Breast cancer disparities and decision-making among U.S. women

OBJECTIVE: The impact of breast cancer is immense for all women, but the literature reveals an even greater impact on women of color and among socially and economically disadvantaged populations. Persistent differences in incidence and outcome are undoubtedly due to multiple factors, but one element in poor outcome may be treatment choice. Those treatments shown to be related to best outcomes are less likely to be chosen by certain groups of women. The effects of economic and cultural factors on breast cancer treatment choice have not been thoroughly explored; these factors must be understood if health care professionals are to intervene effectively to address disparities and improve breast cancer outcomes for all women. METHODS: A review of the breast cancer literature was conducted in order to: (1) describe breast cancer disparities in the United States; (2) delineate factors that might contribute to those disparities; (3) assess possible mitigating factors for predominant causes; (4) begin to decide how health care interventions might allay the factors that contribute to disparities in breast cancer incidence and mortality. RESULTS: Breast cancer incidence and outcome disparities in the United States are due to multiple interacting factors. These include information about treatment, different types of treatment, the emotional context of decision-making, and patient preference for level of involvement. Treatment decision-making is complex. CONCLUSION: Health literacy and level of decision-making involvement, both embedded in social and economic reality, are key components in breast cancer treatment decision-making and may contribute to breast cancer disparities in the United States. Current models of shared decision-making may not be generalizable to all breast cancer patients. PRACTICE IMPLICATIONS: Optimal breast cancer outcomes for all women depend on culturally and ethnically appropriate professional support.     

Time trends in HIV incidence among homosexually active men seen at sexual health clinics in Australia, 1993-1999.

BACKGROUND: Increases in sexual risk behaviour have recently been reported among homosexually active men in Australia and in other industrialised countries, potentially facilitating an increase in HIV incidence. OBJECTIVE: To monitor HIV incidence among homosexually active men seen through a network of sexual health clinics in Australia. STUDY DESIGN: Selected metropolitan public sexual health clinics provided counts of the number of people seen at the clinics during a calendar year, the number voluntarily tested for HIV antibody and the number newly diagnosed with HIV infection, broken down by sex, age group, HIV exposure category and HIV antibody testing history. HIV incidence was estimated among homosexually active men with a history of a negative test in the 12 months prior to last being seen in a calendar year. RESULTS: Of 23924 men seen at the clinics in 1993-1999 with a reported history of male homosexual contact, 7440 (31.1%) had a negative test in the 12 months prior to last being seen in a calendar year. The percentage of men with a recent negative test declined significantly over time, from more than 33% in 1994-1996 to 29% in 1999 (P=0.003), and with increasing age, from 34.3% among men aged 25-29 years to 27.4% among men aged 40 years or older (P<0.0005). A total of 5346 (71.9%) men were retested for HIV antibody within 12 months of the last negative test. The percentage of men retested declined significantly over time, from 77.8% in 1994 to 67.2% in 1999 (P=0.021) but did not change by age group (P=0.132). Overall, 56 men were newly diagnosed with HIV infection. Estimated HIV incidence was 2.1% in 1993-1999; incidence did not change significantly by year (P=0.498) or age group (P=0.757). CONCLUSION: HIV incidence has remained stable among homosexually active men seen through a network of sexual health clinics in Australia.     

Light-to-moderate alcohol consumption and risk of stroke among U.S. male physicians

BACKGROUND: Several studies have shown U- or J-shaped relations between alcohol consumption and the risk of stroke. We evaluated the effect of light-to-moderate alcohol intake on the risk of stroke, with separate analyses of ischemic stroke and hemorrhagic stroke. METHODS: Our analyses were based on a prospective cohort study of 22,071 male physicians, 40 to 84 years old, who were participating in the Physicians' Health Study. At base line, the participants reported that they had no history of stroke, transient ischemic attack, or myocardial infarction and were free of cancer. Alcohol intake, reported by 21,870 participants at base line, ranged from none or almost none to two or more drinks per day. RESULTS: During an average of 12.2 years of follow-up, 679 strokes were reported. As compared with participants who had less than one drink per week, those who drank more had a reduced overall risk of stroke (relative risk, 0.79; 95 percent confidence interval, 0.66 to 0.94) and a reduced risk of ischemic stroke (relative risk, 0.77; 95 percent confidence interval, 0.63 to 0.94). There was no statistically significant association between alcohol consumption and hemorrhagic stroke. The overall relative risks of stroke for the men who had one drink per week, two to four drinks per week, five or six drinks per week, or one or more drinks per day were 0.78 (95 percent confidence interval, 0.59 to 1.04), 0.75 (95 percent confidence interval, 0.58 to 0.96), 0.83 (95 percent confidence interval, 0.62 to 1.11), and 0.80 (95 percent confidence interval, 0.64 to 0.99), respectively, in an analysis in which we controlled for major risk factors for stroke. CONCLUSIONS: Light-to-moderate alcohol consumption reduced the overall risk of stroke and the risk of ischemic stroke in men. The benefit is apparent with as little as one drink per week. Greater consumption, up to one drink per day, does not increase the observed benefit.     

