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This study evaluated two types of barriers that the authors deemed important to resolve during the early stage of cancer clinical trial exploration by Latinx community members. One was the accessibility of information provided on cancer centers’ websites. The other was the telephone responders’ clinical trial knowledge and their conveyance of a warm welcome to Latinx callers inquiring about the centers’ clinical trials. Simulated clinical trial inquiry calls were made to 17 National Cancer Institute-designated centers in this study. The centers were located in cities where the Latinx community accounted for at least 25% of the population, thereby justifying center-wide efforts to encourage the Latinx community to explore clinical trial participation. A rubric was developed to determine and quantify a Total Score that was partially composed of the accessibility of clinical trial information displayed on each cancer center’s website. A research assistant gathered information by posing as a person calling the cancer center to inquire about clinical trials on behalf of a family member with limited English proficiency and evaluated their response using a “mystery shopper” method of data collection. The warmth and sense of welcome conveyed by the telephone responder was also quantified and included in the rubric’s Total Score. A perfect Total Score reflected the likely existence of an environment that would encourage Latinx community members to continue exploring clinical trials, i.e., removed or diminished possible barriers. Welcoming characteristics, such as those elements included in the scoring rubric, can be monitored regularly to assure that centers are consistently conveying an optimal sense of welcome to the Latinx community, while also providing accessible clinical trial information. Among the 17 cancer centers, no correlation was found between the size of the Latinx population served and each center’s Total Score.

Black and Latino adult cancer patients are underrepresented in cancer clinical trials, which limits generalizability of findings and amplifies disparities in healthcare access and outcomes. Community-level education programs designed to address barriers to participation could improve representation in cancer clinical trials. Through a community-campus partner framework, this study evaluated the Women United: Clinical Trials and the Fight Against Breast Cancer Program in Spanish and English. Participants were 422 women (141 Black, 140 Latina Spanish preference, 141 Latina English preference) who were randomized to view either the intervention (n = 215) or a control (n = 207) program. Assessments of clinical trials knowledge and barriers to clinical trials participation were taken before and after viewing. Results suggested that clinical trials knowledge increased and perceived barriers to participation decreased for those who viewed the educational program. More specifically, those in the intervention condition perceived fewer barriers related to personal benefits, mistrust, and familiarity of clinical trials. As expected, there were no differences in perceived barriers related to community support for either condition. Participants in both conditions were equally likely to join a subsequent study or a clinical trials community ambassador program. There were no differences in any of the outcomes across ethnicity or language, suggesting the program works equivalently across groups. This program is easy to administer and can be recommended for use among Black and Latina women to address factors related to clinical trials participation.

OBJECTIVE Improvement in health-related quality of life (HRQoL) is a public health goal of Healthy People 2020. Hispanics living in the United States are at risk for poor HRQoL, but the causes and correlates of this risk are not well understood. Thus, the present study examined individual-level psychosocial and neighborhood-level built environment correlates of physical and mental HRQoL among Hispanic adults. METHOD A community sample of Hispanic adults (N = 383) completed self-report health-related questionnaires, and census tract was used to collect data on neighborhood-level built environment variables. Multilevel modeling was used to examine individual-level psychosocial (language preference, religiosity, subjective social status, discrimination, and number of years lived in the United States) and neighborhood-level built-environment (the retail food environment, proximity to alcohol retailers, and tobacco retailer density) correlates of physical and mental HRQoL. RESULTS Higher subjective social status was significantly associated with better HRQoL, and more experiences with discrimination were significantly associated with lower HRQoL. For physical HRQoL, these relationships were stronger in neighborhoods with a higher density of tobacco retail outlets. CONCLUSIONS Findings from this study suggest that subjective social status and discrimination play important roles in HRQoL among Hispanics, in particular in neighborhoods with a higher density of tobacco retail outlets. This study highlights the importance of considering neighborhood context, and in particular neighborhood disadvantage, when examining the relationship between social status, discrimination and HRQoL among Hispanics. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

The English and Spanish versions of the Multidimensional Health Locus of Control scales have not been psychometrically evaluated for use with Hispanic Americans. Hispanic American adults ( N = 436) completed the English ( n = 210) or Spanish ( n = 226) Multidimensional Health Locus of Control scales. A multiple-group confirmatory factor analysis did not support equivalent four-factor structures for Spanish- and English-speaking Hispanic Americans. Follow-up exploratory factor analyses of the 24 items supported an 18-item, four-factor structure for English-speaking Hispanic Americans and a 22-item, three-factor structure for Spanish-speaking Hispanic Americans. These results suggest caution when using the Multidimensional Health Locus of Control scales with Hispanic Americans.

In the past decade, accessible information in American Sign Language (ASL) about cancer and genetic testing is expanding on eHealth platforms, including social network sites, commercial sites, and mobile apps. Primary data on genetic testing awareness and genetic testing for BRCA 1/2 among Deaf women were gathered using HINTS-ASL survey between November 2016 and April 2018, and secondary data for hearing women were drawn from NCI's HINTS 5 Cycle 1 survey in 2017. Deaf women who had heard of DNA testing (63%) were more likely to be young adults, college graduates, and/or have a family history of cancer. Compared to hearing women, Deaf women who had heard of genetic testing were more likely to use social networking sites to read or share information about medical topics and watch health-related videos. Making eHealth platforms accessible in ASL and easy-to-understand text can help reduce knowledge gap in genetic testing, since some Deaf women may not be using genetic testing to help identify whether they are at increased risk for breast and ovarian cancer early on, before they are diagnosed with cancer.

Objective To assess whether mode of communication and patient centered communication (PCC) with physicians were associated with the likelihood of deaf smokers inquiring about lung cancer screening. Methods An accessible health survey including questions about PCC, modes of communication, smoking status and lung cancer screening was administered in American Sign Language (HINTS-ASL) to a nationwide sample of deaf adults from February to August 2017. Of 703 deaf adults who answered the lung screening question, 188 were 55–80 years old. Results The odds ratio of asking about a lung cancer screening test was higher for people with lung disease or used ASL (directly or through an interpreter) to communicate with their physicians. PCC was not associated with asking about a lung cancer screening test. Conclusion Current or former smokers who are deaf and use ASL are at greater risk for poorer health outcomes if they do not have accessible communication with their physicians. Practice implications Optimal language access through interpreters or directly in ASL is critical when discussing smoking cessation or lung cancer screening tests. Counseling and shared decision-making will help improve high-risk deaf patients' understanding and decision-making about lung cancer screening. A video in American Sign Language is available here .

