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The adoption of US culture among immigrants has been associated with higher leisure-time physical activity and sedentary behavior. However, most research to date assesses this association using single measures of acculturation and physical activity. Our objective was to describe the cross-sectional association between acculturation and both physical activity and sedentary behavior among US Hispanic/Latino adults. Participants included Hispanic/Latinos 18–74 years living in four US locations enrolled in the Hispanic Community Health Study/Study of Latinos from 2008 to 2011. Acculturation was measured using acculturation scales (language and social), years in the US, language preference, and age at immigration. Physical activity and sedentary behavior were measured using the Global Physical Activity Questionnaire (N = 15,355) and Actical accelerometer (N = 11,954). Poisson, logistic, and linear regression were used, accounting for complex design and sampling weights. English-language preference was positively associated with self-reported leisure-time and transportation physical activity and accelerometer-assessed moderate-to-vigorous physical activity (MVPA). Social acculturation was positively associated with self-reported leisure-time and transportation physical activity and MVPA. Years in the US and age at immigration were positively associated with accelerometer-assessed MVPA. Language acculturation, years in the US, and age at immigration were associated with occupational physical activity among those who reported employment. Most acculturation measures were associated with self-reported sitting but not with accelerometer-assessed sedentary behavior. Different measures of acculturation, capturing various domains acculturation, were associated with physical activity and sedentary behavior. However, the direction of the association was dependent on the measures of acculturation physical activity/sedentary behavior, highlighting the complexity of these relationships. Keywords: Physical activity, Acculturation, Hispanic, Latino, Sedentary behavior, Accelerometry

Excessive sedentary behavior is associated with negative health outcomes independent of physical activity. Objective estimates of time spent in sedentary behaviors are lacking among adults from diverse Hispanic/Latino backgrounds. The objective of this study was to describe accelerometer-assessed sedentary time in a large, representative sample of Hispanic/Latino adults living in the United States, and compare sedentary estimates by Hispanic/Latino background, sociodemographic characteristics and weight categories. This study utilized baseline data from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) that included adults aged 18–74 years from four metropolitan areas (N = 16,415). Measured with the Actical accelerometer over 6 days, 76.9% (n = 12,631) of participants had >10 h/day and >3 days of data. Participants spent 11.9 h/day (SD 3.0), or 74% of their monitored time in sedentary behaviors. Adjusting for differences in wear time, adults of Mexican background were the least (11.6 h/day), whereas adults of Dominican background were the most (12.3 h/day), sedentary. Women were more sedentary than men, and older adults were more sedentary than younger adults. Household income was positively associated, whereas employment was negatively associated, with sedentary time. There were no differences in sedentary time by weight categories, marital status, or proxies of acculturation. To reduce sedentariness among these populations, future research should examine how the accumulation of various sedentary behaviors differs by background and region, and which sedentary behaviors are amenable to intervention.

Objective: Community-level social determinants of health impact asthma outcomes among children; however, individual patient's priorities are not often included in designing social care interventions. Identifying connections between patient-prioritized unmet social needs and asthma severity status may allow for improved patient-centered approaches to asthma management. In this analysis, we examined the association between unmet social needs and asthma severity in an urban population of children. We hypothesized that those with a greater number of unmet social needs would report a more severe asthma status., Methods: We conducted a secondary analysis of 4887 patients screened for unmet social needs and asthma severity status. Bivariate associations and adjusted logistic regression modeling were used to assess the association between unmet social needs and asthma severity., Results: Persistent asthma severity status was associated with several unmet social needs, including housing quality and stability, lack of money for food, transportation, and healthcare costs. In the multivariable analysis, having 3 or more unmet social needs was associated with a 59% greater odds of persistent asthma status (CI, 1.18-2.14; P = .002), and having 2 unmet social needs was associated with a 33% greater odds of persistent asthma status (CI, 1.00-1.78; P = .05)., Conclusions: Unmet social needs were associated with asthma severity status, with a greater number of unmet social needs associated with greater odds of severe asthma status. Additional studies are warranted to further evaluate the temporal relationship between unmet social needs and how they may compound one another in their relationship with asthma severity., (Copyright © 2023 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Purpose: Examine the association between neighborhood segregation and 6-year incident metabolic syndrome (MetSyn) in the Hispanic Community Health Study/Study of Latinos., Methods: Prospective cohort of adults residing in Miami, Chicago, the Bronx, and San Diego. The analytic sample included 6,710 participants who did not have MetSyn at baseline. The evenness and exposure dimensions of neighborhood segregation, based on the Gini and Isolation indices, respectively, were categorized into quintiles (Q). Racialized economic concentration was measured with the Index of Concentration at the Extremes (continuously and Q)., Results: Exposure, but not evenness, was associated with higher disease odds (Q1 (lower segregation) vs. Q4, OR = 1.53, 95% CI = 1.082.17; Q5, OR = 2.29, 95% CI = 1.493.52). Economic concentrationprivilege (continuous OR = 0.87, 95% CI = 0.770.98), racial concentrationracialized privilege (Q1 (greater concentration) vs. Q2 OR = 0.75, 95% CI = 0.541.04; Q3 OR = 0.68, 95% CI = 0.441.05; Q4 OR = 0.68, 95% CI = 0.451.01; Q5 OR = 0.64, 95% CI = 0.420.98)(continuous OR = 0.93, 95% CI = 0.821.04), and racialized economic concentrationprivilege (i.e., higher SES non-Hispanic White, continuous OR = 0.86, 95% CI = 0.760.98) were associated with lower disease odds., Conclusion: Hispanics/Latino adults residing in neighborhoods with high segregation had higher risk of incident MetSyn compared to those residing in neighborhoods with low segregation. Research is needed to identify the mechanisms that link segregation to poor metabolic health., (Copyright © 2022. Published by Elsevier Inc.)

