Elizabeth Ward | National Cancer Institute (original) (raw)

Papers by Elizabeth Ward

Forty-five years after the World Health Organization recognized cancer as a world health problem ... more Forty-five years after the World Health Organization recognized cancer as a world health problem by creating the International Agency for Research on Cancer (IARC), carcino genic exposures in the workplace remain a concern. Many known and suspected carcinogens are found in today’s workplaces, and uncertainties about the health effects of exposure to these hazards have delayed regulatory action and the search for safer alternatives. In this review we focus primarily on chemicals, metals, dusts, and physical agents for which there is widespread human exposure, predominantly in occupational settings, and we address unresolved questions regarding carcino genicity. Most of these agents are in IARC Groups 2A and 2B—agents for which there is sufficient evidence of carcinogenicity in animals but limited evidence for carcinogenicity in humans. A project to systematically identify data gaps was initiated by the National Occupational Research Agenda team of the U.S. National Institute for Occu...

The Laryngoscope, Jan 4, 2018

The objectives of the study were to develop a mealtime experience self-assessment questionnaire t... more The objectives of the study were to develop a mealtime experience self-assessment questionnaire that was head and neck cancer (HNC) survivors-driven and based on the International Classification of Functioning, Disability and Health (ICF) framework, and to identify common mealtime issues reported by HNC survivors. Outcomes research. Mealtime issues reported by HNC survivors in prior research was synthesized and classified using the ICF framework to develop the content and structure of the Head and Neck Cancer Survivors' Assessment of Mealtimes (HNSAM). A total of 122 HNC survivors completed both HNSAM and M.D. Anderson Dysphagia Inventory (MDADI) to assess for concurrent validity, whereas 51% of participants completed a second HNSAM for test-retest reliability. The HNSAM scores were significantly correlated with the MDADI scores. Dysphagic participants (n = 45) had significantly higher HNSAM scores than the nondysphagic participants (n = 77). Principal component analysis reveale...

Head & neck, Jun 1, 2017

Studies support using intraoperative voice prosthesis insertion performed at the time of primary ... more Studies support using intraoperative voice prosthesis insertion performed at the time of primary tracheoesophageal puncture (TEP) during laryngectomy. However, none have compared intraoperative voice prosthesis insertion with delayed voice prosthesis insertion. The purpose of this study was to prospectively examine patient, services, and cost benefits of intraoperative versus delayed voice prosthesis placement. Voice prosthesis use, duration to the first voice prosthesis change, early communication, and costs were compared between 14 patients who underwent a laryngectomy and who received intraoperative voice prosthesis placement, and 10 patients who underwent initial catheter stenting and then delayed voice prosthesis insertion. Intraoperative voice prosthesis placement was associated with significantly fewer early device changes (1.4 vs 2), voice prosthesis changes because of resizing (8% vs 80%), longer durations to initial voice prosthesis change (159.7 vs 24.5 days), earlier com...

Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer, 2018

Patients who receive (chemo)radiotherapy [(C)RT] for head and neck cancer (HNC) experience multip... more Patients who receive (chemo)radiotherapy [(C)RT] for head and neck cancer (HNC) experience multiple treatment effects. However, the presence and recovery of treatment toxicities and how these impact on oral intake over time post-treatment are not fully understood. The primary aim of this study was to examine patient perceptions of the toxicities present and which are barriers to oral intake, up to 3 years post (C)RT. The secondary aim was to identify mealtime strategies used to optimise oral intake. A prospective cohort of 96 patients after completion of (C)RT for HNC reported the presence of toxicities, if they were barriers to oral intake, and use of any mealtime strategies at the end of treatment (EoT), and at 3, 6, 12, 24, and 36 months post-treatment. All toxicities and reported barriers changed over time (p < 0.05) except trismus. Odynophagia, reduced appetite, and fatigue improved (p < 0.05) by 3 months. Significantly less patients reported xerostomia and dysgeusia as b...

