) or for those not receiving a recommendation for one procedure over another (21.2%) (P < .001). Discordance in treatment recommendations between surgeons occurred in 12.1% (n = 43) of second opinions and did not differ on the basis of patient race/ethnicity, education, or geographic site. Among the 1459 women for whom BCS was attempted, additional surgery was required in 37.9% of patients, including 358 with reexcision (26.0%) and 167 with mastectomy (11.9%). Mastectomy was most common in patients with stage II cancer (P < .001)., Conclusion: Breast-conserving surgery was recommended by surgeons and attempted in the majority of patients evaluated, with surgeon recommendation, patient decision, and failure of BCS all contributing to the mastectomy rate.

Background: Few studies have evaluated the association between patient decision involvement and surgery received among racially and ethnically diverse patients or patients' attitudes about surgery and the role of family and friends in surgical treatment choices., Methods: Women diagnosed with nonmetastatic breast cancer from June 2005 through February 2007 and reported to the Los Angeles or Detroit Surveillance, Epidemiology, and End Results registries were mailed a survey after diagnosis (N = 3133). Latina and African American women were oversampled. The response rate was 72.4%. The analytic sample (N = 1651) excluded those with stage IIIA or higher disease, self-reported clinical contraindications to breast-conserving surgery with radiation, and unclear race or ethnicity. The dependent variable was receipt of mastectomy initially. The primary independent variables were patient involvement in decision making, race or ethnicity, attitudes about recurrence, the effects of radiation, the impact of surgery on body image, and the role of others in decision making. Latinas were categorized as low or high acculturated. The association between patient involvement in decision making and the receipt of mastectomy was evaluated using logistic regression while controlling for other independent variables. All statistical tests were two-sided., Results: The analytic sample was 23.9% Latina (12.0% low acculturated, 11.9% high acculturated), 27.1% African American, and 48.9% white, and 17.2% received a mastectomy initially. For each racial or ethnic group, more women who reported a patient-based decision received mastectomy than those who reported a shared or surgeon-based decision (P = .022 for low-acculturated Latinas, P < .001 for other groups). Women who reported that concerns about recurrence or radiation effects were very important in their surgery decision were more likely to receive mastectomy than those less concerned (for recurrence concerns, estimated relative risk [RR] = 1.66, 95% confidence interval [CI] = 1.28 to 2.10; for radiation concerns, estimated RR = 2.35, 95% CI = 1.88 to 2.85). Women who reported that body image concerns and their spouse's opinion were very important in their surgery decision less often received mastectomy than those less concerned about body image or who placed less weight on their spouse's opinion (for body image concerns, estimated RR = 0.47, 95% CI = 0.30 to 0.74; for spouse's opinion, estimated RR = 0.53, 95% CI = 0.36 to 0.78)., Conclusion: Greater patient involvement in decision making was associated with receipt of mastectomy for all racial and ethnic groups. Patient attitudes about surgery and the opinions of family and friends contribute to surgical choices made by women with breast cancer.

In a follow-up study of mortality among North American synthetic rubber industry workers, cumulative exposure to 1,3-butadiene was positively associated with leukemia. Problems with historical exposure estimation, however, may have distorted the association. To evaluate the impact of potential inaccuracies in exposure estimation, we conducted uncertainty analyses of the relation between cumulative exposure to butadiene and leukemia. We created the 1,000 sets of butadiene estimates using job-exposure matrices consisting of exposure values that corresponded to randomly selected percentiles of the approximate probability distribution of plant-, work area/job group-, and year specific butadiene ppm. We then analyzed the relation between cumulative exposure to butadiene and leukemia for each of the 1,000 sets of butadiene estimates. In the uncertainty analysis, the point estimate of the RR for the first non zero exposure category (>0-<37.5 ppm-years) was most likely to be about 1.5. The rate ratio for the second exposure category (37.5-<184.7 ppm-years) was most likely to range from 1.5 to 1.8. The RR for category 3 of exposure (184.7-<425.0 ppm-years) was most likely between 2.1 and 3.0. The RR for the highest exposure category (425.0+ ppm-years) was likely to be between 2.9 and 3.7. This range off RR point estimates can best be interpreted as a probability distribution that describes our uncertainty in RR point estimates due to uncertainty in exposure estimation. After considering the complete probability distributions of butadiene exposure estimates, the exposure-response association of butadiene and leukemia was maintained. This exercise was a unique example of how uncertainty analyses can be used to investigate and support an observed measure of effect when occupational exposure estimates are employed in the absence of direct exposure measurements.

