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PURPOSE The terms undertreatment and overtreatment are often used to describe inappropriate management of older adults with cancer. We conducted a comprehensive scoping review of the literature to clarify the meanings behind the use of the terms. METHODS We searched PubMed (National Center for Biotechnology Information), Embase (Elsevier), and CINAHL (EBSCO) for titles and abstracts that included the terms undertreatment or overtreatment with regard to older adults with cancer. We included all types of articles, cancer types, and treatments. Definitions of undertreatment and overtreatment were extracted, and categories underlying these definitions were derived through qualitative analysis. Within a random subset of articles, C.D. and K.P.L. independently performed this analysis to determine final categories and then independently assigned these categories to assess inter-rater reliability. RESULTS Articles using the terms undertreatment (n = 236), overtreatment (n = 71), or both (n = 51) met criteria for inclusion in our review (n = 256). Only 14 articles (5.5%) explicitly provided formal definitions; for the remaining, we inferred the implicit definitions from the terms’ surrounding context. There was substantial agreement (κ = 0.81) between C.D. and K.P.L. in independently assigning categories of definitions within a random subset of 50 articles. Undertreatment most commonly implied less than recommended therapy (148; 62.7%) or less than recommended therapy associated with worse outcomes (88; 37.3%). Overtreatment most commonly implied intensive treatment of an older adult in whom the harms of treatment outweigh the benefits (38; 53.5%) or intensive treatment of a cancer not expected to affect an older adult in his/her remaining lifetime (33; 46.5%). CONCLUSION Undertreatment and overtreatment of older adults with cancer are imprecisely defined concepts. We propose new, more rigorous definitions that account for both oncologic factors and geriatric domains.

Background: Tamoxifen and its metabolites compete with estrogen to occupy the estrogen receptor. The conventional dose of adjuvant tamoxifen overwhelms estrogen in this competition, reducing breast cancer recurrence risk by nearly half. Phase I metabolism generates active tamoxifen metabolites, and phase II metabolism deactivates them. No earlier pharmacogenetic study has comprehensively evaluated the metabolism and transport pathways, and no earlier study has included a large population of premenopausal women. Methods: We completed a cohort study of 5,959 Danish nonmetastatic premenopausal breast cancer patients, in whom 938 recurrences occurred, and a case–control study of 541 recurrent cases in a cohort of Danish predominantly postmenopausal breast cancer patients, all followed for 10 years. We collected formalin-fixed paraffin-embedded tumor blocks and genotyped 32 variants in 15 genes involved in tamoxifen metabolism or transport. We estimated conventional associations for each variant and used prior information about the tamoxifen metabolic path to evaluate the importance of metabolic and transporter pathways. Results: No individual variant was notably associated with risk of recurrence in either study population. Both studies showed weak evidence of the importance of phase I metabolism in the clinical response to adjuvant tamoxifen therapy. Conclusions: Consistent with prior knowledge, our results support the role of phase I metabolic capacity in clinical response to tamoxifen. Nonetheless, no individual variant substantially explained the modest phase I effect on tamoxifen response. Impact: These results are consistent with guidelines recommending against genotype-guided prescribing of tamoxifen, and for the first time provide evidence supporting these guidelines in premenopausal women.

OBJECTIVES To develop a predictive model and risk score for 10-year mortality using health-related quality of life (HRQOL) in a cohort of older women with early-stage breast cancer. DESIGN Prospective cohort. SETTING Community. PARTICIPANTS U.S. women aged 65 and older diagnosed with Stage I to IIIA primary breast cancer (N=660). MEASUREMENTS We used medical variables (age, comorbidity), HRQOL measures (10-item Physical Function Index and 5-item Mental Health Index from the Medical Outcomes Study (MOS) 36-item Short-Form Survey; 8-item Modified MOS Social Support Survey), and breast cancer variables (stage, surgery, chemotherapy, endocrine therapy) to develop a 10-year mortality risk score using penalized logistic regression models. We assessed model discriminative performance using the area under the receiver operating characteristic curve (AUC), calibration performance using the Hosmer-Lemeshow test, and overall model performance using Nagelkerke R(NR). RESULTS Compared to a model including only age, comorbidity, and cancer stage and treatment variables, adding HRQOL variables improved discrimination (AUC 0.742 from 0.715) and overall performance (NR 0.221 from 0.190) with good calibration (p=0.96 from HL test). CONCLUSION In a cohort of older women with early-stage breast cancer, HRQOL measures predict 10-year mortality independently of traditional breast cancer prognostic variables. These findings suggest that interventions aimed at improving physical function, mental health, and social support might improve both HRQOL and survival.

A false-positive mammogram can result in anxiety, distress, and increased perceptions of breast cancer risk, potentially changing how women utilize healthcare. This study examined whether having an abnormal mammogram, considered a proxy for elevated risk perception, was associated with greater future health service use (outpatient visits and referrals).A retrospective cohort study using electronic health record data, spanning 2008 to 2012, from Boston Medical Center, a safety-net hospital.We grouped 3920 women aged 40 to 75 years receiving primary care and who had a mammogram between 2010 and 2011 into 3 categories: false-positive mammogram at index date; previous false positive, but normal index mammogram; and no history of false-positive mammograms. We contrasted the longitudinal changes in outpatient visits and provider referrals, before versus after the index mammogram, between women with false-positive mammogram and those without using Poisson regression models with a difference-in-differences specification. Clinical, visit, and demographic data were obtained from the institutional clinical data warehouse.Adjusting for baseline differences in sociodemographic characteristics across risk groups and for secular changes between pre- and postindex periods, a current false-positive mammogram was associated with an 18% increase in overall outpatient visits (incidence rate ratio [IRR], 1.18; 95% CI, 1.07-1.51), but no corresponding increase in provider referrals (IRR, 1.15; 95% CI, 0.99‑1.34), relative to never having a false positive. A previous false-positive mammogram had no associated change in outpatient utilization (IRR, 0.99; 95% CI, 0.91-1.07).Providers should discuss the implications of mammography findings at the time of screening to help mitigate potential detrimental effects and promote appropriate engagement in health services.

OBJECTIVES To determine life expectancy for older women with breast cancer. DESIGN Prospective longitudinal study with 10 years of follow-up data. SETTING Hospitals or collaborating tumor registries in four geographic regions (Los Angeles, California; Minnesota; North Carolina; Rhode Island). PARTICIPANTS Women aged 65 and older at time of breast cancer diagnosis with Stage I to IIIA disease with measures of self-rated health (SRH) and walking ability at baseline (N = 615; 17% aged ≥80, 52% Stage I, 58% with ≥2 comorbidities). MEASUREMENTS Baseline SRH, baseline self-reported walking ability, all-cause and breast cancer-specific estimated probability of 5- and 10-year survival. RESULTS At the time of breast cancer diagnosis, 39% of women reported poor SRH, and 28% reported limited ability to walk several blocks. The all-cause survival curves appear to separate after approximately 3 years, and the difference in survival probability between those with low SRH and limited walking ability and those with high SRH and no walking ability limitation was significant (0.708 vs 0.855 at 5 years, P ≤ .001; 0.300 vs 0.648 at 10 years, P < .001). There were no differences between the groups in breast cancer-specific survival at 5 and 10 years (P = .66 at 5 years, P = .16 at 10 years). CONCLUSION The combination of low SRH and limited ability to walk several blocks at diagnosis is an important predictor of worse all-cause survival at 5 and 10 years. These self-report measures easily assessed in clinical practice may be an effective strategy to improve treatment decision-making in older adults with cancer.

