***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVES This study analyzed whether inadequate functional health literacy is an independent risk factor for hospital admission . METHODS We studied a prospect i ve cohort of 3260 Medicare managed care enrollees . RESULTS Of the participants , 29.5 % were hospitalized . The crude relative risk ( RR ) of hospitalization was higher for individuals with inadequate literacy ( n = 800 ; RR = 1.43 ; 95 % confidence interval [ CI ] = 1.24 , 1.65 ) and marginal literacy ( n = 366 ; RR = 1.33 ; 95 % CI = 1.09 , 1.61 ) than for those with adequate literacy ( n = 2094 ) . In multivariate analysis , the adjusted relative risk of hospital admission was 1.29 ( 95 % CI = 1.07 , 1.55 ) for individuals with inadequate literacy and 1.21 ( 95 % CI = 0.97 , 1.50 ) for those with marginal literacy . CONCLUSIONS Inadequate literacy was an independent risk factor for hospital admission among elderly managed care enrollees Background . This investigation examined factors affecting  patient involvement in consultations to decide local treatment for early breast cancer and the effectiveness of two methods of preconsultation education aim ed at increasing patient participation in these discussion CONTEXT As the availability of and dem and for genetic testing for hereditary cancers increases in primary care and other clinical setting s , alternative or adjunct educational methods to traditional genetic counseling will be needed . OBJECTIVE To compare the effectiveness of a computer-based decision aid with st and ard genetic counseling for educating women about BRCA1 and BRCA2 genetic testing . DESIGN R and omized controlled trial conducted from May 2000 to September 2002 . SETTING AND PARTICIPANTS Outpatient clinics offering cancer genetic counseling at 6 US medical centers enrolled 211 women with personal or family histories of breast cancer . INTERVENTIONS St and ard one-on-one genetic counseling ( n = 105 ) or education by a computer program followed by genetic counseling ( n = 106 ) . MAIN OUTCOME MEASURES Participants ' knowledge , risk perception , intention to undergo genetic testing , decisional conflict , satisfaction with decision , anxiety , and satisfaction with the intervention . Counselor group measures were administered at baseline and after counseling . Computer group measures were administered at baseline , after computer use , and after counseling . Testing decisions were assessed at 1 and 6 months . Outcomes were analyzed by high vs low risk of carrying a BRCA1 or BRCA2 mutation . RESULTS Both groups had comparable demographics , prior computer experience , medical literacy , and baseline knowledge  of breast cancer and  genetic testing , and both counseling and computer use were rated highly . Knowledge scores increased in both groups ( P<.001 ) regardless of risk status , and change in knowledge was greater in the computer group compared with the counselor group ( P = .03 ) among women at low risk of carrying a mutation . Perception of absolute risk of breast cancer decreased significantly after either intervention among all participants . Intention to undergo testing decreased significantly after either intervention among low-risk but not high-risk women . The counselor group had lower mean scores on a decisional conflict scale ( P = .04 ) and , in low-risk women , higher mean scores on a satisfaction-with-decision scale ( P = .001 ) . Mean state anxiety scores were reduced by counseling but were within normal ranges for both groups at baseline and after either intervention , regardless of risk status . CONCLUSIONS An interactive computer program was more effective than st and ard genetic counseling for increasing knowledge of breast cancer and genetic testing among women at low risk of carrying a BRCA1 or BRCA2 mutation . However , genetic counseling was more effective than the computer at reducing women 's anxiety and facilitating more accurate risk perceptions . These results suggest that this computer program has the potential to st and alone as an educational intervention for low-risk women but should be used as a supplement to genetic counseling for those at high risk CONTEXT The long-term results of r and omized trials have demonstrated equivalent survival rates for mastectomy and breast-conserving therapy for the treatment of early stage breast cancer . Consequently , the choice of treatment should be based on a patient 's preferences . OBJECTIVE To evaluate the impact of a decision aid regarding the different surgical treatment options on patient decision making . DESIGN AND SETTING A cluster r and omized trial for which general surgeons in the communities of central -west , and eastern Ontario , Canada , were r and omly assigned to use the decision aid or not in the surgical consultation . Patients received the decision aid or not based on the surgeon seen . PARTICIPANTS Twenty surgeons participated in the study . Of the 208 eligible women with newly diagnosed clinical stage I or II breast cancer seen by study surgeons , 201 agreed to be evaluated : 94 were assigned to the decision board and 107 to usual practice . Patients were