Barriers to tobacco cessation in clinical practice: report from a National Survey of Oncology Nurses.

This study describes the survey results of a national random sample of members of the Oncology Nursing Society who reported the greatest number of barriers to delivering a tobacco cessation intervention with their patients. Nurses who perceived the greatest number of barriers were more likely to be current smokers and to be young and were less likely to have an advanced degree, to be a nurse practitioner, or to have administrative responsibilities. Those with greater barriers were less likely to deliver tobacco cessation interventions.

Tobacco-control attitudes, advocacy, and smoking behaviors of oncology nurses.

PURPOSE/OBJECTIVES: To describe oncology nurses' attitudes, smoking behaviors, and involvement in tobacco-control policy and legislation. DESIGN: Descriptive, cross-sectional survey. SAMPLE: Responses from 1,508 (38% return) of 4,000 randomly selected members of the Oncology Nursing Society (ONS). The typical respondent was female, age 44, a staff nurse, had practiced as an oncology nurse for 12 years, and was certified as an OCN. METHODS: A mailed survey with specific questions about smoking status and the importance of nursing involvement in healthcare policy and legislation for tobacco control. MAIN RESEARCH CONCEPTS: Attitudes about tobacco-control policies and legislation; sociodemographic, professional, and institutional variables; and tobacco use. FINDINGS: The majority (85%) of members stated that nursing involvement in tobacco-control healthcare policy and legislation was important. More than 90% of respondents supported prevention of youth access to tobacco and providing information about health effects of tobacco and cessation. Seven percent (n = 106) were current smokers. Significantly fewer smokers valued involvement in tobacco-control activities. Respondents with personal experience of tobacco-related illnesses were more likely to value involvement in advocacy activities. Educational programs to prevent tobacco use among youth and to help patients stop smoking received the most support (80%). IMPLICATIONS FOR NURSING PRACTICE: This sample of ONS members strongly supported involvement in tobacco-control policies and legislation. Smoking was associated with more negative attitudes about the importance of actively engaging in tobacco control. These oncology nurses recognized the need for additional educational programs to prevent tobacco initiation by youth.

Is insurance a more important determinant of healthcare access than perceived health? Evidence from the Women's Health Initiative.

Our objectives were to explore health insurance status and insurance type, adjusted for self-reported and perceived health variables, as determinants of having and using a usual care provider in the Women's Health Initiative (WHI) Observational Study (OS). This analysis describes insurance status in a large, diverse group of older women and tests the hypothesis that insurance was a key predictor of their access to healthcare in the mid-1990s. Multiple logistic regression analysis was used to evaluate determinants of having visited a usual healthcare provider within the proceeding 12 months, using cross-sectional information provided by a population-based cohort of 55,278 postmenopausal women. Five percent of women younger than 65 years and 0.2% of women 65 or older in the OS cohort lacked health insurance. Among the 31,684 women, aged 50-64 years, Hispanic women and those with fewer years of education and lower household income and who were current smokers were less likely, and those lacking insurance were the least likely, to have seen their healthcare provider within the preceding year. Among 23,594 women, aged 65-79 years, African American and Hispanic women and those with lower household income, and Medicare only and those who were current smokers, were less likely to have seen their healthcare provider within the preceding year. In both age groups, women with chronic medical conditions and poorer perceived health scores and those with prepaid insurance were more likely to have seen their healthcare provider. In the WHI OS, both health (self-reported and perceived) and type of health insurance remained independently associated with having visited a usual healthcare provider after multivariate adjustment for one another as well as for pertinent sociodemographic characteristics.

The importance of health insurance as a determinant of cancer screening: evidence from the Women's Health Initiative.