Background It remains unknown whether incident chronic diseases are more often fatal among breast cancer survivors than among women free of breast cancer. Methods We conducted a nationwide matched cohort study of all Danish breast cancer patients diagnosed between 1994 and 2007, who survived for five years. We compared their long-term mortality with five times as many women from the general population without breast cancer, matched on age. We used time-varying methods to compute mortality rate ratios (MRRs) for incident diseases included in the Charlson Comorbidity Index (CCI). Results One third of five-year breast cancer survivors developed incident diseases during 14 years of follow-up, with about the same incidence as women without breast cancer. Mortality associated with any incident disease was similar among breast cancer survivors (MRR = 7.1, 95% confidence interval (CI): 6.7, 7.4) and comparison women (MRR = 7.5, 95% CI: 7.3, 7.7). Among breast cancer patients, relative mortality associated with incident diseases was higher among patients treated with chemotherapy (MRR = 10, 95% CI: 8.7, 12) and radiotherapy (MRR = 9.8, 95% CI: 8.8, 11) than among patients who received surgery (MRR = 7.0, 95% CI: 6.7, 7.4) or hormonal therapy (MRR = 6.3, 95% CI: 5.8, 6.9). Conclusion There were no marked differences in mortality of diseases among breast cancer survivors and women from the general population. Among breast cancer patients, new diseases were more often fatal in patients treated with chemotherapy and radiotherapy. Five-year breast cancer survivors have similar risk of dying from new chronic medical conditions as women from the general population without breast cancer. © 2015 Elsevier Ltd. All rights reserved.

Background/Objective Current preoperative assessment tools such as the American College of Surgeons Surgical Risk Calculator (ACS Calculator) are suboptimal for evaluating older adults. The objective was to evaluate and compare the performance of the ACS Calculator for predicting risk of serious postoperative complications with the addition of self-reported physical function versus a frailty score. Design Prospective cohort. Setting Two tertiary care academic medical centers in Massachusetts. Participants Individuals aged 65 and older undergoing any surgery with a risk of serious complication of 5% or greater (N = 403). Measurements We measured self-reported physical function using the Late-Life Function and Disability Instrument (LLFDI FUNCTION) and frailty phenotype (FP), which has a score ranging from 0 to 5 based on slow gait speed, weak handgrip, exhaustion, weight loss, or low activity. Using c-statistic and net classification improvement (NRI), we then analyzed capability of LLFDI-FUNCTION versus FP to improve the ACS Calculator for predicting an adverse postoperative course (serious complication, discharge to nursing home, readmission, death within 30 days of surgery). Increase in c-statistic and net reclassification improvement (NRI) for LLFDI-FUNCTION versus FP in addition to the ACS Calculator for predicting an adverse postoperative course (serious complication, discharge to nursing home, readmission, death within 30 days of surgery) Results Over 30 days, 26% of participants developed an adverse postoperative course. The increase in c-statistic for the ACS Calculator (baseline value 0.645) was slightly greater with LLFDI-FUNCTION (0.076) than with FP (0.058), with a bootstrapped difference in c-statistic of 0.005 (95% confidence interval = 0.002–0.007). NRI was also better with LLFDI-FUNCTION. Conclusion The LLFDI-FUNCTION predicted postoperative complications slightly better than the FP. Further studies are needed to confirm these findings and validate the use of the LLFDI-FUNCTION with the ACS Calculator for preoperative assessments of older adults.

BACKGROUND: Validation studies of the Danish Breast Cancer Group (DBCG) registry show good agreement with medical records for adjuvant treatment data, but inconsistent recurrence information. No studies have validated changes in menopausal status or endocrine therapy during follow-up. In a longitudinal study, we validated DBCG data using medical records as the gold standard.MATERIAL AND METHODS: From a cohort of 5959 premenopausal women diagnosed during 2002-2010 with stage I-III breast cancer, we selected 151 patients - 77 estrogen-receptor-positive and 74 estrogen-receptor-negative - from three hospitals. We assessed the validity of DBCG registry data on patient, tumor, and treatment factors, and follow-up information on menopausal transition, changes in endocrine therapy, and recurrence. We computed positive predictive values (PPVs) with 95% confidence intervals (95%CI).RESULTS: Agreement was near perfect for tumor size, lymph node involvement, receptor status, surgery type, and receipt of radiotherapy, chemotherapy, or tamoxifen treatment. The PPV for a change in endocrine therapy in the DBCG was 96% (95%CI = 83, 100). The PPV for menopausal transition was 61% (95%CI = 42, 77). The PPV for DBCG-recorded recurrence was 100%. However, of 19 patients who had a recurrence documented in their medical record, 13 had the recurrence registered in DBCG.CONCLUSIONS: DBCG data are valid for most epidemiological studies of breast cancer treatment. Data on menopausal transition may be less valid, though this interpretation depends on the suitability of medical records for making this assessment. Although recurrence is missing for some, this would not bias most ratio measures of association.

Little is known about older women’s experience with a benign breast biopsy. To examine the psychological impact and experience of women ≥ 65 years of age with a benign breast biopsy. Prospective cohort study using quantitative and qualitative methods. Three Boston-based breast imaging centers. Ninety-four English-speaking women ≥ 65 years without dementia referred for breast biopsy as a result of an abnormal mammogram, not aware of their biopsy results at baseline, and with a subsequent negative biopsy. We interviewed women at the time of breast biopsy (before women knew their results) and 6 months post-biopsy. At both interviews, participants completed the validated negative psychological consequences of screening mammography questionnaire (PCQ, scores range from 0 to 36 [high distress], PCQ ≥ 1 suggests a psychological consequence, PCQs

BACKGROUND: Knee osteoarthritis (OA) and frailty are two conditions that are associated with functional limitation and disability in elders, yet their relation to one another is not known. METHODS: We included participants from two large, multicenter studies enriched with community dwelling older adults with knee OA (Multicenter Osteoarthritis Study and Osteoarthritis Initiative). Knee OA was defined radiographically (ROA) and symptomatically (SOA). Frailty was defined using the Study of Osteoporotic Fracture index as the presence of ?2 of the following: (i) weight loss >5% between two consecutive visits; (ii) inability to arise from chair five times without support; (iii) poor energy. Cross-sectional and longitudinal associations of knee OA with prevalent and incident frailty, respectively, were examined using binomial regression with robust variance estimation, adjusting for potential confounders. RESULTS: In the cross-sectional analyses, frailty was more prevalent among participants with ROA (4.39% vs 2.77%; PR 1.60 [1.07, 2.39]) and SOA (5.88% vs 2.79%; PR 1.92 [1. 35, 2.74]) compared with those without ROA or SOA, respectively. In the longitudinal analyses, risk of developing frailty was greater among those with ROA (4.73% vs 2.50%; RR 1.45 [0.91, 2.30]) and SOA (6.30% vs 2.83%; RR 1.66 [1.11, 2.48]) than those without ROA or SOA, respectively. CONCLUSIONS: Knee OA is associated with greater prevalence and risk of developing frailty. Understanding the mechanisms linking these two common conditions of older adults would aid in identifying novel targets for treatment or prevention of frailty.

