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Mon, March 19, 2018

The new American Society for Radiation Oncology (ASTRO) guideline for treating breast cancer patients with whole breast irradiation recommends that most patients receive an accelerated treatment, known as hypofractioned therapy, instead of the conventional one. Reshma Jagsi is co-chair of task force that compiled the guideline.

Funded by: NIH

Funding Years: 2016-2021


There is a fundamental gap in understanding how Mild Cognitive Impairment (MCI) influences treatment and Decision Making for serious illnesses, like Cardiovascular disease (CVD), in older patients. Poor understanding of Clinical Decision Making is a critical barrier to the design of interventions to improve the quality and outcomes of CVD care of in older patients with MCI. The long-term goal of this research is to develop, test, and disseminate interventions aimed to improve the quality and outcomes of CVD care and to reduce CVD-related disability in older Americans with MCI. The objective of this application is to determine the extent to which people with MCI are receiving sub-standard care for the two most common CVD events, Acute myocardial infarction (AMI) and acute ischemic stroke, increasing the chance of mortality and morbidity in a population with otherwise good quality of life, and to determine how MCI influences patient preferences and physician recommendations for treatment. AMI and acute ischemic stroke are excellent models of serious, acute illnesses with a wide range of effective therapies for acute management, Rehabilitation, and secondary prevention. Our central hypothesis is that older Adults with MCI are undertreated for CVD because patients and physicians overestimate their risk of dementia and underestimate their risk of CVD. This hypothesis has been formulated on the basis of preliminary data from the applicants' pilot research. The rationale for the proposed research is that understanding how patient preferences and physician recommendations contribute to underuse of CVD treatments in patients with MCI has the potential to translate into targeted interventions aimed to improve the quality and outcomes of care, resulting in new and innovative approaches to the treatment of CVD and other serious, acute illnesses in Adults with MCI. Guided by strong preliminary data, this hypothesis will be tested by pursuing two specific aims: 1) Compare AMI and stroke treatments between MCI patients and cognitively normal patients and explore differences in Clinical outcomes associated with treatment differences; and 2) Determine the influence of MCI on patient and surrogate preferences and physician recommendations for AMI and stroke treatment. Under the first aim, a health services research approach- shown to be feasible in the applicants' hands-will be used to quantify the extent and outcomes of treatment differences for AMI and acute ischemic stroke in older patients with MCI. Under the second aim, a multi-center, mixed-methods approach and a national physician survey, which also has been proven as feasible in the applicants' hands, will be used to determine the influence of MCI on patient preferences and physician recommendations for AMI and stroke treatment. This research proposal is innovative because it represents a new and substantially different way of addressing the important public health problem of enhancing the health of older Adults by determining the extent and causes of underuse of effective CVD treatments in those with MCI. The proposed research is significant because it is expected to vertically advance and expand understanding of how MCI influences treatment and Decision Making for AMI and ischemic stroke in older patients. Ultimately, such knowledge has the potential to inform the development of targeted interventions that will help to improve the quality and outcomes of CVD care and to reduce CVD-related disability in older Americans.

PI: Deborah Levine

CO(s): Darin Zahuranec, MD & Ken Lenga, MD. PhD.

CBSSM Seminar: Anna Kirkland, JD, PhD

Thu, May 05, 2016, 3:00pm to 4:00pm
NCRC, Building 16, Room 266C

Anna Kirkland, JD, PhD
Arthur F. Thurnau Professor
Associate Professor, Women's Studies and Political Science (by courtesy)
Associate Director, Institute for Research on Women and Gender (IRWG)

"Vaccine Court: An American Solution for Recognizing Injuries"

Michael Poulin,PhD, has joined the faculty at the University at Buffalo, State University of New York (SUNY) as an AssistantProfessor of Psychology. Dr. Poulin was a post-doctoral fellow at CBSSM for twoyears, under the mentorship of StephanieBrown, PhD.  During this time he was anactive member of the CBSSM research community and a delightful colleague. Dr. Poulin's research focuses on the effects of stress on health and well-being, especiallythe ways people cope with stressful events. He examines how people's beliefsabout the world, including religious beliefs and beliefs about thetrustworthiness of others, influence adjustment to stress.  

