Bladder cancer: race differences in extent of disease at diagnosis.

BACKGROUND: Blacks are less likely than whites to develop bladder cancer; although once diagnosed, blacks experience poorer survival. This study sought to examine multiple biological and behavioral factors and their influence on extent of disease. METHODS: A population-based cohort of black bladder cancer patients and a random sample of frequency-matched white bladder cancer patients, stratified by age, gender, and race were identified through cancer registry systems in metropolitan Atlanta, New Orleans, and the San Francisco/Oakland area. Patients were ages 20-79 years at bladder cancer diagnosis from 1985-1987, and had no previous cancer history. Medical records were reviewed at initial diagnosis. Of the patients selected for study, a total of 77% of patients was interviewed. Grade, stage, and other variables (including age, socioeconomic status, symptom duration, and smoking history) were recorded. Extent of disease was modeled in 497 patients with urothelial carcinoma using logistic regression. RESULTS: Extent of disease at diagnosis was significantly greater in Blacks than in Whites. Older age group, higher tumor grade, larger tumors, and presence of carcinoma in situ were related to greater extent of disease in blacks and in whites. Large disparities between blacks and whites were found for socioeconomic status and source of care. Blacks had greater symptom duration and higher grade. Black women were more likely to have invasive disease than white women; this difference was not seen among men. Blacks in unskilled occupational categories, perhaps reflecting socioeconomic factors, were at much higher risk for muscle invasion than whites. CONCLUSIONS: While specific relationships between variables were noted, an overall pattern defining black and white differences in stage did not emerge. Future studies should examine the basis upon which occupation and life style factors operate by using biochemical and molecular methods to study the genetic factors involved.

A diagnostic aid for detecting (DSM-IV) mental disorders in primary care.

This study was designed to develop and validate a new computerized version of the Symptom Driven Diagnostic System for Primary Care (SDDS-PC) and examine its feasibility in primary care practice. One thousand and one patients (ages 18-70) coming for routine care to Kaiser-Permanente were screened on a self-administered symptom scale for major depression, alcohol and drug dependence, generalized anxiety, panic and obsessive compulsive disorders, and suicidal behavior. The screen was followed up by a brief diagnostic interview, administered by a nurse, which yielded a one-page summary of positive symptoms and a provisional computer-generated diagnosis for the physician. The physician reviewed the summary results and made a diagnosis. The nurse and physician were blind to the screen results. Patients were reinterviewed within 96 hours by a mental health professional (MHP) blind to previous results. The nurses' interviews ranged between 1.5 and 3.5 minutes for a screened positive diagnosis. Agreement between the nurse and physician diagnoses was excellent to moderate. Disagreement was usually in the direction of the physician ruling out major mental disorders in favor of subsyndromal or medical explanations. Only rarely did physicians diagnose disorders not detected by the nurse interview. Agreement between physician and MHP was moderate. Physicians using the SDDS-PC seldom made diagnoses that were not confirmed by the independent assessment of the MHP. The SDDS-PC may facilitate recognition of psychiatric disorders and minimize the physician's time in information gathering.

Brief screens for mental disorders in primary care.

We evaluated a set of diagnostic screens for mental disorders in primary care. A self-administered screening questionnaire containing 26 items testing for multiple mental disorders was completed by 1,001 patients. Brief diagnostic modules, structured for psychiatric diagnoses, were subsequently administered to each patient by a research nurse. Operating characteristics of the screens were as follows: alcohol dependence (sensitivity [SE] 0.75; positive predictive value [PPV] 0.58; [kappa] 0.63), drug dependence (SE 0.50; PPV 0.50; kappa 0.50), generalized anxiety disorder (SE 0.74; PPV 0.44; kappa 0.44), major depressive disorder (SE 0.71; PPV 0.52; kappa 0.50), obsessive compulsive disorder (SE 0.71; PPV 0.15; kappa 0.21), and panic disorder (SE 0.71; PPV 0.43; kappa 0.48). Other chance-corrected measures of agreement are also reported, and criterion validity of the screens is examined. The results provide evidence that the screens discriminate between patients with symptomatology meeting established diagnostic criteria and those without. They detected previously unrecognized cases in this study and may prove to be valuable tools for psychiatric diagnosis in primary care.

Differences between black and white patients with cancer of the uterine corpus in interval from symptom recognition to initial medical consultation (United States).