Background: Acute hospital readmission of older adults receiving hospice care is not aligned with hospice goals. Objective: To identify factors associated with 30-day readmission among older adults newly discharged to hospice. Design/Subjects: Medical record review of 59 patients, 19 readmitted within 30 days and 40 randomly selected controls not readmitted, from 206 patients newly discharged to home hospice care between February 1, 2005 and January 31, 2010. Measures/Analysis: Information was collected about hospital course, end-of-life planning, and posthospitalization follow-up. We calculated bivariate associations and developed a Cox Proportional Hazards model examining the relation between index admission characteristics and readmission. Results: Patients' mean age was 79.7±8.4; 74.6% were female; 52.5% were black. Among those readmitted, 25% had received a palliative care consultation, compared to 47.1% of those not readmitted (p=0.06). Patients without a participating decision-maker involved in their hospice decision had 3.5 times the risk of readmission within 30 days, compared to those with (hazard ratio [HR] 3.53, confidence interval [CI] 0.97, 12.82). Patients who had one or more telephone contacts with their primary care physician (PCP) during week 1 after discharge had 2.4 times the readmission risk within 30 days, compared to patients with no such contacts during this period (HR 2.35, CI 0.9, 6.1). Conclusions: Readmission within 30 days of initial discharge to hospice is associated with several measures of care and care planning. Further study of these measures may identify opportunities for interventions to improve the hospital-to-hospice transition and to decrease hospital readmissions.

Purpose To determine if older patients with breast cancer have cognitive impairment before systemic therapy. Patients and Methods Participants were patients with newly diagnosed nonmetastatic breast cancer and matched friend or community controls age > 60 years without prior systemic treatment, dementia, or neurologic disease. Participants completed surveys and a 55-minute battery of 17 neuropsychological tests. Biospecimens were obtained for APOE genotyping, and clinical data were abstracted. Neuropsychological test scores were standardized using control means and standard deviations (SDs) and grouped into five domain z scores. Cognitive impairment was defined as any domain z score two SDs below or ≥ two z scores 1.5 SDs below the control mean. Multivariable analyses evaluated pretreatment differences considering age, race, education, and site; comparisons between patient cases also controlled for surgery. Results The 164 patient cases and 182 controls had similar neuropsychological domain scores. However, among patient cases, those with stage II to III cancers had lower executive function compared with those with stage 0 to I disease, after adjustment (P = .05). The odds of impairment were significantly higher among older, nonwhite, less educated women and those with greater comorbidity, after adjustment. Patient case or control status, anxiety, depression, fatigue, and surgery were not associated with impairment. However, there was an interaction between comorbidity and patient case or control status; comorbidity was strongly associated with impairment among patient cases (adjusted odds ratio, 8.77; 95% CI, 2.06 to 37.4; P = .003) but not among controls (P = .97). Only diabetes and cardiovascular disease were associated with impairment among patient cases. Conclusion There were no overall differences between patients with breast cancer and controls before systemic treatment, but there may be pretreatment cognitive impairment within subgroups of patient cases with greater tumor or comorbidity burden.

Objectives To determine whether oral health is better in centenarians than in a published birth cohort–matched sample and to compare oral health in centenarian offspring with a case-controlled reference sample. Design Observational cross-sectional study. Setting New England Centenarian Study (NECS). Participants Seventy-three centenarians, 467 offspring, and 251 offspring generation-reference cohort subjects from the NECS. Measurements A self-report questionnaire was administered to measure oral health in all three groups, with edentulous rate as the primary outcome measure. The NECS made information on sociodemographic characteristics and medical history available. Centenarian results were compared with published birth cohort–matched results. Data from offspring and reference cohorts were analyzed to determine differences in oral health and associations between oral health measures and specific medical conditions. Results The edentulous rate of centenarians (36.5%) was lower than that of their birth cohort (46%) when they were aged 65 to 74 in 1971 to 1974 (according to National Center of Health Statistics). Adjusting for confounding factors, the reference cohort was more likely to be edentulous (adjusted odds ratio (AOR) = 2.78, 95% confidence interval CI = 1.17–6.56), less likely to have all or more than half of their own teeth (AOR = 0.48, 95% CI = 0.3–0.76), and less likely to report excellent or very good oral health (AOR = 0.65, 95% CI = 0.45–0.94) than the centenarian offspring. Conclusion Centenarians and their offspring have better oral health than their respective birth cohorts. Oral health may prove to be a helpful marker for systemic health and healthy aging.

Since 2012, the American Geriatrics Society (AGS) has also been collaborating with the American Board of Internal Medicine (ABIM) Foundation, joining its "Choosing Wisely" campaign on two separate lists of Five Things Healthcare Providers and Patients Should Question. The campaign is designed to engage healthcare organizations and professionals, individuals, and family caregivers in discussions about the safety and appropriateness of medical tests, medications, and procedures. Participating healthcare providers are asked to identify five things-tests, medications, or procedures-that appear to harm rather than help. Providers then share this information in a published article about these things on the ABIM campaign's website (www.choosingwisely.org). The first AGS list was published in February 2013.

Objectives The Getting Out of Bed Scale (GOB) was validated as a health-related quality of life (HRQoL) variable in older women with early stage breast cancer, suggesting its potential as a concise yet powerful measure of motivation. The aim of our project was to assess the association between GOB and mortality over 10 years of follow-up. Materials and Methods We studied 660 women ≥ 65-years old diagnosed with stage I–IIIA primary breast cancer. Data were collected over 10 years of follow-up from interviews, medical records, and death indexes. Results Compared to women with lower GOB scores, women with higher GOB had an unadjusted hazard ratio (HR) of all-cause mortality of 0.78 at 5 years, 95% confidence interval (CI) (0.52, 1.19) and 0.77 at 10 years, 95%CI (0.59, 1.00). These associations diminished after adjusting for age and stage of breast cancer, and further after adjusting for other HRQoL variables including physical function, mental health, emotional health, psychosocial function, and social support. Unadjusted HRs of breast cancer-specific mortality were 0.92, 95%CI (0.49, 1.74), at 5 years, and 0.82, 95%CI (0.52, 1.32), at 10 years. These associations also decreased in adjusted models. Conclusion Women with higher GOB scores had a lower hazard of all-cause mortality in unadjusted analysis. This effect diminished after adjusting for confounding clinical and HRQoL variables. GOB is a measure of motivation that may not be independently associated with cancer mortality, but reflects other HRQoL variables making it a potential outcome to monitor in older patients with cancer.

