Correlates of experiencing life events just before or during pregnancy.

This study evaluates the prevalence of selected life events around the time of pregnancy, examining changes in the prevalence of these events, and identifying maternal characteristics associated with these events. We used data from the Pregnancy Risk Assessment Monitoring System (PRAMS) to examine 18 stressful life events among women who recently gave birth and to identify maternal characteristics associated with these events. PRAMS is a mail sample survey with telephone follow-up for non-respondents. Sixty-four percent of women experienced at least one event. The prevalence of specific events ranged from 0.4 to 30%. Women who experienced events differed from those who did not. Most notably, women of low socioeconomic status (SES) were much more likely to experience stressful life events. These events were also associated with other demographic and behavioral characteristics after controlling for SES. These results have implications for interpreting studies of stressful life events. The strong associations with SES highlight the importance of controlling for SES in studies of life events and health, and of considering differences in SES when interpreting these studies.

Hormonal content and potency of oral contraceptives and breast cancer risk among young women.

Recent use of oral contraceptive pills is associated with a modest risk of breast cancer among very young women. In this US population-based case-control study, we evaluated whether the excess risk associated with recent oral contraceptive use is ubiquitous for all pill types or attributable to specific oral contraceptive preparations. Hormonal content and potency of combination oral contraceptives used for the longest duration within 5 years of interview for breast cancer cases aged 20-44 years (N=1640) were compared with age-matched community controls (N=1492). Women who recently used oral contraceptives containing more than 35 microg of ethinyl oestradiol per pill were at higher risk of breast cancer than users of lower dose preparations when compared to never users (respective relative risks of 1.99 and 1.27, P(trend)<0.01). This relationship was more marked among women <35 years of age, where risks associated with high- and low-dose ethinyl oestradiol use were 3.62 and 1.91 (P(trend)<0.01), respectively. We also found significant trends of increasing breast cancer risk for pills with higher progestin and oestrogen potencies (P(trend)<0.05), which were most pronounced among women aged <35 years of age (P(trend)<0.01). Risk was similar across recently used progestin types. Our findings suggest that newer low-potency/low oestrogen dose oral contraceptives may impart a lower risk of breast cancer than that associated with earlier high-potency/high-dose preparations.

Patterns and predictors of the breast cancer detection methods in women under 45 years of age (United States).

OBJECTIVES: Few studies have examined methods by which breast cancers are detected, and only one study has been published on predictors of those methods. This study examined patterns and predictors of breast cancer detection methods during 1990-1992 among women age 20-44. METHODS: In-person interview and medical record data were obtained during a population-based case-control study of 1619 women newly diagnosed with breast cancer in three areas of the United States (US). RESULTS: Seventy-one percent of the cancers were identified by self-detection, 9% by routine clinical breast exam (CBE), and 20% by routine mammography. Cancers detected by mammography and CBE, but not those detected by breast self-exam, were much more likely to be early-stage. Detection by mammography increased with age, and a history of mammography use was associated with detection by mammography or CBE. Several commonly studied predictors of screening utilization in the US population were associated with CBE detection, but were less clearly related to or unrelated to mammography detection. CONCLUSION: Findings suggest that, during the 1990s in the US, most breast cancers among women under age 45, including those age 40-44, were self-detected. Few factors other than age and prior screening are verified predictors of method of breast cancer detection.

Comparison of telephone sampling and area sampling: response rates and within-household coverage.

Random digit dialing is used frequently in epidemiologic case-control studies to select population-based controls, even when both cases and controls are interviewed face-to-face. However, concerns persist about the potential biases of random digit dialing, particularly given its generally lower response rates. In an Atlanta, Georgia, case-control study of breast cancer among women aged 20-54 years, all of whom were interviewed face-to-face, two statistically independent control groups were compared: those obtained through random digit dialing (n = 652) and those obtained through area probability sampling (n = 640). The household screening rate was significantly higher for the area sample, by 5.5%. Interview response rates were comparable. The telephone sample estimated a significantly larger percentage (by approximately 7%) of households to have no age-eligible women. Both control groups, appropriately weighted, had characteristics similar to US Census demographic characteristics for Atlanta women, except that respondents in both control groups were more educated and more likely to be married. The authors conclude that households contacted through random digit dialing are somewhat less likely to participate in the household screening process, and if they are cooperative, some households may not disclose that age-eligible women reside therein. Investigators need to develop improved methods for screening and enumerating household members in random digit dialing surveys that target a specific subpopulation, such as women.

