The female athlete. The triad of disordered eating, amenorrhoea and osteoporosis

The value of routine follow-up programs for patients with early stage breast cancer remains an area of controversy. In recent years, the cost-effectiveness of routine investigations has been questioned, and 2 prospective randomized clinical trials have shown no survival advantage to more intensive diagnostic follow-up approaches. Under the auspices of the Ottawa Regional Cancer Centre, a national survey of the practice patterns of Canadian surgical, radiation and medical oncologists was undertaken to measure current Canadian standards of care and to determine average costs of 5-year follow-up for patients completing primary treatment for stage I and II breast cancer. Standardized questionnaires were sent out to 130 surgeons, 59 radiation oncologists and 89 medical oncologists. The overall response rate was 44%. Based on the frequency of follow-up visits and investigations recommended by respondents, an average cost per patient for a 5-year follow-up plan was derived for each subspecialist group: $791, $911 and $904 for surgeons, radiation oncologists and medical oncologists respectively. Use of a less interventionist follow-up program was estimated to result in a cost saving of $300 per patient over 5 years. The results indicate that, for the most part, Canadian oncologists have been influenced by the available literature concerning follow-up practices and are ordering fewer routine tests. Further cost savings to the Canadian health care system could be achieved with the adoption of even less interventionist follow-up programs.     

Analysis of Fusarium causing dermal toxicosis in marram grass planters

This study estimates the costs of clinical follow-up for women with early stage breast cancer and evaluates the effects of patient and provider characteristics on follow-up intensity. Claims data were cumulated from 1/1/89 through 4/30/93 for a comprehensive set of follow-up tests (office visits, radiologic, and laboratory) ordered for 222 women diagnosed at a university hospital between 1/1/89 and 12/31/91. Aggregated measures of the volume and costs of follow-up over 6 month intervals were expressed in terms of Medicare's 1993 relative value units (RVUs) and their 1993 cost equivalents. Excluding the first 6 months, women received on average, 11.7 RVUs of follow-up in the first year (equivalent to a cost of $362), and 9.5 RVUs in the second year ($297). In the first year, chest x-rays, clinical chemistry tests, automated hemograms, and bone scans, accounted for 36% of the cost of follow-up, while computerized tomographic scans and magnetic resonance imaging studies accounted for 30%. Multiple regression analysis of the first year data showed that women who received radiation and/or were followed by oncology, were more likely to receive intensive follow-up. Age, race, socioeconomic status, insurance, stage, and treatment did not impact follow-up. Costs of follow-up for breast cancer are substantial, though much lower than suggested by others. Additionally, wide variations in practice are largely unexplained by patient and/or provider characteristics. In light of recent evidence questioning the benefit of intensive surveillance, this study supports the need for an accepted set of follow-up guidelines for breast cancer.     

Attitudes of Canadian oncology practitioners toward psychosocial interventions in clinical and research settings in women with breast cancer

The aim of this study was to survey Canadian oncology practitioners' attitudes toward psychosocial concerns and issues in women with breast cancer. Surveys were mailed to 351 medical, radiation and surgical oncologists and 375 oncology nurses. Standard questionnaires assessed attitudes towards psychosocial issues in women with primary and metastatic breast cancer and evaluated the practitioners' willingness to refer women to psychosocial intervention trials in the presence and absence of competing drug trials. Responses were obtained from 74% of those surveyed. Respondents reported being aware of the common occurrence of psychosocial problems in women with metastatic breast cancer, however, physicians were less likely than nurses to offer these women psychosocial support on a prophylactic basis (p < 0.0001) and they expressed greater concern than nurses about scientific validity of (p = 0.0003), and potential psychological damage from (p = 0.005), psychosocial support groups. Nurses were more likely than physicians to favour a study investigating group psychosocial support over competing drug studies (p < or = 0.003) in the metastatic setting. Physicians were less likely than nurses to deal with weight problems prophylactically in women with primary breast cancer (p = 0.0009) and they expressed greater concern over scientific validity of psychosocial interventions addressing weight than nurses (p = 0.0008); nurses were more concerned about excessive expectations of patients regarding potential benefits of such interventions (p < 0.0001). Regardless, nurses were more likely than physicians to favour a psychosocial intervention study focused on weight management over drug studies in pre- (p = 0.0006) and postmenopausal women (p = 0.05) with primary breast cancer. Canadian oncology practitioners are aware of the common occurrence of psychosocial distress in women with breast cancer. Physicians and nurses assigned differing priorities to psychosocial interventions in both clinical and research situations.     

