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We have used the effect of therapeutic agents on clonogenic growth in agar to discriminate between active and inactive agents for malignant melanoma. We report a prospective study of single-agent chemotherapy for metastatic melanoma. Forty-five separate in vitro/in vivo correlative trials were conducted in 34 patients. A number of agents were used in these evaluations, including actinomycin D, Amsacrine, bisantrene, mitoxantrone, BCNU, vinblastine, vindesine, 5-fluorouracil, MGBG, etoposide, interferon, tamoxifen, and 13-cis-retinoic acid. At the "cut-off" concentration, a colony survival less than 30% was designated as "sensitivity" and greater than 30% as "resistance." Clinical sensitivity was designated to include complete, partial, and mixed responses and was predicted in eight of 18 trials (44%). Clinical resistance (nonresponse) was predicted correctly in 24 of 27 cases (89%). Using Fisher's exact test the association of in vitro and in vivo results was significant (P = .05). These results offer further support for the concept that clonogenic assays may help select useful agents for clinical trials in metastatic melanoma.

Difluoromethylornithine (DFMO) is an irreversible enzyme-activated inhibitor of ornithine decarboxylase, a key enzyme in polyamine synthesis. We have screened for potential anti-cancer activity of DFMO using a clonogenic assay, which suggested that melanoma might have sensitivity to this agent. Accordingly, we have performed a phase II trial of DFMO (2 g/m2 po q 8 h) in 24 patients, 21 of whom were evaluable for response. One patient achieved a complete response of a large subcutaneous mass for 11 months. Although stabilization is frequently difficult to measure, seven patients appeared to stabilize previously active disease, with a median duration of response of eight weeks. Toxicity was significant and DFMO was discontinued in five patients due to side effects - hearing loss alone in four and hearing loss associated with thrombocytopenia in the fifth patient. Hearing changes occurred in ten patients. Other side effects were mild. These data indicate that DFMO as a single agent may be an effective therapy for melanoma. A phase II trial of DFMO in previously untreated patients using a different schedule to decrease hearing loss is warranted. Additionally, several in vitro and animal models suggest that DFMO plus interferon are synergistic, and this combination might be used for a clinical trial as well.

Retinoids, the analogs of vitamin A, are active in vitro and in vivo against squamous cell carcinoma in animals and against certain epithelial precancers and cancers in humans. These data led us to design a prospective, multi-institutional, randomized phase II trial of isotretinoin in advanced head and neck squamous cell carcinoma. We randomly assigned 40 patients to receive isotretinoin or methotrexate, the best-studied and most active single agent for this disease. Overall, the study patients had extremely poor prognoses, i.e., low performance statuses and recurring disease after surgery and/or irradiation. Three objective responses (16%), including one complete response, occurred in the 19 evaluable isotretinoin-treated patients. Only one minor response (5%) occurred in the methotrexate-treated group. Toxicity occurred with both drugs, but was manageable and never life threatening in the retinoid group. These results and the established activity of retinoids in oral leukoplakia (a precursor of head and neck cancer) indicate the need for further study of this class of drugs in head and neck cancer.

To address the psychosocial implications of surviving adult cancers by a comprehensive review of the literature.An English-language literature search using MEDLINE (1970 to 1988). Index Medicus (1970 to 1988), and bibliographic reviews of textbooks and review articles.Of 103 originally identified articles, 58 that specifically addressed the stated purpose were selected.Four authors reviewed and critiqued the literature extrapolating the major themes on this topic.There is little information on the many psychosocial variables that affect an adult's long-term cancer survival trajectory. Collation of data identified the following significant psychosocial themes: fear of recurrence and death, relationships with the health care team, adjustment to physical compromise, alterations in customary social support, isolationism, psychosocial reorientation, and employment and insurance problems.The continuation of a rehabilitation effort begun around the initial diagnosis of cancer would be instrumental in providing post-therapy evaluation and guidance needed by adult long-term survivors of cancer. Education, research, and support interventions need to be mobilized for this population of adults with a history of cancer.