BACKGROUND: Amid current changes in health care access across the United States, the importance of health insurance status and insurance type relative to demographic, actual, and perceived health variables as determinants of screening for breast, colorectal, and cervical cancer is uncertain. This analysis evaluates the hypothesis that health insurance independently predicts cancer screening in the Women's Health Initia tive Observational Study cohort. METHODS: Questionnaire data from 55,278 women en rolled in the Women's Health Initiative Observational Study between September 1994 and February 1997 were analyzed by multiple logistic regression to identify predictors of self-reported mammography within 2 years, Pap smear within 3 years, and stool guaiac or flexible sigmoidoscopy within 5 years. RESULTS: Positive determinants of reporting cancer screening were age, ethnic origin, household income, educational level, family history of cancer, having a usual care provider, time since last provider visit, and insurance status and type. Smoking, diabetes, and, among older women, prior cardiovascular events were negative determinants of cancer screening. Among women younger than 65, lacking health insurance or having fee-for-service insurance was strongly associated with failure to report cancer screening, independently of having or using a usual care provider and of demographics, self-perceived health, and health characteristics. Among women 65 and older, those with Medicare alone were less likely, whereas those with Medicare + prepaid insurance were more likely, to report cancer screening. CONCLUSIONS: In the Women's Health Initiative Obser vational Study, a large, diverse group of older women, health insurance type and status were among the most important determinants of cancer screening indepen dent of demographics, chronic health conditions, and self-perceived health characteristics.

Tobacco interventions by oncology nurses in clinical practice: report from a national survey.

BACKGROUND: Tobacco use is an important risk factor in cancer, cancer recurrence, and increased treatment morbidity, but limited information is available about interventions for tobacco cessation used in oncology clinical practice. In 1996, the Agency for Health Care Policy Research (AHCPR) published the first evidence-based smoking cessation guideline for use by health professionals. Using the AHCPR guideline as a framework, the authors describe the frequency of tobacco interventions provided by oncology nurses. METHODS: A questionnaire was mailed to 4000 randomly selected members of the Oncology Nursing Society in winter of 1998. Of those who were mailed questionnaires, 1508 respondents (38%) were available for analysis. RESULTS: The typical respondent was female, 44 years of age, and had practiced as an oncology nurse for 12 years. Seven percent were current smokers, and 30% were former smokers. Most (86%) encountered smokers on a weekly basis, but only 10% had heard of the AHCPR guideline. The majority (64%) assessed and documented tobacco status, 38% assessed readiness to quit. Few went on to provide interventions: 36% provided counseling, 32% provided cessation advice, 24% recommended nicotine replacement, and 16% taught skills to prevent relapse. Common barriers included perceived lack of patient motivation (74%) and the nurse's lack of time (52%) and skills (53%). The majority stated that they wanted to help patients stop smoking (88%) but needed additional training (92%). CONCLUSIONS: Documentation of tobacco status alone is not adequate in assisting patients with smoking cessation. Greater efforts are needed to educate oncology nurses about the range of tobacco interventions available and to facilitate their use in clinical settings.

Gender influence on weight-loss pattern and survival of nonsmall cell lung carcinoma patients.

BACKGROUND: Gender has recently emerged as a discriminating factor in nonsmall lung carcinoma (NSCLC) patient outcome. Since the potential for interaction among established prognostic factors and gender in this common disease has not been explored, the authors evaluated the role of gender and weight-loss pattern in predicting clinical outcome in a balanced population of men and women presenting with NSCLC. METHODS: From a tumor registry population of 368 NSCLC patients, a gender-balanced sample of 152 cases was randomly selected for review, using prospective inclusion criteria. Study parameters were age, race, tobacco and alcohol history, gender, weight-loss pattern, histology, TNM stage, Eastern Cooperative Oncology Group performance status, and therapy. Influences of study variables on Kaplan-Meier estimates of survival were subsequently determined using univariate and multivariate analyses. RESULTS: Overall median survival after diagnosis was significantly shorter for men with NSCLC than for women with the disease (40 vs. 78 weeks, P = 0.001). Men lost significantly more weight over their disease course than women (12.2 vs. 5.4 pounds, P = 0.006) and experienced an eightfold faster rate of initial weight loss (0.25 vs. 0.03 pounds per week, P = 0.001). In multivariate analysis, the strongest independent predictors of NSCLC patient survival were stage of disease, initial weight-loss rate, and gender (all P < 0.0001). CONCLUSIONS: These results suggest that weight loss may play a role in mediating gender-related differences in NSCLC patient survival and provide an impetus for further studies of gender influence on cancer outcome.

Recent implications of weight loss in lung cancer management.

