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S S Coughlin

Publications and source records attributed to S S Coughlin.

At least 19 recordsLinked to original sources
PubMed2001

Application of population screening principles to genetic screening for adult-onset conditions.

Recent advances in molecular genetics have highlighted the potential use of genetic testing to screen for adult-onset chronic diseases. Several issues must be addressed, however, before such tests can be recommended for population-based prevention programs. These issues include the adequacy of the scientific evidence, the balance of risks and benefits, the need for counseling and informed consent, and the costs and resources required. Ongoing assessment of the screening program and quality assurance of laboratory testing are also needed. This paper considers the application of general principles for mass screening to genetic testing for susceptibility to adult-onset chronic diseases. Evaluation of proposals for genetic screening in context of these principles reveals that needed evidence is often absent, particularly with respect to the predictive value of tests, efficacy of interventions, and social consequences of testing. The principles of population screening are developed into a framework for public health policy on genetic screening that has three stages: assessment of the screening test and interventions for those who test positive, including assessment of risks and costs, policy development, and program evaluation. Essential elements are identified, including evaluation of evidence and processes for consensus development and program evaluation. The proposed framework for public health policymaking outlined in this commentary, when combined with future efforts that involve an authoritative consensus process, may be useful for the evaluation and planning of genetic screening programs aimed at reducing morbidity and mortality from adult-onset chronic diseases.

Adult↗
PubMed2001

Shared expectations for protection of identifiable health care information: report of a national consensus process.

OBJECTIVE: The Ethical Force Program is a collaborative effort to create performance measures for ethics in health care. This report lays out areas of consensus that may be amenable to performance measurement on protecting the privacy, confidentiality and security of identifiable health information. DESIGN: Iterative consensus development process. PARTICIPANTS: The program's oversight body and its expert panel on privacy include national leaders representing the perspectives of physicians, patients, purchasers, health plans, hospitals, and medical ethicists as well as public health, law, and medical informatics experts. METHODS AND MAIN RESULTS: The oversight body appointed a national Expert Advisory Panel on Privacy and Confidentiality in September 1998. This group compiled and reviewed existing norms, including governmental reports and legal standards, professional association policies, private organization statements and policies, accreditation standards, and ethical opinions. A set of specific and assessable expectations for ethical conduct in this domain was then drafted and refined through 7 meetings over 16 months. In the final 2 iterations, each expectation was graded on a scale of 1 to 10 by each oversight body member on whether it was: (1) important, (2) universally applicable, (3) feasible to measure, and (4) realistic to implement. The expectations that did not score more than 7 (mean) on all 4 scales were reconsidered and retained only if the entire oversight body agreed that they should be used as potential subjects for performance measurement. Consensus was achieved on 34 specific expectations. The expectations fell into 8 content areas, addressing the need for transparency of policies and practices, consent for use and disclosure of identifiable information, limitations on information that can be collected and by whom, individual access to one's own health records, security requirements for storage and transfer of information, provisions to ensure ongoing data quality, limitations on how identifiable information may be used, and provisions for meaningful accountability. CONCLUSIONS: This process established consensus on 34 measurable ethical expectations for the protection of privacy and confidentiality in health care. These expectations should apply to any organization with access to personally identifiable health information, including managed care organizations, physician groups, hospitals, other provider organizations, and purchasers. Performance measurement on these expectations may improve accountability across the health care system.

Confidentiality↗
PubMed2000

A meta-analysis of estrogen replacement therapy and risk of epithelial ovarian cancer.

Estrogen replacement therapy (ERT) has not been associated with epithelial ovarian cancer in most reported epidemiologic studies that have looked for an association. Some studies may have found weak statistically nonsignificant associations because the number of cases or number of women who reported estrogen use was small. We performed a meta-analysis of data from 15 case-control studies that provided data on ERT and risk of epithelial ovarian cancer. The 15 combined studies were statistically heterogeneous (chi(2) (14) = 26. 3, P < 0.05) in terms of the effect they found. When we combined these studies using a random effects model, we did not find a significant association of ERT with ovarian cancer (odds ratio = 1.1, 95% confidence interval = 0.9-1.3). There was no clear evidence of a dose-response relation with increasing duration of estrogen use in a subset of five studies that reported estrogen use by duration (overall slope = 0.0012, 95% confidence interval = -0.0055 to 0. 0080). The influences of statistical outliers, study design (hospital or clinic controls vs. community controls), and location (U.S. and Canada vs. Europe and Australia) were examined. The odds ratio was 1.3 (95% confidence interval = 1.0-1.6) in the relatively homogeneous subset of four U.S. case-control studies with community controls, but we cannot rule out the possibility of uncontrolled confounding. The odds ratios for estrogen use for other subgroups defined by geographic location and type of control group were not significantly different from one.

