Columbia Undergraduate Science Journal Open-Access Publication | http://cusj.columbia.com 26 cusjVolume 5Spring 2011 Columbia Undergraduate Sci J http://cusj.columbia.edu O N C O LO G Y cusjcolumbia undergraduate science journalResearch Articles 27cusj Volume 5Spring 2011 Columbia Undergraduate Sci J http://cusj.columbia.edu O N CO LO G Y Relationships between Oncologist Gender, Participatory Decision Making, Anxiety and Breast Cancer Care Kevin Xu1,2,*, Allyson Weseley2 1Columbia College, Columbia University, New York, NY 10027; 2 Roslyn High School, Roslyn Heights, NY 11577 Abstract The discovery that adjuvant treatment (chemotherapy and radiotherapy) after lumpectomy contributes to high survival rates has been a groundbreaking development in modern breast cancer care. Participatory decision-making (PDM) is a communication style that involves active interactions and discourse between doctors and patients. Although the receipt of adjuvant therapy for various types of cancers has been found to be linked to differences in patient-physician com- munication, few studies have explored whether this relationship exists in breast cancer treatment. The present study, one VM�[OL�ÄYZ[�L_WSPJP[S`�[V�L_HTPUL�KLTVNYHWOPJ�HUK�WZ`JOVZVJPHS�MHJ[VYZ�[OH[�TH`�IL�YLSH[LK�[V�HKQ\]HU[�[YLH[TLU[�YH[LZ�� surveyed a sample of inner-city breast cancer patients (N = 105) about the type of care they received, assessing con- comitant levels of participatory decision making (PDM), and anxiety. The results demonstrated that patients who indi- cated higher PDM tended to have lower levels of anxiety (p < .01). Breast cancer patients who saw female oncologists were more likely to receive adjuvant treatment than breast cancer patients who saw male oncologists (p < .05). Contrary to popular belief, patients reported equivalent levels of PDM and anxiety regardless of their physician’s gender or their receipt of adjuvant treatment. The surprisingly low adjuvant treatment rates (45%) in this sample suggest pos- sible system failures in breast cancer care and indicate that more attention needs to be given to public education on the importance of receiving follow-up treatment in breast cancer care. Key words: Adjuvant treatment; anxiety; gender; lumpectomy; participatory decision making A!ecting more than 1.3 million people each year, breast cancer is the second most widespread cancer worldwide and kills more than 40,000 Americans annually (Jemal et al., 2003). A lumpectomy (breast conservation surgery) is the most common treat- ment for breast cancer and consists of the removal of a localized lump of cancerous growth on the breast. Adju- vant treatment is de"ned as the receipt of radiotherapy or chemotherapy after lumpectomy. Clarke et al. (2005) and the Early Breast Cancer Triallists’ Collaborative Group’s (2005) studies were amongst the "rst to "nd that adju- vant treatment after lumpectomy not only reduced breast cancer recurrence, but also signi"cantly raised breast can- cer survival rates. Numerous studies (Lantz et al., 2005; Morris et al., 2000; National Cancer Policy Board, 1999) have indicated that mastectomy, as opposed to adjuvant treatment, is “over-used,” which has been “labeled as a problem in terms of ‘over-treatment.’” Lantz and col- leagues’ (2005) study posited that the use of mastectomy in place of adjuvant treatment may be an indication of breast cancer patients’ “lack of decision involvement or control.” Participatory decision-making (PDM) is a recom- mended communication style that involves active inter- actions and dialogue between doctors and patients and is indicative of high degree of patients decision involve- ment in their health care (Cooper-Patrick et al., 1999). Several studies have shown that female patients have better communication with female physicians than with male physicians, leading some to speculate (Hershman et al., 2008; Lurie et al., 1993) whether female breast cancer patients exhibit higher PDM and lower anxiety with female oncologists than with male oncologists. Past research has found that female patients undergoing breast cancer screening indicated higher PDM and felt less anx- ious when they had a female doctor than a male doctor (Lurie et al., 1993). Lurie and colleagues explained their "ndings by suggesting that female doctors at an obstet- rics-gynecology clinic may be more e!ective in dealing with female patients’ emotional stress and gender-speci"c concerns pertaining to breast health. Other studies have also provided evidence that female breast cancer patients Copyright: © 2011 The Trustees of Columbia University, Columbia University Libraries, some rights reserved, Puru- shothaman, et al. Received Jan. 2, 2011. Accepted Jan. 31, 2011. Published April 1, 2011. *To whom correspondence should be addressed: kyx2001@columbia.edu Introduction Materials and Methods may feel more comfortable talking with female oncolo- gists and may feel less nervous regarding their medical condition than with male oncologists (Roter et al., 1991; Stevens et al., 1996). It has also been ascertained that cancer patients who report better communication with their oncologists tend to have less anxiety (Meeuwesen et al., 1991; Stevens et al., 1996). In an attempt to respect patients’ rights and to address their anxiety, medical communication in re- cent years has become progressively less “paternalistic” by encouraging patients, instead of their doctors, to make decisions about their medical care. #is increasingly patient-centered type of patient-physician dynamic has been found to contribute to increased levels of PDM (Guadagnoli & Ward, 1998; #ompson, 2007). Given that research on determinants of the use of breast can- cer adjuvant treatment remains a relatively new "eld, no research to date has examined di!erences in PDM and anxiety between breast cancer patients who received ad- juvant treatment and those who did not receive adjuvant treatment. Understanding PDM may give doctors an op- portunity to learn about patients’ comorbidities and take patients’ personal concerns into consideration before de- ciding on a medical treatment. In addition, few studies have examined factors that are related to adjuvant treat- ment rates, perhaps due to the recent nature of Clarke et al.’s (2005) "ndings on the tangible bene"ts of adjuvant treatment on breast cancer survival. We hypothesized that: 1. Compared to breast can- cer patients with male oncologists, patients with female oncologists would indicate: (a) higher PDM, (b) higher rates of adjuvant treatment, and (c) less anxiety. 2. Com- pared to patients who did not receive adjuvant treatment, patients who received adjuvant treatment would indicate: (a) higher PDM and (b) lower anxiety. #e present study seeks to examine whether the gender of patients’ oncolo- gists is related to patient anxiety, breast cancer adjuvant treatment rates, and the quality of patient-physician communication. Participants During the fall of 2008, the American Cancer Society (ACS) Patient Database was utilized to randomly select 240 breast cancer patients to be surveyed through the mail. #e sample for this study consisted of 105 female breast cancer patients who had been diag- nosed with and treated for the disease in the past All participants N = 105 N % Age group 40-54 48 45.7 55-69 41 39.0 70-90 16 15.2 Race Caucasian 52 49.5 African American 25 23.8 Hispanic 16 15.2 Asian 10 9.5 Other/Mixed 2 1.9 Borough of residence Brooklyn 76 72.4 Staten Island 29 27.6 Breakdown of treatment Lumpectomy by itself 50 47.6 Mastectomy followed by chemotherapy 6 5.7 Mastectomy followed by radiotherapy 2 1.9 Mastectomy by itself 0 0 Lumpectomy followed by Chemotherapy 15 14.3 Lumpectomy followed by radiotherapy 32 30.5 1 Table 1 Demographic and clinical characteristics of study participants O N CO LO G Y Columbia Undergraduate Science Journal Open-Access Publication | http://cusj.columbia.com 28 cusjVolume 5Spring 2011 Columbia Undergraduate Sci J http://cusj.columbia.edu cusjcolumbia undergraduate science journalResearch Articles 29cusj Volume 5Spring 2011 Columbia Undergraduate Sci J http://cusj.columbia.edu O N CO LO G Y two years, a response rate of 44%. All participants were diagnosed with breast cancer in stages I-III and were thus eligible for adjuvant treatment. Pre- vious studies on PDM and anxiety of breast cancer patients have used similar sample sizes (e.g., Hall et al., 1993; Stewart, 1984). All participants resided in the New York City boroughs of Brooklyn or Staten Island, New York, which have some of the highest rates of advanced cancer staging in the United States (Susan G. Komen for the Cure, 2009). All participants were members of the American Cancer Society who attended support groups in the past or worked with the American Cancer Society’s patient and family services at local hospitals. As seen in Table 1, participants’ ages ranged between 40 and 90; the average age of the participants was 58 years. All par- ticipants had medical insurance and had incomes ranging from $30,000 to $60,000 per year. Procedure Prior to conducting this study, the procedure was