Showing papers by "Karen M. Emmons published in 2008"

Risk Perceptions and Psychosocial Outcomes of Women With Ductal Carcinoma In Situ : Longitudinal Results From a Cohort Study

Abstract: Background Ductal carcinoma in situ (DCIS) has a generally favorable overall prognosis, with a systemic recurrence rate of approximately 1%, a local recurrence rate after mastectomy of 1%, and a local recurrence rate after breastconserving treatment of less than 10%. Preliminary studies have suggested that women with DCIS may overestimate their risk of disease recurrence. Few data exist regarding psychosocial outcomes for women with DCIS. Methods Women in Eastern Massachusetts with newly diagnosed DCIS were asked to participate in a longitudinal study of risk perceptions, psychosocial concerns, and health behaviors. Psychosocial outcomes after DCIS diagnosis and risk perceptions were evaluated at enrollment and at 9 and 18 months. All statistical tests were two-sided. Results Four hundred eighty-seven women with DCIS (64% of eligible participants) completed the enrollment survey. Overall quality of life was good among the women surveyed, and the substantial anxiety at enrollment decreased with time ( P < .001). At enrollment, 54% perceived at least a moderate risk for DCIS recurrence in the next 5 years, 68% in their lifetime; 39% perceived at least a moderate risk for invasive cancer in the next 5 years, 53% in their lifetime; and 28% perceived at least a moderate likelihood of DCIS spreading to other places in their body. At 18 months after enrollment, perceived risks had not statistically significantly changed from those at enrollment ( P = .38). Anxiety at enrollment was the factor that was most consistently and strongly associated with overestimation of future breast cancer – related risks (perceived moderate or greater risk vs less than moderate risk of DCIS recurring within 5 years: odds ratio [OR] = 4.0, 95% confidence interval [CI] = 1.6 to 9.9, P = .003; of invasive breast cancer within 5 years: OR = 4.3, 95% CI = 1.9 to 9.9, P < .001; and of invasive breast cancer during lifetime: OR = 5.3, 95% CI = 2.0 to 14.3, P < .001). Conclusions Many women with newly diagnosed DCIS have inaccurate perceptions of the breast cancer risks that they face, and anxiety is particularly associated with these inaccurate perceptions.

Positive, negative, and disparate--women's differing long-term psychosocial experiences of bilateral or contralateral prophylactic mastectomy

Abstract: Because of recent studies showing strong prevention benefit and acceptable psychosocial outcomes, more women may be considering prophylactic mastectomy. A growing literature shows some positive psychosocial outcomes for women with bilateral prophylactic mastectomy, but less is known about women with contralateral prophylactic mastectomy. Several surveys have shown that a large majority of women with prophylactic mastectomy report satisfaction with their decisions to have the procedure when asked in a quantitative, closed-ended format. We sought to explore the nuances of women's satisfaction with the procedure using a qualitative, open-ended format. We included open-ended questions as part of a mailed survey on psychosocial outcomes of prophylactic mastectomy. The research team coded and analyzed these responses using qualitative methods. We used simple descriptive statistics to compare the demographics of the entire survey sample to those women who answered the open-ended questions; the responses to the open- and closed-ended satisfaction questions, and the responses of women with bilateral and contralateral prophylactic mastectomy. Seventy-one percent of women with prophylactic mastectomy responded to the survey and 48% provided open-ended responses about psychosocial outcomes. Women's open-ended responses regarding psychosocial outcomes could be coded into one of three general categories--positive, negative, and disparate. In the subgroup of women with both open- and closed-ended responses, over 70% of women providing negative and disparate comments to the open-ended question simultaneously indicated satisfaction on a closed-ended question. Negative and disparate open-ended responses were twice as common among women with bilateral prophylactic mastectomy (52%) than women with contralateral prophylactic mastectomy (26%). These findings suggest that even among women who report general satisfaction with their decision to have prophylactic mastectomy via closed-ended survey questions, lingering negative psychosocial outcomes can remain, particularly among women with bilateral prophylactic mastectomy. This dichotomy could be an important factor to discuss in counseling women considering the procedure.

