Juan C Felix

University of California, Los Angeles, Los Ángeles, California, United States

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Publications (133)558.25 Total impact

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    ABSTRACT: Although vaccination against the Human Papilloma Virus (HPV) reduces the risk of related morbidities, the vaccine uptake remains low in adolescents. This has been attributed to limited parental knowledge and misconceptions. In this cross sectional study, we assessed the (1) clarity of educational material informing Hispanic mothers about HPV, cervical cancer and the HPV vaccine, (2) determined vaccination acceptability and (3) identified predictors of vaccine acceptance in an underserved health setting. 418 Hispanic mothers received the educational material and completed an anonymous survey. 91 % of participants understood most or all of the information provided. 77 % of participants reported vaccine acceptance for their children; this increased to 84 % when only those with children eligible to receive vaccination were included. Significant positive predictors of maternal acceptance of the HPV vaccine for their children were understanding most or all of the provided information, older age and acceptance of the HPV vaccine for themselves. Concerns about safety and general dislike of vaccines were negatively associated with HPV vaccine acceptance. Prior knowledge, level of education, previous relevant gynecologic history, general willingness to vaccinate and other general beliefs about vaccines were not significantly associated with HPV vaccine acceptance. The majority of participants reported understanding of the provided educational material. Vaccine acceptability was fairly high, but was even higher among those who understood the information. This study documents a cost-effective way to provide Hispanic mothers with easy-to-understand HPV-related information that could increase parental vaccine acceptability and future vaccine uptake among their children.
    No preview · Article · Oct 2015 · Journal of Community Health
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    ABSTRACT: Background: Cervical cancer is the third most commonly occurring cancer among women and the fourth leading cause of cancer-related deaths in women worldwide, with more than 85 % of these cases occurring in developing countries. These global disparities reflect the differences in cervical cancer screening rates between high-income and medium- and low-income countries. At 19 %, El Salvador has the lowest reported screening coverage of all Latin American countries. The purpose of this study is to identify factors affecting public sector HPV DNA-based cervical cancer screening participation in El Salvador. Methods: This study was nested within a public sector screening program where health promoters used door-to-door outreach to recruit women aged 30-49 years to attend educational sessions about HPV screening. A subgroup of these participants was chosen randomly and questioned about demographic factors, healthcare utilization, previous cervical cancer screening, and HPV knowledge. Women then scheduled screening appointments at their public health clinics. Screening participants were adherent if they attended their scheduled appointment or rescheduled and were screened within 6 months. The association between non-adherence and demographic variables, medical history, history of cancer, sexual history, birth control methods, and screening barriers was assessed using Chi-square tests of significance and logistic regression. Results: All women (n = 409) enrolled in the study scheduled HPV screening appointments, and 88 % attended. Non-adherence was associated with a higher number of lifetime partners and being under-screened-defined as not having participated in cervical cancer screening within the previous 3 years (p = 0.03 and p = 0.04, respectively); 22.8 % of participants in this study were under-screened. Conclusions: Adherence to cervical cancer screening after educational sessions was higher than expected, in part due to interactions with the community-based health promoters as well as the educational session itself. More effective recruitment methods targeted toward under-screened women are required.
    Preview · Article · Oct 2015 · BMC Public Health
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    ABSTRACT: Although patients with early-stage cervical cancer have in general a favorable prognosis, 10% to 40% patients still recur depending on pathologic risk factors. The objective of this study was to evaluate if the presence of lymph node micrometastasis (LNmM) had an impact on patient's survival. We performed a multi-institutional retrospective review on patients with early-stage cervical cancer, with histologically negative lymph nodes, treated with radical hysterectomy and pelvic lymphadenectomy for the study period 1994 to 2004. Tissue blocks of lymph nodes from the patient's original surgery were recut and then evaluated for the presence of micrometastases. One hundred twenty-nine patients were identified who met inclusion criteria. LNmM were found in 26 patients (20%). In an average follow-up time of 70 mo, there were 11 recurrences (8.5%). Of the 11 recurrences, 2 (18%) patients had LNmM. Patients with LNmM were more likely to have received adjuvant radiation and chemotherapy. In stratified log-rank analysis, LNmM were not associated with any other high-risk clinical or pathologic variables. Survival data analysis did not demonstrate an association between the presence of LNmM and recurrence or overall survival. The presence of LNmM was not associated with an unfavorable prognosis nor was it associated with other high-risk clinical or pathologic variables predicting recurrence. Further study is warranted to understand the role of micrometastases in cervical cancer.