Successful lung cancer management has been hindered by the limited efficacy of dietary and pharmacologic interventions to prevent or reverse cancer-associated weight loss. The addition of total parenteral nutrition to chemotherapy in early trials was associated with survival detriment. Dietary counseling and enteral supplement use are common strategies that, when evaluated in randomized trials, do not improve anthropometrics or clinical outcome in lung cancer. Pharmacologic agents including corticosteroids, cyproheptadine, growth hormone, hydrazine sulfate, dronabinol, and pentoxyphylline also have failed to improve even anthropometric parameters in this condition. Megestrol acetate use is associated with appetite stimulation and non-fluid weight gain but, when evaluated in small cell lung cancer patients receiving defined chemotherapy, failed to improve global quality of life, and survival and was associated with toxicity. New strategies for nutrition-based interventions in lung cancer cachexia must consider their potential influence on tumor growth as well as on nutritional status. Recent lung cancer prognostic analyses have identified gender differences in outcome and weight loss that suggest potential targets for combined hormonal and nutrition interventions. Emerging information regarding the influence of specific fatty acids on tumor growth and cachexia development have identified additional approaches for future evaluation.

Altered metabolism and mortality in patients with colon cancer receiving chemotherapy.

To identify the metabolic effects of 5-fluorouracil and hydrazine sulfate therapy, 22 patients with colon cancer were admitted prospectively to a Clinical Research Center for serial measurement of counter-regulatory hormones, fasting hepatic glucose production (HGP), intravenous glucose tolerance test, plasma leucine appearance (LA) and leucine oxidation. Combined therapy was associated with a significant reduction in fasting glucose level (98 +/- 2 mg/dL to 94 +/- 2, P < 0.025) without a significant fall in fasting HGP (2.09 +/- 0.11 mg/kg/min versus 2.03 +/- 0.13; P > 0.05). The decreased fasting glucose value was associated with a mild but not statistically improved glucose disposal rate in response to the intravenous glucose tolerance test (1.34 +/- 0.07 %/min vs 1.47 +/- 0.11, P = 0.15). Plasma leucine appearance was significantly reduced after 2 months of therapy (63.3 +/- 3.0 mumol/kg/hr vs 57.1 +/- 3.9 mumol/kg/hr; P < 0.025), but leucine oxidation (11.5 +/- 1.1 mumol/kg/hr vs 11.2 +/- 1.1 mumol/kg/hr) was not altered. Despite the fact that plasma triiodothyronine concentrations significantly increased with therapy, it was not associated with plasma LA. Half of the patients with cancer died 14 +/- 4 months after the study, and the other half were alive 58 +/- 2 months later. Survival time can be estimated with 59% accuracy using plasma LA, HGP, carcino-embryonic antigen, and insulin concentration. Multiple regression analysis identified that plasma LA was related directly to length of survival time, and baseline HGP, carcino-embryonic antigen, and insulin concentration were related inversely to length of survival.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of a smoking cessation program for pregnant minority women.

The purpose of this project was to develop and test culturally appropriate, low literacy, smoking cessation intervention materials designed to increase quit rates and prevent relapse postpartum for low-income African American and Hispanic women. A quasi-experimental, pretest-posttest design was used. Four Women, Infants, and Children (WIC) clinic sites in south and central Los Angeles were identified, pair-matched based on ethnic mix, and randomized to intervention (2 sites) or control status (2 sites). Participants were 18 years of age or older and either current or exsmokers (stopped smoking in the past year). The intervention group received the "Time for a Change: A Program for Healthy Moms and Babies" program including a 15-minute one-to-one counseling session and self-help guide, incorporating behavior-change strategies, booster postcard, and incentive contest. All materials were designed to match the cultural, language, and literacy needs of the target population. The smoking cessation intervention had a positive impact on both quit-smoking behavior during pregnancy and relapse prevention postpartum. Almost twice as many smokers in the intervention group (43%) reported quitting smoking at 9 months, compared to the control group (25%) (P < 0.01). At 6 weeks postpartum, 25% of the intervention baseline smokers were abstinent, compared to 12% of the control group (P < 0.01). Although no significant differences were observed for relapse during pregnancy among exsmokers at 6 weeks postpartum, a significantly higher proportion of intervention exsmokers were still abstinent (79%), compared to control exsmokers (62%) (P < 0.01). For the exsmokers, relapse prevention rates remained significant when adjusted for cotinine validated abstinence.(ABSTRACT TRUNCATED AT 250 WORDS)

Dietary intake and counseling, weight maintenance, and the course of HIV infection.