Utilization of outpatient diagnostic imaging. Does the physician's gender play a role?

OBJECTIVE: To examine physician and patient characteristics related to the ordering of imaging studies in a general medicine practice and to determine whether physician gender influences ordering patterns. DESIGN: Retrospective cohort study. SETTING: Hospital-based academic general medicine practice of 29 attending physicians. PATIENTS: All 8,203 visits by 5,011 patients during a 6-month period. METHODS: For each visit the following variables were abstracted from the electronic patient record: patient age, patient gender, visit urgency, visit type, and physician seen. All diagnostic imaging studies performed within 30 days of each outpatient visit were identified from the hospital's Radiology Information System. Screening mammography was not included in the analysis. Physician variables included gender and years since medical school graduation. Logistic regression analysis was used to evaluate the effect of various patient, physician, and visit characteristics on the probability of a diagnostic imaging study being ordered. RESULTS: Patient age, urgent visits, visit frequency, and the gender of the physician were all significantly related to the ordering of an imaging study. Correcting for all other factors, the ordering of an imaging study during an outpatient medical visit was 40% more likely if the physician was female (odds ratio = 1.40; 95% confidence interval [CI] 1.01, 1.95). Female physicians were 62% more likely (95% CI 0.99, 2.64) than male physicians to order an imaging study for a male patient and 21% more likely (95% CI 0.87, 1.69) to order an imaging study for a female patient. CONCLUSIONS: Physician gender is a predictor of whether an outpatient medical visit generates an imaging study. Reasons for this observation are unclear, but may be the result of different practice styles of male and female physicians or unmeasured patient characteristics.     

Progress of clinical oncology guidelines development using the Practice Guidelines Development Cycle: the role of practitioner feedback

PURPOSE: To present an update on the development of oncology practice guidelines (PGs) using the Practice Guidelines Development Cycle (Cycle), and to present the results of surveys of oncologists on the first 10 guidelines from the Cancer Care Ontario Practice Guidelines Initiative. METHODS: Practitioners' opinions about guidelines in development were sought using a mail survey method with systematic follow-up. Practitioners were identified by cancer center representatives. Survey packages included evidence-based recommendations (EBRs) and a one-page, nine-item feedback questionnaire. Data were collected between February 1995 and February 1996. RESULTS: Nine hundred fourteen surveys that pertained to 10 guidelines were mailed to 423 practitioners in Ontario. Practitioners included 112 medical oncologists/hematologists, 34 radiation oncologists, 195 surgeons, and 82 practitioners from other medical specialities. One hundred practitioners were located in cancer centers and 323 had community-based practices. The overall response rate by practitioner was 72% and by survey questionnaire, 70%. For the five questionnaire items that assessed guideline quality, approval ratings ranged from 86% to 92%. For the 10 recommendations, 77% ( 63% to 82%) of respondents agreed that the EBR could be approved as a PG. Response and approval rates were consistent across medical specialities and locations of practice. CONCLUSION: The process of obtaining practitioner feedback in the development of PGs is both feasible and useful. The high response rates to the survey indicate that it is possible to obtain broad participation in evidence-based guidelines development throughout Ontario. The changes made to the EBRs in response to feedback suggest that practitioners' opinions can be valuable in shaping evidence-based guidelines.     

Referral of patients with pain from pancreatic cancer for neurolytic celiac plexus block

