Patient-Level Factors Associated with Oncology Provider-Delivered Brief Tobacco Treatment Among Recently Diagnosed Cancer Patients.

BACKGROUND: A cancer diagnosis is seen as a "teachable moment" for patients to consider changing their behavioral risk factors, such as smoking. It also offers an opportunity for oncology providers to engage in a dialogue about how they can support patients changing their smoking behaviors. Brief, evidence-based tobacco cessation treatment delivered by oncology providers through the 5As (Ask, Advise, Assess, Assist Arrange) model is recommended, but provision to cancer patients remains suboptimal. AIM: Explore patient-level factors associated with 5As receipt among current smokers with a newly diagnosed cancer. METHOD: A total of 303 patients self-reported whether they received each of the 5As during their most recent oncology care visit. Multivariable regression analyses were conducted to identify patient-level factors associated with 5As receipt. RESULTS: Oncology provider-delivered 5As rates ranged from 81.5% (Ask) to 30.7% (Arrange). 5As receipt was associated with: reporting lower illness-related stigma, diagnosis of a comorbid smoking-related disease, diagnosis of a smoking-related cancer, and diagnosis of a non-advanced cancer. CONCLUSION: Findings support previous literature in which smoking-related diagnoses were associated with greater receipt of 5As; however, disparities in the receipt of 5As existed for patients with more advanced cancer diagnoses and illness-related stigma. Inequities in the provision of quit assistance may further decrease treatment effectiveness and survival expectancy among certain patient populations. These findings are, therefore, important as they identify specific patient-level factors associated with lower 5As receipt among newly diagnosed cancer patients.

An analysis of adaptations to multi-level intervention strategies to enhance implementation of clinical practice guidelines for treating tobacco use in dental care settings.

INTRODUCTION: Our team conducted a cluster randomized controlled trial (DUET) that compared the effectiveness of three theory-driven, implementation strategies on dental provider adherence to tobacco dependence treatment guidelines (TDT). In this paper we describe the process of adapting the implementation strategies to the local context of participating dental public health clinics in New York City. METHODS: Eighteen dental clinics were randomized to one of three study arms testing several implementation strategies: Current Best Practices (CBP) (i.e. staff training, clinical reminder system and Quitline referral system); CBP + Performance Feedback (PF) (i.e. feedback reports on provider delivery of TDT); and CBP + PF + Pay-for-Performance (i.e. financial incentives for provision of TDT). Through an iterative process, we used Stirman's modification framework to classify, code and analyze modifications made to the implementation strategies. RESULTS: We identified examples of six of Stirman's twelve content modification categories and two of the four context modification categories. Content modifications were classified as: tailoring, tweaking or refining (49.8%), adding elements (14.1%), departing from the intervention (9.3%), loosening structure (4.4%), lengthening and extending (4.4%) and substituting elements (4.4%). Context modifications were classified as those related to personnel (7.9%) and to the format/channel (8.8%) of the intervention delivery. Common factors associated with adaptations that arose during the intervention included staff changes, time constraints, changes in leadership preferences and functional limitations of to the Electronic Dental Record. CONCLUSIONS: This study offers guidance on how to capture intervention adaptation in the context of a multi-level intervention aimed at implementing sustainable changes to optimize TDT in varying public health dental settings.

Barriers to mental health service use among distressed family caregivers of lung cancer patients.

Although family caregivers of patients with lung and other cancers show high rates of psychological distress, they underuse mental health services. This qualitative study aimed to identify barriers to mental health service use among 21 distressed family caregivers of lung cancer patients. Caregivers had not received mental health services during the patient's initial months of care at a comprehensive cancer centre in New York City. Thematic analysis of interview data was framed by Andersen's model of health service use and Corrigan's stigma theory. Results of our analysis expand Andersen's model by providing a description of need variables (e.g. psychiatric symptoms), enabling factors (e.g. finances), and psychosocial factors associated with caregivers' non-use of mental health services. Regarding psychosocial factors, caregivers expressed negative perceptions of mental health professionals and a desire for independent management of emotional concerns. Additionally, caregivers perceived a conflict between mental health service use and the caregiving role (e.g. prioritising the patient's needs). Although caregivers denied stigma associated with service use, their anticipated negative self-perceptions if they were to use services suggest that stigma may have influenced their decision to not seek services. Findings suggest that interventions to improve caregivers' uptake of mental health services should address perceived barriers.

