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House Republicans proffer SGR fix legislation
Republicans on the House Energy and Commerce Committee have released a draft bill that would eliminate the Medicare Sustainable Growth Rate formula that they say has a good chance of being enacted.
Physician groups have been involved in the crafting of the draft, which was first circulated in early February.
"This discussion draft carries on the trend of soliciting more provider feedback than at any point in history on this issue," Rep. Michael Burgess (R-Tex.) said in a statement. "We are taking an important next step with this release by showing providers that we are committed to repealing the SGR and maintaining the option of fee-for-service for providers, while improving the Medicare program."
Rep. Burgess, who is an ob.gyn., and also vice chairman of the Energy and Commerce Health Subcommittee, said that he and his colleagues looked forward to hearing more from physicians.
The draft legislation would repeal the SGR and replace it with a fee-for-service system that would put more emphasis on rewarding quality. Physicians would have a guiding hand in developing quality measures in conjunction with the secretary of Health and Human Services. They would also be given the ability to opt out of fee-for-service and practice instead under new delivery models like accountable care organizations or patient-centered medical homes.
"We are working to restore certainty, fiscal sanity, and we will responsibly pay for these reforms," said Rep. Fred Upton (R-Mich.), chairman of the House Energy and Commerce committee, in a statement. "We will continue working closely with Ways and Means Committee Chairman [Dave] Camp [R-Mich.] as well as maintain our ongoing dialogue with committee Democrats as we work toward long-term solutions in the effort to improve quality of care."
Physician groups were cautious about the proposal at press time. In a statement, Dr. Jeremy Lazarus, president of the American Medical Association, said, "The Energy and Commerce Committee’s framework is another step in the important process of eliminating the SGR and moving toward new ways of delivering and paying for care that reward quality and reduce costs."
He said that the AMA "look[ed] forward to continuing to work to see that progress is made this year."
The American Academy of Family Physicians supports the proposal’s goal of establishing "a period of stable and predictable payment increases," and incentives to improve quality of care, said Dr. Jeffrey Cain, AAFP president, in an interview.
But by largely focusing on the fee-for-service payment system, the committee is overlooking the bigger picture of how physician payment affects health care costs and quality, he said. The AAFP would like to see an increase in pay for primary care because "investing in primary care would improve our country’s health care by increasing quality and decreasing overall costs by reducing unnecessary medical utilization," said Dr. Cain.
In early February, the American College of Physicians and several other groups lent their support to an SGR replacement bill that has elements similar to the Energy and Commerce draft. The bill, the Medicare Physician Payment Innovation Act (H.R. 574), was introduced by Reps. Allyson Schwartz (D-Penn.) and Joe Heck (R-Nev.).
In early May, Rep. Schwartz commended the Energy and Commerce bill, noting that it shared principles in common with H.R. 574. The bill also showed "that there is common ground on a framework for fixing the Medicare reimbursement system," said Rep. Schwartz in a statement.
The Energy and Commerce Committee said that comments on its draft legislation would be accepted until June 10, at [email protected].
On Twitter @aliciaault
Republicans on the House Energy and Commerce Committee have released a draft bill that would eliminate the Medicare Sustainable Growth Rate formula that they say has a good chance of being enacted.
Physician groups have been involved in the crafting of the draft, which was first circulated in early February.
"This discussion draft carries on the trend of soliciting more provider feedback than at any point in history on this issue," Rep. Michael Burgess (R-Tex.) said in a statement. "We are taking an important next step with this release by showing providers that we are committed to repealing the SGR and maintaining the option of fee-for-service for providers, while improving the Medicare program."
Rep. Burgess, who is an ob.gyn., and also vice chairman of the Energy and Commerce Health Subcommittee, said that he and his colleagues looked forward to hearing more from physicians.
The draft legislation would repeal the SGR and replace it with a fee-for-service system that would put more emphasis on rewarding quality. Physicians would have a guiding hand in developing quality measures in conjunction with the secretary of Health and Human Services. They would also be given the ability to opt out of fee-for-service and practice instead under new delivery models like accountable care organizations or patient-centered medical homes.
"We are working to restore certainty, fiscal sanity, and we will responsibly pay for these reforms," said Rep. Fred Upton (R-Mich.), chairman of the House Energy and Commerce committee, in a statement. "We will continue working closely with Ways and Means Committee Chairman [Dave] Camp [R-Mich.] as well as maintain our ongoing dialogue with committee Democrats as we work toward long-term solutions in the effort to improve quality of care."
Physician groups were cautious about the proposal at press time. In a statement, Dr. Jeremy Lazarus, president of the American Medical Association, said, "The Energy and Commerce Committee’s framework is another step in the important process of eliminating the SGR and moving toward new ways of delivering and paying for care that reward quality and reduce costs."
He said that the AMA "look[ed] forward to continuing to work to see that progress is made this year."
The American Academy of Family Physicians supports the proposal’s goal of establishing "a period of stable and predictable payment increases," and incentives to improve quality of care, said Dr. Jeffrey Cain, AAFP president, in an interview.
But by largely focusing on the fee-for-service payment system, the committee is overlooking the bigger picture of how physician payment affects health care costs and quality, he said. The AAFP would like to see an increase in pay for primary care because "investing in primary care would improve our country’s health care by increasing quality and decreasing overall costs by reducing unnecessary medical utilization," said Dr. Cain.
In early February, the American College of Physicians and several other groups lent their support to an SGR replacement bill that has elements similar to the Energy and Commerce draft. The bill, the Medicare Physician Payment Innovation Act (H.R. 574), was introduced by Reps. Allyson Schwartz (D-Penn.) and Joe Heck (R-Nev.).
In early May, Rep. Schwartz commended the Energy and Commerce bill, noting that it shared principles in common with H.R. 574. The bill also showed "that there is common ground on a framework for fixing the Medicare reimbursement system," said Rep. Schwartz in a statement.
The Energy and Commerce Committee said that comments on its draft legislation would be accepted until June 10, at [email protected].
On Twitter @aliciaault
Republicans on the House Energy and Commerce Committee have released a draft bill that would eliminate the Medicare Sustainable Growth Rate formula that they say has a good chance of being enacted.
Physician groups have been involved in the crafting of the draft, which was first circulated in early February.
"This discussion draft carries on the trend of soliciting more provider feedback than at any point in history on this issue," Rep. Michael Burgess (R-Tex.) said in a statement. "We are taking an important next step with this release by showing providers that we are committed to repealing the SGR and maintaining the option of fee-for-service for providers, while improving the Medicare program."
Rep. Burgess, who is an ob.gyn., and also vice chairman of the Energy and Commerce Health Subcommittee, said that he and his colleagues looked forward to hearing more from physicians.
The draft legislation would repeal the SGR and replace it with a fee-for-service system that would put more emphasis on rewarding quality. Physicians would have a guiding hand in developing quality measures in conjunction with the secretary of Health and Human Services. They would also be given the ability to opt out of fee-for-service and practice instead under new delivery models like accountable care organizations or patient-centered medical homes.
"We are working to restore certainty, fiscal sanity, and we will responsibly pay for these reforms," said Rep. Fred Upton (R-Mich.), chairman of the House Energy and Commerce committee, in a statement. "We will continue working closely with Ways and Means Committee Chairman [Dave] Camp [R-Mich.] as well as maintain our ongoing dialogue with committee Democrats as we work toward long-term solutions in the effort to improve quality of care."
Physician groups were cautious about the proposal at press time. In a statement, Dr. Jeremy Lazarus, president of the American Medical Association, said, "The Energy and Commerce Committee’s framework is another step in the important process of eliminating the SGR and moving toward new ways of delivering and paying for care that reward quality and reduce costs."
He said that the AMA "look[ed] forward to continuing to work to see that progress is made this year."
The American Academy of Family Physicians supports the proposal’s goal of establishing "a period of stable and predictable payment increases," and incentives to improve quality of care, said Dr. Jeffrey Cain, AAFP president, in an interview.
But by largely focusing on the fee-for-service payment system, the committee is overlooking the bigger picture of how physician payment affects health care costs and quality, he said. The AAFP would like to see an increase in pay for primary care because "investing in primary care would improve our country’s health care by increasing quality and decreasing overall costs by reducing unnecessary medical utilization," said Dr. Cain.