ap- proved by the Institutional Review Board of the Roslyn Union Free School District and also was approved by the directors of both American Cancer Society sites. Partici- pants’ responses in the survey were anonymous to protect their privacy. Because data were collected through the American Cancer Society, which o!ers counseling and support services to those su!ering from cancer, patients who experienced possible stress while completing the survey had access to appropriately trained professionals. Preceding data collection, a pilot study was conducted at the Staten Island American Cancer Society (ACS) by the investigators in this study. "e ACS sta! distributed the Patient Medical Care Questionnaire to 30 breast can- cer patients involved in the ACS breast cancer support programs. After completing the survey, participants were asked to give feedback on the comprehensibility of the survey’s items. Because participants indicated that several items contained medical jargon that made parts of the survey di#cult to understand, the language of the Pa- tient Medical Care Questionnaire was simpli$ed and was expert-reviewed by one of the authors of the Rochester Participatory Decision-Making Scale. "e revised Patient Medical Care Questionnaire was then distributed to members of the ACS sta! in Brooklyn and Staten Island, who mailed the questionnaire to po- tential participants, and the researchers visited the ACS sites weekly to monitor the data collection process. To increase the response rate, a stamped, addressed return envelope was provided to participants. Completed sur- veys were mailed to the researchers between August 2008 and November 2008. Materials "e $rst section of the survey, participants indicated the gender and race of their oncologists and themselves and whether they had received a lumpectomy, radiother- apy, chemotherapy, or mastectomy. Because breast cancer adjuvant treatment is most commonly de$ned as adju- vant radiotherapy or chemotherapy following lumpec- tomy (Clarke et al.. 2005; Early Breast Cancer Triallists’ Collaborative Group, 2005), only participants who re- ceived a lumpectomy preceding their receipt of adjuvant treatment were classi$ed as having received adjuvant treatment. In the data analysis, participants who received a mastectomy were not classi$ed as having received adju- vant treatment. In the second section of the questionnaire, partici- pants completed a PDM and anxiety scale. To minimize response bias, items from the two scales were mixed throughout the survey. All items were answered on a 6-point bipolar scale ranging from 1 (indicating that a speci$c event “almost never” occurred) to 6 (“almost al- ways” occurred). "e PDM Scale consisted of 13 items (e.g., “"ere are times when I don’t understand my oncologist’s medical language”, see Appendix). Seven items were modeled after the Rochester Participatory Decision-Making Scale (Shields et al., 2005). We created six additional items to measure cross-cultural medical communication and de- lays in medical treatment since past research has noted that these are crucial components of PDM (Cooper- Patrick et al., 1999). Six items on the PDM Scale were reverse-scored. To assess the scale’s internal reliability, the researchers calculated a Cronbach’s alpha. "e PDM scale had a Cronbach’s alpha of .82 on this study’s sample. "e PDM Scale was then scored by taking the mean of the 13 items. "e Anxiety Scale consisted of four items, two of which were modeled after items on the Hospital Anxiety and Depression Scale (Snaith, 2003), and the other two items were created for this study. An example of an item from the Anxiety Scale is “Even if I try not to worry, I still feel frightened about my medical condition.” "e scale had a Cronbach’s alpha of .70 on this study’s sample. "e Anxiety Scale was scored by taking the mean of the four items after correcting for reverse-scoring. Data Analysis Statistical tests were run on the aggregate survey scores of each patient as opposed to the scores from each ques- tion separately. A chi-square test was used to examine hy- pothesized di!erences in adjuvant treatment rates between breast cancer patients of male oncologists and patients of female oncologists. While this study did not hypothesize a correlation between PDM and anxiety, a correlation coe#cient was calculated to quantify the extent of asso- ciation between PDM and anxiety. Independent sample t-tests were used to examine the di!erences in the PDM and anxiety of patients who received versus those who did not receive adjuvant