We examined associations of micro-scale environment attributes (e.g., sidewalks, street crossings) with three physical activity (PA) measures among Hispanic/Latino adults (n = 1776) living in San Diego County, CA. Systematic observation was used to quantify micro-scale environment attributes near each participant's home. Total PA was assessed with accelerometers, and PA for transportation and recreation were assessed by validated self-report. Although several statistically significant interactions between individual and neighborhood characteristics were identified, there was little evidence micro-scale attributes were related to PA. An important limitation was restricted environmental variability for this sample which lived in a small area of a single county., Competing Interests: Declaration of competing interest JFS: Rails-to-Trails Conservancy, Board of Directors; AARP, Advisory Board for Livability Index. All other authors have no conflicts to declare., (Copyright © 2022 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Purpose: Limited research has examined maternal experiences of racial/ethnic discrimination in relation to child cardiometabolic health. In this study, we investigated whether maternal experiences of ethnic discrimination were associated with cardiometabolic risk in Hispanic/Latino youth several years later., Methods: Our sample included 1146 youth (8-16 years) from the Study of Latino Youth (2012-2014), who were children of the Hispanic Community Health Study/Study of Latinos participants (2008-2011). We used regression models to examine the prospective associations between maternal report of ethnic discrimination in relation to her child's body mass index (BMI) z-score, metabolic syndrome score (MetS), and high sensitivity C-reactive protein (hsCRP) levels 2 years later., Results: Maternal ethnic discrimination was associated with youth hsCRP, but not BMI or MetS (P-values >.05). Adjusting for age, nativity, and national background, maternal ethnic discrimination was associated with higher (log) hsCRP levels (β = 0.18, 95% CI = 0.04 to 0.32) in children. This association was robust to adjustment for maternal and household characteristics (β = 0.17, 95% CI = 0.04 to 0.31), as well as maternal depression and maternal BMI., Conclusions: Maternal ethnic discrimination is associated with inflammation among Hispanic/Latino youth, and not BMI z-score or MetS. Studies are needed to address temporality and pathways., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Head and neck squamous cell carcinoma (HNSCC) is a malignancy that often involves the oral cavity, pharynx, larynx, or paranasal sinuses. There is a compelling evidence of the human papilloma virus including HPV16 E6 oncogene drives cell transformation and oncogenic processes of HPV positive (HVP+) HNSCC [in particular, Oropharyngeal Squamous Cell Carcinoma (OPSCC)]. In this study, we determined that human OPSCC-derived, HPV16 E6+ cells (UMSCC-104 and UMSCC-47 cell lines) express CD44 and a regulatory transcription factor, c-Jun. Importantly, interaction between matrix hyaluronan (HA) and CD44 (an HA receptor) promotes c-Jun phosphorylation followed by phospho-c-Jun nuclear translocation and co-localization with HPV16 E6 in the nucleus of both UMSCC-104 and UMSCC-47 cells. Further analyses revealed that HPV16 E6 expression is regulated by an upstream promoter containing AP1/c-Jun binding site(s), and chromatin immunoprecipitation (ChIP) assays demonstrated that stimulation of HPV16 E6 expression by HA-CD44 interaction is phospho-c-Jun dependent in these HPV16+ UMSCC-104 and UMSCC-47 cells. This process results in an upregulation of survival proteins, inhibitors of the apoptosis family of proteins (IAPs) and chemoresistance in these HPV16+ cells. Treatment of UMSCC-104 or UMSCC-47 cells with c-Jun-specific or HPV16 E6-specific small interfering RNAs effectively blocks HA/CD44-mediated c-Jun signaling and abrogates HPV16 E6 expression as well as causes downregulation of survival proteins (cIAP-1 and cIAP-2) expression and enhancement of chemosensitivity. Together, these findings suggest that the HA/CD44-induced c-Jun signaling plays a pivotal role in HPV16 E6 upregulation leading to survival protein (cIAP-1/cIAP-2) production and chemoresistance in HPV16+ UMSCC-104 and UMSCC-47 cells. Most importantly, using a mouse xenograft model, we have observed that Cisplatin chemotherapy combined with the suppression of CD44, c-Jun and HPV16 E6 (by treating both UMSCC-104 cells and UMSCC-47 cells with CD44shRNA or c-Jun shRNA or HPV16 E6 shRNA) appears to be more effective in tumor size reduction than chemotherapy alone. Thus, these newly-discovered HA/CD44-c-Jun/HPV16E6 signaling pathways may provide new drug targets for overcoming cisplatin chemoresistance in HPV16E6-positive OPSCC cells., (Copyright © 2018 International Society of Matrix Biology. Published by Elsevier B.V. All rights reserved.)

