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Health care spending in the months before death varies across geographic areas but is not associated with outcomes. Using data from the prospective multiregional Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) study, we assessed the extent to which such variation is explained by differences in patients’ sociodemographic factors, clinical factors, and beliefs; physicians’ beliefs; and the availability of services. Among 1,132 patients ages sixty-five and older who were diagnosed with lung or colorectal cancer in 2003–05, had advanced-stage cancer, died before 2013, and were enrolled in fee-for-service Medicare, mean expenditures in the last month of life were $13,663. Physicians in higher-spending areas reported less knowledge about and comfort with treating dying patients and less positive attitudes about hospice, compared to those in lower-spending areas. Higher-spending areas also had more physicians and fewer primary care providers and hospices in proportion to their total populatio...

Disparities in breast cancer treatment receipt are common and multifactorial. Data are limited on how knowledge about one's breast cancer and understanding treatment rationales may impact treatment completion. In this qualitative analysis, we explored barriers to care with a focus on knowledge. We conducted 18 in-depth interviews with women from diverse socioeconomic backgrounds who were treated at Dana-Farber Cancer Institute (n = 12; Boston, MA) and Columbia University Medical Center (n = 6; New York, NY) and had undergone neo/adjuvant breast cancer treatment within the prior 3 years. Interviews focused on treatments received, adherence, barriers experienced, and questions related to breast cancer knowledge and treatment rationales. We analyzed transcribed interview recordings in N'Vivo using a two-stage coding process that allowed for both preconfigured and emergent themes. Answers for breast cancer knowledge were confirmed using medical records. In our analysis, over one-third of women reported incomplete therapy, including never initiating treatment, stopping treatment prematurely, or missing/delaying treatments due to logistical reasons (childcare, transportation) or patient preferences. Others reported treatment modifications because of provider recommendations. Nearly all women were able to accurately describe the rationale for recommended treatments. Among 17 women for whom medical records were available, women correctly reported 18–71% of their tumor characteristics; incorrect reporting was not consistently associated with treatment incompletion. In conclusion, logistical issues and patient preferences were the main reasons for incomplete therapy in our study. Understanding of treatment rationale was high, but breast cancer knowledge was variable. Further assessment of how knowledge may impact cancer care is warranted.

Background and aims Global payment and accountable care reform efforts in the United States may connect more individuals with substance use disorders (SUD) to treatment. We tested whether such changes instituted under an Alternative Quality Contract (AQC) model within the Blue Cross Blue Shield of Massachusetts' (BCBSMA) insurer increased care for individuals with SUD. Design Difference-in-differences design comparing enrollees in AQC organizations with a comparison group of enrollees in organizations not participating in the AQC. Setting Massachusetts, USA. Participants BCBSMA enrollees aged 13-64 years from 2006 to 2011 (3 years prior to and after implementation) representing 1 333 534 enrollees and 42 801 SUD service users. Measurements Outcomes were SUD service use and spending and SUD performance metrics. Primary exposures were enrollment into an AQC provider organization and whether the AQC organization did or did not face risk for behavioral health costs. Findings Enrollees in AQC organizations facing behavioral health risk experienced no change in the probability of using SUD services (1.64 versus 1.66%; P = 0.63), SUD spending ($2807 versus $2700; P = 0.34) or total spending ($12 631 versus $12 849; P = 0.53), or SUD performance metrics (identification: 1.73 versus 1.76%, P = 0.57; initiation: 27.86 versus 27.02%, P = 0.50; engagement: 11.19 versus 10.97%, P = 0.79). Enrollees in AQC organizations not at risk for behavioral health spending experienced a small increase in the probability of using SUD services (1.83 versus 1.66%; P = 0.003) and the identification performance metric (1.92 versus 1.76%; P = 0.007) and a reduction in SUD medication use (11.84 versus 14.03%; P = 0.03) and the initiation performance metric (23.76 versus 27.02%; P = 0.005). Conclusions A global payment and accountable care model introduced in Massachusetts, USA (in which a health insurer provided care providers with fixed prepayments to cover most or all of their patients' care during a specified time-period, incentivizing providers to keep their patients healthy and reduce costs) did not lead to sizable changes in substance use disorder service use during the first 3 years following its implementation.

Purpose: Knowledge about one’s breast cancer characteristics is poor, but whether this knowledge affects treatment is uncertain. Among women with breast cancer, we examined whether tumor knowledge was associated with adjuvant treatment receipt. Methods: We surveyed a population-based sample of women in Northern California with stage 0 to III breast cancer diagnosed during 2010 to 2011 (participation rate, 68.5%). Interviews were conducted between 4 months and 3 years after diagnosis. Among 414 respondents with stage I to III disease, we examined receipt of guideline-recommended chemotherapy, radiation, and hormonal therapy by reporting correct information about one’s tumor, including stage, estrogen receptor, human epidermal growth factor receptor 2 (HER2), and grade (using registry data for confirmation). We performed multivariate logistic regression to assess the probability of receiving each treatment in relevant patient groups, adjusting for patient and tumor characteristics, and examined the impact of reporting correct tumor information on treatment receipt. Results: Among relevant treatment-eligible groups, 81% received chemotherapy, 91% received radiation, and 83% received hormonal therapy. In adjusted analyses, having correct (v incorrect) information for stage and HER2 were associated with chemotherapy receipt (odds ratio [OR], 4.45; 95% CI, 1.50 to 12.50 for stage; OR, 2.70; 95% CI, 1.02 to 7.18 for HER2). Correctly reporting estrogen receptor status was associated with hormonal therapy receipt (OR, 3.91; 95% CI, 1.73 to 8.86), and correctly reporting stage was associated with radiation receipt (OR, 2.76; 95% CI, 1.03 to 7.40). Conclusion: Knowledge about one’s tumor characteristics was strongly associated with receipt of recommended therapies. Interventions to improve patients’ knowledge and understanding of their cancers should be tested as a strategy for improving receipt of care.