    No preview · Article · Jul 2015 · International journal of gynecological pathology: official journal of the International Society of Gynecological Pathologists
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    ABSTRACT: Cervical cancer is the leading cause of cancer death among women in El Salvador. Utilizing data from the Cervical Cancer Prevention in El Salvador (CAPE) demonstration project, we assessed the health and economic impact of HPV-based screening and two different algorithms for the management of women who test HPV-positive, relative to existing Pap-based screening. We calibrated a mathematical model of cervical cancer to epidemiologic data from El Salvador and compared three screening algorithms for women aged 30 to 65 years: 1) HPV screening every 5 years followed by referral to colposcopy for HPV-positive women (Colposcopy Management [CM]); 2) HPV screening every 5 years followed by treatment with cryotherapy for eligible HPV-positive women (Screen and Treat [ST]); and 3) Pap screening every 2 years followed by referral to colposcopy for Pap-positive women (Pap). Potential harms and complications associated with overtreatment were not assessed. Under base case assumptions of 65% screening coverage, HPV-based screening was more effective than Pap, reducing cancer risk by approximately 60% (Pap: 50%). ST was the least costly strategy, and cost $2,040 per year of life saved. ST remained the most attractive strategy as visit compliance, costs, coverage, and test performance were varied. We conclude that a screen-and-treat algorithm within an HPV-based screening program is very cost-effective in El Salvador, with a cost-effectiveness ratio below per capita GDP. This article is protected by copyright. All rights reserved.
    No preview · Article · Jan 2015 · International Journal of Cancer
  • Justin T Diedrich · Juan C Felix · Neal M Lonky
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    ABSTRACT: Objective: We investigated the clinical and demographic characteristics that could influence regression of cervical intraepithelial neoplasia (CIN) from colposcopy to excision, and evaluated the association of the performance of multiple biopsies and endocervical curettage (ECC) with regression of high-grade (CIN2+) by the time of excisional therapy. Materials and methods: This was an institutional review board-approved retrospective analysis of 555 patients who had abnormal screening and who underwent colposcopy followed by cervical excision procedures for CIN2+ or high-risk status. We assessed demographic variables, referral reason, colposcopic findings, and the latency between colposcopic biopsy and excision to which we correlated the likelihood of regression of disease on the excisional specimen. Results: Mean age was 39 years, and median interval from colposcopy to excision was 48 days. Neither demographics nor colposcopic findings influenced the probability of regression. Patients with shorter intervals between colposcopy biopsy and excision exhibited a higher rate of regression (p=.04). The addition of ECC to colposcopy was associated with regression (p=.002). Conclusions: During routine colposcopic practice using punch biopsy and ECC when indicated, regression was less likely with longer latency from colposcopy to excision. This was possibly owing to emergence and documentation of persistent occult neoplasia. The effect of intentional complete biopsy excision with conventional tools as a potential therapeutic intervention was not evaluated.
    No preview · Article · Aug 2014 · Journal of Lower Genital Tract Disease
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    ABSTRACT: Objective To determine the acceptability of self-collected versus provider-collected sampling among women participating in public sector HPV-based cervical cancer screening in El Salvador. Methods Two thousand women aged 30–49 years underwent self-collected and provider-collected sampling with careHPV between October 2012 and March 2013 (Qiagen, Gaithersburg, MD, USA). After sample collection, a random sample of women (n = 518) were asked about their experience. Participants were questioned regarding sampling method preference, previous cervical cancer screening, HPV and cervical cancer knowledge, HPV risk factors, and demographic information. Results All 518 women approached to participate in this questionnaire study agreed and were enrolled, 27.8% (142 of 511 responding) of whom had not received cervical cancer screening within the past 3 years and were considered under-screened. Overall, 38.8% (n = 201) preferred self-collection and 31.9% (n = 165) preferred provider collection. Self-collection preference was associated with prior tubal ligation, HPV knowledge, future self-sampling preference, and future home-screening preference (P < 0.05). Reasons for self-collection preference included privacy/embarrassment, ease, and less pain; reasons cited for provider-collection preference were result accuracy and provider knowledge/experience. Conclusion Self-sampling was found to be acceptable, therefore screening programs could consider offering this option either in the clinic or at home. Self-sampling at home may increase coverage in low-resource countries and reduce the burden that screening places upon clinical infrastructure.