Purpose: Metabolic syndrome (MetS), the clustering of several risk factors for cardiovascular disease, is highly prevalent in Hispanics/Latinos. We tested whether all components significantly loaded on the syndrome in Hispanics/Latinos and whether their contribution differed by sex and Hispanic ancestry. We also examined associations of MetS with prevalent diabetes and coronary heart disease in Hispanics/Latinos., Methods: Data were obtained from a population-based cohort of n = 15,823 participants in the HCHS/SOL study who self-identified as being of Central American, Cuban, Dominican, Mexican American, Puerto Rican, or South American ancestry and were aged 18 to 74 years at screening., Results: A latent variable model of waist circumference, systolic and diastolic blood pressure, triglycerides, high-density lipoprotein cholesterol (HDL-C), and fasting glucose fit the data in men and women, but the contribution of HDL-C was weak. No difference in the latent model of MetS was detected across Hispanic/Latino ancestry groups. MetS was significantly associated with diabetes and coronary heart disease., Conclusions: Our results indicate that similar criteria for MetS may be applied across Hispanic/Latino ancestry groups but call into question the role of HDL-C in classifying the MetS in Hispanics/Latinos., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Context: Although prior studies show the importance of self-reported symptom scores as predictors of cancer survival, most are based on scores recorded at a single point in time., Objectives: To show that information on repeated assessments of symptom severity improves predictions for risk of death and to use updated symptom information for determining whether worsening of symptom scores is associated with a higher hazard of death., Methods: This was a province-based longitudinal study of adult outpatients who had a cancer diagnosis and had assessments of symptom severity. We implemented a time-to-death Cox model with a time-varying covariate for each symptom to account for changing symptom scores over time. This model was compared with that using only a time-fixed (baseline) covariate for each symptom. The regression coefficients of each model were derived based on a randomly selected 60% of patients, and then, the predictive performance of each model was assessed via concordance probabilities when applied to the remaining 40% of patients., Results: This study had 66,112 patients diagnosed with cancer and more than 310,000 assessments of symptoms. The use of repeated assessments of symptom scores improved predictions for risk of death compared with using only baseline symptom scores. Increased pain and fatigue and reduced appetite were the strongest predictors for death., Conclusion: If available, researchers should consider including changing information on symptom scores, as opposed to only baseline information on symptom scores, when examining hazard of death among patients with cancer. Worsening of pain, fatigue, and appetite may be a flag for impending death., (Copyright © 2014 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Context: Understanding the longitudinal transitions of performance status among persons with cancer can assist providers in determining the appropriate time to initiate palliative care support., Objectives: To model longitudinal transitions of performance status in cancer outpatients, to determine the probabilities of improvement and deterioration in performance status over time, and to evaluate the factors associated with rates of transitions., Methods: This population-based, retrospective, cohort study comprised adult outpatients diagnosed with any type of cancer and assessed for performance status throughout their observation period using the Palliative Performance Scale (PPS; scale 0-100; 0 indicates death). At every PPS assessment, patients were assigned to one of four states: stable state (PPS score 70-100), transitional state (PPS score 40-60), end-of-life state (PPS score 10-30), or dead. A Markov multistate model under the presence of interval censoring was used to examine the rate of state-to-state transitions., Results: There were 11,374 patients representing nearly 71,000 assessments. Patients with lung cancer in the transitional state had a 27.7% chance of being dead at the end of one month vs. 17.5% in patients with breast cancer. The average time spent in the transitional state was 6.6 weeks for patients diagnosed with gastrointestinal cancer vs. 8.8 weeks for patients with breast cancer. The rate at which one moves from the transitional state to death was higher for patients with lung cancer than those with breast cancer., Conclusion: We estimated the probability and direction of change in performance status in cancer outpatients. Entry into the transitional state may serve as an indicator for referral for palliative care support. Mean end-of-life sojourn times are too short to allow meaningful integration of palliative care., (Copyright © 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.)