OBJECTIVE: To define relationships among dietary intake and counseling, weight maintenance, and the clinical course of patients infected with the human immunodeficiency virus (HIV). DESIGN: A prospective cohort study in an HIV clinic in a county hospital. SUBJECTS: HIV-infected patients (68 with and 40 without acquired immunodeficiency syndrome [AIDS]) who had a good performance status and no chronic diarrhea were assessed at entry to the study and after 6 months. The following assessments were made: energy and nutrient intake based on 7-day food records, anthropometric measurements, immunologic function as lymphocyte T-cell subpopulations (ratio of CD4 to CD8), and serum cholesterol level. Patients were monitored to determine clinical outcome. INTERVENTION: All patients received standardized dietary counseling designed to address identified intake deficiencies and maintain body weight. MAIN OUTCOME MEASURES: Changes in energy and nutrient intake, body weight, and clinical outcome (ie, time to AIDS-defining illness and overall survival time). STATISTICAL ANALYSES PERFORMED: Group differences (HIV group vs AIDS group) were sought using chi 2 analyses and Student's t test. A multivariate regression model was used to determined the best predictors of clinical outcome. RESULTS: At baseline, total energy intake (based on 30 kcal/kg usual body weight) was adequate in both HIV and AIDS patients (101 +/- 4% and 103 +/- 5% [mean +/- standard deviation] of need, respectively). Despite dietary counseling and continued maintenance of energy intake, body weight, serum cholesterol level, and CD4 level progressively decreased. Consequently, saturated fat intake was found to be inversely related (P < .01) to serum cholesterol level. Clinical outcome (after 3.5 years) was associated with baseline ratio of CD4 to CD8 (P < .001), weight (P < .01), and serum cholesterol level (P < .001). Multivariate analysis related ratio of CD4 to CD8 (P < .001) and weight maintenance (P < .001) to favorable outcome in the final model. APPLICATIONS: Weight loss in patients with HIV infection is independently prognostic of clinical outcome, and development of hypocholesterolemia is not favorable for clinical outcome. Because weight loss progresses despite conventional dietary counseling to identify energy need, interventions earlier in the disease course should be considered along with increased target levels for energy intake.

A decade of breast cancer clinical investigation: results as reported in the Program/Proceedings of the American Society of Clinical Oncology.

PURPOSE: To test the hypothesis that clinical research results have driven changes in recent breast cancer management recommendations. METHODS: All breast cancer abstracts in the Program/Proceedings of the American Society of Clinical Oncology (ASCO) from 1984 to 1993 were prospectively reviewed in 31 areas and categorized by study type, study question, whether statistical significance was claimed, and whether the abstract was presented. RESULTS: Of 1,372 abstracts, 54% reported on prospective clinical trials (PCTs) and 17% on randomized clinical trials (RCTs). The total number of published abstracts progressively increased (from 87 in 1984 to 221 in 1993) and author citations nearly quadrupled (from 430 in 1984 to 1,642 in 1993, P < .01); however, RCTs have come to represent a smaller proportion of reports: 37% (33 of 89) in 1986 versus 10% (22 of 221) in 1993 (P < .001). The size of adjuvant-therapy RCTs has progressively increased (mean +/- SEM subjects/trial, 237 +/- 43 in 1984 to 874 +/- 374 in 1993), but has remained small in advanced-disease RCTs (mean +/- SEM subjects/trial, 145 +/- 25 in 1984 to 146 +/- 34 in 1993). For adjuvant therapy, 14 of 90 RCTs (with 51,207 patients) reported a significant (P < .05) survival benefit for investigational therapies (16%). For advanced-disease therapy, only three of 141 RCTs (with 26,281 patients) reported a significant (P < .05) survival benefit for investigational therapies (2%). Randomization was rarely used in trials of dose-intensity with blood-product support (zero of 86 trials) or locally advanced disease. CONCLUSION: For breast cancer ASCO abstracts in the past decade, we determined the following: (1) adjuvant trials have not infrequently supported study hypotheses; and (2) advanced-disease trials have consistently failed to identify new approaches with a significant impact on survival. These results suggest that a critical process evaluation of current policy and procedures involved in directing breast cancer research is warranted, especially for strategies in advanced disease.