The Deaf community members of this community-campus partnership identified the lack of health information in American Sign Language (ASL) as a significant barrier to increasing the Deaf community's health knowledge. Studies have shown that the delivery of health messages in ASL increased Deaf study participants' cancer knowledge. Once health messages are available on the Internet, strategies are needed to attract viewers to the website and to make repeat visits in order to promote widespread knowledge gains. This feasibility study used the entertainment-education strategy of coupling cancer information with jokes in ASL to increase the appeal and impact of the health messages. ASL-delivered cancer control messages coupled with Deaf-friendly jokes were shown to 62 Deaf participants. Participants completed knowledge questionnaires before, immediately after, and 1 week after viewing the paired videos. Participants' health knowledge statistically significantly increased after viewing the paired videos and the gain was retained 1 week later. Participants also reported sharing the newly acquired information with others. Statistically significant results were demonstrated across nearly all measures, including a sustained increase in cancer-information-seeking behavior and intent to improve health habits. Most participants reported that they would be motivated to return to such a website and refer others to it, provided that it was regularly updated with new jokes.

There are unaesthetic aspects in teaching people about the early detection of colorectal cancer using the fecal immunochemical test. Comics were seen as a way to overcome those unaesthetic aspects. This study used the Asian grocery store-based cancer education venue to pilot-test the clarity, cultural acceptability, and alignment of five colorectal cancer education comics intended for publication in Asian American and Pacific Islander (API) community newspapers. After developing the colorectal cancer education comics, API students asked shoppers to review a comic from their collection and provide feedback on how to make the comic clearer and more culturally pertinent to API readers. To evaluate viewers' responses, the students gathered such unobtrusive data as: (1) how many of the predetermined salient information points were discussed as the student educators interacted with shoppers and (2) how many comics the shoppers were willing to review. Shoppers were also asked to evaluate how effective the comics would be at motivating colorectal cancer screening among APIs. The students were able to cover all of the salient information points with the first comic. As evidence of the comics' capacity to engage shoppers' interest, shoppers willingly evaluated all five comics. Using multiple comics enabled the educators to repeatedly address the four salient colorectal cancer information points. Thus, the comics helped student educators to overcome the unesthetic elements of colorectal cancer discussions, while enabling them to engage shoppers in animated discussions, for far more time than with their conventional didactic educational methods.

This study examined the psychometric properties of the Perceived Stress Scale-10 among 436 community-dwelling Hispanic Americans with English or Spanish language preference. Multigroup confirmatory factor analysis examined the factorial invariance of the Perceived Stress Scale-10 across language groups. Results supported a two-factor model (negative, positive) with equivalent response patterns and item intercepts but different factor covariances across languages. Internal consistency reliability of the Perceived Stress Scale-10 total and subscale scores was good in both language groups. Convergent validity was supported by expected relationships of Perceived Stress Scale-10 scores to measures of anxiety and depression. These results support the use of the Perceived Stress Scale-10 among Hispanic Americans.

PURPOSE: Sleep disturbance and cancer-related fatigue (CRF) are among the most commonly reported symptoms associated with breast cancer and its treatment. This study identified symptom cluster groups of breast cancer patients based on multidimensional assessment of sleep disturbance and CRF prior to and during chemotherapy. METHODS: Participants were 152 women with stage I-IIIA breast cancer. Data were collected before chemotherapy (T1) and during the final week of the fourth chemotherapy cycle (T2). Latent profile analysis was used to derive groups of patients at each timepoint who scored similarly on percent of the day/night asleep per actigraphy, the Pittsburgh Sleep Quality Index global score, and the five subscales of the Multidimensional Fatigue Symptom Inventory-Short Form. Bivariate logistic regression evaluated if sociodemographic/medical characteristics at T1 were associated with group membership at each timepoint. RESULTS: Three groups (Fatigued with sleep complaints, Average, Minimal symptoms) were identified at T1, and five groups (Severely fatigued with poor sleep, Emotionally fatigued with average sleep, Physically fatigued with average sleep, Average, Minimal symptoms) at T2. The majority of individuals in a group characterized by more severe symptoms at T1 were also in a more severe symptom group at T2. Sociodemographic/medical variables at T1 were significantly associated with group membership at T1 and T2. CONCLUSIONS: This study identified groups of breast cancer patients with differentially severe sleep disturbance and CRF symptom profiles prior to and during chemotherapy. Identifying groups with different symptom management needs and distinguishing groups by baseline sociodemographic/medical variables can identify patients at risk for greater symptom burden.

BACKGROUND: Some deaf men who use American Sign Language (ASL) experience barriers in patient-physician communication which may leave them at disparity for shared decision making compared to hearing men. Transparent communication accessibility is needed between deaf male ASL users and their physicians to maximize the benefit to risk ratio of using the prostate-specific antigen (PSA) as a screening tool for early detection. The objective is to compare shared decision-making outcomes between deaf and hearing males who are 1) age-eligible for PSA screening; and 2) younger than 45 years old with a family history of cancer. METHODS: An accessible health survey including questions about PSA test, PCC, modes of communication, and cancer history was administered in ASL to a nationwide sample of deaf adults from February 2017 to April 2018. Two subsamples were created: 1) 45 to 69 years old men who were age-eligible for PSA testing, and 2) 18 to 44 years old men with a family history of cancer. RESULTS: Age-eligible and younger deaf men with a family history of cancer are at disparity for shared decision making compared to their hearing peers. Regardless of age and PSA testing status, deaf men felt significantly less engaged in shared decision making with their health care providers compared to hearing men. CONCLUSION: Participation in shared decision making requires not only accessible communication but also cultural competency in working with deaf patients. This is critical in the shared decision-making era in maximizing the benefit of prostate cancer screening in deaf male patient population.