Taconite, although not classified by the United States Government as asbestos or asbestiform material, has been associated with asbestos-related diseases. The mineral is used in the production of steel and as a road-patch material and is mined in Michigan and Minnesota. This report describes the case of a middle-aged Caucasian woman with exposure to taconite mining dust from her miner father's clothing in childhood with a resultant presentation consistent with asbestosis and intractable pleural pain. Intractable pleural pain has been described in asbestos-exposed patients with theorized etiologies. However, no in vivo reported mechanism has demonstrated a plausible, anatomically apparent mechanism for the pain. We utilize an application of the Vitrea software for enhancement of high-resolution computerized tomography which demonstrates at least one likely mechanism for intractable pleural pain.

Background: Population-based cancer registry data from the Surveillance, Epidemiology, and End Results (SEER) Program at the National Cancer Institute (NCI) are mainly based on medical records and administrative information. Individual-level socioeconomic data are not routinely reported by cancer registries in the United States because they are not available in patient hospital records. The U.S. representative National Longitudinal Mortality Study (NLMS) data provide self-reported, detailed demographic and socioeconomic data from the Social and Economic Supplement to the Census Bureau's Current Population Survey (CPS). In 1999, the NCI initiated the SEER-NLMS study, linking the population-based SEER cancer registry data to NLMS data. The SEER-NLMS data provide a new unique research resource that is valuable for health disparity research on cancer burden. We describe the design, methods, and limitations of this data set. We also present findings on cancer-related health disparities according to individual-level socioeconomic status (SES) and demographic characteristics for all cancers combined and for cancers of the lung, breast, prostate, cervix, and melanoma., Methods: Records of cancer patients diagnosed in 1973-2001 when residing 1 of 11 SEER registries were linked with 26 NLMS cohorts. The total number of SEER matched cancer patients that were also members of an NLMS cohort was 26,844. Of these 26,844 matched patients, 11,464 were included in the incidence analyses and 15,357 in the late-stage diagnosis analyses. Matched patients (used in the incidence analyses) and unmatched patients were compared by age group, sex, race, ethnicity, residence area, year of diagnosis, and cancer anatomic site. Cohort-based age-adjusted cancer incidence rates were computed. The impact of socioeconomic status on cancer incidence and stage of diagnosis was evaluated., Results: Men and women with less than a high school education had elevated lung cancer rate ratios of 3.01 and 2.02, respectively, relative to their college educated counterparts. Those with family annual incomes less than $12,500 had incidence rates that were more than 1.7 times the lung cancer incidence rate of those with incomes $50,000 or higher. Lower income was also associated with a statistically significantly increased risk of distant-stage breast cancer among women and distant-stage prostate cancer among men., Conclusions: Socioeconomic patterns in incidence varied for specific cancers, while such patterns for stage were generally consistent across cancers, with late-stage diagnoses being associated with lower SES. These findings illustrate the potential for analyzing disparities in cancer outcomes according to a variety of individual-level socioeconomic, demographic, and health care characteristics, as well as by area measures available in the linked database.

