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Background The expansion of hematopoietic stem cells carrying recurrent somatic mutations, termed clonal hematopoiesis (CH), is common in elderly individuals and is associated with increased risk of myeloid malignancy and all-cause mortality. Though chemotherapy is a known risk factor for developing CH, how myelosuppressive therapies affect the short-term dynamics of CH remains incompletely understood. Most studies have been limited by retrospective design, heterogeneous patient populations, varied techniques to identifying CH, and analysis of single timepoints. Methods We examined serial samples from 40 older women with triple-negative or hormone receptor–positive breast cancer treated on the prospective ADjuVANt Chemotherapy in the Elderly trial to evaluate the prevalence and dynamics of CH at baseline and throughout chemotherapy (6 and 12 weeks). Results CH was detected in 44% of patients at baseline and in 53% at any timepoint. Baseline patient characteristics were not associated with CH. Over the course of treatment, mutations exhibited a variety of dynamics, including emergence, expansion, contraction, and disappearance. All mutations in TP53 (n = 3) and PPM1D (n = 4), genes that regulate the DNA damage response, either became detectable or expanded over the course of treatment. Neutropenia was more common in patients with CH, particularly when the mutations became detectable during treatment, and CH was significantly associated with cyclophosphamide dose reductions and holds (P = .02). Conclusions Our study shows that CH is common, dynamic, and of potential clinical significance in this population. Our results should stimulate larger efforts to understand the biological and clinical importance of CH in solid tumor malignancies. Trial Registration ClinicalTrials.gov (https://clinicaltrials.gov/ct2/show/NCT03858322). Clinical trial registration number: NCT03858322.

The degree to which breast cancer survivors know about their tumors and understand treatment rationales is not well understood. We sought to identify information gaps within a diverse sample and explore whether knowledge about breast cancer and treatment may impact care.We conducted a one-time, interviewer-administered survey of women who were diagnosed with breast cancer during 2013-2017 and received care at one of three centers in Boston, MA, and New York, NY. We examined knowledge of breast cancer and treatment rationales, information preferences, and treatment receipt.During 2018-2020, we interviewed 313 women (American Association for Public Opinion Research Cooperation Rates 58.4-76.5% across centers) who were 56.9% White, 23.6% Black, 14.1% Hispanic, and 5.4% other. Among the 296 included in analyses, we observed high variability in knowledge of breast cancer and treatment rationales, with a substantial number demonstrating limited knowledge despite feeling highly informed; 25% actively avoided information. Black and Hispanic (vs. White) women consistently knew less about their cancers. Lack of understanding of treatment rationales for chemotherapy, radiation, and hormonal therapy was common but not consistently different by race and ethnicity. Understanding treatment rationale (but not cancer knowledge) was associated with treatment initiation, but small sample sizes limited in-depth examination.Our study highlights the need for enhanced informational support for breast cancer survivors, who are challenged with complex information during the decision-making process and beyond. More research is needed to understand how to further educate and empower diverse populations of patients with breast cancer.

Older adults with breast cancer receiving neo/adjuvant chemotherapy are at high risk for poor outcomes and are underrepresented in clinical trials. The ADVANCE (ADjuVANt Chemotherapy in the Elderly) trial evaluated the feasibility of two neo/adjuvant chemotherapy regimens in parallel-enrolling cohorts of older patients with human epidermal growth factor receptor 2-negative breast cancer: cohort 1-triple-negative; cohort 2-hormone receptor-positive.Adults age ≥ 70 years with stage I-III breast cancer warranting neo/adjuvant chemotherapy were enrolled. Cohort 1 received weekly carboplatin (area under the curve 2) and weekly paclitaxel 80 mg/mForty women (n = 20 per cohort) were enrolled from March 25, 2019 through August 3, 2020 from three centers; 45% and 35% of patients in cohorts 1 and 2 were age 75, respectively. Neither cohort achieved targeted thresholds for feasibility. In cohort 1, eight (40.0%) met feasibility (95% confidence interval [CI] = 19.1-63.9%), while ten (50.0%) met feasibility in cohort 2 (95% CI = 27.2-72.8). Neutropenia was the most common grade 3-4 toxicity (cohort 1-65%, cohort 2-55%). In cohort 1, 80% and 85% required ≥1 dose holds of carboplatin and/or paclitaxel, respectively. In cohort 2, 10% required dose hold(s) for cyclophosphamide and/or 65% for paclitaxel.In this pragmatic pilot examining chemotherapy regimens in older adults with breast cancer, neither regimen met target goals for feasibility. Developing efficacious and tolerable regimens for older patients with breast cancer who need chemotherapy remains an important goal.gov Identifier: NCT03858322.