Smoking cessation following CT screening for early detection of lung cancer.

BACKGROUND: This study was conducted to assess the impact of lung cancer screening participation on smoking cessation. METHODS: Individuals (n = 134) who reported active smoking at the time of enrollment in our Early Lung Cancer Action Program (ELCAP) completed a brief, follow-up telephone interview assessing any changes in smoking patterns following lung cancer screening. Using logistic regression, we estimated the probability of decreasing or quitting smoking using each enrollee's background information and computed tomography (CT) scan results. RESULTS: Most survey respondents (74%) agreed that participation in the ELCAP increased their motivation for quitting smoking. In terms of self-reported changes in smoking behavior, 31 (23%) reported that they had quit and 35 (27%) decreased their smoking patterns. Several significant covariates of smoking cessation were identified: perceived benefit of quitting (OR 4.02), cancer anxiety (OR 2.49), younger age (OR 2.47), and abnormal CT finding (1.97). CONCLUSIONS: Our analyses suggest that low-dose helical CT scanning may serve as a strong catalyst for smoking cessation and that delivery of effective smoking cessation interventions along with CT scanning represents a potential opportunity to increase the overall cancer prevention benefit of lung cancer screening.

Age-related changes in detecting a mistuned harmonic.

The effects of age on discriminating simultaneous sounds were investigated by comparing the hearing threshold in detecting a mistuned harmonic in young, middle-aged, and older adults. The stimuli were complex sounds containing multiple harmonics, one of which could be "mistuned" so that it was no longer an integer multiple of the fundamental. Older adults had higher thresholds than middle-aged or young adults. The effect of age was greater for short than for long duration sounds and remained even after controlling for hearing sensitivity. The results are consistent with an age-related decline in parsing simultaneous auditory events, which may contribute to the speech perception difficulties in the elderly.

Post-transplant biliary problems.

Biliary problems after a liver transplantation constitute the most frequent source of morbidity. Early recognition and nonoperative therapy have impacted short-term survival. Endoscopic therapy is the cornerstone in the initial treatment of all post-transplant biliary complications. A multidisciplinary approach involving endoscopic, percutaneous, and surgical therapies are often complementary in the management of these complex patients.

Anxiety and depression in mothers of children undergoing bone marrow transplant: symptom prevalence and use of the Beck depression and Beck anxiety inventories as screening instruments.

This study examined anxiety and depressive symptoms among 115 mothers of children undergoing bone marrow transplant and evaluated the ability of the Beck Anxiety Inventory (BAI; A. T. Beck, N. Epstein, et al., 1988) and the Beck Depression Inventory (BDI; A. T. Beck, 1978) to serve as screening tools for assessing generalized anxiety disorder (GAD), panic disorder (PD), and major depressive disorder (MDD). Mothers with BAI or BDI scores greater than or equal to 14 were administered a structured clinical interview. An additional 20% was randomly selected for interview to determine whether the scale cutoff was an accurate screening method. Among the 64 mothers interviewed, 20% received at least I of the 3 diagnoses. Although the BAI did not demonstrate predictive accuracy in assessing GAD and PD, the BDI did in assessing MDD. The results suggest that a subset of mothers may have an anxiety or depressive disorder and that investigators should use caution before using the BAI as a screening instrument for anxiety disorder.

Dental students' attitudes toward smoking cessation guidelines.

Dentists can be effective in helping their patients achieve smoking cessation. To plan a didactic program, we explored the smoking cessation attitudes and practices of dental students and identified barriers to service provision in the dental setting. We assessed 244 fourth-year dental students at New York University College of Dentistry through a self-report survey. The instrument included a twenty-nine-item measure assessing attitudes towards tobacco-use counseling and adherence to National Cancer Institute tobacco cessation guidelines. The survey also assessed demographics, tobacco use history, and level of preparation to provide services. Generally, students endorsed tobacco prevention practices, but perceived barriers to service provision. Students provided counseling inconsistently, with 69 percent asking about smoking, 58 percent advising cessation, 24 percent offering assistance, and 22 percent providing followup on a routine basis. Those who provided more counseling were more likely to have undergone formal training in smoking cessation, did not feel time was a barrier to counseling, and had more favorable beliefs about dentists' role in promoting smoking cessation. Study findings indicate great receptivity among students as well as a critical need and opportunity to include comprehensive cessation counseling training in the dental curriculum.

