Oncology Education in Medical Schools: Towards an Approach that Reflects Australia’s Health Care Needs

Cancer has recently overtaken heart disease to become the number 1 cause of mortality both globally and in Australia. As such, adequate oncology education must be an integral component of medical school if students are to achieve learning outcomes that meet the needs of the population. The aim of this review is to evaluate the current state of undergraduate oncology education and identify how Australian medical schools can improve oncology learning outcomes for students and, by derivative, improve healthcare outcomes for Australians with cancer. The review shows that oncology is generally not well represented in medical school curricula, that few medical schools offer mandatory oncology or palliative care rotations, and that junior doctors are exhibiting declining oncology knowledge and skills. To address these issues, Australian medical schools should implement the Oncology Education Committee’s Ideal Oncology Curriculum, enact mandatory oncology and palliative care clinical rotations for students, and in doing so, appreciate the importance of students’ differing approaches to learning.     

Predictors of biospecimen donation in the Black Women’s Health Study

Purpose

Although African-Americans experience higher cancer morbidity and mortality rates compared to their White counterparts, their participation in biospecimen research is lower than that of their white peers. This study investigated the prevalence and predictors of biospecimen donation in a large, cohort study of Black women.

Methods

The BWHS is a follow-up study of U.S. Black women aged 21–69 years enrolled through postal health questionnaires. Between January 2004 and December 2007, participants were sent a consent form with a postage-paid return envelope, and a mouthwash collection kit. Univariate and age- and educational status-adjusted logistic regression models were used to estimate the association of socio-demographic, lifestyle and medical factors with donation of biospecimens.

Results

Buccal cells with consent forms were obtained from 26,790 women, for a response rate of 51 %. The strongest predictors of biospecimen donation were age: response increased from 48.6 % among those aged <40 to 63.1 % among those aged 60 and older [RR 1.30 (95 % CI 1.27, 1.34)]; multivitamin use [RR (95 % CI) 1.32 (1.30, 1.34)]; physician visit in the previous 2 years [RR (95 % CI) 1.61 (1.58, 1.65)], and a history of breast [RR (95 % CI) 1.59 (1.56, 1.63)], colon [RR (95 % CI) 1.18 (1.16, 1.20)], and cervical [RR (95 % CI) 1.63 (1.60, 1.67)] cancer screening.

Conclusions

We found that 51 % of women in the geographically-dispersed Black Women’s Health Study cohort were willing to provide mouthwash samples to be used for genetic analyses. The response in this study is encouraging given published findings of low overall participation rates of African-Americans in genetic studies.

     

Association between psoriasis and incident cancer: the Iowa’s Women’s Health Study

Introduction  

Studies have reported higher cancer risk in individuals with psoriasis, a chronic inflammatory autoimmune disease; however, adjustment for potential confounders was lacking.     

Tea and coffee intake in relation to risk of breast cancer in the Black Women’s Health Study

Objective

Prospective studies of tea and coffee intake and breast cancer risk have yielded inconsistent results. None of these studies has reported separately on African-American women. We prospectively examined the relation of tea and coffee consumption to risk of breast cancer among 52,062 women aged 21–69 at enrollment in 1995 in the Black Women’s Health Study.

Methods

Dietary intake was assessed in 1995 and 2001 using a validated food frequency questionnaire. Cox proportional hazards models were used to estimate incidence rate ratios (IRR) and 95% confidence intervals (CI), adjusted for breast cancer risk factors.

Results

During 12 years of follow-up through 2007, there were 1,268 incident cases of breast cancer. Intakes of tea, coffee, and caffeine were not significantly associated with the risk of breast cancer overall. The IRRs for consumption of ≥4 cups/day compared with none were 1.13 (95% CI 0.78–1.63) for tea and 1.03 (95% CI 0.77–1.39) for caffeinated coffee, and the IRR for the top quintile relative to the bottom quintile of caffeine intake was 1.04 (95% CI 0.87–1.24). Consumption of tea, coffee, and caffeine was not significantly associated with breast cancer risk according to menopausal status or hormone receptor status.

Conclusion

Our findings suggest that intakes of tea, coffee, and caffeine are not associated with the risk of breast cancer among African-American women.     