To determine whether Black women with symptoms of uterine corpus cancer had longer times from symptom recognition to initial medical consultation than did White women in the United States, 331 newly diagnosed patients living in Atlanta (GA), New Orleans (LA), and San Francisco/Oakland (CA) during 1985-87 were interviewed to collect information on symptoms, dates of recognition and consultation, and other factors that might affect the interval. Data were analyzed to estimate medical consultation rates and rate ratios following symptom recognition. Median recalled times between symptom recognition and consultation were 16 days for Black women and 14 days for White women. Although poverty, having no usual source of healthcare, and other factors were associated with lower consultation rates, the adjusted rate among Black women was only somewhat lower (0.87) than among White women, and the 95 percent confidence interval (CI = 0.58-1.31) was consistent with no true difference between the races. In addition, the median time to consultation for women with stage IV cancer was only 15 days longer than the time (14 days) for the women with stage I cancer. These results suggest that time from symptom recognition to initial medical consultation does not contribute importantly to the more advanced stage cancer of the uterine corpus commonly found among Black women.

Psychological management by family physicians.

BACKGROUND: It is frequently assumed that primary care physicians seldom provide psychological interventions to their patients with mental health problems. This study examines self-reports of psychological interventions by family physicians. METHODS: Primary care patients (N = 937) completed a mental health screening form immediately prior to their medical visit. Results were withheld from their seven respective physicians. Following the visit, the physicians were asked to classify the range of psychological interventions they used to manage their patients' emotional problems during the visit. A structured psychiatric diagnostic interview was subsequently administered to a subgroup of the patients (n = 388). RESULTS: At least one psychological intervention was provided to nearly one fourth (24.1%) of the patients. The interventions included listening to the patient's emotional problems (22.4%), providing advice (19.0%), discussing the patient's mental disorder diagnosis (11.4%), and providing individual counseling (8.4%) or family counseling (0.6%). Two thirds (66.7%) of the patients who reported that their emotional health was poor received at least one of these psychological interventions. In a multivariate model, the likelihood of receiving a psychological intervention was higher for patients who were separated or divorced; those between 45 and 59 years of age; those with less than a college education; those who received disability payments; those who reported poor emotional health; and those who had a positive screening result for panic disorder, major depressive disorder, or obsessive-compulsive disorder. CONCLUSIONS: Primary care physicians may be far more extensively involved in providing psychological interventions than is commonly assumed.

Prevalence of mental disorders in primary care. Implications for screening.

OBJECTIVES: To determine the prevalence of five mental disorders in primary care and to identify patient groups that have a relatively high prevalence of these disorders. DESIGN: Two-stage case identification design that involves administration of a 16-item screening instrument followed by an independent diagnostic assessment. SETTING: Three family practice offices in Rhode Island. SUBJECTS: A total of 937 primary care patients completed the brief screen, 388 of whom completed the independent diagnostic assessment. PREVALENCE ESTIMATION: A Bayesian procedure was used to estimate prevalence of mental disorder from screening and assessment results. Independent assessments were based on the Structured Clinical Interview for DSM-III-R administered by a mental health professional. RESULTS: The prevalence estimates were alcohol abuse or dependence, 3.2%; generalized anxiety disorder, 2.8%; major depressive disorder, 14.1%; obsessive-compulsive disorder, 2.2%; panic disorder, 6.2%; and any of the five disorders, 22.0%. The prevalence of any of the five disorders was higher in patients returning for follow-up visits (27.9%) than in those either presenting with a new illness (21.7%) or seeking a routine physical examination (11.8%). The combined prevalence was also higher in patients with a chronic medical problem (25.8%) than in those without (16.7%). CONCLUSIONS: Patients returning for follow-up care and, to a lesser extent, those with chronic medical problems appear to be at increased risk of having a mental disorder. The practice of selectively screening new patients for mental health problems is questioned. Screening efforts in primary care should include established patients and those with chronic medical illnesses as well as new patients.

Recognition of emotional distress in physically healthy primary care patients who perceive poor physical health.

This study examines the recognition and treatment of emotional distress in physically healthy primary care patients who perceive themselves to be in fair or poor physical health. Patients (N = 892) from three private primary care practices completed a mental health screening form prior to their medical visit which included an overall assessment of their physical health (1 = excellent, 2 = good, 3 = fair, 4 = poor). Following the visit, their physicians completed a questionnaire that included the same physical health assessment item. The study group, physically healthy patients who perceive poor physical health (HPPPH), included those patients who rated their physical health as 2 or 3 points more impaired than it was rated by their physician. HPPPH (N = 39) were significantly more likely than other patients (N = 853) to report a prior psychiatric hospitalization (p < 0.05), marital difficulties (p < 0.01), recent missed work due to a mental health problem (p < 0.001), and a range of anxiety, depressive, and psychosomatic symptoms. However, HPPPH were also significantly more likely than other patients to receive excellent emotional health ratings (p < 0.001) from their physicians and were less likely to receive mental health treatment (p < 0.05). Detection of emotional distress may be particularly difficult in physically healthy patients who have low physical health perceptions. Identification of pessimistic physical health perceptions may serve as an indicator for underlying emotional distress.

