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Biomedical subjects

James S Goodwin

Publications and source records attributed to James S Goodwin.

At least 55 records · Page 3Linked to original sources
PubMed2004

Hospice use by Hispanic and non-Hispanic white cancer decedents.

OBJECTIVE: To investigate rates of hospice use between Hispanic and non-Hispanic white Medicare beneficiaries diagnosed with cancer using data from a large, population-based study. DATA SOURCES: Secondary data from the linked SEER-Medicare database including the SEER areas of Los Angeles, San Francisco, and San Jose-Monterey, California, and the state of New Mexico. All subjects were Hispanic or non-Hispanic whites, aged 67 and older, had a cancer diagnosis of breast, colorectal, lung, or prostate cancer from 1991-1996, and died of cancer from 1991-1998. STUDY DESIGN: This study employed a retrospective cohort design to compare rates of hospice use between Hispanics and non-Hispanic whites across patient characteristics and over time. PRINCIPAL FINDINGS: Rates of hospice use were similar for Hispanics (39.2 percent) and non-Hispanic whites (41.5 percent). In a bivariate logistic regression model, Hispanics were significantly less likely to use hospice than non-Hispanic whites (OR 0.91; 95 percent CI 0.85-0.97). However, after adjusting for age, marital status, sex, educational attainment, income, urban versus rural residence, and type of insurance using multivariate logistic regression analysis, the estimated odds for being a hospice user among Hispanics is similar to the odds of being a hospice user among non-Hispanic whites (OR 1.05; 95 percent CI 0.98-1.13). Stratified analyses revealed significant differences between ethnic groups in the use of hospice by type of insurance and SEER area, indicating interactions between ethnicity and these variables. CONCLUSIONS: Our findings indicate similar rates of hospice use for Hispanics and non-Hispanic whites diagnosed with one of the four leading cancers. Additional studies from other national registries may be necessary to confirm these findings.

Aged↗
PubMed2004

Effect of depression on diagnosis, treatment, and survival of older women with breast cancer.

OBJECTIVES: To assess the effect of a prior diagnosis of depression on the diagnosis, treatment, and survival of older women with breast cancer. DESIGN: Retrospective analysis of records from Surveillance, Epidemiology and End Results (SEER) and Medicare claims. SETTING: Registries from seven major cities and five states. PARTICIPANTS: A total of 24,696 women aged 67 to 90 diagnosed with breast cancer between 1993 and 1996 and included in the SEER Medicare linked database were studied. MEASUREMENTS: Information on patient demographics, tumor characteristics, treatment received, and survival were obtained from SEER, and the Medicare inpatient and professional charges for the 2 years before diagnosis were searched for a diagnosis of depression. RESULTS: A total of 1,841 of the 24,696 women (7.5%) had been given a diagnosis of depression sometime in the 2 years before the diagnosis of breast cancer. There was no difference in tumor size or stage at diagnosis between depressed and nondepressed women. Women diagnosed with depression were less likely to receive treatment generally considered definitive (59.7% vs 66.2%, P<.0001), and this difference remained after controlling for age, ethnicity, comorbidity, and SEER site. Also, women with a prior diagnosis of depression had a higher risk of death (hazard ratio=1.42; 95% confidence interval= 1.13-1.79) after controlling for other factors that might affect survival. The higher risk of death associated with a prior diagnosis of depression was also seen in analyses restricted to women who received definitive treatment. CONCLUSION: Women with a recent diagnosis of depression are at greater risk for receiving nondefinitive treatment and experience worse survival after a diagnosis of breast cancer, but differences in treatment do not explain the worse survival.

Aged↗
PubMed2004

Neighborhood context and mortality among older Mexican Americans: is there a barrio advantage?

OBJECTIVES: We examined whether Mexican Americans living in high-density Mexican American neighborhoods experience increased morbidity and mortality compared with the rates observed among Mexican Americans living in low-density areas. METHODS: We conducted a prospective analysis of a cohort of 3050 Mexican Americans aged 65 years or older. We examined prevalence of 6 medical conditions and survival over 7 years of follow-up in relation to percentage of Mexican Americans in the census tract. RESULTS: With adjustment for covariates, odds for disease prevalence among older Mexican Americans as a function of percentage of Mexican Americans in the census tract were 0.33 (95% confidence interval [CI]=0.16, 0.71) for stroke, 0.28 (95% CI= 0.11, 0.70) for cancer, and 0.31 (95% CI=0.10, 0.98) for hip fracture. The hazard ratio for all-cause mortality over 7 years' follow-up was 0.64 (95% CI=0.42, 0.96). CONCLUSIONS: Sociocultural advantages conferred on Mexican Americans by living in high-density Mexican American neighborhoods outweigh the disadvantages conferred by the high poverty of those neighborhoods.