In early February, the American College of Physicians and several other groups lent their support to an SGR replacement bill that has elements similar to the Energy and Commerce draft. The bill, the Medicare Physician Payment Innovation Act (H.R. 574), was introduced by Reps. Allyson Schwartz (D-Penn.) and Joe Heck (R-Nev.).
In early May, Rep. Schwartz commended the Energy and Commerce bill, noting that it shared principles in common with H.R. 574. The bill also showed "that there is common ground on a framework for fixing the Medicare reimbursement system," said Rep. Schwartz in a statement.
The Energy and Commerce Committee said that comments on its draft legislation would be accepted until June 10, at [email protected].
On Twitter @aliciaault
Survival equivalent with sublobar, lobar resection of stage Ia NSCLC
MINNEAPOLIS – Sublobar resection and lobectomy resulted in equivalent lung cancer survival and overall recurrence rates in a screen-detected cohort of 348 stage IA non–small-cell lung cancer patients.
In all, 7% of patients (4/54) who underwent sublobar resection and 10% of those (29/294) who underwent lobectomy died of lung cancer after a median follow-up of 73 months (P = .64).
All-cause mortality was also statistically similar at 17% and 22%, said Dr. Nasser Altorki, professor of cardiothoracic surgery and director of thoracic surgery at New York Presbyterian–Weill Cornell Medical Center in New York.
Although lobectomy has been the standard of care for resection of early-stage non–small-cell lung cancer since 1994, several studies support sublobar resection in patients with small peripheral tumors and the elderly with compromised pulmonary reserve.
The best surgical treatment for younger patients with adequate cardiopulmonary function remains controversial, with two large, ongoing trials in the U.S. and Japan evaluating lobar vs. sublobar resection in this setting. A recent best evidence paper (Interact. CardioVasc. Thorac. Surg. 2012;14:816-20) concluded that lobectomy is still the best surgical option for these patients, citing evidence of lower survival and higher recurrence rates with wedge resections than with anatomic segmentectomies. The two sublobar techniques are often lumped together in comparisons with lobectomy, but are not technically or oncologically the same.
Wedge resection in the current study seemed to be associated with a higher rate of recurrence than segmentectomy, Dr. Altorki said at the annual meeting of the American Association for Thoracic Surgery.
Recurrence occurred in 32 patients after lobectomy and 8 after sublobar resection (11% vs. 15%; P = .40), with all of the sublobar resection recurrences occurring after wedge resection (8/38 or 21% vs. 0%).
"I don’t want to say this is a practice-changing study; however, it is a study that calls for more technical equipoise in our approach to the [surgical] treatment of lung cancer," he said during a discussion of the results. "Clearly, we can apply this operation to patients who would be candidates for both lobectomy and sublobar resection, but it does not extend to those patients, for example, that would have been poor candidates for any surgical resection."
The 348 patients had c1A non–small-cell lung cancer that presented as a solid nodule on computed tomography screening and underwent surgery as part of the International Early Lung Cancer Action Program from 1993 to 2011. Comorbidities were similar among the lobectomy and sublobar patients including cardiac disease (6% vs. 11%), chronic obstructive pulmonary disease (15% vs. 26%) and diabetes (9% vs. 7%). Their median age was 63 vs. 65 years, and the median number of pack-years of smoking was 48 vs. 49, respectively.
The lobectomy group had significantly larger tumors (13 mm vs. 11 mm), more frequent sampling of mediastinal nodes (78% vs. 56%) and more resected lymph nodes (mean 8 vs. 5).
The overall rate of hospital mortality in the multicenter study was low at 0.9% (3/348) and "represents what is achievable in screening centers of excellence," Dr. Altorki said.
Ten-year survival was 88% with lobectomy and 90% with sublobar resection (log rank P = .64). There was no difference in patients with tumors less than 2 cm (88% vs. 89%), who represented the majority or 86% of the cohort.
Cox regression analysis, adjusted for the above potential confounders, showed that only age (hazard ratio, 2.9; P less than .0001) and severe emphysema (HR, 4.2; P = .005) significantly predicted survival, whereas sublobar resection did not (HR, 0.8; P = .60), he said.
Invited discussant Dr. Joseph S. Friedberg, chief of thoracic surgery at the University of Pennsylvania Health System-Presbyterian in Philadelphia, expressed surprise that despite undergoing surgery by highly qualified general thoracic surgeons, 70% of sublobar resections were performed as wedge and not segmentectomies, and that more than 40% of sublobar resection patients and nearly a quarter of lobectomy patients did not have one mediastinal node biopsied.
"One would expect, based on the Lung Cancer Study Group analysis and common sense, that some of these patients, especially sublobar resection patients, were understaged and/or undertreated and yet the results are as good as anything in the literature," he said. "How do you reconcile that?"
Dr. Altorki said assessment of the mediastinal field was disappointing and that further education is needed on the prognostic and therapeutic benefits of such assessment, but that the rate far exceeds what is in the published literature. He also speculated that most of the patients were done by video-assisted thoracic surgery and that mediastinal node assessment may not be as straightforward with VATS as it is with open surgery.
Dr. Altorki said that, going in, many of the surgeons may have thought that a 1- to 1.2-cm tumor may be equally resected with wedge resection and anatomic segmentectomy, and that this "is a job we have to address in ongoing randomized trials."
Dr. Altorki reported no relevant financial disclosures.
MINNEAPOLIS – Sublobar resection and lobectomy resulted in equivalent lung cancer survival and overall recurrence rates in a screen-detected cohort of 348 stage IA non–small-cell lung cancer patients.
In all, 7% of patients (4/54) who underwent sublobar resection and 10% of those (29/294) who underwent lobectomy died of lung cancer after a median follow-up of 73 months (P = .64).
All-cause mortality was also statistically similar at 17% and 22%, said Dr. Nasser Altorki, professor of cardiothoracic surgery and director of thoracic surgery at New York Presbyterian–Weill Cornell Medical Center in New York.
Although lobectomy has been the standard of care for resection of early-stage non–small-cell lung cancer since 1994, several studies support sublobar resection in patients with small peripheral tumors and the elderly with compromised pulmonary reserve.
The best surgical treatment for younger patients with adequate cardiopulmonary function remains controversial, with two large, ongoing trials in the U.S. and Japan evaluating lobar vs. sublobar resection in this setting. A recent best evidence paper (Interact. CardioVasc. Thorac. Surg. 2012;14:816-20) concluded that lobectomy is still the best surgical option for these patients, citing evidence of lower survival and higher recurrence rates with wedge resections than with anatomic segmentectomies. The two sublobar techniques are often lumped together in comparisons with lobectomy, but are not technically or oncologically the same.
Wedge resection in the current study seemed to be associated with a higher rate of recurrence than segmentectomy, Dr. Altorki said at the annual meeting of the American Association for Thoracic Surgery.
Recurrence occurred in 32 patients after lobectomy and 8 after sublobar resection (11% vs. 15%; P = .40), with all of the sublobar resection recurrences occurring after wedge resection (8/38 or 21% vs. 0%).
"I don’t want to say this is a practice-changing study; however, it is a study that calls for more technical equipoise in our approach to the [surgical] treatment of lung cancer," he said during a discussion of the results. "Clearly, we can apply this operation to patients who would be candidates for both lobectomy and sublobar resection, but it does not extend to those patients, for example, that would have been poor candidates for any surgical resection."
The 348 patients had c1A non–small-cell lung cancer that presented as a solid nodule on computed tomography screening and underwent surgery as part of the International Early Lung Cancer Action Program from 1993 to 2011. Comorbidities were similar among the lobectomy and sublobar patients including cardiac disease (6% vs. 11%), chronic obstructive pulmonary disease (15% vs. 26%) and diabetes (9% vs. 7%). Their median age was 63 vs. 65 years, and the median number of pack-years of smoking was 48 vs. 49, respectively.
The lobectomy group had significantly larger tumors (13 mm vs. 11 mm), more frequent sampling of mediastinal nodes (78% vs. 56%) and more resected lymph nodes (mean 8 vs. 5).
The overall rate of hospital mortality in the multicenter study was low at 0.9% (3/348) and "represents what is achievable in screening centers of excellence," Dr. Altorki said.
Ten-year survival was 88% with lobectomy and 90% with sublobar resection (log rank P = .64). There was no difference in patients with tumors less than 2 cm (88% vs. 89%), who represented the majority or 86% of the cohort.
