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Background: Radical prostatectomy and external beam radiotherapy are the two major therapeutic options for treating clinically localized prostate cancer. Because survival is often favorable regardless of therapy, treatment decisions may depend on other therapy-specific health outcomes. In this study, we compared the effects of two treatments on urinary, bowel, and sexual functions and on general health-related quality-of-life outcomes over a 2-year period following initial treatment.Methods: A diverse cohort of patients aged 55-74 years who were newly diagnosed with clinically localized prostate cancer and received either radical prostatectomy (n = 1156) or external beam radiotherapy (n = 435) were included in this study. A propensity score was used to balance the two treatment groups because they differed in some baseline characteristics. This score was used in multivariable cross-sectional and longitudinal regression analyses comparing the treatment groups. All statistical tests were two-sided.Results: Almost 2 years after treatment, men receiving radical prostatectomy were more likely than men receiving radiotherapy to be incontinent (9.6% versus 3.5%; P:<.001) and to have higher rates of impotence (79.6% versus 61.5%; P:<.001), although large, statistically significant declines in sexual function were observed in both treatment groups. In contrast, men receiving radiotherapy reported greater declines in bowel function than did men receiving radical prostatectomy. All of these differences remained after adjustments for propensity score. The treatment groups were similar in terms of general health-related quality of life.Conclusions: There are important differences in urinary, bowel, and sexual functions over 2 years after different treatments for clinically localized prostate cancer. In contrast to previous reports, these outcome differences reflect treatment delivered to a heterogeneous group of patients in diverse health care settings. These results provide comprehensive and representative information about long-term treatment complications to help guide and inform patients and clinicians about prostate cancer treatment decisions. [ABSTRACT FROM AUTHOR]

Context: Patients with prostate cancer and their physicians need knowledge of treatment options and their potential complications, but limited data on complications are available in unselected population-based cohorts of patients.Objective: To measure changes in urinary and sexual function in men who have undergone radical prostatectomy for clinically localized prostate cancer.Design: The Prostate Cancer Outcomes Study, a population-based longitudinal cohort study with up to 24 months of follow-up.Setting: Population-based cancer registries in 6 geographic regions of the United States.Participants: A total of 1291 black, white, and Hispanic men aged 39 to 79 years who were diagnosed as having primary prostate cancer between October 1, 1994, and October 31, 1995, and who underwent radical prostatectomy within 6 months of diagnosis for clinically localized disease.Main Outcome Measures: Distribution of and change in urinary and sexual function measures reported by patients at baseline and 6, 12, and 24 months after diagnosis.Results: At 18 or more months following radical prostatectomy, 8.4% of men were incontinent and 59.9% were impotent. Among men who were potent before surgery, the proportion of men reporting impotence at 18 or more months after surgery varied according to whether the procedure was nerve sparing (65.6% of non-nerve-sparing, 58.6% of unilateral, and 56.0% of bilateral nerve-sparing). At 18 or more months after surgery, 41.9% reported that their sexual performance was a moderate-to-large problem. Both sexual and urinary function varied by age (39.0% of men aged <60 years vs 15.3 %-21.7% of older men were potent at > or =18 months [P<.001]; 13.8% of men aged 75-79 years vs 0.7%-3.6% of younger men experienced the highest level of incontinence at > or =18 months [P = .03]), and sexual function also varied by race (38.4% of black men reported firm erections at > or =18 months vs 25.9% of Hispanic and 21.3% of white men; P = .001).Conclusions: Our study suggests that radical prostatectomy is associated with significant erectile dysfunction and some decline in urinary function. These results may be particularly helpful to community-based physicians and their patients with prostate cancer who face difficult treatment decisions. [ABSTRACT FROM AUTHOR]