Tobacco use is the leading cause of preventable death and disability. New payment and delivery system models including global payment and accountable care have the potential to increase use of cost-effective tobacco cessation services. To examine how the Alternative Quality Contract (AQC) established in 2009 by Blue Cross Blue Shield of Massachusetts (BCBSMA) has affected tobacco cessation service use. We used 2006–2011 BCBSMA claims and enrollment data to compare adults 18–64 years in AQC provider organizations to adults in non-AQC provider organizations. We examined the AQC’s effects on all enrollees; a subset at high risk of tobacco-related complications due to certain medical conditions; and behavioral health service users. We examined use of: (1) any cessation treatment (pharmacotherapy or counseling); (2) varenicline or bupropion; (3) nicotine replacement therapies (NRTs); (4) cessation counseling; and (4) combination therapy (pharmacotherapy plus counseling). We also examined duration of pharmacotherapy use and number of counseling visits among users. Rates of tobacco cessation treatment use were higher following implementation of the AQC relative to the comparison group overall (2.02 vs. 1.87 %, p

The reasons for increasing rates of bilateral mastectomy for unilateral breast cancer are incompletely understood, and associations of disease stage with bilateral surgery have been inconsistent. We examined associations of clinical and sociodemographic factors, including stage, with surgery type and reconstruction receipt among women with breast cancer.We surveyed a diverse population-based sample of women from Northern California cancer registries with stage 0 to III breast cancer diagnosed during 2010-2011 (participation rate, 68.5%). Using multinomial logistic regression, we examined factors associated with bilateral and unilateral mastectomy (vs. breast-conserving surgery), adjusting for tumor and sociodemographic characteristics. In a second model, we examined factors associated with reconstruction for mastectomy-treated patients.Among 487 participants, 58% had breast-conserving surgery, 32% had unilateral mastectomy, and 10% underwent bilateral mastectomy. In adjusted analyses, women with stage III (vs. stage 0) cancers had higher odds of bilateral mastectomy (odds ratio [OR], 8.28; 95% confidence interval, 2.32-29.50); women with stage II and III (vs. stage 0) disease had higher odds of unilateral mastectomy. Higher (vs. lower) income was also associated with bilateral mastectomy, while age ≥ 60 years (vs.50 years) was associated with lower odds of bilateral surgery. Among mastectomy-treated patients (n = 206), bilateral mastectomy, unmarried status, and higher education and income were all associated with reconstruction (P.05).In this population-based cohort, women with the greatest risk of distant recurrence were most likely to undergo bilateral mastectomy despite a lack of clear medical benefit, raising concern for overtreatment. Our findings highlight the need for interventions to assure women are making informed surgical decisions.

The effect of racial residential segregation on breast cancer treatment disparities is unclear. We examined whether racial segregation is associated with adjuvant treatment receipt and patient knowledge of disease.We surveyed a population-based sample of women in Northern California with stage I to III breast cancer diagnosed in 2010 to 2011 (participation rate = 68.5%, 500 patients). For black, Hispanic, and white women, we measured black and Hispanic segregation using the location quotient (LQ) of racial residential segregation, a proportional measure of the size of a minority group in the census tract compared with the larger metropolitan statistical area. We categorized LQ values for black and Hispanic participants into quartiles, with quartile 1 representing a lower relative level of segregation than quartile 4. We used multivariable logistical regression to assess the odds of receiving guideline-recommended adjuvant therapy and patient knowledge of tumor characteristics according to relative residential segregation.We observed greater residential segregation for black versus Hispanic patients (P .05). Overall, there were no treatment differences according to Hispanic or black LQ, except for black LQ quartile 3 (vs. 1) for which we observed higher odds of hormonal therapy. Knowledge of disease did not vary according to black LQ, but patients in the Hispanic LQ quartile 3 (vs. quartile 1) had less tumor knowledge.We did not find clear associations for racial residential segregation and treatment or cancer knowledge in Northern California, an area with low levels of segregation. Additional research should assess the effect of segregation on breast cancer treatment disparities in a variety of geographical locations.

BACKGROUND Understanding tumor characteristics is likely important, but little is known about breast cancer patients' knowledge of their own disease. The authors assessed women's knowledge about their tumor characteristics, whether racial/ethnic disparities in knowledge exist, and whether education and health literacy influence associations. METHODS A population-based cohort of women in Northern California with stage 0 through III breast cancers diagnosed from 2010 to 2011 (participation rate 68.5%) was surveyed. Among 500 respondents (222 non-Hispanic white women, 142 non-Hispanic black women, and 136 Hispanic women), racial/ethnic differences in knowledge about tumor characteristics (estrogen receptor [ER] status, human epidermal growth factor receptor 2 [HER2] status, stage, grade) and correctness of tumor information (with California Cancer Registry data for confirmation) were examined. Multivariate logistic regression was used to assess the probability of: 1) knowing tumor stage, receptor status, and grade; and 2) correctly answering questions about tumor information by race/ethnicity. The impact of education and health literacy on findings was examined in sequential models. RESULTS Overall, 32% to 82% of women reported knowing each of the 4 tumor characteristics of interest, and 20% to 58% correctly reported these characteristics. After adjustment, black and Hispanic women were less likely than white women to know and have correct responses for stage, ER status, and HER2 status (all P

Objective. Breast cancer is a leading cause of morbidity and mortality in Mexico. We assessed the effectiveness of a train-the-trainer program in two Mexican states in improving knowledge among professional and nonprofessional community health workers. Materials and Methods. We worked with local organizations to develop and implement a train-the-trainer program to improve breast cancer knowledge among community health workers, including professional health promoters (PHPs) who were trained and then trained nonprofessional community health promoters (CHPs). We surveyed participants before and after training that included in-person and online classes and again approximately 3 months later. We used paired t tests and chi-square tests to compare survey responses at the different times. We also used logistic regression to assess whether promoter characteristics were associated with greater improvements in breast cancer knowledge after training. Results. Overall, 169 PHPs (mean age, 36 years) completed training and provided a 10-hour training course to 2,651 CHPs, who also completed the pre- and post-training survey. For both PHPs and CHPs, post-training surveys demonstrated increases in an understanding of breast cancer as a problem; an understanding of screening, treatment, and insurance coverage issues; and knowledge of breast cancer risk factors, symptoms, and what constitutes a family history of breast cancer (all p < .05). These improvements were maintained 3 to 6 months after training. Conclusion. Train-the-trainer programs hold promise for leveraging community health workers, who far outnumber other health professionals in many low- and middle-income countries, to engage in health promotion activities for cancer and other noncommunicable diseases.