    Preview · Article · Aug 2014 · International Journal of Gynecology & Obstetrics
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    ABSTRACT: Objective: To compare the incidence of histopathological features in placentas from women with cholestasis of pregnancy to healthy individuals without ICP. Methods: Placentas from mothers with and without cholestasis of pregnancy were reviewed by a pathologist masked to the study group. Subjects were excluded if they had medical problems already associated with placental histopathology. Results: Twenty-four cases and 30 controls placentas were reviewed. Seventeen placental histopathological features were found. There was no statistically significant difference between the groups. Amongst patients with cholestasis, there was a decrease in villitis of unknown etiology in those treated with ursodeoxycholic acid. Conclusion: There is no difference in the placental histopathology in cholestasis of pregnancy compared to normal pregnancies, but treatment of patients with cholestasis of pregnancy with ursodeoxycholic acid may decrease findings of villitis of unknown etiology.
    No preview · Article · Apr 2014 · Fetal and pediatric pathology
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    ABSTRACT: Objective. To determine the utility of random biopsy and endocervical curettage (ECC) during colposcopy among women who ultimately underwent cervical excisional biopsy. Materials and Methods. In a retrospective observational study, the charts were reviewed of every patient who underwent cervical excisional procedure performed be-tween June 2010 and August 2011, including the antecedent colposcopic examination and any pathological specimens. A random sample of 15% all pathologic specimens was re-viewed. Practice of biopsy, use of ECC, demographic factors, referral cytology results, lesion distribution, and size were assessed for correlation with high-grade cervical intra-epithelial neoplasia 2 or worse (CIN 2+). Results. A total of 555 patients were included in our analysis. Of them, 333 (60%) had CIN 2+ on colposcopy or excision. CIN 2+ was most likely in younger women and those referred for high-grade cytology. Among 111 women with no visual lesion seen at colposcopy, 66 underwent ECC alone, 33 had ECC and random biopsy, 9 were referred straight to excision, and 3 underwent random biopsy alone. Of the 99 who underwent ECC, this was consistent with the highest-grade lesion in 68% of cases. Among the 36 with random biopsy, this was con-sistent with the highest-grade lesion in 72% of cases. At the time of colposcopy, there were 326 who had CIN 2+ diagnosed with satisfactory colposcopy. Biopsy and ECC were performed in 278 cases. In 235 cases, biopsy alone showed CIN 2+; in 43, the biopsy and ECC both showed CIN 2+. In the remaining 48 cases, CIN 2+ was diagnosed with ECC alone. Conclusions. In those ultimately treated with excision, younger women and those whose referral cytology was high-grade both were at higher risk of high-grade histol-ogy. Random biopsy and ECC (even among satisfactory colposcopy) were significantly associated with disclosure of high-grade pathology.
    Full-text · Article · Jan 2014 · Journal of Lower Genital Tract Disease
  • Nathan R Blue · Juan C Felix · Jenny Jaque
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    ABSTRACT: Primary ovarian leiomyoma is a rare benign ovarian tumor with only several reported cases in adolescents. Little is known about the origin or natural history of these rare tumors as they have occurred in a variety of presentations and were removed upon presentation without observation. A 14-year-old, premenarchal female was found to have a 4 cm mass which grew to 6.5 cm over two years. It appeared sonographically most consistent with a teratoma; however ,during surgical resection it was found to be solid, and on pathologic evaluation was identified as an ovarian leiomyoma. The growth of this patient's tumor with the onset of puberty supports hormonal responsivity, but its presence prior to menarche suggests an alternate origin, independent of gonadal hormones.
