the Department of Family Medicine, Boston University School of Medicine, Massachusettes.

Women with intellectual disabilities (ID) need thoughtful, well-coordinated care from primary care physicians. They are particularly susceptible to experiencing disparities in care because of varied participation in shared decision making. This review of the current literature comments on the quantity and quality of existing studies regarding several key women’s health issues: menstrual disorders, cervical and breast cancer screening, contraception, and osteoporosis. A review of the current thinking regarding ethical and legal issues in medical decision making for these women is also provided. We found that there are several high-quality studies recommending early and frequent screening for osteoporosis, which is more common in women with ID. Smaller and fewer studies comment specifically on techniques for accomplishing the gynecological examination in women with ID, although the cervical cancer screening recommendation should be individualized for these patients. Consensus data on the management of menstrual problems and contraception in women with ID is provided. There are some data on breast cancer incidence but few articles on methods to improve screening rates in women with ID.

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Department of Developmental and Molecular Biology, Center of Reproductive Biology and Women’s Health, Albert Einstein Cancer Center, Albert Einstein College of Medicine, Bronx, New York, USA.

In many human cancers, the abundance of macrophages in the tumor microenvironment is correlated with poor prognosis. Experimental evidence for the causal relationship between macrophages and poor prognosis came from mouse models of breast cancer in which genetic ablation of macrophages resulted in attenuation of tumor progression and metastasis, and premature recruitment to hyperplastic lesions accelerated these processes. Malignancy is defined by the invasion of tumor cells into the stroma, a process that allows escape of these cells into the circulation and dissemination to distant sites. In this review, I argue that macrophages are recruited to the invasive front by expression of tumor-derived chemotactic factors and in response to the disruption of the basement membrane. At this invasive site, macrophages enhance tumor cell migration and invasion through their secretion of chemotactic and chemokinetic factors including epidermal growth factor (EGF). They promote angiogenesis by the synthesis of angiogenic factors including vascular EGF, and they remodel the extracellular matrix and in particular, regulate collagen fibrillogenesis. A combination of these factors provides a triple-whammy, as the more mobile and invasive tumor cells track along collagen fibers that are also anchored to blood vessels, which are fabricated at sites of invasion and through which macrophages potentiate tumor cell intravasation. All of these activities suggest that macrophage functions are significant targets for the generation of novel therapeutics that should improve the current cytotoxic armamentarium.

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Department of Epidemiology and Public Health, University of Miami Miller School of Medicine, Miami, Florida.

BACKGROUND: Early detection of skin cancer by skin examination may reduce its associated morbidity and mortality, in particular for workers routinely exposed to sun. OBJECTIVES: We sought to describe the proportion of US workers reporting skin cancer screening examination in a representative sample of the US worker population in the National Health Interview Survey. METHODS: Report of skin cancer examination in the 2000 and 2005 National Health Interview Survey cancer control supplements were examined by a range of variables. RESULTS: Lifetime and 12-month reported clinical skin examination prevalence was 15% and 8%, respectively. Workers with elevated occupational exposure to ultraviolet light were less likely to have ever received a skin examination than the average US worker. Logistic regression analysis identified occupational category and age, sex, race, education level, health insurance, and sun-protective behavior as significant independent correlates of skin cancer examination. LIMITATIONS: A limitation is potential healthy worker effect and underestimation of skin cancer screening with self-reported data. CONCLUSIONS: Routine examination by primary care physicians frequently does not include a thorough skin examination. Physicians should be even more vigilant with patients at increased risk of excessive occupational sun exposure, as early detection of skin cancer by periodic skin examination decreases morbidity and can improve survival.

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Roswell Park Cancer Institute, Elm & Carlton Streets, Buffalo, New York 14263, USA. mary.reid@roswellpark.org

Nonexperimental studies suggest that individuals with higher selenium (Se) status are at decreased risk of cancer. The Nutritional Prevention of Cancer (NPC) study randomized 1,312 high-risk dermatology patients to 200-mcg/day of Se in selenized yeast or a matched placebo; selenium supplementation decreased the risk of lung, colon, prostate, and total cancers but increased the risk of nonmelanoma skin cancer. In this article, we report on a small substudy in Macon, GA, which began in 1989 and randomized 424 patients to 400-mcg/day of Se or to matched placebo. The subjects from both arms had similar baseline Se levels to those treated by 200 mcg, and those treated with 400-mcg attained plasma Se levels much higher than subjects treated with 200 mcg. The 200-mcg/day Se treatment decreased total cancer incidence by a statistically significant 25%; however, 400-mcg/day of Se had no effect on total cancer incidence.

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Arizona Cancer Center and Department of Medicine, College of Medicine, University of Arizona, Tucson, Arizona, USA.

Perillyl alcohol (POH) is a natural product derived from plants such as cherry and lavendin. Previous studies have indicated that topical POH inhibits ultraviolet (UV) B-induced skin carcinogenesis in vivo, and it may be an effective chemopreventive agent for skin cancer. We performed a 1-mo, first-in-man, Phase 1 trial of topically administered POH cream in human subjects. Endpoints included safety and evaluation of any histopathological changes in skin after 1 mo use of POH cream. We randomized 25 subjects with normal, healthy skin with little or no sun damage and no history of skin cancer in a double-blind fashion to receive topical POH (0.76% wt/wt) on 1 forearm with placebo cream applied to the other forearm twice daily for 30 days. Subjects were monitored for toxicity, and a 4 mm punch biopsy in the treated area was performed at the end of study for histopathological evaluation. The topical cream was well tolerated. No serious cutaneous toxicities, systemic toxicities, or histopathological abnormalities were observed. A total of 8 subjects (32%) reported mild adverse events possibly or probably related to use of cream including reversible appearance of 1 to 2 small papules. However, there was no significant difference between lesions appearing on the POH treated forearm vs. the placebo-treated forearm.

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