treatment. T-tests were also run to analyze the di!erences in the PDM and anxiety of patients of male oncologists and those of female oncologists. Because the hypotheses were all directional, all statistical tests were one-tailed. "e cuto! for statistical signi$cance was p=0.05. Statis- tical Package for Social Sciences Version 16.0 (SPSS 16.0) was utilized to analyze the data. 37 51 0 10 20 30 40 50 60 70 80 90 100 Male Female Oncologist Gender S ta n d a r d C a r e R a te ( % ) Figure 1 (�Z[H[PZ[PJHSS`�ZPNUPÄJHU[�KPMMLYLUJL�^HZ�MV\UK�IL[^LLU�[OL���VM�MLTHSL�VUJVSVNPZ[Z»�WH[PLU[Z��� ����������^OV�YLJLP]LK�HKQ\]HU[� [OLYHW`�HUK�[OL���VM�THSL�VUJVSVNPZ[Z»�WH[PLU[Z�YLJLP]LK�HKQ\]HU[�[YLH[TLU[���������������_õ� ���$�������W�#���� 1 2 3 4 5 6 1 2 3 4 5 6 PDM A n x ie ty Figure 2 /PNOLY�WHY[PJPWH[VY`�KLJPZPVU�THRPUN�^HZ�MV\UK�[V�IL�ZPNUPÄJHU[S`�JVYYLSH[LK�^P[O�SV^LY�SL]LSZ�VM�HU_PL[ �̀�Y�$��������W�#����� Columbia Undergraduate Science Journal Open-Access Publication | http://cusj.columbia.com 30 cusjVolume 5Spring 2011 Columbia Undergraduate Sci J http://cusj.columbia.edu O N CO LO G Y cusjcolumbia undergraduate science journalResearch Articles 31cusj Volume 5Spring 2011 Columbia Undergraduate Sci J http://cusj.columbia.edu O N CO LO G Y Relationship of Oncologist Gender to Adjuvant Treatment As seen in Table 1, 47 of all 105 participating breast cancer patients received adjuvant treatment (lumpectomy followed by either radiotherapy or chemotherapy). Fifty of the 105 participants re- ceived a lumpectomy with no follow-up treatment. About one-half -- 52% (50/97) -- of patients who received a lumpectomy did not receive adjuvant treatment. A chi-square test revealed that oncolo- gist gender was associated with the likelihood of patients’ receiving of adjuvant treatment, x!(96) = 3.41, p < .05. As seen in Figure 1, patients of female oncologists tended to receive adjuvant treatment at higher rates (19/37, 51%) than did patients of male oncologists (22/60, 37%). Relationship of PDM to Anxiety Higher levels of PDM were associated with lower levels of patient anxiety. "e results of a linear correlation are seen in Figure 2, which shows that patients who indi- cated higher PDM with their physicians tended to report lower levels of anxiety related to their medical treatment, r = -0.38, p < .01. Relationship of Oncologist Gender to Anxiety and PDM Overall, participants indicated high levels of PDM with an average rating of 4.50 out of 6.00. As seen in Figure 3, the results of an independent samples t-test show that patients of male and female oncologists re- ported similar levels of PDM, t(94) = 0.64, p =.52. As seen in Figure 4, contrary to hypotheses, patients of male and female oncologists reported similar levels of anxiety t(103) = -1.42, p = .17. Relationship of Adjuvant Treatment to Anxiety and PDM Contrary to predictions, an independent samples t- test indicates that there were no signi#cant di$erences in PDM between patients who received adjuvant treatment (M = 4.46) and those who did not (M = 4.53), t(94) = -0.43, p = .62 (Figure 5). As seen in Figure 6, patients who received adjuvant treatment reported marginally less anxiety (M = 3.71) than those who did not receive adju- vant treatment (M = 4.10), t(103) = 1.57, p = .09. Only 48% of participating breast cancer patients re- ceived adjuvant treatment. Researchers have found that patients from urban areas are not only 54% more likely to be diagnosed with breast cancer but also are more like- ly to face complications in breast cancer treatment and higher mortality than patients elsewhere, re%ective of low adjuvant treatment rates (Ayanian et al. 1993; Fiscella et al., 2000). "e largest group of participants who did not receive adjuvant treatment (48%, N = 51) received a lumpectomy, indicating that patients failed to receive follow-up treatment. A recent study examined dispari- ties in adjuvant treatment and provided a potential ex- planation for this low adjuvant treatment rate (Bickell & Cohen, 2008). "ey attributed patients’ failure to obtain follow-up treatment for breast cancer to a systems fail- ure in which oncologists fail to comply with referrals and communicate with other specialists (e.g., surgeons, radi- ologists) in the cancer treatment #eld. As expected, breast cancer patients of female oncolo- gists were more likely to receive adjuvant treatment than patients of male oncologists. Recent literature has dem- onstrated that female oncologists may be more pro#cient at communicating with their fellow medical profession- als of either