recruited from November 1999 to April 2002 . INTERVENTION The decision board is a decision aid design ed to help physicians inform their patients about different treatment options and to enable patients to express a preference for treatment . MAIN OUTCOME MEASURES Patient knowledge about the surgical treatment of breast cancer ; decisional conflict ; satisfaction with decision making ; and the treatment decision following the consultation . RESULTS Patients in the decision board group had higher knowledge scores about their treatment options ( 66.9 vs 58.7 ; P<.001 ) , had less decisional conflict ( 1.40 vs 1.62 , P = .02 ) , and were more satisfied with decision making ( 4.50 vs 4.32 , P = .05 ) following the consultation . Patients who used the decision board were more likely to choose BCT ( 94 % vs 76 % , P = .03 ) . CONCLUSIONS The decision board was helpful in improving communication and enabling women to make a choice regarding treatment . Such instruments should be considered by surgeons when communicating the different surgical options to women with breast cancer BACKGROUND In 1976 , we initiated a r and omized trial to determine whether lumpectomy with or without radiation therapy was as effective as total mastectomy for the treatment of invasive breast cancer . METHODS A total of 1851 women for whom follow-up data were available and nodal status was known underwent r and omly assigned treatment consisting of total mastectomy , lumpectomy alone , or lumpectomy and breast irradiation . Kaplan-Meier and cumulative-incidence estimates of the outcome were obtained . RESULTS The cumulative incidence of recurrent tumor in the ipsilateral breast was 14.3 percent in the women who underwent lumpectomy and breast irradiation , as compared with 39.2 percent in the women who underwent lumpectomy without irradiation ( P<0.001 ) . No significant differences were observed among the three groups of women with respect to disease-free survival , distant-disease-free survival , or overall survival . The hazard ratio for death among the women who underwent lumpectomy alone , as compared with those who underwent total mastectomy , was 1.05 ( 95 percent confidence interval , 0.90 to 1.23 ; P=0.51 ) . The hazard ratio for death among the women who underwent lumpectomy followed by breast irradiation , as compared with those who underwent total mastectomy , was 0.97 ( 95 percent confidence interval , 0.83 to 1.14 ; P=0.74 ) . Among the lumpectomy-treated women whose surgical specimens had tumor-free margins , the hazard ratio for death among the women who underwent postoperative breast irradiation , as compared with those who did not , was 0.91 ( 95 percent confidence interval , 0.77 to 1.06 ; P=0.23 ) . Radiation therapy was associated with a marginally significant decrease in deaths due to breast cancer . This decrease was partially offset by an increase in deaths from other causes . CONCLUSIONS Lumpectomy followed by breast irradiation continues to be appropriate therapy for women with breast cancer , provided that the margins of resected specimens are free of tumor and an acceptable cosmetic result can be obtained Counseling women about breast cancer risks has been found to decrease screening compliance . We investigated whether women 's reactions to risk information are an artifact of requiring women to estimate the risk of breast cancer prior to receiving risk information . Three hundred and fifty-six women were r and omized to either make or not make a risk estimate prior to receiving risk information . Outcome measures were participants ' estimates of the average woman 's breast cancer risk and their emotional response to the risk information . Women overestimated the lifetime risk of breast cancer ( M = 46 % ) . Women who made risk estimates felt more relieved about the risk and perceived the risk as being lower than women who did not make estimates ( p 's < 0.001 ) . Asking people to estimate risks influenced their subsequent perceptions of the risk of breast cancer PURPOSE : A patient decision aid for the surgical treatment of early stage breast cancer was developed and evaluated . The rationale for its development was the knowledge that breast conserving therapy ( lumpectomy followed by breast radiation ) and mastectomy produce equivalent outcomes , and the current general agreement that the decision for the type of surgery should rest with the patient . METHODS : A decision aid was developed and evaluated in sequential pilot studies of 18 and 10 women with newly diagnosed breast cancer who were facing a decision for breast conserving therapy or mastectomy .  