Cervical Cancer Control: Deaf and Hearing Women’s Response to an Educational Video

Deaf people encounter barriers to accessing cancer information. In this study, a graphically enriched educational video about cervical cancer was created in American Sign Language, with English open captioning and voice overlay. Deaf (n = 127) and hearing (n = 106) women completed cancer knowledge surveys before and after viewing the video. Hearing women yielded higher scores before the intervention. Both groups demonstrated a significant increase in general and cervical cancer knowledge after viewing the video, rendering posttest knowledge scores nearly equal between the groups. These findings indicate that this video is an effective strategy for increasing cervical cancer knowledge among deaf women.     

Consumption of dairy and meat in relation to breast cancer risk in the Black Women’s Health Study

Purpose

Dairy and meat consumption may impact breast cancer risk through modification of hormones (e.g., estrogen), through specific nutrients (e.g., vitamin D), or through products formed in processing/cooking (e.g., heterocyclic amines). Results relating meat and dairy intake to breast cancer risk have been conflicting. Thus, we examined the risk of breast cancer in relation to intake of dairy and meat in a large prospective cohort study.

Methods

In the Black Women’s Health Study, 1,268 incident breast cancer cases were identified among 52,062 women during 12 years of follow-up. Multivariable (MV) relative risks (RRs) and 95 % confidence intervals (CIs) were calculated using Cox proportional hazards models.

Results

Null associations were observed for total milk (MV RR = 1.05, 95 % CI 0.74–1.46 comparing ≥1,000–0 g/week) and total meat (MV RR = 1.04, 95 % CI 0.85–1.28 comparing ≥1,000 < 400 g/week) intake and risk of breast cancer. Associations with intakes of specific types of dairy, specific types of meat, and dietary calcium and vitamin D were also null. The associations were not modified by reproductive (e.g., parity) or lifestyle factors (e.g., smoking). Associations with estrogen receptor (ER) positive (+), ER negative (?), progesterone receptor (PR) +, PR?, ER+/PR+, and ER?/PR? breast cancer were generally null.

Conclusions

This analysis of African-American women provides little support for associations of dairy and meat intake with breast cancer risk.     

Challenges in Indian Women’s Readiness to Quit Smokeless Tobacco Use

Introduction: In India, there are few cessation programs for women smokeless tobacco (SLT) users who want to quit.This paper uses Fishbein’s IM model to identify women SLT users’ challenges to quitting and multilevel correlates of“readiness to quit”. Methods: A survey of SLT use among women of reproductive age was conducted in 2010-13 in anurban slum community of Mumbai with a representative sample of 409 married women aged 18 to 40 years using at leastone type of SLT daily. Data were analyzed using frequencies, bivariate statistics and logistic regression. Results: Socialinfluences to continue SLT use included husband’s use (71%), family influence and positive beliefs and norms about use.Pressure to quit from significant others influenced past quit attempts but media had no effect on reported behavior. Fourgroups represented different readiness to quit statues based on intention to quit and past quit/reduce attempts. Seventeenpercent had no intention of quitting or reducing; their husbands were more likely to be tobacco users. Half of (52%)the sample had attempted to quit/reduce tobacco and intended to do so in the future. These women were depressed.Fifteen percent had tried to quit but did not intend to again. Correlates were positive beliefs and norms about SLT andwithdrawal symptoms. Conclusions: Cessation programs should be made available to women, addressing correlates ofwomen’s readiness to quit statuses. Results suggest the need for more complex social/contextual approaches to sustainedcessation of SLT use including addressing depression and withdrawal, improved media messages and campaigns tailoredto women, and support from family members.     

