Decision and communication aids used in orthopaedic practice had benefits for both patients and surgeons. These findings could be important in facilitating adoption of shared decision-making tools into routine orthopaedic practice.

Compared to control patients, navigated patients were more confident in making decisions about cancer treatment, were more certain they had made the right decision after the consultation and had less regret about their decision 6 months later. Decision navigation was feasible, acceptable and effective for newly diagnosed prostate cancer patients in Scotland.

The growing focus on patient-centered oncology care is increasing the demand on physicians' time and effort to engage patients and their families in treatment decision making. At the same time, the clinical encounter is becoming more challenging because evaluative testing strategies and cancer disease management decisions are increasingly complex. 1 Cancer treatment context is particularly challenging for patients and their families because there are multiple effective therapies that are interconnected, and there is a complex interplay between their benefits and risks. Furthermore, treatment recommendations are based on increasingly complicated clinical information that is revealed variably over time after initial diagnosis. Integrating this information into a treatment plan is challenging because different specialists direct the various treatments. 2

The objective of this study was to determine whether comorbidity, or pre-existing conditions, can account for some of the disparity in survival between African-American and white breast cancer patients. A historical cohort study was conducted of 416 AfricanAmerican and 838 white women diagnosed with breast cancer between 1973 and 1986, and followed through 1999 in the Kaiser Permanente Northern California Medical Care Program. Information on comorbidity, tumor characteristics and breast cancer treatment was obtained from medical records, and Surveillance, Epidemiology and End Results, Northern California Cancer Center Registry. Associations between comorbidity and survival were analyzed with multiple Cox proportional hazards regression. Over a mean follow-up of 9 years, African Americans had higher overall crude mortality than whites: 165 (39.7%) versus 279 (33.3%), respectively. When age, race, tumor characteristics and breast cancer treatment were controlled, the presence of hypertension was associated with all cause survival [hazard ratio (HR) 5 1.33, 95% confidence intervals (CI) 1.07-1.67] and it accounted for 30% of racial disparity in this outcome. Hypertension-augmented Charlson Comorbidity Index was a significant predictor of survival from all causes (HR 5 1.32, 95%CI 1.18-1.49), competing causes (HR 5 1.52, 95%CI 1.32-1.76) and breast cancer specific causes (HR 5 1.18, 95%CI 1.03-1.35). In conclusion, hypertension has prognostic significance in relation to survival disparity between African-American and white breast cancer patients. If our findings are replicated in contemporary cohorts, it may be necessary to include hypertension in the Charlson Comorbidity Index and other comorbidity measures. ' 2008 Wiley-Liss, Inc.Key words: comorbidity; breast cancer; survival; race/ethnicity; cohort African-American breast cancer patients experience shorter survival than their white counterparts, and on average present with more advanced stage and hormone receptor-negative disease at younger ages. 1 African-American ethnicity seems to be an independent predictor of poor breast cancer outcome, even after accounting for socioeconomic factors and inadequate health care access. 2 Importantly, African-American women also tend to have poorer overall health, as reflected in greater prevalence of comorbidity. 3 Furthermore, inadequately controlled comorbidities tend to adversely affect cancer treatment, as exemplified in the National Cancer Institute's Black White Cancer Survival Study, with breast cancer patients presenting with disproportionately increased rates of hypertension. 4 A recent study by Tammemagi et al. 5 reporting on outcomes among breast cancer patients followed for a median of 10 years at the Henry Ford Health System in Michigan showed that comorbidities such as hypertension and diabetes accounted for almost half of the overall survival disparity among African-American and white breast cancer patients. Thus, optimizing comorbidity measurement may help not only to uncover predictors of survival disparity ...