New data suggest that immigration status may help explain why some women decide to be screened for cervical cancer and others do not. The study by Canadian researchers additionally indicates that age and income may also affect screening rates.

	Aisha K. Lofters, MD, with St. Michael’s Hospital in Toronto, Ontario, Canada, and associates examined the medical billing records of 2.9 million women aged 18 to 69 years who were living in urban areas of Ontario between 2006 and 2008.

	The study aimed to compare the prevalence of appropriate cervical cancer screening in Ontario among major geographic regions of the world and Canadian-born women. Canadian guidelines advise women who are at low risk for cervical cancer to have a Pap test every 3 years. Overall, nearly 1.8 million (61.3%) women had had a recent screening per recommended guidelines during the study period.

	Older, poorer women born in South Asia had the lowest screening rates. In fact, only 21.9% of South Asian immigrants who were aged >50 years, were living in a low-income neighborhood, and did not have a primary care doctor had had a recent Pap test compared with 79% of native women residing in the highestincome neighborhoods who had a primary care physician.

	Lofters and colleagues said that the observation that screening inequities were most pronounced in women from South Asia, especially in those aged >50 years, is especially worrisome. First, India is the primary source country for Ontario’s immigrants, and, secondly, South Asians are among the fastestgrowing minority groups in Canada. Further analysis revealed that immigrant women who had lived in Canada for more than 10 years still had significantly lower screening rates, thereby suggesting that a longer time spent in Canada does not eradicate screening barriers.

	Lofters and associates suggested that cultural barriers and women’s prior experience in their country of origin may contribute to low screening rates in immigrant women. Future research is needed to examine the role of such factors and other potential barriers, such as provider gender and ethnicity.

	The investigators emphasized that their study is large and population-based with broad inclusion criteria. Multiple subgroup and sensitivity analyses were done to corroborate the robustness of the findings. They cautioned, however, that they are not sure whether their results can be extrapolated to other settings, although Canada’s immigration patterns are known to be similar to global patterns.

	The findings suggest that primary care providers should pay closer attention to risk factors for low screening, such as immigration status, age, and income when women present who are eligible for cervical cancer screening. The data also mean that policy makers may consider targeting particular subgroups of women for culturally appropriate screening campaigns.

	Cervical cancer is the second most common cancer in women worldwide, with incidence rates in less developed countries nearly double those in developed countries. The significantly higher incidence rates are thought to be primarily due to routine and widespread Pap test-based screening programs in developed countries.

Lofters AK, Hwang SW, Moineddin R, Glazier RH. Cervical cancer screening among urban immigrants by region of origin: a population-based cohort study. Prev Med. 2010. Dec;51(6):509-16 [Epub ahead of print October 7, 2010].

Articles

New data suggest that immigration status may help explain why some women decide to be screened for cervical cancer and others do not

Study Indicates That Immigrant Women in Ontario Shun Cervical Cancer Screening

	New findings indicate that prereferral care does not conform to clinical practice guidelines in nearly half of patients with head and neck cancer who are referred to a tertiary care center with persistent or recurrent disease, new findings indicate.

	The data also show that inadequate surgical management is the main reason for noncompliance with the guidelines.

	"To improve the quality of head and neck cancer care through increased compliance with national guidelines, steps need to be taken toward educating community providers through dissemination of guidelines, implementation of multidisciplinary conferences, and regionalization of the care of this patient population," reported Carol M. Lewis, MD, MPH, and colleagues at the University of Texas MD Anderson Cancer Center in Houston.

	For their study, the investigators evaluated all components of prior care in 107 newly referred patients to determine how well prereferral treatment complied with National Comprehensive Cancer Network (NCCN) guidelines.

	Assessing the quality of care has been a national priority for roughly a decade, and analyses have been largely based on an examination of mortality, morbidity, and duration of hospital stay. However, clinical practice guidelines, which are drawn from expert consensus and scientific evidence, provide specialty— and disease–specific treatment recommendations that establish the standard of care that clinicians should aim to provide.

	Lewis and colleagues stated that, while data on compliance with established clinical practice guidelines are available for axillary lymph node dissection, colorectal cancer care, and the surveillance and management of papillary thyroid cancer, the present study is the first to examine compliance with NCCN guidelines for head and neck cancer outside of tertiary care centers.