    No preview · Article · Dec 2013 · Journal of pediatric and adolescent gynecology
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    ABSTRACT: To determine factors associated with the presence of residual disease in women who have undergone cervical conization for adenocarcinoma in situ (ACIS) of the cervix. We identified women who underwent a cervical conization for a diagnosis of ACIS followed by repeat conization or hysterectomy between January 1, 1995 and April 30, 2010. Data were summarized using standard descriptive statistics. 78 patients met study criteria. The presence of ACIS at the internal conization margin or in the postconization endocervical curettage (ECC) correlated with residual ACIS (p<0.001). A margin positive for ACIS was associated with residual glandular neoplasia in 68% of cases. An ECC positive for ACIS was associated with residual ACIS in 95% of cases. If both the margins and the ECC were positive for the presence of ACIS, 8% did not have residual disease, 77% had residual ACIS and 15% had invasive adenocarcinoma. If both the internal conization margin and the postconization ECC were negative for the presence of ACIS, 14% of the final specimens had residual ACIS and none had invasive cancer. The addition of postconization ECC to cone biopsy for ACIS of the cervix provides valuable prognostic information regarding the risk of residual ACIS. Women with ACIS who have both a negative postconization ECC and a negative conization margin have a 14% risk for residual ACIS and can be treated conservatively if desiring fertility. A positive postconization ECC or internal margin incurs significant risk of residual disease and 12-17% will have cancer.
    No preview · Article · Dec 2013 · American journal of obstetrics and gynecology
  • Jin Guo · Miriam Cremer · Mauricio Maza · Karla Alfaro · Juan C Felix
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    ABSTRACT: We sought to test the diagnostic efficacy of a low-cost, liquid-based cervical cytology that could be implemented in low-resource settings. A prospective, split-sample Pap study was performed in 595 women attending a cervical cancer screening clinic in rural El Salvador. Collected cervical samples were used to make a conventional Pap (cell sample directly to glass slide), whereas residual material was used to make the liquid-based sample using the ClearPrep method. Selected samples were tested from the residual sample of the liquid-based collection for the presence of high-risk Human papillomaviruses. Of 595 patients, 570 were interpreted with the same diagnosis between the 2 methods (95.8% agreement). There were comparable numbers of unsatisfactory cases; however, ClearPrep significantly increased detection of low-grade squamous intraepithelial lesions and decreased the diagnoses of atypical squamous cells of undetermined significance. ClearPrep identified an equivalent number of high-grade squamous intraepithelial lesion cases as the conventional Pap. High-risk human papillomavirus was identified in all cases of high-grade squamous intraepithelial lesion, adenocarcinoma in situ, and cancer as well as in 78% of low-grade squamous intraepithelial lesions out of the residual fluid of the ClearPrep vials. The low-cost ClearPrep Pap test demonstrated equivalent detection of squamous intraepithelial lesions when compared with the conventional Pap smear and demonstrated the potential for ancillary molecular testing. The test seems a viable option for implementation in low-resource settings.
    No preview · Article · Nov 2013 · Journal of Lower Genital Tract Disease
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    ABSTRACT: To determine the preoperative pelvic ultrasonographic characteristics of postmenopausal women diagnosed with endometrial cancer (EC) at our institution. Postmenopausal women with EC who underwent preoperative transvaginal pelvic ultrasound from 1999-2009 were identified from our institutional database. The histologic diagnosis was based on pathologic findings in the hysterectomy specimen. Endometrial echo complex (EEC) thickness was abstracted from ultrasound reports. In all instances, ultrasound preceded the biopsy by a maximum of 3 months. Means with standard deviations were calculated for all categorical data. Differences between type 1 and type 2 ECs were determined using Mann-Whitney U tests and Chi squared/ Fisher's exact tests, as appropriate. A p-value of < 0.05 was considered statistically significant. Among 250 patients with postmenopausal EC, 156 had type 1 EC while 94 had type 2 EC. Thirty-six percent of the cohort had an EEC ≤ 4 mm, including 37% of patients with type 1 EC and 34% of patients with type 2 EC (p = 0.63). There were no significant differences between type 1 and type 2 EC in any demographic characteristic, other than likelihood of postmenopausal bleeding. Current expert opinion recommends no further diagnostic procedure in a woman with postmenopausal bleeding and an EEC ≤ 4 mm. These results indicate that a sizable proportion of women with EC have EECs ≤ 4 mm during their initial evaluation. An EEC ≤ 4 mm does not completely rule out endometrial cancer and cannot supplant histologic evaluation.
    No preview · Article · Jul 2013 · Gynecologic Oncology
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    ABSTRACT: [This corrects the article on p. e62215 in vol. 8.].
