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In recent years, colorectal cancer (CRC) screening rates have increased steadily in the USA, though racial and ethnic disparities persist. In a community-based randomized controlled trial, we investigated the effect of patient navigation on increasing CRC screening adherence among older African Americans.Participants in the Cancer Prevention and Treatment Demonstration were randomized to either the control group, receiving only printed educational materials (PEM), or the intervention arm where they were assigned a patient navigator in addition to PEM. Navigators assisted participants with identifying and overcoming screening barriers. Logistic regression analyses were used to assess the effect of patient navigation on CRC screening adherence. Up-to-date with screening was defined as self-reported receipt of colonoscopy/sigmoidoscopy in the previous 10 years or fecal occult blood testing (FOBT) in the year prior to the exit interview.Compared with controls, the intervention group was more likely to report being up-to-date with CRC screening at the exit interview (OR 1.55, 95 % CI 1.07-2.23), after adjusting for select demographics. When examining the screening modalities separately, the patient navigator increased screening for colonoscopy/sigmoidoscopy (OR 1.53, 95 % CI 1.07-2.19), but not FOBT screening. Analyses of moderation revealed stronger effects of navigation among participants 65-69 years and those with an adequate health literacy level.In a population of older African Americans adults, patient navigation was effective in increasing the likelihood of CRC screening. However, more intensive navigation may be necessary for adults over 70 years and individuals with low literacy levels.

We examined the association between socioeconomic status (SES) and prostate-specific antigen (PSA) cancer screening among older African American men. We analyzed baseline data from a sample of 485 community-dwelling African American men who participated in the Cancer Prevention and Treatment Demonstration Trial. The outcome was receipt of PSA screening within the past year. SES was measured using income and educational attainment. Sequential multivariate logistic regression models were performed to study whether health care access, patient–provider relationship, and cancer fatalism mediated the relationship between SES and PSA screening. Higher educational attainment was significantly associated with higher odds of PSA screening in the past year (odds ratio (OR) 2.08 for college graduate compared to less than high school graduate, 95 % confidence interval (CI) 1.03–4.24); income was not. Health care access and patient–provider communication did not alter the relationship between education and screening; however, beliefs regarding cancer fatalism partially mediated the observed relationship. Rates of prostate cancer screening among African American men vary by level of educational attainment; beliefs concerning cancer fatalism help explain this gradient. Understanding the determinants of cancer fatalism is a critical next step in building interventions that seek to ensure equitable access to prostate cancer screening.

Objectives: Clinical guidelines recommending the use of myeloid growth factors are largely based on the prescribed chemotherapy regimen. The guidelines suggest that oncologists consider patient-specific characteristics when prescribing granulocyte-colony stimulating factor (G-CSF) prophylaxis; however, a mechanism to quantify individual patient risk is lacking. Readily available electronic health record (EHR) data can provide patient-specific information needed for individualized neutropenia risk estimation. An evidence-based, individualized neutropenia risk estimation algorithm has been developed. This study evaluated the automated extraction of EHR chemotherapy treatment data and externally validated the neutropenia risk prediction model. Materials and Methods: A retrospective cohort of adult patients with newly diagnosed breast, colorectal, lung, lymphoid, or ovarian cancer who received the first cycle of a cytotoxic chemotherapy regimen from 2008 to 2013 were recruited from a single cancer clinic. Electronically extracted EHR chemotherapy treatment data were validated by chart review. Neutropenia risk stratification was conducted and risk model performance was assessed using calibration and discrimination. Results: Chemotherapy treatment data electronically extracted from the EHR were verified by chart review. The neutropenia risk prediction tool classified 126 patients (57%) as being low risk for febrile neutropenia, 44 (20%) as intermediate risk, and 51 (23%) as high risk. The model was well calibrated (Hosmer-Lemeshow goodness-of-fit test = 0.24). Discrimination was adequate and slightly less than in the original internal validation (c-statistic 0.75 vs 0.81). Conclusion: Chemotherapy treatment data were electronically extracted from the EHR successfully. The individualized neutropenia risk prediction model performed well in our retrospective external cohort.

