Search

Context: Parents' understanding of prognosis or decision making about palliative care for children who die of cancer is largely unknown. However, a more accurate understanding of prognosis could alter treatment goals and expectations and lead to more effective care.Objectives: To evaluate parental understanding of prognosis in children who die of cancer and to assess the association of this factor with treatment goals and the palliative care received by children.Design, Setting, and Participants: Survey, conducted between September 1997 and August 1998, of 103 parents of children who received treatment at the Dana-Farber Cancer Institute and Children's Hospital, Boston, Mass, and who died of cancer between 1990 and 1997 (72% of those eligible and those located) and 42 pediatric oncologists.Main Outcome Measure: Timing of parental understanding that the child had no realistic chance for cure compared with the timing of physician understanding of this prognosis, as documented in the medical record.Results: Parents first recognized that the child had no realistic chance for cure a mean (SD) of 106 (150) days before the child's death, while physician recognition occurred earlier at 206 (330) days before death. Among children who died of progressive disease, the group characterized by earlier recognition of this prognosis by both parents and physicians had earlier discussions of hospice care (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.01-1.06; P =.01), better parental ratings of the quality of home care (OR, 3.31; 95% CI, 1.15-9.54; P =.03), earlier institution of a do-not-resuscitate order (OR, 1.03; 95% CI, 1.00-1.06; P =.02), less use of cancer-directed therapy during the last month of life (OR, 2.80; 95% CI, 1.05-7.50; P =.04), and higher likelihood that the goal of cancer-directed therapy identified by both physician and parent was to lessen suffering (OR, 5.17; 95% CI, 1.86-14.4; P =.002 for physician and OR, 6.56; 95% CI, 1.54-27.86; P =.01 for parents).Conclusion: Considerable delay exists in parental recognition that children have no realistic chance for cure, but earlier recognition of this prognosis by both physicians and parents is associated with a stronger emphasis on treatment directed at lessening suffering and greater integration of palliative care. JAMA. 2000;284:2469-2475. [ABSTRACT FROM AUTHOR]

Comments on articles on cluster randomization trials (CRT) used in evaluating nontherapeutic interventions. Limitations of CRT; Advantages of CRT design; Development of methods for CRT.

The design and analysis of cluster randomized trials has been a recurrent theme in Statistics in Medicine since the early volumes. In celebration of 25 years of Statistics in Medicine, this paper reviews recent developments, particularly those that featured in the journal. Issues in design such as sample size calculations, matched paired designs, cohort versus cross-sectional designs, and practical design problems are covered. Developments in analysis include modification of robust methods to cope with small numbers of clusters, generalized estimation equations, population averaged and cluster specific models. Finally, issues on presenting data, some other clustering issues and the general problem of evaluating complex interventions are briefly mentioned. Copyright © 2006 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objectives: To compare breast screening outcomes between women with a moderate or strong family history of breast and/or ovarian cancer with those without such a history. Setting: The Ontario Breast Screening Programme (OBSP) is a population-based programme offering mammography and clinical breast examination to Ontario women of 50 and older. Methods: Data from a cohort of 143,574 women screened by the OBSP from 1996 to 1997 were included. Referral rates, cancer detection rates, positive predictive values and the histological features of screen-detected cancers were examined within family history groups, age groups and screening modalities. Logistic regression analysis of cancer detection was conducted to adjust for potential confounding variables; subgroup analysis by hormone replacement therapy (HRT) use was also undertaken. Results: Compared with women with no family history, women with a moderate or strong family history of breast and/or ovarian cancer were more likely to have their cancer detected (odds ratio [OR]=1.44, 95% confidence interval [CI] 1.20-1.74 and OR=1.42, 95% CI 1.10-1.83, respectively). Among women using HRT, however, there was no association observed between family history and cancer detection (moderate: OR=0.98, 95% CI 0.65-1.48; strong: OR=1.17, 95% CI 0.68-2.02) with history. The histological features of invasive tumours were similar among family history groups. Conclusions: Greater cancer detection rates and high proportions of invasive tumours with good prognosis indicate that women aged 50 and over with a family history may have the potential to benefit from regular breast cancer screening. Further studies are required to identify optimal screening guidelines and to examine whether HRT reduces the ability to detect cancer in these women. [ABSTRACT FROM AUTHOR]