Targeting Health Disparity in Breast Cancer: Insights into Women’s Knowledge of their Cancer Profile in Malaysia

Objective: Poor health literacy is positively associated with poorer quality of health decision-making andhealth outcomes in women facing a cancer diagnosis. In developing countries, poor access to complete andaccurate information continues to pose a challenge for women. This paper describes the knowledge of Malaysianwomen with regard to breast cancer and how participation in a self-management program can improve thesituation. Methods: Secondary analysis of data collected during a clinical trial on women newly diagnosed withbreast cancer (n=147) was performed to examine baseline knowledge of breast cancer profile. Knowledge levelsof women in the experimental (n=69) group attending a self-management program were compared to a controlgroup (n=78) to determine change in the level of knowledge over time. Results: At baseline, a high percentageof women were unaware of their breast cancer profile. Not a single woman had knowledge of all six basiccharacteristics; 83% did not know their HER2 status, type of breast cancer (68%), grade of cancer cell (64%),hormonal receptor status (55%), size of breast cancer (18%) and/or their stage of breast cancer (13%). At postintervention, there was significantly better knowledge within the experimental group. Conclusion: Malaysianwomen in this cohort study demonstrated very low levels of knowledge of their cancer profile. Clinical implicationsfor countering treatment-decision difficulties include the need for a shift in the way information and servicesare delivered to allow women to take a more active role in their own care. Multi-modal efforts including basicinformation dissemination to increase women’s knowledge can contribute to narrowing of the gap in healthdisparity.     

Breast cancer in postmenopausal women after non-melanomatous skin cancer: the Women’s Health Initiative observational study

An increased risk of breast cancer has been reported in patients with non-melanomatous skin cancer (NMSC), but this association has not been studied in a large, multi-geographic population. We utilized data from the Women’s Health Initiative observational study to assess whether history of NMSC is associated with breast cancer risk. This analysis included 70,246 postmenopausal White and Hispanic women aged 50–79, in which 4,247 breast cancer cases were identified over a mean (SD) of 11.3 (3.2) years. Baseline information was collected on demographics, medical history, sun exposure, and vitamin D intake. Cox proportional hazards regression was used to calculate hazard ratios (HRs) with 95 % confidence intervals (CIs). The relationship between NMSC and breast cancer was examined as a time-dependent exposure using updated information on NMSC gathered during follow-up visits. All statistical tests were two sided. There were 5,595 women diagnosed with NMSC at study entry. The annualized rate of breast cancer was 0.64 % among women with a history of NMSC and 0.55 % among women with no history of NMSC. The multivariable-adjusted HR for breast cancer among women with a history of NMSC versus no history of NMSC was 1.07 (95 % CI 0.95–1.20, P = 0.27). Further evaluation stratified by tumor characteristics showed an increased risk of lymph node-positive disease, HR = 1.30 (95 % CI 1.01–1.67, P = 0.04), and regional-stage disease, HR = 1.33 (95 % CI 1.05–1.70, P = 0.02), among women with NMSC. There was no significant overall association between NMSC and breast cancer; however, there was an increased risk of more advanced-stage breast cancer which needs further exploration.     

The Women’s Health Initiative Randomized Controlled Dietary Modification Trial: a post-mortem

Ecological correlations derived from national mortality data and case–control studies have suggested a positive relation between dietary fat and risk of breast cancer. However, in the many large prospective studies that have been conducted more recently, little or no association has been found between total fat intake and breast cancer incidence. The recently released results from the Women’s Health Initiative Fat Reduction Trial found no significant effect of a low-fat diet on risk of breast cancer or total cancer incidence. However, methodologic limitations of this trial, particularly low compliance with the dietary intervention, make these data difficult to interpret, and in the end this massive trial contributes little to our understanding of the role of fat intake in the risk of breast cancer. A substantial body of available evidence now suggests that the percentage of energy derived from fat intake during midlife does not appear to be an important risk factor for breast cancer and is not the primary reason for the large international differences in disease incidence. Diet has a major impact on breast cancer risk, mainly mediated through childhood growth rates and weight gain in later life. Minimizing weight gain during midlife or weight loss after menopause reduces the risk of postmenopausal breast cancer. Massive randomized trials of behavior change to prevent cancer will usually not be a good investment, as clear answers are unlikely. The best information on prevention by diet and lifestyle will generally come from long-term prospective studies combined with controlled trials of intermediate endpoints.     