Objective Prostate cancer can have a significant negative impact on patients and their spouses. Problem-solving therapy (PST) has been shown to help reduce distress and improve quality of life among cancer and caregiver populations. This study tested the efficacy of PST for spouses of men with prostate cancer. Methods Spouses of men diagnosed with prostate cancer within the past 18 months (N = 164) were randomly assigned to PST (n = 78) or usual psychosocial care (UPC; n = 86). Spouses completed measures of constructive and dysfunctional problem solving, cancer-related distress, mood, physical and mental health, and dyadic adjustment at preintervention and post-intervention and 3-month post-intervention follow-up. Results Constructive problem solving increased from pre-intervention to post-intervention among spouses receiving PST but not for spouses receiving UPC; this was maintained at follow-up. There was no decrease in dysfunctional problem solving. Spouses receiving PST versus UPC reported less cancer-related distress post-intervention and at follow-up. There were no significant changes in mood or physical and mental health. Dyadic adjustment was significantly better for spouses receiving PST versus UPC at post-intervention but not at follow-up. Improvements in constructive problem solving mediated better mood and dyadic adjustment post-intervention. Conclusions Results support the efficacy of PST for improving spouses' constructive problem solving. There was evidence of both direct and mediated positive effects of PST for both individual and dyadic adjustment. PST may be useful for improving individual and dyadic outcomes for spouses of men with prostate cancer.

Barriers to obtaining breast cancer prevention knowledge and breast cancer screening have been noted among D/deaf women. A randomized controlled trial (RCT) is described that tested a culturally and linguistically tailored breast cancer education program conducted among a racially/ethnically diverse sample of 209 D/deaf women age 40 years or older. The study focused on D/deaf women with no more than a secondary education, a population at relatively high risk for incomplete breast health knowledge and services. This population's inadequate breast cancer knowledge and screening practices and the value of the education program were confirmed. Knowledge increased from -baseline to 12-month follow-up in the intervention group, and in some instances the control group; increased intention to get a mammogram was observed in the intervention group. Possible reasons for the few significant intervention/control group differences at 12 months were examined. Materials from the RCT are available online.

Objective To investigate and compare the demographics of California smokers seeking assistance to quit and those of smokers who called the California Smokers’ Helpline, a large scale state-wide smoking cessation service. Data sources The 1990, 1992, and 1993 California Tobacco Surveys, and screening interviews conducted with callers to the California Smokers’ Helpline in its first 30 months of operation. Design For the California Tobacco Surveys, random digit dialled surveys of 24296 California adults in 1990, 8224 in 1992, and 30716 in 1993 were conducted, which included measures of smokers’ attitudes toward their smoking and of their help-seeking behaviour for smoking cessation. In the California Smokers’ Helpline, 23346 adult callers from August 1992 to January 1995 were surveyed. Demographic information was obtained on all surveys. Main outcome measure Seeking assistance to quit smoking. Results In the general smoking population, males were less likely to seek help in quitting smoking than females. The youngest group of adult smokers (18-24 years) was least likely to seek help. Hispanic, black and Asian smokers in California were only 40% as likely as white smokers to seek assistance. However, an ethnic breakdown of callers to the California Smokers’ Helpline shows that His- panics were as well represented in that programme as in the smoking population of the state. Blacks were actually over-represented by a factor of 2. The Helpline also attracted younger smokers than those who sought assistance in general. Smokers from rural counties were as likely to call the Helpline as those from urban counties. The former were usually referred by health care providers, whereas the latter most often heard about the Helpline through the mass media. Conclusions The California Smokers’ Helpline reached an ethnically and geographically representative sample of smokers. It appears suitable as a model for future programmes providing accessible smoking cessation service on a large scale.

The present study evaluated the psychometric properties of the Patient Health Questionnaire–4 (PHQ-4), a screener of psychological distress, in English- and Spanish-speaking Hispanic Americans. Hispanic American adults ( N = 436) completed the PHQ-4, which yields two subscales (Anxiety and Depression) that can be summed to create a total score. Multiple-group confirmatory factor analysis was used to evaluate structural validity. The two-factor structure was the best fit to the data for both English- and Spanish-speaking Hispanic Americans, and items loaded equivalently across groups, demonstrating measurement invariance. Internal consistency reliability was good as measured by coefficient alpha. Construct validity was evidenced by significant expected relationships with perceived stress. These findings provide support for the reliability and validity of the PHQ-4 as a brief measure of psychological distress for English- or Spanish-speaking Hispanic Americans.

The Life Orientation Test-Revised (LOT-R) is a widely used measure of optimism and pessimism, with three positively worded and three negatively worded content items. This study examined the structural validity and invariance, internal consistency reliability, and convergent and divergent validity of the English and Spanish versions of the LOT-R among Hispanic Americans. A community sample of Hispanic Americans (N = 422) completed self-report measures, including the LOT-R, Patient Health Questionnaire-9, and Generalized Anxiety Disorder-7, in their preferred language of English or Spanish. Based on the literature, four structural models were tested: one-factor, oblique two-factor, orthogonal two-factor method effects with positive specific factor, and orthogonal two-factor method effects with negative specific factor. Baseline support for both of the English and Spanish versions was not achieved for any model; in all models, the negatively worded items in Spanish had non-significant factor loadings. Therefore, the positively worded three-item optimism subscale of the LOT-R was examined separately and fit the data, with factor loadings equivalent across language-preference groups. Coefficient alphas for the optimism subscale were consistent across both language-preference groups (αs = .61 [English] and .66 [Spanish]). In contrast, the six-item total score and three-item pessimism subscale demonstrated extremely low or inconsistent alphas. Convergent and divergent validity were established for the optimism subscale in both languages. In sum, the optimism subscale of the LOT-R demonstrated minimally acceptable to good psychometric properties across English and Spanish language-preference groups. However, neither the total score nor the pessimism subscale showed adequate psychometric properties for Spanish-speaking Hispanic Americans, likely due to translation and cultural adaptation issues, and thus are not supported for use with this population.

Purpose: Diabetes is reaching epidemic proportions in the United States and African Americans are at greater risk than most. Disparities in the incidence of diabetes place African American women at a much higher risk than their white counterparts. As such, the purpose of this study was to evaluate a community-based educational intervention program aimed at changing diabetes attitudes, knowledge, and screening behaviors of African American women via cosmetologists trained as community health educators. Methods: Twenty African American cosmetologists joined the Black Cosmetologist Promoting Health Program. Their salons were randomized to disseminate diabetes or breast cancer information and given educational materials to display in their salons and give to their clients. Their clients (n = 984 women) consented to help evaluate the program, completing a baseline and 6-month follow-up survey regarding their knowledge, attitudes, and behaviors related to diabetes and breast cancer. Results: At the 6-month follow-up, self-reported knowledge about diabetes increased across both groups. However, despite similar programmatic structure offered to the two groups, there were no significant differences in diabetes knowledge, attitudes, and screening at follow-up. Conclusion: This non-significant outcome contrasted with the positive outcomes achieved by the parallel breast cancer program. Gladwell’s Tipping Point theory could explain the different outcomes. The programs differed in message content, messaging tone, and the environment in which the messages were delivered. The diabetes program lacked a clear, memorable, and upbeat call-to-action and an environment that socially and financially supported the uptake of the recommended actions.