gender, ranging from nurses to specialists (Levinson & Lurie, 2004). "us it may be that female oncologists’ greater emphasis on teamwork and coopera- tion with their peers may contribute to fewer sys- tems failures and therefore higher rates of follow-up treatments. Given the study’s correlational nature, it is possible that female and male oncologists, in fact, recommend adjuvant treatment at equal rates. Breast cancer patients may be adhering to physician recommendations more frequently if their physi- cian is a female, as opposed to male. Alternatively, previous studies have noted that female oncologists tend to be younger than male Discussion Results 4.56 4.46 1 2 3 4 5 6 Male Female Oncologist Gender P D M Figure 3 5V�ZPNUPÄJHU[�KPMMLYLUJLZ�^LYL�MV\UK�IL[^LLU�[OL�TLHU�7+4�ZJVYLZ�VM�THSL�VUJVSVNPZ[Z»�WH[PLU[Z��4�$�������HUK�MLTHSL�VUJVSVNPZ[Z»� WH[PLU[Z��4�$��������[� ���$�������W�$���� 3.72 4.07 1 2 3 4 5 6 Male Female Oncologist Gender A n x ie ty Figure 4 5V�ZPNUPÄJHU[�KPMMLYLUJLZ�^LYL�MV\UK�IL[^LLU�[OL�HU_PL[`�VM�THSL�VUJVSVNPZ[Z»�WH[PLU[Z��4�$�������HUK�[OL�HU_PL[`�VM�MLTHSL�VUJVSV- NPZ[Z»�WH[PLU[Z��4�$��������[������$��������W�$����� 4.534.46 1 2 3 4 5 6 Yes NoStandard Care P D M Figure 5 5V�ZPNUPÄJHU[�KPMMLYLUJLZ�^LYL�MV\UK�IL[^LLU�[OL�7+4�VM�WH[PLU[Z�^OV�YLJLP]LK�HKQ\]HU[�[YLH[TLU[��4�$�������HUK�WH[PLU[Z�^OV�KPK� UV[�YLJLP]L�HKQ\]HU[�[YLH[TLU[��4�$��������[� ���$���������W�$����� Columbia Undergraduate Science Journal Open-Access Publication | http://cusj.columbia.com 32 cusjVolume 5Spring 2011 Columbia Undergraduate Sci J http://cusj.columbia.edu O N CO LO G Y 33cusj Volume 5Spring 2011 Columbia Undergraduate Sci J http://cusj.columbia.edu cusjcolumbia undergraduate science journalResearch Articles oncologists and may be more familiar with new devel- opments in breast cancer treatment that emphasize the importance of adjuvant treatment(Lurie et al., 1993; Me- chanic et al., 2001). Because the present study gathered data directly from patients who did not know their doc- tors’ ages, this variable was not examined. However, de- spite controlling for oncologist age, one study (Cooper- Patrick et al., 1999) found that female oncologists are more likely to o!er breast cancer adjuvant treatment than their male counterparts. Still, to investigate this possibil- ity in future studies, data should be gathered on oncolo- gists’ ages. As expected, participants who indicated high levels of PDM tended to report less anxiety. A wealth of research (e.g., Cooper-Patrick et al., 2008; Stevens et al., 1996) has found that patients who have the opportunity to actively participate with their physicians in their health care tend to feel less anxious about their medical condi- tion. "is #nding challenges the “paternalistic” model of patient-physician communication by highlighting a po- tential emotional bene#t of PDM. However, it is important to note that this #nding is correlational. Whereas most research suggests that PDM leads to lower anxiety, it is possible that high anxiety leads to lower PDM or that both PDM and anxiety are confounded by a third factor such as breast cancer patient age. Contrary to predictions, patients of female on- cologists indicated equivalent levels of anxiety as patients of male oncologists. Breast cancer patients ex- perience a great deal of anxiety and believe that their on- cologists’ technical skill is the most important aspect of their medical care (Stevens et al., 1996; Wiggers, et al., 1990). Despite any di!erences patients may perceive be- tween male and female oncologists, they may view them similarly in terms of technical skill, contributing to simi- lar anxiety ratings. In addition to #nding no di!erences in PDM between patients who received adjuvant treatment and those who did not, we also found that patients of female oncologists indicated equivalent levels of PDM as patients of male oncologists. Female patients in general tend to ask their oncologists more questions and exhibit more interest in their medical treatment than do male patients (Elderkin- "ompson & Waitzkin, 1999). However, it has been sug- gested that oncologists, regardless of their genders, may be sensitive to female breast cancer patients’ desire for a highly communicative style of care, contributing to equivalent levels of participatory decision making (Coo- per-Patrick et al., 1999). Participants who received adjuvant treatment indicat- ed marginally lower levels of anxiety relative to those who did not. Because the #nding is correlational, the causal agent is unclear. It is possible