Cancer prevention: major initiatives and looking into the future.

Cancer is one of the major causes of death in countries across the world. However, at least half of cancers could be prevented. This article reviews the relationship between cancer incidence and the major risk factors: tobacco use, exposure to infections, nutrition, obesity and physical activity. Several major current cancer prevention initiatives are presented, including the effort for global tobacco control, vaccination programs for human papilloma virus, chemoprevention, and cohort studies to identify and elucidate cancer causes. Two concerns that cross the cancer prevention research spectrum are the importance of social determinants of health, and the potential role of genetic factors in explaining cancer incidence and guiding intervention development. In the future, optimism is warranted regarding cancer prevention. If currently known criteria are applied and extended, significant reductions in cancer rates are possible.

Impact of a peer-delivered telephone intervention for women experiencing a breast cancer recurrence.

PURPOSE: A first breast cancer recurrence creates considerable distress, yet few psychosocial interventions directed at this population have been reported. The Southwest Oncology Group conducted a phase III randomized trial to evaluate the effectiveness of a brief telephone intervention. PATIENTS AND METHODS: Three hundred five women experiencing a first recurrence of breast cancer were randomly assigned to standard care or intervention. The intervention consisted of four to eight telephone calls delivered over a 1-month period. The calls were conducted by trained peer counselors at a breast cancer advocacy organization, the Y-ME National Breast Cancer Organization, and followed a standard curriculum. Psychosocial distress (Cancer Rehabilitation Evaluation System-Short Form [CARES-SF]) and depressive symptoms (Center for Epidemiologic Studies Depression Scale [CES-D]) outcomes were assessed at baseline and 3 and 6 months. The 3-month assessment was the primary end point and is the focus of this article. RESULTS: Analysis revealed no differences in distress or depressive symptoms at 3 months between the intervention and control groups; at 3 months, 70% of control patients and 66% of intervention patients reported psychosocial distress, and 40% of control patients and 47% of intervention patients exhibited depressive symptoms. CONCLUSION: Telephone peer counseling did not lead to better psychosocial outcomes. The persistent distress in these women supports the urgent need for the development and testing of more intensive or different supportive interventions for this group of patients.

Assessing cancer-related quality of life across a spectrum of applications.

Health-related quality of life (HRQOL) is increasingly assessed to understand the effects of cancer and cancer-related interventions. At the macro level, monitoring HRQOL in the population and in cancer survivors may be important to track progress against cancer and evaluate the outcome of policies and programs. At the meso level, where most research, to date, has been focused, HRQOL data may be used in descriptive and analytic studies to understand the impact of cancer, patterns of care, and effects of interventions for cancer prevention, treatment, and continuing care. At the micro level, HRQOL data can inform individual patient and clinician decision making. Current data show that validated and commonly used HRQOL questionnaires are not interchangeable. Consequently, in determining which HRQOL measures are most appropriate for a given application, it is especially important to carefully consider both the study hypotheses and patient population. Future progress at all levels requires better understanding of the meaning and interpretation of HRQOL scores.

Quality of life in patients who survive a dire prognosis compared to control cancer survivors.

The primary goal of this study was to describe well-being and its correlates in long-term cancer survivors who had exceeded their life expectancies ('exceptional survivors' (ES)) and to identify ways in which exceptional survivors differed from cancer survivors with much better prognoses ('control survivors' (CS)). Survivors were identified through a population-based tumor registry, and ES (n = 160) were matched to CS (n = 160) on age, ethnicity, site of disease, and time since diagnosis. Data were collected through in person interviews and self-administered questionnaires. Outcomes included quality of life, depression, and stress. Predictors included demographics, clinical variables and psychological predictors (sense of coherence, optimism, and resiliency). The findings led to several clear conclusions: (1) cancer survivors are doing well, in comparison to well-being in control populations; (2) cancer survivors exhibit higher levels of sense of coherence and resilience, but not optimism, than control populations; (3) psychological variables explain considerable variance in well-being; and (4) there are few differences between exceptional and control survivors. We conclude that objective disease state is not as important to cancer survivor well-being as personal attributes, and that a cancer diagnosis has such frightening implications that all survivors consider their recovery to be 'exceptional'.

Cancer-related attitudes: A comparative study in Japan and the US.

The cancer-related attitudes and beliefs of adults living in central Japan (N = 357) were compared to those of respondents in a US state (Hawaii) (N = 223) consisting of both Japanese (n = 106) and Caucasian (n = 117) individuals. Almost all US subjects endorsed doctors disclosing cancer diagnoses to their patients, while a minority of the Japan sample supported cancer disclosure as a general practice. However, the majority of Japan respondents expressed a personal preference to be told if they themselves were diagnosed with cancer, as did virtually all US respondents. US subjects were more optimistic than Japanese subjects about cancer's curability, both at the present time and in the future; Japanese Americans scored intermediate between Japanese and Caucasian Americans. Word-association data indicated that cancer was most likely to be associated with death by Japanese respondents. The data support the continued international differences in views about cancer and suggest that some of these differences persist over many generations of US residence.

Health attitudes and behaviors: comparison of Japanese and Americans of Japanese and European Ancestry.

Adults living in Japan (N = 357) and the US (N = 223) completed semi-structured interviews assessing health-related attitudes and practices. The US respondents were of Japanese (N = 106) and European (N = 117) ancestry. Results indicated considerable similarity between the two US groups and significant differences between the Japanese and American respondents. The Japanese respondents placed less priority on health, had less belief in the efficacy of health screening tests, lower levels of internal health locus of control (HLOC), and higher levels of chance and powerful-others HLOC. While Japanese and Americans had similar overall levels of healthy behaviors, the Japanese were less likely to have obtained health screening tests (especially gynecologic exams). The findings have implications for adapting health promotion programs in the context of Japanese and American cultures.