To provide an overview of the physiologic long-term and late effects of adult cancers and cancer treatments by a review of the medical and nursing literature.Primarily from an English-language literature search using MEDLINE (1980 to 1988) and Index Medicus (1980 to 1988).After a consensus review by four observers, 285 articles were selected that addressed the stated purpose.Four observers assessed the literature using predetermined criteria for eliciting information about long-term and late effects. RESULTS AND DATA SYNTHESIS: Much has been written about the acute phases of cancer and cancer treatments. In comparison, relatively few data are available that define physiologic long-term: and late effects of cancer treatments in adult survivors. Review of the existing data showed that these sequelae may affect virtually any body system months or years after treatment ends. In addition, few prospective studies dealing with physiologic survivorship issues have been done.Health care providers need to be aware of long-term or late complications that may affect the increasing number of adult cancer survivors. Attention to treatment regimens in the acute cancer phase and careful follow-up once the disease is eradicated may help to prevent or manage these complications. More prospective research should be done in this area.

The authors have studied the natural history of 377 patients with Stage I cutaneous malignant melanoma followed at the Arizona Cancer Center, Tucson. Two hundred eight patients, or 55%, remained free of metastatic disease after a median follow-up of 30 months. The survival at 5, 8, and 10 years was 69, 65, and 63%, respectively. Natural breakpoints in Breslow thickness for survival occurred at 0.85, 1.95, and 4.00 mm. These are not significantly different from those found by other investigators. A step-down multivariate analysis using the Cox regression model yielded four factors as highly significant in predicting survival: Breslow thickness (P less than 0.001), an age/sex interaction (P = 0.0012), clinical ulceration (P = 0.0039), and a prophylactic node dissection (P = 0.019). No predictive value for a BANS or non-BANS location was detected. These results are discussed in reference to other large series which describe the natural history of cutaneous melanoma.

The survival history of 259 patients with Stage I cutaneous malignant melanoma who were at risk for developing regional nodal metastases (Stage II) were studied. Eighty-seven of 377 Stage I patients (23%) developed regional nodal metastases (Stage IIB) with 40% 5-year survival. Fifty patients had regional nodal metastases at presentation, with or without a known primary (Stages IIA or IIC, respectively), with a 42% 5-year survival. A step-down multivariate analysis using the Cox regression model revealed four risk factors as being highly significant for predicting a more favorable survival outcome: (1) thinner Breslow thickness (P = 0.0001), (2) pathologic Stage I disease (P = 0.004), (3) no clinical ulceration (P = 0.0004), and (4) being a woman younger than 50 years of age (P = 0.029). These results are discussed in reference to other series.

Background: Little is known about hybrid PhD nursing students' experiences., Method: The purpose of this study was to describe and analyze the experiences of PhD nursing students in a hybrid program using a convergent mixed methods design. Recent nursing PhD alumni ( n = 18), and current PhD students ( n = 4) were recruited at a research-intensive university in the southwestern United States., Results: Four metainferences were identified: (1) the facilitator of faculty as both advisors and mentors; (2) the facilitator of peers as support, motivation, and a source of advice that preceded advisors; (3) the barrier of receiving conflicting feedback from advisory and dissertation committees; and (4) the barrier of not understanding the PhD student process., Conclusion: Peer support is fundamental for hybrid PhD nursing student success; conflicting feedback and not understanding the process are significant barriers. Strategies are recommended to mitigate barriers to facilitate hybrid PhD nursing students' success. [ J Nurs Educ . 2024;63(5):328-331.] .

Abstract: BACKGROUND: By 2030, there will be approximately 7.6 million stroke survivors (SSs) in the United States, yet comprehensive transitional care (TC) for stroke is not widely available. Stroke strikes without warning and leaves in its wake a "storm" of uncertainty for SSs and caregivers (CGs) as they encounter a myriad of unmet physical, mental, emotional, and financial needs that are not wholly addressed by passive healthcare delivery systems. Needed is a stroke-specific TC model that bridges this storm to active delivery of SS and CG postacute care. Naylor's Transitional Care Model (NTCM) has not been examined for how it can frame comprehensive stroke care. The purpose of this study was to solicit SS and CG descriptions of TC experiences to inform the NTCM with refined operational definitions and exemplars specific to stroke. METHODS: Focus groups conducted for this qualitative descriptive study were guided by interview questions based on the 8 NTCM operational definitions. Data were analyzed using inductive and deductive qualitative content analysis methods. RESULTS: Post-acute-stroke care does not comprehensively meet the needs of SSs and CGs. Participants described TC deficits across all 8 NTCM components. Two new subcomponents that could be applied for a stroke-specific NTCM emerged: psychological and transportation challenges. CONCLUSION: Unmet needs identified by SSs and CGs were used to extend NTCM specific to the stroke population and to develop the Recommendations and Exemplars for Stroke Specific Comprehensive Transitional Care Delivery (see Supplementary Digital Content, available at http://links.lww.com/JNN/A385). Researchers and practitioners can use the findings to develop and deliver more comprehensive TC to SSs and CGs., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 American Association of Neuroscience Nurses.)