Aged↗
PubMed2004

Health-related social disengagement in elderly diabetic patients: association with subsequent disability and survival.

OBJECTIVE: We examined the relationship between health-related social disengagements, as opposed to disengagements related to financial and other non-health-related factors, and subsequent risk of disability and death among initially nondisabled elderly diabetic patients enrolled in Medicare Managed Care plans. RESEARCH DESIGN AND METHODS: We used data from the Medicare Health Outcomes Survey (HOS) Cohort 1 Baseline (1998) and Cohort 1 Follow-Up (2000). Through mail and telephone surveys, trained interviewers collected information on sociodemographic variables, physical and mental health functioning (using Medical Outcomes Study Short Form-36 [SF-36]), activities of daily living (ADL), and medical conditions. This study reported on diabetic subjects aged >or=65 years with no ADL disability at baseline (n = 8949). Health-related social disengagement (degree to which physical health or emotional problems interfere with social activities) was derived from the social functioning subscale of SF-36 (range 0-100; higher scores depicting better social functioning). RESULTS: For each 10-point increase in social functioning score at baseline, older diabetic subjects in our study experienced an 18% less chance of any ADL disability (odds ratio [OR] 0.82, 95% CI 0.75-0.89; P < 0.001) and a 12% less chance of death (0.88, 0.78-1.00; P = 0.043) over a 2-year period, adjusting for demographic factors, comorbidities, depression, and general health (assessed by the SF-36). CONCLUSIONS: Among initially nondisabled older diabetic subjects, health-related interferences with social activities at baseline may be early warning signs of subsequent ADL disability and premature death, independent of other measures of health status.

Activities of Daily Living↗
PubMed2003

Ethnic differences in antihypertensive medication use in the elderly.

BACKGROUND: Determining the optimal treatment for hypertension in very old patients requires better understanding of interethnic differences in patterns and predictors of antihypertensive drug use in this population. OBJECTIVE: To investigate interethnic variations in antihypertensive drug use in a tri-ethnic sample of community-dwelling adults aged > or =77 years. METHODS: We performed a cross-sectional study of non-Hispanic white, black, and Hispanic adults > or =77 years old residing in Galveston County, TX. In-home interviews in 1997 and 1998 assessed blood pressures and antihypertensive medication use in 281 subjects who reported having hypertension or who had a systolic blood pressure > or =140 mm Hg and/or diastolic blood pressure > or =90 mm Hg. RESULTS: Of the population evaluated, 62.9% of non-Hispanic whites, 60.2% of blacks, and 45.2% of Hispanics with hypertension were on antihypertensive medications (p < 0.027 across the ethnic groups). After adjusting for age, gender, years of education, household income, Medicaid insurance, number of physician visits, and cognitive function, Hispanic ethnicity, unlike black ethnicity, continued to be significantly associated with lower use of antihypertensive drugs compared with non-Hispanic whites (OR 0.41; 95% CI 0.19 to 0.90). Characteristics associated with the lower use of antihypertensive drugs included older age and low income in whites, poor cognition and infrequent physician visits in blacks, and lack of Medicaid insurance in Hispanics. CONCLUSIONS: In the elderly, Hispanic ethnicity, unlike black ethnicity, is significantly associated with lower use of antihypertensive drug therapy compared with non-Hispanic white ethnicity, adjusting for relevant sociodemographic and health factors.

Aged↗
PubMed2003

Discrepancy between consensus recommendations and actual community use of adjuvant chemotherapy in women with breast cancer.