Thu, December 20, 2007

A CBSSM study found that colostomy patients who felt that their condition was irreversible reported better quality of life than those who hoped that they would be cured. For a summary, see this press release and video. The researchers are Dylan M. Smith, PhD; Peter A. Ubel, MD; Aleksandra Jankovic, MS (all at the University of Michigan); and George Loewenstein, PhD, (of Carnegie Mellon University). Health Psychology will publish the article in mid-November 2009.

Press coverage of this research has been extensive. Peter Bregman reported on the study in the July 2009 Business Week Online, applying the concepts to help people manage their stressful and unpredictable lives. Read his full article here. Preliminary data from this study were cited in the 7th Annual “Year in Ideas” issue of the New York Times Magazine in December 2007. Read recent international media coverage:
US News and World Report Health Day
Voice of America Radio
Daily Mail UK
Reuters India

Co-sponsored by the Center for Ethics in Public Life and the Center for Bioethics and Social Sciences in Medicine, the 2nd annual Bioethics Colloquium took place on Friday, May 20, 8:30-3:30 pm, in the Alumni Center.  The colloquium featured presentations of research in or about bioethics conducted by U-M faculty, fellows, and students.

The keynote speaker was Susan Dorr Goold, MD, MHSA, MA, who gave a talk entitled, "Market failures, moral failures, and health reform."

Nearly 70 people attended the event, which featured 10 presentations by faculty, graduate students, and undergraduate students drawn from a variety of disciplines.

Get it out of me! (Dec-05)

A 5% chance of death or a 10% chance of death:  which would you choose?

Imagine that you have been diagnosed with a slow growing cancer. Right now, the cancer is not causing you to feel sick. For most people, the cancer will grow so slowly it will never cause them any trouble. For others, the cancer will grow to the point that it makes them sick. Untreated, five percent (5 out of 100) will die of the cancer. Your doctor tells you that you have two treatment options: watchful waiting or surgery. Watchful waiting means you will not do any treatment right away, but your doctor will follow your cancer closely and treat any symptoms that you have if it begins to spread. Although it would be too late to be cured, you would be comfortable and free of pain. There are no side effects to watchful waiting, but five percent (5 out of 100) of the people who choose this treatment will develop symptoms and die from their cancer within five years. On the other hand, the surgery would cure your cancer permanently. Following surgery you will feel more tired than usual and will experience stomach upset occasionally for the three months following your surgery. However, surgery has a ten percent (10 out of 100) risk of death during the surgery.

Imagine that both of these treatments are completely covered by your health insurance. Which would you choose?

  •  I would not take the surgery and accept the 5% chance of dying from this cancer.
  •  I would take the surgery and accept the 10% chance of dying from the surgery.

How do your answers compare?

In the real world, cancer patients sometimes choose treatments that may have devastating side effects over less invasive, yet equally or more effective, approaches. One explanation for this is that people may feel a strong need to "get the cancer out" of their bodies. Surgical removal of all potentially cancerous tissues may satisfy this desire so thoroughly that people end up ignoring important statistical information about adverse outcomes.

Making a choice not in their best interest

CBDSM investigators Angela Fagerlin, Brian Zikmund-Fisher, and Peter Ubel hypothesized that people perceive cancer diagnoses as a call to action, and more specifically, a call to get rid of the cancer through surgery, regardless of what statistical information might say to the contrary. Consequently, they predicted that when presented with hypothetical cancer diagnoses, many people would say they would pursue surgery even if such an action would decrease their chance of survival.

To explore the relative frequency of people's willingness to choose surgery when it wasn't in their best interest, the investigators designed a cancer scenario similar to the one you read on the previous page. Participants were presented either a surgery or a medication treatment that would either increase or decrease their chance of survival.