OBJECTIVE: To assess whether patients with pancreatic cancer-associated pain living near a pain control center were more likely to undergo neurolytic celiac plexus block (NCPB) than those living at a distance and to determine the rationale of physicians at our institution for referring patients for NCPB. DESIGN: We retrospectively reviewed the frequency of use of NCPB in patients with pancreatic cancer and conducted an anonymous physician survey of referral patterns for NCPB for such patients. MATERIAL AND METHODS: A prospective database of medical diagnoses and a clinical database at our institution were used to identify patients with pancreatic cancer within three geographic regions who were assessed during the inclusive years 1980 through 1989: group I ("local") = all patient with pancreatic cancer in Olmsted County, Minnesota; group II ("surrounding") and group III ("distant") = patients referred for pancreatic cancer evaluation who lived within 100 miles of our institution (excluding Olmsted County) or more than 100 miles from our institution, respectively. Medical records were retrospectively reviewed to assess the use of NCPB at any time during the course of pancreatic cancer. For the physician survey component, all medical oncologists, gastroenterologists, and general surgeons at our institution who might be responsible for the care of patients with pancreatic cancer were sent a questionnaire about their referral patterns for NCPB among patients with pancreatic cancer. RESULTS: Overall, approximately 15% of the 292 patients with pancreatic cancer studied underwent NCPB. Distance from our pain control center was not found to be associated with frequency of use of NCPB. Of the 78 physicians surveyed, 59 (76%) responded, and 35 of the responders (59%) had encountered at least 1 patient with pancreatic cancer during the preceding 12 months. In that subset of physicians, perceived barriers for referral for NCPB were limited appointment availability and need for repeating the procedure. CONCLUSION: On the basis of this study, referral patterns for NCPB in patients with pancreatic cancer do not seem to be associated with the geographic distance of a patient's residence from a pain control center. Improving appointment availability for NCPB might increase the number of patients offered this technique for control of pain.     

A population-based study of contralateral breast cancer following a first primary breast cancer (Washington, United States)

To evaluate predictors of contralateral breast cancer risk, we examined data from a nested case-control study of second primary cancers among a cohort of women in western Washington (United States) diagnosed with breast cancer during 1978 through 1990 and identified through a population-based cancer registry. Cases included all women in the cohort who subsequently developed contralateral breast cancer at least six months after the initial diagnosis, but prior to 1992 (n = 234). Controls were sampled randomly from the cohort, matched to cases on age, stage, and year of initial breast cancer diagnosis. Information on potential risk factors for second primary cancer was obtained through medical record abstractions and physician questionnaires. Women who were postmenopausal due to a bilateral oophorectomy (i.e., a surgical menopause) at initial breast cancer diagnosis had a reduction in contralateral breast cancer risk compared with premenopausal women (matched odds ratio [mOR] = 0.25, 95 percent confidence interval [CI] = 0.09-0.68), whereas no reduction in risk was noted among postmenopausal women who had had a natural menopause (mOR = 0.90, CI = 0.39-2.09). Among postmenopausal women, there was a suggestion of a lower risk associated with relatively high parity (2+). A family history of breast cancer was associated with an increased risk (mOR = 1.96, CI = 1.22-5.15) and varied little by menopausal status. Having an initial tumor with a lobular component (c.f. a ductal histology) was not related strongly to risk (mOR = 1.47, CI = 0.79-2.74). The results of the present and earlier studies argue that we have limited ability to predict the occurrence of a contralateral breast tumor. Better predictors will be required before diagnostic and preventive interventions can be targeted to subgroups of patients with unilateral breast cancer.     

1997 American Urological Association Gallup survey: Changes in diagnosis and management of prostate cancer and benign prostatic hyperplasia, and other practice trends from 1994 to 1997

PURPOSE: The American Urological Association first commissioned the Gallup Organization to conduct a study to assess urologist practice patterns in 1992. We present the results of the 1997 survey, the sixth consecutive Gallup survey performed for the Association. MATERIALS AND METHODS: A random sample of 502 American urologists who had completed urological residency and practiced at least 20 hours weekly in 1996 was interviewed by telephone in February and March 1997. RESULTS: Emerging trends showed significant changes since 1994 in how urologists diagnosed and treated prostate cancer. The survey revealed a significant change in the tests routinely ordered to stage newly diagnosed prostate cancer and for diagnostic evaluation of patients with benign prostatic hyperplasia. CONCLUSIONS: Urologists are becoming more cost conscious and effective in ordering pretreatment testing. Urologists are becoming more oriented toward medical treatment for the management of benign prostatic hyperplasia, and less laser surgery is being performed.     