Background: Skin cancer affects millions of Americans and is an important focus of disease prevention efforts. Partnering with non-health care practitioners such as massage therapists (MTs) can reduce the risk of skin cancer. MTs see clients' skin on a regular basis, which can allow MTs to initiate "helping conversations" (ie, brief behavioral interventions aimed at reducing the risk of skin cancer)., Objective: The purpose of this study was to evaluate (1) the feasibility of recruiting, enrolling, and retaining Arizona MTs in an online electronic training (e-training) and (2) the preliminary efficacy of e-training on knowledge, attitudes/beliefs, and practice of risk reduction for skin cancer. We explored MTs' ability to assess suspicious skin lesions., Methods: We adapted the existing educational content on skin cancer for applicability to MTs and strategies from previous research on helping conversations. We assessed the feasibility of providing such e-training, using Research Electronic Data Capture (REDCap) tools for data capture. We assessed the preliminary efficacy using established self-report surveys at baseline, immediately post training, and at 3 and 6 months post training., Results: A total of 95 participants enrolled in the study, of which 77% (73/95) completed the assessments at 6 months (overall attrition=23%). Project satisfaction and e-training acceptability were high. Knowledge, personal behaviors (skin self-examination, clinical skin examination, sun protection frequency), and practice attitudes (appropriateness and comfort with client-focused communication) of risk reduction for skin cancer improved significantly and were sustained throughout the study., Conclusions: The e-training was feasible and could be delivered online successfully to MTs. Participants were highly satisfied with and accepting of the e-training. As such, e-training has potential as an intervention in larger trials with MTs for reducing the risk of skin cancer., International Registered Report Identifier (irrid): RR2-10.2196/13480., (©Lois Loescher, Kelly Heslin, Graciela Silva, Myra Muramoto. Originally published in JMIR Formative Research (http://formative.jmir.org), 02.11.2020.)

Background: Mobile teledermoscopy allows consumers to send images of skin lesions to a teledermatologist for remote diagnosis. Currently, technology acceptance of mobile teledermoscopy by people at high risk of melanoma is unknown., Objectives: We aimed to determine the acceptance of mobile teledermoscopy by consumers based on perceived usefulness, ease of use, compatibility, attitude/intention, subjective norms, facilitators and trust before use. Consumer satisfaction was explored after use., Methods: Consumers aged 50-64 years at high risk of melanoma (fair skin or previous skin cancer) were recruited from a population-based cohort study and via media announcements in Brisbane, Australia in 2013. The participants completed a 27-item questionnaire preteledermoscopy modified from a technology acceptance model. The first 49 participants with a suitable smartphone then conducted mobile teledermoscopy in their homes for early detection of melanoma and were asked to rate their satisfaction., Results: The preteledermoscopy questionnaire was completed by 228 participants. Most participants (87%) agreed that mobile teledermoscopy would improve their skin self-examination performance and 91% agreed that it would be in their best interest to use mobile teledermoscopy. However, nearly half of participants (45%) were unsure about whether they had complete trust in the telediagnosis. The participants who conducted mobile teledermoscopy (n = 49) reported that the dermatoscope was easy to use (94%) and motivated them to examine their skin more often (86%). However, 18% could not take photographs in hard-to-see areas and 35% required help to submit the photograph to the teledermatologist., Conclusions: Mobile teledermoscopy consumer acceptance appears to be favourable. This new technology warrants further assessment for its utility in the early detection of melanoma or follow-up., (© 2016 British Association of Dermatologists.)