The study examined whether characteristics of the urban physical environment are associated with child and maternal body mass index (BMI) in a sample of 3 year-old children and their mothers from 18 US cities (N=1997 dyads). BMI was determined based on measured height and weight. Characteristics of the interior and exterior physical environment, assessed and rated by trained interviewers, were related to child BMI at age 3 and to their mother's BMI. Negative aspects of the physical environment were more strongly related to maternal BMI among whites than among African-Americans or Hispanics., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Objectives: The purpose of this study was to identify total lifetime medical-care costs and costs associated with first-line chemotherapy treatment among older patients with stage IIIB/IV non-small-cell lung cancer treated with commonly used two-drug chemotherapy ("doublet") regimens in the United States., Methods: Study patients included individuals aged 65 years and older who received a diagnosis of stage IIIB/IV non-small-cell lung cancer in a Surveillance, Epidemiology and End Results cancer registry between 1997 and 2002 and who received first-line treatment with commonly used doublet regimens. Patients were followed retrospectively in the Surveillance, Epidemiology and End Results-Medicare database to evaluate lifetime medical-care costs and costs while on first-line chemotherapy treatment. Pairwise comparisons of treatment costs were estimated by using nonparametric bootstrap methods., Results: Lifetime medical-care costs totaled approximately $70,000 and on-treatment costs for first-line chemotherapy totaled approximately $30,000 among study patients and were dominated by hospitalization and physician costs. Lifetime costs were significantly higher among patients treated with first-line cisplatin/carboplatin (platinum) plus a taxane compared with those who received platinum plus gemcitabine [difference: $4781 ($1558-$8039)] or other doublet therapy [difference: $5961 ($2333-$9614)]. Total on-treatment costs for first-line chemotherapy were significantly higher among patients treated with platinum plus a taxane compared with those who received platinum plus gemcitabine [difference: $5825 ($3872-$7770)], platinum plus another agent [difference: $5968 ($3995-$7975)], or another doublet therapy [difference: $3663 ($1620-$5740)]., Conclusions: There is a cost differential between first-line doublet regimens in terms of lifetime and on-treatment costs. Although doublet therapy with platinum and a taxane was the most frequently utilized regimen, it was associated with the highest lifetime and on-treatment costs.

Background: Recent studies have examined the addition of docetaxel to fluorouracil and cisplatin in advanced esophagogastric cancer., Patients and Methods: We carried out a phase I dose-escalation study of weekly docetaxel, cisplatin, and irinotecan (TPC), given on days 1 and 8 every 3 weeks, in patients with chemonaive solid tumors. Subsequently, we completed a multiinstitutional phase II study of TPC in patients with previously untreated, metastatic esophagogastric cancer., Results: Thirty-nine patients were enrolled in the phase I trial; a weekly schedule of TPC was well tolerated. On that basis, docetaxel 30 mg/m(2), cisplatin 25 mg/m(2), and irinotecan 65 mg/m(2) were selected for the phase II trial, where in the first 18 patients irinotecan 65 mg/m(2) caused too much diarrhea and was reduced to 50 mg/m(2). Among 56 eligible patients with previously untreated, metastatic esophagogastric cancer enrolled in the phase II trial, three complete and 27 partial responses were observed (overall response rate=54%), and 15 patients (30%) had stable disease. Median progression-free survival was 7.1 months, and median survival was 11.9 months. At the final irinotecan dose of 50 mg/m(2), grade 3 or higher toxicity included diarrhea (26%), neutropenia (21%), nausea (18%), fatigue (16%), anorexia (13%), and thrombosis/embolism (13%)., Conclusions: Weekly TPC is an active and well-tolerated regimen for patients with esophagogastric cancer.

