Background. Guidelines recommend that initiation of breast cancer screening (BCS) among women aged 40 to 49 years include a shared decision-making process. The objective of this study is to evaluate the effect of a breast cancer screening patient decision-aid (BCS-PtDA) on the strength of the relationship between individual risk and the decision to initiate BCS, knowledge, and decisional conflict. Methods. We conducted a randomized clinical trial of a BCS-PtDA that included individual risk estimates compared with usual care. Participants were women 39 to 48 years of age with no previous mammogram. Primary outcomes were strength of association between breast cancer risk and mammography uptake at 12 months, knowledge, and decisional conflict. Results. Of 204 participants, 65% were Black, the median age (interquartile range [IQR]) was 40.0 years (39.0-42.0), and median (IQR) breast cancer lifetime risk was 9.7% (9.2-11.1). Women who received mammography at 12 months had higher breast cancer lifetime risk than women who had not in both intervention (mean, 95% CI): 12.2% (10.8-13.6) versus 10.5% (9.8-11.2), P = 0.04, and control groups: 11.8% (10.4-13.1) versus 9.9% (9.2-10.6), P = 0.02. However, there was no difference between groups in the strength of association between mammography uptake and breast cancer risk (P = 0.87). Follow-up knowledge (0-5) was greater in the intervention versus control group (mean, 95% CI): 3.84 (3.5-4.2) versus 3.17 (2.8-3.5), P = 0.01. There was no change in decisional conflict score (1-100) between the intervention versus control group (mean, 95% CI): 24.8 (19.5-30.2) versus 32.4 (25.9-39.0), P = 0.07. Conclusions. The BCS-PtDA improved knowledge but did not affect risk-based decision making regarding age of initiation of BCS. These findings indicate the complexity of changing behaviors to incorporate objective risk in the medical decision-making process.
Valvular heart disease continues to be a significant burden to the U.S. population, and is likely to increase over the next several decades. While major technological advances have been made in repairing or replacing degenerating valves, improved outcomes have not affected all segments of society equally. The source of this disparity in outcomes after treatment of valvular disease is unknown. As clinical outcomes after surgical treatment of valvular disease, and especially mitral regurgitation (MR), are worse if intervention occurs after deterioration of left ventricular (LV) size and function, trans-thoracic echocardiographic (TTE) surveillance of patients with MR is indicated to avoid adverse ventricular remodeling. We hypothesized that patients at a lower socioeconomic status were less likely to receive TTE surveillance for MR within the appropriate guideline-indicated interval. We obtained records of all TTEs from 2001-2016 ordered at a large echocardiography laboratory and linked each TTE to patient demographic data. The primary outcome was receipt of a TTE within guideline recommended intervals for MR surveillance. Intervals between TTEs were coded as appropriate or inappropriate, and logistic regression was used to assess the association of race and income level with appropriateness while controlling for demographic and clinical factors. In total 31,058 patients with MR in 106,659 TTEs were assessed in the final cohort. Hispanic patients were less likely to receive appropriate TTEs (OR 0.89; p = 0.0440) than predicted by guidelines. Black race trended towards lower odds of receiving TTEs at appropriate intervals, but was not significant (OR 0.95; p = 0.2946). As patients aged, the odds of having a TTE within the appropriate time interval decreased across all races. Income level was not significantly associated with TTE appropriateness. We conclude that there are disparities in receipt of timely TTE surveillance, especially associated with Hispanic ethnicity. This may contribute to disparities in clinical outcomes after treatment of valvular disease, and provides an opportunity for care improvement.
Contralateral prophylactic mastectomy use has increased over the past decades among women with early-stage breast cancer. Racial differences in contralateral prophylactic mastectomy use are well described, but with unclear causes. This study examined contralateral prophylactic mastectomy use among black and white women and the contribution of differences in perceived risk to differences in use. We surveyed women diagnosed with early-stage unilateral breast cancer between ages 41-64 in Pennsylvania and Florida between 2007-2009 to collect data on breast cancer treatment, family history, education, income, insurance, and perceived risk. Clinical factors-age,stage at diagnosis, receptor status-were obtained from cancer registries. The relationships between patient factors and contralateral prophylactic mastectomy were assessed using logistic regression. The interaction between race and contralateral prophylactic mastectomy on the perceived risk of second breast cancers was tested using linear regression. Of 2182 study participants, 18% of whites underwent contralateral prophylactic mastectomy compared with 10% of blacks (p < 0.001). The racial difference remained after adjustment for clinical factors and family history (odds ratio = 2.32, 95% confidence interval 1.76-3.06, p < 0.001). The association between contralateral prophylactic mastectomy and a reduction in the perceived risk of second breast cancers was significantly smaller for blacks than whites. Blacks were less likely than whites to undergo contralateral prophylactic mastectomy even after adjustment for clinical factors. This racial difference in use may relate to the smaller impact of contralateral prophylactic mastectomy on the perceived risk of second breast cancers among blacks than among whites. Future research is needed to understand the overall impact of perceived risk on decisions about contralateral prophylactic mastectomy and how that may explain racial differences in use.