	Prereferral Treatment of Head and Neck Cancer Patients Disregards Guidelines In the present series, the mean time from first presentation with initial symptoms to diagnosis was 23.8 weeks in patients who presented with persistent disease and 10.1 weeks in patients who presented with recurrent disease.

	Overall, 43% of patients presenting with persistent or recurrent disease had some aspect of their prereferral care that did not adhere to NCCN guidelines.

	Surgical management deemed to be inadequate on the basis of prereferral imaging, operative notes, and pathology records accounted for 58.7% of cases. Notably, 15.2% of patients were given an incorrect diagnosis, which resulted in inappropriate treatment.

	Also, 10.9% of patients received inadequate adjuvant therapy, 10.9% refused recommended treatment, and 4.4% received inadequate radiation therapy.

	Lewis and associates said that it is possible that the deviation from guidelines may mean that some prereferral physicians are not aware of the guidelines or they may not implement the guidelines used in the study as the standard of quality.

	They also maintained that the large percentage of patients who refused recommended treatment may suggest that these patients were not sufficiently wellinformed when they made their decision to refuse treatment and were also perhaps not sufficiently knowledgeable about the possible consequences of their decisions.

	Finally, the researchers said that they were not always able to obtain complete records of prereferral treatment despite trying to contact both the patient and the referring physician. When they were not able to obtain the requisite information and when they were unable to establish that prereferral care was not in sync with NCCN guidelines, the researchers gave providers “the benefit of the doubt” and classified the care as being compliant with guidelines. Thus, deviation from NCCN guidelines is probably more common than seen in their study.

New findings indicate that prereferral care does not conform to clinical practice guidelines in nearly half of patients with head and neck cancer who are referred to a tertiary care center with persistent or recurrent disease, new findings indicate. 

Prereferral Treatment of Head and Neck Cancer Patients Disregards Guidelines

	New data suggest that unrealistic optimism is common in patients who participate in early-phase cancer clinical trials and may interfere with their ability to provide informed consent.

	Lynn A. Jansen, PhD, with Oregon Health Sciences University in Portland, and colleagues reviewed responses to questionnaires completed by 72 patients enrolled in phase I, phase I/II, or phase II clinical cancer trials at a major comprehensive cancer center during a recent 14-month period.

	Forty-one patients had blood cancer, 29 had myelodysplastic syndrome, 1 had breast cancer, and 1 had lung cancer.

	The term “unrealistic optimism,” which is also called “optimism bias,” refers to optimism that results from a bias in which a person believes that he/she is more likely to experience positive outcomes or less likely to experience negative outcomes than other patients in the same situation. Jansen and associates caution that unrealistic optimism may undercut the informed consent process by making it difficult for a patient to “apply information realistically.”

	For their study, the investigators used the comparative risk/ benefit assessment questionnaire that aimed to assess how well participants understood the trial’s objective. Participants demonstrated unrealistic optimism in response to 3 of 5 questions about the likelihood of particular cancerrelated events happening to them compared with other trial participants. Overall, 59.7% were unrealistically optimistic when they were asked whether their cancer was likely to be controlled by the experimental drug being evaluated in the trial, 62.5% were unrealistically optimistic when asked whether they would experience a health benefit from the drug used in the trial, and 38.9% were unrealistically optimistic when asked whether they would experience a health problem from the drug tested in the trial.

	Trial participants were also asked an open-ended question to gauge their understanding of the purpose of the trial. Results of the so-called “Purpose Question” showed that 72.9% of respondents correctly understood that the purpose of the trial in which they were enrolled was to advance generalizable knowledge with the potential to benefit future patients, and not necessarily to benefit them.

	No significant association was found between responses to the Purpose Question and the unrealistic optimism scores.

	Jansen and colleagues noted that their results are preliminary and emphasized that their study was conducted at a single institution, and that the distribution of malignancies was “skewed away” from solid tumors. They also say that they have not yet looked at patients who decline to participate in early-phase clinical trials, and thus do not know whether this group also demonstrates unrealistic optimism regarding cancer-related events.

	"Improving the consent process in oncology research will require us to do more than address deficits in understanding," the investigators pointed out. "It will require us to pay more attention to how patients apply information to themselves and to become more aware of the social-psychological factors that might impair decision-making in this context.”