Sleep disturbance, fatigue and depression are common complaints in patients with cancer, and often contribute to worse quality of life (QoL). Circadian activity rhythms (CARs) are often disrupted in cancer patients. These symptoms worsen during treatment, but less is known about their long-term trajectory.Sixty-eight women with stage I-III breast cancer (BC) scheduled to receive ≥4 cycles of chemotherapy, and age-, ethnicity-, and education-matched normal, cancer-free controls (NC) participated. Sleep was measured with actigraphy (nocturnal total sleep time [nocturnal TST] and daytime total nap time [NAPTIME]) and with the Pittsburgh Sleep Quality Index (PSQI); fatigue with the Multidimensional Fatigue Symptom Inventory-Short Form (MFSI-SF); depression with the Center of Epidemiological Studies-Depression (CES-D). CARs were derived from actigraphy. Several measures of QoL were administered. Data were collected at three time points: before (baseline), end of cycle 4 (cycle 4), and 1 year post-chemotherapy (1 year).Compared to NC, BC had longer NAPTIME, worse sleep quality, more fatigue, more depressive symptoms, more disrupted CARs, and worse QoL at baseline (all p values0.05). At cycle 4, BC showed worse sleep, increased fatigue, more depressive symptoms, and more disrupted CARs compared to their own baseline levels and to NC (all p values0.05). By 1 year, BC's fatigue, depressive symptoms, and QoL returned to baseline levels but were still worse than those of NC, while NAPTIME and CARs did not differ from NC's.Additional research is needed to determine if beginning treatment of these symptoms before the start of chemotherapy will minimize symptom severity over time.

ObjectivesThis study examined the psychometric properties of the Multidimensional Fatigue Symptom Inventory-Short Form (MFSI-SF) in a community-based sample of African-Americans.DesignA sample of 340 African-Americans (116 men, 224 women) ranging in age from 18-81 years were recruited from the community (e.g., churches, health fairs, and beauty salons). Participants completed a brief demographic survey, the MFSI-SF and the Positive and Negative Affect Schedule.ResultsThe structural validity of the MFSI-SF for a community-based sample of African-Americans was not supported. The five dimensions of fatigue (General, Emotional, Physical, Mental, Vigor) found for Whites in prior research were not found for African-Americans in this study. Instead, fatigue, while multidimensional for African-Americans, was best represented by a unique four-four profile in which general and emotional fatigue are collapsed into a single dimension and physical fatigue, mental fatigue, and vigor are relatively distinct. Hence, in the absence of modifications, the MFSI-SF cannot be considered to be structurally invariant across ethnic groups. A modified four-factor version of the MFSI-SF exhibited excellent internal consistency reliability and evidence supports its convergent validity. Using the modified four-factor version, gender, and age were not meaningfully associated with MFSI-SF scores.ConclusionFuture research should further examine whether modifications to the MFSI-SF would, as the findings suggest, improve its validity as a measure of multidimensional fatigue in African-Americans.

Background: Limited scientific evidence is available regarding D/deaf women's breast cancer knowledge and early detection practices, as well as about how to increase D/deaf women's breast cancer control practices. Objective/hypothesis: To assess baseline breast cancer knowledge and practices among a sample of D/deaf women recruited into a randomized controlled trial of a breast cancer education program developed for this population. Methods: A written and signed (American Sign Language) survey was administered to a racially/ethnically diverse sample of 209 D/deaf women, 40+ years old, with lower levels of education, recruited in California between October 2008 and May 2009. Results: There were misconceptions about breast cancer risk factors, screening, and treatment; only 64.2% of respondents correctly identified the purpose of mammography. Mammography in the prior 2 years was reported by 57.3% of the sample, by 69.8% of White women, and by 43.5% of women from other racial/ethnic groups. Rates also varied by education, having seen a physician in the prior year, and type of insurance. Conclusions: This study underscores significant gaps in breast cancer screening knowledge and practices, communication issues in health care settings, and unmet needs for tailored health information and materials in this population. Challenges faced in conducting the research needed to develop and test such programs are noted. © 2013 Elsevier Inc. All rights reserved.

Members of the Deaf community report language and cultural barriers to accessing health information and care. This study evaluated whether an ovarian cancer education video in American Sign Language with English captioning and voice-over could close the anticipated knowledge gap between Deaf and hearing women's cancer knowledge. Consented Deaf (n = 55) and hearing (n = 52) women's General, Ovarian, and Total Cancer Knowledge were assessed before and after viewing the video. At baseline, hearing women demonstrated significantly higher General, Ovarian, and Total Cancer Knowledge scores than Deaf women. By the post-test, all of Deaf women's knowledge scores had increased, closing the baseline gap. However, hearing women's post-video knowledge had also increased, thereby creating a new knowledge gap. The ovarian cancer education video offers an effective method to increase ovarian and general cancer knowledge for Deaf and hearing women.

BACKGROUND: Breast cancer (BC) patients often experience cancer-related fatigue (CRF) before, during, and after their chemotherapy. Circadian rhythms are 24-hour cycles of behavior and physiology that are generated by internal pacemakers and entrained by zeitgebers (e.g., light). A few studies have suggested a relationship between fatigue and circadian rhythms in some clinical populations. METHODS: One hundred and forty-eight women diagnosed with stage I-III breast cancer and scheduled to receive at least four cycles of adjuvant or neoadjuvant chemotherapy, and 61 controls (cancer-free healthy women) participated in this study. Data were collected before (Baseline) and after four cycles of chemotherapy (Cycle-4). Fatigue was assessed with the Short Form of Multidimensional Fatigue Symptom Inventory (MFSI-SF); circadian activity rhythm (CAR) was recorded with wrist actigraphy (six parameters included: amplitude, acrophase, mesor, up-mesor, down-mesor and F-statistic). A mixed model analysis was used to examine changes in fatigue and CAR parameters compared to controls, and to examine the longitudinal relationship between fatigue and CAR parameters in BC patients. RESULTS: More severe CRF (total and subscale scores) and disrupted CAR (amplitude, mesor and F-statistic) were observed in BC patients compared to controls at both Baseline and Cycle-4 (all p's0.05); BC patients also experienced more fatigue and decreased amplitude and mesor, as well as delayed up-mesor time at Cycle-4 compared to Baseline (all p's0.05). The increased total MFSI-SF scores were significantly associated with decreased amplitude, mesor and F-statistic (all p's0.006). CONCLUSION: CRF exists and CAR is disrupted even before the start of chemotherapy. The significant relationship between CRF and CAR indicate possible underlying connections. Re-entraining the disturbed CAR using effective interventions such as bright light therapy might also improve CRF.

