Using pictures to evoke spiritual feelings in breast cancer patients: development of a new paradigm for neuroimaging studies.

This study was designed to develop and validate a method for enhancing spiritual feelings, particularly in women who have received a diagnosis of breast cancer. The protocol specifically was developed to be used in functional magnetic resonance imaging (fMRI) studies. Eighteen breast cancer survivors rated pictures for their ability to enhance feelings of spirituality, happiness, and sadness. Results indicate that presenting carefully selected pictures with spiritual content (e.g., nature scenes, people engaged in contemplative behaviors) can effectively enhance spiritual feelings among breast cancer survivors. Future fMRI studies will explore the use of the protocol developed in this study for investigating neural activity during spiritual feelings and states.

Maternal levels of dichlorodiphenyl-dichloroethylene (DDE) may increase weight and body mass index in adult female offspring.

OBJECTIVES: To investigate the effect of prenatal exposure to polychlorinated biphenyls (PCBs) and dichlorodiphenyl-dichloroethylene (DDE) on weight, height and body mass index (BMI) in adult female offspring of the Michigan fisheater cohort examined between 1973 and 1991. METHODS: 259 mothers from the Michigan fisheater cohort were studied. Prenatal exposure to PCBs and DDE was estimated by extrapolating maternal measurements to the time that the women gave birth. 213 daughters aged 20-50 years in 2000 were identified and 83% of them participated in at least one of two repeated investigations in 2001/02 (n = 151) and 2006/07 (n = 129). To assess the effect of prenatal PCB and DDE exposure on anthropometric measurements, generalised estimating equations nested for repeated measurements (2001/02 and 2006/07) and for sharing the same mother were used. We controlled for maternal height and BMI and for daughters' age, birth weight, having been breastfed and number of pregnancies. RESULTS: Maternal height and BMI were significant predictors of the daughters' height, weight and BMI. Low birth weight (<2500 g) was significantly associated with reduced adult offspring weight and BMI. The weight and BMI of adult offspring were statistically significantly associated with the extrapolated prenatal DDE levels of their mothers. Controlling for confounders and compared to maternal DDE levels of <1.503 microg/l, offspring BMI was increased by 1.65 when prenatal DDE levels were 1.503-2.9 microg/l and by 2.88 if levels were >2.9 microg/l. Prenatal PCB levels showed no effect. CONCLUSION: Prenatal exposure to the oestrogenic endocrine-disrupting chemical DDE may contribute to the obesity epidemic in women.

Observation interval for evaluating the costs of surgical interventions for older women with a new diagnosis of breast cancer.

OBJECTIVE: To estimate the episodic costs of surgical treatments for breast cancer. METHODS: The surgical treatment period as the 6 weeks following diagnosis is defined. Using a sample of 205 women aged 65 and older and their Medicare claim files, the cost of treatment is estimated and the progression from first to subsequent surgical procedures during the 6-week interval is demonstrated with a decision tree. Two equations are then estimated: the probability of mastectomy versus breast conserving surgery (BCS) as first surgery using Probit regression and the log of total charges using a generalized linear regression model. RESULTS: It was found that only stage predicts the probability of mastectomy versus BCS and that 54% of women receiving BCS undergo a second surgery. Once all treatments in the initial surgical period are accounted, the difference between the adjusted cost of mastectomy alone and BCS followed by a second surgery was not statistically significant. Only a successful first BCS is statistically significantly (P <0.05) less costly than a mastectomy alone ($4,955 vs. $9,049). CONCLUSIONS: By defining a 6-week surgical treatment episode it is shown that BCS followed by subsequent surgeries is the more costly option for initial treatment. Given the high prevalence of second surgeries, previous work may have underestimated the costs of surgical interventions for breast cancer.

DNA flow cytometry does not predict 5- or 10-year recurrence rates for T1-2 node-negative breast cancer.