Cox regression analysis, adjusted for the above potential confounders, showed that only age (hazard ratio, 2.9; P less than .0001) and severe emphysema (HR, 4.2; P = .005) significantly predicted survival, whereas sublobar resection did not (HR, 0.8; P = .60), he said.
Invited discussant Dr. Joseph S. Friedberg, chief of thoracic surgery at the University of Pennsylvania Health System-Presbyterian in Philadelphia, expressed surprise that despite undergoing surgery by highly qualified general thoracic surgeons, 70% of sublobar resections were performed as wedge and not segmentectomies, and that more than 40% of sublobar resection patients and nearly a quarter of lobectomy patients did not have one mediastinal node biopsied.
"One would expect, based on the Lung Cancer Study Group analysis and common sense, that some of these patients, especially sublobar resection patients, were understaged and/or undertreated and yet the results are as good as anything in the literature," he said. "How do you reconcile that?"
Dr. Altorki said assessment of the mediastinal field was disappointing and that further education is needed on the prognostic and therapeutic benefits of such assessment, but that the rate far exceeds what is in the published literature. He also speculated that most of the patients were done by video-assisted thoracic surgery and that mediastinal node assessment may not be as straightforward with VATS as it is with open surgery.
Dr. Altorki said that, going in, many of the surgeons may have thought that a 1- to 1.2-cm tumor may be equally resected with wedge resection and anatomic segmentectomy, and that this "is a job we have to address in ongoing randomized trials."
Dr. Altorki reported no relevant financial disclosures.
MINNEAPOLIS – Sublobar resection and lobectomy resulted in equivalent lung cancer survival and overall recurrence rates in a screen-detected cohort of 348 stage IA non–small-cell lung cancer patients.
In all, 7% of patients (4/54) who underwent sublobar resection and 10% of those (29/294) who underwent lobectomy died of lung cancer after a median follow-up of 73 months (P = .64).
All-cause mortality was also statistically similar at 17% and 22%, said Dr. Nasser Altorki, professor of cardiothoracic surgery and director of thoracic surgery at New York Presbyterian–Weill Cornell Medical Center in New York.
Although lobectomy has been the standard of care for resection of early-stage non–small-cell lung cancer since 1994, several studies support sublobar resection in patients with small peripheral tumors and the elderly with compromised pulmonary reserve.
The best surgical treatment for younger patients with adequate cardiopulmonary function remains controversial, with two large, ongoing trials in the U.S. and Japan evaluating lobar vs. sublobar resection in this setting. A recent best evidence paper (Interact. CardioVasc. Thorac. Surg. 2012;14:816-20) concluded that lobectomy is still the best surgical option for these patients, citing evidence of lower survival and higher recurrence rates with wedge resections than with anatomic segmentectomies. The two sublobar techniques are often lumped together in comparisons with lobectomy, but are not technically or oncologically the same.
Wedge resection in the current study seemed to be associated with a higher rate of recurrence than segmentectomy, Dr. Altorki said at the annual meeting of the American Association for Thoracic Surgery.
Recurrence occurred in 32 patients after lobectomy and 8 after sublobar resection (11% vs. 15%; P = .40), with all of the sublobar resection recurrences occurring after wedge resection (8/38 or 21% vs. 0%).
"I don’t want to say this is a practice-changing study; however, it is a study that calls for more technical equipoise in our approach to the [surgical] treatment of lung cancer," he said during a discussion of the results. "Clearly, we can apply this operation to patients who would be candidates for both lobectomy and sublobar resection, but it does not extend to those patients, for example, that would have been poor candidates for any surgical resection."
The 348 patients had c1A non–small-cell lung cancer that presented as a solid nodule on computed tomography screening and underwent surgery as part of the International Early Lung Cancer Action Program from 1993 to 2011. Comorbidities were similar among the lobectomy and sublobar patients including cardiac disease (6% vs. 11%), chronic obstructive pulmonary disease (15% vs. 26%) and diabetes (9% vs. 7%). Their median age was 63 vs. 65 years, and the median number of pack-years of smoking was 48 vs. 49, respectively.
The lobectomy group had significantly larger tumors (13 mm vs. 11 mm), more frequent sampling of mediastinal nodes (78% vs. 56%) and more resected lymph nodes (mean 8 vs. 5).
The overall rate of hospital mortality in the multicenter study was low at 0.9% (3/348) and "represents what is achievable in screening centers of excellence," Dr. Altorki said.
Ten-year survival was 88% with lobectomy and 90% with sublobar resection (log rank P = .64). There was no difference in patients with tumors less than 2 cm (88% vs. 89%), who represented the majority or 86% of the cohort.
Cox regression analysis, adjusted for the above potential confounders, showed that only age (hazard ratio, 2.9; P less than .0001) and severe emphysema (HR, 4.2; P = .005) significantly predicted survival, whereas sublobar resection did not (HR, 0.8; P = .60), he said.
Invited discussant Dr. Joseph S. Friedberg, chief of thoracic surgery at the University of Pennsylvania Health System-Presbyterian in Philadelphia, expressed surprise that despite undergoing surgery by highly qualified general thoracic surgeons, 70% of sublobar resections were performed as wedge and not segmentectomies, and that more than 40% of sublobar resection patients and nearly a quarter of lobectomy patients did not have one mediastinal node biopsied.
"One would expect, based on the Lung Cancer Study Group analysis and common sense, that some of these patients, especially sublobar resection patients, were understaged and/or undertreated and yet the results are as good as anything in the literature," he said. "How do you reconcile that?"
Dr. Altorki said assessment of the mediastinal field was disappointing and that further education is needed on the prognostic and therapeutic benefits of such assessment, but that the rate far exceeds what is in the published literature. He also speculated that most of the patients were done by video-assisted thoracic surgery and that mediastinal node assessment may not be as straightforward with VATS as it is with open surgery.
Dr. Altorki said that, going in, many of the surgeons may have thought that a 1- to 1.2-cm tumor may be equally resected with wedge resection and anatomic segmentectomy, and that this "is a job we have to address in ongoing randomized trials."
Dr. Altorki reported no relevant financial disclosures.
AT THE AATS ANNUAL MEETING
Major finding: Lung cancer–specific mortality was 7% with sublobar resection and 10% with lobar resection.
Data source: Retrospective analysis of 348 patients with stage IA non–small-cell lung cancer in the prospective International Early Lung Cancer Action Program.
Disclosures: Dr. Altorki reported no relevant financial disclosures.
Fewer graduates, more thoracic surgery board failures
MINNEAPOLIS – The number of residents failing the American Board of Thoracic Surgery exams has risen significantly in the wake of reduced residency hours, a new study confirms.
The change is particularly alarming for the ABTS oral boards, Dr. Susan Moffatt-Bruce reported at the annual meeting of the American Association for Thoracic Surgery.
The failure rate for the oral exams doubled from 14.4% to 28.1% between 2000 to 2005 and 2006 to 2011, the 6 years before and 6 years after the Accreditation Council for Graduate Medical Education imposed an 80-hour residency work week. By 2012, 30% of residents were failing the oral exam.
Of the 903 residents who took the written exam between 2000 and 2005, 10.6% failed, compared with 17.4% of the 672 residents writing the exam between 2006 and 2007. By 2012, however, the success rate reached 85.4%.
Although the percentage failing the written exam was lower than for the oral exams in both time periods, it remained significantly higher from 2006 to 2011 than before the 80-hour work week requirement (12% vs. 21%) said Dr. Moffatt-Bruce, a cardiothoracic surgeon at the Ohio State Medical Center in Columbus.
"There are a decreasing number of trainees, and we will not meet the needs of a growing American population," she said, observing that the shortfall of certified cardiothoracic surgeons could be realized as early as 2020.
Dr. Moffatt-Bruce speculated that the higher failure rate for the oral exams could be the result of a decrease in the number of critical cardiac cases and in experiential learning for thoracic surgery residents, particularly on the weekends and evenings.
"It is very hard to pass an oral exam question about a scenario that you may never have encountered as a resident," she said.
Since 2000, the number of new certificates awarded by the ABTS has decreased steadily from a peak of 126 certificates in 2002 to 93 certificates in 2011. An additional 100 residents would need to be trained to meet the need for cardiothoracic surgeons by 2030, Dr. Moffatt-Bruce said.