Improving utilization of breast and cervical cancer screening in your office practice

It has been well documented that early detection and early intervention for breast and cervical cancer saves lives. However, the challenge is to ensure that physicians' practices are effective in implementing the standard guidelines for screening and that all women are screened and undergo appropriate follow-up. Early detection and intervention are imperative since African-American women are twice as likely as European-American women to die from breast cancer even though the incidence of breast cancer is lower. African-American women have fewer mammograms and are being diagnosed later after metastases have occurred. Studies also show that women are more likely to have mammograms if their physicians so advise. However, the most common reason women give for not obtaining mammograms is, "My doctor never recommended it." By using a simple critical path analysis tool to systematically evaluate an office practice and by implementing practical, simple principles, a physician can increase utilization of breast and cervical cancer screening.     

Purification of the porcine platelet GP IIb-IIIa complex and the propolypeptide of von Willebrand factor

BACKGROUND: In response to the importance of early stage breast carcinoma as a public health concern and to the complexity of the clinical literature devoted to treatment of the disease, the National Institutes of Health has held a series of Consensus Development Conferences on the treatment of early stage breast carcinoma. The authors assessed compliance with standards of care for women treated in two states. METHODS: The authors identified patients diagnosed at 18 randomly selected hospitals (N = 1514) in Massachusetts and at 30 hospitals (N = 1061) in Minnesota. They collected data from medical records, patients, and their surgeons to assess compliance with four indicators of quality of care: radiation therapy after breast-conserving surgery, axillary lymph node dissection, chemotherapy for premenopausal women with positive lymph nodes, and hormonal therapy for postmenopausal women with positive lymph nodes and positive estrogen receptor status. RESULTS: Rates of compliance for 3 of the 4 standards of care were > 80% in both states. Only the rate for hormonal therapy for postmenopausal women was low (< 64%). However, the proportion of these women who received either chemotherapy or hormonal therapy was > 90% in both states. CONCLUSIONS: In the states studied, practice appears to be consistent with the results of national consensus conferences and clinical trials regarding the treatment of early stage breast carcinoma. For practices demonstrated to be associated definitively with better outcomes (for example, chemotherapy for premenopausal women with positive lymph nodes) or to be important with respect to prognosis (axillary lymph node dissection) high rates of compliance were observed.     

Social support and survival among women with breast cancer

BACKGROUND: Two recently reported randomized trials, one among patients with advanced breast cancer and the other among patients with early stage melanoma, suggested that social support may affect survival favorably. This study assesses relationships of social support indicators with 7-year survival among women diagnosed with localized or regional stage breast cancer. METHODS: All newly diagnosed patients with surgically treated localized or regional disease in seven Quebec City hospitals in 1984 were considered for this analysis. Among 235 eligible patients, 224 (95%) participated in a home interview 3 months after surgery. This interview provided information on the use of confidants in the 3 months after surgery. Data on disease and treatment characteristics were abstracted from patients' medical records. RESULTS: Compared with women who used no confidant in the 3 months after surgery, the hazard ratio for the 7-year period was 0.61 (95% confidence interval [CI], 0.33-1.12) among those who had used at least one confidant, 0.54 (95% CI, 0.28-1.06) in women who used two or more types of confidant, and 0.51 (95% CI, 0.22-1.18) among those whose confidants included either physician or nurse. These results were adjusted for age, presence of invaded axillary lymph nodes, adjuvant radiotherapy, and adjuvant systemic therapy (hormone or chemotherapy). CONCLUSION: These results support the view that social support may be associated with longer survival among women with localized or regional stage breast cancer.     

Congenital toxoplasmosis and seroconversion at the end of pregnancy: clinical observations