Objective: Describe the treatment and survival patterns among a population-based sample of vulvar cancer patients diagnosed in the United States in 1999., Methods: Cases were identified for the National Cancer Institute's Patterns of Care Study (POC) using the Surveillance, Epidemiology, and End Results Program (SEER). A stratified random sample of non-Hispanic white, non-Hispanic black, and Hispanic women age 20 years and older was selected from cases reported by 11 SEER registries. Analyses of the association between vulvar cancer and key demographic, clinical, and hospital characteristics by stage were performed. Cox proportional hazards was used to estimate the odds of death due to cancer. All estimates were weighted, and analyses were conducted with SUDAAN., Results: Ninety percent of cases were diagnosed with in situ or early-stage invasive disease. Older patients were more likely to present at advanced stages. Twenty-five percent of women with Stage III-IV vulvar cancer received chemotherapy plus radiation. We noted widespread use of radical local excision among women with Stage I/II cancer, but 46-54% with invasive disease underwent a radical or total vulvectomy. Factors associated with cancer death were limited to age and stage. Women 75 years and older were at higher risk compared to women aged 20-49 years and the risk of death increased with advancing stage., Conclusions: Vulvar cancer is diagnosed at early stages. Late-stage disease is associated with a significant increase in mortality. Radical surgery was still commonly performed in 1999. Radiation was more common in women diagnosed at late stage, while the use of chemoradiation remained limited.

Background: Because of the lack of results from randomized clinical trials comparing the efficacy of aggressive therapies with that of more conservative therapies for clinically localized prostate cancer, men and their physicians may select treatments based on other criteria. We examined the association of sociodemographic and clinical characteristics with four management options: radical prostatectomy, radiation therapy, hormonal therapy, and watchful waiting., Methods: We studied 3073 participants of the Prostate Cancer Outcomes Study diagnosed from October 1, 1994, through October 31, 1995, with clinically localized disease (T1 or T2). Participants completed a baseline survey, and diagnostic and treatment information was abstracted from medical records. Multiple logistic regression analysis identified factors associated with initial treatment. All statistical tests were two-sided., Results: Patients with clinically localized disease received the following treatments: radical prostatectomy (47.6%), radiation therapy (23.4%), hormonal therapy (10.5%), or watchful waiting (18.5%). Men aged 75 years or older more often received conservative treatment (i.e., hormonal therapy alone or watchful waiting; 57.9% of men aged 75-79 years and 82.1% of men aged 80 years and older) than aggressive treatment (i.e., radical prostatectomy or radiation therapy) (for all age groups, P

In 1995-1996, the authors mailed a food frequency questionnaire to 3.5 million American Association of Retired Persons members who were aged 50-69 years and who resided in one of six states or two metropolitan areas with high-quality cancer registries. In establishing a cohort of 567,169 persons (340,148 men and 227,021 women), the authors were fortunate in that a less-than-anticipated baseline response rate (threatening inadequate numbers of respondents in the intake extremes) was offset by both a shifting and a widening of the intake distributions among those who provided satisfactory data. Reported median intakes for the first and fifth intake quintiles, respectively, were 20.4 and 40.1 (men) and 20.1 and 40.0 (women) percent calories from fat, 10.3 and 32.0 (men) and 8.7 and 28.7 (women) g per day of dietary fiber, 3.1 and 11.6 (men) and 2.8 and 11.3 (women) servings per day of fruits and vegetables, and 20.7 and 156.8 (men) and 10.5 and 97.0 (women) g per day of red meat. After 5 years of follow-up, the cohort is expected to yield nearly 4,000 breast cancers, more than 10,000 prostate cancers, more than 4,000 colorectal cancers, and more than 900 pancreatic cancers. The large size and wide intake range of the cohort will provide ample power for examining a number of important diet and cancer hypotheses.

Medical records are generally accepted as the most accurate source of information documenting cancer treatments. However, as the health care system becomes more decentralized and more cancer care is delivered in outpatient settings, it is increasingly difficult and expensive to review records from the many surgeons and medical/radiation oncologists who administer cancer therapies in the community setting. Using 1994-1995 data, the authors compared initial treatment for prostate cancer self-reported (from a mailed questionnaire or telephone/in-person interview) by 3,196 US men in the population-based Prostate Cancer Outcomes Study with information obtained from medical records. Agreement between self-reports and medical records varied by type of treatment. Generally, agreement was excellent for more invasive procedures such as prostatectomy or radiation (kappa values > 0.8), with decreasing agreement for hormone shots and pills (kappa values < 0.7). If the medical record abstract is assumed to be the "gold standard," the estimated sensitivity was generally high (>80%) for prostatectomy and radiation but low (68%) for hormone pills, although the estimated specificity was 90% or greater for all treatments. These results can serve as a useful guide to researchers contemplating the use of surveys as an alternative to medical record abstraction to ascertain treatment in studies of patient outcomes.