that patients who receive adjuvant treatment may have lower levels of anxiety be- cause they are receiving a higher quality of cancer care. Alternatively, patients with lower levels of anxiety may be more likely to obtain follow-up treatment in breast can- cer care and complete their medical treatment. Limitations and Further Study Although this study drew from a random sample of breast cancer patients generated by the American Cancer Society’s Siebel database, all participants were active ACS members whose ideas and views may not be representa- tive of the general population of breast cancer patients. "e study’s overall response rate of 44% is an issue of concern because low response rates typically result in unrepresentative samples. However, it should be noted that this study had a comparable response rate to similar studies surveying breast cancer patients (e.g., Cyran et al., 2001; Frank & Clancy, 1993). "e participants’ high PDM suggests that they may not be re$ective of the population of breast cancer pa- tients in the New York City boroughs. Urban cancer patients tend to face problems in medical care that are characteristic of low PDM, including short medical visits and long wait times (Mehta et al., 2008). "e generaliz- ability of our study’s #ndings was also limited in that all the participants’ were members of the American Cancer Society, and all were insured. Because an optional mail survey was utilized, volunteer bias may have impacted the results. Participants who were more likely to respond may have felt stronger positive or negative feelings towards their oncologists and their medical treatments. In an era in which medical treatment can be a!ected drastically by the insurance providers of the patients, it would be valuable to investigate potential associations of patients’ insurance coverage with adjuvant treatment rates and PDM. Whereas past research has found insurance- based discrepancies in breast cancer screening (Ayanian et al., 1993), studies have yet to examine associations be- tween breast cancer adjuvant treatment and insurance. In addition, due to #ndings that patients and physicians of the same race to have higher PDM than those of di!er- ent races (e.g., Murray-Garcia et al., 2000), future studies should examine potential di!erences in adjuvant treat- ment rates and anxiety between race concordant versus discordant patients and physicians. "is is one of the #rst studies to date to examine psy- chosocial and demographic factors that may be related to adjuvant treatment rates. Contrary to the assumptions of past studies (e.g., Johnson et al., 1988; Lurie et al., 1993), this study found that PDM between oncologists and patients is not related to adjuvant treatment. "e surprisingly low adjuvant treatment rates (48%) in this sample suggest possible system failures in breast cancer care and indicate that more attention needs to be given to educating people about the importance of follow-up treatment in breast cancer care. In addition, this study’s #nding that breast cancer patients who select female on- cologists are more likely to receive breast cancer adjuvant treatment highlights the need for more research to probe the cause of di!erences in adjuvant treatment rates. Ayanian, J, Kohler, B, Abe, T, Epstein, A (1993). "e relation between health insurance coverage and clinical outcomes among women with breast cancer. New Eng- land Journal of Medicine 329 326-331. Bickell, N, and Cohen, A (2008). Understanding rea- sons for underuse: an approach to improve quality of care and reduce disparities in breast cancer treatment. Mt. Si- nai Journal of Medicine 72 23-30. Clarke, M, Collins, R, Darby, S, Davies, C, El- phinstone P, et al. (2005). E!ects of radiotherapy and of di!erences in the extent of surgery for early breast cancer on local recurrence and 15-year sur- vival. Lancet 366 2087-2106. Cooper-Patrick, L, Gallo, J, Gonazlez, J, Vu, H, Powe, N, et al. (1999). Race, gender and part- nership in the patient-physician relationship. "e Journal of the American Medical Association 282 583-589. Cyran, E, Crane, L, and Palmer, L (2001). Physician sex and other factors associated with type of breast cancer surgery in older women. Annals of Surgery 136 185-191. Elderkin-"ompson, V, and Waitzkin, H (1999). Dif- ferences in clinical communication by gender. Journal of General Internal Medicine 14 112-121. Fiscella, K, Frank, P, Gold, M, and Clancy, C (2000). Addressing socioeconomic, racial, and ethnic disparities in health care. Journal of the American Medical Associa- tion 283 2579-2584. Guadagnoli, E, and Ward, P (1998). Patient partici- pation in decision-making. Social Science Medicine 47 329-339. Frank, P, and Clancy, C (1993). Physician gender bias in clinical decision-making: screening for cancer in pri- mary care. Medical Care 31 213-218. 