She was careful to acknowledge existing efforts by various groups to attract students, such as the 6-year Integrated Cardiothoracic Surgery Residency Program (I-6), but she said additional strategies are needed to improve not only the number of trainees, but also the way in which they learn.
During a discussion of the results, Dr. Edward Verrier, surgical director, Joint Council of Thoracic Surgery Education, said various societies have gotten together and this spring will roll out a completely new content management system for the cardiothoracic surgery curriculum as well as a new curriculum and learning management tool that will help track issues related to competency and various milestones.
"It’s very important to recognize that these issues have been on the table; they’ve been very carefully thought out at the board level, the society level and by some of the other organizations dedicated to education, and we will see significant transitions over the next year," he said.
Dr. Teresa Kieser, a cardiothoracic surgeon with University of Calgary in Canada, said that more than half of medical school graduates in Canada are women, but that perhaps women aren’t choosing cardiothoracic surgery as a career.
Dr. Moffatt-Bruce, who trained in both the U.S. and Canada, agreed there are challenges facing women in cardiothoracic surgery, but said the curriculum needs to be more attractive to everyone and that providing experiences early on in the medical school curriculum and environment will entice residents "to see that this really is a great career choice, that this is the way of the future and that the need is going to be very real. We have to set the burning platform for everyone and we can do that very easily as an association with the various societies."
Dr. Moffatt-Bruce and her coauthors reported having no financial disclosures.
MINNEAPOLIS – The number of residents failing the American Board of Thoracic Surgery exams has risen significantly in the wake of reduced residency hours, a new study confirms.
The change is particularly alarming for the ABTS oral boards, Dr. Susan Moffatt-Bruce reported at the annual meeting of the American Association for Thoracic Surgery.
The failure rate for the oral exams doubled from 14.4% to 28.1% between 2000 to 2005 and 2006 to 2011, the 6 years before and 6 years after the Accreditation Council for Graduate Medical Education imposed an 80-hour residency work week. By 2012, 30% of residents were failing the oral exam.
Of the 903 residents who took the written exam between 2000 and 2005, 10.6% failed, compared with 17.4% of the 672 residents writing the exam between 2006 and 2007. By 2012, however, the success rate reached 85.4%.
Although the percentage failing the written exam was lower than for the oral exams in both time periods, it remained significantly higher from 2006 to 2011 than before the 80-hour work week requirement (12% vs. 21%) said Dr. Moffatt-Bruce, a cardiothoracic surgeon at the Ohio State Medical Center in Columbus.
"There are a decreasing number of trainees, and we will not meet the needs of a growing American population," she said, observing that the shortfall of certified cardiothoracic surgeons could be realized as early as 2020.
Dr. Moffatt-Bruce speculated that the higher failure rate for the oral exams could be the result of a decrease in the number of critical cardiac cases and in experiential learning for thoracic surgery residents, particularly on the weekends and evenings.
"It is very hard to pass an oral exam question about a scenario that you may never have encountered as a resident," she said.
Since 2000, the number of new certificates awarded by the ABTS has decreased steadily from a peak of 126 certificates in 2002 to 93 certificates in 2011. An additional 100 residents would need to be trained to meet the need for cardiothoracic surgeons by 2030, Dr. Moffatt-Bruce said.
She was careful to acknowledge existing efforts by various groups to attract students, such as the 6-year Integrated Cardiothoracic Surgery Residency Program (I-6), but she said additional strategies are needed to improve not only the number of trainees, but also the way in which they learn.
During a discussion of the results, Dr. Edward Verrier, surgical director, Joint Council of Thoracic Surgery Education, said various societies have gotten together and this spring will roll out a completely new content management system for the cardiothoracic surgery curriculum as well as a new curriculum and learning management tool that will help track issues related to competency and various milestones.
"It’s very important to recognize that these issues have been on the table; they’ve been very carefully thought out at the board level, the society level and by some of the other organizations dedicated to education, and we will see significant transitions over the next year," he said.
Dr. Teresa Kieser, a cardiothoracic surgeon with University of Calgary in Canada, said that more than half of medical school graduates in Canada are women, but that perhaps women aren’t choosing cardiothoracic surgery as a career.
Dr. Moffatt-Bruce, who trained in both the U.S. and Canada, agreed there are challenges facing women in cardiothoracic surgery, but said the curriculum needs to be more attractive to everyone and that providing experiences early on in the medical school curriculum and environment will entice residents "to see that this really is a great career choice, that this is the way of the future and that the need is going to be very real. We have to set the burning platform for everyone and we can do that very easily as an association with the various societies."
Dr. Moffatt-Bruce and her coauthors reported having no financial disclosures.
MINNEAPOLIS – The number of residents failing the American Board of Thoracic Surgery exams has risen significantly in the wake of reduced residency hours, a new study confirms.
The change is particularly alarming for the ABTS oral boards, Dr. Susan Moffatt-Bruce reported at the annual meeting of the American Association for Thoracic Surgery.
The failure rate for the oral exams doubled from 14.4% to 28.1% between 2000 to 2005 and 2006 to 2011, the 6 years before and 6 years after the Accreditation Council for Graduate Medical Education imposed an 80-hour residency work week. By 2012, 30% of residents were failing the oral exam.
Of the 903 residents who took the written exam between 2000 and 2005, 10.6% failed, compared with 17.4% of the 672 residents writing the exam between 2006 and 2007. By 2012, however, the success rate reached 85.4%.
Although the percentage failing the written exam was lower than for the oral exams in both time periods, it remained significantly higher from 2006 to 2011 than before the 80-hour work week requirement (12% vs. 21%) said Dr. Moffatt-Bruce, a cardiothoracic surgeon at the Ohio State Medical Center in Columbus.
"There are a decreasing number of trainees, and we will not meet the needs of a growing American population," she said, observing that the shortfall of certified cardiothoracic surgeons could be realized as early as 2020.
Dr. Moffatt-Bruce speculated that the higher failure rate for the oral exams could be the result of a decrease in the number of critical cardiac cases and in experiential learning for thoracic surgery residents, particularly on the weekends and evenings.
"It is very hard to pass an oral exam question about a scenario that you may never have encountered as a resident," she said.
Since 2000, the number of new certificates awarded by the ABTS has decreased steadily from a peak of 126 certificates in 2002 to 93 certificates in 2011. An additional 100 residents would need to be trained to meet the need for cardiothoracic surgeons by 2030, Dr. Moffatt-Bruce said.
She was careful to acknowledge existing efforts by various groups to attract students, such as the 6-year Integrated Cardiothoracic Surgery Residency Program (I-6), but she said additional strategies are needed to improve not only the number of trainees, but also the way in which they learn.
During a discussion of the results, Dr. Edward Verrier, surgical director, Joint Council of Thoracic Surgery Education, said various societies have gotten together and this spring will roll out a completely new content management system for the cardiothoracic surgery curriculum as well as a new curriculum and learning management tool that will help track issues related to competency and various milestones.
"It’s very important to recognize that these issues have been on the table; they’ve been very carefully thought out at the board level, the society level and by some of the other organizations dedicated to education, and we will see significant transitions over the next year," he said.
Dr. Teresa Kieser, a cardiothoracic surgeon with University of Calgary in Canada, said that more than half of medical school graduates in Canada are women, but that perhaps women aren’t choosing cardiothoracic surgery as a career.
Dr. Moffatt-Bruce, who trained in both the U.S. and Canada, agreed there are challenges facing women in cardiothoracic surgery, but said the curriculum needs to be more attractive to everyone and that providing experiences early on in the medical school curriculum and environment will entice residents "to see that this really is a great career choice, that this is the way of the future and that the need is going to be very real. We have to set the burning platform for everyone and we can do that very easily as an association with the various societies."
Dr. Moffatt-Bruce and her coauthors reported having no financial disclosures.
AT THE AATS ANNUAL MEETING
Major finding: The failure rate for ABTS oral exams doubled from 14.4% to 28.1% between 2000-2005 and 2006-2011, the 6 years before and after the 80-hour residency work week.
Data source: Retrospective analysis of ABTS Board scores, both written and oral, from 2000-2011.
Disclosures: Dr. Moffatt-Bruce and her coauthors reported having no financial disclosures.
Colon cancer screening in African Americans
Data show that African Americans present with colon cancer at an earlier age than whites. But there's debate about the appropriate screening age. Should all African American patients be screened at age 40? Dr. Byron Cryer, professor of medicine at the University of Texas Southwestern Medical Center, discusses the pros and cons of earlier screening and shares his opinion on the issue.
