We investigated patients' willingness to have their reading ability documented in their medical records and the degree of shame and embarrassment associated with such disclosure. Structured interviews were conducted among a consecutive sample of 283 primary care patients at an urban public hospital. Patients' literacy was measured using the Rapid Estimate of Adult Literacy in Medicine (REALM). Self-report of degree of shame and embarrassment related to literacy skills was measured using an orally administered questionnaire. Fifty-one percent of patients had low literacy skills (< or =sixth grade) and 27.9% were assessed as having marginal literacy (seventh-eighth grade). Half (47.6%) of patients reading at or below the third-grade level admitted feeling ashamed or embarrassed about their difficulties reading, compared with 19.2% of those reading at the fourth-sixth-grade level and 6.5% of those reading at the seventh-eighth-grade level (p < 0.001). More than 90% of patients with low or marginal literacy reported it would be helpful for the doctor or nurse to know they did not understand some medical words. Patients with limited literacy were more likely to report feelings of shame as a result of disclosure (p < 0.05). Health care providers must recognize the potential shame patients might experience as a result of literacy screening.
Purpose
To evaluate the rate of gastrointestinal (GI) toxicity of neoadjuvant chemoradiation with capecitabine, oxaliplatin, and intensity modulated radiation therapy (IMRT) in cT3-4 rectal cancer.
Materials and Methods
Patients with localized, non-metastatic T3 or T4 rectal cancer < 12 cm from the anal verge were enrolled in a prospective, multi-institutional, single arm study of preoperative chemoradiation. Patients received 45 Gy with IMRT in 25 fractions, followed by a 3D-conformal boost of 5.4 Gy in 3 fractions with concurrent capecitabine/oxaliplatin (CAPOX). Surgery was performed in 4-8 weeks following completion of therapy. Patients were recommended to receive FOLFOX chemotherapy after surgery. The primary endpoint of the study was acute grade 2-5 GI toxicity. Seventy-one patients provided 80% probability to detect at least a 12% reduction in the specified GI toxicity with the treatment of CAPOX and IMRT, at a significance level of 0.10 (1-sided).
Results
79 patients were accrued, of whom 68 were evaluable. 61 patients (89.7%) had cT3 and 37 (54.4%) cN (+) disease. 42/68 patients received post-operative chemotherapy. 58 patients had target contours drawn per protocol, 5 patients with acceptable variation, and 5 patients with unacceptable variations. 35 patients (51.5%) developed grade ≥ 2 GI toxicity. 12 patients (17.6%) developed grade 3 or 4 diarrhea. pCR was achieved in 10 patients (14.7%). With a median follow-up of 3.98 years, the 4-year locoregional failure (LRF) rate was 7.4% (95% CI: 1.0% - 13.7%). 4-year OS and DFS were 82.9% (95% CI: 70.1% - 90.6%) and 60.6% (95% CI: 47.5% - 71.4%), respectively.
Conclusion
The use of IMRT in neoadjuvant chemoradiation for rectal cancer did not reduce the rate of gastrointestinal toxicity.
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