Background: African-Americans have twice the risk of non-Hispanic whites for presenting with advanced-stage prostate cancer. To investigate the reasons for this difference, we evaluated the association between race/ethnicity and advanced-stage prostate cancer, adjusting for demographic, socioeconomic, clinical, and pathologic factors., Methods: A population-based cohort of 3173 men diagnosed with prostate cancer between October 1, 1994, and October 31, 1995, was analyzed. Medical record abstracts and self-administered survey questionnaires were used to obtain information regarding race/ethnicity, age, marital status, insurance status, educational level, household income, employment status, comorbidity, urinary function, prostate-specific antigen level, tumor grade, and clinical stage. The odds ratio (OR) for advanced-stage prostate cancer was estimated with weighted logistic regression analysis. All P: values were two-sided., Results: Clinically advanced-stage prostate cancers were detected more frequently in African-Americans (12.3%) and Hispanics (10.5%) than in non-Hispanic whites (6.3%). Socioeconomic, clinical, and pathologic factors each accounted for about 15% of the increased relative risk. After adjusting for all covariates, the risk remained statistically significantly increased for African-Americans (OR = 2.26; 95% confidence interval [CI] = 1.43 to 3.58) but not for Hispanics (OR = 1.23; 95% CI = 0.73 to 2.08)., Conclusion: Traditional socioeconomic, clinical, and pathologic factors accounted for the increased relative risk for presenting with advanced-stage prostate cancer in Hispanic but not in African-American men.

Purpose: During the 1980s and 1990s the number, incidence rate and proportion of moderately differentiated prostate cancer cases ascertained by population based cancer registries increased substantially. The increase is thought to have resulted from the widespread use of prostate specific antigen (PSA) for screening because it occurred coincidentally with the introduction of PSA for early detection of prostate cancer. We investigate this increase in a population based study., Materials and Methods: To report the trends in tumor grade we conducted a blinded, standardized pathological study and reviewed medial records of a stratified random sample of cases diagnosed before and after the introduction of PSA (1983 to 1984 and 1992 to 1993). Archival tumor biopsy specimens or transurethral resection of the prostate specimens were reviewed for the diagnosis of cancer and assignment of Gleason score. Medical records were reviewed to determine the method of prostate cancer detection for each case., Results: We found a small but statistically insignificant shift in the distribution of Gleason scores assigned after review of biopsy or transurethral resection specimens. The proportion of Gleason score 2, 3 and 4 tumors decreased, and the proportion of 7, 8, 9 and 10 tumors as a group did not change. The shifts in Gleason score resulted in a slight statistically nonsignificant increase in mean Gleason score. There was a significant shift in the method of detection from predominately incidental detection in the earlier period to predominately screen detection in the later period. Because the proportion of screen detected tumors increased and they had a significantly higher mean Gleason score than incidentally detected tumors within each interval, the overall mean Gleason score increased., Conclusions: After a standardized pathological review a small shift in the distribution of Gleason scores occurred resulting in a small increase in mean Gleason score between 1983 and 1984, and 1992 and 1993. There was little change in the proportion of Gleason score 7, 8, 9 and 10 tumors between the 2 periods.