Purpose: To obtain preliminary evidence on the effect of a skin cancer prevention video for adult solid organ transplant recipients (SOTR) and informational brochures on outcomes of skin cancer knowledge, beliefs, prevention and detection behaviors, and personal agency (self-confidence/personal control) for behaviors., Background: SOTR have a high risk of skin cancer potentiated by life-long immunosuppressive therapy posttransplantation. Skin cancer in SOTR is aggressive and difficult to treat. Prevention and early detection are important for reducing risk and improving skin cancer outcomes, but methods to inform SOTR about their risk are understudied., Methods: A brief, evidence-based skin cancer informational video tailored to SOTR was evaluated using a quasi-experimental design that compared the outcome variables in two groups of SOTR seen in 4 transplantation clinics within 4-6 weeks posttransplantation. The video/brochure group (VBG) viewed the video once and received skin cancer information brochures. The brochure group (BG) received brochures only. Participants completed a survey on sun protection behavior (6 items; alpha = 0.75), personal agency (6 items; alpha = 0.64), beliefs (6 items; alpha = 0.60), skin cancer knowledge (6 items), and skin self-examination (SSE; 1 item) at baseline and 3 months postintervention. Data were analyzed using descriptive statistics and 2 × 2 analysis of variance., Results: Of 113 participants, 90 completed both surveys (VBG, n = 46; BG, n = 44). Both groups had a significant increase in sun protective behavior (P < .001), skin cancer knowledge (P < .001), beliefs (P = .003), and personal agency (P = .003). There was no effect of either intervention on SSE., Conclusion: Both interventions effectively informed SOTR about skin cancer and sun protection, promoted favorable beliefs, and improved personal agency, but were not differentially effective, suggesting that the addition of the video may not be necessary or that the video may need to be viewed more than once. More in-depth SSE teaching strategies may be necessary., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objectives: To summarize technologies that have been described in nursing literature (in the context of oncology) over the last 25 years, and to present projections of possible technology in the future of oncology nursing., Data Sources: CINAHL (1982 to present), MEDLINE (1976 to 1984), and author identification of articles., Conclusions: Technology has greatly influenced the evolution of oncology nursing, particularly concerning treatment (chemotherapy, radiation therapy, biotherapy, marrow and blood transplantation), access devices, and genetic and information technologies., Implications for Nursing Practice: Nurses must be prepared to deal with how technology affects their philosophical perspective of nursing and the challenges presented by technology.

Family history is an important risk factor for inherited cancers. Obtaining a family history is therefore a key component of cancer genetic risk counseling (CGRC). Many oncology nurses do not have training in cancer genetic risk counseling. However, every nurse is capable of obtaining a basic family history. The family history can help in identifying patterns of cancer transmission in families. Nurses can then refer families with a strong history of cancer to nurse geneticists, genetic counselors, or others qualified to make a further assessment of risk. If those resources are unavailable locally, the Internet can be of assistance. This article summarizes genetic and clinical characteristics of inherited cancers, the significance of family history, interview approaches, questions to ask about personal and family history of cancer, what a pedigree is and how to draw one, what to do with family information including risk analysis and documentation, and available resources on the Internet.

Purpose/objectives: To describe and review scientific and regulatory aspects of molecular genetic technology in the context of DNA testing for cancer predisposition., Data Sources: Published professional articles, texts, and proceedings; commercial testing companies; computerized data bases; and the World Wide Web., Data Synthesis: This article reviews the basic molecular biology (e.g., DNA, genes, chromosomes, DNA mutations) that is the foundation for indirect and direct methods of DNA testing for cancer predisposition. Key issues in DNA testing include who should be tested, provision of testing, and regulatory concerns. Benefits and problems of testing contribute to its current controversial status., Conclusions: Understanding the mechanisms of DNA testing for cancer requires knowledge of basic molecular biology. Family history of the cancer in question is a key indicator for predisposition testing. Accessing information regarding research-based testing is challenging. DNA testing for cancer predisposition is not a perfect test, as exemplified by issues related to test regulation and sensitivity., Implications for Nursing Practice: Basic knowledge of DNA testing for cancer predisposition will help nurses to (a) have a better understanding of the indications for and ramifications of testing, (b) provide information about testing to patients and the lay public, (c) counsel patients and families at high risk for inherited cancers more effectively, and (d) interpret DNA test results.

Technology changes the face of science and, ultimately, nature. How do we as nurses come to know technology? Nurses' ways of knowing, as described by Carper, help nurses better understand technology as a way of knowing; that is, using empirical, ethical, personal, and esthetic ways of knowing provides a means to incorporate technology into holistic nursing practice. Knowledge of technology also requires considering clients' and families' multiple facets of knowing. The article summarizes the nature of technology, nurses' ways of knowing in the context of genetic technology, and the rationale for understanding clients' and families' ways of knowing.