Cigarette smoking patterns in patients after treatment of bladder cancer.

BACKGROUND: Assessment of smoking status and identification of those most likely to continue smoking are important in the management of patients who have bladder cancer, because continued smoking following diagnosis and treatment increases the likelihood of treatment-related complications, recurrence, second primary malignancies, and morbidity and mortality. METHODS: Patients (n = 224) receiving follow-up care of previously treated bladder cancers completed a brief written survey assessing their post-diagnosis smoking patterns. RESULTS: Despite the risks of continued smoking, 69% of the patients who had been active smokers at the time of diagnosis (n = 84) reported smoking at some point following the diagnosis and 45% reported smoking at the time of assessment. Patients diagnosed at earlier stages were more likely to continue smoking. Patients diagnosed at later stages were 2.80 times more likely to be continuous abstainers than those diagnosed sooner (95% CI, 1.08-7.25). CONCLUSIONS: The findings underscore the need to assess smoking status and provide smoking-cessation advice and counseling within routine comprehensive care of bladder cancer patients.

Phase I trial of the anti-Lewis Y drug immunoconjugate BR96-doxorubicin in patients with lewis Y-expressing epithelial tumors.

PURPOSE: We conducted a phase I clinical trial of BR96-Doxorubicin (BR96-Dox), a chimeric anti-Lewis Y (Le(Y)) monoclonal antibody conjugated to doxorubicin, in patients whose tumors expressed the Le(Y) antigen. The study aimed to determine the toxicity, maximum-tolerated dose, pharmacokinetics, and immunogenicity of BR96-Dox. PATIENTS AND METHODS: This was a phase I dose escalation study. BR96-Dox was initially administered alone as a 2-hour infusion every 3 weeks. The occurrence of gastrointestinal (GI) toxicity necessitated the administration of BR96-Dox as a continuous infusion over 24 hours and use of antiemetics and antigastritis premedication. Patients experiencing severe GI toxicity underwent GI endoscopy. All patients underwent restaging after two cycles. RESULTS: A total of 66 patients predominantly with metastatic colon and breast cancer were enrolled onto the study. The most common side effects were GI toxicity, fever, and elevation of pancreatic lipase. At higher doses, BR96-Dox was associated with nausea, vomiting, and endoscopically documented exudative gastritis of the upper GI tract, which was dose-limiting at a maximum dose of 875 mg/m(2) (doxorubicin equivalent, 25 mg/m(2)) administered every 3 weeks. Toxicity was reversible and generally of short duration. Premedication with the antiemetic Kytril (granisetron hydrochloride; SmithKline Beecham, Philadelphia, PA), the antacid omeprazole, and dexamethasone was most effective in ameliorating GI toxicity. A dose of 700 mg/m(2) BR96-Dox (doxorubicin equivalent, 19 mg/m(2)) every 3 weeks was determined to be the optimal phase II dose when administered with antiemetic and antigastritis prophylaxis. BR96-Dox deposition on tumor tissue was documented immunohistochemically and by confocal microscopy. At the 550-mg/m(2) dose, the half-life (mean +/- SD) of BR96 and doxorubicin was 300 +/- 95 hours and 43 +/- 4 hours, respectively. BR96-Dox elicited a weak immune response in 37% of patients. Objective clinical responses were seen in two patients. CONCLUSION: BR96-Dox provides a unique strategy to deliver doxorubicin to Le(Y)-expressing tumor and was well tolerated at doses of 700 mg/m(2) every 3 weeks. BR96-Dox was not associated with the typical side-effect profile of native doxorubicin and can potentially deliver high doses of doxorubicin to antigen-expressing tumors. A phase II study in doxorubicin-sensitive tumors is warranted.

A survey of smoking status and cancer risk perceptions among participants attending a hospital-based head and neck screening program.