Excessive daytime sleepiness (EDS) has been shown to be associated with depression; however, this relationship has not been confirmed among Hispanic Americans.This study examined the link between EDS and depression among Hispanic Americans (N = 411) and explored the potential moderating roles of age, gender, income, education, health status, and acculturation. The Epworth Sleepiness Scale and Patient Health Questionnaire-9 measured EDS and depression, respectively.Hierarchical linear regression demonstrated that EDS was significantly related to depression. Receiver operating characteristic curve analysis suggested that the Epworth Sleepiness Scale discriminated with adequate sensitivity and specificity between participants with moderately severe depression and those with less severe symptoms. No sociodemographic variables moderated the EDS-depression relationship.These findings suggest that depression should be considered when Hispanic Americans present with EDS.Somnolencia diurna excesiva (EDS) se ha demostrado que se asocia con la depresión; sin embargo, esta relación no ha sido confirmado entre los hispanos.En este estudio se examinaron la relación entre EDS y la depresión entre los hispanos (Regresión lineal jerárquica demostraron que EDS fue significativamente relacionados con la depresión. Análisis de la curva ROC sugiere que la escala de Epworth distinguió con una adecuada sensibilidad y especificidad entre los participantes con depresión moderadamente severa y aquellos con síntomas menos graves. Ninguna variable sociodemográfica moderó la relación EDS-depresión.Estos resultados sugieren que la depresión debe ser considerada cuando los hispanoamericanos presentan con EDS.

The pilot study reported in this article culturally and linguistically adapted an educational intervention to promote cancer clinical trials (CCTs) participation among Latinas/os and African Americans. The single-session slide presentation with embedded videos, originally developed through a campus–community partnership in Southern California, was chosen for adaptation because it was perceived to fit the CORRECT model of innovation (credible, observable, relevant, relatively advantageous, easy to understand, compatible, and testable) and because of the potential to customize any components not identified as core, allowing them to be revised for cultural and linguistic alignment in New York City. Most of the 143 community participants (76.2%) were female; most (54.6%) were older than 59 years. More than half (78.3%) preferred to speak English or were bilingual in English and Spanish. A large proportion (41.3%) had not completed high school. Knowledge and perceived benefits and barriers regarding CCT showed small, though statistically significant, increases. There were no statistically significant group differences for changes in mean knowledge, perceived benefits, or perceived barriers when examined by ethnicity, education level, language, or other included sociodemographic variables. However, a small, but statistically significant difference in perceived barriers was observed when examined by country of origin, with the foreign born score worsening 0.08 points ( SD = 0.47, p = .007) on the 5-point Likert-type scale administered posteducation compared to preeducation. Participants’ open-ended comments demonstrated the acceptability of the topic and intervention. This adaptation resulted in an intervention with the potential to educate African American and Latina/o general community members in a new geographic region about the purpose, methods, and benefits of CCTs.

Asian American women's historically low breast cancer mortality rate has remained constant as rates decreased for all other races. From 2000 to 2004, a randomized controlled trial explored the Asian grocery store-based breast cancer education program's impact on Chinese, Filipino, Korean, and Vietnamese women (n = 1,540). Women aged 40 and older and non-adherent for annual screening mammograms were more likely to schedule a mammogram after receiving the breast cancer education program than women randomized to the prostate cancer program (X (2) = 3.85, p = 0.05). With the right program ingredients, late adopters of breast cancer screening can be prompted to change.

Deaf community members face many barriers to accessing health information. This paper discusses the feasibility of creating a nationwide network of Deaf-friendly ministries to help disseminate cancer information in American Sign Language (ASL) to the Deaf community. Deaf-friendly ministries (N = 403), identified through Internet searches and one-on-one referrals, were sent up to three mailed invitations to join the network. Over half of the ministries responded, with 191 (47.4 %) of the ministries joining the network, completing a baseline survey and receiving ASL cancer education videos to share with members of their congregation and community. Fifteen (3.7 %) responded that they were not interested or no longer had a Deaf-friendly ministry; the rest did not respond or their invitations were returned as undeliverable. As the program progressed, an additional 238 Deaf-friendly ministries were identified. To date, 61 (25.6 %) agreed to participate after the single invitation that was mailed. This network of Deaf-friendly ministries offers a promising dissemination partner.

Skin cancer is the most common, preventable, and treatable cancer, so public education has been a priority. Unfortunately, for the Deaf community, most skin cancer information is difficult to access, so tailored approaches are needed. Participants (N = 136) were randomly assigned to view either a skin cancer education video in American Sign Language (ASL) (n = 75) or an alternate video (n = 61). All participants completed skin cancer knowledge questionnaires at baseline, immediately post-intervention, and two-months post-intervention. Control group participants could then transfer to the experimental condition, using their two-month follow-up data as their baseline. Participants who saw the skin cancer video gained significantly more knowledge than control participants, demonstrating the video’s effectiveness in increasing skin cancer control knowledge. There was no difference between the original experimental group and the delayed intervention group on knowledge gains.

Deaf people encounter barriers to accessing cancer information. In this study, a graphically enriched educational video about cervical cancer was created in American Sign Language, with English open captioning and voice overlay. Deaf (n = 127) and hearing (n = 106) women completed cancer knowledge surveys before and after viewing the video. Hearing women yielded higher scores before the intervention. Both groups demonstrated a significant increase in general and cervical cancer knowledge after viewing the video, rendering posttest knowledge scores nearly equal between the groups. These findings indicate that this video is an effective strategy for increasing cervical cancer knowledge among deaf women.