Cancer is the leading cause of death in older adults aged 60 to 79 years. Older patients with good performance status are able to tolerate commonly used treatment modalities as well as younger patients, particularly when adequate supportive care is provided. For older patients who are able to tolerate curative treatment, options include surgery, radiation therapy (RT), chemotherapy, and targeted therapies. RT can be highly effective and well tolerated in carefully selected patients, and advanced age alone should not preclude the use of RT in older patients with cancer. Judicious application of advanced RT techniques that facilitate normal tissue sparing and reduce RT doses to organs at risk are important for all patients, and may help to assuage concerns about the risks of RT in older adults. These NCCN Guidelines Insights focus on the recent updates to the 2016 NCCN Guidelines for Older Adult Oncology specific to the use of RT in the management of older adults with cancer.

e23020 Background: The terms “undertreatment” and “overtreatment” are often used to describe the management of older adults with cancer. The aim of this scoping review was to explore the explicit and implicit definitions associated with the use of these terms. Methods: We searched PubMed (NCBI), Embase (Elsevier), and CINAHL (EBSCO) for titles and abstracts that included the terms "undertreatment" or "overtreatment" (overtreat OR undertreat OR over treat OR under treat) of older adults with cancer. We included all types of articles, cancers, and treatments. We excluded studies that only included patients younger than 60 years old or studies without a defined focus on older adults. CD and KL independently reviewed a subset of included articles to assess for inter-reviewer reliability. Results: We identified 224 primary and secondary research articles that used the terms “undertreatment” (192), “overtreatment” (72), or both (45) regarding the management of older adults with cancer. Only 14 (6.3%) articles provided an explicit definition; for the remaining articles, we derived the implicit definitions from the terms’ surrounding context. There was substantial agreement between CD and KL in their interpretation of definitions of these terms (kappa 0.81). “Undertreatment” was commonly used to imply less than “standard” therapy (130 articles, 67.7%), or less than “standard” therapy that contributed to worse outcomes (62, 32.3%). Many articles did not account for the underrepresentation of older adults in trials leading to “standard” therapy, and 24 primary studies performed no or limited adjustment for geriatric domains (e.g., function) in their analyses that suggested worse survival in older adults treated with substandard therapy. “Overtreatment” was commonly used to imply cancer treatment in an older adult whose cancer would not have caused symptoms in his/her remaining lifetime (31, 43.1%), or aggressive treatment in whom the harms of treatment outweigh its benefits (41, 56.9%). Conclusions: Nearly all articles used the terms “undertreatment” and/or “overtreatment” without an explicit definition, and we identified variability and limitations in the meanings implied by these terms.

Objectives: To compare the efficacy of a computer-based physical activity program (Embodied Conversational Agent�ECA) with that of a pedometer control condition in sedentary older adults. Design: Single-blind block-randomized controlled trial stratified according to clinic site and health literacy status. Setting: Three urban ambulatory care practices at Boston Medical Center between April 2009 and September 2011. Participants: Older adults (N = 263; mean age 71.3; 61% female; 63% African American; 51% high school diploma or less). Intervention: ECA participants were provided with portable tablet computers with touch screens to use for 2 months and were directed to connect their pedometers to the computer using a data cable and interact with a computer-animated virtual exercise coach daily to discuss walking and to set walking goals. Intervention participants were then given the opportunity to interact with the ECA in a kiosk in their clinic waiting room for the following 10 months. Control participants were given a control pedometer intervention that only tracked step counts for an equivalent period of time. Intervention participants were also provided with pedometers. Measurements: The primary outcome was average daily step count for the 30 days before the 12-month interview. Secondary outcomes were average daily step count for the 30 days before the 2-month interview. Outcomes were also stratified according to health literacy level. Results: ECA participants walked significantly more steps than control participants at 2 months (adjusted mean 4,041 vs 3,499 steps/day, P = .01), but this effect waned by 12 months (3,861 vs 3,383, P = .09). For participants with adequate health literacy, those in the ECA group walked significantly more than controls at both 2 months (P = .03) and 12 months (P = .02), while those with inadequate health literacy failed to show significant differences between treatment groups at either time point. Intervention participants were highly satisfied with the program. Conclusion: An automated exercise promotion system deployed from outpatient clinics increased walking among older adults over the short-term. Effective methods for long-term maintenance of behavior change are needed.

Life expectancy for US women lags behind that for women in other countries. Factors contributing to inequitable health for women are complex and include policy, community, healthcare access, and the interaction between the patient and her healthcare provider working within the healthcare system. We propose a societal pyramid of health accounting for the effects of these different factors and their impact on prevention, screening, diagnosis, and management of disease using the examples of smoking and obesity, two of the most important yet modifiable risk factors for chronic disease and death among US women.美国女性的平均寿命低于其它国家女性。造成这种不公平女性健康状况的因素很复杂，其中包括政策、社区、医疗护理获取途径以及患者与其在医疗护理系统中工作的医疗护理提供者之间的互动。我们提出了一个社会健康金字塔模型，通过列举吸烟和肥胖这两个导致美国女性罹患慢性疾病和死亡的最重要但可改变的风险因素，说明了该等差异因素的效应以及它们对疾病预防、筛选、诊断及管理的影响。La esperanza de vida de las mujeres de los Estados Unidos va por detrás de la de las mujeres de otros países. Los factores que contribuyen a las desigualdades en la salud de las mujeres son complejos e incluyen la política, la comunidad, el acceso a la atención médica y la interacción entre la paciente y su médico que trabaja dentro del sistema sanitario. Proponemos una pirámide social de la salud que dé cuenta de los efectos de esos distintos factores y de su impacto sobre la prevención, detección, diagnóstico y tratamiento de la enfermedad utilizando los ejemplos del tabaquismo y la obesidad, dos de los factores de riesgo más importantes, aunque modificables, de enfermedad crónica y muerte entre las mujeres estadounidenses.

Objectives: To examine the effect of breast cancer and its treatment on fracture risk in older breast cancer survivors. Design: A 10-year prospective cohort study beginning 5 years after a diagnosis of breast cancer for survivors and match date for comparison women. Setting: Six integrated healthcare systems. Participants: Women aged 65 and older (1,286 survivors, 1,286 comparison women, mean age 77.7 in both groups, white, non-Hispanic: survivors, 81.6%; comparison women, 85.2%) who were alive and recurrence free 5 years after a diagnosis of early-stage breast cancer and matched on age, study site, and enrollment year to a comparison cohort without breast cancer. Measurements: Cox proportional hazards models were used to estimate the association between fracture risk and survivor-comparison status, adjusting for drugs and risk factors associated with bone health. A subanalysis was used to evaluate the association between tamoxifen exposure and fracture risk. Results: No difference was observed in fracture rates between groups (hazard ratio (HR) = 1.1, 95% confidence interval (CI) = 0.9�1.3). The protective effect of tamoxifen was not statistically significant (HR = 0.9, 95% CI = 0.6�1.2). Conclusion: Long-term survivors of early-stage breast cancer diagnosed at age 65 and older are not at greater risk of osteoporotic fractures than age-matched women without breast cancer. There appears to be no long-term protection from fractures with tamoxifen use.

Limited health literacy is associated with worse executive function, but the association between limited health literacy and decline in executive function has not been established because of a lack of longitudinal studies. The authors aimed to examine this association by studying a prospective cohort in the setting of a randomized controlled trial to promote walking in older adults. Participants were community-dwelling older adults (65 years of age or older) who scored 2 or more on the Mini-Cog, without depression (score of less than 15 on the 9-item Patient Health Questionnaire), and who completed baseline and 12-month evaluations (n = 226). Health literacy was measured using the Short Test of Functional Health Literacy in Adults. Executive function measured at baseline and 12 months using the Trail Making Test (TMT), Controlled Oral Word Association Test, and Category Fluency. The associations between health literacy and 12-month decline in each test of executive function were modeled using multivariate linear regression. Health literacy was found to be limited in 37% of participants. Limited health literacy was associated with reduced performance on all 3 executive function tests. In fully adjusted models, limited health literacy was associated with greater 12-month decline in performance on the TMT than higher health literacy (p =.01). In conclusion, older adults with limited health literacy are at risk for more rapid decline in scores on the TMT, a measure of executive function. © 2013 Copyright Shwetha S. Sequeira, Laura H. P. Eggermont, Rebecca S. Silliman, Timothy W. Bickmore, Lori E. Henault, Michael R. Winter, Kerrie Nelson, and Michael K. Paasche-Orlow.