Late mortality and levamisole adjuvant therapy in colorectal cancer.

Beginning in 1975, 78 patients with resected stage B and C colorectal carcinoma were randomly assigned (2:1) to receive either levamisole 2.5 mg kg-1 day-1 given for 2 days every week for 18 months or placebo therapy in the same schedule. Pretreatment characteristics (age, gender, disease site, CEA and stage) and the pattern of follow-up were similar in both groups. For the first 5 years following randomisation, relapse-free survival and overall survival were similar in the two treatment groups. Subsequently, excess late mortality was associated with levamisole group assignment. Consequently, overall survival was somewhat greater in the placebo group than in the levamisole group, 68% vs 38% (P < 0.08). For patients surviving 5 years from randomisation, subsequent survival favoured placebo over levamisole (100% vs 57%; P < 0.03). The absolute numbers of deaths were 27 in the levamisole group (19 definitely cancer related) and seven in the group placebo (five definitely cancer related). This long-term result seen with a more intensive adjuvant levamisole dose and schedule suggests: (1) other levamisole adjuvant trials in patients with colorectal cancer should be examined for long-term outcome; (2) future trials utilising the even higher levamisole dosage required for clinical immunomodulation should proceed cautiously.

Long-term effects of early nutritional support with new enterotropic peptide-based formula vs. standard enteral formula in HIV-infected patients: randomized prospective trial.

Despite association with adverse clinical outcome, human immunodeficiency virus (HIV)-associated malnutrition has been relatively refractory to conventional nutrition management. Consequently, a prospective randomized trial was conducted to evaluate a new peptide-based enteral formula (NEF) in contrast to a standard enteral formula (SEF) in patients with HIV infection. Eighty early-stage largely asymptomatic patients were randomized into a dietary regimen supplemented with either a ready-to-feed NEF (18.7% protein, 65.5% carbohydrate, 15.8% fat; 1.28 kcal/ml) or SEF (14% protein, 55% carbohydrate, 31% fat; 1.06 kcal/ml). Patients received 2-3 8-oz cans of the NEF or SEF supplement per day for 6 mo. Parameters evaluated at 0 (baseline), 3, and 6 mo included adherence, weight change, anthropometric measurements, serum biochemical indices, gastrointestinal symptoms, physical performance, and intercurrent health events (including hospitalizations). For the 56 evaluable patients, those supplemented with NEF maintained their body weight significantly (p = 0.04) better, had significantly (p = 0.03) more stable triceps skin-fold measurements, and had significantly (p = 0.04) lower blood urea nitrogen than patients consuming the SEF supplement. Consumption of the NEF supplement was also associated with significantly reduced hospitalizations during the 3- to 6-mo evaluation period (p = 0.02). The NEF supplement was well tolerated and did not result in untoward clinical effects. These data suggest that supplemental use of an NEF provides superior nutritional management compared with an SEF for patients with early-stage HIV infection.

Factors influencing nurses' breast cancer control activity.

A needs assessment survey of 2800 registered nurses in a major metropolitan area was performed to identify: (1) knowledge about breast cancer risk and screening; (2) attitudes toward cancer prevention and early detection; (3) practice of breast cancer control activities; and (4) perceived barriers to practice. Responses from 1,117 nurses were obtained. Nurses reported knowledge deficits regarding breast cancer risk factors (36%) and signs and symptoms of breast cancer (35%). Compared with physicians, nurses reported more favorable attitudes toward cancer prevention and early detection. More than 85% of nurses believed that nursing had a role in breast cancer screening and early detection, and 60% believed that nursing activity in this area would increase in the future. The most common breast cancer control activity performed by nurses was assessment of breast cancer history (61%). The least frequent early detection activity was performance of a breast examination (27%). Approximately 50% of nurses taught women about breast self-examination and mammography. Common barriers limiting practice included work setting obstacles (64%), knowledge and skill deficits (57%), lack of patient education materials (51%), uncertainty about nurses' versus physicians' role in breast cancer control (52%), and time constraints (42%). It is important to note that 70% of nurses viewed themselves as resources for breast cancer screening and early detection, particularly in reducing fears and misconceptions about cancer, assessing and informing patients about individual cancer risk, and developing a plan for screening. Based on the results of this survey, nurses may represent a key potential resource for implementing breast cancer screening and early detection activities if barriers limiting practice can be overcome.