Race and restless sleep complaint in older chronic dialysis patients and nondialysis community controls.

There is mixed evidence about the relation of race to risk of sleep disturbance. We explored the relation of race to restless sleep complaint in survey data from a cohort of 311 older patients undergoing chronic renal dialysis and a similarly aged cohort of 354 nondialysis controls. Older dialysis patients were significantly more likely to report restless sleep. Restless sleep complaint was related to comorbidity, depressed mood, use of sleep medications, and perceived health status in both groups. Black patients in the dialysis cohort had decreased odds of restless sleep, but Black and White controls did not differ significantly in reporting restless sleep. Compared with their more socially advantaged White counterparts, older Black dialysis patients may perceive the chronic dialysis care environment more favorably. The findings are consistent with the view that sleep quality in late life is likely to reflect a delicate balance between psychological as well as physical well-being.

Implementing the Institute of Medicine report on lesbian health.

The Institute of Medicine (IOM) recently published the report of its committee on lesbian health research priorities, which concluded that there has been little emphasis on and funding for research on the health of lesbians, despite the increased emphasis on women's health research in the 1990s. The report recommended additional research to determine if lesbians are at higher (or lower) risk for certain health problems than other women. It noted significant barriers to conducting lesbian health research, including lack of funding and several methodological issues. The IOM anticipates that the research recommended will benefit other populations as well. Several federal agencies in the Department of Health and Human Services can provide technical expertise and support to implement the report's recommendations, and suggestions are given here. The IOM report legitimizes scientific investigation into lesbian health, which should increase public and private research funding and the number of researchers in this area. A paradigm shift for lesbian health research is on the horizon, and we are grateful to the dedicated cadre of researchers, both published and unpublished, who have pioneered and persisted in this research during the past 25 years.

Methodologic concerns in defining lesbian for health research.

A recent report from the Institute of Medicine recommends more methodologic and substantive research on the health of lesbians. This study addresses one methodologic topic identified in the Institute of Medicine report and by a subsequent scientific workshop on lesbian health: the definition and assessment of sexual orientation among women. Data are from the Women Physicians' Health Study, a questionnaire-based U.S. probability sample survey (N = 4,501). The two items on sexual orientation (current self-identity and current sexual behavior) had a high response rate (96%), and cross-tabulation of responses indicated several combinations of identity and behavior. Three conceptually different definitions of "lesbian" are compared on the basis of (1) identity only, (2) sexual behavior only, and (3) both identity and sexual behavior. Suggestions and cautions are given to researchers who will add items on sexual orientation to new or ongoing research on women's health.

Black/white differences in symptoms and health satisfaction reported by older hemodialysis patients.

Although Black end-stage renal disease (ESRD) patients on dialysis report better functioning and well-being than do White patients, little is known about the association of race with disease symptoms and treatment side effects. Interviews were conducted with 183 older Black and 125 older White in-center hemodialysis (HD) patients in Georgia. Patients were identified in a stratified (by race and sex) random sample of patients aged 60+ years selected from the ESRD Network census of all patients in that age category. Self-assessed disease symptoms and/or side effects of treatment, disability days, and health satisfaction were measured. Data were analyzed via logistic or linear regression, controlling for the effects of patients' gender, age, months on dialysis, primary diagnosis of diabetes, cardiovascular co-morbidity, HD treatment time, and usual interdialytic weight gain. Older Whites, compared to older Blacks, were at increased risk for reporting nausea, sexual dysfunction, recent bed disability days, fatigue, greater HD recovery time, and health dissatisfaction. The relation of these complaints to dialysis adequacy and patients' nutritional status merits continued study.