Global payment and accountable care reform efforts in the United States may connect more individuals with substance use disorders (SUD) to treatment. We tested whether such changes instituted under an Alternative Quality Contract (AQC) model within the Blue Cross Blue Shield of Massachusetts' (BCBSMA) insurer increased care for individuals with SUD.Difference-in-differences design comparing enrollees in AQC organizations with a comparison group of enrollees in organizations not participating in the AQC.Massachusetts, USA.BCBSMA enrollees aged 13-64 years from 2006 to 2011 (3 years prior to and after implementation) representing 1 333 534 enrollees and 42 801 SUD service users.Outcomes were SUD service use and spending and SUD performance metrics. Primary exposures were enrollment into an AQC provider organization and whether the AQC organization did or did not face risk for behavioral health costs.Enrollees in AQC organizations facing behavioral health risk experienced no change in the probability of using SUD services (1.64 versus 1.66%; P = 0.63), SUD spending ($2807 versus $2700; P = 0.34) or total spending ($12 631 versus $12 849; P = 0.53), or SUD performance metrics (identification: 1.73 versus 1.76%, P = 0.57; initiation: 27.86 versus 27.02%, P = 0.50; engagement: 11.19 versus 10.97%, P = 0.79). Enrollees in AQC organizations not at risk for behavioral health spending experienced a small increase in the probability of using SUD services (1.83 versus 1.66%; P = 0.003) and the identification performance metric (1.92 versus 1.76%; P = 0.007) and a reduction in SUD medication use (11.84 versus 14.03%; P = 0.03) and the initiation performance metric (23.76 versus 27.02%; P = 0.005).A global payment and accountable care model introduced in Massachusetts, USA (in which a health insurer provided care providers with fixed prepayments to cover most or all of their patients' care during a specified time-period, incentivizing providers to keep their patients healthy and reduce costs) did not lead to sizable changes in substance use disorder service use during the first 3 years following its implementation.

Objective Assess the relative importance of proximity and other hospital characteristics in the choice of hospital for breast cancer surgery by race/ethnicity. Data SEER-Medicare data. Study design Observational study of women aged >65 years receiving surgery for stage I/II/III breast cancer diagnosed in 1992-2007 in Detroit (N = 10,746 white/black), Atlanta (N = 4,018 white/black), Los Angeles (N = 9,433 white/black/Asian/Hispanic), and San Francisco (N = 4,856 white/black/Asian). We calculated the distance from each patient's census tract of residence to each area hospital. We estimated discrete choice models for the probability of receiving surgery at each hospital based on distance and assessed whether deviations from these predictions entailed interactions of hospital characteristics with the patient's race/ethnicity. We identified high-quality hospitals by rates of adjuvant radiation therapy and by survey measures of patient experiences, and we assessed how observed surgery rates at high-quality hospitals deviated from those predicted based on distance alone. Principal findings Proximity was significantly associated with hospital choice in all areas. Minority more often than white breast cancer patients had surgery at hospitals with more minority patients, those treating more Medicaid patients, and in some areas, lower quality hospitals. Conclusions Residential location alone does not explain concentration of racial/ethnic-minority breast cancer surgery patients in certain hospitals that are sometimes of lower quality.

Objective Assess validity of the retrospective Dartmouth hospital referral region (HRR) end-of-life spending measures by comparing with health care expenditures from diagnosis to death for prospectively identified advanced lung cancer patients. Data/Setting/Design We calculated health care spending from diagnosis (2003–2005) to death or through 2011 for 885 patients aged ≥65 years with advanced lung cancer using Medicare claims. We assessed the association between Dartmouth HRR-level spending in the last 2 years of life and patient-level spending using linear regression with random HRR effects, adjusting for patient characteristics. Findings For each $1 increase in the Dartmouth metric, spending for our cohort increased by $0.74 (p

BACKGROUND: Massachusetts law requires all residents to maintain a minimum level of health insurance, and rates of uninsurance in that state decreased from 6.4% in 2006 to 1.9% in 2010. The authors of this report assessed whether health insurance expansion was associated with use of mammography and earlier stage at breast cancer diagnosis. METHODS: By using a prereform/postreform design with a concurrent control (California), mammography rates in the last year were assessed using the Behavioral Risk Factor Surveillance System survey and the diagnosis of stage I (vs II/III/IV) breast cancers based on cancer registry data among women ages 41 to 64. Propensity score analyses were used to compare California women who were most similar to women in Massachusetts with Massachusetts women. RESULTS: Among propensity-weighted cohorts, adjusted mammography rates in Massachusetts were 69.2% in 2006, 69.5% in 2008, and 69.0% in 2010. In California, the rates were 59% in 2006, 60.3% in 2008, and 56.2% in 2010 (P = .89 for interaction by state for 2010 vs 2006). Among propensity-weighted cohorts, adjusted rates of diagnosis with stage I cancers were 52.2% in 2006, 53.5% in 2007, and 52.4% in 2008 in Massachusetts versus 46.4% in 2006, 46.3% in 2007, and 45.7% in 2008 in California (P = .58 for interaction by state for 2010 vs 2006). CONCLUSIONS: Health insurance reform in Massachusetts was not associated with increased rates of mammography or earlier stage at diagnosis compared with California, possibly because of insurance and mammography rates that already were high. Additional research is needed to assess the impact of insurance expansions in other populations, especially those with higher uninsurance rates. Cancer 2013. © 2012 American Cancer Society.

Many older veterans who are eligible for care in the Veterans Health Administration (VHA) also receive care in the private sector through Medicare (Fleming et al. 1992; Weeks et al. 2002, 2003; Ashton et al. 2003; Hynes et al. 2007). Studies examining health care utilization among veterans with dual eligibility for VHA and Medicare services have shown an increasing proportion of veterans relying on Medicare for care (Wright et al. 1999; Shen et al. 2005). In 2003 and 2004, among veterans eligible for both VHA and Medicare services who were hospitalized, 63% received inpatient care from Medicare only, 26% received inpatient care from VHA only, and 11% received care from both Medicare and the VHA (Petersen et al. 2010). Prior studies have found that up to 70% of VHA users hospitalized for acute myocardial infarction and 76% of patients hospitalized for stroke were admitted to non-VHA hospitals, which may reflect greater access to non-VHA hospitals during an acute illness, where proximity is important (Wright et al. 1999; Shen et al. 2008). Veterans also receive substantial elective care outside the VHA. In a recent study, West and colleagues reported that more than three-quarters of older veterans undergoing elective high-risk surgeries underwent surgery in non-VHA hospitals under Medicare (West, Weeks, and Wallace 2008). However, because they studied veterans eligible for VHA care rather than VHA users, it is not clear whether the high rates of elective surgery outside of the VHA among their population reflected a desire of regular VHA users to obtain certain services, such as high-risk surgery, outside the VHA or whether their VHA cohort primarily consisted of veterans who received very little or no care from the VHA. If VHA users are choosing to obtain care outside the VHA, it would suggest that the VHA is not meeting their needs, in which case this could be an area of focus to assure better access to care and better coordination of care for VHA users. In this study, we attempted to differentiate between these two options using a more comprehensive approach to identifying veterans who were active users of the VHA system versus those who were not. We studied patients with lung cancer or colorectal cancer for this purpose.