Abstract Background: Racial differences in cancer treatment may result, in part, from distinct physician practice styles in the setting of regional healthcare environments. Emerging methodological tools allow for physician social networks to be constructed and analyzed using claims data. Objective: To examine whether physician social networks are associated with variation and racial differences in treatment for men with localized prostate cancer. Research design: We performed a retrospective cohort study using 2004–2005 SEER-Medicare data from three cities. Algorithms were generated to identify a patient's primary care physicians, urologists, and radiation oncologists. Within each city, a network of these physicians was constructed, with physicians as the nodes and shared patients as the links (edges) between nodes. From the overall network structure, distinct subgroups of physicians were identified using the Girvan-Newman algorithm. Subgroups were defined as those physicians who were highly clustered with one another and with relatively sparse connections to physicians in other subgroups. Patients were assigned to the subgroup of their diagnosing urologist. Network measures were then incorporated in logistic regression analyses with robust standard errors to examine the predictors of treatment, adjusting for patient-level factors. Results: Patients who were seen by different subgroups of physician varied widely in their unadjusted rates of prostatectomy and the racial/ethnic and socioeconomic composition. In city A, for example, rates of prostatectomy varied from 8.6% to 25.3% for patients who saw different subgroups of doctors. Similarly, in city A, the proportion of minority patients ranged from 15.9% in one subgroup to 64.8% in another. After adjustment for patient-level covariates, patients who were diagnosed by a urologist in one of four subgroups had significantly lower odds of prostatectomy compared to those patients who saw urologists in the subgroup with the highest rates of prostatectomy. Similarly, in cities B and C, patients who saw specific subgroups had significantly lower odds of prostatectomy compared to the subgroup with the highest rates of prostatectomy. Contrary to our expectations, accounting for subgroups, did not appear to mediate racial/ethnic differences in rates of active treatment. Conclusions: Using claims data to map physician networks may provide insight into the observed variation in treatment patterns for men with prostate cancer. Physician networks may be used to identify densely connected physicians who disproportionately care for minority patients. Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):A98.
Introduction: Lower socioeconomic status (SES) associates independently with poorer outcomes after stroke. We have previously demonstrated that the relationship between low SES and worse stroke outcomes is mediated by larger infarct size on presentation. Here, we tested the hypothesis that the relationship between SES and initial stroke severity varies across stroke subtypes. Methods: Consecutive patients (N=1168) presenting to Massachusetts General Hospital with acute ischemic stroke (mean age= 68, 55.1% male) underwent brain MRI within 24 hrs of admission. Infarct volume on DWI and admission NIH stroke scale (NIHSS) score were recorded. Stroke etiology was classified using the causative classification system. SES was assessed using local median household income as a proxy (by home zip code, using U.S. Census Bureau Fact Finder). Results: Both infarct volume and admission NIHSS score increased with decreasing SES tertiles: [NIHSS median (IQR): 5.0 (2.0, 12.0) vs. 4.0 (2.0, 11.0), vs. 3.0 (1.0, 9.0), p = 0.002], [Infarct volume median (IQR): 7.2 (1.5, 28.2) vs. 5.9 (1.5, 30.2) vs. 4.6 (1.0, 19.9), p = 0.02]. This relationship was mainly driven by LAA and CE categories (Figure). Lower SES predicted infarct volume and NIHSS score in combined group of LAA and CE after adjusting for traditional stroke risk factors and history of previous stroke (standardized β [95% CI]) NIHSS: -0.15 [-1.6, - 0.5] p < 0.001, infarct size: - 0.10 [-10.6, -1.8], p = 0.006). Conclusions: While disparities in post stroke care may play an important role in the relationship between lower SES and worse outcomes, we show that this association is also significantly driven by a tendency towards developing larger, more severe strokes on presentation, mainly caused by LAA and CE.
Increasingly, cultural beliefs and values are being recognized as important to decision-making about cancer prevention and control. While empirical data are emerging on the relationship between cultural factors and prevention and control behaviors, this research has been conducted in only racial group using general instruments that were developed and validated in this population. To address this limitation, we conducted a multi-phased psychometric study to identify cultural values for cancer prevention and control in a racially and ethnically diverse sample and evaluate the properties of a multi-dimensional cultural values assessment tool (MCVAT). Subjects were 315 African American, 233 white, and 97 Hispanic adult men and women who participated in qualitative research to identify cultural values for cancer prevention and control (n=212) and a quantitative survey (n=430) to evaluate the psychometric properties of the MCVAT. In Phase I, values related to religion and spirituality (e.g., important to rely on God to prevent cancer), temporal orientation (e.g., use past health care experiences to make decisions about cancer screening), individualism (e.g., I should decide for myself when to have cancer screening), and collectivism (e.g., important to consider the impact on family members when making decisions about cancer screening) were identified through focus groups with study participants; items were generated to assess these values using an iterative process. In Phase II, we evaluated the psychometric properties of the MCVAT. Consistent with the results in Phase I, three reliable factors for religion (Cronbach9s alpha=0.95), collectivism (Cronbach9s alpha=0.80), and individualism (Cronbach9s alpha=0.75) were identified using exploratory factor analysis. Analysis of variance was used to evaluate the discriminate validity of cultural factors; religious values for cancer prevention and control were significantly different between African Americans, whites, and Hispanics (F=89.99, p=0.0001). Further, compared to whites, African Americans and Hispanics reported significantly greater levels of familial values for cancer prevention and control (F=3.09, p=0.05). Our findings demonstrate that specific cultural values for may be important for cancer prevention and control among African Americans, whites, and Hispanics.
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