BACKGROUND: Although the efficacy of adjuvant chemotherapy in prolonging survival for women with breast cancer has been well documented, limited population-based information is available on the actual use of chemotherapy. OBJECTIVE: To examine the relationship between age and chemotherapy use. DESIGN: Cohort study. SETTING: New Mexico. PATIENTS: 5101 women 20 years of age or older receiving a diagnosis of stage I, stage II, or stage IIIA breast cancer from 1991 through 1997. MEASUREMENTS: Pattern of chemotherapy use by age; logistic regression analysis to generate the odds and probabilities of receiving chemotherapy; and sensitivity analysis to estimate potential effects of unmeasured confounders. RESULTS: Overall, 29% of women received chemotherapy. The rate of chemotherapy use for women with stage I, stage II, or stage IIIA breast cancer was 11%, 47%, and 68%, respectively. Across all tumor stages, the use of chemotherapy decreased substantially with increasing age (P < 0.001). Overall, 66% of women younger than 45 years of age received chemotherapy compared with 44% of women between 50 and 54 years of age, 31% of women between 55 and 59 years of age, and 18% of women between 60 and 64 years of age. The decreasing pattern of chemotherapy use with age continued after adjustment for prognostic factors and was relatively insensitive to changes in unmeasured factors. CONCLUSIONS: There is considerable discrepancy between the 1990 National Institutes of Health Consensus Conference recommendations for chemotherapy administration in women with breast cancer and the actual use of chemotherapy in the community. The decrease in use with age may relate to the decreasing efficacy of chemotherapy with age, as reported in clinical trials. Outcomes studies should address whether the recommendations are overly aggressive or whether practicing oncologists are too conservative in their use of chemotherapy.

Adult↗
PubMed2003

Predictors of recovery in activities of daily living among disabled older Mexican Americans.

BACKGROUND AND AIMS: Although functional ability decreases with age and is associated with poor health outcomes, decline in functional ability is reversible. The aim of this study is to describe the rate of recovery of functional ability and to identify factors associated with it over a two-year period among older Mexican Americans. METHODS: 245 functionally disabled older Mexican Americans were included in a two-year prospective cohort study. Data are from the Hispanic Established Population for the Epidemiological Study of the Elderly (H-EPESE), a population-based study of non-institutionalized Mexican Americans in the South-western United States. Activities of daily living (ADL), lower body mobility (tandem balance, eight-foot walk, and repeated chair stands), depressive symptomatology, body mass index, and self-reported medical conditions were obtained. RESULTS: Over a two-year period, of the 245 subjects at baseline who reported functional disability in at least 1 of 7 ADLs, 83 totally recovered their ADL ability, 108 remained disabled, 36 died, and 18 were lost to follow-up. Factors significantly associated with recovery included younger age (65-74) (OR 2.18, 95% CI 1.08-4.42), higher summary performance measure of lower body function (OR 1.19, 95% CI 1.05-1.34), few depressive symptoms (OR 2.84, 95% CI 1.39-5.78), and a BMI > or = 30 Kg/m2 (OR 3.08, 95% CI 1.17-8.07). Higher numbers of ADL limitations at baseline were associated with lower odds of ADL recovery. CONCLUSIONS: Two-year recovery from ADL disability among older Mexican Americans was high (33.9%). Factors independently associated with recovery include younger age, few depressive symptoms, good lower body function, and high BMI.

Activities of Daily Living↗
PubMed2003

Effect of nurse case management on the treatment of older women with breast cancer.

OBJECTIVES: To evaluate the effect of nurse case management on the treatment of older women with breast cancer. DESIGN: Randomized prospective trial. SETTING: Sixty surgeons practicing at 13 community and two public hospitals in southeast Texas. PARTICIPANTS: Three hundred thirty-five women (166 control and 169 intervention) aged 65 and older newly diagnosed with breast cancer. INTERVENTION: Women seeing surgeons randomized to the intervention group received the services of a nurse case manager for 12 months after the diagnosis of breast cancer. MEASUREMENTS: The primary outcome was the type and use of cancer-specific therapies received in the first 6 months after diagnosis. Secondary outcomes were patient satisfaction and arm function on the affected side 2 months after diagnosis. RESULTS: More women in the intervention group received breast-conserving surgery (28.6% vs 18.7%; P=.031) and radiation therapy (36.0% vs 19.0%; P=.003). Of women undergoing breast-conserving surgery, greater percentages in the case management group received adjuvant radiation (78.3% vs 44.8%; P=.001) and axillary dissection (71.4% vs 44.8%; P=.057). Women in the case management group were also more likely to receive more breast reconstruction surgery (9.3% vs 2.6%, P=.054), and women in the case management group with advanced cancer were more likely to receive chemotherapy (72.7% vs 30.0%, P=.057). Two months after surgery, higher percentages of women in the case manager group had normal arm function (93% vs 84%; P=.037) and were more likely to state that they had a real choice in their treatment (82.2% vs 69.9%, P=.020). Women with indicators of poor social support were more likely to benefit from nurse case management. CONCLUSION: Nurse case management results in more appropriate management of older women with breast cancer.