Perillyl alcohol (POH) is a naturally occurring lipid with preclinical activity against mammary carcinomas. We conducted a phase II multi-institutional study of oral POH administered four times daily in women with advanced treatment-refractory breast cancer.Eligible women were treated with POH four times daily at 1,200-1,500 mg m(-2) dose(-1) on a 28-day cycle. Patients tolerating 1,200 mg m(-2) day(-1) four times daily after one cycle were dose-escalated to 1,500 mg/m(2). The primary endpoint was 1-year freedom-from-progression (FFP) rate. Secondary endpoints were response rate, tolerability and correlative evaluations.Twenty-nine cycles of POH were administered to 14 women. Three patients were dose-escalated to 1,500 mg/m(2). Grade 1 and grade 2 gastrointestinal effects and fatigue were predominant toxicities. Of seven patients receiving up to one cycle, three stopped therapy due to intolerance. Only two patients received more than two cycles, with disease stabilization of 3 and 8 months. Thirteen patients were evaluable for response. One-year FFP rate was zero. No objective responses were seen. The median time to progression was 35 days (95% CI, 29-123 days). Median overall survival was 389 days (95% CI, 202-776 days). Pharmacokinetic parameters were similar to previous investigations. The ability to correlate plasma TGF-beta1 levels with outcome was limited by lack of clinical benefit and inter- and intra-patient variability.Enrollment was suspended short of planned accrual because of lack of response and poor tolerance to POH. This regimen does not appear to provide benefit in advanced treatment-refractory breast carcinoma.

Background/Aims The colony stimulating factors (CSFs), filgrastim and its long-acting form, pegfilgrastim, are indicated by the Food and Drug Administration to decrease infections in patients with non-myeloid malignancies receiving myelosuppressive chemotherapy. Roughly 25–40% of treatment-naive patients receiving common chemotherapy regimens develop febrile neutropenia (FN). FN is associated with treatment delays, dose reductions, hospitalizations, and a high cost burden. CSFs decrease the incidence, length and severity of chemotherapy-related neutropenia in several solid tumors and prophylactically, decrease infection rates and neutropenia, infection-related mortality, and early deaths associated with chemotherapy. A reduction in absolute and relative risk for all-cause mortality is associated with CSF use and in combination with antibiotics for the treatment of FN, CSFs decrease the length of hospitalization; however, recent studies have shown these agents are frequently administered in a manner inconsistent with the recommended guidelines. The high costs associated with FN treatment, the high cost of CSFs and administration of CSFs in a manner inconsistent with scientific evidence creates both a clinical and economic challenge for health plans. To date, CSF data within the Virtual Data Warehouse (VDW) has not been evaluated for accuracy.

Multiple myeloma (MM) in patients aged greater than 80 years poses an increasingly common challenge for oncology providers. A multidisciplinary workshop was held in which MM-focused hematologists/oncologists, geriatricians, and associated health-care team members discussed the state of research for MM therapy, as well as themes from geriatric medicine that pertain directly to this patient population. A summary statement of our discussions is presented here, in which we highlight several topics. MM disproportionately affects senior adults, and demographic trends indicate that this trend will accelerate. Complex issues impact cancer in seniors, and although factors such as social environment, comorbidities, and frailty have been well characterized in nononcological geriatric medicine, these themes have been inadequately explored in cancers such as MM, despite their clear relevance to this field. Therapeutically, novel agents have improved survival for MM patients of all ages, but less so for seniors than younger patients for a variety of reasons. Lastly, both MM- and treatment-related symptoms and toxicities require special attention in senior adults. Existing research provides limited insight into how best to manage these often complex patients, who are often not reflected in typical clinical trial populations. We hence offer suggestions for clinical trials that address knowledge gaps in how to manage very old and/or frail patients with MM, given the complicated issues that often surround this patient population.

Background/Aims Rural health describes a set of health issues, health care challenges and research priorities driven by a single geo-demographic factor: low population density. Rural areas compared to urbanized areas have fewer providers per capita, longer distance to care, lower socioeconomic status, higher rates of untreated illness, greater exposure to agricultural chemicals, and higher rates of alcohol use, fatal motor vehicle crashes, and suicide. Accessing clinical data for large numbers of rural residents can be challenging. To meet this challenge, seven sites formed the HMORN Rural Health Scientific Interest Group (SIG).

