Slightly less than half of early-stage breast cancer patients complete their full prescribed course of hormone therapy, finds a new study.
U.S. researchers examined the automated pharmacy records of 8,769 women diagnosed with stage 1, 2 or 3 hormone-sensitive breast cancer between 1996 and 2007. Each woman filled at least one prescription for hormone therapy within a year of breast cancer diagnosis. The women used tamoxifen (43 percent), aromatase inhibitors (26 percent) or both (30 percent).
Overall, only about 49 percent of the women completed their full prescribed regimen of hormone therapy, the study found. After 4.5 years, 32 percent of the women had stopped taking their hormone therapy. Of those who did not stop, 72 percent finished on schedule (meaning they took their medication more than 80 percent of the time).
Those most likely to discontinue hormone therapy early were found to be women younger than 40. Among these women and women older than 75, those who had a lumpectomy rather than a mastectomy and those who had other medical illnesses were more likely to discontinue the therapy. Those most likely to complete 4.5 years of hormone therapy were Asian/Pacific Islanders, women who'd undergone chemotherapy in the past, those who were married and women who had longer prescription refill intervals.
In general, the researchers said, women stop hormone therapy early for a variety of reasons, including such side effects such as joint pain, hot flashes and fatigue; a lack of understanding about the benefits of the therapy; and the high cost of medications and insurance co-payments.
"Physicians are often unaware of patient compliance, and this is becoming an increasingly important issue in cancer," the study's leader, Dr. Dawn Hershman, an associate professor of medicine and epidemiology at Columbia University Medical Center, said in a news release from the Journal of Clinical Oncology. The study appears online June 28 in the journal.
"It's very disturbing that patients under 40 had the highest discontinuation rates because those patients have the longest life expectancy," Hershman said. "If we can better understand the issues surrounding compliance with hormonal therapy, this might help us understand why patients don't adhere to other treatments that are moving out of the clinic and into the home, such as oral chemotherapy, as often as we would like."
SOURCE: Journal of Clinical Oncology, June 28, 2010, news release.
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Showing posts with label patients. Show all posts
Showing posts with label patients. Show all posts
20100705
Comparative Effectiveness of Nonoperative and Operative Treatments for Rotator Cuff Tears Part 4
Results
Description of Included Studies
The search strategy identified 5,677 citations; 137 unique studies met the eligibility criteria and were included in the review. The studies included 27 trials, 39 cohort studies, and 71 uncontrolled studies. The number of participants in the studies ranged from 12 to 224 (median=55 [IQR: 33 to 93]). The mean age of study participants ranged from 41.2 to 80 years.
Methodological Quality of Included Studies
All the randomized controlled trials and controlled clinical trials were considered to have a high risk of bias. The most common sources of potential bias were inadequate blinding, inadequate allocation concealment, and incomplete outcome data. The methodological quality of the cohort studies was moderate, with a median score of 5 stars on a possible score of 8 stars (IQR: 4 to 6). Common weaknesses in the design of the studies included lack of independent blind outcome assessment and failure to control adequately for potential confounding factors. Uncontrolled studies generally had moderate quality, with consecutive enrollment, adequate followup, and standardized outcome assessment being reported in 63 percent, 77 percent, and 44 percent of studies, respectively. Across all studies, a source of funding was rarely reported (n=49, 36 percent).
Results of Included Studies
The results of the included studies are presented by the key question(s) they address. A table with the summary of findings for nonoperative and operative interventions is presented below.
Key Question 1: Early versus late surgical repair. One study compared early surgical repair versus late surgical repair after failed nonoperative treatment. Patients receiving early surgery had superior function compared with the delayed surgical group; however, the level of significance was not reported.
Key Question 2: Comparative effectiveness of operative interventions and postoperative rehabilitation. A total of 113 studies examined the effectiveness of operative interventions, while 11 studies evaluated postoperative rehabilitation protocols following surgery. A median of 55 patients (IQR: 34 to 95) with a median age of 58.6 years (IQR: 55.5 to 61.7) were included in the operative studies. Males comprised an average of 64.6 percent of study participants. For postoperative rehabilitation, studies included a median of 61 participants (IQR: 36 to 79.5) with a median age of 58.0 years (IQR: 56.3 to 60.8). Males comprised an average of 58.9 percent of study participants.