OBJECTIVE: To determine the knowledge of HIV-disease management and the adherence to contemporary guidelines among British Columbia physicians whose practices focused on HIV/AIDS. DESIGN: Self-administered mail survey. PARTICIPANTS: All 659 physicians registered in a province-wide HIV/AIDS drug treatment program. OUTCOME MEASURES: Data on demographic and personal characteristics of respondents, level of HIV-related experience, use of preventive vaccinations and tests, and preferred approaches to the prophylaxis and treatment of common opportunistic infections. Knowledge scores in 4 areas of patient care, as well as an overall score, were computed by comparing respondents' answers with the therapeutic strategies recommended at the time of the survey. Associations between physician characteristics and knowledge scores were identified by linear regression analysis. RESULTS: Of the 659 physicians surveyed, 65% returned responses: only 38% returned completed surveys while a further 27% returned a follow-up survey that asked nonrespondents about their demographic characteristics and HIV-related experience. Scores for specific areas of patient management ranged from 29% for the treatment of opportunistic infections to 62% for preventive measures, with a mean overall score of 47%. Physician knowledge in all areas of patient care was associated with the number of HIV-positive patients in the practice (p = 0.003 to p < 0.001). Physicians who were younger were more knowledgeable regarding preventive measures (p = 0.001); those whose practice location was in Vancouver had a greater knowledge of prophylaxis (p = 0.047); and those who had medical specialty training were more knowledgeable about the treatment of opportunistic infections (p = 0.009). CONCLUSIONS: There is substantial disparity in how physicians approach the management of HIV and related conditions. Deviations from therapeutic guidelines are common and may be associated with physician characteristics, particularly lack of experience in managing HIV.     

KSA antigen Ep-CAM mediates cell-cell adhesion of pancreatic epithelial cells: morphoregulatory roles in pancreatic islet development

STUDY OBJECTIVES: To analyze variation in beliefs that potentially motivate thoracic surgeons in the design of posttreatment surveillance strategies for lung cancer patients and to examine the relationship between motivation and follow-up intensity. DESIGN: International survey. SETTING: Ambulatory care. PARTICIPANTS: All 3,700 members of the Society of Thoracic Surgeons were surveyed to measure their follow-up practices during the 5-year period after treatment, physician beliefs, and variation in these beliefs. The relationship between beliefs, as potentially motivating factors, and follow-up intensity was also analyzed. MEASUREMENTS AND RESULTS: Age, General Thoracic Surgery Club membership, percentage of practice that was noncardiac, South Central United States practice location, and overseas practice location were most frequently related to beliefs that potentially motivate physicians in the design of surveillance strategies. When viewed independently of follow-up practice patterns, thoracic surgeons appear to be motivated by the desire to please patients, avoid malpractice suits, and improve patient quality of life. When viewed in relation to self-reported follow-up, none of these motivating factors were consistently associated with follow-up intensity. Belief in curative treatment of recurrence and enhanced likelihood of immediate palliative treatment leading to improved survival were the factors most frequently associated with variation in follow-up. Although the ability of the logistic and stepwise regression models to predict test use and follow-up intensity was less than optimal for TNM stage I patients, predictive ability was substantially improved for TNM stage II and III patients by including earlier-stage practice patterns as an independent variable. CONCLUSIONS: Physician characteristics and beliefs predicted a less than expected amount of the variation in self-reported follow-up intensity by TNM stage when modelled without knowledge of follow-up practice for any other TNM stage. Discrepancies between self-reported and actual follow-up may be partially responsible, although lack of surveillance guidelines is more likely. The inclusion of barriers to follow-up may improve future models.     

Preventive care for women. Does the sex of the physician matter?

BACKGROUND: Emphasis on ensuring women's access to preventive health services has increased over the past decade. Relatively little attention has been paid to whether the sex of the physician affects the rates of cancer screening among women. We examined differences between male and female physicians in the frequency of screening mammograms and Pap smears among women patients enrolled in a large Midwestern health plan. METHODS: We identified claims for mammography and Pap tests submitted by primary care physicians for 97,962 women, 18 to 75 years of age, who were enrolled in the health plan in 1990. The sex of the physician was manually coded, and the physician's age was obtained from the state licensing board. After identifying a principal physician for each woman, we calculated the frequency of mammography and Pap smears for each physician, using the number of women in his or her practice during 1990 as the denominator. Using unconditional logistic regression, we also calculated the odds ratio of having a Pap smear or mammogram for women patients with female physicians as compared with those with male physicians, controlling for the physician's and the patient's age. RESULTS: Crude rates for Pap smears and mammography were higher for the patients of female than male physicians in most age groups of physicians. The largest differences between female and male physicians were in the rates of Pap smears among the youngest physicians. For the subgroup of women enrolled in the health plan for a year who saw only one physician, after adjustment for the patient's age and the physician's age and specialty, the odds ratio for having a Pap smear was 1.99 (95 percent confidence interval, 1.72 to 2.30) for the patients of female physicians as compared with those of male physicians. For women 40 years old and older, the odds ratio for having a mammogram was 1.41 (95 percent confidence interval, 1.22 to 1.63). For both Pap smears and mammography, the differences between female and male physicians in screening rates were much more pronounced in internal medicine and family practice than in obstetrics and gynecology. CONCLUSIONS: Women are more likely to undergo screening with Pap smears and mammograms if they see female rather than male physicians, particularly if the physician is an internist or family practitioner.     