Abuse victimization and risk of breast cancer in the Black Women’s Health Study

Few studies have examined the relation between abuse victimization and breast cancer, and results have been inconclusive. Using data from 35,728 participants in the Black Women’s Health Study, we conducted multivariable Cox regression to estimate incidence rate ratios (IRRs) and 95% confidence intervals (CI) for the association of abuse across the life span (childhood, adolescence, and adulthood) with breast cancer. Incident breast cancer diagnoses were reported during 1995–2009, and abuse histories were reported in 2005. No associations were found between abuse victimization in either childhood or adolescence and breast cancer. We found a weak positive association between abuse in adulthood and breast cancer (IRR = 1.18, 95% CI = 1.03–1.34). IRRs for physical abuse only, sexual abuse only, and both physical and sexual abuse in adulthood, relative to no abuse, were 1.28 (95% CI = 1.09–1.49), 0.96 (95% CI = 0.76–1.20), and 1.22 (95% CI = 1.00–1.49), respectively. IRRs for low, intermediate, and high frequencies of physical abuse in adulthood, relative to no abuse, were 1.28 (95% CI = 1.07–1.52), 1.37 (95% CI = 1.04–1.79), and 1.24 (95% CI = 0.95–1.62), respectively. Our data suggest an increased risk of breast cancer among African-American women who reported physical abuse in adulthood, but there was little evidence of a dose–response relation. These results require confirmation in other studies.     

Examination with the Health Belief Model of Women’s Attitudes to Cervical Cancer and Early Diagnosis in Turkey: A Qualitative Study

Objective: The study was planned with the purpose of examining women’s attitude to the health belief model,and their attitudes and behavior towards cervical cancer and early diagnosis. Materials and methods: Thequalitative (case-study) method was used in this study. Data were collected between October 2010 and November2010 using a purposive sampling method for qualitative research. The study sample constituted from 11 womenbeing treated at two clinics, between the ages of 15 and 49, who were married, and who had not previously had apap-smear test. Data collection tool consist of two parts that are an “Information Form” identifying women andsemi-structured “Interview Form”. Interviews were done face to face by using in-depth interviews technique.Semi-structured interview was recorded in audio recording device. Content analysis method was used to assessthe data. Results: Awareness is insufficient that of women about cervical cancer prevention and early diagnosis,there is less fear of cervical cancer. Information of women is inadequate about early diagnosis and preventionof cervical cancer and there are various barriers about early detection and prevention. According to contentanalysis, three main themes emerge. These are the themes of belief, knowledge and barriers. Conclusions: Itbecame clear from interviews carried out in line with the health belief model why women did not exhibit positivehealth behavior. It is recommended that this study should be repeated in other parts of Turkey. In addition, thisstudy can serve as a guide to quantitative studies in wider communities.     

Vitamin D intake and breast cancer risk in postmenopausal women: the Iowa Women’s Health Study

Vitamin D, a prosteroid hormone with anti-proliferative and pro-differentiation activity, is thought to act as a cancer chemopreventive agent. This study evaluated the association between vitamin D intake and breast cancer risk among women in a large prospective cohort study. A total of 34,321 postmenopausal women who had completed a questionnaire that included diet and supplement use were followed for breast cancer incidence from 1986 to 2004. Adjusted relative risks (RR) for breast cancer were calculated for dietary, supplemental, and total vitamin D intake among all women. The adjusted RR of breast cancer for women consuming >800 IU/day versus <400 IU/day total vitamin D was 0.89 (95% CI: 0.77–1.03). RRs were stronger among women with negative than positive ER or PR status. The association of high vitamin D intake with breast cancer was strongest in the first 5 years after baseline dietary assessment (RR = 0.66; 95% CI: 0.46–0.94 compared with lowest-intake group), and diminished over time. Changes in vitamin D intake over time might have contributed to the diminished association observed in later years. Vitamin D intake of >800 IU/day appears to be associated with a small decrease in risk of breast cancer among postmenopausal women. Studies evaluating all sources of vitamin D, especially sun exposure, are needed to fully understand the association between vitamin D and breast cancer risk.     

