The association between post-diagnosis health behaviors and long-term quality of life in survivors of ductal carcinoma in situ: a population-based longitudinal cohort study.

PURPOSE: Women diagnosed with ductal carcinoma in situ (DCIS) often experience adverse changes in health-related behaviors following diagnosis. The impact of health behaviors on long-term quality of life (QoL) in DCIS survivors has not been investigated. METHODS: We examined the association of post-diagnosis body mass index (BMI), physical activity, alcohol, and smoking with QoL among 1448 DCIS survivors aged 20-74 enrolled in the population-based Wisconsin in situ Cohort from 1997 to 2006. Health behaviors and QoL were self-reported during biennial post-diagnosis interviews. Physical and mental QoL were measured using the validated SF-36 questionnaire. Generalized linear regression was used to determine the association between behaviors and QoL with adjustment for confounders. Lagged behavior variables were used to predict QoL during follow-up and avoid reverse causation. RESULTS: Women reported 3,536 QoL observations over an average 7.9 years of follow-up. Women maintaining a healthy BMI had on average a significantly higher summary measure score of physical QoL than obese women (normal versus obese: ß = 3.02; 2.18, 3.85). Physical QoL scores were also elevated among those who were physically active (5 + h/week vs. none: ß = 1.96; 0.72, 3.20), those consuming at least seven drinks/week of alcohol (vs. none; ß = 1.40; 0.39, 2.41), and nonsmokers (vs. current smokers: ß = 1.80; 0.89, 2.71). Summary measures of mental QoL were significantly higher among women who were moderately physically active (up to 2 h/week vs. none: ß = 1.11; 0.30, 1.92) and nonsmokers (vs. current smokers: ß = 1.49;0.45, 2.53). CONCLUSIONS: Our results demonstrate that maintaining healthy behaviors following DCIS treatment is associated with modest improvements in long-term QoL. These results inform interventions aimed at promoting healthy behaviors and optimizing QoL in DCIS survivors.

Is health care payment reform impacting nurses' work settings, roles, and education preparation?

This study explores nurses' work settings and educational preparation in the five years before passage of the Affordable Care Act (ACA) and five years after ACA passage, with the aim of identifying areas for nurse educators' attention. The study setting was one small state undergoing rapid transition away from fee-for-service service and thus provided the ideal laboratory to assess the impact of health reform on the nursing workforce. A secondary analysis of data gathered during relicensure compared the nursing workforce at an interval of one decade, with surveys in 2005 (n=4075; 65% response rate) and in 2015 (n=6723; 97% response rate). Findings demonstrated an increase in the proportion of nurses who reported working in ambulatory care and community settings (p=0.001). However, there was no associated decrease in the proportion of nurses who reported working in hospitals. Among respondents who reported employment in the ambulatory care/community settings in 2005, 34.3% had a BSN or higher, a proportion that increased to 41.2% in 2015 (p=0.010); nevertheless, the greatest proportional increase was among AD prepared nurses (34% to 48%). Although new nursing roles emerging as a result of health reform offer baccalaureate nurses the opportunity use the full complement of their knowledge and skills, these data suggest that BS prepared nurses are not fully accessing these opportunities. Implications for nursing education and further research are detailed.

Electronic Health Record's Effects on the Outpatient Office Visit and Clinical Education.

BACKGROUND: During an office visit, the provider has the important cognitive task of attending to the patient while actively using the electronic health record (EHR).  Prior literature suggests that EHR may have a positive effect on simple tasks, but a negative effect on tasks that require complex cognitive processes.  No study has examined the provider's perception of EHR on multiple distinct aspects of the office visit. METHODS: We surveyed providers/preceptors regarding their perception of EHR on multiple aspects of the office visit.  We summarized their EHR utilization history and their perceptions of the EHR during the visit using descriptive statistics.  We tested for associations between time spent using the EHR and distinct aspects of the visit using Chi-square tests of association. RESULTS: In total, 83 providers/preceptors reported use of EHR (response rate 52%). Provider/preceptors reported an overall negative effect of EHR on the patient-provider connection, but an overall positive effect on the review of medications/medical records, communication between providers, review of results with patients and review of follow-up to testing results with patients. The effect of EHR on history taking and teaching students was neutral.  We observed no correlation between the provider's time spent using the EHR and their perception of its effectiveness. CONCLUSIONS: Providers reported a positive perception of EHR on aspects of the office visit that involved a single cognitive task.  However, providers reported a negative perception of EHR on patient-provider connection, which involves a high degree of cognitive processing.

Health-related behaviors and mortality outcomes in women diagnosed with ductal carcinoma in situ.