Adenoid cystic carcinoma (ACC) is an uncommon type of breast cancer. There are limited data about its epidemiology, tumor characteristics, and outcomes. Using a large, population-based data base, this study aimed to identify specific characteristics of patients with adenoid cystic breast cancer, investigate its natural history, and determine its long-term prognosis. The California Cancer Registry, a population-based registry, was reviewed from the years 1988 to 2006. The data were analyzed with relation to patient age, tumor size and stage, and overall survival. Relative cumulative actuarial survival was determined using the Berkson-Gage life table method. A total of 244 cases of invasive adenoid cystic cancer were identified in women during this time period. The patients' median age was 61.9 years. Most cases were diagnosed in non-Hispanic White women (82%, n = 200), followed by African American (6%, n = 15), Asian/Pacific-Islander (5.7%, n = 14) and Hispanic women (4.4%, n = 12). The remainder of the patients was of unknown or other ethnicity. Tumors were between 1 and 140 mm in size. At the time of diagnosis, 92% (n = 225) of patients had localized disease, 5% (n = 12) of patients had regional disease, and even fewer (n = 7) had either distant or unknown staged disease. Lymph node involvement was not present in any tumors smaller than 1.4 cm. The relative cumulative survival of patients with adenoid cystic breast carcinoma was 95.6% at 5 years and 94.9% at 10 years. ACC of the breast is a rare disease with an overall good prognosis. Knowing that this cancer usually presents as localized disease, with lymph node involvement seen only with larger tumors, can help clinicians plan the operative management of these tumors.

Background : African American women have disproportionately higher rates of breast cancer mortality than all other ethnic groups, thus highlighting the importance of promoting early detection. Methods : African American women (N = 984) from San Diego, California, participated in a randomized controlled trial testing the efficacy of breast cancer education sessions offered in beauty salons. Cosmetologists received ongoing support, training, and additional culturally aligned educational materials to help them engage their clients in dialogues about the importance of breast cancer early detection. Posters and literature about breast cancer early detection were displayed throughout the salons and cosmetologists used synthetic breast models to show their clients how breast cancer lumps might feel. Participants in the control group received a comparable diabetes education program. Baseline and 6-month follow-up surveys were administered to evaluate changes in women’s breast cancer knowledge, attitudes, and screening behaviors. Results : This intervention was well received by the participants and their cosmetologists and did not interfere with or prolong the client’s salon visit. Women in the intervention group reported significantly higher rates of mammography compared to women in the control group. Training a single educator proved sufficient to permeate the entire salon with the health message, and salon clients agreed that cosmetologists could become effective health educators. Conclusions : Cosmetologists are in an ideal position to increase African American women’s breast cancer knowledge and adherence to breast cancer screening guidelines.

Depression is a significant problem for ethnic minorities that remains understudied partly due to a lack of strong measures with established psychometric properties. One screening tool, the Patient Health Questionnaire-9 (PHQ-9), which was developed for use in primary care has also gained popularity in research settings. The reliability and validity of the PHQ-9 has been well established among predominantly Caucasian samples, in addition to many minority groups. However, there is little evidence regarding its utility among Hispanic Americans, a large and growing cultural group in the United States. In this study, we investigated the reliability and structural validity of the PHQ-9 in Hispanic American women. A community sample of 479 Latina women from southern California completed the PHQ-9 in their preferred language of English or Spanish. Cronbach’s alphas suggested that there was good internal consistency for both the English- and Spanish-language versions. Structural validity was investigated using multigroup confirmatory factor analysis (CFA). Results support a similar one-factor structure with equivalent response patterns and variances among English- and Spanish-speaking Latinas. These results suggest that the PHQ-9 can be used with confidence in both English and Spanish versions to screen Latinas for depression.

Nurse researchers and educators often engage in outreach to narrowly defined populations. This article offers examples of how variations on the snowball sampling recruitment strategy can be applied in the creation of culturally appropriate, community-based information dissemination efforts related to recruitment to health education programs and research studies. Examples from the primary author's program of research are provided to demonstrate how adaptations of snowball sampling can be used effectively in the recruitment of members of traditionally underserved or vulnerable populations. The adaptation of snowball sampling techniques, as described in this article, helped the authors to gain access to each of the more-vulnerable population groups of interest. The use of culturally sensitive recruitment strategies is both appropriate and effective in enlisting the involvement of members of vulnerable populations. Adaptations of snowball sampling strategies should be considered when recruiting participants for education programs or for research studies when the recruitment of a population-based sample is not essential.

The Medical Students, Cancer Control, and the Deaf Community Training program (DCT) intended to create physicians who were culturally competent to care for deaf patients were evaluated. DCT medical students (n = 22), UCSD medical faculty (n = 131), and non-DCT medical students (n = 211) were anonymously surveyed about their perceptions related to deaf patients, deaf cultural competency, and interpreter use. The faculty and non-DCT medical students displayed less knowledge than the DCT students. These findings suggest that training medical students in deaf cultural competency can significantly increase their capacity to care for community members and reduce the health disparities experienced by this community.

This study analyzed early breast cancer detection rates as a surrogate for breast cancer mortality rates. Stage at diagnosis was broken down by race/ethnicity and year of diagnosis for the cases of female breast cancer in the California Cancer Registry from 1988 to 2002.A quarter million cases of breast cancer in womenor =50 years of age recorded in the California Cancer Registry over the period 1988-2002 were classified as early (in situ and localized stages) or late (regional and distant stages). The increases in the percent of cases that were early were studied by 3-year periods over this interval. In addition to the total group, data were broken down by race/ethnicity. The 3-year periods were used to compensate for small numbers of cases in some of the nonwhite groups.The proportion of early stage female breast cancers reached a plateau at 70% in the mid-1990s. African American and Hispanic women's screening rates reached a plateau at a considerably lower rate. Only Pacific Islander/Asian American women demonstrated a sustained rise in the percent of early breast cancers detected through 2002, eventually nearing the rate of early detection set by white women.The plateaus observed suggest that focused interventions continue to be needed for all women, especially for African American and Hispanic women if the American Cancer Society's 2015 goals are to be achieved.

This study examined the role of sociodemographic characteristics, health insurance, cancer knowledge, perceived health risk, and having a recent physicians’ visit on breast and cervical cancer screening utilization among a randomly selected group of Chamorro women (n = 250) residing in San Diego, California. Data were collected by a telephone survey and analyzed using multiple logistic regression models. After adjusting for covariates, having a recent full exam was the strongest predictor of having had a Pap exam in the past 2 years for women 21 years and older and a clinical breast exam in the past 2 years for women 40 years and over.