A Test of Numeric Formats for Communicating Risk Probabilities

Abstract: BACKGROUND: Because people frequently encounter information about the probability of health risks, there is a need for research to help identify the best formats for presenting these probabilities. METHODS: . Three waves of participants were recruited from visitors to a cancer-related Internet site. Participants were presented with a hypothetical scenario that required them to perform 2 mathematical operations of the types that might be encountered in discussions of risk. Each wave encountered different operations. The operations used were compare, halve, triple, add, sequence, and tradeoff. Three numeric formats for communicating risk likelihoods were tested: percentages (e.g., 12%), frequencies (e.g., 12 in 100), and 1 in n (e.g., 1 in 8), and many levels of risk magnitude were crossed with the 3 formats. RESULTS: . The total sample of 16,133 individuals represented an overall participation rate of 36.1%. Although the relative performance of the formats varied by operation, aggregated across operations, the percentage and frequency formats had higher overall accuracy rates than the 1-in-n format (57% and 55% v. 45%, respectively). Participants with less education, African Americans, Hispanics, and women had more difficulty with the mathematical operations. DISCUSSION: . Percentage and frequency formats facilitate performance of simple operations on risk probabilities compared with the 1-in-n format, which should usually be avoided. Language: en

Translating science to practice: community and academic perspectives.

Abstract: While evidence Reviews inform practice and policy guidelines, the gap between guidelines and implementation may be growing. We place dissemination and implementation Research in the context of other changes needed to drive Research into practice. Multilevel approaches to Research and dissemination are needed as are metrics to inform academic appointment and promotions. Moving beyond funding that stops and starts with grant cycles is a key issue from the community perspective to ensure continuity and improved health. Transdisciplinary approaches that cut across disciplinary boundaries to develop shared conceptual frameworks may help speed the integration of Research with practice. Identifying and implementing structural changes to develop and support transdisciplinary teams may further facilitate this process. Changes in the approaches used to structure and implement scientific advances into practice will help achieve the enormous potential to advance the health of the population.

Has the surge in media attention increased public awareness about colorectal cancer and screening

Abstract: The Centers for Disease Control and Prevention’s Screen for Life campaign in March 1999 followed by the creation of National Colorectal Cancer Awareness Month in March 2000 heralded a surge in media attention to promote awareness about CRC and stimulate interest in screening. Our objective was to assess whether these campaigns have achieved their goal of educating the public about CRC and screening. The study sample was comprised of mostly unscreened, average-risk, English-speaking patients aged 50–75 years seen in an urban primary care setting. Knowledge was assessed using a 12-item true/false questionnaire based primarily on the content of key messages endorsed by the National Colorectal Cancer Roundtable (Cancer 95:1618–1628, 2002) and adopted in many of the media campaigns. Multiple linear regression was performed to identify demographic correlates of knowledge. A total of 356 subjects (83%

Nativity and Cigarette Smoking among Lower Income Blacks: Results from the Healthy Directions Study

Abstract: Blacks in the United States bear the greatest disease burden associated with cigarette smoking. Previous studies have shown that the rapidly increasing population of foreign-born Blacks has lower smoking rates compared to their native-born counterparts. However, less is known about whether cigarette smoking among Blacks varies by region of birth (US, Africa, or the Caribbean), generational status, or acculturation. We examined the association between nativity and cigarette smoking among 667 Black adult men and women enrolled in the Harvard Cancer Prevention Program project. In multi-variable analyses, US-born Blacks were more likely to be smokers compared to those born in the Caribbean (OR = 0.16, 95% CI 0.08, and 0.34) or in Africa (OR = 0.24, 95% CI 0.08, and 0.74). Language acculturation was positively associated with cigarette smoking (OR = 2.62, 95% CI 1.17, and 5.85). We found that US-born Blacks were more likely to be current cigarette smokers than those born in either Caribbean or African countries. Our findings highlight the importance of intervening early new Black immigrants to stem the uptake of cigarette smoking behaviors as individuals become acculturated.