Data show that African Americans present with colon cancer at an earlier age than whites. But there's debate about the appropriate screening age. Should all African American patients be screened at age 40? Dr. Byron Cryer, professor of medicine at the University of Texas Southwestern Medical Center, discusses the pros and cons of earlier screening and shares his opinion on the issue.
Data show that African Americans present with colon cancer at an earlier age than whites. But there's debate about the appropriate screening age. Should all African American patients be screened at age 40? Dr. Byron Cryer, professor of medicine at the University of Texas Southwestern Medical Center, discusses the pros and cons of earlier screening and shares his opinion on the issue.
Primary tumor resection is linked to growth of CRC liver metastases
PHOENIX – The standard sequential approach to treatment of patients with isolated synchronous liver metastases of colorectal cancer, entailing up-front removal of the primary tumor, is associated with growth of the metastases, according to results from a retrospective cohort study.
A team led by Dr. Alistair Slesser, a surgical registrar at the Royal Marsden Hospital in London, studied 114 patients with colorectal cancer who had synchronous liver metastases, meaning ones identified within a year of the cancer diagnosis, and no other metastases.
Results showed that patients whose initial treatment was resection of the colorectal primary tumor had ninefold higher odds of progression of their liver metastases at 3 months, compared with patients whose initial treatment was chemotherapy, he reported at the annual meeting of the American Society of Colon and Rectal Surgeons.
Although liver metastases showed regression during 3-6 months of treatment in both groups, the rate was somewhat slower in the primary tumor resection group.
"Our findings suggest that an up-front primary tumor resection is actually an adverse prognostic factor. Indeed, our results have demonstrated that up-front primary tumor resection seemed to negate the effects of the adjuvant therapy on the treatment of the liver metastasis," Dr. Slesser commented.
"How does this apply clinically? We would recommend that patients who have limited metastatic disease, instead of having an up-front primary tumor resection perhaps [they should] be treated with neoadjuvant chemotherapy first. Or perhaps another surgical approach, like a simultaneous resection, should be considered to negate the adverse effects of a primary tumor resection on the metastatic disease," he said.
"When patients have lesions which are suspicious for liver metastases, we would recommend that these patients [be] thoroughly investigated, and if metastatic disease is confirmed, then again, we would recommend that they have chemotherapy prior to any subsequent intervention," he added.
The mechanism leading to growth of liver metastases after primary tumor resection is unknown, according to Dr. Slesser. "There is possibly an association for ... biological reasons. The other reason is that perhaps when a patient has an up-front primary tumor resection, there is a delay in getting chemotherapy, and that can cause the progression that we see."
Session attendee Dr. Gary Dunn, of the University of Oklahoma, Oklahoma City, asked how much time elapsed between up-front resection and receipt of adjuvant chemotherapy in that group, and the variance in this measure, noting, "That will significantly affect your outcome, if some patients started at 6 weeks and some patients started at 12 weeks postop."
"Usually, patients waited 6 weeks before they started chemotherapy postoperatively," Dr. Slesser explained. "The majority of patients who had primary tumor resection had the adjuvant chemotherapy after the postoperative scan; the 3-month scan tends to be the postoperative scan."
Dr. Dunn further wondered about the comparability between groups of the chemotherapy received, asking what agents were used.
"At the Royal Marsden, the chemotherapy regimes tend to be quite uniform," Dr. Slesser replied. "Generally, all patients are on capecitabine [Xeloda] and oxaliplatin, with a monoclonal agent such as bevacizumab [Avastin]. They tend to get that when they have neoadjuvant chemotherapy."
Another attendee said, "Excellent paper, very well presented data, particularly considering there are a lot of retrospective series out there that are showing the up-front resection as a favorable prognostic indicator, which I don’t believe. ... But I would like to see a little more information about how the patients were treated subsequently. Were these patients who they were planning to get to surgery for resection, or were these patients who were treated for palliative intent? Did they have symptomatic primaries?"
"In the majority of these patients, the intent was curative surgery," Dr. Slesser replied. "We tried to exclude patients who were clearly referred for palliative treatment because we really wanted to assess patients who were referred for curative treatment."
Attendee Dr. David Shibata, of the Moffitt Cancer Center in Tampa, commented, "I think a critical question is that you have done a primary tumor resection and the liver tumor has tended to grow, which is not entirely surprising, but then in those cases, how many became unresectable from a liver standpoint?"
"About 60% ended up having hepatectomies," Dr. Slesser said, noting that the data reported looked only at the short-term time frame. "We do have further results, which will be in the paper, pertaining to survival. But the real aim of this study was to look at initial radiological progression of disease, because we thought that the primary tumor resection may be associated with a sudden increase in the size of metastasis."
The finding of a better liver outcome with initial chemotherapy "makes sense," session comoderator Dr. Marylise Boutros, of McGill University in Montreal, said in an interview. "That’s something that we would expect, that you can treat the largest burden of the disease, which is the metastasis – it’s a systemic disease – with chemotherapy up-front."
"But it’s definitely a smaller study, and this needs to be looked at in a larger subset and in a prospective fashion," she added.
Giving some background to the research, Dr. Slesser noted that "the mainstay of surgical treatment for these patients with limited metastatic disease is a sequential resection. Patients tend to have an up-front primary tumor resection, followed by adjuvant chemotherapy, followed by hepatic resection if feasible. On the other hand, patients who have extensive metastatic disease tend to have neoadjuvant chemotherapy prior to a surgical intervention."
He and his coinvestigators studied patients with isolated synchronous colorectal liver metastases who were referred to the Royal Marsden Hospital for treatment between 2005 and 2010 and had imaging done at baseline, 3 months, and 6 months.
The mean age of the cohort was 64 years, and the ratio of men to women was about 2:1. In terms of treatment, 51% of the patients underwent primary tumor resection, while the other 49% received neoadjuvant chemotherapy.
In univariate analysis, the factor most strongly associated with progression of liver metastases – defined as an increase in their cumulative diameter of at least 20% – at 3 months was a primary tumor resection, according to Dr. Slesser.
In a multivariate analysis, relative to their counterparts in the neoadjuvant chemotherapy group, patients undergoing primary tumor resection had dramatically elevated odds of progression of liver metastases (odds ratio, 9.0; P = .001).
Additionally, metastatic burden showed an upward trend between baseline and 6 months in the group undergoing primary tumor resection (from 40 to 51 mm; P = .19), whereas it decreased significantly in the neoadjuvant chemotherapy group (from 96 to 52 mm; P = .001).
Overall, 93% of patients having a primary tumor resection went on to receive adjuvant chemotherapy, according to Dr. Slesser.
Comparing baseline to 3 months versus 3 months to 6 months, liver metastases began regressing in the primary tumor resection group, with the growth rate changing from 4.0 to –3.0 mm/month (P less than .001), reflecting the effect of the adjuvant chemotherapy, he said. Liver metastases in the neoadjuvant chemotherapy group continued to regress, albeit also at a slower pace, with the growth rate changing from –5.6 to –4.0 mm/month (P = .003).
Dr. Slesser disclosed no relevant conflicts of interest.
PHOENIX – The standard sequential approach to treatment of patients with isolated synchronous liver metastases of colorectal cancer, entailing up-front removal of the primary tumor, is associated with growth of the metastases, according to results from a retrospective cohort study.
A team led by Dr. Alistair Slesser, a surgical registrar at the Royal Marsden Hospital in London, studied 114 patients with colorectal cancer who had synchronous liver metastases, meaning ones identified within a year of the cancer diagnosis, and no other metastases.
Results showed that patients whose initial treatment was resection of the colorectal primary tumor had ninefold higher odds of progression of their liver metastases at 3 months, compared with patients whose initial treatment was chemotherapy, he reported at the annual meeting of the American Society of Colon and Rectal Surgeons.
Although liver metastases showed regression during 3-6 months of treatment in both groups, the rate was somewhat slower in the primary tumor resection group.
"Our findings suggest that an up-front primary tumor resection is actually an adverse prognostic factor. Indeed, our results have demonstrated that up-front primary tumor resection seemed to negate the effects of the adjuvant therapy on the treatment of the liver metastasis," Dr. Slesser commented.