Ethnic identities and lifestyles in a multi-ethnic cancer patient population.

This report examined ethnic identity in 367 recently diagnosed cancer patients in Hawai'i's primary ethnic groups: Japanese, Hawaiians, Europeans, and Filipinos. The study assessed ethnic self-identify; definitions of and participation in different ethnic lifestyles; and relationships between measures of ethnic self-identity, lifestyle, and other indicators of ethnic and cultural affiliations. Results indicated that medical record-based ethnic indicators were well linked to individual self-reports of family pedigree. Self-descriptors included non-standard terms such as "American" and "Local," and respondents reported following between five and six different ethnically-associated ways of life. Multivariate analysis indicated that ethnic self-identity made a unique contribution that went beyond standard ethnic and acculturative markers in explaining lifestyles. This study provides strong support for multiculturalism in this ethnically heterogeneous population.

Quality of life assessment in cancer clinical research: current status and a look to the future.

Quality of life (QOL) is a term that has been used to denote outcomes as experienced by the patient. Although definitions of QOL vary, virtually all investigators agree that QOL in clinically-ill individuals encompasses multiple domains or areas of well-being (including, at a minimum, physical, psychological and social functioning, as well as symptoms) and that the perspective of the patient is critical in any measurement of QOL. While patient perspectives are important in any health condition, they become particularly so in diseases which are chronic or incurable and for which treatments have toxic or long-lasting consequences. Cancer fits these criteria. Cancer is the second leading cause of death in the USA, with one in every four deaths due to the disease. Approximately 38% of cancer patients die within 5 years of diagnosis. Cancer treatments are powerful and toxic. For example, surgery removes tumors and in many cases, adjacent body parts. Radiation therapy kills cancer cells by directing high energy x-rays, electron beams or radioactive isotopes at tumors. Chemotherapy causes the death of cancer cells through the administration of agents that disrupt a cancer cell's growth cycle. All of these treatments affect normal tissue, as well as cancer cells, and generally result in multiple side effects, such as loss of hair, nausea and frequently vomiting which are associated with chemotherapy. Treatment-related effects may be short-term and time-limited, chronic and persistent or late that only emerge after therapy has been completed, sometimes many years later. Cancer therapy involves continual efforts to minimize side effects while at the same increasing the chances of surviving the disease. As such, patient perspectives become critical in evaluating whether or not therapies and their toxicities are tolerable and acceptable.

Assessment of quality of life in a multicultural cancer patient population.

Quality of life (QOL) is increasingly assessed in cancer patients. In this article, the authors examined the psychometric performance of a commonly used QOL questionnaire, the Quality of Life Questionnaire--Cancer 30 (QLQ-C30; N. K. Aaronson et al., 1993), in multiethnic cancer patients. Content validation studies in patients and clinicians identified possible new items. Multiple-group confirmatory factor analysis supported equivalent structure across ethnic groups (Caucasians and Asian/Pacific Islanders [APIs]). A higher order QOL factor appeared to directly affect functioning scales and symptom count. Exploratory factor analysis examined effects of new items. Ten factors were extracted, 6 consistent with the original instrument and 4 reflecting potentially new aspects of QOL: Positive Social Support, Coping, Existential Well-Being, and Sexuality/Intimacy. The QLQ-C30 appears appropriate for use in API cancer patients. Further work needs to ensure that it includes all important domains.

Ethnic differences in quality of life among early breast and prostate cancer survivors.

This study assessed quality of life (QOL) in recently diagnosed breast and prostate cancer patients of European American and Asian Pacific Islanders (specifically, individuals of Filipino, Japanese, and Native Hawaiian ancestry) to investigate whether QOL varied according to ethnicity and the relative importance of ethnicity as a predictor of QOL. Participants were identified through consecutive registrations on the Hawaii Tumor Registry, based on a diagnosis of breast or prostate cancer 4-6 months previously. QOL was measured by the QLQ-C30, a standardized questionnaire widely used in cancer patient populations. Two hundred and twenty-seven individuals participated (101 prostate and 126 breast cancer patients). QOL was similar across ethnic groups in most areas of QOL. However, differences were found in several areas, all in the direction of Filipino patients reporting worse outcomes. Hierarchical stepwise regressions supported the importance of ethnicity, controlling for clinical and demographic predictors. We conclude that additional research is needed to understand the relationship between ethnicity and QOL in cancer survivors.

Preferences for Psychosocial Interventions Among Newly Diagnosed Cancer Patients from a Multiethnic Population.

This article addresses preferences for psychosocial interventions in newly diagnosed cancer patients in a multiethnic sample consisting of Americans of European, Filipino, Native Hawaiian, and Japanese ancestry. Patients who were diagnosed with cancer four to six months before the study were identified through consecutive registrations on the Hawai'i Tumor Registry. Data were collected through personal interviews using a standardized questionnaire. Among 194 patients who participated in the study, 162 (84%) reported experiencing cancer-related stress. Although few patients had participated in supportive interventions, there was considerable interest in these techniques. Most patients had received information about diagnosis and treatment, but only 10% had received information about psychological counseling. When preferences for supportive interventions were linked with demographic characteristics (e.g., gender, age, and ethnicity), the most consistent finding was higher levels of interest among Filipino patients. Additional research examining ethnic differences in preferences for psychosocial support is warranted. Because of the potential for greater use of behavioral therapies by patients, educating providers about the availability, efficacy, and patients' interest in such interventions is needed.