Studies assessing operative treatments were categorized as focusing on an operative approach (e.g., open, mini-open, arthroscopic, and debridement), technique (i.e., suture or anchor type or configuration) or augmentation for RC repair. The majority of surgical studies (32 comparative studies and 58 uncontrolled studies) evaluated operative approaches. The comparative studies provided moderate evidence indicating no statistical or clinically important differences in function between open and mini-open repairs; however, there was some evidence suggesting an earlier return to work by approximately 1 month for mini-open repairs. Similarly, there was moderate evidence demonstrating no difference in function between mini-open and arthroscopic repair and arthroscopic repair with and without acromioplasty. There was moderate evidence for greater improvement in function for open repairs compared with arthroscopic debridement. The strength of evidence was low for the remaining comparisons and outcomes examined in the studies, precluding any conclusions regarding their comparative effectiveness. The uncontrolled studies consistently reported functional improvement from preoperative to postoperative scores, regardless of the type of approach used (open, mini-open, or arthroscopic), the study design, the sample size of the study, or the type of outcome measure used.
Operative techniques were examined in 15 comparative studies. Six studies compared single-row versus double-row fixation of repairs, providing moderate evidence of no clinically significant difference in function and no difference in cuff integrity. There was moderate evidence for no difference in cuff integrity between mattress locking and simple stitch. The evidence was too limited to make conclusions about the other techniques.
Eight studies, including three comparative and five uncontrolled studies, assessed augmentations for operative repair. The three comparative studies were relatively small and no overall conclusions were possible. Although the five uncontrolled studies evaluated different types of augmentation, they all indicated improvement in functional score from baseline to final followup.
Of the 11 postoperative rehabilitation studies (10 comparative, 1 uncontrolled), 3 compared continuous passive motion with physical therapy versus physical therapy alone. These three studies provided moderate evidence of no clinically important or statistically significant difference in function, but some evidence for earlier return to work with continuous passive motion. Each of the remaining studies examined different rehabilitation protocols; therefore, the evidence was too limited to make any conclusions regarding their comparative effectiveness.
Key Question 3: Comparative effectiveness of nonoperative interventions. Nonoperative interventions were examined in three comparative and seven uncontrolled studies. The studies included a median of 42 patients (IQR: 25.3 to 73.3), with a median age of 61 years (IQR: 60.4 to 61.5). Males comprised an average of 50 percent of participants. Each of the comparative studies assessed different interventions, including: sodium hyaluraonate versus dexamethasone; rehabilitation versus no rehabilitation (not otherwise specified); and physical therapy, oral medications, and steroid injection versus physical therapy, oral medications, and no steroid injection. The limited evidence precludes conclusions of comparative effectiveness. The degree of improvement in functional outcome scores varied considerably across the uncontrolled studies.
Key Question 4: Comparative effectiveness of nonoperative versus operative interventions. Five studies compared nonoperative to operative treatments, with a median sample size of 103 (IQR: 40 to 108). The mean ages in the studies ranged from 46.8 to 64.8 years. Males represented 55 percent of study participants. The interventions varied across studies, but generally the nonoperative arms included components such as steroid injection, stretching, and strengthening and were compared with open repair or debridement. The evidence was too limited to make conclusions regarding the comparative effectiveness of the interventions.
Key Question 5: Complications. A total of 85 studies provided data on 34 different complications of nonoperative, operative, and postoperative rehabilitation interventions. Complications were poorly reported, with studies providing limited information on how complications were defined and assessed. In 21 studies, it was reported that no complications occurred during the course of the study. In general, the rates of complication were low and the majority of complications were not deemed to be clinically important or were reported in few studies.
Key Question 6: Prognostic factors. Overall, 72 of the 137 studies examined the impact of prognostic factors on patient outcomes. General conclusions are limited, due to the varied methodologies across studies, particularly the different outcomes for which prognostic factors were evaluated. There is some evidence that tear size, age, and extent of preoperative symptoms may modify outcomes; while, workers’ compensation board (WCB) status, sex, and duration of symptoms generally showed no significant impact.