Case-Control Studies↗
PubMed2000

Predictors of pancreatic cancer mortality among a large cohort of United States adults.

OBJECTIVES: Cigarette smoking is considered an important risk factor for pancreatic cancer, but other purported risk factors are less well established. To learn more about the epidemiology of this important cause of mortality we examined associations with a variety of possible risk factors for death from pancreatic cancer in a large, prospective study of United States adults. METHODS: We used proportional hazards models to obtain adjusted estimates of relative risks (hazards ratios). During 14 years of follow-up, 3751 persons died of pancreatic cancer in a cohort of 483,109 men and 619,199 women who had no reported history of cancer at enrollment in 1982. RESULTS: Cigarette smoking at baseline was associated with fatal pancreatic cancer among men (multivariate relative risk [RR] = 2.1, 95% confidence interval [CI] 1.9-2.4) and among women (RR = 2.0, 95% CI 1.8-2.3). A trend in risk was observed with increasing number of cigarettes smoked per day among current smokers at baseline. With several variables included in separate models for men and women, we found additional factors to be predictive of pancreatic cancer mortality, including family history of pancreatic cancer, black race, diabetes, and increased body mass index. History of gallstones was predictive of pancreatic cancer among men. An inverse association with vegetable consumption was observed among men, that was not statistically significant. CONCLUSION: Our findings confirm that cigarette smoking is an important predictor of pancreatic cancer mortality, and identify several other factors that may contribute to increased risk.

Adult↗
PubMed2000

Breast and cervical cancer screening practices among Asian and Pacific Islander women in the United States, 1994-1997.

Recent studies suggest that Asian and Pacific Islander women in the United States may underuse cancer screening tests. We examined the breast and cervical cancer screening practices of 6048 Asian and Pacific Islander women in 49 states from 1994 through 1997 using data from the Behavioral Risk Factor Surveillance System. About 71.7% [95% confidence interval (CI), 66.3-77.0%] of women in this sample aged > or =50 years had a mammogram in the past 2 years, and 69.5% (95% CI, 63.9-75.1%) had a clinical breast exam in the past 2 years. About 73.7% (95% CI, 71.3-76.0%) of women aged > or =18 years who had not undergone a hysterectomy had a Papanicolaou test in the past 3 years. Women with health insurance and those who had seen a physician in the past year were more likely to have been screened. These results underscore the need for continued efforts to ensure that Asian and Pacific Islander women who are medically underserved, including those without health insurance, have access to cancer screening services.

Adolescent↗
PubMed1999

Gonorrhea incidence and HIV testing and counseling among adolescents and young adults seen at a clinic for sexually transmitted diseases.

OBJECTIVE: To determine whether HIV testing and posttest counseling may be associated with an increase in gonorrhea incidence among adolescents and young adults seen at a clinic for sexually transmitted diseases (STD). DESIGN: A historical cohort study with the collection of longitudinal data on the patients' HIV testing and counseling experience. SETTING: Delgado STD clinic of New Orleans, Louisiana, a public ambulatory primary care center that serves mainly the economically disadvantaged Black population. PATIENTS: A record-based inception cohort of 4031 patients aged 15-25 years diagnosed at the clinic between June 1989 and May 1991 with a first lifetime gonorrhea infection. INTERVENTION: Routine confidential HIV tests and posttest counseling sessions experienced at the clinic during follow-up. OUTCOME MEASURE: Incidence rate of reported gonorrhea reinfection. RESULTS: Of the patients, 51.5% were tested once for HIV antibodies and 25.9% twice or more. Formal posttest counseling occurred after 8.5% of the 4665 HIV-negative and 44.0% of the 49 HIV-positive tests. In the most pessimistic of several models controlling for history of gonorrhea, HIV testing and counseling history, and other potential confounding factors, a significantly lower rate of gonorrhea reinfection was observed after a first HIV-negative test than before [adjusted relative risk (RR), 0.66; 95% confidence interval (CI), 0.59-0.74; P < 0.00011. As compared with the pretest period, significantly higher rates of gonorrhea were observed after respectively a second (RR, 1.18; 95% CI, 1.01-1.37; P = 0.03) and a third (RR, 1.52; 95% CI, 1.22-1.88; P = 0.0001) HIV-negative test. No significant association was found between HIV-positive testing and any variation in gonorrhea rate (RR, 0.95; 95% CI, 0.56-1.62; P = 0.85). Posttest counseling for HIV-negative and HIV-positive results were followed respectively by a significantly higher rate of gonorrhea (RR; 1.27; 95% CI, 1.09-1.48; P = 0.002) and a non-significantly lower rate of gonorrhea (RR, 0.53; 95% CI, 0.17-1.60; P = 0.85). CONCLUSION: Our results do not exclude the possibility of a modest increase in gonorrhea incidence after routine HIV testing and counseling in an STD clinic. Nevertheless, this conclusion holds only under the least favorable assumptions and applies solely to a minority of patients.