Purpose: We determine the positive yield of imaging studies performed on men with newly diagnosed prostate cancer., Materials and Methods: A prospective, population based survey was conducted on 3,690 men with prostate cancer diagnosed between October 1, 1994 and October 31, 1995. Cases were identified by the rapid case ascertainment systems used in 6 geographic regions participating in the Surveillance, Epidemiology and End Results Program. Based on information captured in primary medical record reviews we estimated the positive yield of bone scans, computerized tomography (CT) and magnetic resonance imaging., Results: The positive yield of bone scan and CT was less than 5% and 12%, respectively, for all men with prostate specific antigen (PSA) 4 to 20 ng./ml., and less than 2% and 9%, respectively, for those who also had a Gleason score of 6 or less. Only men with PSA greater than 50 ng./ml. and those with Gleason scores 8 to 10 and PSA greater than 20 ng./ml. had positive yields greater than 10% and 20% for bone scan and CT, respectively., Conclusions: Imaging studies designed to identify metastases and/or extracapsular extension in men with newly diagnosed prostate cancer frequently have a low positive yield. Wide variations exist in the use of imaging studies and are associated with tumor factors, such as Gleason score and serum PSA, and nontumor factors, such as state of residence. More extensive cost-effectiveness analyses are needed to define appropriate guidelines for ordering imaging studies to optimize the positive yield among men with newly diagnosed prostate cancer.

Background: In addition to demographic and health care-related characteristics, the age and physiologic status of women at the time of breast cancer diagnosis have been reported to influence receipt of standard treatments. Previous studies of the influence of age and comorbidity have not examined whether other patient-, region-, or health care-related characteristics altered the association of age and comorbidity with type of treatment received., Purpose: This study examined factors associated with receipt of breast-conserving surgery and radiation therapy, both of which are recommended treatments for breast cancer, among a cohort of 18,704 women aged 65 years or more who had breast cancer diagnosed during the period from 1985 through 1989., Methods: A data file linking Medicare claims records to data from the Surveillance, Epidemiology, and End Results (SEER) Program of the U.S. National Cancer Institute was utilized. Logistic regression analysis was used to examine associations between patient, region, and hospital characteristics and the receipt of specific treatments. The likelihood test was used to assess the significance of observed associations (expressed as odds ratios [ORs]). Because of multiple comparisons, only those ORs with two-sided P values <.01 were considered statistically significant., Results: The frequency of breast-conserving surgery was highest (54%) among women aged 80 years or more, who had two or more comorbid conditions and stage I disease. However, in general, the receipt of radiation therapy among women undergoing breast-conserving surgery declined markedly with age, irrespective of comorbidity status and disease stage. Between the ages of 65-69 years and 80 years or older, radiation therapy declined from 77% to 24% among women with no comorbid conditions and from 50% to 12% among women with two or more comorbid conditions. In regression models that included hospital, region, and patient characteristics as variables, age and comorbidity remained independently associated with the receipt of radiation therapy (OR = 0.12 and 95% confidence interval [CI] = 0.10-0.14 for women aged 80 years or more compared with women 65-69 years of age and OR of 0.33 [95% CI = 0.24-0.46] for women with two or more comorbid conditions versus no comorbid conditions)., Conclusions: After adjustment for multiple clinical and nonclinical factors influencing treatment, chronologic age remains an important independent factor associated with the receipt of radiation therapy after breast-conserving surgery among women aged 65 years or more who were diagnosed with early stage breast cancer., Implications: Future studies should determine whether these differences in treatment patterns among older women result in increased morbidity (e.g., from recurrence), shortened disease-free or overall survival, or decreased quality of life.

To determine whether Black women with symptoms of uterine corpus cancer had longer times from symptom recognition to initial medical consultation than did White women in the United States, 331 newly diagnosed patients living in Atlanta (GA), New Orleans (LA), and San Francisco/Oakland (CA) during 1985-87 were interviewed to collect information on symptoms, dates of recognition and consultation, and other factors that might affect the interval. Data were analyzed to estimate medical consultation rates and rate ratios following symptom recognition. Median recalled times between symptom recognition and consultation were 16 days for Black women and 14 days for White women. Although poverty, having no usual source of healthcare, and other factors were associated with lower consultation rates, the adjusted rate among Black women was only somewhat lower (0.87) than among White women, and the 95 percent confidence interval (CI = 0.58-1.31) was consistent with no true difference between the races. In addition, the median time to consultation for women with stage IV cancer was only 15 days longer than the time (14 days) for the women with stage I cancer. These results suggest that time from symptom recognition to initial medical consultation does not contribute importantly to the more advanced stage cancer of the uterine corpus commonly found among Black women.