Age Factors↗
PubMed2003

Cognitive function and incidence of stroke in older Mexican Americans.

BACKGROUND: Given the high prevalence of cognitive impairment in older Mexican Americans and limited longitudinal research examining cognitive function in this ethnic group, we conducted a study examining whether cognitive impairment is a risk factor for new onset of stroke among older Mexican Americans. METHODS: We performed a prospective cohort study of 2682 Mexican Americans aged 65 years and older living in the southwestern United States. For subjects with no prior history of stroke and who completed the Mini-Mental State Examination (MMSE) at baseline, stroke incidence was assessed after 2, 5, and 7 years of follow-up. RESULTS: In Cox proportional regression models, MMSE score at baseline predicted risk of incident stroke over a 7-year follow-up period. For the unadjusted model, subjects with an MMSE score of 21 or higher were half as likely to report stroke at follow-up (hazard ratio [HR], 0.49; 95% confidence interval [CI], 0.35-0.69; p <.001) compared with those with a score of less than 21. We found similar results after controlling for relevant risk factors for stroke including age, gender, smoking status, education, body mass index, diabetes, heart attack, systolic blood pressure, and depressive symptoms (HR, 0.54; 95% CI, 0.38-0.77; p =.001). Additionally, each 1-point increase in MMSE score was associated with a 5% reduction in risk (HR, 0.95; 95% CI, 0.92-0.99; p =.01). CONCLUSIONS: Increasing MMSE score is associated with a decreasing incidence of stroke in older Mexican Americans. This study highlights the need for a more aggressive focus on identifying and addressing cognitive decline in the Mexican American population.

Aged↗
PubMed2003

Embracing complexity: A consideration of hypertension in the very old.

The consequences of hypertension and its treatment differ in very old men and women compared to younger populations. In populations aged 85 years and older, higher levels of systolic and diastolic blood pressures are associated with increased survival, and this relationship is not eliminated by controlling for comorbidity, blood pressure treatment, and other relevant factors. In addition, in 3 of the 4 published randomized controlled trials of treatment of hypertension that included subjects aged 80 years or older, the investigators reported loss of efficacy of treatment in preventing the primary end points in subjects aged 80 and older. In a meta-analysis of those trials, total mortality was actually 14% higher (p =.05) in the treatment group for subjects aged 80 years and older. These data suggest 2 conclusions. First, we should reexamine that dictum that nontreatment of hypertension in those aged 80 years and older is de facto evidence of "ageism." Second, we are unlikely to come to any set of coherent "rules" regarding treatment of hypertension (and several other conditions) in the very old until we routinely stratify all older subjects enrolled in interventional or observational trials by indicators of physiologic vigor.

Aged↗
PubMed2003

Measuring the performance of screening mammography in community practice with Medicare claims data.

BACKGROUND: Few studies have examined the outcomes of screening mammography in community practice, particularly the extent of false positive exams among older asymptomatic women. RESEARCH DESIGN: Subjects were female Medicare beneficiaries, age 67 or older, residing in one of eleven SEER areas, with no evidence of breast cancer. Medicare claims data were used to identify their screening mammograms over two time periods, 1993-1995 and 1996-1998, and to measure their use of follow-up diagnostic testing (diagnostic mammography, breast ultrasound and breast biopsy) within three months of the screening mammogram. RESULTS: There were significant differences among the rates of diagnostic testing for each age group (67-74; 75+ ) by year, but no clear trend toward higher or lower rates over time. Although rates of diagnostic testing differed significantly by geographic region in both time periods 1993-1995 and 1996-1998, estimates of specificity for all regions were within AHRQ clinical practice guidelines (specificity greater than 90%). Specificity significantly improved with the volume of the radiologist's practice for the latter time period (1996-1998) but not for the former (1993-1995). CONCLUSION: Medicare claims offer an accessible population-based source of data for mammography performance indicators. As such, they offer a low cost method for evaluating individual mammography practices as well as monitoring the impact of reimbursement policies, practice guidelines and laws mandating requirements for accrediting facilities.