	Contrary to popular opinion, “hope and optimism in the research context” are not necessarily “ethically benign,” noted Jansen and colleagues.

New data suggest that unrealistic optimism is common in patients who participate in early-phase cancer clinical trials and may interfere with their ability to provide informed consent. 

Excessive Optimism Plagues Early Cancer Studies

	Researchers are calling for prostate cancer survivors to incorporate physical activity into their daily routine.

	The recommendation was issued by a team from the Harvard School of Public Health, Brigham and Women's Hospitals, and Harvard Medical School in Boston, Massachusetts, and the University of California, San Francisco, who found that prostate cancer survivors who exercise regularly can decrease their risk of prostate cancer-specific and overall mortality.

	The study also showed that men who did more vigorous physical activity for longer durations had the lowest risk of dying from the disease. Vigorous exercise was defined as more than 3 hours of weekly exercise.

	Stacey A. Kenfield, ScD, with the Harvard School of Public Health, and associates analyzed data in 2705 men who had been diagnosed with nonmetastatic prostate cancer between 1990 and 2008 in the 51,529-patient, prospective Health Professionals Follow-Up Study. Prostate cancer is the most frequently diagnosed cancer in men in the United States, and more than 2 million men in this country are prostate cancer survivors, Kenfield said.

	While studies have shown that breast and colon cancer survivors who perform regular physical activity have significantly lower overall mortality and cancer-specific mortality than survivors who do not exercise regularly, this association has not been evaluated in prostate cancer survivors, she noted.

	Prior research by her group had shown that high levels of vigorous physical activity were significantly associated with a decreased risk of advanced prostate cancer in men aged 65 years and older.

	In the present analysis, trial participants completed questionnaires every 2 years that focused on their leisure-time activities. Specifically, they were asked to report the average amount of time they spent each week during the prior year performing physical activities (eg, walking, jogging, running, riding a bicycle, swimming, tennis, etc), as well as heavy outdoor work and weight training. The men were also asked to cite the frequency, duration, and intensity of physical activity.

	Of the 548 deaths that occurred during follow-up, 112 (20%) were due to prostate cancer. The median length of follow-up from the first post-diagnosis physical activity assessment was 9.7 years for survivors and 7.8 years for patients who died.

	Both vigorous activity and nonvigorous activity were associated with significantly lower overall mortality. Men who walked 90 minutes or more per week at a normal to very brisk pace had a 46% lower risk of all-cause mortality (HR, 0.54) compared to men who walked for a shorter length of time at a slower pace.

	Men who did 3 or more hours per week of vigorous activity had a 61% lower risk of prostate cancerspecific death than men who did less than 1 hour of vigorous activity per week (HR, 0.39; 

	In a news release, Kenfield points out that benefits were achieved--at very attainable levels--of activity, thereby suggesting that prostate cancer patients should do some form of physical activity for their overall health. Even as little as 15 minutes a day may be useful, she said. Vigorous activity for at least 3 hours per week confers additional benefit by potentially preventing both prostate cancer deaths and deaths from all causes.

	Further research, however, is needed to determine whether physical activity can thwart prostate cancer progression, and also to identify optimal exercise regimens, she added.

	_________________________________________________________

Kenfield SA, Stampfer MJ, Giovannucci E, Chan JM. Physical activity and survival after prostate cancer diagnosis in the Health Professionals Follow-Up Study. J Clin Oncol. 2011 Jan 4. [Epub ahead of print] doi:10.1200/JCO.2010.31.5226.

Published in Oncology & Biotech News. February 2011.

Researchers are calling for prostate cancer survivors to incorporate physical activity into their daily routine.

Exercise Routine Recommended for Prostate Cancer Survivors

	New data demonstrate that older adolescents with acute lymphoblastic leukemia (ALL) can be cured using risk-adjusted intensive chemotherapy without prophylactic cranial irradiation or routine stem cell transplantation.

	The regimen credited with the high cure rate was used in Total Therapy Study XV and included intensive dexamethasone, vincristine, and asparaginase, as well as early triple intrathecal therapy for higherrisk ALL, all of which have been associated with improved outcomes in teenagers and young adults with ALL.