Development and validation of the SDDS-PC screen for multiple mental disorders in primary care.

OBJECTIVE: To develop, validate, and cross-validate a patient-completed screen for multiple mental disorders in primary care. DESIGN: Comparison of a patient self-report screen with an independent diagnostic assessment by mental health professionals using the Structured Clinical Interview for DSM-III-R diagnoses as criterion standard. SETTING: Three Rhode Island family practices and a South Carolina family medicine residency. SUBJECTS: In the initial validation study, 937 patients in Rhode Island were screened; 388 were interviewed. In the cross-validation study, 775 patients were screened in Rhode Island and South Carolina, and 257 were interviewed. SCREEN ITEMS: Sixty-two questions pertaining to nine mental disorders and suicidal ideation. RESULTS: A 16-item screen remained after analysis of item and scale performance. Sensitivity, specificity, and positive predictive value, respectively, were calculated for the following scales: alcohol abuse or dependence (62%, 98%, and 54%), generalized anxiety disorder (90%, 54%, and 5%), major depression (90%, 77%, and 40%), obsessive-compulsive disorder (65%, 73%, and 5%), panic disorder (78%, 80%, and 21%), and suicidal ideation (43%, 91%, and 51%). Replication in a new sample showed attenuated but acceptable operating characteristics for cross-validation. CONCLUSIONS: The Symptom-Driven Diagnostic System for Primary Care screen assesses multiple mental disorders that are common to primary care. It serves as a sensitive, valid, and patient-friendly first step in a new approach to recognizing and managing mental disorders in primary care. Finally, it aids the primary care clinician in selecting an appropriate diagnostic interview module for the disease for which the patient screened positive.

Brief diagnostic interviews (SDDS-PC) for multiple mental disorders in primary care. A pilot study.

OBJECTIVE: To pilot test the feasibility and validity of new, brief, structured, physician-administered diagnostic interviews for six mental disorders in primary care patients identified from a patient-completed screen. DESIGN: Comparison of the new diagnostic interviews with the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition, version P (SCID-P), administered independently by a mental health professional. SETTING: Three Rhode Island family practices and a South Carolina family medicine residency. SUBJECTS: Consecutive patients of either sex, aged 18 to 70 years, who were able to read and write English were eligible for screening; 775 patients completed the screen. Of these, 246 screened positive for at least one disorder and received at least one module. Of these, 158 received a SCID-P interview. RESULTS: The diagnostic interviews were found useful by all 16 participating physicians. Eighty-seven percent reported that they diagnosed a new mental problem, and 93% said that the modules clarified suspected symptoms. However, 26% thought the procedure was too time consuming, and 80% believed that reimbursement would be necessary for routine use. Detection of cases using the diagnostic modules was associated with physician intervention and with independent assessment of patient impairment. Over three quarters of the patients (76.4%) who were classified as positive by the physician interview for any of the diagnoses also tested positive on the SCID-P. Two thirds of the patients (62.7%) with at least one of the disorders (according to SCID-P) were classified by the physician interview as having a mental disorder. However, the operating characteristics varied across specific disorders and indicated a need for revisions and testing in larger samples. CONCLUSIONS: These brief physician-administered diagnostic interview modules are part of a screening and diagnostic system (Symptom-Driven Diagnostic System for Primary Care [SDDS-PC], The UpJohn Co, Kalamazoo, Mich) to detect mental disorders in primary care patients. The pilot results help establish their feasibility and validity.

The SDDS-PC: a diagnostic aid for multiple mental disorders in primary care.

The Symptom Driven Diagnostic System for Primary Care (SDDS-PC) is a new computerized clinical procedure to assist primary care physicians in diagnosing mental disorders during the course of routine practice. It has three components: (1) a 5-minute patient-administered 16-item screening questionnaire, (2) six 5-minute physician-administered diagnostic interview modules based on DSM-III-R criteria, and (3) a longitudinal tracking form. The SDDS-PC covers five disorders (major depression, panic disorder, alcohol abuse or dependence, generalized anxiety disorder, and obsessive compulsive disorder) as well as suicidal ideation. Patients who screen positive for a disorder receive the corresponding diagnostic interview module. Patients who meet mental disorder criteria on the diagnostic interview module are then followed with the longitudinal tracking form. Minor or subsyndromal conditions are also addressed at the physician's discretion. This article describes the development of SDDS-PC and summarizes results from two studies which involved comparisons between the SDDS-PC and independently administered full-length structured diagnostic interviews.

The relationship between social ties and survival among black and white breast cancer patients. National Cancer Institute Black/White Cancer Survival Study Group.