Aged↗
PubMed2003

Potentially inappropriate medication use by elderly Mexican Americans.

BACKGROUND: Use of inappropriate medications by the elderly is a public health concern with potentially serious health consequences. Research indicates relatively high rates of inappropriate prescription drug usage for older whites and African Americans. However, rates for older Mexican Americans are unknown. OBJECTIVE: To examine the prevalence and predictors of inappropriate prescription medication use by older Mexican Americans. METHODS: A cross-sectional study of 3050 Mexican Americans aged > or =65 years living in the southwestern US was conducted. In-home interviews in 1993 and 1994 assessed prescription medication use. Descriptive statistics and logistic regression models were used to estimate prevalence and risk of inappropriate prescription drug use. RESULTS: Approximately 12% (n = 365) of the sample had used at least 1 of 32 potentially inappropriate prescription medications within 2 weeks of the baseline assessment. Four drugs, chlorpropamide, propoxyphene, amitriptyline, and dipyridamole, accounted for 54% of all inappropriate prescribing. Unmarried subjects, those with >/=1 chronic diseases, high depressive symptoms, frequent physician visits, and combined Medicaid and Medicare insurance were more likely to have used at least 1 of the 32 potentially inappropriate drugs. CONCLUSIONS: The prevalence of inappropriate medication use is lower in older Mexican Americans than in similar white and African American populations. More studies are needed on the pattern of inappropriate prescribing over time and on intervention programs to reduce potentially adverse health outcomes in older Mexican Americans most at risk.

Aged↗
PubMed2003

Inconsistent use of diabetes medications, diabetes complications, and mortality in older mexican americans over a 7-year period: data from the Hispanic established population for the epidemiologic study of the elderly.

OBJECTIVE: The aim of this study was to examine the relationship between inconsistency in use of diabetes drugs and risk of renal, eye, and circulation problems and death over a 7-year period in community-dwelling older Mexican Americans. RESEARCH DESIGN AND METHODS: Data are from the four waves of the Hispanic Established Population for the Epidemiologic Study of the Elderly. In-home interviewers assessed consistency in use of diabetes medications among 908 diabetic Mexican Americans, aged >or=65 years. Diabetes and complications were by self-report. Subjects with poor consistency in use of medication were those who, at any time during the 7-year follow-up, discontinued or inconsistently used their diabetes medications and those who had no diabetic medications at home despite self-report of taking medicine for diabetes. RESULTS: Thirty-six percent of our sample were inconsistent with diabetes medication usage. Older age and lack of supplemental health insurance were significantly associated with inconsistency of use of medication. In a multivariate logistic regression model, subjects with poor consistency in use of medication were more likely to report kidney problems (odds ratio [OR] 1.59; 95% CI 1.13-2.23; P = 0.008) at follow-up compared with those with good consistency, after controlling for age, sex, medication type, duration of diabetes, education, income, marital status, language of interview, insurance status, cognitive function, presence of depressive symptoms, activities of daily living, and instrumental activities of daily living. In Cox regression models, poor consistency with diabetic medication was also associated with increased all-cause mortality (hazard ratio [HR] 1.43; 95% CI 1.13-1.82; P = 0.003) and diabetes-related deaths (1.66; 1.20-2.30; P = 0.002) over a 7-year period after adjusting for relevant confounders. CONCLUSIONS: Inconsistent use of diabetic medication was associated with an increased risk of kidney problems and deaths over a 7-year period in older Mexican Americans.

Aged↗
PubMed2003

Hospice use by older women dying with breast cancer between 1991 and 1996.

The purpose of this study was to assess the use of hospice by women dying with breast cancer as a function of time period, geographic area, and patient characteristics. We used data from the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database to study hospice care use in the United States in women aged 65 and older, diagnosed with breast cancer from 1986 to 1996, who died from 1991 to 1996. Of the 25,161 women who met those criteria, 5,198 (20.7%) were enrolled in hospice before they died. The rate of hospice use in this population increased from 11.5% in 1991 to 27.1% in 1996. Use of hospice care was inversely related to age and was higher among those who were married. There were no differences in use by ethnicity. Rates of use varied significantly by geographic area. Future research should further examine why rates of hospice use differ by geographic area and certain patient characteristics.

