American Society of Clinical Oncology 1998 update of recommended breast cancer surveillance guidelines.
OBJECTIVE: To determine an effective, evidence-based, postoperative surveillance strategy for the detection and treatment of recurrent breast cancer. Tests are recommended only if they have an impact on the outcomes specified by American Society of Clinical Oncology (ASCO) for clinical practice guidelines. POTENTIAL INTERVENTION: All tests described in the literature for postoperative monitoring were considered. In addition, the data were critically evaluated to determine the optimal frequency of monitoring. OUTCOME: Outcomes of interest include overall and disease-free survival, quality of life, toxicity reduction, and secondarily cost-effectiveness. EVIDENCE: A search was performed to determine all relevant articles published over the past 20 years on the efficacy of surveillance testing for breast cancer recurrence. These publications comprised both retrospective and prospective studies. VALUES: Levels of evidence and guideline grades were rated by a standard process. More weight was given to studies that tested a hypothesis directly relating testing to one of the primary outcomes in a randomized design. BENEFITS, HARMS, AND COSTS: The possible consequences of false-positive and -negative tests were considered in evaluating a preference for one of two tests providing similar information. Cost alone was not a determining factor. RECOMMENDATIONS: The attached guidelines and text summarize the updated recommendations of the ASCO breast cancer expert panel. Data are sufficient to recommend monthly breast self-examination, annual mammography of the preserved and contralateral breast, and a careful history and physical examination every 3 to 6 months for 3 years, then every 6 to 12 months for 2 years, then annually. Data are not sufficient to recommend routine bone scans, chest radiographs, hematologic blood counts, tumor markers (carcinoembryonic antigen, cancer antigen [CA] 15-5, and CA 27.29), liver ultrasonograms, or computed tomography scans. VALIDATION: The recommendations of the breast cancer expert panel were evaluated and supported by the ASCO Health Services Research Committee reviewers and the ASCO Board of Directors. (+info)
A patient-derived disease activity score can substitute for a physician-derived disease activity score in clinical research.
OBJECTIVE: Joint counts have a central role in assessing disease activity in rheumatoid arthritis (RA). They are usually undertaken by physicians or nurses. We investigated whether joint counts can be devolved to patients and evaluated the use of a patient-derived Disease Activity Score (DAS). METHODS: One hundred RA patients attending a specialist unit were evaluated, comparing joint counts by a physician with patient-assessed joint counts and DAS derived from both methods. They were related to other measures of disease activity in the European League Against Rheumatism (EULAR) core data set and with the Rheumatoid Arthritis Disease Activity Index (RADAI; a validated patient self-assessment index). RESULTS: Regression analysis showed no significant differences between a physician's and patient's joint counts and DAS. There were middle to high correlations between patient and physician assessments of tender joints and swollen joints; using R2, this explained 70% of the variance for tender joints and 40% for swollen joints. Kappa analysis showed good agreement between physician and patient assessments of individual joint tenderness (kappa values 0.49-0.84). There was lower agreement for individual swollen joints (kappa values 0.02-0.61). Physician DAS and patient DAS had a similar correlation with the Health Assessment Questionnaire (HAQ) (r = 0.50 and r = 0.48, respectively). CONCLUSION: The agreements between physician and patient assessments are sufficient to allow patients' assessments to be used for clinical research. This is especially the case with a patient-derived DAS. However, the results are not directly interchangeable and further studies are needed before patients' assessments are used to guide clinical practice. (+info)
Evaluation of factors associated with skin self-examination.