U.S. Women Physicians' personal and clinical breast cancer screening practices.

Little is known about predictors of physicians' personal or clinical compliance with breast cancer screening recommendations. We explored this in 4501 respondents to the Women Physicians' Health Study, a questionnaire-based study of a representative sample of U.S. women M. D.s. Overall, 21% of women physicians performed breast self-examination (BSE) at least monthly, about two thirds had received a clinical breast examination (CBE) within the last year, and 85% had received one within the last 2 years. Of those <40 years old, 14% had received a mammogram in the past year, as had 42% of those 40-49 and 59% of those 50-70 years old. Being a primary care practitioners or obstetrician/gynecologist was a significant predictor of counseling or screening for CBE and mammography. Only 46% of all women physicians reported discussing or performing mammograms at least once a year for those >/=50-

Characteristics of respondents and non-respondents from a case-control study of breast cancer in younger women.

BACKGROUND: This study assessed the nature of potential biases by comparing respondents with non-respondents from a case-control study of breast cancer in younger women. METHODS: The case-control study was conducted in three regions in the US: Atlanta GA, Seattle/Puget Sound WA, and central New Jersey. An abbreviated interview or mailed questionnaire was completed by willing non-respondents, most of whom had refused participation in the main study. RESULTS: Respondents and non-respondents appeared similar with respect to age, race, relative weight, smoking, family history of breast cancer, number of births, age at first birth, and several dietary items. Compared to non-respondents, case and control respondents were of shorter stature, and reported less frequent consumption of doughnuts/pastries. Respondent cases, compared with non-respondent cases, were more highly educated and more likely to have consumed alcohol regularly; similar but not statistically significant tendencies were observed for controls. Respondent cases experienced menarche earlier than non-respondents. Respondent controls were more likely to have used oral contraceptives than non-respondents; a similar but not statistically significant tendency was observed in cases. Comparisons of crude and simulated relative risks using available non-respondents' data generally showed a low impact of non-response on relative risks in this study. CONCLUSIONS: Our results suggest that non-response would not greatly affect relative risk estimates in this study, except possibly regarding height. However, we were limited by the numbers of informative non-respondents and the amount of data collected. Collecting similar information in future studies would be useful, especially since varying methods used to encourage participation may lead to differences in respondents' characteristics.

Functional decline among older adults: comparing a chronic disease cohort and controls when mortality rates are markedly different.

In studies of functional status decline in older persons, the strategy for handling deaths during follow-up may influence policy implications. We compared 301 older ESRD dialysis patients with 322 controls to determine whether functional decline over 3 years among dialysis patients exceeded that of "normal aging." We used two different statistical methods and, for each, compared results when deaths were excluded and then included in the analysis. Dialysis patients incurred a larger follow-up mortality rate and were more impaired at baseline. Findings based on functional transition over time, assessed by a nominal variable, were sensitive to whether or not deaths were included in the analysis. However, findings based on nonparametric methods for an ordinal scale (functional impairment) were not sensitive to whether or not deaths were included in the analysis. Analyzing data with and without deceased subjects may be the most comprehensive approach to comparing two cohorts over time.

Menstrual risk factors and early-onset breast cancer.