The following table summarizes the findings of the studies and indicates the overall strength of the evidence on each topic examined.
Summary of strength of evidence for nonoperative and operative interventions for RC tears
See Summary of strength of evidence for nonoperative and operative interventions for RC tears
Source: Summary of strength of evidence for nonoperative and operative interventions for RC tears
Table of Contents
Comparative Effectiveness of Nonoperative and Operative Treatments for Rotator Cuff Tears
Comparative Effectiveness of Nonoperative and Operative Treatments for Rotator Cuff Tears Part 2
Key Questions
The following key questions (KQ) were investigated for a population of adult patients with partial- and full-thickness RC tears:
1. Does early surgical repair compared to late surgical repair (i.e., nonoperative intervention followed by surgery) lead to improved health-related quality of life, decreased disability, reduced time to return to work/activities, higher rate of cuff integrity, less shoulder pain, and increased range of motion and/or strength?
2. What is the comparative effectiveness of operative approaches (e.g., open surgery, mini-open surgery, and arthroscopy) and postoperative rehabilitation on improved health-related quality of life, decreased disability, reduced time to return to work/activities, higher rate of cuff integrity, less shoulder pain, and increased range of motion and/or strength?
* Which operative approach should be used for different types of tears (e.g., partial-thickness or full-thickness; small, medium, large, or massive; with or without fatty infiltration of muscle tissue)?
3. What is the comparative effectiveness of nonoperative interventions on improved health-related quality of life, decreased disability, reduced time to return to work/activities, higher rate of cuff integrity, less shoulder pain, and increased range of motion and/or strength? Nonoperative interventions include, but are not limited to, exercise, manual therapy, cortisone injections, acupuncture, and treatments and modalities typically delivered by physical therapists, osteopaths, and chiropractors.
* Which nonoperative treatment approach should be used for different types of tears (e.g., partial-thickness, full-thickness; small, medium, large, or massive; with or without fatty infiltration of muscle tissue)?
4. Does operative repair compared with nonoperative treatment lead to improved health-related quality of life, decreased disability, reduced time to return to work/activities, higher rate of cuff integrity, less shoulder pain, and increased range of motion and/or strength?
5. What are the associated risks, adverse effects, and potential harms of nonoperative and operative therapies?
6. Which demographic (e.g., age, gender, ethnicity, comorbidities, workers’ compensation claims) and clinical (e.g., size/severity of tear, duration of injury, fatty infiltration of muscle) prognostic factors predict better outcomes following nonoperative and operative treatment?
* Which (if any) demographic and clinical factors account for potential differences in surgical outcomes between patients who undergo early versus delayed surgical treatment?
Source: Summary of strength of evidence for nonoperative and operative interventions for RC tears
Table of Contents
The following key questions (KQ) were investigated for a population of adult patients with partial- and full-thickness RC tears:
1. Does early surgical repair compared to late surgical repair (i.e., nonoperative intervention followed by surgery) lead to improved health-related quality of life, decreased disability, reduced time to return to work/activities, higher rate of cuff integrity, less shoulder pain, and increased range of motion and/or strength?
2. What is the comparative effectiveness of operative approaches (e.g., open surgery, mini-open surgery, and arthroscopy) and postoperative rehabilitation on improved health-related quality of life, decreased disability, reduced time to return to work/activities, higher rate of cuff integrity, less shoulder pain, and increased range of motion and/or strength?
* Which operative approach should be used for different types of tears (e.g., partial-thickness or full-thickness; small, medium, large, or massive; with or without fatty infiltration of muscle tissue)?
3. What is the comparative effectiveness of nonoperative interventions on improved health-related quality of life, decreased disability, reduced time to return to work/activities, higher rate of cuff integrity, less shoulder pain, and increased range of motion and/or strength? Nonoperative interventions include, but are not limited to, exercise, manual therapy, cortisone injections, acupuncture, and treatments and modalities typically delivered by physical therapists, osteopaths, and chiropractors.
* Which nonoperative treatment approach should be used for different types of tears (e.g., partial-thickness, full-thickness; small, medium, large, or massive; with or without fatty infiltration of muscle tissue)?