Head & neck, Jan 13, 2018

Conformal radiotherapy modalities may minimize treatment toxicities. The purpose of this study wa... more Conformal radiotherapy modalities may minimize treatment toxicities. The purpose of this study was to document the extent and timing of dysphagia and related toxicities during helical intensity-modulated radiotherapy (IMRT) with chemotherapy for oropharyngeal squamous cell carcinoma (SCC). We conducted a prospective study of 76 patients with oropharyngeal SCC undergoing helical IMRT with chemotherapy. Dysphagia and acute toxicity data were collected weekly during treatment and at 2, 4, and 12 weeks posttreatment using the Functional Oral Intake Scale, diet descriptors, and Common Terminology Criteria for Adverse Events (CTCAE) version 4.0. Patients experienced maximum incidence of grade 3 dysphagia (61%), mucositis (30%), and thick saliva (38%), with grade 2 xerostomia (87%) and dysgeusia (97%). Only 14.5% were nil-by-mouth. Symptoms peaked in week 7 and improved thereafter. Grade 3 dysphagia was twice as common for T3 to T4 tumors compared with T2. Results confirm that patients wit...

Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer, Jan 17, 2018

Reports of acute treatment-related dysphagia and toxicities for patients with parotid tumours or ... more Reports of acute treatment-related dysphagia and toxicities for patients with parotid tumours or cutaneous head and neck cancer (HNC) are limited. This study aimed to describe the severity and timing of dysphagia and related toxicities experienced during radiotherapy for cutaneous HNC and parotid tumours, to inform the nature of future speech pathology (SP) service models required during treatment. Prospective study of 32 patients with parotid tumours and 36 with cutaneous HNC undergoing curative non-surgical management. Dysphagia and acute toxicity data was collected weekly during treatment and at 2, 4 and 12 weeks post-treatment using the Functional Oral Intake Scale, diet descriptors and CTCAE v4.0. In both groups, minimal treatment toxicities (grades 0-1) were observed. Xerostomia and dysgeusia were the most frequently reported grade 2 toxicities. Only 3% of parotid patients and 6% with cutaneous HNC experienced grade 3 dysphagia. Full or soft texture diets were maintained by &g...

Journal of the National Cancer Institute, Jan 9, 2017

Glyphosate is the most commonly used herbicide worldwide, with both residential and agricultural ... more Glyphosate is the most commonly used herbicide worldwide, with both residential and agricultural uses. In 2015, the International Agency for Research on Cancer classified glyphosate as "probably carcinogenic to humans," noting strong mechanistic evidence and positive associations for non-Hodgkin lymphoma (NHL) in some epidemiologic studies. A previous evaluation in the Agricultural Health Study (AHS) with follow-up through 2001 found no statistically significant associations with glyphosate use and cancer at any site. The AHS is a prospective cohort of licensed pesticide applicators from North Carolina and Iowa. Here, we updated the previous evaluation of glyphosate with cancer incidence from registry linkages through 2012 (North Carolina)/2013 (Iowa). Lifetime days and intensity-weighted lifetime days of glyphosate use were based on self-reported information from enrollment (1993-1997) and follow-up questionnaires (1999-2005). We estimated incidence rate ratios (RRs) and ...

Journal of telemedicine and telecare, 2017

Introduction Following (chemo)radiotherapy (C/RT) for head and neck cancer (HNC), patients return... more Introduction Following (chemo)radiotherapy (C/RT) for head and neck cancer (HNC), patients return to hospital for regular outpatient reviews with speech pathology (SP) and nutrition and dietetics (ND) for acute symptom monitoring, nutritional management, and swallowing and communication rehabilitation. The aim of the current study was to determine the feasibility of a home-based telehealth model for delivering SP and ND reviews, to provide patients with more convenient access to these appointments. Methods Service outcomes, costs, and consumer satisfaction were examined across 30 matched participants: 15 supported via the standard model of care (SMOC), and 15 via the home-based telehealth model of care (TMOC). Results All patients were successfully managed via telehealth. The TMOC was more efficient, with a reduced number ( p < 0.003) and duration ( p < 0.01) of appointments required until discharge. Significant patient cost savings ( p = 0.002) were reported for the TMOC due ...