10008Background: Health care spending at the end of life varies across geographic areas and yet is not associated with improved outcomes. The factors underlying these variations are poorly understo...

Prior research has documented racial disparities in patterns of care and outcomes for women with breast cancer.To assess whether black women receive care from lower-quality or lower-volume hospitals and if such differences explain disparities in receipt of definitive primary breast cancer therapy.Observational study of a population-based sample of breast cancer patients included in the SEER-Medicare database.Fifty five thousand four hundred seventy white or black women aged65 diagnosed with stage I/II breast cancer during 1992-2002.Surgery at a high-quality hospital (top quartile rates of radiation after breast-conserving surgery) or high volume (top quartile) hospital and receipt of definitive primary therapy (mastectomy or breast-conserving surgery with radiation).Black women were significantly less likely than white women to be treated at high-quality hospitals (adjusted odds ratio [OR] 0.60; 95% confidence interval [CI]: 0.40-0.87) but not high-volume hospitals (adjusted OR 0.85; 95% CI: 0.54-1.34). Black women were less likely than white women to receive definitive primary therapy, a finding partially explained by having surgery at a high-quality hospital but not by having surgery at a high-volume hospital.Older black women were more likely than white women to undergo breast cancer surgery at hospitals with lower rates of radiation following breast-conserving surgery, and this explains some of the reported racial disparities previously observed in receipt of definitive therapy for early-stage breast cancer. Interventions to help hospitals treating large numbers of black women improve rates of radiation after breast-conserving surgery may help to decrease racial disparities in care.

Accountable care using global payment with performance bonuses has shown promise in controlling spending growth and improving care. This study examined how an early model, the Alternative Quality Contract (AQC) established in 2009 by Blue Cross Blue Shield of Massachusetts (BCBSMA), has affected care for mental illness. We compared spending and use for enrollees in AQC organizations that did and did not accept financial risk for mental health with enrollees not participating in the contract. Compared with BCBSMA enrollees in organizations not participating in the AQC, we found that enrollees in participating organizations were slightly less likely to use mental health services and, among mental health services users, small declines were detected in total health care spending, but no change was found in mental health spending. The declines in probability of use of mental health services and in total health spending among mental health service users attributable to the AQC were concentrated among enrollees in organizations that accepted financial risk for behavioral health. Interviews with AQC organization leaders suggested that the contractual arrangements did not meaningfully affect mental health care delivery in the program's initial years, but organizations are now at varying stages of efforts to improve mental health integration.

Importance Racial differences in breast cancer treatment may result in part from differences in the surgeons and hospitals from whom patients receive their care. However, little is known about differences in patients’ selection of surgeons and hospitals. Objective To examine racial/ethnic differences in how women selected their surgeons and hospitals for breast cancer surgery. Design, Setting, and Participants We surveyed 500 women (222 non-Hispanic white, 142 non-Hispanic black, 89 English-speaking Hispanic, and 47 Spanish-speaking Hispanic) from northern California cancer registries with stage 0 to III breast cancer diagnosed during 2010 through 2011. We used multivariable logistic regression to assess the reasons for surgeon and hospital selection by race/ethnicity, adjusting for other patient characteristics. We also assessed the association between reasons for physician selection and patients’ ratings of their surgeon and hospital. Main Outcomes and Measures Reasons for surgeon and hospital selection and ratings of surgeon and hospital. Results The 500 participants represented a response rate of 47.8% and a participation rate of 69%. The most frequently reported reason for surgeon selection was referral by another physician (78%); the most frequently reported reason for hospital selection was because it was a part of a patient’s health plan (58%). After adjustment, 79% to 87% of black and Spanish-speaking Hispanic women reported selecting their surgeon based on a physician’s referral vs 76% of white women ( P = .007). Black and Hispanic patients were less likely than white patients to report selecting their surgeon based on reputation (adjusted rates, 18% and 22% of black and Hispanic women, respectively, vs 32% of white women; P = .02). Black and Hispanic women were also less likely than white women to select their hospital based on reputation (adjusted rates, 7% and 15% vs 23%, respectively; P = .003). Women who selected their surgeon based on reputation more often rated the care from their surgeon as excellent (adjusted odds ratio, 2.21; 95% CI, 1.24-3.93); those reporting their surgeon was one of the only surgeons available through the health plan less often reported excellent quality of surgical care (adjusted odds ratio, 0.56; 95% CI, 0.34-0.91). Conclusions and Relevance Compared with white patients with breast cancer, minority patients were less actively involved in physician and hospital selection, relying more on physician referral and health plans rather than on reputation. Interventions to promote involvement in surgeon and hospital selection may have potential for addressing disparities related to lower-quality care from surgeons and hospitals.

A growing number of recent reports have demonstrated sex and menstrual cycle differences in the subjective, physiological and pharmacokinetic effects of stimulant drugs in humans. The present study was conducted to further investigate the relationship between gonadal hormones and cocaine effects by examining whether oral contraceptives (OCs) alter the acute effects of cocaine. Seven female volunteers, who were taking triphasic OCs and who were occasional users of cocaine, provided informed consent and participated in this placebo-controlled, four-visit study. Subjects were studied twice during days 6-10 of the menstrual cycle (equivalent to the follicular phase) and twice during days 21-28 of the menstrual cycle (equivalent to the luteal phase) and were challenged with an acute dose of intranasal (in) cocaine (0.9 mg/kg or placebo). There were no differences in cocaine-induced subjective, physiologic or plasma cocaine and metabolite levels during the times equivalent to the follicular and luteal phases of the menstrual cycle. Our findings provide evidence that OCs do not present an added risk of cocaine-induced cardiovascular effects and that exogenous administration of estrogen and progesterone at the physiologic doses found in OCs do not alter the subjective responses to acute cocaine.