4. Does operative repair compared with nonoperative treatment lead to improved health-related quality of life, decreased disability, reduced time to return to work/activities, higher rate of cuff integrity, less shoulder pain, and increased range of motion and/or strength?
5. What are the associated risks, adverse effects, and potential harms of nonoperative and operative therapies?
6. Which demographic (e.g., age, gender, ethnicity, comorbidities, workers’ compensation claims) and clinical (e.g., size/severity of tear, duration of injury, fatty infiltration of muscle) prognostic factors predict better outcomes following nonoperative and operative treatment?
* Which (if any) demographic and clinical factors account for potential differences in surgical outcomes between patients who undergo early versus delayed surgical treatment?
Source: Summary of strength of evidence for nonoperative and operative interventions for RC tears
Table of Contents
Comparative Effectiveness of Nonoperative and Operative Treatments for Rotator Cuff Tears
20100704
Finding the silver lining in cancer
When a member of a family is diagnosed with cancer the impacts on a family can be dramatic but is it necessarily all “doom and gloom?”
PhD student Janelle Levesque has just started research investigating the effects that having a parent with cancer has on adults, and, in particular whether there have been positive benefits such as a changed outlook on life.
“Previous research suggests that patients and their spouses are able to find the ‘silver lining’ when dealing with cancer,” said Janelle, a member of Charles Sturt University’s Institute for Land, Water and Society.
“However we don’t know whether or not this is the case with their adult children who have experienced parental cancer.”
Janelle said it was important to consider the psychological impact of chronic and terminal illness on the family network and that there has been a growing recognition of family members as secondary patients.
“However there has also been an almost exclusive focus on the negative impact of illness in terms of outcomes like depression and high stress,” said Janelle. “This limited approach is short-sighted. There are a lot of potentially positive changes that may arise that need to be investigated.”
Janelle is planning to interview adults whose parents have been diagnosed with cancer to discover how they adjusted to their parent’s illness and what the positive outcomes may be. People interested in taking part in her research can contact her by email on jlevesque@csu.edu.au or by phone on 02 6971 1919.
She hopes the knowledge gained from her study can be used to inform support services for family members. Her research is being supervised by Institute members Dr Darryl Maybery and Dr Kent Patrick.
PhD student Janelle Levesque has just started research investigating the effects that having a parent with cancer has on adults, and, in particular whether there have been positive benefits such as a changed outlook on life.
“Previous research suggests that patients and their spouses are able to find the ‘silver lining’ when dealing with cancer,” said Janelle, a member of Charles Sturt University’s Institute for Land, Water and Society.
“However we don’t know whether or not this is the case with their adult children who have experienced parental cancer.”
Janelle said it was important to consider the psychological impact of chronic and terminal illness on the family network and that there has been a growing recognition of family members as secondary patients.
“However there has also been an almost exclusive focus on the negative impact of illness in terms of outcomes like depression and high stress,” said Janelle. “This limited approach is short-sighted. There are a lot of potentially positive changes that may arise that need to be investigated.”
Janelle is planning to interview adults whose parents have been diagnosed with cancer to discover how they adjusted to their parent’s illness and what the positive outcomes may be. People interested in taking part in her research can contact her by email on jlevesque@csu.edu.au or by phone on 02 6971 1919.
She hopes the knowledge gained from her study can be used to inform support services for family members. Her research is being supervised by Institute members Dr Darryl Maybery and Dr Kent Patrick.
Mental illness: who cares for the kids?
With one in five Australians expected to experience some form of mental illness during their life, researchers at Charles Sturt University (CSU) have examined one of society’s most vulnerable groups – the children of mental health patients - and how to prevent mental illness from being passed from their parents to them.
According to Charles Sturt University psychology researcher Dr Daryl Maybery, children have a greater risk of developing behavioural, developmental and emotional problems when their parents have a mental illness.
“We are aiming to break the cycle of mental health disorders, given that children of parents with a mental illness such as depression are more likely to develop depression themselves,” Dr Maybery said.