Background: Previous research has shown colorectal cancer (CRC) screening disparities by gender. Little research has focused primarily on gender differences among older Black individuals, and reasons for existing gender differences remain poorly understood. Methods: We used baseline data from the Cancer Prevention and Treatment Demonstration Screening Trial. Participants were recruited from November 2006 to March 2010. In-person interviews were used to assess self-reported CRC screening behavior. Up-to-date CRC screening was defined as self-reported colonoscopy or sigmoidoscopy in the past 10 years or fecal occult blood testing in the past year. We used multivariable logistic regression to examine the association between gender and self-reported screening, adjusting for covariates. The final model was stratified by gender to examine factors differentially associated with screening outcomes for males and females. Results: The final sample consisted of 1,552 female and 586 male Black Medicare beneficiaries in Baltimore, Maryland. Males were significantly less likely than females to report being up-to-date with screening (77.5% vs. 81.6%, P = 0.030), and this difference was significant in the fully adjusted model (OR: 0.72; 95% confidence interval, 0.52–0.99). The association between having a usual source of care and receipt of cancer screening was stronger among males compared with females. Conclusions: Although observed differences in CRC screening were small, several factors suggest that gender-specific approaches may be used to promote screening adherence among Black Medicare beneficiaries. Impact: Given disproportionate CRC mortality between White and Black Medicare beneficiaries, gender-specific interventions aimed at increasing CRC screening may be warranted among older Black patients. Cancer Epidemiol Biomarkers Prev; 22(6); 1037–42. ©2013 AACR.

The purpose of this study was to determine the activity of topotecan given by 21-day continuous infusion in patients previously treated with one prior therapy for a diffuse large-cell lymphoma or immunoblastic lymphoma. Patients with appropriate histology and measurable disease who had been treated with one prior chemotherapy regimen were eligible for study. Slides of tumor biopsies were submitted for central review of pathology. Patients were required to have an Eastern Cooperative Oncology Group (ECOG) performance status of 0, 1 or 2 and adequate bone marrow function. Patients were treated with continuous infusion topotecan, 0.4 mg/m(2)/day × 21 days. Therapy could be escalated to 0.5 and then 0.6 mg/m(2)/day in subsequent cycles if there was no dose-limiting toxicity at the initial dose level. Patients were treated with two cycles after achieving a complete response or until disease progression or unacceptable toxicity occurred. Thirty-seven patients were enrolled. However, only 26 cases were eligible due to a performance status of2 (n = 2), more than one prior chemotherapy (n = 1) and wrong histology on review (n = 8). Due to the unexpectedly high ineligibility rate, two sets of analysis were done for all 37 patients enrolled and for the 26 eligible patients, respectively. Of the 37 patients (15 males and 22 females), the International Prognostic Index included 11% low risk, 30% low intermediate risk, 46% high intermediate risk and 8% high risk. The median follow-up was 77 months. A total of 136 cycles of therapy were given with a median of 3 cycles per patient. Grade 4 toxicities included: 14% grade 4 thrombocytopenia; 14% grade 4 granulocytopenia, 8% leukopenia, 3% each anemia, hemorrhage, infection, vomiting, thrombosis, liver toxicity and neuromotor toxicity. The response analysis including all 37 patients showed five complete responses (CRs) and four partial responses (PRs) for a total response rate of 24% (90% two-stage confidence interval 13-39%). Median progression-free survival (PFS) was 3.7 months, with 1- and 2-year PFS of 21% and 6%, respectively (90% confidence interval 11-34% and 2-15%). Median overall survival (OS) was 10.5 months, with 1- and 2-year OS of 41% and 27%, respectively (90% confidence interval 27-53% and 16-39%). Analysis including only eligible patients showed similar response rates and survival outcomes. Single agent topotecan has moderate activity for previously treated high-grade lymphoma equivalent to that of several newer agents, and should be considered for incorporation into multi-drug salvage chemotherapy programs.

Based on theories regarding cognitive representations of illness and processes of conceptual change, a representational intervention to decrease cancer pain (RIDcancerPain) was developed and its efficacy tested.A two-group RCT (RIDcancerPain versus control) with outcome and mediating variables assessed at baseline (T1) and 1 and 2 months later (T2 and T3). Subjects were 176 adults with pain related to metastatic cancer.Outcome variables were two pain severity measures (BPI and TPQM), pain interference with life, and overall quality of life. Mediating variables were attitudinal barriers to pain management and coping (medication use).One hundred and fifty subjects completed the study. Subjects in RIDcancerPain (T1-T2 and T1-T3) showed greater decreases in Barrier scores than those in control. Subjects in RIDcancerPain (T1-T3) showed greater decreases in pain severity than those in control. Change in Barriers scores mediated the effect of RIDcancerPain on pain severity.RIDcancerPain was efficacious with respect to some outcomes. Further work is needed to strengthen it.