Breast cancer chemoprevention. Tamoxifen: current issues and future prospective.

Intervention clinical trials are under way to address whether tamoxifen can prevent breast cancer development. This effort is based on laboratory evidence that tamoxifen interferes with the initiation and promotion of mammary cancer, clinical evidence of decreased breast cancer incidence in the opposite breast of women participating in tamoxifen adjuvant breast cancer trials, and a favorable toxicity profile of tamoxifen providing reasonable assurance of drug safety when used in a population without cancer. The apparently favorable effects of tamoxifen on lipid metabolism and bone mineral density provide additional impetus to this evaluation. Potentially life threatening toxicity of thromboembolism and development of a second cancer remain concerns. With respect to implications of such clinical trials, even upon successful study completion, difficult issues will remain; these issues include the potential for interaction between tamoxifen and dietary fat reduction (also proposed as potential breast cancer prevention), the cost and cost-effectiveness of wide scale (or selective) implementation of positive results, and the generalizability of study results to socioeconomically disadvantaged and racial and ethnic minority populations that historically have been under-represented in medical clinical trials. These important issues should be addressed concurrently as large-scale prevention trials go forward to optimize the practical utility of efficacy data obtained.

Current attitudes and practice of American Society of Clinical Oncology-member clinical oncologists regarding cancer prevention and control.

PURPOSE AND METHODS: A nationwide needs assessment survey including a validated Cancer Prevention and Early Detection Attitude Inventory of 1,500 randomly selected American Society of Clinical Oncology (ASCO)-member clinical oncologists was conducted via a 67-item, mailed questionnaire to assess practice and attitudes regarding cancer prevention and control. RESULTS: Responses of 729 physicians from 48 states representing medical (57%), radiation (17%), surgical (16%), and pediatric oncology (6%), and hematology/other (4%) fields were obtained. Except for ambivalence regarding an important role for diet in cancer causation, cancer prevention and control recommendations were widely endorsed despite skepticism about their impact on reducing deaths from cancer. Surprisingly, a significantly (P less than .001) more favorable attitude for cancer prevention and control issues was found in physicians with greater than 20 years practice compared with younger oncology colleagues, as measured by a 22-item Cancer Prevention and Early Detection Attitude Inventory. Among all physicians, participation in cancer therapy trials exceeded that in cancer prevention and control trials (91% v 27%, P less than .01). Formal instruction during postgraduate training in cancer screening (34%) or prevention (23%) was received by few oncologists; nonetheless, 69% considered themselves a resource for cancer prevention and control issues in their practice communities. Of potential barriers to cancer prevention and control activity, only lack of patients without cancer (53%) and difficulty in including such activity economically into clinical practice (65%) were majority selections. Importantly, 64% agreed they could "motivate their patients to change lifestyle to reduce cancer risk." CONCLUSION: Clinical oncologists may represent a potential resource for implementation of cancer prevention and control objectives if economically feasible models for their use in practice settings can be identified.

Nurses' practice of breast cancer screening and early detection: results of a pilot survey.

Nursing has a professional responsibility to participate in cancer screening and early detection. Nurses represent the largest professional group in the health care workforce and are presently an underutilized potential resource for implementing breast cancer screening and early detection. Development of a reliable and valid instrument which could be used to evaluate the effectiveness of mechanisms designed to increase nursing's role in breast cancer screening and early detection is needed. The questionnaire tested in this pilot study represents an initial attempt at fulfilling this need. This questionnaire in its present form may be used to evaluate the results of intervention studies aimed at increasing nurses' practice of breast cancer screening and early detection. For example, the questionnaire could be used as an evaluation tool to examine the effectiveness of educational programs regarding breast cancer screening and early detection. It may also be used as an outcome measure to evaluate change in practice activities such as the effect on nursing practice of including questions on the nursing history and assessment form related to BSE, clinical breast exam and mammography. Results of nursing action in breast cancer screening and early detection could have a significant impact on the achievement of the NCI's year 2000 goal of a 30% reduction in breast cancer mortality.