Rationale: The majority of pharmacotherapies proposed for cocaine dependence have been marginally effective and frequently have undesirable side effects. We recently demonstrated that short-term treatment with citicoline decreased self-reported desire to use cocaine in crack cocaine users. Objective: The present study was conducted to assess the safety of citicoline in combination with cocaine by investigating whether cocaine-induced cardiovascular and behavioral effects and cocaine plasma levels are altered by citicoline pretreatment. Methods: Eight healthy male and female volunteers who used cocaine on an occasional basis participated in this randomized, placebo-controlled, three-visit study. During all three visits, subjects received an acute intranasal dose of cocaine (0.9 mg/kg) and were continuously monitored for the ensuing 3.5 h. The first visit involved no pretreatment, and visits 2 and 3 were preceded by a 4-day pretreatment period of either citicoline (1 g/day) or placebo. Results: Citicoline pretreatment did not alter the cardiovascular, physiologic, or subjective effects of acute cocaine. Conclusions: Although citicoline did not block the acute subjective effects of cocaine in a laboratory environment, the combined use of citicoline and a moderate dose of intranasal cocaine presented no added risk of cardiovascular effects. Further study is necessary to determine whether this medication (which is currently used to treat strokes) will be a useful adjunct to treat cocaine dependence.

The present study investigated the relationship between crime and substance abuse in a sample of 133 consecutively evaluated male prisoners. Using the Structured Clinical Interview for DSM-III-R, we assessed the prevalence of various forms of substance abuse in this population and attempted to judge whether substance abuse played a role in the index crime which has led to the present incarceration. In addition, we assessed whether there was a relationship between the nature of substance dependence and the type of crime committed, whether sexual, violent, or non-violent. Among the 133 prisoners, 95% obtained a diagnosis of dependence on one or more substances. Fifty-eight percent of the inmates reported that they were acutely intoxicated with one or more substances at the time they committed the index crime and an additional 6% were withdrawing from a substance at the time of the crime. There was no significant correlation between the type of substance abuse diagnosis and the type of crime committed. Similarly, there was no significant correlation between the number of individuals who reported they were intoxicated at the time of the offense and the type of crime committed.

We assessed cognitive function following heroin and cocaine detoxification and investigated whether buprenorphine treatment improves the disruptive effects of detoxification. Three groups of male volunteers meeting DSM-III-R criteria for concurrent opiate and cocaine dependence were tested using an auditory oddball paradigm before and after detoxification, and again on the 15th day of either buprenorphine or placebo treatment. There were no significant differences in P300 amplitude, latency, or topographic distribution between drug-dependent subjects and controls on admission day. Following detoxification there was a significant decrease in P300 amplitude in the drug-dependent group at a time when self-reported signs of withdrawal were minimal. Buprenorphine treatment significantly reversed the P300 amplitude decrement following detoxification, whereas placebo-treated subjects continued to show depressed P300 amplitudes. These data demonstrate that buprenorphine treatment is effective in eliminating detoxification-induced impairments in one measure of cognitive ability.

OBJECTIVE The objective of this study was to examine the relationship between anabolic--androgenic steroids and lipoprotein levels in men receiving weekly injections of gradually escalating doses of up to 600 mg/week of testosterone cypionate. DESIGN The design was a placebo-controlled, double-blind, 24-week cross-over design in which subjects were randomized to one of two treatment sequences: (a) weekly testosterone cypionate injections for 6 weeks, no treatment for 6 weeks, weekly placebo injections for 6 weeks, and then again no treatment for 6 weeks; or (b) placebo, no treatment, testosterone, and then no treatment, with each interval also lasting 6 weeks as in the first sequence. SETTING The setting was a private hospital. PARTICIPANTS Participants were normal male volunteers. INTERVENTIONS Testosterone cypionate injections were given in gradually increasing doses of 150 mg/week for 2 weeks, 300 mg/week for 2 weeks, and 600 mg/week for 2 weeks. Eight subjects received testosterone injections during the first injection phase and placebo during the second injection phase, and the remaining eight subjects received placebo first and testosterone second. RESULTS We found a 21% depression of high-density lipoprotein cholesterol (HDL-C) levels following the first 300-mg testosterone dose. This depression remained unchanged after the two 600-mg doses. In contrast, we did not find any changes in low-density lipoprotein or total cholesterol levels at any of the time points studied. Subjects' total cholesterol/HDL-C ratios were significantly elevated during testosterone administration and even 4 weeks following the last injection. CONCLUSION Our findings suggest that testosterone cypionate adversely affects cholesterol fractions, that this effect reaches its full magnitude even at very modestly supraphysiologic doses, and that this effect persists for several weeks after discontinuation of the drug.

Gender differences after acute cocaine administration have received little attention in spite of the fact that males and females respond differently to many drugs. Seven male and seven female occasional cocaine users received both an intranasal dose of cocaine hydrochloride (0.9 mg/kg) and placebo powder in a randomized order and reported subjective effects via an instrumental joystick device and various questionnaires. Blood samples were withdrawn at 5-min intervals to assess pharmacokinetic differences. Male subjects achieved the highest peak plasma cocaine levels (144.4 +/- 17.5 ng/ml), detected cocaine effects significantly faster than females and also experienced a greater number of episodes of intense good and bad effects. Women studied during the follicular phase of their menstrual cycle had peak plasma cocaine levels of 73.2 +/- 9.9 ng/ml, which was significantly higher than when they were studied during their luteal phase (54.7 +/- 8.7 ng/ml), but there were no differences in their subjective reports of cocaine effects. In spite of the different cocaine blood levels and subjective effects, peak heart rate increases did not differ between males and females suggesting that women may be more sensitive than males to the cardiovascular effects of cocaine. These data suggest that there are significant gender and menstrual cycle differences in the response to acute intranasal cocaine administration and these differences may have implications for the differential abuse of this drug.

The present study assessed the effects of supraphysiologic doses of testosterone on aggressive responding in a controlled laboratory setting. Eight male subjects received gradually increasing doses of testosterone cypionate (150 mg/week for two weeks, 300 mg/week for two weeks, and 600 mg/week for two weeks) or placebo using a double-blind, randomized, cross-over design. Subjects were tested both before and after the series of injections. During the experimental session subjects could press a button to accumulate points exchangeable for money (non-aggressive response) or press another button to subtract points from a fictitious opponent (aggressive response). Aggressive responding was instigated by subtracting points from the subject which was attributable to the fictitious opponent. Testosterone administration resulted in a significantly higher number of aggressive responding compared to placebo.