4.13.71 1 2 3 4 5 6 Yes No Standard Care A n x ie t y Figure 6 7H[PLU[Z�^OV�YLJLP]LK�HKQ\]HU[�[YLH[TLU[�OHK�THYNPUHSS`�SV^LY�SL]LSZ�VM�HU_PL[`��4�$�������[OHU�WHY[PJPWHU[Z�^OV�KPK�UV[�YLJLP]L�HKQ\- ]HU[�[YLH[TLU[��4�$��������[������$�������W�$��� � Conclusion References O N CO LO G Y Low energy surface acoustic waves (SAW) have been shown to reduce bio!lm formation on urinary catheters in rabbits (Hazan et al., 2006). Recently, the FDA has approved SAW as a safe method to enhance wound heal- ing (Howell-Taylor et al, 2008). Low-energy SAW devic- es generate and spread vibrational energy at frequencies of 100 to 300 kHz and amplitudes of 300 to 800 nm. "e waves are propagated uniformly and in all directions, covering the entire system (Hazan et al., 2006). We hy- pothesized that the e#ectiveness of SAW was based on an underlying immunological mechanism since it showed clinical use in wound and bone healing, processes which involve immune cells. While there is no current research on the impact of SAW on immune cell function, recent unpublished studies in our lab have shown that SAW sig- ni!cantly improves the capacity of human neutrophils, which are innate immune cells, to kill bacteria within a three-dimensional in vitro !brin gel environment. Based on these results, it was hypothesized that SAW enhanced bacterial killing in a tissue-like matrix by facilitating chemotaxis of neutrophils; the mechanical vibrations induced by SAW may cause activation of neutrophil through an unidenti!ed mechanoreceptor. Since SAW appeared to enhance neutrophil function, we wanted to examine if other immune cells could also be stimu- lated by SAW. T-cells constitute an important arm of the adaptive immune system and are ubiquitous- ly involved in defense against cancerous cells. We extended our study to examine whether SAW has an e#ect on T-cells’ ability to kill melanoma tumor cells. Cutaneous melanoma is a type of skin cancer. Each year, the incidence of cutaneous melanoma continues to escalate, with over 50,000 new cases being diagnosed within the United States in one year. Approximately 10- 20% of all such melanomas are located in the head and neck region and mortality is growing at a very high rate, second only to that of lung cancer. In most cases, excision of the tumor is the best treatment option available to pa- tients (Rigel et al, 2000). "e application of SAW can of- fer a treatment alternative perhaps not for serious cases of melanoma in which lesions must be immediately excised, Columbia Undergraduate Science Journal Open-Access Publication | http://cusj.columbia.com 34 cusjVolume 5Spring 2011 Columbia Undergraduate Sci J http://cusj.columbia.edu O N C O LO G Y cusjcolumbia undergraduate science journalResearch Articles 35cusj Volume 5Spring 2011 Columbia Undergraduate Sci J http://cusj.columbia.edu CA N C ER BIO LO G Y Surface acoustic waves cause net reduction in mouse and human melanoma growth in vitro Komal Kothari1,*, Jona Zumeris2,, Harold Jacob2, John Loike3* 1Department of Biological Sciences, Columbia University, New York, NY 10027, 2NanoVibronix, Nesher, Israel 36603; 3Depart- ment of Physiology and Cellular Biophysics, Columbia University College of Physicians and Surgeons, New York, NY 10032. . Low-energy surface acoustic waves (SAW) have been shown to be effective in curing urinary catheter infections and in enhancing neutrophil killing of bacteria. Here, we examined whether cellular immunity, the killing of melanoma tumor cells by T-cells, can be enhanced with the application of SAW. From the preliminary data, it appears that SAW is capable of reducing mouse and human melanoma cell growth independently of T-cell activity. In the B16 mouse melanoma model, NYV^[O�PU�:(>�[YLH[LK�JVSSHNLU�ÄIYPU�NLSZ�^HZ�YLK\JLK�I`�����H[�+H`���HUK�I`�����H[�+H`���^OLU�JVTWHYLK�[V�NYV^[O� PU�JVU[YVS�JVSSHNLU�ÄIYPU�NLSZ��(�7YVWPKP\T�0VKPKL�HZZH �̀�^OPJO�Å\VYLZJLZ�KLHK�JLSSZ��Z\NNLZ[LK�[OH[�[OL�HWWSPJH[PVU�VM� SAW kills B16 cells directly, since the SAW-treated gels showed almost twice the percentage of dead cells (44.25%) as compared to the control gels (26.09%). In addition, SAW-treated A375 cells, or human melanoma cells, showed ap- WYV_PTH[LS`�H�����YLK\J[PVU�PU�NYV^[O�PU�JVSSHNLU�ÄIYPU�NLSZ�PU�JVTWHYPZVU�[V�NYV^[O�PU�JVU[YVS�NLSZ��;�JLSS�RPSSPUN�HUK� migration