Colorectal cancer screening: Racial/ethnic and gender disparities in a population-based cross-sectional analysis of the United States

Gender and racial/ethnic disparities in colorectal cancer screening (CRC) has been observed and associated with income status, education level, treatment and late diagnosis. According to the American Cancer Society, among both males and females, CRC is the third most frequently diagnosed type of cancer and accounts for 10% of cancer deaths in the United States. Differences in CRC test use have been documented and limited to access to health care, demographics and health behaviors, but few studies have examined the correlates of CRC screening test use by gender. This present study examined the prevalence of CRC screening test use and assessed whether disparities are explained by gender and racial/ethnic differences. To assess these associations, the study utilized a cross-sectional design and examined the distribution of the covariates for gender and racial/ethnic group differences using the chi square statistic. Logistic regression was used to estimate the prevalence odds ratio and to adjust for the confounding effects of the covariates. ^ Results indicated there are disparities in the use of CRC screening test use and there were statistically significant difference in the prevalence for both FOBT and endoscopy screening between gender, χ2, p≤0.003. Females had a lower prevalence of endoscopy colorectal cancer screening than males when adjusting for age and education (OR 0.88, 95% CI 0.82–0.95). However, no statistically significant difference was reported between racial/ethnic groups, χ 2 p≤0.179 after adjusting for age, education and gender. For both FOBT and endoscopy screening Non-Hispanic Blacks and Hispanics had a lower prevalence of screening compared with Non-Hispanic Whites. In the multivariable regression model, the gender disparities could largely be explained by age, income status, education level, and marital status. Overall, individuals between the age "70–79" years old, were married, with some college education and income greater than $20,000 were associated with a higher prevalence of colorectal cancer screening test use within gender and racial/ethnic groups. ^

The coordinated approach to child health in underserved population (CATCH UP) curriculum: A quantitative evaluation of an innovative preschool obesity prevention program

Obesity has been on the rise in the United States over the last 30 years for all populations, including preschoolers. The purpose of the project was to develop an observation tool to measure physical activity levels in preschool children and use the tool in a pilot test of the CATCH UP curriculum at two Head Start Centers in Houston. Pretest and posttest interobserver agreements were all above 0.60 for physical activity level and physical activity type. Preschoolers spent the majority of their time in light physical activity (75.33% pretest, 87.77% posttest), and spent little time in moderate to vigorous physical activity (MVPA) (24.67% pretest, 12.23% posttest). Percent time spent in MVPA decreased significantly pretest to posttest from (F=5.738, p=0.043). While the pilot testing of the CATCH UP curriculum did not show an increase in MVPA, the SOFIT-P tool did show promising results as being a new method for collecting physical activity level data for preschoolers. Once the new tool has undergone more reliability and validity testing, it could allow for a more convenient method of collecting physical activity levels for preschoolers. ^

Theory of uncertainty in illness in patients with cancer of unknown primary origin: Structure providers as antecedents of uncertainty in a population of cancer patients with an unknown primary diagnosis

Uncertainty has been found to be a major component of the cancer experience and can dramatically affect psychosocial adaptation and outcomes of a patient's disease state (McCormick, 2002). Patients with a diagnosis of Carcinoma of Unknown Primary (CUP) may experience higher levels of uncertainty due to the unpredictability of current and future symptoms, limited treatment options and an undetermined life expectancy. To date, only one study has touched upon uncertainty and its' effects on those with CUP but no information exists concerning the effects of uncertainty regarding diagnosis and treatment on the distress level and psychosocial adjustment of this population (Parker & Lenzi, 2003). ^ Mishel's Uncertainty in Illness Theory (1984) proposes that uncertainty is preceded by three variables, one of which being Structure Providers. Structure Providers include credible authority, the degree of trust and confidence the patient has with their doctor, education and social support. It was the goal of this study to examine the relationship between uncertainty and Structure Providers to support the following hypotheses: (1) There will be a negative association between credible authority and uncertainty, (2) There will be a negative association between education level and uncertainty, and (3) There will be a negative association between social support and uncertainty. ^ This cross-sectional analysis utilized data from 219 patients following their initial consultation with their oncologist. Data included the Mishel Uncertainty in Illness Scale (MUIS) which was used to determine patients' uncertainty levels, the Medical Outcomes Study-Social Support Scale (MOSS-SSS) to assess patients, levels of social support, the Patient Satisfaction Questionnaire (PSQ-18) and the Cancer Diagnostic Interview Scale (CDIS) to measure credible authority and general demographic information to assess age, education, marital status and ethnicity. ^ In this study we found that uncertainty levels were generally higher in this sample as compared to other types of cancer populations. And while our results seemed to support most of our hypothesis, we were only able to show significant associations between two. The analyses indicated that credible authority measured by both the CDIS and the PSQ was a significant predictor of uncertainty as was social support measured by the MOSS-SS. Education has shown to have an inconsistent pattern of effect in relation to uncertainty and in the current study there was not enough data to significantly support our hypothesis. ^ The results of this study generally support Mishel's Theory of Uncertainty in Illness and highlight the importance of taking into consideration patients, psychosocial factors as well as employing proper communication practices between physicians and their patients.^