Detection of the first recurrence during intensive follow-up of breast cancer patients

BACKGROUND: Breast cancer patients are routinely followed after primary treatment. Many intensive diagnostic methods (tumor markers, chest X-ray, mammography, liver echography, bone scans) are performed periodically. However, it remains to be determined how often attempts should be made to detect the first recurrence of breast cancer by these methods. METHODS: To evaluate the effect of imaging diagnosis and tumor markers, we analyzed methods of detection of first recurrence sites during intensive follow-up of breast cancer patients. RESULTS: Of 550 female patients who had been surgically treated between July 1992 and December 1996, 65 recurrent cases had been diagnosed as of December 1997. Thirty cases (46%) had been found as a result of symptoms related to the site of recurrence and 14 cases (22%) were detected by physical examination. In the remaining 21 cases (32%), detection was by other methods: in eight cases by imaging diagnosis, in three cases based on abnormal tumor markers and in 10 cases by imaging diagnosis and abnormal tumor markers. Twenty-nine cases (45%) followed every 1-3 months had presented with symptoms at routine or interval appointments. There was a significant difference between first recurrence sites (loco-regional, bone and viscera) and the methods of detection (symptoms, physical examination and other diagnostic methods) (P < 0.0001). However, no statistical difference in overall survival after operation was observed between the 30 cases found as a result of symptoms and the 35 cases detected by physical examination or other diagnostic methods. CONCLUSIONS: Taken together with ASCO's surveillance guidelines (J Clin Oncol 1997;15:2149-56), intensive follow-up of breast cancer patients should be limited to high-risk breast cancer patients, especially those who enter randomized clinical trials. A careful history and physical examination are in practice indicated every 3-6 months for 3 years and then every 6 months for the following 2 years.     

Patients' trust in their physicians: effects of choice, continuity, and payment method

OBJECTIVE: To evaluate the extent to which physician choice, length of patient-physician relationship, and perceived physician payment method predict patients' trust in their physician. DESIGN: Survey of patients of physicians in Atlanta, Georgia. PATIENTS: Subjects were 292 patients aged 18 years and older. MEASUREMENTS AND MAIN RESULTS: Scale of patients' trust in their physician was the main outcome measure. Most patients completely trusted their physicians "to put their needs above all other considerations" (69%). Patients who reported having enough choice of physician (p < .05), a longer relationship with the physician (p < .001), and who trusted their managed care organization (p < .001) were more likely to trust their physician. Approximately two thirds of all respondents did not know the method by which their physician was paid. The majority of patients believed paying a physician each time a test is done rather than a fixed monthly amount would not affect their care (72.4%). However, 40.5% of all respondents believed paying a physician more for ordering fewer than the average number of tests would make their care worse. Of these patients, 53.3% would accept higher copayments to obtain necessary medical tests. CONCLUSIONS: Patients' trust in their physician is related to having a choice of physicians, having a longer relationship with their physician, and trusting their managed care organization. Most patients are unaware of their physician's payment method, but many are concerned about payment methods that might discourage medical use.     

Shared management of children with cancer

OBJECTIVE: To determine the risks and benefits of university-based pediatric oncologists and community-based primary care physicians sharing the management of children with cancer. DESIGN: Physicians participating in shared management of children with cancer were surveyed, and the outcomes of the children were measured. SETTING AND PARTICIPANTS: One hundred thirty-seven community-based primary care physicians participated in the management of the 226 children with cancer in Iowa and western Illinois during the past 15 years. The survival of the 226 children was compared with that of 240 randomly selected children treated using the identical treatment protocols but treated only by pediatric oncologists. INTERVENTION: A 7-point Likert scale questionnaire was completed by 97 (71%) of the participating primary care physicians. RESULTS AND OUTCOME MEASURES: There were no differences in the survival of children using shared management compared with those treated only by pediatric oncologists. Primary care physicians believed that shared management is of economic and psychosocial benefit to patients, improves the treatment choices available to patients, does not require excessive time, and does not result in loss of practice income. The system strengthens the primary care physicians' relationships with oncologists and results in additional referrals to the university-based pediatric oncologists. It is of educational value, is personally satisfying, and provides relief from the stress associated with caring for these families. Primary care physicians would like to see this system expanded to include other children with special health care needs. CONCLUSION: The shared-management approach to care is a viable attractive option of health care provision for children.     