“We need to look at causes and intervention points to interrupt the cycle and prevent the transfer of mental illness from parent to child. If a child’s environment is carefully managed, there is less chance of an illness developing.”
Dr Maybery, who is with CSU’s Centre for Rural Social Research, and Dr Andrea Reupert, a CSU education lecturer, examined the needs of an estimated 1 million Australian children who live with parents who have a mental illness. The research aimed to help children develop coping strategies and define and provide information to support agencies that will help them meet the critical needs of children and parents.
The children in the study confirmed that while external supports such as state health agencies are helpful, it is the family and friendship connections that may protect them from extreme emotional upheaval.
“Our research revealed that the crisis time for children is when their parent is hospitalised due to a major mental health episode,” said Dr Maybery.
“It’s at this time when children are most vulnerable, they are under significant pressure and this can trigger mental health concerns for themselves.
“We can help kids cope in this situation by giving them a feeling of control. We recommend that families are assisted and supported to develop ‘family crisis plans’ these would include provisions for a grandparent or friend to step in when a parent is hospitalised. The knowledge and sense of security this offers is a great comfort to kids,” he said.
According to Dr Maybery, these children are lost in a system which caters for adult and child patients exclusively and not the children of parents with a mental illness. Dr Maybery estimates that 30 in 1 000 children are living in extreme risk, in a households with one parent that has a severe mental illness.
“There was no ‘home’ for these children and often when a parent was hospitalised with a mental illness there was no thought given to whether they may have children and what their needs may be,” Dr Maybery said.
They have undertaken research project involving over 800 participants in New South Wales, North East Victoria and the eastern suburbs of Melbourne, with the research expected to result in guidelines to be rolled-out to mental health support agencies across Victoria.
Dr Maybery received funding from the Victorian Department of Health, VicHealth and the national depression initiative Beyond Blue in the past year for the study, as well as assistance from North-East Victorian communities, Victoria’s La Trobe University and CSU.
According to Charles Sturt University psychology researcher Dr Daryl Maybery, children have a greater risk of developing behavioural, developmental and emotional problems when their parents have a mental illness.
“We are aiming to break the cycle of mental health disorders, given that children of parents with a mental illness such as depression are more likely to develop depression themselves,” Dr Maybery said.
“We need to look at causes and intervention points to interrupt the cycle and prevent the transfer of mental illness from parent to child. If a child’s environment is carefully managed, there is less chance of an illness developing.”
Dr Maybery, who is with CSU’s Centre for Rural Social Research, and Dr Andrea Reupert, a CSU education lecturer, examined the needs of an estimated 1 million Australian children who live with parents who have a mental illness. The research aimed to help children develop coping strategies and define and provide information to support agencies that will help them meet the critical needs of children and parents.
The children in the study confirmed that while external supports such as state health agencies are helpful, it is the family and friendship connections that may protect them from extreme emotional upheaval.
“Our research revealed that the crisis time for children is when their parent is hospitalised due to a major mental health episode,” said Dr Maybery.
“It’s at this time when children are most vulnerable, they are under significant pressure and this can trigger mental health concerns for themselves.
“We can help kids cope in this situation by giving them a feeling of control. We recommend that families are assisted and supported to develop ‘family crisis plans’ these would include provisions for a grandparent or friend to step in when a parent is hospitalised. The knowledge and sense of security this offers is a great comfort to kids,” he said.
According to Dr Maybery, these children are lost in a system which caters for adult and child patients exclusively and not the children of parents with a mental illness. Dr Maybery estimates that 30 in 1 000 children are living in extreme risk, in a households with one parent that has a severe mental illness.
“There was no ‘home’ for these children and often when a parent was hospitalised with a mental illness there was no thought given to whether they may have children and what their needs may be,” Dr Maybery said.
They have undertaken research project involving over 800 participants in New South Wales, North East Victoria and the eastern suburbs of Melbourne, with the research expected to result in guidelines to be rolled-out to mental health support agencies across Victoria.
Dr Maybery received funding from the Victorian Department of Health, VicHealth and the national depression initiative Beyond Blue in the past year for the study, as well as assistance from North-East Victorian communities, Victoria’s La Trobe University and CSU.
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