Population-based cancer registry data from the Surveillance, Epidemiology, and End Results (SEER) Program at the National Cancer Institute are based on medical records and administrative information. Although SEER data have been used extensively in health disparities research, the quality of information concerning race, Hispanic ethnicity, and immigrant status has not been systematically evaluated. The quality of this information was determined by comparing SEER data with self-reported data among 13,538 cancer patients diagnosed between 1973-2001 in the SEER--National Longitudinal Mortality Study linked database. The overall agreement was excellent on race (kappa = 0.90, 95% CI = 0.88-0.91), moderate to substantial on Hispanic ethnicity (kappa = 0.61, 95% CI = 0.58-0.64), and low on immigrant status (kappa = 0.21. 95% CI = 0.10, 0.23). The effect of these disagreements was that SEER data tended to under-classify patient numbers when compared to self-identifications, except for the non-Hispanic group which was slightly over-classified. These disagreements translated into varying racial-, ethnic-, and immigrant status-specific cancer statistics, depending on whether self-reported or SEER data were used. In particular, the 5-year Kaplan-Meier survival and the median survival time from all causes for American Indians/Alaska Natives were substantially higher when based on self-classification (59% and 140 months, respectively) than when based on SEER classification (44% and 53 months, respectively), although the number of patients is small. These results can serve as a useful guide to researchers contemplating the use of population-based registry data to ascertain disparities in cancer burden. In particular, the study results caution against evaluating health disparities by using birthplace as a measure of immigrant status and race information for American Indians/Alaska Natives.

Objective: This study evaluated the association between exposure to several chemicals and mortality from lymphohematopoietic cancer (LHC) among 16,579 synthetic rubber industry workers who were followed up from 1943 to 1998., Methods: Poisson regression analyses examined LHC rates in relation to butadiene, styrene, and DMDTC exposure. Models provided maximum likelihood estimates of the relative rate for the contrast between categories of one agent, adjusting for other agents and for additional potential confounders., Results: Cumulative exposure to 1,3-butadiene was associated positively with all leukemia (relative rates of 1.0, 1.4, 1.2, 2.9, and 3.7, respectively, for exposures of 0, >0 to <33.7, 33.7 to <184.7, 184.7 to <425.0, and 425.0+ ppm-years), chronic myelogenous leukemia and to a lesser extent with chronic lymphocytic leukemia. Adjusting for styrene and DMDTC attenuated these associations. After controlling for butadiene, neither styrene nor DMDTC displayed a consistent exposure-response trend with all leukemia, chronic myelogenous leukemia, or chronic lymphocytic leukemia., Conclusions: This study found a positive association between butadiene and leukemia that was not explained by exposure to other agents examined.

We evaluated incidence and survival trends of non-Hodgkin's lymphoma (NHL) in a large population-based cancer registry. Data regarding demographics, histology, incidence, and survival were obtained on all patients with NHL registered in the Metropolitan Detroit Cancer Surveillance System, a participant in the Surveillance Epidemiology and End Results (SEER) Program of the National Cancer Institute. Incidence and survival trends from 1973 through 1995 were evaluated and stratified based on age at diagnosis, sex, race, and tumor grade. There were 11,978 patients diagnosed with NHL and recorded in the Metropolitan Detroit SEER registry from 1973 to 1995. The age-adjusted incidence rate increased from 8.6 to 15.8 per 100,000, leading to an overall increase in incidence of 83% and an average annual increase of 3.2% per year. Incidence increased significantly (p < 0.05) over time in all age groups except the youngest (ages 0-19) and in all demographic groups studied. Incidence was highest in white men and lowest in black women. The incidence of both low-grade and intermediate/high-grade NHL increased significantly for each age group (p < 0.05) except the youngest (ages 0-19). In the oldest patients (70+ years), the incidence of intermediate/high-grade NHL was almost double that of low-grade NHL. Five-year relative survival increased from 64% (1973-1983) to 68% (1984-1991) for patients with low-grade NHL and from 40% to 44% for those with intermediate/high-grade NHL. The increase in relative survival was only seen in whites, however, with 5-year relative survival in blacks decreased from 53% (1973-1983) to 45% (1984-1991). In metropolitan Detroit, the current NHL epidemic affects all age groups except the very young (ages 0-19), both sexes, and both whites and blacks and is due to increases in the incidence of both low-grade and intermediate/high-grade NHL. Five-year survival rates have increased for whites but not for blacks.