Abstract Screening for head and neck cancer is underutilized. Given that lack of knowledge of the risk factors may partially account for screening underutilization. we surveyed subjective risk and knowledge of risk factors for head and neck cancer among 124 individuals who attended a free. hospital-based head and neck cancer screening. Few participants were current smokers. Most attendees perceived their risk as similar to others of their age and sex. Personal health habits comprised almost all of the risk-decreasing factors, yet less than half of the risk-increasing factors. generated. Personal habits were less frequently endorsed than factors such as pollution and heredity. Those who mentioned a risk behavior, or a family cancer history, reported higher subjective risk. Those who mentioned a personal health habit reported lower subjective risk. Results highlight needed efforts to increase screening among high-risk individuals through targeted education messages.

Influence of smoking status on the disease-related outcomes of patients with tobacco-associated superficial transitional cell carcinoma of the bladder.

BACKGROUND: The aim of this study was to assess the influence of tobacco exposure, at the time of diagnosis, on the disease-related outcomes of patients with tobacco-associated superficial transitional cell carcinoma (TCC) of the bladder. METHODS: A retrospective cohort study was performed using the MSKCC Registry to identify all institutional cases of "noninvasive" TCC (n = 1632) between 1985 and 1995. After employing exclusion criteria, 286 cases of incident tobacco-associated superficial TCC were divided into 3 strata of tobacco exposure (127 ex-smokers, 51 quitters, and 108 continued smokers) by chart review and post hoc questionnaires (n = 82). Measured outcomes included recurrence free survival and survival free of adverse events (defined a priori as disease progression or other urinary tract TCC). RESULTS: There were no significant differences among ex-smokers, quitters, and continued smokers in terms of stage, grade, tumor size, multifocality, up-front bacillus Calmette-Guérin therapy, or median follow-up. Ex-smokers presented at a later age than individuals who continued to smoke. Post hoc questionnaires and chart reviews were compared in terms of smoking status at time of diagnosis, and reliability was excellent (kappa = 0.89). Multivariate analyses revealed diminished recurrence free survival among continued smokers versus quitters or ex-smokers. Univariate analyses revealed diminished adverse event free survival among continued smokers versus quitters or ex-smokers. Multivariate models assessing adverse event free survival revealed a similar trend (P = 0.06). CONCLUSIONS: Continued smokers experience worse disease-associated outcomes than patients who quit smoking. Smoking cessation should thus be employed as a tertiary prevention strategy for patients with superficial TCC.

Nicotine dependence and withdrawal in an oncology setting: a risk factor for psychiatric comorbidity and treatment non-adherence.

Highly nicotine dependent oncology patients are at high risk for psychiatric morbidity when they enter the medical care setting where smoking restrictions apply. Nicotine withdrawal symptoms exacerbate cancer-related distress as well as common physical side effects of cancer treatment. This case report illustrates the management of a patient whose ongoing treatment for bladder cancer was jeopardized as a result of nicotine dependence and withdrawal. Several associated complications are described, the most serious of which were his acute anxiety and non-adherence to medical recommendations. A short-term management approach that included anxiolytics and nicotine replacement was effectively used to reduce this patient's excessive anxiety and thus facilitate compliance with stressful treatments. The severity of complications that can result from untreated nicotine dependence and withdrawal underscores the importance of assessing and monitoring smoking status in every patient. Greater staff awareness of the clinical practice guidelines regarding the diagnosis and treatment of nicotine dependence will likely result in improved patient care and compliance.

Motivating smoking cessation among dental patients: smokers' interest in biomarker testing for susceptibility to tobacco-related cancers.

This study examined interest in receiving biomarker testing for tobacco-related cancer susceptibility among 148 smokers seeking routine oral health care in a public dental clinic. Patients completed a brief, self-report survey assessing their smoking history, tobacco-related illness history, readiness to quit smoking, perceived risk and worry about cancer, and their interest in being tested for genetic susceptibility for tobacco-related cancers. Participants were socioeconomically and ethnically diverse, and were primarily long-standing, nicotine-dependent smokers. Most reported (83%) interest in biomarker feedback, and most (86%) understood that a certain genetic make-up could place them at increased risk for tobacco-related cancers. Those participants who felt that quitting smoking would reduce future cancer risk, were at least in the contemplation stage of quitting readiness, felt more worried and more at risk for developing cancer, women and younger smokers were more interested in genetic testing (all ps < 0.20). Multivariate logistic regression analyses indicated that gender and risk perceptions were associated with interest in testing. The public dental clinic setting holds potential for innovative smoking cessation interventions using personalized risk feedback.