Outcomes associated with chemotherapy in elderly patients with early stage operable breast cancer

Background. Various clinical trials have proved the efficacy of adjuvant chemotherapy in women with breast cancer. Chemotherapy efficacy and guidelines for its use differ by stage of tumor and age of the patient with no clear recommendations for patients aged 70 and above. Objective. To examine the clinical and economic outcomes associated with chemotherapy use in and to examine the disparities in treatment and survival in elderly patients with early stage operable breast cancer by age and axillary node status. Methods. We studied a cohort of 23,110 node positive and 31,572 node negative women aged 65 and over diagnosed with incident American Joint Committee on Cancer (AJCC) stage I, II or IIIa breast cancer between January 1, 1991 and December 31, 2002 using SEER-Medicare data. Total patient costs were estimated using the phase of care approach and adjusted cost estimates were obtained from regression analysis using a 3% discount rate. Cox proportional hazard ratio of mortality was used to determine the effectiveness of chemotherapy. Propensity score approach was also used to minimize the bias associated with receipt of chemotherapy. To assess disparity in treatment, multivariate logistic regression analyses were performed to assess the relative odds of receiving surgery, chemotherapy and radiation after BCS for African Americans compared to Whites. Results. Regression adjusted cost estimates for all node positive patients receiving chemotherapy was approximately $2,300 and was significantly higher (p<0.05) than for patients not receiving chemotherapy. Mortality was significantly lower in node positive and node negative women aged 65-74 years receiving chemotherapy. There was a significant difference between African American and White women in receiving BCS and radiation after BCS; however this difference was explained by patient demographics, tumor characteristics and socioeconomic status (SES). African American node positive women were 21% less likely to receive chemotherapy than White women (OR, 0.79; CI, 0.68-0.92) in multivariate analysis. Conclusion. Chemotherapy is associated with increased survival in patients aged 65-74 and total costs attributable to chemotherapy differ by phase and age of the patient. Underutilization of systemic adjuvant chemotherapy in African American women requires attention and may serve as potential areas for appropriate intervention.^

Ethnicity as a risk factor for diabetes incidence in a population of diagnosed hypertensives

Significant racial/ethnic differences exist in prevalence of hypertension (HTN) and non-insulin dependent diabetes mellitus (NIDDM). Hypertension is more common in diabetics than in non-diabetics, and an etiologic link between the two conditions has been proposed. Since there are few longitudinal studies of persons with both HTN and NIDDM, a retrospective cohort study was conducted to determine if ethnicity (Black, Hispanic (Mexican-American), and non-Hispanic White) was related to NIDDM incidence in a low-SES, multi-ethnic clinic population of diagnosed hypertensives. Two thousand nine hundred forty-one hypertensives free of NIDDM at baseline were followed for up to 10 years. Mean baseline age was 56 $\pm$ 12 years, M:F percent was 33:67, and Black:Hispanic:White percent was 63:17:20. There were 236 incident cases of NIDDM. In Cox proportional hazards analysis, the risk of developing NIDDM over 10 years was not related to ethnicity after controlling for significant covariates, including age, baseline blood glucose and body mass index (adjusted RR for Blacks compared to Whites =.82, 95 percent CI =.57-1.18; adjusted RR for Hispanics compared to Whites =.84, 95 percent CI =.51-1.38). This result contrasts with the increased risk of NIDDM among Blacks and Hispanics compared to Whites found in the general population. The study suggests that a diagnosis of hypertension equalizes the risk of developing NIDDM among the three ethnic groups. ^