OBJECTIVES: Epidemiologic studies provide evidence for increased breast cancer risk among women with prolonged exposure to endogenous estrogens and progesterone. Menstrual cycle characteristics, such as early menarche, rapid initiation of regular ovulatory cycles, short cycle length, and more days of flow, all potentially contribute to higher cumulative ovarian hormone exposure. METHODS: We assessed the associations between these characteristics and breast cancer risk in a population-based, case-control study of 1505 controls and 1647 newly diagnosed cases, all younger than 45 years of age. RESULTS: Compared to women with menarche at > or =15 years, we observed some increase in risk for women with younger ages at menarche, although those with very early ages were not at particularly high risk [odds ratio (OR) = 1.5, 95% confidence interval (CI) = 1.1-1.9 for menarche at age 12 and OR = 1.2, 95% CI = 0.9-1.7 for menarche at age < or =10]. Women who reported having regular menstrual cycles within 2 years of menarche were at increased breast cancer risk (OR = 1.7, 95% CI = 1.2-2.3), compared to those never having regular cycles. Stratification by current body mass index revealed slightly stronger associations with menstrual characteristics among thinner women (< 22.0 kg/m2) compared to heavier women (> 28.8 kg/m2). CONCLUSIONS: These findings suggest that future studies should focus on clarifying how the interrelated effects of body size and menstrual factors, such as age at menarche and cycle regularity, contribute to breast cancer etiology.

Functional impairment, depression, and life satisfaction among older hemodialysis patients and age-matched controls: a prospective study.

OBJECTIVE: To compare change over time in functional impairment, depression, and life satisfaction among older dialysis patients and age-matched controls. DESIGN: Prospective cohort study over 3 years. SETTING: Urban and rural communities throughout Georgia. SUBJECTS: One hundred thirteen prevalent renal failure patients on in-center hemodialysis and 286 controls. MAIN OUTCOME MEASURES: Ordinal functional impairment index and life satisfaction rating, and Center for Epidemiologic Studies Depression Scale. RESULTS: Dialysis patients, compared with controls, reported significantly more functional impairment at baseline, and also at follow-up after adjusting for baseline impairment and covariates. Dialysis patients had higher depression scores at baseline, and also at follow-up after adjusting for baseline depression and covariates. In contrast, dialysis patients reported lower life satisfaction at baseline than did controls, but the two cohorts were not significantly different on reported life satisfaction at follow-up, after adjusting for baseline life satisfaction and race. In both cohorts, functional impairment and depression were significantly related. CONCLUSION: Older dialysis patients' life satisfaction at a 3-year follow-up, which was similar to life satisfaction among age-matched controls, indicates the value of delivered dialysis care; the value of this care would be increased by reducing excess functional impairment in these patients.

Characteristics associated with recent recreational exercise among women 20 to 44 years of age.

Data on 1,501 control women from a multi-center, population-based, case-control study of breast cancer were used to examine characteristics associated with recreational exercise during the year prior to the interview among women 20 to 44 years of age. In a univariate analysis, higher levels of recreational exercise were associated with: higher education; higher family income; white race; previous participation in recreational exercise above the median level at ages 12 to 13 and at age 20; being nulliparous; ever lactating; being a never or past smoker; having a low current Quetelet's index (QI: weight in kilograms divided by height in meters squared); and living in Atlanta or Seattle (compared to New Jersey). In a multiple linear regression model, independent predictors of higher levels of recreational exercise were: participation in higher levels of exercise at 20 years of age; having a low current QI; and never having smoked. Though all women should be encouraged to participate in exercise, these findings identity subgroups of women that may need targeting when developing exercise intervention programs.

Breast cancer risk in young women and history of selected medical conditions.

BACKGROUND: Several common medical conditions are associated with altered hormone levels, and may thus plausibly influence breast cancer risk. Few studies have examined such relationships, and we utilized a population-based case-control study of young women in the US to examine breast cancer risk following a history of various medical conditions. Relationships between breast cancer and each medical condition examined are biologically plausible, and relevant in terms of public health. METHODS: The study included 2173 breast cancer cases and 1990 population-based controls from three areas of the US, under 55 years, who were administered a questionnaire including details of physician-diagnosed medical conditions. RESULTS: No significantly increased or decreased breast cancer risk was associated with a history of thyroid disease, gallbladder disease, colorectal polyps, diabetes, high blood pressure, high cholesterol or surgery for endometriosis. There was some evidence of an increased breast cancer risk associated with ovarian cysts among women who did not receive an oophorectomy (relative risk [RR] = 1.94, 95% CI: 1.0-3.9). Non-significant increases in breast cancer risk were observed following diagnoses of several other cancers, including thyroid cancer, basal cell carcinoma, Hodgkin's disease and malignant melanoma. CONCLUSIONS: To conclude, our generally null results from this large, population-based study support results from previous studies in providing reassurance that women with a history of several common medical conditions do not appear to be at an increased risk of breast cancer at a young age.