Prior cross-sectional studies have shown that cancer patients have sleep-wake activity cycles that show little distinction between daytime and nighttime, a pattern indicative of circadian disruption. This pattern is seen both before and during cancer treatment. Long-term data are needed, however, to assess to what extent circadian rhythm impairments evolve over the course of chemotherapy. The goal of this study was to assess the longitudinal course of sleep-wake activity rhythms before and during chemotherapy for breast cancer.Ninety-five women scheduled to receive neoadjuvant or adjuvant anthracycline based chemotherapy for a stage I-III breast cancer participated. The participants wore a wrist actigraph for 72 consecutive hours at baseline (pre-chemotherapy), as well as during the weeks 1, 2 and 3 (W1, W2, W3) of cycle 1 and cycle 4 of chemotherapy. Sleep-wake circadian activity variables were computed based on actigraphic data.Compared to baseline, with the exception of acrophase, all circadian rhythm variables examined, including amplitude, mesor, up-mesor, down-mesor, and rhythmicity were significantly impaired during the first week of both chemotherapy cycles. Although the circadian variables approached baseline values during W2 and W3 of cycle 1, most remained significantly more impaired during W2 and W3 of cycle 4.These data suggest that the first administration of chemotherapy is associated with transient disruption of sleep-wake rhythm, while repeated administration of chemotherapy results in progressively worse and more enduring impairments in sleep-wake activity rhythms.

Surgical management of renal cell carcinoma is the most effective treatment for patients with localized disease. In patients with advanced renal cell carcinoma, immune modulation-based therapies are typically used to improve cancer-specific survival. Similar to most cancers, tumor grade and stage are linked to the tumor's biologic potential. Integrating these factors with patients' performance status can help predict their long-term disease-free survival, the likelihood of tumor recurrence, and the median time to failure following surgery and immunotherapy. A novel integrated staging system and a postoperative renal cell carcinoma specific nomogram, along with standardized quality of life assessments have been shown to be useful clinical tools to aid in patient counseling, determining optimal follow-up imaging protocols, and identifying patients who might benefit from early enrollment in adjuvant therapy protocols. This article offers clinicians a review and summary of the most recent evidence-based research related to risk assessment among patients with newly diagnosed renal cell carcinoma.

The concept of symptom clusters is relatively new in cancer patients' symptom management. This study, which spanned four cycles of chemotherapy, combined three commonly seen pre-treatment symptoms in cancer patients (i.e. sleep disturbances, fatigue and depression) into one symptom cluster, to explore the associations between pre-treatment cluster categories and longitudinal profiles of these same symptoms during chemotherapy.This was a prospective study. Seventy-six women with newly diagnosed stage I-III breast cancer, scheduled to receive at least four cycles of adjuvant or neoadjuvant anthracycline-based chemotherapy participated. Data were collected at seven time points before and during treatment. Sleep quality was measured with the Pittsburgh Sleep Quality Index. Fatigue was measured with the Multidimensional Fatigue Symptom Inventory--Short Form. Depressive symptoms were measured with the Center of Epidemiological Studies--Depression. Patients were divided into three groups based on the number of symptoms they experienced before the start of chemotherapy (i.e. no symptoms, 1-2 symptoms or all three symptoms) and a symptom cluster index (SCI) was computed.All women reported worse sleep, more fatigue and more depressive symptoms during treatment compared with baseline (all p's0.01); however, those women with a higher SCI (i.e. more symptoms pre-treatment) continued to experience worse symptoms during treatment compared with those who began with fewer symptoms (all p's0.01).A higher clinically relevant-based pre-treatment symptom cluster was associated with more sleep disturbances, greater fatigue and more depressive symptoms during chemotherapy. Specific interventions for these pre-treatment symptoms may improve the frequency and severity of these same symptoms during chemotherapy, when they are most severe and most disruptive to quality of life.

Background. Breast cancer is Asian American women’s most frequently occurring cancer. Methods. Asian American women completed breast cancer-related baseline surveys for 2 studies 5 years apart. Results. Statistically significant and rapid improvements in knowledge and screening practices were seen between the 948 participants in the first study (1995) and the 1540 participants in the second study. This increase paralleled the reported climb in early detection rates among Asian American women. Conclusions. The data document the achievement of a tipping point in breast cancer screening rates with culturally and linguistically focused education programs and increased access to screening among disadvantaged women.

Background—Intracystic papillary carcinoma (IPC) is an uncommon breast neoplasm. There are limited data about its epidemiology and only small studies focusing on outcomes. Using a large, population-based database, this study aims to identify specific characteristics of patients with IPC, investigate its natural history, and determine its long-term prognosis. Materials and Methods—The California Cancer Registry (CCR), a population-based registry, was reviewed from the years 1988 to 2005. The data were analyzed with relation to patient gender, age at presentation, tumor stage, and overall survival. Cumulative relative actuarial survival was determined using a Berkson-Gage life table method. The CCR classifies IPC as either in-situ (CIS) or invasive, as determined by the local pathologist. Results—A total of 917 cases of IPC were identified. Forty-seven percent of cases (n=427) were CIS while 53% of cases had invasion (n=490). Most of the invasive cases were localized at the time of diagnosis (89.6%, n=439). At 10 years, patients with CIS and invasive disease had a similar relative cumulative survival (96.8% and 94.4%, P=0.18). Discussion—Intracystic papillary carcinoma is a rare disease. There is no significant difference in the long-term survival of patients in the two histologically-derived subgroups of IPC. There is an excellent prognosis for patients diagnosed with IPC regardless of whether the tumor is diagnosed as in-situ or invasive. Clinicians should keep this in mind when planning surgical and adjuvant treatments. Sentinal lymph node biopsy may be a prudent way to evaluate axillary involvement in patients with IPC

Purpose: We used a population based cancer registry to examine trends in renal cell carcinoma incidence and survival among 4 racial/ethnic groups (white, black, Hispanic and Asian/Pacific Islander) and both genders.Materials and Methods: Race/ethnicity, gender, age, staging, length of survival and cause of death data were analyzed using 39,434 cases of renal cell carcinoma from 1988 to 2004 from the California Cancer Registry. Annual age adjusted incidence rates and relative survival rates were calculated for the racial/ethnic and gender groups. These rates and the percent of localized cancer were plotted by year, and Microsoft Excel® was used to calculate linear regression equations. Median age was also calculated. Z-tests and chi-square tests were performed to determine p values.Results: An increase in renal cell carcinoma incidence was found with localized cancer accounting for most of the increase. Black patients had a significantly higher incidence rate (p

Purpose: We examined the incidence rates of bladder cancer using California Cancer Registry data to determine if any trends exist.Materials and Methods: Complete records of the 55,159 cases of invasive bladder cancer were examined from the original 92,677 bladder cancer cases recorded in the California Cancer Registry between 1988 and 2004.Results: California Cancer Registry data showed a universal late age peak in age specific incidence of bladder cancer in men and women, and across ethnic boundaries. The rate of annual increase in the percent of bladder cancer in individuals 85 years or older was increasing about 10 times as rapidly as the percent of the population that was 85 years or older (slope = 0.395 vs 0.0336). Furthermore, during all 17 years the proportion of patients 85 or older with bladder cancer was about twice that of patients with other cancers regardless of gender.Conclusions: California Cancer Registry data illustrate a peak in the incidence of bladder cancer in individuals 85 years or ...