The investigators found that participants who were presented with the opportunity to rid themselves of their cancer through surgery were significantly more inclined to take action than those who were presented with the medication treatment. For example, when the treatment reduced their overall chance of survival, 65% chose the surgery, whereas only 38% chose the medication treatment. This suggests that people's treatment decisions may be based not on the effectiveness of the treatments, but rather on their beliefs about how cancer should be treated. Specifically, cancer diagnoses seem to conjure up a strong desire for active treatment. And people seem to have an intuitive belief that action should not just involve treatment, but surgical removal of the cancer.

Why these findings are important

The results of this study may resonate with many clinicians who have encountered cancer patients who seem to desire treatment for treatment's sake, or who have a preference for surgical intervention even before they learn about the pros and cons of their treatment alternatives. This study should serve to remind clinicians that patients' preference for action can be strong enough, at times, to be a bias. At a minimum, it is important for health care professionals to be aware of the potential for such biases, so they can decide whether to accept patients' preferences at face value, or try to convince patients that aggressively treating a tumor may not be in their best interests.

Read the article:

Cure me even if it kills me: Preferences for invasive cancer treatment.
Fagerlin A, Zikmund-Fisher BJ, Ubel PA. Medical Decision Making 2005;25(6):614-619.

The Importance of First Impressions (Jun-05)

How do your risk estimate and your actual level of risk impact your anxiety? Please answer the following question to the best of your ability:

What is the chance that the average woman will develop breast cancer in her lifetime?

The average lifetime chance of developing breast cancer is actually 13%.

How does this risk of breast cancer (13% or 13 out of 100 women) strike you?
As an extremely low risk 1       2       3       4       5        6        7        8       9       10 As an extremely high risk

How do your answers compare?

Making a risk estimate can change the feel of the actual risk

CBDSM investigators Angela Fagerlin, Brian Zikmund-Fisher, and Peter Ubel designed a study to test whether people react differently to risk information after they have been asked to estimate the risks. In this study, half the sample first estimated the average woman's risk of breast cancer (just as you did previously), while the other half made no such estimate. All subjects were then shown the actual risk information and indicated how the risk made them feel and gave their impression of the size of the risk. The graph below shows what they found:


As shown in the graph above, subjects who first made an estimated risk reported significantly more relief than those in the no estimate group. In contrast, subjects in the no estimate group showed significantly greater anxiety. Also, women in the estimate group tended to view the risk as low, whereas those in the no estimate group tended to view the risk as high.

So what's responsible for these findings? On average, those in the estimate group guessed that 46% of women will develop breast cancer at some point in their lives, which is a fairly large overestimate of the actual risk. It appears, then, that this overestimate makes the 13% figure feel relatively low, leading to a sense of relief when subjects find the risk isn't as bad as they had previously thought.

Why this finding is important

Clinical practice implications - The current research suggests that clinicians need to be very deliberate but very cautious in how they communicate risk information to their patients. These results argue that a physician should consider whether a person is likely to over-estimate their risk and whether they have an unreasonably high fear of cancer before having them make a risk estimation. For the average patient who would overestimate their risk, making a risk estimation may be harmful, leading them to be too relieved by the actual risk figure to take appropriate actions. On the other hand, if a patient has an unreasonably high fear of cancer, having them make such an estimate may actually be instrumental in decreasing their anxiety. Physicians may want to subtly inquire whether their patient is worried about her cancer risk or if she has any family history of cancer to address the latter type of patient.

Research implications - Many studies in cancer risk communication literature have asked participants at baseline about their perceived risk of developing specific cancers. Researchers then implement an intervention to "correct" baseline risk estimates. The current results suggest that measuring risk perceptions pre-intervention will influence people's subsequent reactions, making it difficult to discern whether it was the intervention that changed their attitudes or the pre-intervention risk estimate. Researchers testing out such interventions need to proceed with caution, and may need to add research arms of people who do not receive such pre-tests.