We sought to understand the attitudes of individuals with abnormal breast imaging findings prompting a diagnostic breast biopsy toward donation of blood, excised tissue, or percutaneous biospecimens for research, and to understand medical oncologists' attitudes toward research biospecimen collection in this population.We included individuals who presented to a single academic medical center for a clinically indicated, image-guided, percutaneous breast biopsy. We administered a survey prior to knowledge of biopsy results to assess willingness to consider, entirely for research purposes, donating blood or excess excised breast tissue, or having additional biospecimens (AB) obtained during a clinically indicated percutaneous biopsy. We also surveyed breast medical oncologists from National Cancer Institute-designated cancer centers to assess attitudes toward approaching patients for biospecimen research.Overall, 53/63 patients responded to the survey; 70% would consider donating blood, 85% would consider donating excess excised breast tissue, and 32% would consider having AB obtained during a clinically indicated biopsy. Main motivating factors for considering AB included contributing to scientific knowledge and return of study or biopsy results, whereas anxiety and the potential discomfort were the main dissuading factors. Among 191 medical oncologists, most were very comfortable (59.2%), or somewhat comfortable (32.5%) asking patients to have AB obtained during a clinically indicated breast biopsy. Medical oncologists reported hesitancy to refer a patient for AB due to potential pain/discomfort, and other procedure risks.Only one-third of individuals with breast imaging findings would consider consenting to AB during a diagnostic biopsy, whereas most were open to donating blood or excess excised breast tissue. Most medical oncologists would be comfortable asking patients to have AB obtained during the biopsy. Understanding patients' and oncologists' baseline attitudes may inform the design and approach to breast biospecimen-based research.

BACKGROUND: The loss of a child is associated with elevated grief severity, and sudden infant death syndrome (SIDS) is the leading cause of postneonatal mortality in the United States. The diagnosis of prolonged grief disorder (PGD) has gained broader acceptance and use. Little is known about PGD in mothers after SIDS. METHODS: Between May 2013 and July 2016, we assessed 49 SIDS-bereaved mothers living in informal settlements near Cape Town, South Africa, and on the Pine Ridge Indian Reservation and 359 SIDS-bereaved mothers affiliated with SIDS parent-support organizations in the United States, United Kingdom, Australia, New Zealand, and the Netherlands. We examined PGD symptom severity and diagnostic prevalence rates between the samples and other significant grief indicators during the period 2 to 48 months after the deaths of their infants. RESULTS: Extremely high, persistent, and similar rates of PGD were found in both samples at every time interval. The prevalence of PGD was 50.0% in either sample (mean months from loss: 20.5 vs 24.9). Daily, intrusive emotional pain or yearning was found in 68.1% of subjects; yearning was significantly associated with emotional pain (P < .0001). Role confusion and anger were the most prevalent symptoms, reported by the majority at every time interval. Rates of role confusion, anger, and diminished trust in others remained constant. Acceptance was less prevalent than other grief indicators at every interval. CONCLUSIONS: Severe symptoms and heightened risk for PGD was seen in mothers after their infants died of SIDS, with discernible symptom profiles. Given their involvement with families after SIDS, pediatricians may have a unique role in identifying this problem and helping address its consequences.

In a large survey (n = 809) conducted to understand how oncologists differ from nononcologists regarding routinely sharing visit notes with patients, oncologists were less likely to agree patient safety would improve (p = .03) or that patients would be offended after reading notes (p = .01); however, they agreed with nononcologists that sharing notes would lead to less candid documentation (69% vs. 73%; p = .39). Oncologists share a high level of worry about the impact of sharing notes on documentation practices, a concern that will need to be addressed as the practice of sharing visit notes expands to cancer care.