BACKGROUND: A small proportion of T1 or T2 node-negative breast cancer tumors will recur in patients by 5 years, and more by 10 years. Results of recent studies have suggested improvement in overall survival with administration of adjuvant chemotherapy to all patients. More sensitive and specific methods are needed to identify patients at highest risk for recurrence who might benefit most from adjuvant therapy, saving others from unnecessary treatment. Some investigators have suggested DNA flow cytometry as a method to discriminate patients at greatest risk for recurrence. HYPOTHESIS: DNA flow cytometry has predictive value for breast cancer recurrence in node-negative patients. METHODS: The cancer registry of a medium-sized university-affiliated hospital was used to identify patients with T1-2 N0 M0 breast cancer treated with a uniform surgical approach and no adjuvant therapy who had completed at least 5 years of follow-up or had recurrence. Flow cytometric analysis was performed on paraffin-embedded specimens. RESULTS: Of 115 patients, 92 (80%) had disease-free survival without recurrence and 23 (20%) had recurrence. Comparison of diploid and nondiploid tumors for likelihood of recurrence revealed no association (P = .79). Furthermore, the DNA index and S-phase fraction were not significantly different between recurrent and nonrecurrent groups. CONCLUSIONS: The likelihood of recurrence of small node-negative breast cancers after mastectomy cannot be accurately predicted on the basis of DNA flow cytometric analysis. Traditional methods for determining risks-such as nuclear and histological grade, lymph node status, and tumor size-seem to be more useful. Sentinel lymph node biopsy techniques may increase the detection of micrometastases.

Breast carcinoma etiology: current knowledge and new insights into the effects of reproductive and hormonal risk factors in black and white populations.

BACKGROUND: A crossover in breast carcinoma incidence at ages 45-49 years has been observed between black and white women, with blacks experiencing higher incidence at younger ages and lower incidence after age 50 years. Can this phenomenon be partially explained by the differences in the distributions of reproductive risk factors? This article focuses on the effects and distributions of age at first full term pregnancy (FFTP), parity, and oral contraceptive (OC) use in younger versus older and black and white populations. Effects of hormone replacement therapy (HRT) are also summarized. METHODS: A literature review was conducted and information integrated on the effects and distributions of reproductive and hormonal risk factors in black and white populations, the crossover effect of parity, and the Pike model of "breast tissue age." RESULTS: Overall, early age at FFTP and higher parity decreased risk for both races. Distributions of age at FFTP and parity varied widely between the two races. Based on the effects and distributions of age at FFTP and parity, the authors formulated the hypothesis that a crossover in incidence curves between the two races would be expected, rather than be considered an anomaly. Regarding OC use, generally a stronger increase in risk was observed for younger women than for older women. Regarding HRT, a recent meta-analysis observed an increased risk of 1.35 for 5 years of use or more. CONCLUSIONS: To promote public health in diverse populations, and to provide further insight into breast carcinoma etiology, research needs to focus on multicultural differences and similarities in the relation of hormonal risk factors and breast carcinoma.

Hormone replacement therapy with estrogen or estrogen plus medroxyprogesterone acetate is associated with increased epithelial proliferation in the normal postmenopausal breast.

The relative effects of postmenopausal hormone replacement therapy (HRT) with estrogen alone vs. estrogen+progestin on breast cell proliferation and on breast cancer risk are controversial. A cross-sectional observational study was carried out to examine the proliferative effects of HRT with estrogen or estrogen plus the progestin, medroxyprogesterone acetate, in breast tissue of postmenopausal women. Benign breast biopsies from 86 postmenopausal women were analyzed with antiproliferating cell nuclear antigen (anti-PCNA) and Ki67 antibodies to measure relative levels of cell proliferation. Epithelial density and estrogen and progesterone receptor status were also determined. The women were categorized either as users of: 1) estrogen (E) alone; 2) estrogen+medroxyprogesterone acetate (E+P); or 3) no HRT. Compared with no HRT, the breast epithelium of women who had received either E+P or E alone had significantly higher PCNA proliferation indices, and treatment with E+P had a significantly higher index (PCNA and Ki67) than treatment with E alone. Breast epithelial density was significantly greater in postmenopausal women treated with E and E+P, compared with no HRT. Thus, the present study shows that postmenopausal HRT with E+P was associated with greater breast epithelial cell proliferation and breast epithelial cell density than E alone or no HRT. Furthermore, with E+P, breast proliferation was localized to the terminal duct-lobular unit of the breast, which is the site of development of most breast cancers. Further studies are needed to assess the possible association between the mitogenic activity of progestins and breast cancer risk.