Objective: This study examined the relationship of clinicopathologic, health status, medical system, and socioeconomic factors to differences in stage at diagnosis of endometrial cancer in black and white patients., Study Design: A population-based study of 130 black and 329 white patients with invasive endometrial cancer was conducted as part of the National Cancer Institute's Black/White Cancer Survival Study. Logistic regression was used to determine the relative importance of factors thought to be related to stage at diagnosis after age and geographic location were adjusted for., Results: High-grade (poorly differentiated) lesions increased the risk for stage III or IV disease (odds ratio 8.3, 95% confidence interval 3.4 to 20.3), as did serous histologic subtype (odds ratio 3.5, 95% confidence interval 1.4 to 8.8) and no usual source of care (odds ratio 5.5, 95% confidence interval 1.4 to 20.9). In the final statistical model these three factors also accounted for the majority of the excess risk of advanced stage for blacks., Conclusions: Black-white racial disparities in stage at diagnosis appear to be related to higher-grade lesions and more aggressive histologic subtypes occurring more frequently in black patients with endometrial cancer.

Purpose: Black patients with colon cancer are more likely to have poorer survival from colon cancer than are white patients. To determine whether anatomic site differences might contribute to survival differences, we compared anatomic site distributions of black and white patients., Methods: As part of the Black/White Cancer Survival Study, we collected medical record data for 1,045 patients from Atlanta, New Orleans, and San Francisco/Oakland, newly diagnosed in 1985 or 1986 and interviewed 745 of them., Results: In polychotomous logistic regression analysis, site was related to stage, grade, and histologic type and among women with age, parity, and possibly smoking. However, it was not related to race, except perhaps among men age 65 and older, among whom blacks were somewhat likely to have more transverse and distal, not proximal, cancer. These relations were consistent across subgroups and were independent of other factors examined., Conclusion: Results suggest that site differences are unlikely to contribute to poorer survival commonly observed among black colon cancer patients in the United States.

Dietary guidelines posit an association between diet and cancer. Different cancer mortality rates among whites, blacks, and Hispanics may be related to differences in diet. Food frequency data from the 1987 National Health Interview Survey on 20,143 adults were used to estimate the percentage of adults, by gender and race/ethnicity, who consume some 59 foods six or more times per year, median number of servings for consumers, and frequency of consumption of skin on poultry and fat on red meat. On the basis of percent consumption of these foods, women appear to have a more diverse diet than men. Women eat more fruits and vegetables, less meat, and fewer high-fat foods and drink fewer alcoholic beverages. Whites eat a more varied diet than blacks and Hispanics; blacks eat more fried and high-fat food; consumption of high-fat foods is lowest among Hispanics. Public health messages, especially those aimed at cancer prevention, should be targeted at increasing the overall consumption of fruits and vegetables, decreasing consumption of high-fat foods, especially among white and black men, and increasing consumption of those healthful foods already consumed by particular race/ethnicity groups.

Background: This national study of breast cancer incidence and mortality was conducted to determine whether patterns of change differ for black and white women, to evaluate patterns by extent of disease, and to determine whether recent patterns of breast cancer are consistent with results that one would expect due to increases in use of screening examinations by women., Methods: The study included 104,351 cases of in situ or invasive breast cancer diagnosed between 1983 and 1989 among women from the nine geographic areas participating in the National Cancer Institute Surveillance, Epidemiology, and End Results program. Breast cancer incidence patterns were examined by extent of disease for black and white women and by age at diagnosis., Results: Significant increases occurred in the incidence of all early-stage breast cancers. Concomitantly, significant decreases occurred in the incidence of the most advanced-stage breast cancers. Although both white and black women experienced significant increases in early-stage breast cancer, black women have substantially lower rates of the least extensive breast cancers., Conclusions: These results strongly suggest that a major explanation for the increase in breast cancer incidence in the 1980s may well be the increased prevalence of breast cancer screening among women in the United States. They also suggest a consistent benefit of screening across all age groups from 40 to 49 years through 70 years and older.

