Informing the delivery of cancer survivorship care in rural primary care practice.

PURPOSE: The cancer survivor population is projected to increase to 22.2 million by 2030, requiring improved collaboration between oncology and primary care practices (PCP). PCPs may feel ill-equipped to provide cancer survivorship care to patients without input from cancer specialists. Compared with nonrural cancer survivors, rural cancer survivors report experiencing worse treatment-related symptoms. The goal of this study was to gain a better understanding of the perspectives of PCP teams towards survivorship care and to develop and test an interdisciplinary training program to improve cancer survivorship care in rural practice. METHODS: This study was conducted in two phases. First, focus groups were conducted with rural PCP teams to gather information regarding beliefs, practices, and barriers related to cancer survivorship care delivery. A thematic analysis was completed using an iterative process of reviewing transcripts. Results from phase 1 were used to inform the development of a pilot intervention tested within seven rural PCPs (phase 2). Pre- and post-intervention knowledge changes were compared, and post-session interviews assessed planned or sustained practice changes. RESULTS: Seven PCPs participated in focus groups (phase 1). Cross-cutting themes identified included (1) organizational barriers affecting the delivery of cancer survivorship care, (2) challenges of role delineation with specialists and patients, (3) difficulty accessing survivorship care and resources, and (4) providers' lack of knowledge of cancer survivorship care. For phase 2, seven practices participated in four case-based educational sessions. Within and between practice changes were identified. CONCLUSION: This project explored cancer survivorship perspectives among PCP teams. Lack of familiarity with evidence-based guidelines and the inability to identify cancer survivors was apparent during discussions and led to the implementation of the phase 2 intervention, iSurvive. As a result, PCPs either changed or planned changes to improve the identification and evidence-based care of cancer survivors. IMPLICATIONS FOR CANCER SURVIVORS: Address barriers to access cancer survivorship care in rural primary care practices.

Decisional stage distribution for colorectal cancer screening among diverse, low-income study participants.

Colorectal cancer (CRC) screening uptake among minorities and those with lower incomes is suboptimal. Behavioral interventions specifically tailored to these populations can increase screening rates and save lives. The Precaution Adoption Process Model (PAPM) allows assignment of a decisional stage for adoption of a behavior such as CRC screening. Here, we characterize the PAPM decisional stage distribution among 470 low income, racially and ethnically diverse study participants at intake into a behavioral intervention study designed to increase CRC screening uptake. We staged participants for stool blood test (SBT) and colonoscopy separately and used the highest stage for the two tests as the 'overall' stage for CRC screening. For SBT, sex, language (English versus Spanish) and doctor recommendation were significantly related to PAPM stage for CRC screening. For colonoscopy, language, education level, doctor recommendation and self-efficacy were related to stage. For overall CRC screening stage, all the variables associated with either SBT or colonoscopy, with the exception of language were significant. This study suggests attending to these key variables in designing interventions to promote CRC screening, particularly with respect to medically underserved populations.

Role of bacterial infection in the epigenetic regulation of Wnt antagonist WIF1 by PRC2 protein EZH2.

The enhancer of zeste homolog-2 (EZH2) represses gene transcription through histone H3 lysine-27-trimethylation (H3K27me3). Citrobacter rodentium (CR) promotes crypt hyperplasia and tumorigenesis by aberrantly regulating Wnt/ß-catenin signaling. We aimed at investigating EZH2's role in epigenetically regulating Wnt/ß-catenin signaling following bacterial infection. NIH:Swiss outbred and Apc(Min/+) mice were infected with CR (10(8) CFU); BLT1(-/-)Apc(Min/+) mice, azoxymethane (AOM)/dextran sodium sulfate (DSS)-treated mice and de-identified human adenocarcinoma samples were the models of colon cancer. Following infection with wild-type but not mutant CR, elevated EZH2 levels in the crypt at days 6 and 12 (peak hyperplasia) coincided with increases in H3K27me3 and ß-catenin levels, respectively. Chromatin immunoprecipitation revealed EZH2 and H3K27me3's occupancy on WIF1 (Wnt inhibitory factor 1) promoter resulting in reduced WIF1 mRNA and protein expression. Following EZH2 knockdown via small interfering RNA or EZH2-inhibitor deazaneplanocin A (Dznep) either alone or in combination with histone deacetylase inhibitor suberoylanilide hydroxamic acid, WIF1 promoter activity increased significantly while the overexpression of EZH2 attenuated WIF1 reporter activity. Ectopic overexpression of SET domain mutant (F681Y) almost completely rescued WIF1 reporter activity and partially rescued WIF1 protein levels, whereas H3K27me3 levels were significantly attenuated suggesting that an intact methyltransferases activity is required for EZH2-dependent effects. Interestingly, although ß-catenin levels were lower in EZH2-knocked down cells, F681Y mutants exhibited only partial reduction in ß-catenin levels. Besides EZH2, increases in miR-203 expression in the crypts at days 6 and 12 post infection correlated with reduced levels of its target WIF1; overexpression of miR-203 in primary colonocytes decreased WIF1 mRNA and protein levels. Elevated levels of EZH2 and ß-catenin with concomitant decrease in WIF1 expression in the polyps of CR-infected Apc(Min/+) mice paralleled changes recorded in BLT1(-/-)Apc(Min/+), AOM/DSS and human adenocarcinomas. Thus, EZH2-induced downregulation of WIF1 expression may partially regulate Wnt/ß-catenin-dependent crypt hyperplasia in response to CR infection.