Hormone replacement therapy in women with breast cancer. Do the risks outweigh the benefits?

PURPOSE: To review critically the literature regarding effects of estrogen replacement therapy (ERT)/combined estrogen and progesterone replacement therapy (HRT) on the risk of breast cancer and on other health risks and benefits in postmenopausal women, with a focus on risks and benefits in women with a previous diagnosis of breast cancer. METHOD: A literature search was conducted using Medline, Cancerline, and the bibliographies of reports published as of March 1995. All five published meta-analyses that examined the risk of breast cancer in relation to ERT/HRT in otherwise healthy women were critically reviewed. All known reports of women with a history of breast cancer given ERT/HRT subsequent to diagnosis and additional reports regarding the benefits of ERT/HRT were also reviewed. RESULTS: None of the five meta-analyses demonstrated a significantly increased risk of developing breast cancer in ever users compared with never users of ERT/HRT. Current use may be associated with a small increased risk. This increased risk should be balanced by the expected benefits of ERT/HRT on quality of life, bone metabolism, and cardiovascular function. Preliminary information does not suggest a major detrimental effect of ERT/HRT in women with a previous diagnosis of breast cancer, but these reports include few women with limited follow-up data. There are no randomized trials in women with a previous diagnosis of breast cancer. CONCLUSION: In healthy postmenopausal women, the benefits associated with ERT/HRT outweigh the risks. In women with a previous diagnosis of breast cancer, the balance of risks and benefits should be explored in randomized controlled trials.     

Conservation surgery for breast cancer: selection criteria and technical considerations

Patients with stage I or II breast cancer are candidates for either modified radical mastectomy or breast preservation therapy involving limited resection of the primary tumor, axillary dissection, and breast irradiation. The overall survival rates of both these approaches are comparable according to retrospective reviews and ongoing clinical trials, and long-term follow-up confirms the earlier findings. Thus, patients should be given the choice between these two options by surgeons, radiation therapists, and other physicians involved in their care. However, not all breast cancer patients will choose breast preservation surgery, and because of tumor-related and other factors not all patients are candidates. The patient selection criteria are discussed herein and the optimal surgical techniques are reviewed.     

Diabetes care for Medicare beneficiaries. Attitudes and behaviors of primary care physicians

OBJECTIVE: To obtain information related to primary care physician (PCP) attitudes, knowledge, and practice patterns, as well as perceptions about barriers to care and the use of materials to assist in the delivery of diabetes care for elderly patients in the office setting. RESEARCH DESIGN AND METHODS: A survey was mailed to a random sample (n = 900) of PCPs (internal medicine, family practice, and general practice physicians and endocrinologists) from the states of Alabama, Iowa, and Maryland who met selection criteria and provided diabetes care to > or = 25 Medicare beneficiaries during calendar year 1993. RESULTS: Respondents provided self-reported information regarding diabetes care for elderly patients. PCP respondents (n = 370) considered blood glucose control to be the most important treatment goal. Most respondents (92%) considered acceptable GHb values to be those < 8%. Blood pressure measurement and foot inspections for the detection of ulcers and infection were the most commonly reported routine procedures performed as part of an office visit. Laboratory tests reported to be frequently ordered included GHb, serum creatinine, and proteinuria tests. Patient nonadherence to the treatment regimen was reported to be the most common barrier to care. The majority of respondents reported using two treatment aids in caring for patients with diabetes. CONCLUSIONS: The results of this study provide some evidence that PCP self-reported attitudes, knowledge, and practice patterns in delivering diabetes care for elderly patients in the office setting more closely reflect current recommended practice than reported in previous physician surveys. Opportunities for improvement still exist.