BACKGROUND Of the approximately 2.4 million American women with a history of breast cancer, 43% are aged ≥ 65 years and are at risk for developing subsequent malignancies. METHODS Women from 6 geographically diverse sites included 5-year breast cancer survivors (N = 1361) who were diagnosed between 1990 and 1994 at age ≥ 65 years with stage I or II disease and a comparison group of women without breast cancer (N = 1361). Women in the comparison group were age-matched and site-matched to breast cancer survivors on the date of breast cancer diagnosis. Follow-up began 5 years after the index date (survivor diagnosis date or comparison enrollment date) until death, disenrollment, or through 15 years after the index date. Data were collected from medical records and electronic sources (cancer registry, administrative, clinical, National Death Index). Analyses included descriptive statistics, crude incidence rates, and Cox proportional hazards regression models for estimating the risk of incident malignancy and were adjusted for death as a competing risk. RESULTS Survivors and women in the comparison group were similar: >82% were white, 55% had a Charlson Comorbidity Index of 0, and ≥ 73% had a body mass index ≤ 30 kg/m(2) . Of all 306 women (N = 160 in the survivor group, N = 146 in the comparison group) who developed a first incident malignancy during follow-up, the mean time to malignancy was similar (4.37 ± 2.81 years vs 4.03 ± 2.76 years, respectively; P = .28), whereas unadjusted incidence rates were slightly higher in survivors (1882 vs 1620 per 100,000 person years). The adjusted hazard of developing a first incident malignancy was slightly elevated in survivors in relation to women in the comparison group, but it was not statistically significant (hazard ratio, 1.17; 95% confidence interval, 0.94-1.47). CONCLUSIONS Older women who survived 5 years after an early stage breast cancer diagnosis were not at an elevated risk for developing subsequent incident malignancies up to 15 years after their breast cancer diagnosis.

Evaluation and validation of the psychometric properties of the eight-item modified Medical Outcomes Study Social Support Survey (mMOS-SS).Secondary analyses of data from three populations: Boston breast cancer study (N=660), Los Angeles breast cancer study (N=864), and Medical Outcomes Study (N=1,717). The psychometric evaluation of the eight-item mMOS-SS compared performance across populations and with the original 19-item Medical Outcomes Study Social Support Survey (MOS-SS). Internal reliability, factor structure, construct validity, and discriminant validity were evaluated using Cronbach's alpha, principal factor analysis (PFA), and confirmatory factor analysis (CFA), Spearman and Pearson correlation, t-test and Wilcoxon rank sum tests.mMOS-SS internal reliability was excellent in all three populations. PFA factor loadings were similar across populations; one factor0.6, well-discriminated two factor (instrumental/emotional social support four items each)0.5. CFA with a priori two-factor structure yielded consistently adequate model fit (root mean squared errors of approximation 0.054-0.074). mMOS-SS construct and discriminant validity were similar across populations and comparable to MOS-SS. Psychometric properties held when restricted to women aged ≥ 65 years.The psychometric properties of the eight-item mMOS-SS were excellent and similar to those of the original 19-item instrument. Results support the use of briefer mMOS-SS instrument; better suited to multidimensional geriatric assessments and specifically in older women with breast cancer.

Rehospitalizations may indicate care quality problems. The authors conducted a retrospective cohort study of adults aged 65 years and older, comparing 30-day rehospitalization rates. Rates were compared for comprehensive geriatrics practice patients and for patients receiving usual general medical care. The unadjusted 30-day rehospitalization rate was 18% overall, 21% for geriatrics patients cared for on the geriatrics inpatient service, 22% for geriatrics practice patients on general medical services (GMSs), and 17% for older patients on GMS. Compared with older adults discharged from a GMS, geriatrics patients on the geriatrics service had an adjusted odds ratio for readmission of 1.00 (95% confidence interval = 0.88-1.13). Despite greater frailty, patients cared for in an interdisciplinary geriatrics practice were no more likely to be rehospitalized than adults receiving "usual care," when adjusted for age and disease burden. Incomplete adjustment may account for this finding, which did not confirm the hypothesis that comprehensive geriatrics care would yield fewer rehospitalizations.

To assess the risk of re-operation due to post-surgical bleeding after initial breast cancer surgery and to identify predictors of re-operation.We conducted a population-based study in Denmark. Patients were categorized according to age group, surgery type, and glucocorticoid use before surgery: never, current (0-90 days), and former (90 days). We calculated the risk of re-operation due to post-surgical bleeding within 14 days after surgery, risk differences, and risk ratios of re-operation associated with age group, surgery type, and glucocorticoid use.19,919 women were studied; 508 were re-operated. 3573 of the 19,919 women ever used glucocorticoids. Older age and mastectomy increased the risk of post-surgical bleeding compared with breast conserving surgery and younger age among both ever and never users of glucocorticoids. The crude risk of re-operation was 2.5% among never users of glucocorticoids, 2.6% among ever users and 4.0% among current users. Women aged ≥80 who were ever users of glucocorticoids and who had a mastectomy had 8.1% risk of re-operation due to post-surgical bleeding, whereas women80 years old who never used glucocorticoids and who had breast conserving surgery had a 1.7% risk of re-operation.Older age, mastectomy, and - in some women - glucocorticoid use add an extra risk of re-operation due to bleeding. Clinicians and their patients can use this information to evaluate the patient-specific risk of this complication.

To examine five- and ten-year survival based on cancer-specific geriatric assessment (C-SGA) in older women with early stage breast cancer.We evaluated 660 women ≥65-years old diagnosed with stage I-IIIA primary breast cancer and attending physician permission to contact in four geographic regions in the United States of America (USA). Data were collected over ten-years of follow-up from consenting women's medical records, telephone interviews, National Death Index and Social Security Death Index. C-SGA was described by four domains using six measures: socio-demographic (financial resources); clinical (comorbidity, obesity); function (physical function limitations); and psychosocial (general mental health, social support). Survival from all-cause and breast-cancer-specific mortality and receipt of guideline-recommended therapy was assessed for different groups of subjects with C-SGA domain deficits (cut-off ≥3 deficits).The proportion of women with ≥3 C-SGA deficits surviving ten-years was consistently statistically significantly lower (all-cause 26% versus 46% and breast-cancer-specific 76% versus 89%, p≤0.04). The proportion significantly decreased as number of C-SGA deficits increased (linear trend p0.0001). Receipt of guideline-recommended therapy decreased with age but not consistently by number of C-SGA deficits. The all-cause and breast-cancer-specific death rate at five- and ten-years was consistently approximately two times higher in women with ≥3 C-SGA deficits even when fully adjusted for confounding factors (HR(5-yrAllCauseFullyAdjusted)=1.87 [1.36-2.57], HR(10-yrAllCauseFullyAdjusted)=1.74 [1.35-2.15], HR(5-yrBreastCancerFullyAdjusted)=1.95 [1.18-3.20], HR(10-yrBreastCancerFullyAdjusted)=1.99 [1.21-3.28]).Regardless of age and stage of disease, C-SGA predicts five- and ten-year all-cause and breast-cancer-specific survival in older women. Hence, C-SGA may provide an effective strategy to guide treatment decision-making and to identify risk factors for intervention.