The Behavioral Risk Factor Surveillance System (BRFSS) is designed to provide statewide estimates of the prevalence of preventive health practices, including screening. We assessed the reproducibility of responses to the women's health module, which covers breast and cervical cancer screening, hysterectomy, and pregnancy. A random sample of women in Massachusetts (n = 91; response rate for the repeat interview, 70.0%) and a separate random sample of minority women in the state (n = 179; response rate for the repeat interview, 69.4%) were interviewed by telephone twice, 21 to 94 days apart. Differences across administrations in mean prevalence of screening were small. Concordance exceeded 85% for almost all the variables examined, but tended to be lower for nonwhite respondents. After correction for agreement occurring by chance, moderate to excellent values of kappa (range, 0.41 to 0.86) were observed. The women's health module of the BRFSS questionnaire yields highly consistent group mean estimates of prevalence when administered repeatedly to the same individuals. Individual reproducibility is excellent, but may be reduced among minority respondents.

The reproducibility of responses to the Behavioral Risk Factor Surveillance System questionnaire was examined across the demographic strata used by the Centers for Disease Control and Prevention and state health departments for reporting prevalence estimates (specifically age, sex, income, employment, and marital status), as well as race/ethnicity, which has been previously examined. The authors administered the questionnaire twice, 21-94 days apart, to randomly selected residents of Massachusetts (response rates: first administration, 68% of eligible households; second administration, 68% of persons who completed the first interview). Initial interviews were conducted in March and October 1992. Among 448 respondents to both interviews, group mean distributions of seven demographic characteristics and 19 risk factors were highly consistent across the two interviews. Discordance in individual risk factor status ranged from 1.2% to 21.8% (median, 7.8%) and was symmetric in direction, i.e., as many respondents were considered at increased risk on the basis of the first interview and at low risk on the basis of the second interview as the reverse. Kappas ranged from 0.30 to 0.90 (median, 0.75). Education, household income, and interval between administrations were not associated with prevalence of discordance for any risk factor. Sex, age, race/ethnicity, marital status, and employment status were each predictive of variation in discordance for one or more risk factors, but no consistent effect of any individual demographic characteristic across risk factors was observed. The questionnaire has relatively uniform and generally good reproducibility across all demographic strata used for monitoring the Health Objectives for Year 2000 and other chronic disease surveillance activities.

Universal screening of the adult population for detection of elevated serum cholesterol has been recommended. We examined the relation of eight risk factors for morbidity and mortality (hypertension, overweight, inactivity, tobacco use, safety belt nonuse, binge alcohol consumption, driving after alcohol consumption, and chronic alcohol consumption) to adoption of cholesterol screening and to awareness of cholesterol level. Data were collected through the Massachusetts Behavioral Risk Factor Surveillance System between 1987 and 1991 (mean number of respondents interviewed annually, 1240). We compared trends in prevalence of cholesterol screening and awareness within risk groups defined on the basis of the presence or absence of each risk factor. Cholesterol screening prevalence increased from 46.8% in 1987 to 67.9% in 1991. Overweight and hypertensive respondents were more likely to have been screened than nonoverweight or normotensive respondents; for the other six risk factors, individuals at increased risk were less likely to have been screened. The difference in cholesterol screening prevalence between increased-risk and lower-risk respondents increased between 1987–1988 and 1990–1991 for four risk factors. Prevalence of awareness of cholesterol level increased from 7.8% in 1987 to 35.4% in 1991. Trends by risk status were comparable to those observed for cholesterol screening. Individuals already motivated toward a preventive life style appear to be those most likely to avail themselves of a new prevention possibility.

The reliability of the Behavioral Risk Factor Surveillance System questionnaire was assessed in a random sample of adults (n = 122) and a separate sample of Black and Hispanic adults (n = 200) in Massachusetts. The questionnaire was administered twice, 21 to 44 days apart, by telephone (210 completed reinterviews, 65% response rate for second administration). There were no statistically significant differences in the distribution of demographic or risk factor variables across administrations. Individual-level reliability (kappa for categorical variables, correlation for continuous variables) for demographic characteristics was more than 0.80 for White respondents and more than 0.60 for Black and Hispanic respondents. Employment and income were reported less consistently than other variables. Reliability coefficients for behavioral risk factors were generally above 0.70. Exceptions were variables with extreme distributions. These data support the use of the Behavioral Risk Factor Surveillance System questionnaire for surveillance and research.