Primary care guide to managing a breast mass: a legal perspective on risk management.

Failure to diagnose breast cancer in a timely manner is the most common reason for malpractice litigation in the US, and it is the most costly claim made against physicians. Common reasons for delay of diagnosis include unimpressive physical findings, failure to follow up with the patient, and a negative mammogram report. Equally important for quality patient care and for defense against malpractice suits is thorough documentation of history, examination, test results, recommendations, and patient interactions. This article provides guidelines with case studies that stress the importance of effective documentation and communication with the patient and offers recommendations for risk management.

Primary care guide to managing a breast mass: step-by-step workup.

Missed breast cancer is the most common malpractice suit filed in the US. But even without a biopsy of every mass, clinicians can reduce the risk of failed diagnosis to 1% by using a triple-diagnosis method to working up a breast mass, according to these experts, who offer a step-by-step guide. Includes QuickTimeTM video of breast exam. Failure to diagnose breast cancer in a timely manner is the most common reason for malpractice litigation in the US. Unless the potential for false-negative results of physical examination, mammography, ultrasound, and fine-needle aspiration biopsy (FNAB) is recognized, delay in the diagnosis of breast cancer will continue to occur. A systematic, thorough approach to the workup of any breast mass-- including a careful history, clinical breast examination, and documentation--is crucial. Upon detection of a mass, distinguishing the cyst from the solid mass (often by fine-needle aspiration or FNAB) is one of the most important tasks facing the clinician. Although most cysts resolve upon aspiration, solid masses require further workup to rule out cancer. Because of the false-negatives associated with individual methods of diagnosis, the authors recommend the triple-diagnosis method of detection. Simultaneous evaluation of a breast mass using clinical breast examination, radiography, and FNAB can lower the risk of missing cancer to only 1%, effectively reducing the rate of diagnostic failure and increasing the quality of patient care.

A national breast cancer database.

The medical audit of technical and interpretive aspects of mammography has been recommended by a number of expert panels and as part of some regulations that govern the oversight of mammography. The value of the medical audit is to aid practitioners in the performance evaluation of mammography in their facilities. Collection and analysis of audit data at a regional or national level have the potential to allow for the comparison of practice-level performance with regional and national-level performance and to provide a public health tool for the evaluation and improvement of breast cancer detection. In addition, a regional and national-level breast cancer database has the potential for allowing monitoring and tracking of women participating in a screening program. Prior to establishing such a database, data must be protected from discovery and disclosure, and patient and physician confidentiality must be ensured.

The mammography audit: a primer for the mammography quality standards act (MQSA).

The medical audit of a mammography practice is a recognized method for evaluating mammography and the accuracy of mammographic interpretation [1-4]. As such, portions of the audit will become integral to the quality assurance activities of every mammography practice under the Mammography Quality Standards Act (MQSA) of 1992, administered by the Food and Drug Administration (FDA). The FDA Interim Rules, which became effective October 1, 1994, state that "each facility shall establish a system for reviewing outcome data from all mammography performed, including follow-up on the disposition of positive mammograms and correlation of surgical biopsy results with mammogram reports" [5]. It is expected that the proposed final rules, due to be released for public comment in 1995, will require collection of additional data for medical audits (public meeting of the National Mammography Advisory Committee, May 3, 1994). Although most mammography practices are now collecting clinical outcomes data on abnormal mammographic examinations, very few have established an organized and deliberate system of data collection necessary for a more complete mammography audit [6]. A detailed discussion of and recommendations for such an audit were recently published as part of the Quality Determinants of Mammography Guideline by the Agency for Healthcare Policy and Research (AHCPR) [7]. As members and consultants on the multidisciplinary panel that produced the guideline, we offer the following review of the various elements, definitions, and processes of the mammography audit. This is intended as a primer for all radiologists who will be performing some of the same audit activities for the MQSA.

A proposal for a national mammography database: content, purpose, and value.

A national mammography database is a centralized, computerized method of data collection consisting of two possible parts: a national mammography audit and a system for monitoring and tracking patients. A national mammography audit refers to collecting and analyzing medical audit data of individual mammography practices at a national level and is a critical step in improving the interpretive component of mammography. The monitoring and tracking component refers to a centralized system that provides women and physicians with a recruitment and follow-up mechanism to optimize participation in mammography services. Both parts of a national mammography database represent important components in the improvement of mammography quality. However, unique scientific, legal, and fiscal concerns are important to consider before establishing a national mammography database.