AIDS Serodiagnosis↗
PubMed1999

Breast and cervical cancer screening practices among American Indian and Alaska Native women in the United States, 1992-1997.

BACKGROUND: Recent studies suggest that American Indian and Alaska Native women have important barriers to cancer screening and underuse cancer screening tests. METHODS: We examined the breast and cervical cancer screening practices of 4,961 American Indian and Alaska Native women in 47 states from 1992 through 1997 by using data from the Behavioral Risk Factor Surveillance System. RESULTS: About 65.1% [95% confidence interval (CI) 60.2 to 69.9%] of women in this sample aged 50 years or older had received a mammogram in the past 2 years. About 82.6% (95% CI 80.1 to 85.2%) of women aged 18 years or older who had not undergone a hysterectomy had received a Papanicolaou test in the past 3 years. Older women and those with less education were less likely to be screened. Women who had seen a physician in the past year were much more likely to have been screened. CONCLUSIONS: These results underscore the need for continued efforts to ensure that American Indian and Alaska Native women who are elderly or medically underserved have access to cancer screening services.

Adolescent↗
PubMed1999

BRCA1 and BRCA2 gene mutations and risk of breast cancer. Public health perspectives.

CONTENT: Breast cancer is the most common cancer and the second most common cause of cancer death among U.S. women. In 1998, about 178,700 new cases will be diagnosed and 43,500 women will die from the disease. Mutations in the BRCA1 gene, which was cloned in 1994 and is located on chromosome 17q, have been identified as causes of predisposition to breast, ovarian, and other cancers. A second breast cancer gene, BRCA2, has been localized to chromosome 13q. Using inferential procedures, the overall carrier frequency of BRCA1 gene mutations has been estimated at 1 in 500 in the general U.S. population. Recent studies have indicated that the carrier frequency of a specific BRCA1 allele, the 185delAG mutation, may be as high as 0.8% to 1% among women of Ashkenazi Jewish descent. CONCLUSIONS: Due to the proliferation of laboratories offering genetic tests for breast cancer susceptibility, their appropriate use in public health needs careful scrutiny. Several issues are raised when such genetic tests are considered for population-based prevention programs for breast cancer. Public health agencies, such as the Centers for Disease Control and Prevention, are important to monitoring and evaluating genetic testing done outside of research protocols. If genetic tests for breast cancer are to be incorporated into future prevention programs, evaluation is needed of whether the testing can have the intended effect.

BRCA2 Protein↗
PubMed1999

Public health perspectives on testing for colorectal cancer susceptibility genes.

CONTEXT: About 131,600 new cases of colorectal cancer will be diagnosed in the United States in 1998. About 27,900 men and 28,600 women will die from colorectal cancer in 1998. Mutations to the hMSH2 gene on chromosome 2p and to the hMLH1 gene on chromosome 3p have been identified as causes of colorectal cancer. These mismatch repair genes, which have recently been cloned, account for most cases of hereditary nonpolyposis colorectal cancer (HNPCC), one of the most common cancer susceptibility syndromes known. The carrier frequency of hMSH2 and hMLH1 gene mutations in the U.S. population is unknown. An adenomatous polyposis coli (APC) gene variant (I1307K allele), which was recently reported in 1 in 17 Ashkenazi Jewish persons, may double the risk for colorectal cancer in that population. CONCLUSIONS: The use of genetic tests for susceptibility to cancer of the colon and other sites needs careful scrutiny. Several issues must be addressed before such tests can be recommended for population-based prevention programs. For example, the screening of population subgroups raises concern about potential discrimination and stigmatization. Before genetic tests for colorectal cancer are incorporated into future programs, the safety, effectiveness, and quality of these tests must be evaluated.