Just when it looked like we had finally decided that patients were in charge, doctors and patients are again at odds over just “whose life it is anyway.” Not long ago it was the patients and their families taking the doctors and their hospitals to court for the right to have unwanted life support withdrawn.1 Now it seems that the tables have turned. It is the doctors and their hospitals who are going to court2,3,4,5,6 to “deal... with families who demand inappropriate medical treatment for moribund patients.”7

Background/Aims Convenient for its oral route of administration, capecitabine is increasingly used in the older population with colorectal and other solid tumors. Since renal impairment increases with age, we designed a pilot study to assess adherence to standard dose reductions for renal insufficiency and dosing recommendations for older patients. We sought to describe patterns of capecitabine use in older patients and factors that influence dosing; specifically age and renal insufficiency.

Introduction: Medicare beneficiaries, especially those from racial/ethnic minority populations, underutilize benefits for cancer screening. There is growing evidence that patient navigation helps overcome barriers to screening; however there is limited data on which subgroups benefit most from navigation. The Cancer Prevention and Treatment Demonstration (CPTD) was a randomized controlled trial that assessed the effect of patient navigation on cancer screening among Black Medicare beneficiaries in Baltimore, Maryland. We investigated whether patient navigation's effect on female participants' breast cancer screening adherence varied by distance between residence and mammography facilities. Methods: Utilizing two sampling methods, 2,593 participants were enrolled into the CPTD trial with recruitment beginning in October 2006 and follow-up ending in December 2010. This analysis focuses on 1,856 Black female participants and utilizes baseline data as well as three follow-up surveys and exit data. The geographic software ArcGIS 10.0 spatially analyzed each participant's address relative to her three nearest mammography facilities in Baltimore City. With Stata 12.1, bivariate analyses assessed the independent effects of baseline demographics and other health variables on mammography screening adherence. While controlling for these factors, multivariable logistic regression models provided adjusted odds ratios (aORs) for the association between adherence and patient navigation. Adherence was having a mammogram within a year of the questionnaire being conducted. To assess the outcome's sensitivity, two definitions were used: 1) non-adherent at baseline and initiated adherence during follow-up; and 2) adherent at any point during follow-up regardless of baseline status. These models were stratified to assess heterogeneity based on whether or not participants were on average within two miles from their three closest facilities. Results: There were no significant differences in adherence at baseline between the intervention and control arms. Among women who lived on average less than two miles from the three closest facilities, those in the patient navigation arm were more likely to be non-adherent at baseline and become adherent during follow-up than those in the control arm (aOR 2.12; 95% CI 1.08 - 4.18). Among those who lived two or more miles away, women in the patient navigation arm had a stronger effect on adherence initiation than did women in the control arm (aOR 2.67; 95% CI 1.21 - 5.90). For adherence at any point during the study, patient navigation was effective among those who lived less than an average of two miles but was not significantly different than controls (aOR 1.47; 95% CI 0.95 - 2.27). In comparison, those randomized to patient navigation were more likely to adhere at any point in the study than control participants if they lived further from facilities (aOR 1.89; 95% CI 1.15 - 3.10). Conclusions: Our results suggest that among Black female Medicare beneficiaries in Baltimore City, the effect of patient navigation on mammography screening adherence was stronger for those further from facilities. These findings indicate that patient navigation might be helpful among those with more pronounced logistical barriers, including physical distance from health services. Additionally, the analyses suggest potential uses for geographic software in assessing the effectiveness of patient navigation and other community-based interventions. Citation Format: Aracelis Z. Torres, Darcy F. Phelan, Craig E. Pollack, Lee Bone, Jennifer Wenzel, Mollie Howerton, Gary R. Shapiro, Mary A. Garza, Lawrence Johnson, Carlos Castillo-Salgado, Jean G. Ford. Distance to mammography facilities modifies the effect of patient navigation on breast cancer screening adherence among female black Medicare beneficiaries in Baltimore City. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr A85.