Head & neck, 2017

The purpose of this study is to report the economic outcomes of a new synchronous telepractice se... more The purpose of this study is to report the economic outcomes of a new synchronous telepractice service providing speech pathology intervention to patients with head and neck cancer at nonmetropolitan facilities. A multisite randomized controlled trial comparing standard care versus a new synchronous telepractice model was conducted within a large Australian public cancer service. Data pertaining to health service costs (staff wages, equipment, and patient travel reimbursement), patient +/- carer costs (travel and wages), and patient-reported quality of life (Assessment of Quality of Life questionnaire 4D) were collected. Eighty-two referrals (39 standard care and 43 synchronous telepractice care) were managed. The new telepractice service reported average cost savings of 12% (P < .0058) for the health service and $40.05 saving per patient per referral. An equivalent positive increase in quality of life (0.04) was reported for both groups. The synchronous telepractice service prov...

Preventive medicine, Jan 5, 2017

The present study examined educational disparities in mortality for 49 states and the District of... more The present study examined educational disparities in mortality for 49 states and the District of Columbia in the United States based on the 2010-2014 national mortality data. A total of 3,165,762 deaths at ages 25-74years were included in analysis. Absolute and relative disparities were estimated as Relative Index of Inequality (RII) and Slope Index of Inequality (SII), respectively, based on age-standardized death rates by education, race/ethnicity sex, and state. We found that educational disparities in mortality existed in every US state with varying magnitude across states and by sex. The disparities were generally larger in men than in women on both absolute and relative scales. Across states, for all races combined, the RII varied in the range of 4.2 to 14.9 in men and 3.2 to 10.1 in women; the SII (1/100,000 persons) ranged from 934.0 to 1633.4 in men and from 333.7 to 672.5 in women. Hispanic origin seems to alter the pattern of educational disparities by state. In non-Hisp...

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, Jan 16, 2017

Purpose To estimate the contribution of differences in demographics, comorbidity, insurance, tumo... more Purpose To estimate the contribution of differences in demographics, comorbidity, insurance, tumor characteristics, and treatment to the overall mortality disparity between nonelderly black and white women diagnosed with early-stage breast cancer. Patients and Methods Excess relative risk of all-cause death in black versus white women diagnosed with stage I to III breast cancer, expressed as a percentage and stratified by hormone receptor status for each variable (demographics, comorbidity, insurance, tumor characteristics, and treatment) in sequentially, propensity-scored, optimally matched patients by using multivariable hazard ratios (HRs). Results We identified 563,497 white and black women 18 to 64 years of age diagnosed with stage I to III breast cancer from 2004 to 2013 in the National Cancer Data Base. Among women with hormone receptor-positive disease, who represented 78.5% of all patients, the HR for death in black versus white women in the demographics-matched model was 2...

Journal of Telemedicine and Telecare, 2017

Introduction Telehealth offers a solution to assist delivery of occupational therapy (OT) service... more Introduction Telehealth offers a solution to assist delivery of occupational therapy (OT) services for hand therapy in rural and remote locations. However, there is currently no evidence to validate this service model. The aim of this study was to examine the validity of clinical decisions made during hand therapy sessions conducted via telehealth compared to a traditional clinical model (TCM) assessment, and explore patient and clinician satisfaction. Methods Eighteen patients referred for hand therapy to a rural/remote hospital-based outpatient service were assessed simultaneously via telehealth and a TCM assessment. An allied health assistant supported data collection at the patient end. Hand function was assessed using a range of objective measures, subjective scales and patient reported information. Minimal level of percent exact agreement (PEA) between the telehealth OT (T-OT) and the TCM-OT was set at ≥80%. Results Level of agreement for all objective measures (dynamometer an...