Measuring the Costs of Outreach Motivational Interviewing for Smoking Cessation and Relapse Prevention Among Low-Income Pregnant Women

Abstract: Background: Economic theory provides the philosophical foundation for valuing costs in judging medical and public health interventions. When evaluating smoking cessation interventions, accurate data on costs are essential for understanding resource consumption. Smoking cessation interventions, for which prior data on resource costs are typically not available, present special challenges. We develop a micro-costing methodology for estimating the real resource costs of outreach motivational interviewing (MI) for smoking cessation and relapse prevention among low-income pregnant women and report results from a randomized controlled trial (RCT) employing the methodology. Methodological standards in cost analysis are necessary for comparison and uniformity in analysis across interventions. Estimating the costs of outreach programs is critical for understanding the economics of reaching underserved and hard-to-reach populations. Methods: Randomized controlled trial (1997-2000) collecting primary cost data for intervention. A sample of 302 low-income pregnant women was recruited from multiple obstetrical sites in the Boston metropolitan area. MI delivered by outreach health nurses vs. usual care (UC), with economic costs as the main outcome measures. Results: The total cost of the MI intervention for 156 participants was $48,672 or $312 per participant. The total cost of $311.8 per participant for the MI intervention compared with a cost of $4.82 per participant for usual care, a difference of $307 ([CI], $289.2 to $322.8). The total fixed costs of the MI were $3,930 and the total variable costs of the MI were $44,710. The total expected program costs for delivering MI to 500 participants would be 147,430, assuming no economies of scale in program delivery. The main cost components of outreach MI were intervention delivery, travel time, scheduling, and training. Conclusion: Grounded in economic theory, this methodology systematically identifies and measures resource utilization, using a process tracking system and calculates both component-specific and total costs of outreach MI. The methodology could help improve collection of accurate data on costs and estimates of the real resource costs of interventions alongside clinical trials and improve the validity and reliability of estimates of resource costs for interventions targeted at underserved and hard-to-reach populations.

The SunWise Policy intervention for school-based sun protection: a pilot study.

Abstract: Skin cancer is highly preventable, but clearly there is a critical need to focus on better ways to disseminate information about known skin cancer prevention. The U.S. Environmental Protection Agency's (EPA) SunWise Program is one channel for reaching children, teachers, and school nurses. In a pilot study designed to increase adoption of school-based sun protection policies, 28 schools were randomly assigned to one of three groups: Control, which included the EPA's original SunWise curriculum toolkit; SunWise Policy, which included a revised toolkit emphasizing policy; and SunWise Policy plus Technical Assistance, which included the policy toolkit and 3 technical assistance phone calls. The enhanced SunWise Policy plus Technical Assistance intervention led to more new sun protection policies. Use of study interventions for improving sun protection practices such as policy toolkits or brief counseling can be easily interwoven into school hours by school nurses and other health educators.

Colorectal cancer screening awareness and intentions among low income, sociodemographically diverse adults under age 50

Abstract: Colorectal cancer (CRC) screening rates in the US are suboptimal, particularly among lower income and racial/ethnically diverse groups. If specific populations have limited awareness of screening when they reach age 50, there may be delays in screening adoption. This study investigated sociodemographic and social contextual factors associated with awareness of CRC and intentions to be screened at age 50 among 692 low income, racial, and ethnic minority adults living in low income housing. The majority of respondents (62%) were between ages 30 and 49, and 94% had some form of health insurance (e.g., Medicaid). About 70% reported having heard about CRC screening; 66% reported intentions to be screened at age 50. In multivariable analyses, screening awareness was associated with age and education. Immigrants who had English as a second language had lower awareness. Females tended to have higher awareness if they had private insurance; there were no differences among males. Multivariable analyses found that screening intentions were higher among men, those with more role responsibilities, more role conflicts, and higher levels of social cohesion. It is important to identify opportunities for maximizing screening uptake among those who become age-eligible for screening if we are to make a significant impact on CRC disparities.