Background: Tamoxifen is oxidized by cytochrome-P450 enzymes (e.g., CYP2D6) to two active metabolites, which are eliminated via glucuronidation by UDP-glucuronosyl transferases (UGT). We measured the association between functional polymorphisms in key UGTs (UGT2B15*2, UGT2B7*2, and UGT1A8*3) and the recurrence rate among breast cancer survivors. Methods: We used the Danish Breast Cancer Cooperative Group registry to identify 541 cases of recurrent breast cancer among women with estrogen receptor-positive tumors treated with tamoxifen for at least 1 year (ER+/TAM+), and 300 cases of recurrent breast cancer among women with estrogen receptor-negative tumors who were not treated with tamoxifen (ER−/TAM−). We matched one control to each case on ER status, menopausal status, stage, calendar period, and county. UGT polymorphisms were genotyped from archived primary tumors. We estimated the recurrence OR for the UGT polymorphisms by using logistic regression models, with and without stratification on CYP2D6*4 genotype. Results: No UGT polymorphism was associated with breast cancer recurrence in either the ER+/TAM+ or ER−/TAM− groups [in the ER+/TAM+ group, compared with two normal alleles: adjusted OR for two UGT2B15*2 variant alleles = 1.0 (95% CI, 0.70–1.5); adjusted OR for two UGT2B7*2 variant alleles = 0.96 (95% CI, 0.65–1.4); adjusted OR for one or two UGT1A8*3 variant alleles = 0.95 (0.49–1.9)]. Associations were similar within strata of CYP2D6*4 genotype. Conclusions: Functional polymorphisms in key tamoxifen-metabolizing enzymes were not associated with breast cancer recurrence risk. Impact: Our results do not support the genotyping of key metabolic enzyme polymorphisms to predict response to tamoxifen therapy. Cancer Epidemiol Biomarkers Prev; 20(9); 1937–43. ©2011 AACR.

Embodied Conversational Agents (ECA) are computer-animated characters that simulate face-to-face conversation with patients. These agents can be programmed with best practices in human-human health communication and used for automated health education and behavior change counseling interventions. Evidence is presented from two ongoing clinical trials demonstrating that patients at different levels of health literacy find these agents acceptable and easy to use for automated health communication interventions. Innovative computer interface systems can be used to ensure that inadequate health literacy not serve as a barrier to interventions using health information technology.

PurposeThe Predictors of Breast Cancer Recurrence (ProBe CaRe) study was established to evaluate modification of tamoxifen (TAM) effectiveness in premenopausal women through reduced activity of TAM-metabolising enzymes. It comprehensively evaluates the effects of pharmacogenetic variants, use of concomitant medications and biomarkers involved in oestrogen metabolism on breast cancer recurrence risk.ParticipantsThe ProBe CaRe study was established using resources from the Danish Breast Cancer Group (DBCG), including 5959 premenopausal women diagnosed with stage I–III primary breast cancer between 2002 and 2010 in Denmark. Eligible participants were divided into two groups based on oestrogen receptor alpha (ERα) expression and receipt of TAM therapy, 4600 are classified as ERα+/TAM+ and 1359 are classified as ERα−/TAM−. The ProBe CaRe study is a population-based cohort study nested in a nearly complete source population, clinical, tumour and demographic data were abstracted from DBCG registry data. Linkage to Danish registries allows for abstraction of information regarding comorbid conditions, comedication use and mortality. Formalin-fixed paraffin-embedded tissue samples have been prepared for DNA extraction and immunohistochemical assay.Findings to dateTo mitigate incorrect classification of patients into specific categories, we conducted a validation substudy. We compared data acquired from registry and from medical record review to calculate positive predictive values (PPVs) and negative predictive values. We observed PPVs near 100% for tumour size, lymph node involvement, receptor status, surgery type, receipt of radiotherapy, receipt of chemotherapy and TAM treatment. We found that the PPVs were 96% (95% CI 83% to 100%) for change in endocrine therapy and 61% (95% CI 42% to 77%) for menopausal transition.Future plansThe ProBeCaRe cohort study is well positioned to comprehensively examine pharmacogenetic variants. We will use a Bayesian pathway analysis to evaluate the complete TAM metabolic path to allow for gene–gene interactions, incorporating information of other important patient characteristics.

OBJECTIVES To compare longitudinal patterns of health care utilization and quality of care for other health conditions between breast cancer-surviving older women and a matched cohort without breast cancer. DESIGN Prospective five-year longitudinal comparison of cases and matched controls. SUBJECTS Newly identified breast cancer patients recruited during 1997–1999 from four geographic regions (Los Angeles, CA; Minnesota; North Carolina; and Rhode Island; N = 422) were matched by age, race, baseline comorbidity and zip code location with up to four non-breast-cancer controls (N = 1,656). OUTCOMES Survival; numbers of hospitalized days and physician visits; total inpatient and outpatient Medicare payments; guideline monitoring for patients with cardiovascular disease and diabetes, and bone density testing and colorectal cancer screening. RESULTS Five-year survival was similar for cases and controls (80% and 82%, respectively; p = 0.18). In the first follow-up year, comorbidity burden and health care utilization were higher for cases (p

Lymphedema of the arm is a common complication of breast cancer with symptoms that can persist over long periods of time. For older women (over 50% of breast cancer cases) it means living with the potential for long-term complications of persistent lymphedema in conjunction with the common diseases and disabilities of aging over survivorship. We identified women > or =65 years diagnosed with primary stage I-IIIA breast cancer. Data were collected over 7 years of follow-up from consenting patients' medical records and telephone interviews. Data collected included self-reported symptoms of persistent lymphedema, breast cancer characteristics, and selected sociodemographic and health-related characteristics. The overall prevalence of symptoms of persistent lymphedema was 36% over 7 years of follow-up. Having stage II or III (OR = 1.77, 95% CI: 1.07-2.93) breast cancer and having a BMI >30 (OR = 3.04, 95% CI: 1.69-5.45) were statistically significantly predictive of symptoms of persistent lymphedema. Women > or =80 years were less likely to report symptoms of persistent lymphedema when compared to younger women (OR = 0.44, 95% CI: 0.18-0.95). Women with symptoms of persistent lymphedema consistently reported worse general mental health and physical function. Symptoms of persistent lymphedema were common in this population of older breast cancer survivors and had a noticeable effect on both physical function and general mental health. Our findings provide evidence of the impact of symptoms of persistent lymphedema on the quality of survivorship of older women. Clinical and research efforts focused on risk factors for symptoms of persistent lymphedema in older breast cancer survivors may lead to preventative and therapeutic measures that help maintain their health and well-being over increasing periods of survivorship.

OBJECTIVE: To develop and evaluate the psychometric properties of a measure of motivation and life outlook (Getting-Out-of-Bed [GoB]). DESIGN: Secondary analysis of baseline and 6-month data from a longitudinal follow-up study of older breast cancer survivors. PARTICIPANTS: Women (N = 660) diagnosed with primary breast cancer stage I-IIIA disease, age >or=65 years, and permission to contact from an attending physician in four geographic regions in the United States (city-based Los Angeles, California; statewide in Minnesota, North Carolina, and Rhode Island). MEASUREMENT: Data were collected over 6-months of follow-up from consenting patients' medical records and telephone interviews with patients. Data collected included the 4-item GoB, health-related quality of life (HRQoL), breast cancer, sociodemographic, and health-related characteristics. RESULTS: Factor analysis produced, as hypothesized, one principal component with eigen values of 2.74(baseline) and 2.91(6-months) which explained 68.6%(baseline) and 72.7%(6-months) of total variance. In further psychometric analyses, GoB exhibited good construct validity (divergent: low nonstatistically significant correlations with unrelated constructs; convergent: moderate statistically significant correlations with related constructs; discriminant: distinguished high HRQoL groups with a high level of significance), excellent internal reliability (Cronbach's alpha 0.84(baseline), 0.87(6-months)), and produced stable measurements over 6-months. Women with GoB scores >or=50 at baseline were more likely at 6-months to have good HRQoL, good self-perceived health, and report regular exercise, indicating good predictive ability. CONCLUSION: GoB demonstrated overall good psychometric properties in this sample of older breast cancer survivors, suggestive of a promising tool for assessing motivation and life outlook in older adults. Nevertheless, because it was developed and initially evaluated in a select sample, using measures with similar but not exact content overlap further evaluation is needed before it can be recommended for widespread use.