We sought to assess whether college students who smoked marijuana heavily were distinguishable from students who had used the drug only occasionally. We compared 45 long-term heavy marijuana smokers (individuals who had smoked daily for at least 2 years) with 44 "occasional" smokers (individuals who had never smoked more than 10 times in a month at any time in their lives), drawn from the student populations at two Boston-area colleges. measures included a questionnaire covering a range of demographic, drug use, and subjective items; the Rand Mental Health Inventory; and both the Axis I and Axis II sections of the Structured Clinical Interview for DSM-III-R. Heavy smokers reported higher rates of use of other substances, especially hallucinogens and cocaine, and they described greater subjective impairment of memory and motivation than occasional smokers; however, on a wide range of demographic, family background, and mental health measures, the heavy smokers proved almost indistinguishable from occasional smokers. Even the heaviest college marijuana smokers exhibit few demographic or psychiatric features that distinguish them from students who smoke only occasionally.

Massachusetts law requires all residents to maintain a minimum level of health insurance, and rates of uninsurance in that state decreased from 6.4% in 2006 to 1.9% in 2010. The authors of this report assessed whether health insurance expansion was associated with use of mammography and earlier stage at breast cancer diagnosis.By using a prereform/postreform design with a concurrent control (California), mammography rates in the last year were assessed using the Behavioral Risk Factor Surveillance System survey and the diagnosis of stage I (vs II/III/IV) breast cancers based on cancer registry data among women ages 41 to 64. Propensity score analyses were used to compare California women who were most similar to women in Massachusetts with Massachusetts women.Among propensity-weighted cohorts, adjusted mammography rates in Massachusetts were 69.2% in 2006, 69.5% in 2008, and 69.0% in 2010. In California, the rates were 59% in 2006, 60.3% in 2008, and 56.2% in 2010 (P = .89 for interaction by state for 2010 vs 2006). Among propensity-weighted cohorts, adjusted rates of diagnosis with stage I cancers were 52.2% in 2006, 53.5% in 2007, and 52.4% in 2008 in Massachusetts versus 46.4% in 2006, 46.3% in 2007, and 45.7% in 2008 in California (P = .58 for interaction by state for 2010 vs 2006).Health insurance reform in Massachusetts was not associated with increased rates of mammography or earlier stage at diagnosis compared with California, possibly because of insurance and mammography rates that already were high. Additional research is needed to assess the impact of insurance expansions in other populations, especially those with higher uninsurance rates.

The reasons why individuals use this combination are not entirely clear, however, it has been speculated that marihuana may potentiate cocaine's subjective effects. Five male recreational drug users provided informed consent and volunteered to participate in this study. Each subject participated on 3 different days, separated by at least 1 week. Subjects sat in an isolated chamber and were prepared with electrocardiographic (ECG) electrodes for heart rate monitoring and an IV catheter for blood withdrawal. After adapting to the experimental chamber, they smoked a marihuana cigarette containing either 0.004% (placebo), 1.24%, or 2.64% delta 9-tetrahydrocannabinol (THC). Thirty minutes later they received an intranasal dose of 0.9 mg/kg cocaine. On subsequent visits, the marihuana dose was varied on a random basis. Subjects continuously reported changes in their mood state via an instrumental joystick device and filled out visual analog scales. Marihuana-induced tachycardia was increased even more after cocaine. The duration of all marihuana- and cocaine-related positive subjective effects was unchanged when both drugs were given, but marihuana pretreatment significantly reduced the latency to cocaine effects, from 1.87 to 0.53 min, and decreased the duration of dysphoric or bad effects, from 2.1 to 0.5 min. Peak plasma cocaine levels were 122.8 +/- 26.6 ng/ml after placebo marihuana, but pretreatment with the high-dose marihuana resulted in a significant increase in peak cocaine levels (233.8 +/- 19.2 ng/ml) and the apparent bioavailability as determined by area under the curve (AUC) analysis. We conclude that marihuana-induced vasodilation of the nasal mucosa attenuates the vasoconstrictive effects of cocaine and thus increases its absorption.

The importance of quality of life (QOL) among cancer survivors is second only to survival [1]. A cancer survivor’s general well-being significantly impacts his or her ability to successfully engage in everyday activities and to adapt to living with cancer [2], and it has been shown to be a powerful predictor of survival and treatment-related toxicity among cancer survivors [3–7]. How well a cancer survivor copes with the changes resulting from the cancer and its treatment depends on a variety of physical and psychosocial factors that determine the cancer survivor’s overall QOL.

Research has shown that Hispanic women in the United States are diagnosed with breast cancer at more advanced stages and initiate treatment later than non-Hispanic white women. We investigated whether stage at breast cancer diagnosis and receipt of primary therapy differ by ethnicity and birthplace among US-born Hispanic, foreign-born Hispanic, and white women. We studied 31,012 Hispanic women and 372,313 white women with a first diagnosis of invasive breast cancer during 1988 and 2005 living in a SEER area. We used multinomial logistic regression to assess the association of ethnicity and birthplace with stage at diagnosis and, among women with stage I or II cancers, primary therapy [mastectomy, breast-conserving surgery (BCS) with radiation, BCS without radiation], adjusting for other patient and tumor characteristics. Rates of stage at diagnosis differed significantly by race/ethnicity and birthplace (P < 0.001). Foreign-born Hispanics had lower adjusted rates of stage I breast cancer at diagnosis (35.4%) than US-born Hispanics (40.6%), birthplace-unknown Hispanics (42.3%), and whites (47.4%). Receipt of primary therapy also differed significantly by race/ethnicity and birthplace (P < 0.001). Foreign-born Hispanics and birthplace-unknown Hispanics had lower rates of BCS with radiation (34.9%, 30.7%) than US-born Hispanics (41.5%) and whites (38.8%). Foreign-born Hispanic women in the United States have a lower probability of being diagnosed at earlier stages of breast cancer and, for women with early-stage disease, of receiving radiation following BCS compared to US-born Hispanics and whites. Identifying factors mediating these disparities may help in developing culturally and linguistically appropriate interventions and improving outcomes.