Risk factors for hysterectomy among Mexican‐American women in the U.S. southwest

The purpose of this study was to assess risk factors associated with a history of hysterectomy among Mexican‐American women living in the United States Southwest. Mexican‐American women ages 20–74 at time of interview were defined as a subpopulation among adults in the Hispanic Health and Nutrition Examination Survey (HHANES), 1982–1984. Language preference, reproductive history, level of education, poverty status, generation of immigration, marital status, and insurance coverage were examined in relation to risk of hysterectomy using weighted tabulation and logistic regression for data resulting from complex survey designs. Heretofore, language preference has not been a variable considered in relation to risk of hysterectomy. In the HHANES, over 60% of women who spoke English most often rather than Spanish reported a history of hysterectomy. Women who had previously been pregnant were almost four times as likely (odds ratio 3.972) to have had a hysterectomy compared to women who had never been pregnant. Women who expressed any preference for English were twice as likely (odds ratio 2.050) to have had a hysterectomy than were those who responded that they exclusively preferred Spanish. Age, higher levels of education, and higher economic status also increased the risk of hysterectomy. In contrast, reproductive history, marital status, prior tubal ligation, generation of immigration, and health insurance did not have substantial effects on the risk of hysterectomy. This study suggests that, in the future, the effect of language preference should not be overlooked when considering risk factors for hysterectomy. Am. J. Hum. Biol. 15:38–47, 2003. © 2002 Wiley‐Liss, Inc.     

Patient-related factors predicting HIV medication adherence among men and women with alcohol problems

The study explored the relationship between HIV medication adherence and alcohol, cognitive, social and affective factors in 272 persons with alcohol problems. Alcohol and cognitive factors significantly differentiated those who did and did not adhere. Specifically, adherence confidence and number of drinks emerged as subfactors driving the associations to adherence. Among those who were less than perfectly adherent (n = 154), only alcohol factors predicted levels of nonadherence. Cognitive factors play a role in understanding some of the differences between those who do and do not adhere to their HIV medications, but they do not differentiate among levels of nonadherence.     

Fertility in young men and women after treatment for lymphoma: a study of a population.

All young patients in the Grampian area attending the lymphoma review clinic who had received first line treatment for Hodgkin's disease and had attained complete remission without subsequent relapse were studied between 1980 and 1983. Chemotherapy with MVPP (mustine, vinblastine, procarbazine, and prednisolone) had more severe effects on the fertility of men than that of women; younger women and those taking oral contraceptives were more likely to retain fertility than those over 30 or not taking the pill at the time of chemotherapy, but these two effects could not be differentiated. Premature menopause was common after treatment with MVPP. Mantle radiotherapy had no discernible effect on gonadal function.     

STD-/HIV-related sexual risk behaviors and substance use among U.S. rural adolescents

OBJECTIVES: The present study aims to examine the relationship between substance use and HIV/sexually transmitted disease (STD)-related sexual risk behaviors among a national sample of sexually active adolescents in rural settings. METHODS: Participants included 9th-12th grade rural adolescents (N=5,745) who completed the 2003 national Youth Risk Behavior Survey. The independent variables were six substance use behaviors, including alcohol, marijuana, tobacco and cocaine use. The dependent variables were unprotected sex and the number of recent sexual partners. Univariate and multivariate logistic regression models were examined. RESULTS: Smoking > or =3 days during the past 30 days was associated with unprotected sex. Alcohol or drug use before last sexual intercourse, having ever used marijuana, having ever used cocaine and drinking alcohol during the past 30 days were associated with having multiple sexual partners. CONCLUSIONS: Results from the current study highlighted the need to provide youth with increased STD/HIV prevention knowledge in rural areas. Our finding confirmed that in order to achieve more effective STD/HIV prevention among high-risk substance-abusing youth, more intensive and better-tailored efforts will be needed to promote sexual risk reduction.     