Purpose Some women with early-stage breast cancer are at higher risk of recurrence and can benefit from chemotherapy. We describe patterns of referral, receipt, and completion of chemotherapy among older women at high risk of recurrence. Patients and Methods A total of 2,124 women age 65 years or older who were diagnosed with early-stage breast cancer between 1990 and 1994 and 1996 to 1999 were included; 1,090 of these were at high risk of recurrence. We reviewed medical records to categorize chemotherapy outcomes as follows: did not discuss or were not referred to a medical oncologist (n = 133); discussed and/or referred to a medical oncologist but received no chemotherapy (n = 742); received an incomplete chemotherapy course (n = 29), or received a completed chemotherapy course (n = 186). Results Overall, 19.7% of high-risk women received any chemotherapy, and 86.5% of these women completed their chemotherapy courses. Just greater than 10% of high-risk women did not have a discussion about chemotherapy as part of breast cancer treatment documented in the medical record; these women also received fewer diagnostic assessments of their initial tumors. Conclusion Individuals who receive chemotherapy for early-stage breast cancer are a select subgroup of patients at high risk of recurrence. This study identifies characteristics of women who were referred for and who received chemotherapy, and this study plays an important role in understanding generalizability of studies that examine chemotherapy treatment effectiveness. Outcomes after breast cancer could continue to be improved with increased receipt of chemotherapy among older women at high risk of breast cancer recurrence.

Family history1-3 and estrogen replacement therapy4-12 each demonstrate an independent association with the incidence of breast cancer among postmenopausal women. Earlier studies suggested that longer exposure to endogenous estrogens was more strongly associated with breast cancer risk among women having a family history of breast cancer.13 Family history and estrogen risk potentially share biologic pathways of effect.14 It remains unresolved as to whether familial predisposition to breast cancer enhances the carcinogenic effects of estrogen. Several studies have observed a stronger association between estrogen and breast cancer among women with a family history.7-11,15 Others, however, have failed to observe this interaction.12,16-18 Some of this discrepancy might have arisen because of differences in the definitions of interaction, the classification of family history, and residual confounding. Women’s knowledge about their own family history can influence their decisions about use of estrogen therapy.19 The Women’s Health Initiative randomized placebo-controlled trial of estrogen plus progesterone hormone replacement therapy eliminates the link between family history and decisions about estrogen use. This advantage allows direct evaluation of a potential interaction between family history and hormone therapy on breast cancer incidence.

Purpose To examine outcomes of mammography screening among women ≥ 80 years to inform decision making. Patients and Methods We conducted a cohort study of 2,011 women without a history of breast cancer who were age ≥ 80 years between 1994 and 2004 and who received care at one academic primary care clinic or two community health centers in Boston, MA. Medical record data were abstracted on all screening and diagnostic mammograms, breast ultrasounds and biopsies performed, all breast cancers diagnosed through December 31, 2006, and on sociodemographics. Date and cause of death were confirmed using the National Death Index. Results The majority of patients (78.6%) were non-Hispanic white and 51.4% (n = 1,034) had been screened with mammography since age 80 years. Among women who were screened, eight were diagnosed with ductal carcinoma in situ, 16 with early stage disease (1.5%), two with late stage disease, and one died as a result of breast cancer. Many (110; 11%) experienced a false-positive screening mammogram that led to 19 benign breast biopsies, eight refused work-up, and three experienced a false-negative screening mammogram; 97 were screened within 2 years of their death from other causes. There were no significant differences in the rate, stage, recurrence rate, or deaths due to breast cancer between women who were screened and those who were not screened. Conclusion The majority of women ≥ 80 years are screened with mammography yet few benefit. Meanwhile, 12.5% experience a burden from screening. The data from this study can be used to inform elderly women's decision making and potentially lead to more rational use of screening.

Risk information for Alzheimer disease (AD) may be communicated through susceptibility gene disclosure, even though this is not currently in clinical use. The REVEAL Study is the first randomized clinical trial of risk assessment for AD with apolipoprotein E (APOE) genotype and numerical risk estimate disclosure. We examined whether APOE genotype and numerical risk disclosure to asymptomatic individuals at high risk for AD alters health behaviors. One hundred sixty-two participants were randomized to either intervention (APOE disclosure) or control (no genotype disclosure) groups. Subjects in both groups received numerical lifetime risk estimates of future AD development based on sex and family history of AD. The intervention group received their APOE genotype. Subjects were informed that no proven preventive measures for AD existed and given an information sheet on preventative therapies under investigation. Participants who learned they were epsilon 4 positive were significantly more likely than epsilon 4 negative participants to report AD-specific health behavior change 1 year after disclosure (adjusted odds ratio: 2.73; 95% confidence interval: 1.14, 6.54; P=0.02). Post hoc analyses revealed similar significant associations between numerical lifetime risk estimates and self-report of AD-specific health behavior change. Despite lack of preventive measures for AD, knowledge of APOE genotype, numerical lifetime risk, or both, influences health behavior.

The management of older patients with chronic medical conditions dominates medical practice. Cardiovascular disease (CVD) and diabetes mellitus type 2 (DM) in patients aged 65 and older have reached epidemic proportions. Using elements of the Chronic Care Model (CCM), a quality improvement project was undertaken to restructure the Geriatric Ambulatory Practice at Boston Medical Center, Boston's safety net hospital, to improve the quality of care for CVD and diabetes mellitus. Two hundred eighty-three eligible patients who had CVD, DM, or both were identified. The 39-month project period was divided into a 12-month baseline period and three follow-up periods. The multifaceted intervention consisted of development of a disease registry that centralized clinical information, implementation of an electronic medical record, patient education, physician education regarding evidence-based guidelines, feedback of provider-specific and practice data to physicians, and implementation of a foot examination protocol. Clinical measures included glycosylated hemoglobin, a diabetic foot examination, lipid profile, and blood pressure measurement. These were collected at baseline and at each patient visit for the entire project period. The average age of all patients was 76; 64% were female, 64% were African American, 72% had Medicare, and 22% had state subsidized medical insurance. Patients in all disease groups showed significant improvement in all clinical measures over time, independent of the frequency of visits. Using the CCM as a quality improvement framework can improve clinical measures for older urban minority populations with CVD and DM.