    No preview · Article · May 2013 · PLoS ONE
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    ABSTRACT: The molecular signals that control decisions regarding progenitor/stem cell proliferation versus differentiation are not fully understood. Differentiation of motile cilia from progenitor/stem cells may offer a simple tractable model to investigate this process. Wnt and Notch represent two key signaling pathways in progenitor/stem cell behavior in a number of tissues. Adenomatous Polyposis Coli, Apc is a negative regulator of the Wnt pathway and a well known multifunctional protein. Using the cre-LoxP system we inactivated the Apc locus via Foxj1-cre, which is expressed in cells committed to ciliated cell lineage. We then characterized the consequent phenotype in two select tissues that bear motile cilia, the lung and the testis. In the lung, Apc deletion induced β-catenin accumulation and Jag1 expression in ciliated cells and by lateral induction, triggered Notch signaling in adjacent Clara cells. In the bronchiolar epithelium, absence of Apc blocked the differentiation of a subpopulation of cells committed to the ciliogenesis program. In the human pulmonary adenocarcinoma cells, Apc over-expression inhibited Jag1 expression and promoted motile ciliogenic gene expression program including Foxj1, revealing the potential mechanism. In the testis, Apc inactivation induced β-catenin accumulation in the spermatogonia, but silenced Notch signaling and depleted spermatogonial stem cells, associated with reduced proliferation, resulting in male infertility. In sum, the present comparative analysis reveals the tissue-dependent consequences of Apc inactivation on proliferation and differentiation of ciliated cell progenitors by coordinating Wnt and Notch signaling.
    Preview · Article · Apr 2013 · PLoS ONE
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    ABSTRACT: Objective: This study aims to determine whether long-term isoflavone soy protein (ISP) supplementation affects endometrial thickness and rates of endometrial hyperplasia and cancer in postmenopausal women. Methods: In this randomized, double-blind, placebo-controlled trial, 350 postmenopausal women aged 45 to 92 years were randomized to a total daily dose of 154 mg of ISP or a milk protein-matched placebo for a 3-year period. Women with a surgically absent uterus were excluded from the analysis (final study population, N = 224). The main outcome measures were as follows: mean change in endometrial thickness on transvaginal ultrasound from baseline until up to 36 months of follow-up and the incidence of endometrial sampling, endometrial hyperplasia, and endometrial cancer. Results: A total of 666 visits among 224 participants were evaluated. Treatment groups did not significantly differ on the mean baseline or on-trial changes in endometrial thickness. Of the 103 placebo-treated participants, 7 (6.8%) underwent endometrial biopsy; 6 (85.7%) of these biopsies were benign. One woman in the placebo group was diagnosed with complex endometrial hyperplasia with atypia and underwent hysterectomy. The pathology result from this surgical operation was stage IB endometrial cancer. Of the 121 participants in the soy group, 9 (7.4%) underwent endometrial biopsy. The results were benign in all nine cases (100%). Although the rate of hyperplasia/malignancy was higher in the placebo group (14.3% vs 0%), the difference was not statistically significant. Conclusions: Three-year ISP supplementation has no effect on endometrial thickness or on the rates of endometrial hyperplasia and cancer in postmenopausal women.
    No preview · Article · Feb 2013 · Menopause (New York, N.Y.)
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    ABSTRACT: Background: The major contraceptive action of the levonorgestrel-releasing intrauterine system (LNG-IUS) is cervical mucus (CM) thickening, which prevents sperm penetration. No study to date has examined the temporal relationship between the insertion of the LNG-IUS and changes in CM quality and sperm penetration. Study design: Participants were enrolled in a clinically descriptive study to compare the quality of CM and three parameters of sperm penetration prior to insertion of the LNG-IUS and on Days 1, 3 and 5 after insertion. Measurements of estradiol, progesterone and levonorgestrel (LNG) in serum and LNG in CM were also carried out at these times. CM was analyzed using the World Health Organization CM grading criteria. Sperm penetration was determined using an in vitro sperm-CM penetration test. Results: All 10 participants underwent LNG-IUS insertion during midcycle when CM quality was good and sperm penetration was excellent. On Day 1 after LNG-IUS insertion, the majority of participants demonstrated poor CM quality and poor sperm penetration. On Day 3, all participants had poor CM quality, and all but one subject had poor sperm penetration. By Day 5, all participants had poor CM quality and poor sperm penetration. LNG levels in CM peaked on the day after LNG-IUS insertion. Conclusion: Significant changes in quality of CM and sperm penetration were observed shortly after LNG-IUS insertion; however, CM can remain penetrable for up to 5 days when the LNG-IUS is inserted midcycle.