Background: Prostate specific antigen (PSA) testing is frequently used for early detection of prostate cancer, including among older adults. Since both race and socioeconomic status are associated with prostate cancer incidence and outcomes, it is often difficult to separate race from socioeconomic status as a determinant of prostate cancer screening. We sought to describe the relationship between socioeconomic status and PSA testing in a sample of urban, African American Medicare beneficiaries, and to examine factors that may contribute to this relationship. Methods: We examined baseline questionnaire data collected from the Cancer Prevention and Treatment Demonstration, a community-based randomized, controlled trial in Baltimore, MD. The study population consisted of 511 community-dwelling African-American men, age 65–75, without a history of prostate cancer. Our main outcome was PSA testing within the past year. Sequential multivariate logistic regression models were performed to study factors that may mediate the relationship between socioeconomic status and PSA screening. Results: Eighty percent of participants reported having had at least one PSA test in their lifetime, and approximately 50% reported having one within the past year. About half of the sample population reported a household income of less than $30,000 a year and one-third reported education past high school, but only 14% reported a bachelor's degree or higher. In bivariate analyses both higher income ($30,000 vs. < $10,000) (Odds Ratio [OR] 3.14, 95% Confidence Interval [CI] 1.79, 5.52) and higher levels of education (Bachelor's degree vs. less than high school) (OR 3.19, CI 1.72, 5.71) were associated with screening in the past year. In a multivariable regression model, which controlled for marital status, family history, and self-reported health status, income was no longer a significantly associated with PSA testing while the association between educational attainment and PSA testing was reduced (OR 2.13, 95% CI 1.07–4.22). The addition of increased healthcare access and patient-provider relationship measures in sequential models did not alter the relationship between educational attainment and screening. However, upon inclusion of cancer knowledge and belief measures the association between education and PSA testing was no longer significant (OR 1.84, 95% CI 0.90–3.75). Conclusions: In this urban, African American Medicare population, socioeconomic status was associated with PSA testing. This relationship may be explained, in part, by demographic factors and cancer knowledge and beliefs. Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):B23.

Background: In recent years, colorectal cancer screening rates have increased steadily in the United States, though racial and ethnic disparities persist. We investigated the effect of a patient navigation intervention on adherence to colorectal cancer screening guidelines among African American older adults in Baltimore, MD. Methods: We examined data collected from the Cancer Prevention and Treatment Demonstration (CPTD), a community-based randomized, controlled trial. Our study population consisted of 661 African American men and women aged 65 to 75 years who were Medicare beneficiaries and residents of Baltimore City. Participants were randomized to receive either printed educational materials only (PEM) or the addition of a patient navigator (NAV). The Johns Hopkins trained and certified patient navigator assisted participants with identifying and overcoming potential barriers to cancer screening. Self-reported colorectal cancer screening data were collected at baseline and at one-year follow-up through inperson interviews. Rates of screening between the two groups were examined using multivariable logistic regression modeling. All participants irrespective of their baseline screening status were included in calculating the adjusted odds of completing colorectal cancer screening during the follow-up period. Results: At baseline, 68% of the PEM group and 71% of the NAV group (P = 0.45) reported being up-to-date with colorectal cancer screening, defined as having either a fecal occult blood test (FOBT) within one year or colonoscopy/sigmoidoscopy within ten years of randomization. At the one-year follow-up visit, participants in the NAV group were more likely to report having undergone any colorectal cancer screening during the previous year, compared to the PEM group, 54% versus 46%, though this did not reach statistical significance (P = 0.12). After adjusting for age, gender, number of co-morbidities, education, participants’ health perception and level of health literacy, individuals in the NAV group were more likely to report being screened by colonoscopy/sigmoidoscopy (OR, 1.53; 95% CI, 1.07–2.18) compared to those in the PEM group. Individuals who underwent patient navigation did not have a statistically significant change in the likelihood of reporting a FOBT compared to the PEM group. Conclusions: In a population of urban African American older adults, patient navigation was effective in increasing the likelihood of screening by colonoscopy/sigmoidoscopy but not fecal occult blood testing at one-year follow-up. The lack of effect on screening by FOBT likely represents the relatively low rate of provider utilization of this screening modality in the target population. Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):B11.