PURPOSE: Women diagnosed with ductal carcinoma in situ (DCIS) of the breast are at greater risk of dying from cardiovascular disease and other causes than from breast cancer, yet associations between health-related behaviors and mortality outcomes after DCIS have not been well studied. METHODS: We examined the association of body mass index, physical activity, alcohol consumption, and smoking with mortality among 1925 women with DCIS in the Wisconsin In Situ Cohort study. Behaviors were self-reported through baseline interviews and up to three follow-up questionnaires. Cox proportional hazards regression was used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for mortality after DCIS, with adjustment for patient sociodemographic, comorbidity, and treatment factors. RESULTS: Over a mean of 6.7 years of follow-up, 196 deaths occurred. All-cause mortality was elevated among women who were current smokers 1 year prior to diagnosis (HR = 2.17 [95% CI 1.48, 3.18] vs. never smokers) and reduced among women with greater physical activity levels prior to diagnosis (HR = 0.55 [95% CI: 0.35, 0.87] for ≥5 h per week vs. no activity). Moderate levels of post-diagnosis physical activity were associated with reduced all-cause mortality (HR = 0.31 [95% CI 0.14, 0.68] for 2-5 h per week vs. no activity). Cancer-specific mortality was elevated among smokers and cardiovascular disease mortality decreased with increasing physical activity levels. CONCLUSIONS: There are numerous associations between health-related behaviors and mortality outcomes after a DCIS diagnosis. IMPLICATIONS FOR CANCER SURVIVORS: Women diagnosed with DCIS should be aware that their health-related behaviors are associated with mortality outcomes.

Menopausal vasomotor symptoms and incident breast cancer risk in the Study of Women's Health Across the Nation.

PURPOSE: Two case-control studies reported a 50 % decreased breast cancer risk among women who experienced menopausal vasomotor symptoms (VMS), but one cohort study found no association. VMS may be triggered by declining estrogen levels during menopause, whereas elevated estrogen levels have been associated with increased breast cancer risk. VMS may thus be indicative of lower susceptibility to breast cancer. METHODS: We evaluated this relationship in the longitudinal Study of Women's Health Across the Nation (SWAN), using discrete survival analysis of approximately annual data on VMS and self-reported breast cancer occurrences for up to 13 years of follow-up in 3,098 women who were pre- or early perimenopausal at enrollment. RESULTS: Over an average 11.4 years of follow-up, 129 incident breast cancer cases were self-reported, and approximately 50 % of participants experienced VMS. Symptomatic women had a reduced risk of breast cancer compared to non-symptomatic women (adjusted HR 0.63, 95 % CI 0.39, 1.00). The association was stronger in the subgroup of women who fully transitioned to postmenopause during follow-up (n = 67 cases, adjusted HR 0.45, 95 % CI 0.26, 0.77). CONCLUSION: VMS appeared to be a marker of reduced breast cancer risk. Future research is needed to understand the biology underlying this relationship.

Teaching Electronic Health Record Communication Skills.

This pilot study investigated nurse practitioner students' communication skills when utilizing the electronic health record during history taking. The nurse practitioner students (n = 16) were videotaped utilizing the electronic health record while taking health histories with standardized patients. The students were videotaped during two separate sessions during one semester. Two observers recorded the time spent (1) typing and talking, (2) typing only, and (3) looking at the computer without talking. Total history taking time, computer placement, and communication skills were also recorded. During the formative session, mean history taking time was 11.4 minutes, with 3.5 minutes engaged with the computer (30.6% of visit). During the evaluative session, mean history taking time was 12.4 minutes, with 2.95 minutes engaged with the computer (24% of visit). The percentage of time individuals spent changed over the two visits: typing and talking, -3.1% (P = .3); typing only, +12.8% (P = .038); and looking at the computer, -9.6% (P = .039). This study demonstrated that time spent engaged with the computer during a patient encounter does decrease with student practice and education. Therefore, students benefit from instruction on electronic health record-specific communication skills, and use of a simple mnemonic to reinforce this is suggested.

Trends in Health-Related Quality of Life After a Diagnosis of Ductal Carcinoma In Situ.

PURPOSE: Studies of quality of life (QoL) are scarce among survivors of ductal carcinoma in situ (DCIS). The objective of this study was to assess long-term QoL in DCIS survivors in relation to age at diagnosis, time since diagnosis, and treatments received. METHODS: We assessed physical and mental measures of health-related QoL in 1,604 patients with DCIS diagnosed in 1997 to 2006 with up to four follow-up interviews. We further compared baseline QoL to 1,055 control patients without DCIS. QoL was measured using the validated Medical Outcomes Study Short Form 36 Health Status Survey questionnaire. Among patients with DCIS, we examined trends in QoL over time since diagnosis using generalized linear regression models, adjusting for confounders. We tested for effect modification by surgical treatment choice, post-treatment endocrine therapy use, and age at diagnosis. RESULTS: Both physical and mental measures of QoL among DCIS survivors at fewer than 2 years after diagnosis were comparable to controls. Mental measures of QoL among patients with DCIS declined at ≥ 10 years after diagnosis and were significantly lower than at less than 2 years after diagnosis (47.4 v 52.0; P < .01). In the first 5 years after a DCIS diagnosis, mental QoL was significantly higher among women diagnosed at ages 50 to 74 years compared with those diagnosed at ages 28 to 49 years, although this difference was not sustained in later time periods. CONCLUSION: QoL after a DCIS diagnosis was generally comparable to that of women of similar age without a personal history of DCIS. Our findings suggest that DCIS survivors, and particularly those diagnosed at a younger age, may benefit from support for mental QoL.