Background: Targeting the epidermal growth factor receptor and angiogenesis have proven useful strategies against metastatic colorectal cancer. The benefit of combining inhibitors of both pathways is unknown., Patients and Methods: Patients with previously untreated metastatic colorectal cancer were enrolled in a phase II trial of infusional 5-fluorouracil, leucovorin, oxaliplatin (FOLFOX), bevacizumab and erlotinib. The primary end point was progression-free survival., Results: Thirty-five patients were enrolled and all came off trial for reasons other than progression; 18 (51%) had protocol-defined adverse events requiring removal, nine (26%) withdrew consent due to toxicity, six pursued surgery or localized therapies and two requested a treatment holiday. Principal toxic effects included rash, neuropathy and diarrhea. Seven patients came off trial before first restaging. By intention-to-treat analysis, one patient had a confirmed complete response, 10 had confirmed partial responses and one had an unconfirmed partial response (response rate = 34%). One patient had progressive disease at time of withdrawal from the trial, thus progression-free survival could not be calculated., Conclusion: The combination of FOLFOX, bevacizumab and erlotinib led to higher than expected early withdrawal due to toxicity, limiting conclusions regarding efficacy. These findings raise concern regarding the tolerability of adding more agents to already complex combination regimens for metastatic colorectal cancer.

Background: Hodgkin's lymphoma patients have an elevated risk of developing lung cancer and may be targeted for lung cancer screening. We used a decision-analytic model to estimate the potential clinical benefits and cost-effectiveness of computed tomography (CT) screening for lung cancer in Hodgkin's lymphoma survivors., Materials and Methods: We developed a Markov decision-analytic model to compare annual low-dose CT screening versus no screening in a hypothetical cohort of patients diagnosed with stage IA-IIB Hodgkin's lymphoma at age 25, with screening starting 5 years after initial diagnosis. We derived model parameters from published studies and the Surveillance, Epidemiology and End Results (SEER) Program, and assumed that stage-shift produces a survival benefit., Results: Annual CT screening increased survival by 0.64 years for smokers and 0.16 years for non-smokers. The corresponding benefits in quality-adjusted survival were 0.58 quality-adjusted life-years (QALYs) for smokers and 0.14 QALYs for non-smokers. The incremental cost-effectiveness ratios for annual CT screening compared with no screening were $34 100/QALY for smokers and $125 400/QALY for non-smokers., Conclusions: Our analysis suggests that if early promising results for lung cancer screening hold, CT screening for lung cancer may increase survival and quality-adjusted survival among Hodgkin's lymphoma survivors, with a benefit and incremental cost-effectiveness ratio for smokers comparable to that of other recommended cancer screening strategies.

Objective: To examine the relationship between serum iron and body composition in a multiracial adult cohort., Methods: The analysis consisted of 670 participants on whom blood analysis and anthropometric data were available. The participants were recruited as part of the Rosetta Study (1990-2000), which was designed to assess body composition in a multiethnic cohort of healthy adults. Fasting iron level was measured as part of a biochemistry panel. Dual x-ray absorptiometry was used to assess fat mass. Anthropometric measures included waist circumference and body mass index (BMI; calculated as kg/m(2)) as an index of abdominal adiposity and overall body fatness, respectively., Results: In the study cohort the mean age was 54+/-17 years and 60.9% were overweight or obese (BMI > or =25). Men had higher serum iron levels (94.91+/-34.52 microg/dL [16.99+/-6.18 micromol/L] vs 82.17+/-32.62 microg/dL [14.71+/-5.84 micromol/L]) and larger waist circumference (91.98+/-11.87 cm vs 85.24+/-12.37 cm) compared with women (P<0.001). Iron was inversely correlated with BMI (r=-0.23, P<0.001), waist circumference (r=-0.19, P<0.05), and fat mass (r=-0.19, P<0.05) among Hispanic women but not among African-American, white, or Asian women or in men of any race/ethnic group., Conclusions: The results of this study show an inverse association of measures of body fat distribution and total fat mass with serum iron level in Hispanic women. Studies designed to explore how micronutrients are used by the body at varying degrees of body fatness could provide useful information on the micronutrient-related comorbidities of obesity.