Menstrual and reproductive factors in relation to mammographic density: the Study of Women’s Health Across the Nation (SWAN)

Menstrual and reproductive factors may increase breast cancer risk through a pathway that includes increased mammographic density. We assessed whether known or suspected menstrual and reproductive breast cancer risk factors were cross-sectionally associated with mammographic density, by measuring area of radiographic density and total breast area on mammograms from 801 participants in the Study of Women’s Health Across the Nation (SWAN), a multi-ethnic cohort of pre- and early perimenopausal women. From multivariable linear regression, the following menstrual or reproductive factors were independently associated with percent mammographic density (area of dense breast/breast area): older age at menarche (β = 10.3, P < 0.01, for >13 vs. <12 years), premenstrual cravings and bloating (β = −3.36, P = 0.02), younger age at first full-term birth (β = −8.12, P < 0.01 for ≤23 years versus no births), greater number of births (β = −6.80, P < 0.01 for ≥3 births versus no births), and premenopausal status (β = 3.78, P < 0.01 versus early perimenopausal). Only number of births remained associated with percent density after adjustment for age, race/ethnicity, study site, body mass index (BMI), and smoking. In addition, stratified analyses revealed that the association with number of births was confined to women within the lowest BMI tertile (β = −12.2, P < 0.01 for ≥3 births versus no births). Our data support a mechanism for parity and breast cancer that involves mammographic density among pre- and early perimenopausal women that may be modified by body size.     

Dietary carbohydrate, glycemic index, and glycemic load in relation to colorectal cancer risk in the Women’s Health Initiative

Evidence implicating hyperinsulinemia and insulin resistance in the etiology of colorectal cancer suggests that a diet characterized by a high glycemic index and load may increase the risk of this disease, but previous studies have yielded inconsistent results. We assessed the association between intake of total carbohydrates, sugars, fiber, and the glycemic index (GI) and glycemic load (GL) of individual diets, and risk of developing colorectal cancer among 158,800 participants in the Women’s Health Initiative (WHI). We used a GI/GL database developed specifically for the WHI food-frequency questionnaire. Over an average of 7.8 years of follow-up, 1,476 incident cases of colorectal cancer were identified. Cox proportional hazards models were used to estimate the association between dietary factors classified by quintiles and risk of colorectal cancer, with adjustment for covariates. Total carbohydrate intake, glycemic index, glycemic load, and intake of sugars and fiber showed no association with colorectal cancer. Analyses by cancer subsite also yielded null results, with the exception of a borderline positive association between glycemic load and rectal cancer (HR for the highest versus lowest quintile 1.84, 95% confidence interval 0.95–3.56, p for trend 0.05). Analyses stratified by tertiles of body mass index and physical activity showed no evidence of effect modification by these factors. Results of this large study do not support of a role of a diet characterized by high glycemic index or load in colorectal carcinogenesis in postmenopausal women. S. A. A. Beresford, B. Caan, M. L. Neuhouser, and L. F. Tinker are for the Women’s Health Initiative Investigators.     

C-reactive protein concentration and risk of selected obesity-related cancers in the Women’s Health Initiative

Background

Obesity is a chronic inflammatory condition strongly associated with the risk of numerous cancers. We examined the association between circulating high-sensitivity C-reactive protein (hsCRP), a biomarker of inflammation and strong correlate of obesity, and the risk of three understudied obesity-related cancers in postmenopausal women: ovarian cancer, kidney cancer, and multiple myeloma.

Methods

Participants were 24,205 postmenopausal women who had measurements of baseline serum hsCRP (mg/L) in the Women’s Health Initiative (WHI) CVD Biomarkers Cohort, a collection of four sub-studies within the WHI. Incident cancers were identified over 17.9 years of follow-up (n?=?153 ovarian, n?=?110 kidney, n?=?137 multiple myeloma). hsCRP was categorized into study-specific quartiles. Adjusted Cox regression models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for associations of baseline hsCRP with the risk of these cancers.

Results

There was no clear association between baseline hsCRP concentration and the risk of ovarian cancer (quartile 4 vs. 1: HR 0.87, 95% CI 0.56–1.37), kidney cancer (HR 0.95, 95% CI 0.56–1.61), or multiple myeloma (HR 0.82, 95% CI 0.52–1.29). HRs for 1 mg/L increases in hsCRP also approximated the null value for each cancer.

Conclusions

The results of this study suggest that elevated CRP is not a major risk factor for these obesity-related cancers (ovarian or kidney cancers, or multiple myeloma) among postmenopausal women. Given the importance of elucidating the mechanisms underlying the association of obesity with cancer risk, further analysis with expanded biomarkers and in larger or pooled prospective cohorts is warranted.