Background: The familial implications of genetic information can lead to a conflict between a physician's duties to maintain patient confidentiality and to inform at-risk relatives about susceptibility to genetic diseases. As genes are discovered that can identify patients at risk of adverse outcomes, this conflict has become the subject of discussion and debate.Methods: We performed a one-time telephone survey of a population-based sample of 200 Jewish women to assess knowledge and attitudes about genetic testing. Attitudes toward sharing genetic test results with family members were evaluated using three hypothetical scenarios that described an easily preventable disease, a disease (breast cancer) in which the only option for prevention was prophylactic mastectomies, and a nonpreventable disease.Results: Nearly all respondents believed that a patient should inform at-risk family members when the disease was preventable (100% and 97% in the relevant scenarios), compared with only 85% who felt a duty to inform at-risk family members about a nonpreventable disease (P <0.001). The proportions of respondents who believed that physicians should seek out and inform at-risk family members against a patient's wishes was much lower: only 18% of respondents to the easily preventable disease scenario, 22% of respondents to the breast cancer scenario, and 16% of respondents to the nonpreventable disease scenario.Conclusions: Most women surveyed believed that genetic information should be shared within families, unless it violated a patient's wishes. These sorts of opinions should be considered in the debate over the confidentiality of genetic information. [ABSTRACT FROM AUTHOR]

Community intervention trials are becoming increasingly popular as a tool for evaluating the effectiveness of health education and intervention strategies. Typically, units such as households, schools, towns, counties, are randomized to receive either intervention or control, then outcomes are measured on individuals within each of the units of randomization. It is well recognized that the design and analysis of such studies must account for the clustering of subjects within the units of randomization. Furthermore, there are usually both subject level and cluster level covariates that must be considered in the modelling process. While suitable methods are available for continuous outcomes, data analysis is more complicated when dichotomous outcomes are measured on each subject. This paper will compare and contrast several of the available methods that can be applied in such settings, including random effects models, generalized estimating equations and methods based on the calculation of 'design effects', as implemented in the computer package SUDAAN. For completeness, the paper will also compare these methods of analysis with more simplistic approaches based on the summary statistics. All the methods will be applied to a case study based on an adolescent anti-smoking intervention in Australia. The paper concludes with some general discussion and recommendations for routine design and analysis. [ABSTRACT FROM AUTHOR]

Mononuclear cells play an important role in the elimination of immune complexes (IC). In the presence of complement (C) the binding and degradation of IC by mononuclear cells is enhanced at least two-fold. The enhancement of binding is caused by a synergistic interaction of the IC with cellular Fc and complement receptors (R). In the present study we have investigated the contribution of the complement receptors CRI and CR3 of human monocyte cell line U937 on the complement- mediated binding and degradation of immune complexes and soluble aggregates of IgG (AIgG) bearing C3b or iC3b. It was found that deposition of C3b on AIgG enhanced the binding of AIgO to U937 cells at least two-fold. The C3b-mediated enhancement of binding was abolished by anti-CR1. iC3b-bound to AIgG also enhanced the binding of AIgO to the cells. This binding was only partially reduced by anti-CR3 antibodies, but the combination of anti-CR1 and anti-CR3 fully abolished the iC3b-mediated enhancement of binding. These results suggest that both CR1 and CR3 contribute to the complement-mediated binding and degradation of soluble IC by mononuclear phagocytes. [ABSTRACT FROM AUTHOR]

Purpose: The association between body mass index (BMI=weight in kg/height in m2) and colorectal cancer (CRC) risk is complex. It is somewhat established that high BMI is associated with increased risk of cancer in the colon among men, but risk estimates among women vary according to age and menopausal status. There is some evidence suggesting that risk also differs according to tumor subsite (proximal colon, distal colon, rectum) for both men and women, but further studies are needed to confirm the pattern of the association. Here, we examine the association between BMI and CRC risk, stratified according to tumor location in the colon or rectum, and sex. Methods: Data for this case–control study were collected from the Ontario Familial Colorectal Cancer Registry. Cases were men and women diagnosed with incident colon or rectal cancer identified through the Ontario Cancer Registry since July 1997. Controls were identified from provincial property assessment files in 2000. Family history was determined through review of a family history questionnaire and reviewed by a genetic counselor for classification. Height and weight 2 years prior were assessed with a self-administered questionnaire. BMI was calculated and categorized according to World Health Organization criteria: low BMI, <18.5 kg/m2; normal, 18.5 to <25 kg/m2; overweight, 25 to <30 kg/m2; and obese, BMI ≥30 kg/m2. Results: Among men, an overweight or obese BMI was associated with about a 50% increased risk of colorectal cancer relative to men with a normal BMI. The BMI risk for colorectal cancer was attenuated among premenopausal women, and null for postmenopausal women. Increased risk from overweight and obesity were also found among men, but not women, for proximal and distal subsites of colon cancer. Overweight was associated with increased risk of rectal cancer in women only. Conclusion: These results suggest that BMI among men and women is differentially associated with colon and rectal cancer risk. Endogenous or exogenous estrogens may, in part, influence this discordance. [Copyright &y& Elsevier]