Early detection and excision of thin lesions may be important in reducing mortality from melanoma. Periodic skin self-examination may be beneficial in identifying thin lesions. The purpose of this study was to evaluate factors associated with skin self-examination. The study population was comprised of 549 Caucasian residents of Connecticut 18 years of age or older who were selected as controls as part of a population-based case-control study on skin self-examination and melanoma conducted during 1987-1989. Personal interviews were conducted to obtain information on skin self-examination, demographics, history of cancer, phenotypic characteristics, sun exposure habits, and screening and health behaviors. Nevus counts were performed by trained nurse interviewers. Logistic regression was used to model the relationship between the variables of interest and skin self-examination. Female gender was identified a priori as a predictor of skin self-examination, and thus all analyses were stratified by gender. Age, education, and marital status were also identified a priori as important predictor variables and were selected for inclusion in the final models. Skin awareness was a strong factor associated with skin self-examination for both females and males. For females, previous benign biopsy or the presence of an abnormal mole was identified as important for future skin self-examination using our criteria. A family history of cancer, physician examination, and change in diet to reduce cancer risk increased the likelihood of skin self-examination in males but not females. In women, light hair color may increase the likelihood of performing skin self-examination. Older age and college or postgraduate education was associated with a decreased likelihood of performing skin self-examination in both males and females. Identifying factors associated with skin self-examination will enable health care providers to target individuals who may not be performing skin self-examination but who are at increased risk for developing melanoma. (+info)
Agreement between self-assessment of melanocytic nevi by patients and dermatologic examination.
The number of melanocytic nevi is the strongest risk factor for cutaneous melanoma. As pigmented skin lesions are visible to everybody, the question has been raised about whether people can identify themselves as being at risk for melanoma through self-counting of moles. In 1991, a total of 513 central European melanoma patients and 498 controls were asked to count the total number of nevi and the number of atypical nevi on the whole body. Whole-body examination by dermatologists followed. Agreement was assessed on categorized nevus counts by means of ordinal kappa values and log-linear modeling. Study subjects significantly underestimated the total number of melanocytic nevi (p < 0.0001). Chance-corrected overall agreement was rather poor (kappa = 0.14), and the ability to detect many existing nevi was low. Agreement was higher for atypical melanocytic nevi counts (kappa = 0.37), and the sensitivity to detect more than one atypical nevus was 0.48. Self-assessment of the number of melanocytic nevi was difficult to perform accurately, and people severely underestimated the actual number. Despite these results, people should be encouraged to perform regular skin self-examination for early detection of melanoma. (+info)
Feasibility and validity of the RADAI, a self-administered rheumatoid arthritis disease activity index.
OBJECTIVE: The goal of the Rheumatoid Arthritis Disease Activity Index (RADAI) is to provide an easy to use assessment of disease activity. It is a self-administered questionnaire that combines five items into a single index: current and past global disease activity, pain, morning stiffness and a joint count. METHODS: A sample of 484 rheumatoid arthritis (RA) patients was used to assess the internal consistency and the convergent validity of the RADAI. This was achieved by calculating Cronbach's alpha and RADAI item and total score correlations with core set measures and DAS28. RESULTS: Cronbach's alpha was 0.87, supporting the summation of the items into a single index. The index correlated best with physicians' global assessment (r = 0.59; P < 0.0001), the Health Assessment Questionnaire (r = 0.55; P < 0.0001) and the number of tender joints (r = 0.55; P < 0.0001). Correlation with the erythrocyte sedimentation rate was low (r = 0.27; P < 0.0001). The RADAI and the DAS28 were correlated (r = 0.53; P < 0.0001), but there was low agreement. CONCLUSIONS: The RADAI is valid to assess disease activity in RA patients. However, the RADAI may not automatically replace other measures of disease activity, such as the DAS28. (+info)
Association of individual activities of daily living with self-rated health in older people.