For more details: Fagerlin A, Zikmund-Fisher BJ, Ubel PA. How making a risk estimate can change the feel of that risk: shifting attitudes toward breast cancer risk in a general public survey. Patient Educ Couns. 2005 Jun;57(3):294-9.



How bad would it be? (May-05)

For certain diseases, receiving treatment can disrupt daily life considerably. How would this disruption affect your happiness?

Think about your average mood during a typical week. How would you rate your average mood?

  • very pleasant
  • slightly pleasant
  • neutral
  • slightly unpleasant
  • very unpleasant
Now imagine you have end-stage renal disease, a condition in which your kidneys fail to perform their normal function of cleaning and filtering the blood. Treatment consists of a procedure called hemodialysis, in which your blood is filtered through a machine. You require treatment three times per week for about three hours each time. Discomfort is minor, and you can read, write, talk, eat, sleep, or watch TV during the treatment. Your lifestyle includes most normal activities, including work, exercise, and leisure; however, you feel fatigued if you miss treatment for several days. Also, you must follow a strict diet that involves reducing salt intake, consuming relatively little meat, and drinking only small amounts of fluids. Imagine, you have been on hemodialysis for a year.
Now imagine your average mood during a typical week if you had end-stage renal disease as described above. If you had end-stage renal disease, how do you think you would rate your average mood?
  • very pleasant
  • slightly pleasant
  • neutral
  • slightly unpleasant
  • very unpleasant

How do your answers compare?

The discrepancy between Patients and Non-patients

Past research has shown that there are serious health conditions that do not seem to be as badly experienced by the people living with them as healthy people would expect. Although the existence of this discrepancy is well established at this point, its cause is not. One possibility is that patients are exaggerating their well-being. They may be focusing on periods of positive mood even though they actually experience lengthy periods of negative mood. On the other hand, patients might be as happy as they report and healthy people might very much be overestimating the negative impact of the illness. A related explanation comes from evidence that healthy people tend to underestimate their own past moods, recalling negative times more readily than positive times. This would then make them more likely to also understate the well-being of other people as well, and this could contribute to the discrepancy.

Which explanation is correct?

Jason Riis, a researcher at the University of Michigan, teamed up with investigators from CBDSM and the University of Pennsylvania to conduct a study with the goal of finding out which of the above explanations is accountable for the discrepancy. To accomplish this, they set out to measure mood in two ways. One way is to ask individuals to estimate their average mood. The other way is to measure mood on a momentary basis, asking individuals at frequent intervals to indicate their mood at the moment, and then taking the average of these responses. This latter way of assessing mood is less influenced by biased recall than just asking subjects to estimate overall mood.

The investigators recruited 49 end-stage renal patients receiving hemodialysis treatment three times per week and 49 healthy controls who were matched to the patients on age, race, sex, and education. Subjects were first given an entry interview during which they estimated their average mood. They were then asked to carry around Palm Pilots for a week that beeped at random intervals, prompting them to indicate their mood at the moment. After carrying the Palm Pilots around for a week, subjects completed an exit interview that asked them to recall their average mood in the last week and to again estimate their average mood in general. Healthy subjects also estimated what they thought their average mood would be if they were a hemodialysis patient.

The investigators found that patients' average momentary moods were no lower than their estimated average mood, thus finding no evidence that patients exaggerate their mood. In fact, they failed to find any evidence that patients experience lower moods than healthy controls. In appears, then, that hemodialysis patients do largely adapt to their condition. On the other hand, healthy controls did rate that their average mood would be lower if they were homodialysis patients. Thus, the previously observed tendency of healthy people to underestimate the reported quality of life of people with various health conditions does seem to be due, in large part, to their misperception of the extent to which people can adapt to such conditions. In this study, healthy people also underestimated their own average mood. This could also account for some of the discrepancy, but the effect was not very large.