Data from the Cancer Control Supplement of the 1987 Health Interview Survey (NHIS), a nationally representative sample of the United States population, was used to examine rates of six screening tests for cancer. The rates of screening were compared for people who receive their usual source of medical care in an HMO or prepaid group practice versus those who receive it in the fee-for-service sector. The purpose of this article is to determine whether HMOs remain more likely to offer cancer screening examinations than the fee-for-service sector. Results indicate that for five of six screening tests examined (Pap smear, mammography, breast physical examination, digital rectal examination, and blood stool test), members of HMOs are significantly more likely to have received the test within the last 3-year period. These results hold in a multivariate analysis when many factors correlated with selection into HMOs, health status, and use of medical services are controlled for, although results are only generalizable to whites. Future research should focus on why the rates for five of the six cancer screening tests examined are higher in HMO settings, and how we can use the HMO experience to improve consensus as to the usefulness of the tests in the non-HMO physician pool, and ultimately increase rates of screening tests in the non-HMO population.

This review of epidemiological studies has several general implications. First, the most relevant population data for extrapolation in providing public health or medical advice should come from intra-population studies, either observational or interventional. Second, the observational studies require follow-up with long-term intervention trials in representative segments of the population before broad pronouncements are made. Third, not all people respond uniformly to changes in the intake of a single electrolyte, at the levels that can be safely achieved in our society. Finally, there are clear indications of useful directions in which to alter dietary electrolytes, either singly or multiply, but the most effective, safe and achievable combinations of dietary change remain to be defined and tested over prolonged periods in naturalistic settings.

Heavy lead exposure has been connected to cardiovascular disease, but modest exposures encountered in the general environment have not been associated previously with disease risk. The relationship between blood lead levels and blood pressures was examined using data from the second National Health and Nutrition Examination Survey. A direct relationship was found between blood lead levels and systolic and diastolic pressures for men and women and for white and black persons aged 12 to 74 years. Blood lead levels were significantly higher in younger men and women (aged 21 to 55 years) with high blood pressure, but not in older men or women (aged 56 to 74 years). In multiple regression analyses, the relationship of blood lead to blood pressure was independent of other variables for men, but not for women. Dietary calcium and serum zinc levels were inversely related to blood pressure.

To evaluate the differential charges for treating end-stage renal disease (ESRD) associated with diabetes mellitus, Medicare billing data are analyzed. The charges of 244 patients in the Michigan Kidney Registry identified as having (ESRD) from diabetes are compared with charges of 902 nondiabetic patients. Average annual charges for ESRD treatment for diabetics are +29,671 (+/- 27,662) which are +4695 (+/- 1344) higher than charges for nondiabetics. The majority of the difference (84.3%) is attributable to higher inpatient hospital charges. Most of the remainder (14.5%) is attributable to higher physician and medical supply charges. Charges for treatment of diabetics are higher on all modalities of treatment, but differences are not significant among modalities.

The effects of labeling a person as hypertensive have important implications for hypertension screening. The Hypertension Detection and Follow-up Program (HDFP) provides an opportunity to examine the effects of labeling, treatment, and study assignment on a large group of hypertensives (n = 10,070). Their answers to questions regarding perceived health and general well-being asked at baseline and again one year later were analyzed. There was no significant change in the perceived health status of persons who were unaware of their hypertension at baseline and remained untreated at one year (labeling alone). The effect of labeling plus treatment was associated with a significant decrease in perceived health. The effect of antihypertensive drug therapy on perceived health status was examined in persons who were aware of their hypertension but not on treatment at baseline, and on treatment at one year. The stepped care group (SC) had a significant improvement in their perceived health and a significant decrease in the amount of time spent worrying about their health. The referred care group (RC) had no change. Program assignment effects were studied in individuals aware of their hypertension and on treatment both at baseline and one year later. Both the SC and RC groups had a significant improvement in their perceptions of their health status. The SC group had a significant decrease in time spent worrying about their health, while the RC group showed no change. These reassuring results fail to support the suggestion that labeling persons as hypertensive is necessarily followed by negative psychological consequences.(ABSTRACT TRUNCATED AT 250 WORDS)