OBJECTIVE: to evaluate the associations of 18 activities of daily living with self-rated health in older people. DESIGN AND SETTING: cross-sectional study of a representative sample of 781 people aged 65 or over (response rate: 89.9%). METHODS: self-rated health was assessed by the question: "Overall, how would you rate your current health status-very good, good, fair, poor or very poor?" We used the Barthel index and Lawton and Brody's index for basic and instrumental activities of daily living, respectively. We classified subjects into three groups according to their Barthel index score: level 1 (score 100), level 2 (score 91-99) and level 3 (score 0-90). Logistic regression was used to identify associations between each activity and self-rated health. RESULTS: use of stairs [odds ratio (OR) = 4.28, 95% confidence interval (95% CI): 2.82-6.52], ambulation (OR = 3.67, 95% CI: 2.39-5.64) and chair/bed transfer (OR = 3.00, 95% CI: 1.68-5.36) were the basic activities of daily living best associated with self-rated health. Among instrumental activities of daily living, ability to handle finances (OR = 2.20), laundry (OR = 2.15) and transport (OR = 2.12) were associated with self-rated health. On the Barthel index, only transport was associated with self-rated health in subjects at levels 1 (OR = 2.55) and 2 (OR = 2.72). For subjects with poor functional status (level 3), no instrumental activities of daily living were related to self-rated health. CONCLUSION: in terms of self-rated health, the most important activities of daily living were those involving mobility. The effect of each instrumental activity of daily living on self-rated health depends on the level of functional capacity in basic activities of daily living. (+info)
Canadian National Breast Screening Study-2: 13-year results of a randomized trial in women aged 50-59 years.
BACKGROUND: Screening for breast cancer with mammography in women aged 50 years or more has been shown to reduce mortality from breast cancer. However, the extent to which mammography contributes to the reduction of mortality in women who also undergo physical examination of the breasts is not known. This study was designed to compare breast cancer mortality following annual screening consisting of two-view mammography and physical examination of the breasts with mortality following annual screening by physical examination only. Breast self-examination was taught to all participants. METHODS: This trial randomly and individually assigned 39 405 women aged 50-59 years, recruited from January 1980 through March 1985, to one of the study arms. The women were followed by record linkage with the Canadian National Cancer Registry and National Mortality Database to December 31, 1993, and by active follow-up of breast cancer patients to June 30, 1996. RESULTS: Randomization achieved virtually equal distribution of demographic and breast cancer risk variables. At the first annual screen, 21% of the cancers found by mammography alone (in the mammography plus physical examination group) were 20 mm or more in size compared with 46% of those found by physical examination in the mammography plus physical examination group and 56% in the physical examination-only group. The corresponding percentages for screens 2-5 were 10%, 42%, and 50%, respectively. Screening detected 267 invasive breast cancers in the mammography plus physical examination group compared with 148 in the physical examination-only group. By December 31, 1993, 622 invasive and 71 in situ breast carcinomas were ascertained in the mammography plus physical examination group, and 610 and 16 were ascertained in the physical examination-only group. At 13-year follow-up, with 107 and 105 deaths from breast cancer in the respective groups, the cumulative rate ratio was 1.02 (95% confidence interval = 0.78-1.33). CONCLUSION: In women aged 50-59 years, the addition of annual mammography screening to physical examination has no impact on breast cancer mortality. (+info)
Home sampling versus conventional swab sampling for screening of Chlamydia trachomatis in women: a cluster-randomized 1-year follow-up study.
We compared the efficacy of a screening program for urogenital Chlamydia trachomatis infections based on home sampling with that of a screening program based on conventional swab sampling performed at a physician's office. Female subjects, comprising students at 17 high schools in the county of Aarhus, Denmark, were divided into a study group (tested by home sampling) and a control group (tested in a physician's office). We assessed the number of new infections and the number of subjects who reported being treated for pelvic inflammatory disease (PID) at 1 year of follow-up; 443 (51.1%) of 867 women in the intervention group and 487 (58.5%) of 833 women in the control group were available for follow-up. Thirteen (2.9%) and 32 (6.6%) new infections were identified in the intervention group and the control group, respectively (Wilcoxon exact value, P=.026). Nine (2.1%) women in the intervention group and 20 (4.2%) in the control group reported being treated for PID (P=.045), indicating that a screening strategy involving home sampling is associated with a lower prevalence of C. trachomatis and a lower proportion of reported cases of PID. (+info)