Context: African American older adult women are diagnosed with more advanced breast cancer and have lower survival rates than White women. While differences in health literacy may contribute to this disparity, there is limited information on intervention strategies to promote cancer screening among low-literate African American older adults. Objective: To evaluate the effect of a patient navigator on adherence to mammography screening among African American female Medicare beneficiaries with low literacy scores. Design, Setting, and Participants: We analyzed data from the Cancer Prevention and Treatment Demonstration (CPTD) at Johns Hopkins, an ongoing community-based trial designed to determine whether patient navigation is an effective strategy for improving adherence to cancer screening among African American older adults. Participants are randomized to either a high intensity group (patient navigation = educational materials) or a low intensity group (educational materials only). This analysis included 272 women ages of 65 and older with low literacy scores, who were enrolled into the study between November 2006 and March 2010, and had at least one year of follow up data. Baseline and one year follow up interviews were conducted face to face by trained interviewers through standardized questionnaires. The REALM-R instrument was used to identify participants at risk for low health literacy, based on their score. Main Outcome Measure: The outcome measure for this analysis was the between-group difference in the proportion of women receiving mammography screening during the follow up period. Multiple logistic regression was performed to control for potential confounders such as age, education, Medicaid coverage, and perceived health status. Results: Compared to the educational materials only group (n=77), the patient navigation group (n=107) had a similar proportion of women who reported a mammogram at one year follow up (64% vs. 71 %, p-value = 0.32). However, after adjusting for baseline health and demographic characteristics, women in the patient navigation group were more likely to report a mammogram at one year follow up, compared to those in the educational materials group (OR 1.90 95% CI 1.01-3.54). Women who rated themselves as having excellent to good health at baseline were less likely to report a mammogram, than those who reported fair to poor health (OR 0.43 95% CI 0.21-0.87). Conclusions: Use of a patient navigation-based intervention was positively associated with mammography screening adherence among African American older adult women with low literacy scores. In this study population, perception of health status may influence mammography screening adherence. Our findings underscore the need for tailored intervention strategies to reduce cancer screening disparities among low-literate African American older adults. Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):B15.

The claim that a treatment is futile is often used to justify a shift in the physician's ethical obligations to patients. In clinical situations in which non-futile treatments are available, the physician has an obligation to discuss therapeutic alternatives with the patient. By contrast, a physician is under no obligation to offer, or even to discuss, futile therapies. This shift is supported by moral reasoning in ancient and modern medical ethics, by public policy, and by case law. Given this shift in ethical obligations, one might expect that physicians would have unambiguous criteria for determining when a therapy is futile. This is not the case. Rather than being a discrete and definable entity, futile therapy is merely the end of the spectrum of therapies with very low efficacy. Ambiguity in determining futility, arising from linguistic errors, from statistical misinterpretations, and from disagreements about the goals of therapy, undermines the force of futility claims. Decisions to withhold therapy that is deemed futile, like all treatment choices, must follow both clinical judgments about the chance of success of a therapy and an explicit consideration of the patient's goals for therapy. Futility claims rarely should be used to justify a radical shift in ethical obligations.

We evaluated the outcome of seven severe hemophilic patients who underwent four total hip and four total knee arthroplasties since 1976. These patients have been followed at regular intervals over a period of 2.5-9.5 years (mean 5.8). Of the four total hip replacements, one had to be removed because of loosening and secondary infection 3 years after the initial surgery but was salvaged by pseudoarthrosis; the other three are pain-free and radiologically stable and have an excellent range of motion 2.5, 5, and 7 years postoperatively. Of the four total knee replacements, one had to be removed because of infection but was successfully salvaged by arthrodesis; one patient has loose components, but the prosthesis is still functional; and the final patient with bilateral knee prostheses is pain-free with limited but functional range of motion. Clotting-factor replacement therapy was effective in controlling intraoperative bleeding, even in a patient with an inhibitor, and only one procedure was complicated by hematoma formation. We conclude that prosthetic joint replacement may be safely performed in hemophilic patients but should be reserved for those who have limited function because of severe pain, joint destruction, and deformity. Total hip arthroplasty is as successful in these patients as in nonhemophiliacs. Total knee arthroplasty provides relief of pain, reduces the frequency of hemarthroses, and corrects most of the deformity, but it is usually associated with a limited range of motion.