This study examined the relationship of internalized racism (INR) and hostility to body fat distribution and insulin resistance in black adolescent children age 14-16 years on the Caribbean island of Barbados. Questionnaire data on psychosocial variables and anthropometric measurements, together with a fasting blood sample, were obtained from 53 low-birthweight and 119 normal-birthweight adolescents. Insulin resistance was calculated using the homeostasis model assessment (HOMA). Spearman correlation analyses showed that both INR (r = 0.244) and hostility (r = 0.204) were significantly (p < 0.05) correlated with waist circumference in girls but not boys. Among girls, age- and birthweight-adjusted mean levels of BMI and waist circumference were greater for those with high levels of INR and hostility compared to those with low levels of both variables. In multiple logistic regression analyses, a high INR remained independently associated [odds ratio = 3.30 (95% CI = 1.30-8.36); p = 0.012] with having an elevated HOMA value in models that included age, income, birthweight, hostility, physical activity and family history of diabetes. The results of the current study show that the positive relationship between INR and metabolic health risk seen in African-Caribbean adults also exists in African Caribbean adolescent youth independent of birthweight.

The objective of this study was to determine whether acculturation and psychosocial stress exert differential effects on body fat distribution and insulin resistance among native-born African Americans and African-Caribbean immigrants living in the US Virgin Islands (USVI). Data collected from a non-diabetic sample of 183 USVI-born African Americans and 296 African-Caribbean immigrants age > 20 on the island of St. Croix, USVI were studied. Information on demographic characteristics, acculturation and psychosocial stress was collected by questionnaire. Anthropometric measurements were taken, and serum glucose and insulin were measured from fasting blood samples. Insulin resistance was estimated by the homeostasis model assessment (HOMA) method. The results showed that in multivariate regression analyses, controlling for age, education, gender, BMI, waist circumference, family history of diabetes, smoking and alcohol consumption, acculturation was independently related to logarithm of HOMA (InHOMA) scores among USVI-born African Americans, but not among African-Caribbean immigrants. In contrast, among USVI-born African Americans psychosocial stress was not significantly related to InHOMA, while among African-Caribbean immigrants psychosocial stress was independently related to InHOMA in models that included BMI, but not in those which included waist circumference. This study suggests that acculturation and psychosocial stress may have a differential effect on body fat distribution and insulin resistance among native-born and immigrant blacks living in the US Virgin Islands.

Background: The optimal follow-up strategy for colorectal cancer is unknown., Materials and Methods: We surveyed all Canadian radiation oncologists, medical oncologists and surgeons specializing in colorectal cancer to assess their recommendations for follow-up after potentially curative treatment, the beliefs and attitudes underlying these practices, and the cost implications of different follow-up strategies., Results: One hundred and sixty practitioners (58%) returned completed surveys. Most recommended clinical assessments every 3-4 months in the first 2 years including carcino-embryonic antigen testing, gradually decreasing in frequency over 5 years. Ninety per cent recommend a surveillance colonoscopy in the first year. The majority felt that specialist involvement in follow-up was important because of the increased opportunities for patients to contribute to research (76%) and teaching (73%). About half felt that specialists were more efficient at providing follow-up than primary care physicians, but these same physicians recommended significantly longer and more expensive follow-up routines on average than others. Primary care physicians were felt to be important allies, especially in managing the psychosocial concerns of patients., Conclusions: Surveillance practices are generally in keeping with published recommendations. Most specialists feel that they should remain involved in follow-up, but this may result in increased resource utilization.