Recruiting Latino women in the U.S. and women in Mexico in postpartum depression prevention research

The negative consequences of untreated depression on the health and well-being of women and their children are well-documented, underscoring the need to develop effective interventions to prevent the onset of major depression during the perinatal period. This article describes recruitment data from two randomized controlled trials of preventive interventions for postpartum depression: one conducted with immigrant Latinas in Washington, DC, United States, and the other with women in Mexico City, Mexico. In both countries, pregnant women met a priori eligibility criteria and were randomized into an 8-week theory-based group intervention. Two hundred and seventeen Latinas in the U.S. and 377 women born and raised in Mexico were enrolled in their respective countries. The recruitment rates (i.e., the number of participants who met eligibility criteria, consented, and randomized into the study) were 70% in the U.S. and in Mexico. Issues and recommendations related to recruiting Hispanic women into preventive intervention trials for postpartum depression are discussed.     

Molecular testing for Trichomonas vaginalis in women: results from a prospective U.S. clinical trial

Trichomoniasis is a common sexually transmitted disease associated with preterm birth, low birth weight, and increased susceptibility to infection with other pathogenic sexually transmitted microorganisms. Nucleic acid amplification tests for Trichomonas vaginalis have improved sensitivity for detecting infected individuals compared to existing culture-based methods. This prospective, multicenter U.S. clinical trial evaluated the performance of the automated Aptima T. vaginalis assay for detecting T. vaginalis in 1,025 asymptomatic and symptomatic women. Vaginal swab, endocervical swab, ThinPrep PreservCyt, and urine specimens were collected. Subject infection status was determined by wet-mount microscopy and culture. Aptima T. vaginalis assay performance was determined for each specimen type by comparison to subject infection status. Of 933 subjects analyzed, 59.9% were symptomatic. Aptima T. vaginalis clinical sensitivity and specificity were, respectively, 100% and 99.0% for vaginal swabs, 100% and 99.4% for endocervical swabs, 100% and 99.6% in ThinPrep samples, and 95.2% and 98.9% in urine specimens. Aptima T. vaginalis performance levels were similar in asymptomatic and symptomatic subjects. This study validates the clinical performance of the Aptima T. vaginalis assay for screening asymptomatic and symptomatic women for T. vaginalis infection.     

Genetic epidemiological studies of early-onset deafness in the U.S. school-age population

Profound, early-onset deafness is present in 4–11 per 10,000 children, and is attributable to genetic causes in at least 50% of cases. Family history questionnaires were sent to 26,152 families of children with profound, early-onset deafness not known to be related to an environmental cause. The probands were ascertained through the 1988–89 Gallaudet University Annual Survey of Hearing Impaired Children and Youth. The analysis is based on the responses that were received from 8,756 families. Classical segregation analysis was used to analyze the family data, and to estimate the proportions of sporadic, recessive and dominant causes of deafness in the families. These data were consistent with 37.2% of the cases due to sporadic causes, and 62.8% due to genetic causes (47.1% recessive, and 15.7% dominant). An earlier study using the 1969–70 Annual Survey found 49.3% sporadic cases and 50.6% genetic, demonstrating that the proportion of sporadic cases of early-onset deafness has significantly decreased since 1970. © 1993 Wiley-Liss, Inc.     

Religiosity,spirituality and antenatal anxiety in Southern U.S. women

Summary Introduction: We investigated the association between religiosity, spirituality, and anxiety in pregnant women, taking into account potential confounders. Materials and methods: From September 2005 through March 2006, pregnant women in three obstetrics practices in the American South were included in a cross-sectional study. The anxiety subscale of the Hospital Anxiety and Depression Scale (HADS) was used to measure anxiety. Results: Of the 344 participating women, 23 screened positive for moderate to severe anxiety (HADS [anxiety] score greater than 10). Overall religiosity or spirituality (odds ratio [OR], 0.53; p = 0.006) and social support (OR, 0.42; p < 0.0001) were significantly associated with significantly lower odds of a positive anxiety screen. Among the specific measures of religiosity or spirituality, self-rated religiosity, self-rated spirituality, and participation in nonorganizational religious activities were significantly associated with lower odds of moderate to severe anxiety symptoms. Discussion and conclusions: Religiosity and spirituality are associated with reduced anxiety in pregnant women. Additional study is needed to evaluate whether the association is causal. Correspondence: Joshua Mann, MD, MPH, Department of Family and Preventive Medicine, University of South Carolina School of Medicine, 3209 Colonial Drive, Columbia, SC 29203, U.S.A.     