The relationship between social ties, stage of disease, and survival was analyzed in a population-based sample of 525 black and 486 white women with newly diagnosed breast cancer. There were significant differences between the two race groups in reported social ties. Using logistic regression to adjust for the effects of age, race, study area, education, and the presence of symptoms, there was little or no evidence for an association between individual network measures of social ties and stage of disease. However, a summary measure of social networks was found to be associated modestly with late stage disease, attributable in part to significantly more advanced disease among black, but not white, women reporting few friends and relatives [relative risk (RR) = 1.8; 95% confidence interval (CI) = 1.1-3.0]. With adjustments for differences in stage of disease and other covariates, and with the use of Cox proportional hazards modeling to estimate hazard ratios, the absence of close ties and perceived sources of emotional support were associated significantly with an increased breast cancer death rate. White women in the lowest quartile of reported close friends and relatives had twice the breast cancer death rate of white women in the highest quartile (RR = 2.1; 95% CI = 1.1-4.4). Notably, both black and white women reporting few sources of emotional support had a higher death rate from their disease during the 5-year period of follow-up (RR = 1.8; 95% CI = 1.3-2.5).(ABSTRACT TRUNCATED AT 250 WORDS)

Breast cancer: factors associated with stage at diagnosis in black and white women. Black/White Cancer Survival Study Group.

BACKGROUND: Numerous studies have reported differences in cancer staging at diagnosis and in survival between Black and White patients with breast cancer. Utilizing data obtained from the National Cancer Institute's (NCI's) Black/White Cancer Survival Study for the period 1985-1986, a new study is presented here that systematically examines multiple explanatory factors (e.g., lack of mammograms) associated with these cancer-staging differences. PURPOSE: We evaluated within a single study the relationship of selected demographic, lifestyle, antecedent medical experiences, and health care access factors to cancer staging at diagnosis in Black and White breast cancer patients. METHODS: Data utilized in this population-based cohort study of 1222 eligible women (649 Black and 573 White) newly diagnosed for the period 1985-1986 with histologically confirmed primary breast cancer were obtained from the NCI's Black/White Cancer Survival Study. Sources of data included abstracts of hospital medical records, central review of histology slides by a study consultant pathologist, and patient interviews obtained from three metropolitan areas: Atlanta, New Orleans, and San Francisco-Oakland. Within each area, 70% of all Black incident cases were randomly selected, and a sample of White cases, frequency matched by age groups (20-49 years, 50-64 years, and 65-79 years), was selected for comparison. Stage of breast cancer at diagnosis was classified according to the international tumor-lymph node-metastases (TNM) system. Statistical models utilized in this study included the log-linear and polychotomous logistic regression with multiple predictor variables. RESULTS: Factors associated with cancer staging were differentially expressed in Blacks and Whites. Indicators of access to health care, a lack of mammograms, and an increased body mass index significantly (P < .02) contributed to stage differences in Blacks, whereas income was marginally associated (P = .06) with stage for Whites only. Nuclear grade, having a breast examination by a physician, and a history of patient delay explained approximately 50% of the excess risk for stage III-IV cancer versus stage I-IIN0 cancer among Blacks compared with Whites (odds ratio reduction from 2.19 to 1.68). CONCLUSION: These findings suggest that no single factor or group of factors can explain more than half of the race-stage differences noted in this study with respect to Black and White breast cancer patients.

Further psychometric evaluations of a class-ranking model as a predictor of graduates' clinical competence in the first year of residency.

PURPOSE: To investigate further the psychometrics of a class-ranking model in which a weight of one-third was assigned to performance measures in basic sciences and a weight of two-thirds to ratings on six core clerkships. METHOD: The first part of the study involved 215 graduates of Jefferson Medical College who--based on the ranking model--had been in the top and bottom quarters of the classes of 1991 and 1992. Six faculty, who did not know the graduates' ranks but were familiar with their performances and characteristics, were asked to judge the graduates' potential to become competent physicians. The graduates' ranks according to the model were then compared with the ratings they received from the faculty. The second part of the study investigated whether there was a linear relationship between class ranks and ratings of postgraduate competence, by using directors' ratings of the data-gathering skills of 598 graduates (1986-1990) at the end of their first year of residency. RESULTS: A concordance rate of 85% was obtained between the graduates' ranks and the ratings they received from the medical school faculty, which supports the criterion-related validity of the ranking model. In addition, class ranks were linearly related to ratings of postgraduate competence. However, women and graduates who had been low achievers in medical school were less likely to have given permission for collecting postgraduate ratings, which led to range restriction and a possible underestimation of the validity of the model. CONCLUSION: The psychometric evidence supports the class-ranking model, but other schools should exercise caution in employing the model until they accumulate evidence from data obtained from their own students.