Purpose There are more than 2,000,000 breast cancer survivors in the United States today. While surveillance for asymptomatic recurrence and second primary is included in consensus recommendations, the effectiveness of this surveillance has not been well characterized. Our purpose is to estimate the effectiveness of surveillance mammography in a cohort of breast cancer survivors with complete ascertainment of surveillance mammograms and negligible losses to follow-up. Patients and Methods We enrolled 1,846 stage I and II breast cancer patients who were at least 65 years old at six integrated health care delivery systems. We used medical record review and existing databases to ascertain patient, tumor, and therapy characteristics, as well as receipt of surveillance mammograms. We linked personal identifiers to the National Death Index to ascertain date and cause of death. We matched four controls to each breast cancer decedent to estimate the association between receipt of surveillance mammogram and breast cancer mortality. Results One hundred seventy-eight women died of breast cancer during 5 years of follow-up. Each additional surveillance mammogram was associated with a 0.69-fold decrease in the odds of breast cancer mortality (95% CI, 0.52 to 0.92). The protective association was strongest among women with stage I disease, those who received mastectomy, and those in the oldest age group. Conclusion Given existing recommendations for post-therapy surveillance, trials to compare surveillance with no surveillance are unlikely. This large observational study provides support for the recommendations, suggesting that receipt of surveillance mammograms reduces the rate of breast cancer mortality in older patients diagnosed with early-stage disease.

To investigate the effectiveness of adjuvant tamoxifen in older women with early-stage breast cancer. Between 1997 and 1999, women > or = 65 years old at diagnosis with stage I-IIIa breast cancer were recruited from four geographic regions of the United States and followed prospectively for 5 years after diagnosis. Data sources included tumor registries, medical records review, and telephone interviews. The primary end points were breast cancer-specific and overall survival ascertained by matching identifying data with the National Death Index and Social Security Administration master death file. Tamoxifen prescription was operationalized as tamoxifen prescribed by 6 months after diagnosis. Survival analysis was undertaken using Kaplan-Meier curves and Cox proportional hazards modeling. We studied 689 women whose average age was 74.2 years at diagnosis (SD = 6.3, range 65-96 years). The median follow-up was 67 months (range 3.5-88 months). Of the 689 patients, 519 (76%) were prescribed tamoxifen. The 5-year breast cancer-specific survival was 93% (95% CI = 90-95) and 89% (95% CI = 83-94) for the ever tamoxifen and never tamoxifen groups, respectively. The ratio of adjusted breast cancer mortality hazards was 0.61 (95% CI = 0.31-1.12) for the ever tamoxifen group versus the never tamoxifen group. Similarly, the 5-year overall survival was 81% (95% CI = 76-85) and 70% (95% CI = 61-78) for the ever tamoxifen and never tamoxifen groups, respectively, with an adjusted hazard ratio of 0.53 (95% CI = 0.37-0.77). Adjuvant tamoxifen is associated with improvement in 5-year breast cancer-specific and overall survival in older women with early-stage breast cancer.

Purpose During the 5 years after primary breast cancer diagnosis for women ≥ 65 years old, we examined factors associated with change in emotional well-being. Patients and Methods We identified women diagnosed with primary breast cancer and selected women with stage I to IIIa disease, age ≥ 65 years, and for whom we had permission from the attending physician to contact. Data were collected during 5 years of follow-up from consenting patients' medical records and telephone interviews with patients. Outcomes included a five-question Mental Health Inventory general measure of emotional health (MHI5) and two cancer-specific measures: breast cancer–specific emotional health (BCSEH) and Cancer Rehabilitation Evaluation System–Short Form (CARES-SF) Psychosocial Summary Scale. Results During 5 years of follow-up of older breast cancer survivors, 57% had less than a ± 10-point change in MHI5, 38% had less than a ± 10-point change in BCSEH, and 52% had less than a ± 10-point change in CARES-SF Psychosocial Summary Scale. Women with less than 12 years of education were at greatest risk for having negative changes in both general and breast cancer–specific emotional health. Moreover, we also found that women who perceived themselves as never being cured had greater negative changes in all outcomes. Conversely, those who had better physical function, emotional social support, and positive ratings regarding the quality of medical interactions at baseline were less likely to have poor emotional health during follow-up. Conclusion For the majority of older breast cancer survivors, cancer-specific well-being and general emotional health do not change substantially after a breast cancer diagnosis. Among those in whom change occurs, risk factors are similar and may be related to other age-related diseases.

The quality of medical record abstracts is often characterized in a reliability substudy. These results usually indicate agreement, but not the extent to which lack of agreement affects associations observed in the complete data. In this study, medical records were reviewed and abstracted for patients diagnosed with stage I or stage II breast cancer between 1990 and 1994 at one of six US Cancer Research Network sites. For a subsample, interrater reliability data were available. The authors calculated conventional hazard ratios and 95% confidence intervals for the association of demographic, tumor, and treatment characteristics with recurrence rate. These conventional estimates of effect were compared with three sets of estimates and 95% simulation intervals that took account of the uncertainty assessed by lack of agreement in the reliability substudy. The rate of recurrence was associated with increasing cancer stage and with treatment modality but not with demographic characteristics. The hazard ratios and simulation intervals that took account of the reliability data showed that the simulation interval grew wider as the sources of uncertainty taken into account grew more complete, but the associations expected a priori remained readily apparent. While many investigators use reliability data only as a metric for data quality, a more thorough approach can also quantitatively depict the uncertainty in the observed associations.

Measurement of comorbidity affects all variable axes that are considered in health care research: confounding, modifying, independent, and dependent variable. Comorbidity measurement particularly affects research involving older adults because they bear the disproportionate share of the comorbidity burden.We examine how well researchers can expect to segregate study participants into those who are healthier and those who are less healthy, given the variable axis for which they are measuring comorbidity, the comorbidity measure they select, and the analytic method they choose. We also examine the impact of poor measurement of comorbidity.Available comorbidity measures make use of medical records, self-report, physician assessments, and administrative databases. Analyses using these scales introduce uncertainties that can be framed as measurement error or misclassification problems, and can be addressed by extant analytic methods. Newer analytic methods make efficient use of multiple sources of comorbidity information.Consideration of the comorbidity measure, its role in the analysis, and analogous measurement error problems will yield an analytic solution and an appreciation for the likely direction and magnitude of the biases introduced.

OBJECTIVES: To determine the relationship between blood pressure (BP) and all-cause mortality in subjects aged 80 and older with hypertension. DESIGN: Retrospective cohort study with 5 years of follow-up. SETTING: Ten Veterans AFFAIRS (VA) sites. PARTICIPANTS: Four thousand seventy-one ambulatory patients aged 80 and older with hypertension. MEASUREMENTS: The outcome measure was likelihood of survival during the follow-up period. Vital status was obtained from VA and Social Security files. Variables collected for adjustment in Cox regression models were baseline BP, medications, demographics, diagnoses, and health-related quality of life (HRQoL); HRQoL information was available on 1,289 subjects based on Veterans Health Study Short From-36 (SF-36) questionnaire scores. RESULTS: Subjects with higher BP (up to a systolic BP (SBP) of 139 mmHg and a diastolic BP (DBP) of 89 mmHg) were less likely to die during follow-up than subjects with lower BP. After baseline adjustments, the hazard ratio for a 10-point increase in SBP was 0.82 (95% confidence interval (CI)=0.74–0.91), up to a SBP of 139 mmHg, and for DBP was 0.85 (95% CI=0.78–0.92), up to a DBP of 89 mmHg. There was no significant association between survival and BP levels in subjects with uncontrolled hypertension. CONCLUSION: In a cohort of very old, hypertensive veterans, in subjects with controlled BPs, subjects with lower BP levels had a lower 5-year survival than those with higher BPs. This suggests that clinicians should use caution in their approach to BP lowering in this age group.