Multiple Levels of Influence in the Adoption of Sun Protection Policies in Elementary Schools in Massachusetts

Abstract: Objective To understand the factors that may influence sun protection policy development if the Centers for Disease Control and Prevention guidelines are to be realized. Design Qualitative research methodology incorporating a socioecological framework using individual or small-group interviews, surveys, and environmental assessments with school superintendents, elementary school principals, elementary school nurses, and parent-teacher organization presidents and co-chairs as well as coding of school documents. Setting Elementary schools in Massachusetts. Participants Nine school superintendents, 18 elementary school principals, 18 elementary school nurses, and 16 parent-teacher organization presidents or co-chairs. Main Outcome Measures Presence of school sun protection policies, sun protection curriculum, and communication portals for sun protection information to parents. Results None of the schools in the 9 districts had a sun protection policy, and only 1 had any type of sun protection curriculum. However, nearly all principals were receptive to developing sun protection policies and to making structural changes to increase the amount of accessible shade if funding were available. Conclusions The schools' communication infrastructure could provide a key portal for disseminating sun protection information to parents. Although there are other resources that could be brought to bear, many challenges must be surmounted to develop effective sun protection policies.

Low discretionary time as a barrier to physical activity and intervention uptake.

Abstract: OBJECTIVE To determine whether self-reported discretionary time was associated with physical activity and uptake of a physical activity promotion intervention in a multi-ethnic urban sample. METHODS We examined the association of self-reported discretionary time with hours/week of leisure-time physical activity at baseline and physical activity intervention uptake. RESULTS Low levels of discretionary time were significantly (P<0.01) associated with fewer hours/week (beta=-0.78, 95%CI=-1.34, -0.22) of physical activity at baseline. Discretionary time was not associated with physical activity intervention uptake. CONCLUSION Lack of discretionary time may serve as barrier to physical activity, but its importance on intervention uptake is less clear.

Primary prevention, aging, and cancer: overview and future perspectives.

Abstract: Cancer specific primary prevention efforts for the geriatric population are not well-understood and are currently underutilized, despite the rapidly growing elderly population. Lifestyle changes such as smoking cessation, dietary change, and increasing physical activity have been shown to decrease the incidence of cancer in younger populations. However, a multitude of conceptual, methodological, and dissemination challenges arise when the goal is to apply primary prevention of cancer to the elderly. The state of the science is reviewed to reveal barriers in the uptake of cancer specific primary prevention practices, including the lack of data for the applicability of clinical research findings to older populations. Under representation of older adults in behavioral trials and research programs is hindering progress in understanding the physical health and lifestyle choices of older people. Efforts directed towards prevention in terms of promoting health behaviors may not only be clinically advantageous, but also cost-effective. Additionally, models for translating research findings on primary prevention from younger individuals to the elderly population needs to be addressed. Practitioners need to better understand opportunities for cancer specific primary prevention could enhance chronic disease management.

Perceptions of Health Promotion and Cancer Prevention Among Adults in Working-Class Occupations and Neighborhoods

Abstract: A social-contextual approach to cancer prevention among participants associated with the working class may result in behavior-change messages that are more relevant to them and contribute to a reduction in health disparities among classes. This article reports findings from a qualitative study of adults in working-class occupations and/or living in predominantly working-class neighborhoods that was designed to explore the circumstances influencing perceptions of health promotion, disease prevention, and cancer-risk reduction. Participants made only a weak connection between cancer prevention and general health-promotion behaviors. Results suggest that the complexity of communicating cancer-prevention messages with this audience may be compounded by their unfamiliarity with cancer prevention and their lack of recognition that certain behaviors may reduce cancer risk. Therefore, developing messages that consider the social context of participants' lives and link cancer prevention with health promotion, while maintaining cancer prevention as a distinct subcategory, may prove to be an effective education strategy.