	Importantly, treatment intensity was guided by risk stratification based on minimal residual disease (MRD) findings, which enables the precise identification of patients with a poor initial treatment response who might not have been identified by standard morphologic bone examination.

	Ching-Hon Pui, MD, and associates said that their results are on a par with the best reported outcomes for younger children.

	Historically, older adolescents with ALL have had a markedly worse prognosis than younger patients, the investigators said. Reasons include an increased prevalence of high-risk leukemia subtypes coupled with lower tolerance and adherence to therapy.

	Research has shown consistently better outcomes for older adolescents with ALL who are treated in pediatric rather than adult clinical trials. The investigators note that this may be a function of the more intensive treatment, as well as stricter compliance due to parental involvement in the pediatric trials.

	Pui and colleagues reviewed the outcomes of older adolescents (ranging from 15 to 18 years of age) who were treated in 4 consecutive Total Therapy studies between 1991 and 2007. In studies XIIIA, XIIIB, and XIV enrolling a total of 44 older and 421 younger patients, treatment selection was based on presenting clinical features and leukemic cell genetics.

	In study XV, 45 older adolescents and 453 younger patients underwent risk-directed intensive chemotherapy.

	Results showed that older teens enrolled in the 3 earlier studies had a 5-year, event-free survival rate of 59.1% and a 5-year overall survival rate of 59.1%, dramatically lower than the corresponding 82.6% (P <.001) and 88.3% (P <.001) rates occurring in the younger teens enrolled in the same studies.

	In study XV, 5-year, event-free survival rates were 86.4% ± 5.2% for the older adolescents and 87.4% ± 1.7% for the younger patients. Overall survival rates were 87.9% ± 5.1% and 94.1% ± 1.2%, respectively.

	The improved prognosis for older teenagers treated in study XV occurred without a noteworthy hike in toxicity. In fact, younger and older patients had similar cumulative rates of seizures, disseminated fungal infections, and allergic reactions. Older patients were, however, more likely to develop severe infection, osteonecrosis, thrombosis, and hyperglycemia, which the investigators said may be partly attributable to slower clearance of dexamethasone in this age group.

	In addition, no patient in study XV developed central nervous system relapse even though prophylactic cranial irradiation was excluded from the protocol.

	In study XV, older adolescents tended to require transplantation for poor early response more often than younger patients. Five of 6 older adolescents who underwent transplantation remain in first remission.

	Pui and colleagues noted that their findings demonstrate that use of the Total Therapy Study XV treatment approach “abolished” the unfavorable prognostic impact of older age in childhood ALL. What’s more, given that 3 deaths from infection were responsible for half of the failures that occurred in older patients, the investigators maintain that the impressive cure rate in older adolescents may be even higher with increased vigilance in supportive care.

	Finally, they said that the protocol should be evaluated in young adults with ALL.

New data demonstrate that older adolescents with acute lymphoblastic leukemia (ALL) can be cured using risk-adjusted intensive chemotherapy without prophylactic cranial irradiation or routine stem cell transplantation. 

Intensive Chemotherapy Boosts Prognosis in Older Teens With Acute Lymphoblastic Leukemia

	A false-positive result on a mammogram may trigger anxiety and decrease quality of life, and the effects may remain apparent a year later, new data suggest.

	In addition, the study by Dutch investigators confirmed that women with a false-positive mammogram require more diagnostic procedures than women with breast cancer before a final diagnosis is established.

	Alida van der Steeg, PhD, with the department of surgery at St. Elisabeth Hospital in Tilburg, Netherlands, and colleagues reviewed responses to surveys completed by 385 women who had an abnormal screening mammogram. Of the study cohort, 152 women were diagnosed with breast cancer and 233 had a falsepositive result.

	Cancer screening is "intuitively appealing," and it is reasonable to assume that early detection is a desirable goal and risk-free, van der Steeg pointed out. Indeed, the majority of breast cancer screening programs have decreased breast cancer-related deaths.

	In the Netherlands, women 50 to 75 years of age are sent a standardized invitation for mammography every 2 years as part of a nationwide screening program; however, the information brochure included with the invitation does not succinctly describe possible drawbacks to mammography, she said. In fact, while the brochure stated that about 60% of women who are recalled will be found to have a benign diagnosis, it makes no mention of the sometimes invasive diagnostic procedures that may be needed to make the correct diagnosis; nor is there any mention of the negative psychological effects of a recall assessment.