    No preview · Article · Oct 2012 · Contraception
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    Sucheta Anand Srivastava · Yan Wang · John Vallone · Juan Carlos Felix
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    ABSTRACT: Neuroendocrine tumors are uncommon in the female genital tract and have been described in the ovary, uterus, cervix, and vagina. Primary carcinoid tumors have not been described in the vulva. We report 3 cases in 3 middle-aged women who presented with a solitary vulvar nodule without any other associated symptoms. All were treated with simple local excision. Two tumors were composed exclusively of clear cells arranged in nests separated by fibrovascular septae. The third tumor predominantly exhibited nests of eosinophilic granular cells with scattered areas of cells showing clear cytoplasm. Immunohistochemical staining for chromogranin and neuron-specific enolase confirmed neuroendocrine differentiation in all cases. Follow-up of 5.5 to 16 years showed no evidence of recurrence or metastasis. Primary clear cell carcinoid tumors of the vulva need to be considered in the differential diagnosis of vulvar masses with clear cell features. Immunohistochemistry plays an important role in the diagnosis of these lesions.
    Full-text · Article · Sep 2012 · The American journal of surgical pathology
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    ABSTRACT: Fabric-based endocervical and exocervical biopsy tools were compared with exocervical punch biopsy and sharp endocervical curettage. We compared the level of pain reported by the patient and the amount of bleeding rated by the physician relative to the type of biopsy used. This was a 2-center institutional review board-approved study of patients undergoing colposcopy. One center randomized patients to undergo either conventional (punch biopsy, sharp endocervical curettage) or fabric-based biopsy of the endocervix and exocervix, and a second center enrolled nonrandomized controls. The patient and physician subjectively rated bleeding (exocervical) and pain (endocervical and exocervical) from the biopsy procedure(s), which were compared using the nonparametric Wilcoxon test. Exocervical and endocervical biopsies from 55 patients were compared. Fabric-based biopsies were abundant full-thickness curettage and showed statistically significant less pain and bleeding than the conventional biopsy methods (p < .0001). Fabric-based biopsies are significantly less traumatic than conventional biopsies. The benefits of a less-invasive biopsy could increase the willingness to perform multiple biopsies, increase disease detection, and improve patient satisfaction, which could impact future gynecologic health-seeking behavior and compliance with colposcopy recall.
    No preview · Article · Apr 2012 · Journal of Lower Genital Tract Disease

  • No preview · Article · Nov 2011 · Gynecologic Oncology
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    ABSTRACT: Cancer-related coping strategies and social support, life stress, and optimism were tested in regression analyses as predictors of depression, affect, and quality of life among 54 low-income, immigrant Latina cervical cancer patients. Sixty-seven percent of the patients endorsed symptoms similar to diagnosable depression. Predictors significantly accounted for 35% to 54% of the variance in outcomes. Cancer-related coping strategies were found to mediate several of the relations between life stress, social support, and optimism and outcomes. Findings emphasize the need to consider the context within which patients live when assessing adjustment to cancer and developing culturally-sensitive interventions.
    No preview · Article · Sep 2011 · Journal of Psychosocial Oncology

Publication Stats

3k Citations
558.25 Total Impact Points


  • 1997-2015
    • University of California, Los Angeles
      • Department of Obstetrics and Gynecology
      Los Ángeles, California, United States
  • 1996-2015
    • Keck School of Medicine USC
      Los Ángeles, California, United States
  • 2014
    • Kaiser Permanente
      Oakland, California, United States
  • 1997-2014
    • University of Southern California
      • • Department of Obstetrics and Gynecology
      • • Department of Medicine
      • • Department of Pathology
      • • Keck School of Medicine
      • • Norris Comprehensive Cancer Center
      Los Ángeles, California, United States
  • 2002
    • Permanente Medical Group
      Pasadena, California, United States
  • 2000
    • Johns Hopkins Medicine
      • Department of Pathology
      Baltimore, Maryland, United States
    • Johns Hopkins University
      Baltimore, Maryland, United States