THE RELATIONSHIP BETWEEN SERUM CHOLESTEROL AND CANCER INCIDENCE IN THE POPULATION OF THE HYPERTENSION DETECTION AND FOLLOW-UP PROGRAM

The relationship between serum cholesterol and cancer incidence was investigated in the population of the Hypertension Detection and Follow-up Program (HDFP). The HDFP was a multi-center trial designed to test the effectiveness of a stepped program of medication in reducing mortality associated with hypertension. Over 10,000 participants, ages 30-69, were followed with clinic and home visits for a minimum of five years. Cancer incidence was ascertained from existing study documents, which included hospitalization records, autopsy reports and death certificates. During the five years of follow-up, 286 new cancer cases were documented. The distribution of sites and total number of cases were similar to those predicted using rates from the Third National Cancer Survey. A non-fasting baseline serum cholesterol level was available for most participants. Age, sex, and race specific five-year cancer incidence rates were computed for each cholesterol quartile. Rates were also computed by smoking status, education status, and percent ideal weight quartiles. In addition, these and other factors were investigated with the use of the multiple logistic model.^ For all cancers combined, a significant inverse relationship existed between baseline serum cholesterol levels and cancer incidence. Previously documented associations between smoking, education and cancer were also demonstrated but did not account for the relationship between serum cholesterol and cancer. The relationship was more evident in males than females but this was felt to represent the different distribution of occurrence of specific cancer sites in the two sexes. The inverse relationship existed for all specific sites investigated (except breast) although a level of statistical significance was reached only for prostate carcinoma. Analyses after exclusion of cases diagnosed during the first two years of follow-up still yielded an inverse relationship. Life table analysis indicated that competing risks during the period of follow-up did not account for the existence of an inverse relationship. It is concluded that a weak inverse relationship does exist between serum cholesterol for many but not all cancer sites. This relationship is not due to confounding by other known cancer risk factors, competing risks or persons entering the study with undiagnosed cancer. Not enough information is available at the present time to determine whether this relationship is causal and further research is suggested. ^

SEVERITY OF IRON DEFICIENCY ANEMIA AND ITS RELATIONSHIP TO GROWTH AND MORBIDITY IN A POPULATION OF PRE-SCHOOLERS IN RURAL GUATEMALA (IRON DEFICIENCY, MORBIDITY, GROWTH)

The objectives of this study were to determine the nature of the relationship between severity of iron deficiency anemia, response to iron treatment, respiratory and gastrointestinal illness and weight change. Seventy-five pre-school children from rural Guatemala received daily oral iron therapy for an eleven week period, and were classified into one of three groups having different degrees of iron deficiency anemia. Anthropometric and biochemical data were collected prior and after iron treatment; morbidity data were collected throughout the period of treatment. The outcome variables were percentage weight change, percentage of total days ill with any type of symptom, percentage of total days ill with gastrointestinal symptoms, percentage of total days ill with respiratory symptoms, percentage of total days ill with combination syndrome symptoms. Age, sex and socio-economic status, were independent of any of the independent or outcome variables used. On the other hand, the level of hemoglobin covaried with the height of the children, the smallest children were the most severely anemic. The relationships between hemoglobin levels and weight change, frequency of morbidity (gastrointestinal, respiratory and combination syndrome) and total number of days ill with any symptomatology were investigated. No statistical significance was found in these analyses except when contrasting children with normal hemoglobin levels to iron deficient children, where the findings indicated the normal children experienced more gastrointestinal morbidity. The same relationship were again analyzed but including delta hemoglobin as covariate in the analysis, this latter one was found to be significant at 7% when the percentage of days ill from gastrointestinal morbidity was tested against the hemoglobin groups. The relationship found indicates that, all other covariates accounted for, the percentage of days ill from gastrointestinal morbidity will decrease approximately 1% for each 1% increase in delta of hemoglobin. ^