"How does this apply clinically? We would recommend that patients who have limited metastatic disease, instead of having an up-front primary tumor resection perhaps [they should] be treated with neoadjuvant chemotherapy first. Or perhaps another surgical approach, like a simultaneous resection, should be considered to negate the adverse effects of a primary tumor resection on the metastatic disease," he said.
"When patients have lesions which are suspicious for liver metastases, we would recommend that these patients [be] thoroughly investigated, and if metastatic disease is confirmed, then again, we would recommend that they have chemotherapy prior to any subsequent intervention," he added.
The mechanism leading to growth of liver metastases after primary tumor resection is unknown, according to Dr. Slesser. "There is possibly an association for ... biological reasons. The other reason is that perhaps when a patient has an up-front primary tumor resection, there is a delay in getting chemotherapy, and that can cause the progression that we see."
Session attendee Dr. Gary Dunn, of the University of Oklahoma, Oklahoma City, asked how much time elapsed between up-front resection and receipt of adjuvant chemotherapy in that group, and the variance in this measure, noting, "That will significantly affect your outcome, if some patients started at 6 weeks and some patients started at 12 weeks postop."
"Usually, patients waited 6 weeks before they started chemotherapy postoperatively," Dr. Slesser explained. "The majority of patients who had primary tumor resection had the adjuvant chemotherapy after the postoperative scan; the 3-month scan tends to be the postoperative scan."
Dr. Dunn further wondered about the comparability between groups of the chemotherapy received, asking what agents were used.
"At the Royal Marsden, the chemotherapy regimes tend to be quite uniform," Dr. Slesser replied. "Generally, all patients are on capecitabine [Xeloda] and oxaliplatin, with a monoclonal agent such as bevacizumab [Avastin]. They tend to get that when they have neoadjuvant chemotherapy."
Another attendee said, "Excellent paper, very well presented data, particularly considering there are a lot of retrospective series out there that are showing the up-front resection as a favorable prognostic indicator, which I don’t believe. ... But I would like to see a little more information about how the patients were treated subsequently. Were these patients who they were planning to get to surgery for resection, or were these patients who were treated for palliative intent? Did they have symptomatic primaries?"
"In the majority of these patients, the intent was curative surgery," Dr. Slesser replied. "We tried to exclude patients who were clearly referred for palliative treatment because we really wanted to assess patients who were referred for curative treatment."
Attendee Dr. David Shibata, of the Moffitt Cancer Center in Tampa, commented, "I think a critical question is that you have done a primary tumor resection and the liver tumor has tended to grow, which is not entirely surprising, but then in those cases, how many became unresectable from a liver standpoint?"
"About 60% ended up having hepatectomies," Dr. Slesser said, noting that the data reported looked only at the short-term time frame. "We do have further results, which will be in the paper, pertaining to survival. But the real aim of this study was to look at initial radiological progression of disease, because we thought that the primary tumor resection may be associated with a sudden increase in the size of metastasis."
The finding of a better liver outcome with initial chemotherapy "makes sense," session comoderator Dr. Marylise Boutros, of McGill University in Montreal, said in an interview. "That’s something that we would expect, that you can treat the largest burden of the disease, which is the metastasis – it’s a systemic disease – with chemotherapy up-front."
"But it’s definitely a smaller study, and this needs to be looked at in a larger subset and in a prospective fashion," she added.
Giving some background to the research, Dr. Slesser noted that "the mainstay of surgical treatment for these patients with limited metastatic disease is a sequential resection. Patients tend to have an up-front primary tumor resection, followed by adjuvant chemotherapy, followed by hepatic resection if feasible. On the other hand, patients who have extensive metastatic disease tend to have neoadjuvant chemotherapy prior to a surgical intervention."
He and his coinvestigators studied patients with isolated synchronous colorectal liver metastases who were referred to the Royal Marsden Hospital for treatment between 2005 and 2010 and had imaging done at baseline, 3 months, and 6 months.
The mean age of the cohort was 64 years, and the ratio of men to women was about 2:1. In terms of treatment, 51% of the patients underwent primary tumor resection, while the other 49% received neoadjuvant chemotherapy.
In univariate analysis, the factor most strongly associated with progression of liver metastases – defined as an increase in their cumulative diameter of at least 20% – at 3 months was a primary tumor resection, according to Dr. Slesser.
In a multivariate analysis, relative to their counterparts in the neoadjuvant chemotherapy group, patients undergoing primary tumor resection had dramatically elevated odds of progression of liver metastases (odds ratio, 9.0; P = .001).
Additionally, metastatic burden showed an upward trend between baseline and 6 months in the group undergoing primary tumor resection (from 40 to 51 mm; P = .19), whereas it decreased significantly in the neoadjuvant chemotherapy group (from 96 to 52 mm; P = .001).
Overall, 93% of patients having a primary tumor resection went on to receive adjuvant chemotherapy, according to Dr. Slesser.
Comparing baseline to 3 months versus 3 months to 6 months, liver metastases began regressing in the primary tumor resection group, with the growth rate changing from 4.0 to –3.0 mm/month (P less than .001), reflecting the effect of the adjuvant chemotherapy, he said. Liver metastases in the neoadjuvant chemotherapy group continued to regress, albeit also at a slower pace, with the growth rate changing from –5.6 to –4.0 mm/month (P = .003).
Dr. Slesser disclosed no relevant conflicts of interest.
PHOENIX – The standard sequential approach to treatment of patients with isolated synchronous liver metastases of colorectal cancer, entailing up-front removal of the primary tumor, is associated with growth of the metastases, according to results from a retrospective cohort study.
A team led by Dr. Alistair Slesser, a surgical registrar at the Royal Marsden Hospital in London, studied 114 patients with colorectal cancer who had synchronous liver metastases, meaning ones identified within a year of the cancer diagnosis, and no other metastases.
Results showed that patients whose initial treatment was resection of the colorectal primary tumor had ninefold higher odds of progression of their liver metastases at 3 months, compared with patients whose initial treatment was chemotherapy, he reported at the annual meeting of the American Society of Colon and Rectal Surgeons.
Although liver metastases showed regression during 3-6 months of treatment in both groups, the rate was somewhat slower in the primary tumor resection group.
"Our findings suggest that an up-front primary tumor resection is actually an adverse prognostic factor. Indeed, our results have demonstrated that up-front primary tumor resection seemed to negate the effects of the adjuvant therapy on the treatment of the liver metastasis," Dr. Slesser commented.
"How does this apply clinically? We would recommend that patients who have limited metastatic disease, instead of having an up-front primary tumor resection perhaps [they should] be treated with neoadjuvant chemotherapy first. Or perhaps another surgical approach, like a simultaneous resection, should be considered to negate the adverse effects of a primary tumor resection on the metastatic disease," he said.
"When patients have lesions which are suspicious for liver metastases, we would recommend that these patients [be] thoroughly investigated, and if metastatic disease is confirmed, then again, we would recommend that they have chemotherapy prior to any subsequent intervention," he added.
The mechanism leading to growth of liver metastases after primary tumor resection is unknown, according to Dr. Slesser. "There is possibly an association for ... biological reasons. The other reason is that perhaps when a patient has an up-front primary tumor resection, there is a delay in getting chemotherapy, and that can cause the progression that we see."
Session attendee Dr. Gary Dunn, of the University of Oklahoma, Oklahoma City, asked how much time elapsed between up-front resection and receipt of adjuvant chemotherapy in that group, and the variance in this measure, noting, "That will significantly affect your outcome, if some patients started at 6 weeks and some patients started at 12 weeks postop."
"Usually, patients waited 6 weeks before they started chemotherapy postoperatively," Dr. Slesser explained. "The majority of patients who had primary tumor resection had the adjuvant chemotherapy after the postoperative scan; the 3-month scan tends to be the postoperative scan."
Dr. Dunn further wondered about the comparability between groups of the chemotherapy received, asking what agents were used.
"At the Royal Marsden, the chemotherapy regimes tend to be quite uniform," Dr. Slesser replied. "Generally, all patients are on capecitabine [Xeloda] and oxaliplatin, with a monoclonal agent such as bevacizumab [Avastin]. They tend to get that when they have neoadjuvant chemotherapy."
Another attendee said, "Excellent paper, very well presented data, particularly considering there are a lot of retrospective series out there that are showing the up-front resection as a favorable prognostic indicator, which I don’t believe. ... But I would like to see a little more information about how the patients were treated subsequently. Were these patients who they were planning to get to surgery for resection, or were these patients who were treated for palliative intent? Did they have symptomatic primaries?"