Risk of breast cancer in young women in relation to body size and weight gain in adolescence and early adulthood.

Findings have been inconsistent on effects of adolescent body size and adult weight gain on risk of breast cancer in young women. These relations were examined in a population-based case control study of 1590 women less than 45 years of age newly diagnosed with breast cancer during 1990-1992 in three areas of the US and an age-matched control group of 1390 women. Height and weight were measured at interview and participants asked to recall information about earlier body size. Logistic regression was used to estimate the relative risk of breast cancer adjusted for other risk factors. Women who were either much heavier or lighter than average in adolescence or at age 20 were at reduced risk. Weight gain after age 20 resulted in reduced risk, but the effect was confined to early-stage and, more specifically, lower grade breast cancer. Neither the risk reduction nor the variation by breast cancer stage or grade was explained by the method of cancer detection or by prior mammography history. These findings suggest that relations between breast cancer risk in young women and body weight at different ages is complex and that the risk reduction with adult weight gain is confined to less aggressive cancers.

Intake of food groups and associated micronutrients in relation to risk of early-stage breast cancer.

Epidemiologic studies have evaluated the risk of breast cancer related to dietary fat intake, but only recently have other dietary factors received attention. Frequent intakes of fruit, vegetables and fiber have been associated with low risk of the disease in some studies but results are inconsistent. In a large case-control study of early-onset breast cancer, we evaluated risk related to a variety of food groups, associated micronutrients and non-nutritive constituents. Cases treated with chemotherapy appeared to have altered reporting of food intake and were excluded. Analyses were restricted to 568 cases with in situ and localized disease and 1,451 population-based controls. Reduced risks were observed for high intake of cereals and grains [odds ratio (OR) = 0.84, 95% confidence interval (CI) = 0.6-1.1 for highest compared with lowest quartile], vegetables (OR = 0.86, 95% CI = 0.6-1.1), beans (OR = 0.87, 95% CI = 0.7-1.2) and fiber from beans (OR = 0.88, 95% CI = 0.7-1.2). However, no trends of decreasing risk across quartiles of increasing intake were observed. Risk was not associated with dietary constituents related to these food groups including dietary fiber, carotenoids, vitamins A, C and E and folate. Incorporation of information from vitamin supplements did not alter the results for micronutrients. Our data suggest that intakes of cereals and grains, vegetables and beans are associated with minimal, if any, reduction in risk of early-stage breast cancer among young women.

Stage of breast cancer in relation to body mass index and bra cup size.

Most studies on women with breast cancer indicate that obesity is positively associated with late-stage disease. Some results have shown a similar relationship between breast size and stage. A recent study found that the association between body mass index (BMI) and stage was limited to cancers that were self-detected, suggesting that the BMI-stage relation may be due to delayed symptom recognition. We examined the relationships between stage and both BMI and breast (bra cup) size, stratified by method of detection, using data from a population-based case-control study of 1,361 women (ages 20-44 years) diagnosed with breast cancer during 1990-1992. Height and weight measurements and information on bra cup size, method of cancer detection and other factors predictive of stage at diagnosis were collected during in-person interviews. A case-case comparison was conducted using logistic regression to estimate odds of regional or distant stage rather than local stage in relation to BMI and bra size. Odds of late-stage disease were increased with higher BMI [adjusted odds ratio (OR) for highest to lowest tertile = 1.46, 95% confidence interval (CI) 1.10-1.93] and larger bra cup size (OR for cup D vs. cup A = 1.61, 95% CI 1.04-2.48). These relationships were not modified by the method of detection. Differences in etiologic effects, rather than differences in detection methods, may explain the relations observed between stage and both BMI and breast size.