Why this is important

Ignorance of adaptation can have negative consequences for decision making. It can cause individuals to opt for unnecessarily risky surgeries and policymakers to invest in programs that have a minimal impact on people's well-being. This is not to say that research and treatment of kidney disease should not continue to be priorities, but in making difficult policy decisions, consideration of the moods experienced by patients may influence priorities between serious conditions such as, for example, paraplegia and depression. The results of this study suggest that policy makers should proceed with caition because healthy people's apparent exaggeration of the influence of illness on mood can lead to incorrect perceptions of how illness will influence quality of life.

Read the article:

Ignorance of hedonic adaptation to hemo-dialysis: a study using ecological momentary assessment.
Riis J, Loewenstein G, Baron J, Jepson C, Fagerlin A, Ubel PA. Journal of Experimental Psychology: General 2005;134:3-9.

Give or take a few years (Feb-05)

A longer life may result from the amount of social support present in your life, but is the longevity due to giving or receiving that support?

Imagine that in your busy schedule each week, you typically at least have Wednesday and Saturday nights free as time to spend however you want. Recently, however, one of your close friends had her car break down and now she is wondering whether you would be willing to drive her to and from a yoga class on Wednesday nights for the next three weeks while the car is in the shop. She told you that the class is only about a 15 minute drive each way. She said that you shouldn't feel pressured, and she just thought she'd ask if you had the time to help her out.

Would you be willing to drive your friend to and from her yoga class for the next three weeks?
  • Yes, I'd take the time to help her out.
  • No, I'd keep my Wednesday nights free.
Do you think that helping out others could at all affect your health?
  • Yes
  • No

Giving vs. receiving: effects on mortality

A research team of investigators at the U of M Institute for Social Research teamed up with CBDSM investigator, Dylan Smith, to conduct a study investigating whether giving or receiving help affects longevity. The researchers noted that receiving social support is likely to be correlated with other aspects of close relationships, including the extent to which individuals give to one another. Based on this, they hypothesized that some of the benefits of social contact, sometimes attributed to receiving support from others, may instead be due to the act of giving support to others.

Using a sample of 423 married couples from the Detroit area, the investigators conducted face-to-face interviews over an 11-month period. The interviews assessed the amount of instrumental support respondents had given to and received from neighbors, friends, and relatives, as well as the amount of emotional support they had given to and received from their spouse. Instrumental support included things like helping with transportation, errands, and child care, whereas emotional support involved having open discussions with a spouse and feeling emotionally supported. Mortality was monitored over a 5-year period by checking daily obituaries and monthly death record tapes provided by the State of Michigan. To control for the possibility that any beneficial effects of giving support are due to a type of mental or physical robustness that underlies both giving and mortality risk, the investigators also measured a variety of demographic, health, and individual difference variables, including social contact and dependence on the spouse.

The investigators found that those who reported giving support to others had a reduced risk of mortality. This was true for both instrumental supoprt given to neighbors, friends, and relatives, and for emotional support given to a spouse. They also found that the relationship between receiving social support and mortality depended on other factors. Specifically, receiving emotional support appeared to reduce the risk of mortality when dependence on spouse, but not giving emotional support, was controlled. Receiving instrumental support from others actually increased the risk of mortality when giving support, but not dependence on spouse, was controlled.

What can we make of these findings?

It appears from these results that the benefits of social contact are mostly associated with giving rather than receiving. Measures that assess receiving alone may be imprecise, producing different results as a function of dependence and giving support.

Given the correlational nature of this study, it is not possible to determine conclusively that giving support accounts for the social benefit traditionally associated with receiving support. Nevertheless, the results of the present study should be considered a strong argument for the inclusion of measures of giving support in future studies of social support, and perhaps more importantly, researchers should be cautious of assuming that the benefits of social contact reside in receiving support.

It's true that when helping others out, you might have to give up some of your own time, but based on the above findings, it looks like in the long run you may end up ultimately gaining more time.

Read the article:

Providing social support may be more beneficial than receiving it: results from a prospective study of mortality.
Brown S, Nesse RM, Vinokur AD, Smith DM. Psychological Science 2003;14:320-327.