"In the majority of these patients, the intent was curative surgery," Dr. Slesser replied. "We tried to exclude patients who were clearly referred for palliative treatment because we really wanted to assess patients who were referred for curative treatment."
Attendee Dr. David Shibata, of the Moffitt Cancer Center in Tampa, commented, "I think a critical question is that you have done a primary tumor resection and the liver tumor has tended to grow, which is not entirely surprising, but then in those cases, how many became unresectable from a liver standpoint?"
"About 60% ended up having hepatectomies," Dr. Slesser said, noting that the data reported looked only at the short-term time frame. "We do have further results, which will be in the paper, pertaining to survival. But the real aim of this study was to look at initial radiological progression of disease, because we thought that the primary tumor resection may be associated with a sudden increase in the size of metastasis."
The finding of a better liver outcome with initial chemotherapy "makes sense," session comoderator Dr. Marylise Boutros, of McGill University in Montreal, said in an interview. "That’s something that we would expect, that you can treat the largest burden of the disease, which is the metastasis – it’s a systemic disease – with chemotherapy up-front."
"But it’s definitely a smaller study, and this needs to be looked at in a larger subset and in a prospective fashion," she added.
Giving some background to the research, Dr. Slesser noted that "the mainstay of surgical treatment for these patients with limited metastatic disease is a sequential resection. Patients tend to have an up-front primary tumor resection, followed by adjuvant chemotherapy, followed by hepatic resection if feasible. On the other hand, patients who have extensive metastatic disease tend to have neoadjuvant chemotherapy prior to a surgical intervention."
He and his coinvestigators studied patients with isolated synchronous colorectal liver metastases who were referred to the Royal Marsden Hospital for treatment between 2005 and 2010 and had imaging done at baseline, 3 months, and 6 months.
The mean age of the cohort was 64 years, and the ratio of men to women was about 2:1. In terms of treatment, 51% of the patients underwent primary tumor resection, while the other 49% received neoadjuvant chemotherapy.
In univariate analysis, the factor most strongly associated with progression of liver metastases – defined as an increase in their cumulative diameter of at least 20% – at 3 months was a primary tumor resection, according to Dr. Slesser.
In a multivariate analysis, relative to their counterparts in the neoadjuvant chemotherapy group, patients undergoing primary tumor resection had dramatically elevated odds of progression of liver metastases (odds ratio, 9.0; P = .001).
Additionally, metastatic burden showed an upward trend between baseline and 6 months in the group undergoing primary tumor resection (from 40 to 51 mm; P = .19), whereas it decreased significantly in the neoadjuvant chemotherapy group (from 96 to 52 mm; P = .001).
Overall, 93% of patients having a primary tumor resection went on to receive adjuvant chemotherapy, according to Dr. Slesser.
Comparing baseline to 3 months versus 3 months to 6 months, liver metastases began regressing in the primary tumor resection group, with the growth rate changing from 4.0 to –3.0 mm/month (P less than .001), reflecting the effect of the adjuvant chemotherapy, he said. Liver metastases in the neoadjuvant chemotherapy group continued to regress, albeit also at a slower pace, with the growth rate changing from –5.6 to –4.0 mm/month (P = .003).
Dr. Slesser disclosed no relevant conflicts of interest.
AT THE ASCRS ANNUAL MEETING
Major finding: Patients had ninefold higher odds of radiologic progression of their liver metastases at 3 months if they had a primary tumor resection as compared with neoadjuvant chemotherapy.
Data source: A retrospective cohort study of 114 patients with colorectal cancer and isolated synchronous liver metastases.
Disclosures: Dr. Slesser disclosed no relevant conflicts of interest.
CDC urges doctors to help patients quit smoking
WASHINGTON – Doctors need to step up their efforts to counsel patients on smoking cessation.
That was the message from officials at the Centers for Disease Control and Prevention and primary care physicians group at a press briefing May 22.
"Every doctor can help their patients quit, and every doctor should do everything possible to help their patients quit," Dr. Tom Frieden, CDC director, said at a press conference. "Even spending 3-5 minutes on personalized, clear advice will double the likelihood that they will quit for good."
He added that talking about smoking – or about quitting – is still not a part of routine doctor visits.
"That extra moment can make all the difference and help them quit," agreed Surgeon General Regina Benjamin, who also spoke at the briefing.
The CDC estimates that 43 million American adults smoke, and that smoking kills about 440,000 of them each year.
Representatives of the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, the American Congress of Obstetricians and Gynecologists, and the American Medical Association, joined Dr. Frieden in urging their members and other physicians to do more.
"It’s very important for all of the medical associations to be speaking with one voice," Dr. Charles Cutler, chair of the ACP Board of Regents, said in an interview. "When we’re all saying the same thing, the message for doctors throughout America becomes more resonant."
Advertisements that are part of the CDC’s current "Tips From Former Smokers" campaignwill be tagged with a new line from May 27 through June 2. During that time, ads will say "You can quit. Talk with your doctor for help."
So far, the Tips campaign, which features individuals disfigured from a lifetime of smoking, has generated 200,000 excess calls to the 1-800-QUIT-NOW line managed by the CDC, Dr. Frieden said. The campaign is funded at about $50 million a year with money from the Public Health and Prevention Fund, which was established by the Affordable Care Act.
AAFP president Jeffrey Cain said that physicians are crucial allies for patients who are trying to quit. He noted that the AAFP has several tools to help physicians counsel and care for smokers, including the "Ask and Act Practice Toolkit," and a treating tobacco dependence practice manual. "You have to make it so that tobacco is a vital sign when a patient comes in," said Dr. Cain.
The Tips campaign gives patients a critical way to start conversations about smoking, said Dr. Patrice Harris of the AMA Board of Trustees. "Physicians should talk to every patient who smokes about quitting at every office visit," she said. The AMA’s Healthier Life Steps program helps direct physicians toward resources they can share with patients, she said.
The AAP joined the effort because so many children are exposed to second-hand smoke and because very often, the smoking habit begins in adolescence, said AAP President Thomas K. McInerny. He said that many pediatricians had been remiss in either asking patients or parents about smoking, or encouraging them to quit.
"Pediatricians must intervene during a clinical encounter, yet, unfortunately, many don’t do so," he said.
ACOG president Jeanne A. Conry said that the Tips campaign would help her colleagues improve women’s health and support healthier pregnancies – but only if ob.gyns. make it a part of every visit. "If we are able to discuss tobacco use and well-woman health care with every woman at every time, we will make a difference," she said.
In an editorial published simultaneously in JAMA, Dr. Tim McAfee of the CDC Office on Smoking and Health further underlined and explained the resources available to physicians for smoking cessation counseling (2013;1-2 [doi:10.1001/jama.2013.5975]).
"Physicians have made major strides over the past 2 decades in helping smokers quit, but still fall short of making cessation treatment a routine part of standard care," he wrote. "By making it easier to discuss smoking, the ‘talk with your doctor’ initiative can help bring the nation a step closer to achieving the goal of substantially reducing smoking and smoking-related disease and death."
For smoking cessation counseling information and tools, visit the CDC’s Tips website.
On Twitter @aliciaault
WASHINGTON – Doctors need to step up their efforts to counsel patients on smoking cessation.
That was the message from officials at the Centers for Disease Control and Prevention and primary care physicians group at a press briefing May 22.
"Every doctor can help their patients quit, and every doctor should do everything possible to help their patients quit," Dr. Tom Frieden, CDC director, said at a press conference. "Even spending 3-5 minutes on personalized, clear advice will double the likelihood that they will quit for good."
He added that talking about smoking – or about quitting – is still not a part of routine doctor visits.
"That extra moment can make all the difference and help them quit," agreed Surgeon General Regina Benjamin, who also spoke at the briefing.
The CDC estimates that 43 million American adults smoke, and that smoking kills about 440,000 of them each year.
Representatives of the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, the American Congress of Obstetricians and Gynecologists, and the American Medical Association, joined Dr. Frieden in urging their members and other physicians to do more.
"It’s very important for all of the medical associations to be speaking with one voice," Dr. Charles Cutler, chair of the ACP Board of Regents, said in an interview. "When we’re all saying the same thing, the message for doctors throughout America becomes more resonant."