The history and the effect of the mammography quality assurance legislation in Michigan.

This paper describes the history of mammography quality assurance legislation in Michigan, the first of its kind in the nation. It discusses the collaboration of multiple organizations in the legislative process as well as in the implementation of it. It describes the effect of the legislation on the quality of mammography throughout the state and summarizes the lessons learned from the process, especially as they apply to the implementation of the Mammography Quality Standards Act at the national level.

The timely diagnosis of breast cancer. Principles of risk management for primary care providers and surgeons.

Alleged delay in the diagnosis of breast cancer is one of the most common reasons for medical malpractice claims in the United States, accounting for the largest indemnity payments of any single medical condition. Although the diagnosis of breast cancer can be challenging and sometimes difficult, principles of management exist to assist health providers in pursuing a resolution of any breast complaint. Studies have shown that when litigation is pursued for alleged failure to diagnose breast cancer, multiple specialists are named in the suit. In most cases, patients filing claims of alleged failure to diagnose breast cancer are premenopausal, while the majority of women diagnosed with breast cancer are postmenopausal. This reflects, in part, the challenge of diagnosing the disease in women who have difficult clinical exams to interpret, as well as dense parenchyma on mammograms, which decreases the sensitivity of the radiograph interpretation. Principles of risk management to avoid a delay in diagnosis include (1) pursuing every breast complaint to resolution, (2) following breast cancer screening guidelines, (3) establishing an office tracking system for breast cancer screening reminders, (4) tracking results of all mammograms and follow-up studies ordered, (5) referring premenopausal women for the evaluation of any breast mass that persists through a menstrual cycle, (6) considering any asymmetrical breast finding as a cause for concern, (7) referring every woman with a breast finding on physical examination for consultation, regardless of the mammogram report, and (8) carefully documenting patient history, physical exam findings, clinical impression, and follow-up plans.

The influence of cancer patients' symptoms and functional states on patients' depression and family caregivers' reaction and depression.

In this article the paths among cancer patients' physical and mental health and the reactions and mental health of their family caregivers were examined. Data for these analyses came from a cross-sectional sample of cancer patients who were recruited through ambulatory outpatient chemotherapy units, and their family caregivers. Patients' depression was explained largely by their symptomatology and, to a lesser extent, by loss of mobility. Patients' physical limitations impacted caregivers' daily schedules but not their physical health. Patients' levels of depression were related to those of their caregivers. However, caregivers' optimism proved to be a significant predictor of their mental health and reactions to caregiving.

The design and implementation of a community breast cancer screening project.

A breast cancer screening program offers a community the opportunity to highlight and address an important health issue. This article has described the important elements of any such screening effort. To be successful, the program will require a multidisciplinary cadre of health care professionals working collaboratively throughout all phases of the planning, screening, and follow-up process. An agency should be identified to lead these professionals and monitor the progress of the screening effort. These screening programs can have direct and indirect benefits in the community. The direct benefits include improved access and delivery of health services, particularly those that meet state-of-the-art quality standards. The indirect benefits involve the promotion of breast cancer screening through education of women and providers about good breast health practices. As our experience in Michigan has shown, efforts featuring a broad coalition of forces can foster debate and discussion throughout the community and ultimately lead to improvements in the delivery of breast cancer screening services.

A pilot study of the relationship between experts' ratings and scores generated by the NBME's Computer-Based Examination System.

This pilot study evaluates the consistency of experts' ratings of students' performances on the National Board of Medical Examiners' Computer Based Examination (CBX) cases and the relationship of those ratings to the CBX's scoring algorithm. The authors were investigating whether an automated scoring algorithm can adequately assess an examinee's management of a computer-simulated patient. In 1989-90, at the Michigan State University College of Human Medicine, eight students, completing a surgery clerkship, each managed eight CBX cases and took a computer-administered, multiple-choice examination. Six clerkship coordinators rated the students' performances in terms of overall management, efficiency, and dangerous actions. The ratings correlated highly with scores produced by the CBX's scoring system.