Skin cancers are a serious health problem in the United States. One common method of skin cancer primary prevention is use of sunscreens. Research has been conducted to ascertain the role of active ingredients of sunscreen products in photoprotection and possible carcinogenesis. In contrast, little is known about the "other ingredients", listed or unlisted, on sunscreen product labels. One such ingredient is vitamin E. usually in the form of alpha-tocopherol acetate. Results of recent studies of skin carcinogenesis in an ultraviolet (UV) B mouse carcinogenesis model suggest that topically applied alpha-tocopherol acetate does not prevent and, under some conditions, enhances skin cancer development and growth, whereas the free unesterified from of alpha-tocopherol significantly reduces experimental UVB carcinogenesis. We have performed a Phase II cancer prevention study to evaluate whether topically applied alpha-tocopherol acetate is absorbed in human skin and metabolizes to the free or other forms. In this double-blind study, 19 men and women > 30 years of age who had at least three actinic keratoses on their forearms were randomly assigned to apply alpha-tocopherol acetate (125 mg/g) or difluoromethylornithine cream to their arms twice daily for three months. Blood samples and photographs and punch biopsies of actinic keratoses were obtained before and at the end of the study (Month 4). Plasma and skin concentrations of free alpha-tocopherol, alpha-tocopherol acetate, and gamma-tocopherol were analyzed by high-performance liquid chromatography at Month 4. The results of this report focus only on data obtained from the 11 participants randomized to the alpha-tocopherol acetate arm of the study. Topically applied alpha-tocopherol acetate was substantially absorbed in skin, with no evidence of conversion within skin to its unesterified form (i.e., free alpha-tocopherol). There was no evidence of systemic availability or biotransformation of topically applied alpha-tocopherol acetate. In summary, we have determined that alpha-tocopherol acetate is not metabolized to the free form of alpha-tocopherol in plasma or skin.

Purpose/objectives: To describe an expanded role for oncology nurses in genetic counseling for cancer., Data Sources: Published professional articles, computerized data bases, lay publications., Data Synthesis: A description of the availability of genetic counseling, of motivation for undergoing genetic counseling, and of the basic components of genetic counseling for cancer., Conclusions: The need for genetic counseling will increase as more families with inherited cancer are identified, more cancer genes are isolated, and genetic analysis becomes more available., Implications for Nursing Practice: Advances in genetic technology provide nurses with the opportunity for an expanded role in genetic counseling for cancer. Oncology nurses also can act as case finders of families with inherited cancers and conduct research in this area.

Purpose/objectives: To review molecular biology and gene technology as they relate to cancer prediction and screening., Data Sources: Published professional articles, texts, and proceedings; computerized data bases., Data Synthesis: Basic principles of inheritance and mutations; a discussion of proto-oncogenes, oncogenes, and anti-oncogenes; a summary of gene-mapping techniques; and a review of genes linked to familial, breast, ovarian, and colorectal cancers., Conclusions: Most human cancers are influenced genetically but are not inherited. Discoveries about cancer genes play a major role in identifying individuals and families who are likely to develop cancer., Implications for Nursing Practice: Nurses need to heighten their awareness of this science and its ramifications, which ultimately will affect recommendations for early detection and screening.

Background: Skin cancer affects more Americans than any other type of cancer. Children are prime targets for prevention education, because sun overexposure in early childhood may affect the development of skin cancer later in life. Preventive behaviors adopted early in life may be less resistant to change than those acquired in adulthood. Thus, there is a need to educate children at an early age about sun overexposure., Methods: This article describes the evolution of skin cancer prevention research at the Arizona Cancer Center, a National Cancer Institute--designated comprehensive cancer center. Research focusing on children is high-lighted., Results: From its roots in the Arizona Sun Awareness Project, an informal public skin cancer education program, skin cancer prevention research at the Arizona Cancer Center has produced two developmentally appropriate, age-based curricula aimed at teaching children about the benefits and dangers of the sun. The elementary school curriculum, Sunny Days, Healthy Ways, has undergone two tests of feasibility and is the intervention used in a large, randomized, experimental trial. The preschool curriculum, Be Sun Safe, has been tested in a randomized trial and was found to have a positive effect on preschoolers' knowledge and comprehension of sun safety., Conclusions: Educating children about skin cancer may be an important way of decreasing the incidence of skin cancer. Although informal skin cancer prevention education can be helpful, educational programs preferably should be research based and evaluated for effectiveness before public distribution. The Arizona Cancer Center experience can serve as a model for other programs.