Cortical evoked response to acoustic change within a syllable.

OBJECTIVE: To investigate whether the evoked potential to a complex naturally produced speech syllable could be decomposed to reflect the contributions of the acoustic events contained in the constituent phonemes. DESIGN: Auditory cortical evoked potentials N1 and P2 were obtained in eight adults with normal hearing. Three naturally produced speech stimuli were used: 1) the syllable [sei]; 2) the sibilant [s], extracted from the syllable; 3) the vowel [ei] extracted from the syllable. The isolated sibilant and vowel preserved the same time relationships to the sampling window as they did in the complete syllable. Evoked potentials were collected at Fz, Cz, Pz, A1, and A2, referenced to the nose. RESULTS: In the group mean waveforms, clear responses were observed to both the sibilant and the isolated vowel. Although the response to the [s] was weaker than that to [ei], both had N1 and P2 components with latencies, in relation to sound onset, appropriate to cortical onset potentials. The vowel onset response was preserved in the response to the complete syllable, though with reduced amplitude. This pattern was observable in six of the eight waveforms from individual subjects. CONCLUSIONS: It seems likely that the response to [ei] within the complete syllable reflects changes of cortical activation caused by amplitude or spectral change at the transition from consonant to vowel. The change from aperiodic to periodic stimulation may also produce changes in cortical activation that contribute to the observed response. Whatever the mechanism, the important conclusion is that the auditory cortical evoked potential to complex, time-varying speech waveforms can reflect features of the underlying acoustic patterns. Such potentials may have value in the evaluation of speech perception capacity in young hearing-impaired children.

Gastrointestinal bleeding in the hospitalized patient: a case-control study to assess risk factors, causes, and outcome.

PURPOSE: To determine the risk factors, etiology, and outcome of clinically important gastrointestinal bleeding that occurs after hospital admission (nosocomial gastrointestinal bleeding). PATIENTS AND METHODS: Cases consisted of consecutive patients who developed gastrointestinal bleeding more than 24 hours after admission to the hospital. Cases were compared with two control populations: a set of hospitalized patients without gastrointestinal bleeding matched with cases for age, gender, and length of stay; and all patients admitted to the hospital with clinically important gastroduodenal ulcer bleeding during the study period. Case and controls were compared with respect to risk factors for gastrointestinal bleeding and outcomes. Data were obtained through a comprehensive review of medical records. RESULTS: Clinically important nosocomial gastrointestinal bleeding occurred in 67 inpatients after a mean hospital length of stay of 14 +/- 10 days. The majority (64%) of the patients were not hospitalized in the intensive care unit at the onset of the bleeding. Seventy-two percent of the patients who developed bleeding had been receiving some form of bleeding prophylaxis. In a multivariate analysis, a prior intensive care unit stay (odds ratio 2.5; 95% confidence interval 1.0 to 6.1; P <0.05) and mechanical ventilation (OR 3.4; 95% CI 1.1 to 10.7; P = 0.03) were independent risk factors for the onset of bleeding. Nosocomial gastrointestinal bleeding was associated with poor outcome, with an associated mortality of 34%. Duodenal ulcer disease was the most common source of nosocomial gastrointestinal bleeding, accounting for 36% of cases overall. Nosocomial ulcer bleeders were less likely to have a previous history of ulcer disease (13% versus 50%; P <0.05) Helicobacter pylori infection (14% versus 62%; P <0.0001), chronic active gastritis (29% versus 91%; P <0.0001), or to be taking NSAIDs (48% versus 68%; P <0.08) than patients admitted to the hospital with ulcer bleeding. CONCLUSIONS: Gastrointestinal bleeding remains an important complication of hospitalization, with a high associated mortality. Our current approaches to prevention of this complication are imperfect. Bleeding tends to occur after a prolonged hospital stay and is more likely to occur in patients with more severe underlying illnesses. Duodenal ulcer disease is the most common source of this bleeding. Nosocomial gastroduodenal ulcer disease is distinct in etiology from the ulcer disease that occurs in outpatients.