Background: This study compares the health care costs and effectiveness of multiple staging options for patients with esophageal cancer. Techniques studied included computed tomographic (CT) scan, endoscopic ultrasound with fine-needle aspiration biopsy (EUS-FNA), positron emission tomography (PET), thoracoscopy/laparoscopy, and combinations of these., Methods: A decision-analysis model was constructed to compare different staging strategies. Costs were derived from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked databases and from other Medicare reimbursement rates. Life expectancies were obtained from the 1973-1996 SEER database and adjusted for quality of life. Cost and effectiveness measures were discounted at 0% and 3% per year. Sensitivity and specificity measures were obtained from the published literature and a parallel prospective clinical trial, and all key variables were subjected to sensitivity analyses., Results: Under baseline assumptions, CT + EUS-FNA was the most inexpensive strategy and offered more quality-adjusted life-years, on average, than all other strategies with the exception of PET + EUS-FNA. The latter was slightly more effective but also more expensive. The marginal cost-effectiveness ratio for PET + EUS-FNA was $60,544 per quality-adjusted life-year. These findings were robust and changed very little in all of the sensitivity analyses., Conclusions: The combination of PET + EUS-FNA should be the recommended staging procedure for patients with esophageal cancer, unless resources are scarce or PET is unavailable. In these instances, CT + EUS-FNA can be considered the preferred strategy.

The current study examined the relationship of internalized racism to glucose intolerance in a population of Afro-Caribbean women aged 18 to 55. Also of interest was whether this relationship would be differentially influenced by the type of body fat distribution or confounded by the level of hostility. A total of 244 women were selected from a systematic sample of households on the island of Dominica, West Indies. Demographic data together with information on internalized racism were collected by questionnaire. Anthropometric information and fasting blood glucose were also measured. Women with high levels of internalized racism exhibited an increased risk of elevated fasting glucose compared to those with low levels of internalized racism (odds ratio (OR) = 2.4; 95% confidence interval (CI) = 1.1-5.5). There was no difference in mean body mass index (BMI) by level of internalized racism. However those with high internalized racism had a significantly larger waist circumference after adjusting for age, education, hostility, and elevated fasting glucose status. In multivariate analyses controlling for age, education, hostility, and either weight or BMI, internalized racism remained independently associated with elevated fasting glucose. However, once waist circumference was included in the model, the relationship of internalized racism to elevated fasting glucose was not statistically significant. This study demonstrates a significant relationship between internalized racism and abnormal levels of fasting glucose which may be mediated through abdominal fat. The exact nature of the relationship of internalized racism to glucose intolerance may be an important area of future study.

Study Objectives: To determine the prevalence and factors associated with chemotherapy use in elderly patients presenting with advanced lung cancer., Design: A retrospective cohort study using administrative data., Setting and Patients: We analyzed the medical bills for the 6,308 Medicare patients > 65 years old with diagnosed stage IV non-small cell lung cancer (NSCLC) in the 11 SEER (survival, epidemiology, and end results) regions between 1991 and 1993. The main outcome measure, chemotherapy administration, was identified by the relevant medical billing codes. Patient sociodemographic and disease characteristics were obtained from the SEER database and census data., Results: Almost 22% of patients received chemotherapy at some time for their metastatic NSCLC. As expected, younger patients and those with fewer comorbid conditions were more likely to receive chemotherapy. However, several nonmedical factors, such as nonblack race, higher socioeconomic status, treatment in a teaching hospital, and living in the Seattle/Puget Sound or Los Angeles SEER regions, also significantly increased a patient's likelihood of receiving chemotherapy., Conclusion: Compared to previous reports, the prevalence of chemotherapy use for advanced NSCLC appears to be increasing. However, despite uniform health insurance coverage, there is wide variation in the utilization of palliative chemotherapy among Medicare patients, and nonmedical factors are strong predictors of whether a patient receives chemotherapy. While it is impossible to know the appropriate rate of usage, nonmedical factors should only influence a patient's likelihood of receiving treatment if they reflect patient treatment preference. Research to further clarify the costs, benefits, and patient preferences for chemotherapy in this patient population is warranted in order to minimize the effect of nonmedical biases on management decisions.

Physicians are faced with a burgeoning literature of economic studies. However, most physicians have little training in evaluating economic research. Economic studies involve a comparison of the costs and benefits of alternative treatment options. To be of use for medical decision making, they should meet appropriate methodological standards. These include clear specification of the research question and the perspective from which the study is being undertaken, comparison of relevant treatment options, identification and quantification of all important costs and benefits, the use of discounting to allow for time preferences for costs and benefits, and sensitivity analyses to test the robustness of the study's results. Unfortunately, not all adhere to these principles. Physicians need to be able to understand and critically assess the quality of economic studies, and the applicability of the results to their own situation, in order to participate in medical policy decisions.