Aged↗
PubMed2002

Population-based assessment of hospitalizations for toxicity from chemotherapy in older women with breast cancer.

PURPOSE: There are no population-based data on hospitalization rate for toxicity from breast cancer chemotherapy, and even large clinical trials often do not report this information. Medicare data, linked to the Surveillance, Epidemiology, and End-Results (SEER) tumor registries, are now used to assess rates of hospitalization for chemotherapy-related toxicity in a population-based setting. PATIENTS AND METHODS: A total of 35,060 women diagnosed with stages I through IV breast cancer aged >or= 65 from 1991 through 1996 were identified from the SEER-Medicare linked program and studied. Patients were defined as being hospitalized for adverse effects of chemotherapy if there was a Medicare inpatient claim for neutropenia, fever, thrombocytopenia, or adverse effect of systemic therapy less than 7 months after diagnosis of breast cancer. RESULTS: More than 9% of women with breast cancer who received chemotherapy were admitted with the diagnosis of neutropenia, fever, thrombocytopenia, or adverse effect of systemic therapy, compared with 0.5% of women with breast cancer who did not receive chemotherapy. The rates for stage I to IV were 6.3%, 8.1%, 12.3%, and 13.2% in those treated with chemotherapy, and 0.4%, 0.6%, 0.7%, and 1.5% in women not treated with chemotherapy. The hospitalization rates for adverse effects increased significantly with comorbidity score and varied more than two-fold across the nine SEER areas but did not vary by age. Use of anthracycline-containing chemotherapy agents was associated with greater odds of these toxicities (eg, odds ratio, 2.53 for neutropenia; 95% confidence interval, 1.97 to 3.26). CONCLUSION: This study demonstrated the feasibility of using Medicare data to assess rates of hospitalization for serious toxicity associated with cancer chemotherapy. Rates in actual practice were higher than those reported in clinical trials and did not vary by age.

Aged↗
PubMed2002

Regular mammography use is associated with elimination of age-related disparities in size and stage of breast cancer at diagnosis.

BACKGROUND: There is little consensus about recommending mammography for women 75 years of age and older. These women have mammography less frequently and are more likely to receive a diagnosis of advanced breast cancer. OBJECTIVE: To examine the relationship between use of screening mammography and size and stage of cancer at diagnosis in older women. DESIGN: Retrospective cohort study. SETTING: Tumor registries in the Surveillance, Epidemiology, and End Results (SEER) program. PATIENTS: 12 038 women who were Medicare beneficiaries, were at least 69 years of age, resided in a SEER area, and received a new diagnosis of breast cancer in 1995 through 1996. MEASUREMENTS: Screening mammograms obtained in the 2 years before breast cancer diagnosis (none, one, or at least two) and stage and size of tumor at diagnosis. RESULTS: Older women (> or =75 years of age) had larger tumors at diagnosis and were less likely to have undergone screening mammography than younger women (69 to 74 years of age). The association between increased mammography use and smaller tumor size and stage was significantly greater in older women than in younger women (P = 0.010 for stage; P = 0.001 for size). The percentage of regular mammography users who received a diagnosis of high-stage disease (28% vs. 26%; P > 0.2) and the mean size of the tumors (15.0 mm vs. 15.1 mm; P > 0.2) did not significantly differ between younger and older women, respectively. These findings remained constant after controlling for factors that might contribute to biases. CONCLUSION: Mammography in older women is associated with elimination of age-related disparities in size and stage of breast cancer at diagnosis.

Age Distribution↗
PubMed2002

Bringing the patient back in. Guidelines, practice variations, and the social context of medical practice.

We challenge assumptions that have guided much research and policy aimed at understanding and reducing medical practice variation. Paramount is the focus on doctors as the cause of variation to the neglect of other possible influences. Some research literature suggests that patients, families, and the community context of practice may also influence treatment decisions. Failure to question present assumptions, despite weak evidence in support of them, may account for inability to explain persistent practice variation, develop appropriate implementable guidelines, or anticipate the effect on treatment decisions of greater patient involvement. In this paper, we discuss the weak response to the NIH Consensus Conference on early stage breast cancer because it may have reflected these problems. We urge a more complex and more empirical approach in explaining treatment choice and guidelines sensitive to the potential for value differences.

Attitude to Health↗