Both qualitative ( general reaction , self-reported anxiety , clarity , satisfaction ) and quantitative ( knowledge and decisional conflict ) measures were assessed . RESULTS : The decision aid consists of an audiotape and workbook and takes 36 min to complete . Based on qualitative comments and satisfaction ratings , 17 of 18 women reported a positive reaction to the decision aid , and all 18 reported that it helped clarify information given by the surgeon . Women did not report an increase in anxiety and 17 of 18 women were either satisfied or very satisfied with the decision aid . CONCLUSION : This pilot study supports the hypothesis that this decision aid may be a helpful adjunct in the decision for surgical management of early stage breast cancer . We are currently conducting a r and omized trial of the decision aid versus a simple educational pamphlet to evaluate its efficacy as measured by knowledge , decisional conflict , anxiety and post-decisional regret A decision aid for the surgical treatment of early breast cancer was evaluated in a r and omized controlled trial . The decision aid , a tape and workbook , includes explicit presentation of probabilities , photographs and graphics , and a values clarification exercise . Community surgeons were r and omized to use the decision aid or a control pamphlet .  Patients completed a question naire prior to using the decision aid , after review ing it but prior to surgery , and 6 months after enrollment . There was no difference in anxiety , knowledge , or decisional regret across the 2 groups . There was a nonsignificant trend toward lower decisional conflict in the decision aid group . A subgroup of women who were initially leaning toward mastectomy or were unsure had lower decisional conflict . Although the decision aid had minimal impact on the main study outcomes , a subgroup may have benefited . Such subgroups should be identified , and appropriate decision support interventions should be developed and evaluated OBJECTIVE Although involving women in breast cancer treatment decisions is advocated , there is little underst and ing of whether women have the information they need to make informed decisions . The objective of the current study was to evaluate women 's knowledge of survival and recurrence rates for mastectomy and breast conserving surgery ( BCS ) and the factors associated with this knowledge . METHODS We used a population -based sample of women diagnosed with breast cancer in metropolitan Los Angeles and Detroit between December 2001 and January 2003 . All women with ductal carcinoma in situ and a r and om sample of women with invasive disease were selected ( N=2382 ) , of which 1844 participated ( 77.4 % ) . All participants were mailed surveys . The main outcome measures were knowledge of survival and recurrence rates by surgical treatment type . RESULTS Only 16 % of women knew that recurrence rates were different for mastectomy and BCS , and 48 % knew that the survival rates were equivalent across treatment . Knowledge about survival and recurrence was improved by exposure to the Internet and health pamphlets ( p<0.01 ) . Women who had a female ( versus male ) surgeon , and /or a surgeon who explained both treatments ( rather than just one treatment ) demonstrated higher survival knowledge ( p<0.01 ) . The majority of women had inadequate knowledge with which to make informed decisions about breast cancer surgical treatment . CONCLUSION Previous explanations for poor knowledge , such as ir relevance of knowledge to decision making and lack of access to information , were not shown to be plausible explanations for the low levels of knowledge observed in this sample . PRACTICE IMPLICATION S These results suggest a need for fundamental changes in patient education to ensure that women are able to make informed decisions about their breast cancer treatment . These changes may include an increase in the use of decision aids and in decreasing the speed at which treatment decisions are made Background : In nonindustrialized nations , illiteracy is independently associated with poor health . The objective of this research was to determine whether such a relation exists in the United States . Methods : One hundred ninety-three persons were r and omly selected from a group of adult students enrolled in a publicly funded literacy training program . Subjects ’ health status was measured with the Sickness Impact Profile ( SIP ) , a behaviorally based measure of sickness-related dysfunction . Subjects ’ literacy skills were also measured . Multivariate statistical techniques were then used to evaluate the relation between health status and literacy level and to adjust for confounding sociodemographic factors . Results : The physical health ( measured by the SIP ) of subjects with extremely low reading levels was poor compared with that of subjects with higher reading levels . The relation between reading level and physical health was statistically significant ( P < 0.002 ) , even after adjusting for confounding sociodemographic variables . Psychosocial health ( measured by the SIP ) was 
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The data also suggested that decision aids decreased decisional conflict and increased satisfaction with the decision-making process .
Decision aids were well received by surgeons and patients , facilitated patients ' desire for shared decision making , and were feasible to implement into practice .
Decision aids are important adjuncts for counseling women with early-stage breast cancer .
Their use increases the likelihood that women will choose breast-conserving surgery  , and enhances patient knowledge of treatment options