American Indian/Alaska Native willingness to provide biological samples for research purposes.

This article examines the willingness of American Indian/Alaska Natives (AI/AN) to provide biological samples for research purposes. Prior cases of abuse and misuse of individuals, materials, and data highlight ethical research concerns. Investigators may be hesitant to engage AI/ANs in research projects. We conducted a survey of AI/ANs in the central plains region of the US over 1 year. This convenience sample completed a series of questions on biological samples and research. Survey results (N=998) indicate that 70.15% of AI/ANs would be willing to provide saliva/spit for a specific study with the proper consent and control of samples. In conclusion, researchers should find ways to work with and for AI/ANs, assuring participant input in the research process.

"Cutting" on cancer: attitudes about cancer spread and surgery among primary care patients in the U.S.A.

Many underserved groups in the United States experience disparities in cancer survival. Part of the disparity may be due to differences in treatment or treatment uptake. Previous studies uncovered patient beliefs that surgery could cause cancer to spread and have suggested that this belief may affect uptake of cancer treatment. We explored patients' explanations about surgical treatment of cancer and cancer spread, as well as the perceived impact on decision-making among primary care patients from an underserved area. Focus groups and interviews were conducted with patients (n = 42) at a primary care federally qualified health center in 2006 and 2007. Focus groups/interviews were semi-structured and were audio-taped and transcribed. An inductive text analysis with multiple coders was used to analyze the data and extract themes. We found that nearly all respondents had heard that surgery ("cutting") and exposing cancer to the air would hasten cancer spread and result in worse outcomes. Most participants expressed agreement with this belief. Many participants said this concern would influence their decision about whether to have surgery and/or reported that a family member had refused surgery for this reason. A smaller group of respondents disagreed with this belief and offered experiential evidence to the contrary or hypotheses about its origination. The idea that "cutting" and "air" during surgery can cause cancer to spread may be more prevalent among patients than suspected, based on this sample of predominantly African American patients. While we were unable to disentangle the ideas about "cutting" from those about "exposure to air", this set of beliefs, when held strongly, can negatively influence patients' or family members' decisions to seek surgical care and, if it is more prevalent in underserved groups, may contribute to cancer disparities.

Medical student interest in alternative medicine.

BACKGROUND OBJECTIVES: An increasing sector of the American population is seeking health services from alternative practitioners and using alternative therapies. This study investigated whether medical students perceived that information on alternative therapies would be useful to them as future practicing physicians. METHODS: A one-page anonymous questionnaire was distributed to the entire first-year medical class of a large, public, Midwestern medical school during their first semester. They responded to a series of five statements concerning alternative medicine and medical school coverage of this topic. RESULTS: The majority (84%) of students reported that knowledge about alternative medical therapies would be important to them as future physicians. The respondents wanted to learn about alternative therapies while in medical school (72%), but very few thought they would receive adequate exposure to this topic (6%). The majority also reported that direct observation of alternative practitioners would be the best method of instruction in this area (58%). CONCLUSIONS: The results suggest that medical students are interested in learning about alternative medical therapies and they perceive this knowledge will be important to them as physicians. As medical schools undertake various curriculum reforms they should be aware of rising student interest in alternative medical therapies.

Patient-provider relations--understanding the social and cultural circumstances of difficult patients.

Clinicians who have understanding and insight into the social and cultural background of their patients will be better prepared to foster the mutual respect required for effective chronic disease management. This paper will develop an argument linking respect in patient-physician relations to the social determinants of health.

Erectile dysfunction.

Erectile dysfunction affects millions of men in this country. Impairment of neurologic, hormonal and vascular function can inhibit the corporal smooth muscle relaxation necessary for erectile function. Physicians should employ a diagnostic work-up that proceeds from a history and physical examination to laboratory studies and physiologic testing. Treatment, which should be prescribed with constant patient input, is successful in a high percentage of cases. For erectile dysfunction with psychogenic or hormonal etiologies, treatments target the specific underlying problem. For dysfunction caused by nonspecific vascular and neurogenic problems, useful treatments include medication, vacuum devices, intracavernosal injections and penile implants.