Nutrition & Dietetics, 2017

Aim: Malnutrition has a significant impact on patient outcomes and duration of inpatient stay. Ho... more Aim: Malnutrition has a significant impact on patient outcomes and duration of inpatient stay. However, conducting timely nutrition assessments can be challenging for rural dietitians. A solution could be for allied health assistants (AHAs) to assist with these assessments. The present study aimed to assess the accuracy and confidence of AHAs trained to conduct the subjective global assessment (SGA) compared with dietitians. Methods: A non-inferiority study design was adopted. Forty-five adult inpatients admitted to a rural and remote health service were assessed independently by both a trained AHA and dietitian within 24 hours. The order of assessment was randomised, with the second assessor blind to the outcome of the initial SGA. Levels of agreement were examined using kappa and percent exact agreement (PEA; set a priori at ≥80%). Rater confidence after each assessment was assessed using a 10-point scale. Results: Agreement for overall SGA ratings was high (kappa = 0.84; PEA 84.4%). PEA for individual sub-components of the SGA ranged from 66.4 to 86.7%. Where discrepancies were identified in global SGA ratings, AHAs provided a more severe rating of malnutrition than dietitians. AHAs reported significantly lower confidence than dietitians (t = 4.49, P < 0.001), although mean confidence for both groups was quite high (AHA=7.5, dietitians = 9.0). Conclusions: Trained AHAs completed the SGA with similar accuracy to dietitians. Using AHAs may help facilitate timely nutrition assessment in rural health services when a dietitian is not physically present. Further investigation is required to determine the benefits of incorporating this extended role into rural and remote health-care services.

International Journal of Telerehabilitation, 2016

Understanding end-user populations is required in designing telepractice applications. This study... more Understanding end-user populations is required in designing telepractice applications. This study explored computer literacy and health locus of control in head/neck cancer (HNC) patients to inform suitability for telerehabilitation. Sixty individuals with oropharygneal cancer were recruited. Computer literacy was examined using a 10-question survey. The Multidimensional Health Locus of Control Scale Form C (MHLC-C) examined perceptions of health “control”. Participants were mostly middle-aged males, from high socioeconomic backgrounds. Only 10% were non-computer users. Of the computers users, 91% reported daily use, 66% used multiple devices and over 75% rated themselves as “confident” users. More than half were open to using technology for health-related activities. High internal scores (MHLC-C) signified a belief that own behaviour influenced health status. HNC patients have high computer literacy and an internal health locus of control, both are positive factors to support tel...

International Journal of Pediatric Otorhinolaryngology, 2017

To explore the experiences of children with dysphagia and/or feeding difficulties post-chemical o... more To explore the experiences of children with dysphagia and/or feeding difficulties post-chemical or button battery ingestion injury from the perspective of the primary caregiver. Method: Five primary caregivers of children with a history of dysphagia and/or feeding difficulties post-ingestion injury (4 chemical, 1 button battery) completed the Children's Picky Eating Questionnaire (CPEQ), and participated in a semi-structured interview. Interviews explored experiences of caring for a child with dysphagia and/or feeding difficulties, impressions of services and supports, and additional impacts to the child and family. Content analysis was used to identify key themes. Result: Primary caregiver report and CPEQ results confirmed all children had some degree of persisting dysphagia and/or feeding difficulties at time of interview (mean 4.13 years' postinjury). Interviews identified five key themes: 1) The initial trauma of the injury, 2) The experience of associated and ongoing medical issues, 3) Managing altered oral intake, 4) Experiences of services and support, and 5) Impacts on the child, primary caregiver, and wider family unit. All caregivers reported significant challenges and concerns, and potential areas of service improvement were highlighted. Conclusion: The current data highlights specific issues experienced by primary caregivers, and poses areas for improving primary caregiver and family supports. Family-centered models of care are needed to support the whole family unit in caring for a child with dysphagia and/or feeding difficulties post-ingestion injury.