experiments performed with B16s in the presence or absence of SAW showed that SAW seems to adopt an independent mechanism in killing B16 melanoma cells, while enhancing T-cell chemotactic capacity. Our future experiments involve studying the effect of SAW on other types of dermatological cancers and understanding the underlying mechanisms of SAW in reducing tumor cell growth. Key words: surface acoustic waves, melanoma, T-cells. Abstract Introduction Copyright: © 2011 The Trustees of Columbia University, Colum- bia University Libraries, some rights reserved, Thomas, et al. Received Jan. 2, 2011. Accepted Jan. 26, 2011. Published April 1, 2011. *To whom correspondence should be addressed: Department of Physiology and Cellular Biophysics, College of Physicians and Surgeons, Columbia University, New York, NY 10032. krk2122@columbia.edu Hall, J, Epstein, A, DeCiantis, M, and McNeil, B (1993). Physicians’ liking for their patients: more evi- dence for the role of a#ect in medical care. Health Psy- chology 12 140-146. Hershman, D, Buono D, McBride R, Tsai W, Joseph K, et al. (2008). Surgeon characteristics and the receipt of adjuvant radiotherapy in women with breast cancer. Journal of the National Cancer Institute 100 199-206. Jemal, A, Murray, T, and "um, M (2003). Cancer sta- tistics. CA: A Cancer Journal for Clinicians 53 5-26. Johnson, J, Nail, L, Lauver, D, King K, and Keys, H (1988). Reducing the negative impact of radiation thera- py on functional status. Cancer 61 46-51. Lantz, P, Janz, N, Fagerlin, A, Schwartz K, Liu, L, et al. (2005). Satisfaction with surgery outcomes and the deci- sion process in a population-based sample of wom- en with breast cancer. Health Services Research 40 745-768. Levinson, W, and Lurie, N (2004). When most doctors are women: what lies ahead? Annals of In- ternal Medicine 141 471-474. Lurie, N, Slater, J, McGovern, P, Ekstrum, J, Quam, L, et al. (1993). Preventive care for women – does the sex of the physician matter? "e New England Journal of Medicine 329 478-482. Mechanic, D, McAlpine, D, and Rosenthal, M (2001). Are patients’ o$ce visits with physicians getting shorter? "e New England Journal of Medicine 344 198-204. Meeuwesen, L, Schaap, C, and van der Staak, C (1991). Verbal analysis of doctor-patient communication. Social Science Medicine 32 1143-1150. Mehta, R, Liang, L, Karve, A, Hernandez, A, Rums- feld, J, Fonarow, G, et al. (2008). Association of patient case-mix adjustment, hospital process performance rank- ings, and eligibility for !nancial incentives. Journal of the American Medical Association 300 1897-1903. Morris C, Cohen R, Schlag R, Wright, W (2000). In- creasing trends in the use of breast-conserving surgery in California. American Journal of Public Health 90 281-4. Murray-Garcia, J, Selby, J, Schmittidiel, J, Grumbach, K (2000). Racial and ethnic di#erences in a patient sur- vey. Medical Care 38 300-310. National Cancer Policy Board. Institute of Medicine and National Regional Council. In: Ensuring Quality Cancer Care. Hewitt M, Simone JV, editors. Washing- ton, DC: National Academy Press; 1999. Roter, D, Lipkin, M, Korsgaard, A (1991). Sex di#er- ences in patients’ and physicians’ communication during primary care medical visits. Medical Care 29 1083-1093. Shields, C, Frank, P, Fiscella, K, Meldrum, S, and Ep- stein, R (2005). Rochester participatory decision-making scale (RPAD): reliability and validity. Annals of Family Medicine 3 436-442. Snaith, R (2003) Hospital anxiety and depression scale. Health and Quality of Life Outcomes 2 1-4. Stevens, F, Courtens, A, Crebolder, H, and Philipsen, H (1996). Longitudinal study on quality of life and social support in cancer patients. Cancer Nursing 19 162-169. Stewart, M (1984). Patient characteristics which are related to the doctor-patient interaction. Family Practice 1 30-6. Susan G. Komen for the Cure (2009). New York City Community Pro!les. Retrieved October 13, 2009 from the Susan G. Komen for the Cure New York City Af- !liate website: http://www.komennyc.org/site/DocServ- er/2009_Community_Pro!le_Report_FINAL_for_Web. pdf?docID=3341. Early Breast Cancer Triallists’ Collaborative Group (2005). E#ects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomized trials. Lancet 365 1687- 717. "ompson, A (2007). "e meaning of patient involve- ment and participation in health care consultations. So- cial Science and Medicine 64 1297-1310. Wiggers, J, Donovan, K, Redman, S, and Sanson- Fisher, R (1990). Cancer patient satisfaction with care. Cancer 66 610-616.