Risk of persistent or recurrent and intractable upper gastrointestinal bleeding in the era of therapeutic endoscopy.

OBJECTIVES: Patients who present to the emergency department with upper gastrointestinal bleeding can have persistent or recurrent (further) bleeding or self-limited bleeding. We performed a study to determine the frequency, risks factors, and impact on outcome of further bleeding. METHODS: Clinical predictors of further bleeding were retrospectively identified in 137 consecutive patients presenting to our institution with upper gastrointestinal bleeding in 1994-1995. RESULTS: Persistent or recurrent bleeding occurred in 30.7% of the cases, bleeding intractable to endoscopic therapy occurred in 15.3%. Hematemesis (odds ratio [OR] 5.7; 95% confidence interval [CI], 2.4-13.1, p = 0.0001) and a initial hemoglobin (OR, 0.8; 95% CI, 0.7-0.96; p = 0.01) were independent risk factors for persistent or recurrent bleeding, whereas liver disease (OR, 6.0; 95% CI, 2.0-18.4; p = 0.002) and hematemesis were independent risk factors for intractable bleeding. The mortality rate was 14.3 and 1%, respectively, in patients with and without further bleeding. In patients who did not present with hematemesis, liver disease, coagulopathy, hypotension, and initial hemoglobin < 11 g/dl, the frequency of further bleeding and mortality was 0%. CONCLUSIONS: Persistent, recurrent, and intractable bleeding occurs in a substantial proportion of patients admitted with upper gastrointestinal bleeding. The risk of further bleeding can be estimated on the basis of clinical presentation. Further bleeding is associated with a worse outcome.

Endoscopic sclerotherapy compared with percutaneous transjugular intrahepatic portosystemic shunt after initial sclerotherapy in patients with acute variceal hemorrhage. A randomized, controlled trial.

BACKGROUND: Hemorrhage from esophageal varices remains a substantial management problem. Endoscopic sclerotherapy was preferred for more than a decade, but fluoroscopically placed intrahepatic portosystemic stents have recently been used with increasing frequency. OBJECTIVE: To compare sclerotherapy with transjugular intrahepatic portosystemic shunt (TIPS) in patients with bleeding from esophageal varices. DESIGN: Randomized, controlled clinical trial. SETTING: Three teaching hospitals. PATIENTS: 49 adults hospitalized with acute variceal hemorrhage from November 1991 to December 1995: 25 assigned to sclerotherapy and 24 assigned to TIPS. INTERVENTION: Patients assigned to repeated sclerotherapy had the procedure weekly. In those assigned to TIPS, an expandable mesh stent was fluoroscopically placed between an intrahepatic portal vein and an adjacent hepatic vein. MEASUREMENTS: Pretreatment measures included demographic and laboratory data. Postrandomization data included index hospitalization survival, duration of follow-up, successful obliteration of varices, rebleeding from varices, number of variceal rebleeding events, total days of hospitalization for variceal bleeding, blood transfusion requirements after randomization, prevalence of encephalopathy, and total health care costs. RESULTS: Mean follow-up (+/-SE) was 567 +/- 104 days in the sclerotherapy group and 575 +/- 109 days in the TIPS group. Varices were obliterated more reliably by TIPS than by sclerotherapy (P < 0.001). Patients having TIPS were significantly less likely to rebleed from esophageal varices than patients receiving sclerotherapy (3 of 24 compared with 12 of 25; P = 0.012). No other follow-up measures differed significantly between groups. A trend toward improved survival, which was not statistically significant, was noted in the TIPS group (hazard ratio, 0.53 [95% CI, 0.18 to 1.5]). CONCLUSIONS: In obliterating varices and reducing rebleeding events from esophageal varies, TIPS was more effective than sclerotherapy. However, TIPS did not decrease morbidity after randomization or improve health care costs. It seemed to produce better survival, but the increase in survival was not statistically significant.