The present report shows that nicotine enhances some of alcohol's positive and negative effects in women and that these effects are most pronounced during the luteal phase of the menstrual cycle. Ten low progesterone and 10 high progesterone/luteal-phase women received nicotine patch pretreatments (placebo or 21 mg) 3 hours before an alcohol challenge (0.4 g/kg). Subjective effects were recorded on mood adjective scales and the Addiction Research Center Inventory (ARCI). Heart rate and skin temperature were recorded. Luteal-phase women reported peak positive (e.g. "stimulated") and peak negative effects (e.g. "clumsy", "dizzy") almost twice as great as low progesterone women.

Despite the fact that tobacco and marihuana are often used together, relatively little is known about the effects of this combination. In order to investigate the effects of the principal psychoactive component in tobacco smoke, nicotine, on marihuana-induced intoxication, we conducted a double blind, cross-over experiment using nicotine transdermal patches. Ten male and 10 female participants received either placebo or a 21 mg transdermal nicotine patch 4 h before smoking one of two marihuana cigarettes (1.99 or 3.51% delta-9-tetrahydrocannabinol (Δ 9 THC) content). Measurements of physiological activity (heart rate, blood pressure, and skin temperature) and subjective effects (self-reports of drug effects on visual analog scales (VAS) and the Addiction Research Center Inventory (ARCI)) were made periodically before and for 3 h after smoking. Nicotine pre-treatment enhanced several responses to marihuana, in particular, heart rate, reports of “stimulated” on the visual analog scales, and scores on the Amphetamine scale of the ARCI. Male participants reported a more pronounced effect of marihuana that persisted longer than that of the female participants. Compared to the male participants, female participants experienced an attenuated response to marihuana and were less affected by the drug combination. The results of this study show that nicotine can have an important influence on the subjective and physiological effects of smoked marihuana. These effects have implications for the safety and efficacy of marihuana smokers who are self-medicating with the nicotine transdermal patch to manage their tobacco dependence.

Nicotine and alcohol are often consumed together and smokers are more likely than non-smokers to drink alcohol. In spite of the high prevalence of the combined use of alcohol and nicotine, only a few laboratory studies have examined the effects of this drug combination in humans. The present study was conducted to further investigate the nature of nicotine/alcohol interactions by examining whether nicotine pretreatment via a transdermal patch (placebo or 21 mg) alters the subjective and physiologic effects of acute ethanol (0.4 and 0.7 g/kg) administration. Twelve male smokers who drank alcohol on an occasional basis provided informed consent to participate in the study. Subjective reports of feeling drunk, feeling ethanol's effects and ethanol-induced euphoria were increased by nicotine pretreatment. In addition, reports of desire to smoke a tobacco cigarette were significantly elevated after ethanol administration and were most pronounced during the active nicotine conditions. Heart rate was elevated by nicotine and ethanol-induced increases in heart rate were enhanced by nicotine pretreatment. The time to peak ethanol concentration was faster in the nicotine-patch condition and this paralleled the more rapid detection of ethanol effects after drinking the low-dose beverage. These findings suggest that nicotine enhances some of the positive subjective effects of acute ethanol and may help explain the high prevalence of the combined use of these two drugs.

Tobacco smoking and cocaine use often co-occurs and the frequency of smoking has been positively correlated with the likelihood of cocaine use. In addition, nicotine pretreatment has been shown to increase the rate of cocaine self-administration in rats and to enhance cue-induced cocaine craving in humans. The present study was conducted to investigate whether nicotine pretreatment via a transdermal patch alters the behavioral, physiological, and pharmacokinetic effects of an acute dose of cocaine in nondependent human volunteers. Seven male tobacco smokers who used cocaine occasionally provided informed consent and participated in this placebo-controlled, four-visit study. Following pretreatment with a transdermal nicotine patch (placebo, 14 mg), subjects were challenged with an acute dose of intranasal cocaine (placebo, 0.9 mg/kg). Nicotine pretreatment attenuated cocaine-induced increases in reports of "high" and "stimulated" and increased the latency to detect cocaine effects and cocaine-induced euphoria. Nicotine did not alter cocaine's effects on heart rate, skin temperature, and blood pressure or plasma cocaine, benzoylecgonine (BE), or ecgonine methylester (EME) concentrations. Our findings indicate that nicotine pretreatment alters some of the positive subjective effects of cocaine in humans without affecting cocaine's effects on physiologic responses or pharmacokinetic profiles.

Rationale: The importance of genetic factors in the development of alcoholism has been demonstrated repeatedly. However, the impact of a family history of alcoholism on the development of other drug use has been less thoroughly studied. Objective: The present study was conducted to investigate whether individuals with a positive family history of alcoholism (FHP) differ from individuals without a history (FHN) in their pharmacokinetic profile, subjective and physiological response to an acute intranasal dose of cocaine (0.9 mg/kg). Methods: Nine FHP and nine FHN male occasional cocaine users provided informed consent and participated in this double-blind, placebo-controlled, two-visit study. Responses to cocaine were assessed via a joystick device, the Addiction Research Center Inventory, visual analog scales and heart rate. Plasma concentrations of cocaine and its metabolites, benzoylecgonine and ecgonine methylester also were measured. Results: There were no significant differences between FHP and FHN subjects in subjective reports of intoxication, physiologic responses or plasma cocaine and benzoylecgonine concentrations following cocaine administration. Plasma levels of the cocaine metabolite ecgonine methylester were significantly higher in FHP subjects from 50 to 120 min post-cocaine administration compared to FHN subjects. Conclusions: Our findings indicate that family history of alcoholism does not appear to influence the behavioral and physiological responses to acute cocaine administration, but that some aspects of cocaine metabolism may be different between the two groups.

Rationale: Even though marijuana is the most commonly abused illicit drug in the United States, it is still undetermined whether withdrawal after chronic use results in changes in aggressive behavior in humans. Objective: The present study investigated the pattern and duration of changes in aggressive behavior in long-term marijuana users during a 28-day abstinence period verified by daily urines. Methods: Chronic marijuana users who had smoked marijuana on at least 5000 occasions (the equivalent of smoking daily for approximately 14 years) and who were smoking regularly when recruited were studied on days 0 (when they were still smoking), 1 (during acute withdrawal), 3, 7 and 28 of a 28-day detoxification period. Aggressive behavior was measured using the Point Subtraction Aggression Paradigm. Results: Compared to controls and to the pre-withdrawal data, chronic marijuana users displayed more aggressive behavior on days 3 and 7 of marijuana abstinence. These increases in aggressive responding returned to pre-withdrawal levels after 28 days and were paralleled by small, non-significant changes in depression and anxiety scores. Conclusions: Our findings confirm previous reports of an abstinence syndrome associated with chronic marijuana use and suggest that aggressive behavior should be an additional component of this syndrome.