Smoking Among Childhood Cancer Survivors: We Can Do Better

Abstract: JNCI Vol. 100, Issue 15 | August 6, 2008 The past several decades have brought unparalleled success in the treatment of childhood cancers, in many cases rendering once-fatal diseases curable. Along with these remarkable achievements has been an increased emphasis on survivorship and the late effects experienced following treatment. Although the specific types of health issues experienced later in life by childhood cancer survivors vary considerably by cancer type and treatment, recent work has shown that, compared with the general population, these survivors have increased risks of developing cardiovascular disease by early adulthood ( 1 ), a subsequent or second primary cancer, and pulmonary complications ( 2 ). Thus, it is important to minimize survivors ’ exposures to factors that might further increase the risks for these late effects. Smoking is a major cause of cardiovascular and pulmonary disease in the general population, and survivors of childhood cancer who smoke, especially those who have had cardiopulmonary toxic treatments, are at increased risks of developing these diseases. In this issue of the Journal, Frobisher et al. ( 3 ) present the prevalence of smoking among almost 15 000 childhood cancer survivors who are part of the British Childhood Cancer Survivor Study. They report that almost 30% of the survivors were ever smokers and 20% were current smokers. The good news is that this smoking prevalence is lower than that found among the general British population. These fi ndings are remarkably similar to the fi ndings from the US Childhood Cancer Survivor Study, in which 28% of survivors were ever smokers and 17% were current smokers ( 4 ). The methodologies, defi nitions of survivorship, and eligibility criteria of these two large cohorts are very similar. Thus, together these two studies suggest that regardless of the different health care systems and very different national approaches to tobacco control in Britain and the United States, almost one-third of the childhood cancer survivors in each country become a smoker at some point and about one-fi fth continue to smoke. The bad news, of course, is that even at a smoking rate of only 20%, the thousands of childhood cancer survivors who do smoke are increasing their risk of having a poor outcome. The fact that a preventable risk factor — smoking — may exacerbate late effects of cancer and its treatment and negatively affect long-term survival in the context of a once-fatal disease is disheartening. The goal from both oncology and public health perspectives should be for no childhood cancer survivors to smoke. It is indeed tragic for those who survive one cancer to be put at risk for other life-threatening diseases as a result of smoking. Particularly distressing is that both the British and US studies found that social factors are key predictors of smoking among childhood cancer survivors, refl ecting trends in the general population of both countries ( 5 , 6 ). In both cohorts, survivors who had lower incomes and less education were more likely to smoke. Given the extensive interactions with the health care system that survivors have had, it is disappointing, although perhaps not surprising, that they have not escaped the persistent impact that Affiliation of author : Dana-Farber Cancer Institute and Harvard School of Public Health, Boston, MA .

Understanding the role of ethnic status in Intensive Care Unit (ICU) deaths among advanced cancer patients

Abstract: 6506 Background: Studies suggest Blacks receive less aggressive, curative care for cancer but more aggressive care at end of life (EOL). This study investigated possible socio-cultural mediators (e...

Economic Evaluations of Smoking Cessation and Relapse Prevention Programs for Pregnant Women: A Systematic Review

Abstract: Objective: Smoking cessation and relapse prevention during and after pregnancy reduces the risk of adverse maternal and infant health outcomes, but the economic evaluations of such programs have not been systematically reviewed. This study aims to critically assess economic evaluations of smoking cessation and relapse prevention programs for pregnant women.Methods: All relevant English-language articles were identified using PubMed (January 1966-2003), the British National Health Service Economic Evaluation Database, and reference lists of key articles. Economic evaluations of smoking cessation and relapse prevention among pregnant women were reviewed. Fifty-one articles were retrieved, and eight articles were included and evaluated. A single reviewer extracted methodological details, study designs, and outcomes into summary tables. All studies were reviewed, and study quality was judged using the criteria recommended by the Panel on Cost-Effectiveness in Health and Medicine and the British Medical Journal (BMJ) checklist for economic evaluations.Results: The search retrieved 51 studies. No incremental cost-effectiveness studies or cost-utility studies were found. A narrative synthesis was conducted on the eight studies that met the inclusion criteria. Roughly one-third employed cost-benefit analyses (CBA). Those conducting CBA have found favorable benefit-cost ratios of up to 3:1; for every dollar invested $3 are saved in downstream health-related costs.Conclusions: CBA suggests favorable cost-benefit ratios for smoking cessation among pregnant women, although currently available economic evaluations of smoking cessation and relapse prevention programs for pregnant women provide limited evidence on cost-effectiveness to determine optimal resource allocation strategies. Although none of these studies had been performed in accordance with Panel recommendations or BMJ guidelines, they are, however, embryonic elements of a more systematic framework. Existing analyses suggest that the return on investment will far outweigh the costs for this critical population. There is significant potential to improve the quality of economic evaluations of such programs; therefore, additional analyses are needed. The article concludes with ideas on how to design and conduct an economic evaluation of such programs in accordance with accepted quality standards.