	One percent of Dutch women who undergo screening mammography are asked to return for repeat assessment, van der Steeg noted.

	In the present study, women in the breast group were significantly older than women in the false-positive group and also had larger tumors.

	The study found that women in the false-positive group required significantly more diagnostic procedures to obtain a final diagnosis, including biopsies. In fact, only 14% of the breast cancer group needed 4 procedures after their initial screening to reach a final diagnosis, while 32% of the falsepositive group needed 4 or more procedures in order to make a final diagnosis.

	Notably, 54.9% of the falsepositive group revisited the outpatient clinic within the first year of their initial screening, some as often as 8 times.

	In addition, women in the falsepositive group had a significant reduction in their quality of life, especially if they were prone to anxiety, and the effects lasted for at least a year. Also, women who tended to be anxious fared much worse if they were given a false-positive mammogram result than women who were actually diagnosed with breast cancer.

	In the study, quality of life was measured by the World Health Organization (WHO) Quality of Life assessment instrument 100 (WHOQOL-100) and anxiety by the State and Trait Anxiety Inventory (STAI), both of which have been widely validated.

	The investigators maintain that the anxiety and decreased quality of life occurring in women in the false-positive group were probably entirely a result of the recall after screening coupled with the subsequent diagnostic procedures.

	Based on their results, van der Steeg and associates recommend that women be better informed about the purported benefits of screening mammography, as well as liabilities that may include increased anxiety and decreased quality of life.

van der Steeg AF, Keyser-Dekker CM, De Vries J, Roukema JA. Effect of abnormal screening mammogram on quality of life. Br J Surg. 2010 Dec 20 [Epub ahead of print] doi:10.1002/bjs.7371.

A false-positive result on a mammogram may trigger anxiety and decrease quality of life, and the effects may remain apparent a year later, new data suggest.

False-Positive Mammograms Lead to Anxiety and Quality-of-Life Issues

	For women who have survived childhood cancer, breastfeeding may help counter some of the long-term complications that occur as a result of their prior cancer treatments, researchers say.

	Susan Ogg and associates at St. Jude Children's Research Hospital in Memphis, Tennessee, reviewed medical literature that examined whether female childhood cancer survivors were able to successfully breastfeed. Given the established benefits of breastfeeding in healthy women, the group aimed to determine whether childhood cancer survivors could garner the same benefits.

	Their analysis showed that breastfeeding was able to improve the deleterious late effects of cancer treatment on bone mineral density deficits, metabolic syndrome risk factors, cardiovascular disease, and second malignant cancers.

	Eighty percent of children and adolescent cancer patients who are treated with current cancer regimens will achieve long-term survival, the researchers pointed out. The number of adult survivors of childhood cancer is expected to continue to increase, and as many as 75% of these survivors will develop a chronic health problem because of their prior cancer therapy.

	To date, strategies to decrease the "expression and severity" of the adverse side effects related to childhood cancer have involved primarily preventive measures, including frequent medical screenings and recommendations for "protective health behaviors," Ogg and colleagues stated in their article. They maintain that breastfeeding should be included in such initiatives.

	"Follow-up care of survivors should include secondary and tertiary prevention such as strategies to promote tobacco cessation or avoidance, physical activity, safe sexual practices, and proper weight management," they say. "Because of its associated positive health benefits, breastfeeding is an additional strategy that should be recommended to mothers surviving cancer as a behavior that may modify risks associated with late effects."

	The investigators emphasized, however, that it is extremely important that healthcare providers consider the possibility that female survivors of childhood cancer may be unable to lactate or successfully breastfeed because of specific cancer treatments. In fact, early data suggest that childhood cancer survivors with intact hypothalamic-pituitary-ovarian axes who retain their fertility are sometimes not able to lactate as a result of cranial irradiation therapy during their childhood. Healthcare providers should assess women survivors of a childhood cancer individually and discuss nutritional options with mothers who may be at risk of lactation dysfunction due to cancer treatment.

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Ogg SW, Hudson MM, Randolph ME, Klosky JL. Protective effects of breastfeeding for mothers surviving childhood cancer. J Cancer Surviv. 2010 Jan 21. [Epub ahead of print] doi:10.1007/ s11764-010-0169-z.