A prospective study of 87 independently living adults with spinal cord injury (SCI) as a major disabling condition showed the following average annual health care utilization rates: 1.3 hospital admissions, 16.8 days hospitalized, 1.7 emergency room (ER) visits, and 22.4 outpatient contacts (in person or by telephone). Those hospitalized (n = 66) experienced a mean of 22.2 days hospitalized per person per year. Mean length of stay (LOS) was 11.1 days per admission. Stepwise regression analysis indicated no statistically significant (p less than or equal to .05) predictors of hospital admissions. There were three independent predictors of days hospitalized (greater age, fewer years of education, and more days hospitalized during the previous year), three predictors of days hospitalized for those hospitalized only (greater age, fewer years of education, and longer hospital LOS during the previous year), one predictor of LOS (self-assessment of health), three of emergency room (ER) visits (more unmet instrumental activities of daily living needs, lack of organizational memberships, and more ER visits during the previous year), and five predictors of outpatient contacts (greater age, less satisfaction with health care providers' expressions of concern for their health, lower frequency of leaving apartments, lower levels of life satisfaction, and nonparticipation in a managed medical care demonstration project). Many predictors of health services utilization are immutable. However, changes which facilitate social interaction and changes in the organization of health services may reduce certain types of medical care utilization by people with SCI.

There is substantial evidence of the permanent disabling effects of such conditions as spinal cord and head injuries, cerebral palsy, paralytic polio, and such degenerative neurologic conditions as multiple sclerosis and muscular dystrophy.1 There is also considerable evidence that people with these conditions require extraordinary amounts of acute hospital care.1-7 However, there are few data on temporary morbidity or disability among those with major disabling conditions, particularly those who live independently in the community rather than in institutions.

A prospective study of the medical care utilization experience of 205 severely-disabled independently-living adults in Eastern Massachusetts shows that there was a mean of 0.83 ± 1.26 hospital admissions, 9.9 ± 22.7 hospital days, 1.5 ± 2.31 emergency room (ER) visits, and 26.88 ± 44.4 outpatient contacts per person per year. Among those hospitalized, the mean experience was 16.2 ± 27.1 days per person per year; mean length-of-stay was 9.3 ± 14.7 days per admission. Regression analysis indicates that those with spinal cord injuries as major disabling conditions were significantly more likely to be hospitalized. So were those with lower self-assessments of health, higher levels of depressions, and more baseline ER visits. Self-assessment of health is a significant predictor of hospital days for the total cohort (including those with no admissions); so are age at onset of disability (greater age; higher risk), and bed disability days in the month before the baseline survey (more disability days; higher risk). Among those hospitalized, the total number of days hospitalized is significantly related to both age at onset of disability (later onset; more days) and baseline days hospitalized (greater number; more days). Lengths-of-stay are significantly related to two factors; age and age at onset of disability (in both cases, greater age associated with longer stays). Prior ER visits are a significant predictor of subsequent ER visits (more baseline; more subsequent); so are respondents' reported satisfaction with their participation in their medical care (lower reported satisfaction; more ER visits), organizational affiliations, and frequencies of contacts with friends or relatives. Higher levels of social interaction (.e. organizational affiliation and more frequent social contacts) were associated with more ER visits. Prior contacts with physicians, nurse-practitioners, or physician-assistants was the most powerful predictor of subsequent outpatient contacts (more baseline;,more subsequent). There were also significant relationships between subsequent contacts and respondents' assessments of their health relative to others with similar disabilities (relatively worse health; more contacts), age (greater age; more contacts), and baseline ER visits (more visits; more contacts).

We conducted an 18-month longitudinal evaluation of a model-managed medical care program for severely disabled, independently living adults. Regression analyses using an additive model (no interaction effects) suggest that persons in the study group did not have statistically significantly different utilization experiences than members of the comparison group. Regression analyses that include interaction effects suggest that, for certain segments of the cohort, the study group's utilization experience was significantly lower than that of members of the comparison group. Persons in the study group with higher baseline emergency room (ER) utilization had significantly fewer hospital admissions (P = 0.0055). The participants with better self-assessments of health experienced significantly fewer hospital days per person (P = 0.0075) and days per person hospitalized (P = 0.0056), and persons with organizational affiliations reported significantly fewer ER visits (P = 0.0264).

Data from an 18-month prospective study of 205 adults with major disabling conditions revealed that there is a positive but not statistically significant association (p greater than .10) between respondents' scores on a scale which measures both numbers and amounts of substances (alcohol, tobacco, and cannabis) used and bed disability days. There are also nonsignificant positive relationships between scale scores and five of six measures of utilization of medical care.