This article discusses issues to be considered by nurse researchers when groups should be used as the unit of randomization. Advantages and disadvantages are presented, with statistical calculations needed to determine the effective sample size. Examples of these concepts are presented using data from the Black Cosmetologists Promoting Health Program. Different hypothetical scenarios and their impact on sample size are also presented. Given the complexity of calculating the sample size when using groups as the unit of randomization, it is advantageous for researchers to work closely with statisticians when designing and implementing studies that anticipate the use of groups as the unit ofrandomization.

Multiple barriers contribute to the slow recruitment of participants to research studies, which in turn extends the time required to translate promising scientific discoveries into proven therapeutic interventions. A small but growing literature is developing on the extraordinary costs of recruiting participants to studies, and thereby demonstrating that underestimating the cost of participant recruitment can contribute to these recruitment problems. These recruitment challenges and costs are exacerbated when the participants' study eligibility is determined by relatively narrowly defined illness parameters. Recruitment challenges are further compounded when dyads (two individuals engaged in a sociologically significant relationship, such as husbands and wives, siblings or extended families) must be recruited to an illness-focused study. For these latter groups, there are no data to guide researchers in how to anticipate those participant recruitment costs. This paper describes the staff costs for a variety of strategies used to recruit participants to a randomized supportive care study for couples who were within 18 months of a prostate cancer diagnosis. Pegged to the value of the U.S. dollar for the period, the average cost of staff time was $288 per recruited and enrolled dyad, plus a promised additional $100 incentive for study retention. Within the strategies used, the staff costs per recruited dyad ranged from $152 to $1688. Accrual per strategy ranged from 0 to 107 enrolled couples. When asked for secondary sources of information about the study, many participants reported more than one source of study referral, reflective of the multifaceted recruitment strategies deployed. In spite of innovative, culturally competent, and broad based recruitment methods, attainment of a diverse sample was difficult to accomplish in this study. Having estimates of the actual cost of recruiting dyads to research studies can help investigators prepare realistic study budgets.

Operating since 1994, the UCSD Moores Cancer Center's Asian Grocery Store-Based Cancer Education Program (the Program) is a proven and sustainable strategy for disseminating cancer and poison control information to Asian and Pacific Islander (API) communities. This paper describes the process taken to identify health topics that can be readily addressed within the Program's infrastructure and reports results of the pilot testing of the educational module that was developed by following that process. The development of each new module is guided by the Health Belief Model and the Tipping Point Model. The process starts with the selection of a health topic demonstrating pressing need and treatment options in the API community. Then, using the Pareto principle, reasonably modifiable risk factors are chosen to be addressed in the module. "Sticky messaging" for the modifiable risk factors is developed to package the health information as memorable and transmissible calls-to-action. Finally, grocery store outreaches were used to pilot test the new module to assess its effectiveness at facilitating health care information to API community members. By adhering to the steps described in this paper, the authors were able to: (1) select liver cancer as a pressing API health issue that could be positively impacted by the Program; (2) identify reasonably modifiable risk factors for the chosen health issue; (3) generate compelling call-to-action messages to decrease risk of exposure; and (4) demonstrate the cultural and linguistic alignment of the liver cancer control module. The development and testing of new health education modules follow a methodical process guided by scientific principles. Understanding and employing the elements of an existing evidence-based and sustainable health education program can increase the likelihood of success in addressing the health needs of the API community.

Latent profile analysis identified health locus of control profiles among 436 Hispanic Americans who completed the Multidimensional Health Locus of Control scales. Results revealed four profiles: Internally Oriented-Weak, -Moderate, -Strong, and Externally Oriented. The profile groups were compared on sociocultural and demographic characteristics, health beliefs and behaviors, and physical and mental health outcomes. The Internally Oriented-Strong group had less cancer fatalism, religiosity, and equity health attributions, and more alcohol consumption than the other three groups; the Externally Oriented group had stronger equity health attributions and less alcohol consumption. Deriving multidimensional health locus of control profiles through latent profile analysis allows examination of the relationships of health locus of control subtypes to health variables.

Fatigue is one of the most common and distressing complaints among cancer patients, not only during radiation and chemotherapy, but also for months to years after the completion of treatment. Fatigue interferes with patients' daily lives, reduces their quality of life, and is often a significant reason why patients discontinue treatment. We hypothesized that some of the fatigue may be related to disrupted circadian rhythms and low light exposure. The main objective of this study therefore was to investigate the association between fatigue and light exposure among patients with breast cancer.As part of a larger, ongoing prospective study on fatigue, sleep, and circadian rhythms in patients with breast cancer, an analysis of 63 women newly diagnosed with stage I-IIIA breast cancer and scheduled to receive four cycles of adjuvant or neoadjuvant anthracycline-based chemotherapy was conducted. Data were collected before and during weeks 1, 2, and 3 of cycle 1 and cycle 4. Fatigue was assessed using the Short Form of Multidimensional Fatigue Symptom Inventory. Light exposure was recorded with a wrist actigraph.There were significant correlations between fatigue levels and light exposure (r=-0.28 to -0.45) within both cycle 1 and cycle 4, such that higher levels of fatigue were associated with less light exposure. There were also significant correlations between changes in light exposure and changes in fatigue within the first 2 weeks of each cycle (r=-0.28 to -0.52).Increased fatigue was significantly correlated with decreased light exposure among patients with breast cancer. Although the cause and effect of exacerbated fatigue and decreased light exposure cannot be confirmed by the current study, and lower light exposure may just in part be due to the fatigued patients spending less time outdoors in bright light, two hypotheses are proposed about the mechanisms by which light may alleviate the fatigue of patients with breast cancer. These results suggest the need for prospective intervention studies of light therapy for breast-cancer-related fatigue.