We performed a forensic evaluation of a 16-year-old boy convicted of murdering his 14-year-old girlfriend while he was taking anabolic steroids. Prior to steroid use, he had displayed no features of antisocial personality disorder and no criminal record. Prompted by this index case, we interviewed 133 consecutive male convicts at the same facility where this boy was incarcerated to assess whether steroid use frequently contributed to criminal acts. Two other cases of apparent steroid-induced crimes were found in this cohort, suggesting that steroid use is an uncommon, though occasionally significant, factor in criminal behavior.

We calculated fat-free mass index (FFMI) in a sample of 157 male athletes, comprising 83 users of anabolic-androgenic steroids and 74 nonusers. FFMI is defined by the formula (fat-free body mass in kg) x (height in meters)-2. We then added a slight correction of 6.3 x (1.80 m - height) to normalize these values to the height of a 1.8-m man. The normalized FFMI values of athletes who had not used steroids extended up to a well-defined limit of 25.0. Similarly, a sample of 20 Mr. America winners from the presteroid era (1939-1959), for whom we estimated the normalized FFMI, had a mean FFMI of 25.4. By contrast, the FFMI of many of the steroid users in our sample easily exceeded 25.0, and that of some even exceeded 30. Thus, although these findings must be regarded as preliminary, it appears that FFMI may represent a useful initial measure to screen for possible steroid abuse, especially in athletic, medical, or forensic situations in which individuals may attempt to deny such behavior.

Previous studies using visual inspection and spectral analysis procedures have found that ethanol increases the voltage and slows the predominant frequency of the resting electroencephalogram (EEG) (Abramson 1945; Begleiter and Platz, 1972; Davis et al., 1941; Docter et al., 1966; Ekman et al., 1963, 1964; Engel and Rosenbaum, 1945; Lukas et al., 1986a,c,d; Myrsten et al., 1975; Warren and Raynes, 1972). Although the results from these studies are fairly consistent, they were based on recordings from only a few EEG electrode sites, usually located over the occipital and parietal cortex. A re-examination of ethanol’s effects on brain electrical activity has been prompted by recent technical advances in quantitative analysis of the topographic distribution of EEG activity using far more recording sites than conventional EEG studies.

The relationship among topographic brain electrical activity mapping, auditory-evoked response potentials (ERPs), plasma ethanol levels and subjective reports of intoxication was examined in 4 male volunteers. The source of the auditory P300 ERP (a measure of selective attention and memory encoding) was estimated using a recently developed computer program. The effect of ethanol on the P300 wave was studied using a standard oddball paradigm both with and without a concomitant divided attention task. Ethanol (0.7 g/kg) administration produced marked increases in EEG alpha activity during the ascending limb of the blood ethanol curve. Acute ethanol administration caused a delay in the latency and a reduction in the amplitude of the auditory P300 ERP. A similar effect on P300 topography was noted in waves that were affected by the tones while the subjects also listened to a story (divided attention). After ethanol, the source of the P300 wave appeared to have shifted to a position posterior and inferior to its original location. P300 ERP's generated during the divided attention task were also disrupted and shifted to positions inferior to their original. However, the variability of the dipole vector was much greater during the divided attention task than after ethanol administration. These data demonstrate that ethanol's effects on cognitive processing skills may be similar to those produced when individuals experience distractions while concentrating on a task.

BACKGROUND: Field studies of illicit anabolic-androgenic steroid users suggest that some develop manic or aggressive reactions to these drugs o a potential public health problem. However, controlled laboratory evaluations of these effects remain limited. METHODS: In a randomized, placebo-controlled, crossover trial, we administered testosterone cypionate for 6 weeks in doses rising to 600 mg/wk and placebo for 6 weeks, separated by 6 weeks of no treatment, to 56 men aged 20 to 50 years. Psychiatric outcome measures included the Young Mania Rating Scale (YMRS), the Point Subtraction Aggression Paradigm (a computerized provocation test of aggression), the Aggression Questionnaire of Buss and Perry, the Symptom Checklist-90-R, daily diaries of manic and depressive symptoms, and similar weekly diaries completed by a "significant other" who knew the participant well. RESULTS: Testosterone treatment significantly increased manic scores on the YMRS (P=.002), manic scores on daily diaries (P=.003), visual analog ratings of liking the drug effect (P=.008), and aggressive responses on the Point Subtraction Aggression Paradigm (P=.03). Drug response was highly variable: of 50 participants who received 600 mg/wk of testosterone cypionate, 42 (84%) exhibited minimal psychiatric effects (maximum YMRS score, 20). The 8 "responders" and 42 "nonresponders" did not differ significantly on baseline demographic, psychological, laboratory, or physiological measures. CONCLUSIONS: Testosterone administration, 600 mg/wk increased ratings of manic symptoms in normal men. This effect, however, was not uniform across individuals; most showed little psychological change, whereas a few developed prominent effects. The mechanism of these variable reactions remains unclear. (Abstract Adapted from Source: Archives of General Psychiatry, 2000. Copyright © 2000 by the American Medical Association) Adult Aggression Adult Male Adult Substance Use Steroid Use Effects Substance Use Effects Male Aggression Aggression Causes Steroid Related Aggression Drug Use Effects Drug Related Aggression Testosterone 05-01

To the Editor. —We read with interest the recent article of Yesalis and colleagues 1 that found, on the basis of household survey data, that more than 300 000 Americans had used anabolic-androgenic steroids (AASs) during the year prior to the survey. We used these figures to estimate the total amount of money spent illicitly on steroids in the United States on a yearly basis. We performed this calculation with data from a recent interview study of 88 AAS users that we conducted over the past 3 years. 2 In the study, 64 of these 88 users reported at least some AAS use during the year prior to interview. We calculated the total amount of each AAS that these subjects reported they had purchased during the prior year, and then estimated current street prices of each AAS using "underground" steroid guides, 3,4 updated with information on current street prices of