Colorectal Neoplasms↗
PubMed1999

New ethics guidelines for epidemiology: background and rationale.

In the past decade, at least four sets of ethics guidelines for epidemiologists have been prepared by various national and international organizations. None, however, have been officially adopted by the American College of Epidemiology (ACE). Recently, the ACE asked its Ethics and Standards of Practice (ESOP) Committee to produce ethics guidelines. In this paper, we explain the context and rationale for this effort, describe the purpose and content of ethics guidelines in epidemiology, and discuss their strengths and weaknesses. Three issues that are central to the mission of ACE-education, policy, and advocacy-are inadequately addressed in existing ethics guidelines. In addition, ethics guidelines are not static documents; they should reflect the changing role of epidemiologists in society, including issues arising in emerging subspecialty areas. New, more dynamic, guidelines that emphasize core values, obligations, and virtues, may help to further define and legitimize the profession of epidemiology and will provide a foundation for the discussion of specific ethical issues in the classroom and in professional practice. Guidelines however, do not provide the final word on ethical issues. Specific decisions in particular cases require judgments made upon reflection of the core values, obligations, and virtues described in the guidelines. From our review, we conclude that a new set of guidelines is reasonable and warranted.

Epidemiology↗
PubMed1999

Ethics instruction at schools of public health in the United States. Association of Schools of Public Health Education Committee.

OBJECTIVES: A survey of US schools of public health was undertaken in 1996 and 1997 to obtain a general picture of public health ethics curricula. METHODS: An explanatory letter with a list of questions for discussion was sent to the deans of the accredited US schools of public health. The deans were asked that at least 1 individual at their school who "is most knowledgeable about ethics curricula" review the list of questions and complete an ethics survey contact form. RESULTS: Ethics instruction was required for all students at only 1 (4%) of the 24 schools surveyed, while 7 schools required ethics instruction for some students. Two of the schools had no ethics courses. Ethics instruction was required for all MPH students at 9 (38%) of the schools and for all doctoral students at 4 (17%) of the schools. Most of the schools (19 of 24, or 79%) offered short courses, seminar series, or invited lectures on ethical topics, and 23 (96%) included lectures on ethics topics in other courses such as health law. CONCLUSIONS: Training programs at US schools of public health vary greatly in how much attention is given to ethics instruction. Model curricula in public health ethics should be developed to help fill this gap.

Curriculum↗
PubMed1998

Mammography use helps to explain differences in breast cancer stage at diagnosis between older black and white women.

BACKGROUND: Older black women are less likely to undergo mammography and are more often given a diagnosis of advanced-stage breast cancer than older white women. OBJECTIVE: To investigate the extent to which previous mammography explains observed differences in cancer stage at diagnosis between older black and white women with breast cancer. DESIGN: Retrospective cohort study using the Linked Medicare-Tumor Registry Database. SETTING: Population-based data from three geographic areas of the United States included in the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program (Connecticut; metropolitan Atlanta, Georgia; and Seattle-Puget Sound, Washington). PARTICIPANTS: Black and white women 67 years of age and older in whom breast cancer was diagnosed between 1987 and 1989. MEASUREMENTS: Medicare claims were used to classify women according to mammography use in the 2 years before diagnosis as nonusers (no previous mammography), regular users (> or =2 mammographies done at least 10 months apart), or peri-diagnosis users (mammography done only within 3 months before diagnosis). Information on mammography use was linked with SEER data to determine cancer stage at diagnosis. Stage was classified as early (in situ or local) or late (regional or distant). RESULTS: Black women were more likely to not undergo mammography (odds ratio [OR], 3.00 [95% CI, 2.41 to 3.75]) and to be given a diagnosis of late-stage disease (OR, 2.49 [CI, 1.59 to 3.92]) than white women. When women were stratified by previous mammography use, the black-white difference in cancer stage occurred only among nonusers (adjusted OR, 2.54 [CI, 1.37 to 4.71]). Among regular users, cancer was diagnosed in black and white women at similar stages (adjusted OR, 1.34 [CI, 0.40 to 4.51]). In logistic modeling, previous mammography alone explained about 30% of the excess late-stage disease in black women. In a separate model, previous mammography explained 12% of the excess late-stage disease among black women after adjustment for sociodemographic and comorbidity information. CONCLUSION: Differences in breast cancer stage at diagnosis between older black and white women are related to previous mammography use. Increased regular use of mammography may result in a shift toward earlier-stage disease at diagnosis and narrow the observed differences in stage at diagnosis between older black and white women.

Black or African American↗