Partnership Status and Socioeconomic Factors in Relation to Health Behavior Changes after a Diagnosis of Ductal Carcinoma In Situ.

BACKGROUND: Change in health behaviors can occur among women newly diagnosed with ductal carcinoma in situ (DCIS). We sought to understand whether partnership status and socioeconomic status (SES) affected behavioral changes in body weight, physical activity, alcohol consumption, and smoking. METHODS: The Wisconsin In Situ Cohort (WISC) study comprises 1,382 women diagnosed with DCIS with information on demographics, SES factors, and pre- and post-DCIS diagnosis health-related behaviors. Logistic regression models were used to determine the association between partnership status, education, and income with change in behavior variables. RESULTS: Higher educational attainment was associated with lower likelihood of stopping physical activity [OR, 0.45; 95% confidence interval (CI), 0.32-0.63; college vs. high school degree], or starting to drink alcohol (OR, 0.34; 95% CI, 0.15-0.80). Results suggested that higher family income was associated with lower likelihood of gaining >5% body mass index (P = 0.07) or stopping physical activity (P = 0.09). Living with a partner was not strongly associated with behavior changes. CONCLUSION: Higher educational attainment and higher income, but not living with a partner, were associated with positive health behaviors after a DCIS diagnosis. IMPACT: The associations between higher educational attainment and, to a lesser extent, higher income with positive health behaviors underscore the importance of considering SES when identifying those at risk for negative behavioral change after DCIS diagnosis.

The effect of change in body mass index on volumetric measures of mammographic density.

BACKGROUND: Understanding how changes in body mass index (BMI) relate to changes in mammographic density is necessary to evaluate adjustment for BMI gain/loss in studies of change in density and breast cancer risk. Increase in BMI has been associated with a decrease in percent density, but the effect on change in absolute dense area or volume is unclear. METHODS: We examined the association between change in BMI and change in volumetric breast density among 24,556 women in the San Francisco Mammography Registry from 2007 to 2013. Height and weight were self-reported at the time of mammography. Breast density was assessed using single x-ray absorptiometry measurements. Cross-sectional and longitudinal associations between BMI and dense volume (DV), non-dense volume (NDV), and percent dense volume (PDV) were assessed using multivariable linear regression models, adjusted for demographics, risk factors, and reproductive history. RESULTS: In cross-sectional analysis, BMI was positively associated with DV [ß, 2.95 cm(3); 95% confidence interval (CI), 2.69-3.21] and inversely associated with PDV (ß, -2.03%; 95% CI, -2.09, -1.98). In contrast, increasing BMI was longitudinally associated with a decrease in both DV (ß, -1.01 cm(3); 95% CI, -1.59, -0.42) and PDV (ß, -1.17%; 95% CI, -1.31, -1.04). These findings were consistent for both pre- and postmenopausal women. CONCLUSION: Our findings support an inverse association between change in BMI and change in PDV. The association between increasing BMI and decreasing DV requires confirmation. IMPACT: Longitudinal studies of PDV and breast cancer risk, or those using PDV as an indicator of breast cancer risk, should evaluate adjustment for change in BMI.

Health behavior change following a diagnosis of ductal carcinoma in situ: An opportunity to improve health outcomes.

Ductal carcinoma in situ (DCIS) is a non-invasive breast cancer that comprises approximately 20% of new breast cancer diagnoses. DCIS is predominantly detected by screening mammography prior to the development of any clinical symptoms. Prognosis following a DCIS diagnosis is excellent, due to both the availability of effective treatments and the frequently benign nature of the disease. However, a DCIS diagnosis and its treatment have psychological and physical impacts that often lead to adverse changes in health-related behaviors, including changes in physical activity, body weight, alcohol intake, and smoking, which may represent a greater threat to the woman's overall health than the DCIS itself. Depending on age at diagnosis, women diagnosed with DCIS are 3-13 times more likely to die from non-breast cancer related causes, such as cardiovascular disease, than from breast cancer. Thus, the maintenance and improvement of healthy behaviors that influence a variety of outcomes after diagnosis may warrant increased attention during DCIS management. This may also represent an important opportunity to promote the adoption of healthy behaviors, given that DCIS carries the psychological impact of a cancer diagnosis but also a favorable prognosis. Particular focus is needed to address these issues in vulnerable patient subgroups with pre-existing higher rates of unhealthy behaviors and demonstrated health disparities.

Lymphangiography: a case study.

Lymphatic leak is a rare but well-described complication of a multitude of surgeries, whose sequela may potentially be life threatening. For cases refractory to conservative management, surgical therapy has been the mainstay of treatment. Although radiology has always played a contributory role in the diagnosis of lymphatic leaks with lymphoscintigraphy and lymphangiography, minimally invasive management of lymphatic leaks by interventional radiologists has only been described in the last decade. We present a case of percutaneous disruption of the cisterna chyli to treat a lymphatic leak of the thoracic duct.