surgical oncology were more likely than surgeons with general board certification to recommend BCS to elderly patients (Mandelblatt et al., 1998).

Delays in adoption or lack of compliance with practice guidelines can limit access to recommended cancer care. In 1985, for example, a consensus statement of expert opinion was published accepting the use of BCS and radiation therapy in selected patients with early-stage breast cancer (Harris, et al., 1985). By 1990, the rates of BCS among women 65 to 79 in the Medicare program ranged from only 8 to 26 percent across regions of the United States and rates of BCS use had not increased appreciably nationally (i.e., from 14 percent in 1986 to 15 percent in 1990) (Nattinger et al., 1996). Physicians have also not adhered to recommended chemotherapy regimens. In one study, more than half of patients had their chemotherapy modified by their physicians in ways that were considered inappropriate (Schleifer et al., 1991).

The quality of physician-patient communication can affect clinical outcomes (Greenfield et al., 1988; Kaplan et al., 1989), adjustment to cancer (Roberts et al., 1994), patient quality of life, and satisfaction with care (Greenfield et al., 1988; Kaplan et al., 1989). Evidence of communication gaps is therefore worrisome. Patients and their physicians report the content of their interactions differently (Mackillop et al., 1988; Mosconi et al., 1991; Siminoff et al., 1989), assess the role of the patient in the decision-making process differently (Strull et al., 1984), and have different expectations of treatment benefits (Mackillop et al., 1988; Mosconi et al., 1991; Siminoff et al., 1989). In one study, relatively few women with breast cancer (15 to 27 percent) who had had a mastectomy reported that their physicians discussed BCS as a treatment option (Guadagnoli et al., 1998). Physicians who believe that patients should participate in treatment decisions are more likely to recommend BCS (Liberati et a1., 1991).

Cancer Treatment in Clinical Trials

Clinical trials are the mechanism through which new technologies, pharmaceuticals, or therapeutic strategies are evaluated against current standards of care. For patients with cancer, clinical trials can provide access to the best available and most promising new treatments.

There are striking variations in age-specific rates of participation in cancer clinical trials: more than 70 percent of children with cancer participate, but fewer than two percent of individuals age 50 and older with cancer participate in cooperative group clinical trials sponsored by the National Cancer Institute (Tejeda et al., 1996). Pediatric cancers are relatively rare and care within the context of a clinical trial has become standard practice (Simone and Lyons, in press). The elderly have historically been excluded from cancer clinical trials because of concerns about treatment complications or side effects, comorbid conditions, and interactions with current medications (although this has been changing).

Studies conducted to identify inequalities in access to clinical trials among racial or ethnic groups suggest that African Americans are represented in treatment trials, but underrepresented in screening and chemoprevention trials, in proportion to their age-specific rates of cancer (Bleyer et al., 1997a, b; Chlebowshi et al., 1993; Tejeda et al., 1996; Thompson et al., 1995). Negative attitudes toward medicine and research may inhibit African-American participation in clinical trials (Mouton et al., 1997; Robinson, 1996). The National Institutes of Health (NIH) Revitalization Act of 1993 specified that women, minorities, and other subpopulations must be



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