CA: A Cancer Journal for Clinicians, 2017

is accredited by the Accreditation Council for Continuing Medical Education to provide continuing... more is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education (CME) for physicians. Blackwell Futura Media Services designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Head & neck, May 1, 2017

The purpose of this study was to present our evaluation of a new speech pathology telepractice se... more The purpose of this study was to present our evaluation of a new speech pathology telepractice service supporting the swallowing and communication management of patients with head and neck cancer. A multicenter randomized controlled trial was conducted within a large public cancer service. Referrals from speech pathologists at 3 regional sites (spoke sites) were managed by a specialist clinician from a cancer center (hub site) either via standard care (phone/email support/appointments at the hub site) or a newly established telepractice service (online consultation between the hub site and spoke site). Eighty-two referrals (39 for standard care and 43 for telepractice care) were managed. Service efficiency favoring the telepractice model was reported with a significant reduction in the number (p = .004) and duration (p = .024) of contact events required to manage the referrals. Higher consumer and clinician satisfaction was also reported for the telepractice service. A speech pathol...

JAMA internal medicine, Jan 24, 2017

The findings and conclusions of this study are those of the authors and do not necessarily repres... more The findings and conclusions of this study are those of the authors and do not necessarily represent the views of the Food and Drug Administration. Additional Contributions: We thank Charles Rommel, a summer research fellow at the FDA, for his valuable contributions to this manuscript. He was not compensated for his contributions. 1. US Code. Acts affecting a personal financial interest. 18 USC §208. 2. US Code. Personal and business relationships. 5 CFR §2635.502. 3. US Food and Drug Administration. Guidance for the public, FDA advisory committee members and FDA staff on procedures for determining conflict of interest and eligibility for participation in FDA advisory committees. https://www.fda.gov/downloads/RegulatoryInformation/Guidances /UCM125646.pdf. Accessed December 22, 2016. 4. US Food and Drug Administration. Procedures for evaluating appearance issues and granting authorizations for participation in FDA advisory committees. https://www.fda.gov/downloads/RegulatoryInformation /Guidances/UCM508852.pdf. Accessed March 9, 2017. 5. US Food and Drug Administration. FDA advisory committee members and 'appearance issues'.

CA: a cancer journal for clinicians, Jul 6, 2017

Liver cancer is highly fatal, and death rates in the United States are increasing faster than for... more Liver cancer is highly fatal, and death rates in the United States are increasing faster than for any other cancer, having doubled since the mid-1980s. In 2017, it is estimated that the disease will account for about 41,000 new cancer cases and 29,000 cancer deaths in the United States. In this article, data from the Surveillance, Epidemiology, and End Results (SEER) Program and the National Center for Health Statistics are used to provide an overview of liver cancer incidence, mortality, and survival rates and trends, including data by race/ethnicity and state. The prevalence of major risk factors for liver cancer is also reported based on national survey data from the Centers for Disease Control and Prevention. Despite the improvement in liver cancer survival in recent decades, only 1 in 5 patients survives 5 years after diagnosis. There is substantial disparity in liver cancer death rates by race/ethnicity (from 5.5 per 100,000 in non-Hispanic whites to 11.9 per 100,000 in Americ...

Oral oncology, 2017

There is limited prospective data reporting the extent of treatment related toxicities associated... more There is limited prospective data reporting the extent of treatment related toxicities associated with helical Intensity Modulated Radiotherapy (H-IMRT) for head and neck cancer (HNC). The study aim was to investigate severity, peak incidence and recovery patterns of dysphagia and related toxicities in patients undergoing H-IMRT±chemotherapy to examine when patients are experiencing symptoms requiring supportive clinical care. Prospective study of 212 patients undergoing H-IMRT. Dysphagia and associated acute toxicities were monitored weekly during treatment and at weeks 2, 4 and 12 post treatment using the CTCAE v4, Functional Oral Intake Score and National Dysphagia Diet Descriptors. 75% experienced Grade 2-3 dysphagia. Over 70% had grade 2-3 dysguesia, xerostomia, and thick saliva, and >50% experienced grade 2-3 pharyngeal mucositis, oral mucositis, and nausea. 13% patients declined to NBM requiring complete enteral nutrition, 25% required enteral nutrition but maintained some...