Efficacy of a tailored tobacco control program on long-term use in a population of U.S. military troops

The authors evaluated the effect of a brief tailored smoking control intervention delivered during basic military training on tobacco use in a population of military personnel (N = 33,215). Participants were randomized to either a tobacco use intervention (smoking cessation, smokeless tobacco use cessation, or prevention depending on tobacco use history) or a health education control condition. Results indicated that smokers who received intervention were 1.16 (95% confidence interval [CI] = 1.04, 1.30) times (7-day point prevalence) and 1.23 (95% CI = 1.07, 1.41) times (continuous abstinence) more likely to be abstinent than controls from smoking cigarettes at the 1-year follow-up (p < .01); the cessation rate difference was 1.60% (31.09% vs. 29.49%) and 1.73% (15.47% vs. 13.74%) for point prevalence and continuous abstinence, respectively. Additionally, smokeless tobacco users were 1.33 (95% CI = 1.08, 1.63) times more likely than controls (p < .01) continuously abstinent at follow-up, an overall cessation rate difference of 5.44% (33.72% vs. 28.28%). The smoking prevention program had no impact on smoking initiation. These results suggest potential for large-scale tobacco control efforts.     

Prevalence of overweight and obesity in a U.S. pediatric surgical population

OBJECTIVE: To describe the prevalence of overweight and obesity in a pediatric surgical population from a large teaching hospital in the United States. METHODS AND PROCEDURES: We carried out a retrospective review of the perioperative database for the period January 2000 to December 2004 at the University of Michigan. Using directly measured height and weight, we computed body mass index (BMI) on 6,017 children. Overweight and obesity were defined using age- and gender-specific cut-off according to the National Center for Health Statistics (NCHS)/Centers for Disease Control and Prevention (CDC) (2000) growth charts. We also examined the type of surgical procedures most commonly performed on overweight and obese children, and the distribution of overweight and obese patients by preoperative American Society of Anesthesiologist (ASA) classification. RESULTS: We found a somewhat "heavy" pediatric population with a mean BMI of 21.6kg/m(2). The mean BMI in males was 21.7 kg/m(2) and 21.6 kg/m(2) in females. BMI showed a positive correlation with age overall (r=0.48, p < 0.01), and in both males and females. The overall prevalence of overweight and obesity using age-specific criteria was 14.4% and 17.2%, respectively. Approximately 10% of the children met adult criterion for obesity (BMI > or =30 kg/m(2)). Orthopedic and otolaryngological procedures were the most common surgeries in this cohort of overweight and obese children. We further found that 35.3% of obese and 20.6% of morbidly obese children were classified as ASA I. CONCLUSION: The prevalence of overweight and obesity is high in this pediatric surgical population. Follow-up studies examining the impact of overweight and obesity on perioperative outcome are needed.     

A randomized controlled trial of goal choice interventions for alcohol use disorders among men who have sex with men

This study tested the efficacy of behavioral treatments for alcohol use disorders (AUD) among men who have sex with men (MSM) and who are at risk for HIV transmission. HIV-negative MSM with current AUD (N = 198) were recruited, offered treatment focused on reducing drinking and HIV risk, and followed during treatment and 12 months posttreatment. Participants (n = 89) accepted treatment and were randomized to either 4 sessions of motivational interviewing (MI) or 12 sessions of combined MI and coping skills training (MI + CBT). Other participants (n = 109) declined treatment but were followed, forming a non-help-seeking group (NHS). MI yielded significantly better drinking outcomes during the 12-week treatment period than MI + CBT, but posttreatment outcomes were equivalent. NHS participants significantly reduced their drinking as well. Service delivery and treatment research implications are discussed.