Skin cancer rates are increasing. Instilling preventive behavior in youngsters is essential to prevent overexposure during childhood. The effectiveness of a curriculum for increasing knowledge and skills, creating supportive attitudes, and engendering a supportive environment to enhance skin cancer prevention was tested on 139 fourth-, fifth-, and sixth-graders. One class in each grade was assigned to treatment (curriculum) and another to control. The curriculum increased knowledge of the effects of exposure to sunlight, skin cancer, and prevention immediately and eight weeks later, across all grades. It also cultivated less favorable attitudes toward tanning and, among fourth-graders, reduced unfavorable attitudes toward sunscreen. Behavioral changes were less consistently evident, with students reporting less suntanning, fourth-graders more frequently using sunscreen, and fifth- and sixth-graders more frequently wearing protective clothing compared with controls. The curriculum was more effective at influencing knowledge and attitudes than changing behavior, highlighting the need for student- and parent-oriented cues to action.

In order to parallel the advances in cancer prevention science, nurses need to develop alternative approaches to viewing cancer prevention and cancer screening. An alternative cancer prevention model bases prevention and screening on the science of carcinogenesis.

The best way to remedy the skin cancer epidemic is for the population to collectively practice primary preventive behaviors. However, many advances have been made in the areas of secondary and tertiary prevention, including the search for intermediate markers to facilitate skin cancer screening of high-risk groups and the use of chemopreventive agents in individuals with a history of high-risk lesions.

Although it cannot be said that "everything causes cancer," our environment will never be carcinogen-free. As a result, there are many substances we come in contact with daily that could be potentially harmful to our health. Even with the growing knowledge of the mechanisms of carcinogenesis, it is difficult to single out the exact cancer-causing or -promoting effects of single substances. The confusion that exists about the environment, lifestyle, and cancer can be overwhelming for everyone. Garfinkel offered the following suggestions for health care providers to use in putting this issue into better perspective for consumers: (1) no single study of cancer risk factors should be used as a basis for writing or changing public health policy; (2) animal studies should be supportive of findings in epidemiological studies; (3) any environmental factor-cancer effect relationship should be demonstrated biologically; (4) regulatory agencies such as the EPA tend to be conservative in their interpretation of study results, and may suggest caution even when the risk of developing cancer is low; (5) regulatory agencies have been known to extrapolate future effects of carcinogen exposure from current incomplete or limited information about the carcinogen in question. With the knowledge that we do have, we must strive to take personal control over life-style factors that may cause cancer.

Little is known about the impact of the cancer experience on long-term survivors of adult cancers. This exploratory study describes survivors' needs and identifies emic (in the subject's own words) categories and patterns among physiological, psychological, and socioeconomic changes, problems/concerns, and needs. A purposive sample of 17 adults more than two years post-cancer therapy was interviewed using the semi-structured Cancer Survivor Questionnaire (CSQ). Deductive content analysis was used to identify specific changes, problems/concerns, or needs associated with physiological, psychological, and socioeconomic categories. Inductive content analysis identified major emic themes and patterns. Findings indicate that the cancer experience permanently changes life patterns and suggest guidelines for nurses to use in helping the cancer survivor better adapt holistically to long-term survival.

Development of contingency recruitment plans in cancer chemoprevention research is as important as formulation of the initial plan. We found that requesting recruitment information from our initial CTCD subjects provided a framework for our contingency plan. The revised recruitment plan consisted of: 1) calling and sending letters to community gynecologists in private practice or affiliated with HMO's to explain the study and ask for referrals; 2) continued personal contact by the principal investigator with referring physicians; 3) sending thank you and follow-up letters to every physician who referred patients to the study; 4) soliciting Papanicolaou smear reports from HMO's if physicians of women with abnormal Papanicolaou smears gave permission to pathologists to release this information; 5) utilizing free media such as feature articles on the CTCD in local papers, public service announcements, and television "spots;" 6) continued use of brochures and posters printed for the initial recruitment effort; and 7) continued presentations to local professional physician and nurse groups about the study. Our contingency plan to date has provided us with 100% of our projected accrual. Thus, our recruitment methods have proved to be effective in accruing subjects for this cancer chemoprevention trial.