Advertisements that are part of the CDC’s current "Tips From Former Smokers" campaignwill be tagged with a new line from May 27 through June 2. During that time, ads will say "You can quit. Talk with your doctor for help."
So far, the Tips campaign, which features individuals disfigured from a lifetime of smoking, has generated 200,000 excess calls to the 1-800-QUIT-NOW line managed by the CDC, Dr. Frieden said. The campaign is funded at about $50 million a year with money from the Public Health and Prevention Fund, which was established by the Affordable Care Act.
AAFP president Jeffrey Cain said that physicians are crucial allies for patients who are trying to quit. He noted that the AAFP has several tools to help physicians counsel and care for smokers, including the "Ask and Act Practice Toolkit," and a treating tobacco dependence practice manual. "You have to make it so that tobacco is a vital sign when a patient comes in," said Dr. Cain.
The Tips campaign gives patients a critical way to start conversations about smoking, said Dr. Patrice Harris of the AMA Board of Trustees. "Physicians should talk to every patient who smokes about quitting at every office visit," she said. The AMA’s Healthier Life Steps program helps direct physicians toward resources they can share with patients, she said.
The AAP joined the effort because so many children are exposed to second-hand smoke and because very often, the smoking habit begins in adolescence, said AAP President Thomas K. McInerny. He said that many pediatricians had been remiss in either asking patients or parents about smoking, or encouraging them to quit.
"Pediatricians must intervene during a clinical encounter, yet, unfortunately, many don’t do so," he said.
ACOG president Jeanne A. Conry said that the Tips campaign would help her colleagues improve women’s health and support healthier pregnancies – but only if ob.gyns. make it a part of every visit. "If we are able to discuss tobacco use and well-woman health care with every woman at every time, we will make a difference," she said.
In an editorial published simultaneously in JAMA, Dr. Tim McAfee of the CDC Office on Smoking and Health further underlined and explained the resources available to physicians for smoking cessation counseling (2013;1-2 [doi:10.1001/jama.2013.5975]).
"Physicians have made major strides over the past 2 decades in helping smokers quit, but still fall short of making cessation treatment a routine part of standard care," he wrote. "By making it easier to discuss smoking, the ‘talk with your doctor’ initiative can help bring the nation a step closer to achieving the goal of substantially reducing smoking and smoking-related disease and death."
For smoking cessation counseling information and tools, visit the CDC’s Tips website.
On Twitter @aliciaault
WASHINGTON – Doctors need to step up their efforts to counsel patients on smoking cessation.
That was the message from officials at the Centers for Disease Control and Prevention and primary care physicians group at a press briefing May 22.
"Every doctor can help their patients quit, and every doctor should do everything possible to help their patients quit," Dr. Tom Frieden, CDC director, said at a press conference. "Even spending 3-5 minutes on personalized, clear advice will double the likelihood that they will quit for good."
He added that talking about smoking – or about quitting – is still not a part of routine doctor visits.
"That extra moment can make all the difference and help them quit," agreed Surgeon General Regina Benjamin, who also spoke at the briefing.
The CDC estimates that 43 million American adults smoke, and that smoking kills about 440,000 of them each year.
Representatives of the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, the American Congress of Obstetricians and Gynecologists, and the American Medical Association, joined Dr. Frieden in urging their members and other physicians to do more.
"It’s very important for all of the medical associations to be speaking with one voice," Dr. Charles Cutler, chair of the ACP Board of Regents, said in an interview. "When we’re all saying the same thing, the message for doctors throughout America becomes more resonant."
Advertisements that are part of the CDC’s current "Tips From Former Smokers" campaignwill be tagged with a new line from May 27 through June 2. During that time, ads will say "You can quit. Talk with your doctor for help."
So far, the Tips campaign, which features individuals disfigured from a lifetime of smoking, has generated 200,000 excess calls to the 1-800-QUIT-NOW line managed by the CDC, Dr. Frieden said. The campaign is funded at about $50 million a year with money from the Public Health and Prevention Fund, which was established by the Affordable Care Act.
AAFP president Jeffrey Cain said that physicians are crucial allies for patients who are trying to quit. He noted that the AAFP has several tools to help physicians counsel and care for smokers, including the "Ask and Act Practice Toolkit," and a treating tobacco dependence practice manual. "You have to make it so that tobacco is a vital sign when a patient comes in," said Dr. Cain.
The Tips campaign gives patients a critical way to start conversations about smoking, said Dr. Patrice Harris of the AMA Board of Trustees. "Physicians should talk to every patient who smokes about quitting at every office visit," she said. The AMA’s Healthier Life Steps program helps direct physicians toward resources they can share with patients, she said.
The AAP joined the effort because so many children are exposed to second-hand smoke and because very often, the smoking habit begins in adolescence, said AAP President Thomas K. McInerny. He said that many pediatricians had been remiss in either asking patients or parents about smoking, or encouraging them to quit.
"Pediatricians must intervene during a clinical encounter, yet, unfortunately, many don’t do so," he said.
ACOG president Jeanne A. Conry said that the Tips campaign would help her colleagues improve women’s health and support healthier pregnancies – but only if ob.gyns. make it a part of every visit. "If we are able to discuss tobacco use and well-woman health care with every woman at every time, we will make a difference," she said.
In an editorial published simultaneously in JAMA, Dr. Tim McAfee of the CDC Office on Smoking and Health further underlined and explained the resources available to physicians for smoking cessation counseling (2013;1-2 [doi:10.1001/jama.2013.5975]).
"Physicians have made major strides over the past 2 decades in helping smokers quit, but still fall short of making cessation treatment a routine part of standard care," he wrote. "By making it easier to discuss smoking, the ‘talk with your doctor’ initiative can help bring the nation a step closer to achieving the goal of substantially reducing smoking and smoking-related disease and death."
For smoking cessation counseling information and tools, visit the CDC’s Tips website.
On Twitter @aliciaault
FROM A CDC PRESS BRIEFING
EHR use reaches 'tipping point'
More than half of the nation’s physicians and other health care providers use electronic health records in their practices, new statistics from the Health and Human Services department show.
"We have reached a tipping point in adoption of electronic health records," HHS Secretary Kathleen Sebelius said in a statement. "More than half of eligible professionals and 80% of eligible hospitals have adopted these systems, which are critical to modernizing our health care system."
As of the end of April, more than 291,000 physicians and other eligible professionals received incentive payments from the Medicare and Medicaid EHR Incentive Programs. This is a significant jump in adoption since the incentives were created under the 2009 Recovery Act. In 2008, only 17% of office-based physicians reported that they had a basic EHR system and 4.4% had a fully functional system, according to the Centers for Disease Control and Prevention.
The number of hospitals using EHRs is also reaching critical mass, according to HHS. More than 3,800 facilities have received incentive payments for their EHR use as of the end of April.
Under the Medicare program, physicians can earn up to $44,000 in bonus payments from the government over 5 years by using electronic systems to meet and report on a set of quality measures. Under Medicaid, the bonus payments add up to $63,750 over 6 years.
More than half of the nation’s physicians and other health care providers use electronic health records in their practices, new statistics from the Health and Human Services department show.
"We have reached a tipping point in adoption of electronic health records," HHS Secretary Kathleen Sebelius said in a statement. "More than half of eligible professionals and 80% of eligible hospitals have adopted these systems, which are critical to modernizing our health care system."
As of the end of April, more than 291,000 physicians and other eligible professionals received incentive payments from the Medicare and Medicaid EHR Incentive Programs. This is a significant jump in adoption since the incentives were created under the 2009 Recovery Act. In 2008, only 17% of office-based physicians reported that they had a basic EHR system and 4.4% had a fully functional system, according to the Centers for Disease Control and Prevention.
The number of hospitals using EHRs is also reaching critical mass, according to HHS. More than 3,800 facilities have received incentive payments for their EHR use as of the end of April.
Under the Medicare program, physicians can earn up to $44,000 in bonus payments from the government over 5 years by using electronic systems to meet and report on a set of quality measures. Under Medicaid, the bonus payments add up to $63,750 over 6 years.
More than half of the nation’s physicians and other health care providers use electronic health records in their practices, new statistics from the Health and Human Services department show.
"We have reached a tipping point in adoption of electronic health records," HHS Secretary Kathleen Sebelius said in a statement. "More than half of eligible professionals and 80% of eligible hospitals have adopted these systems, which are critical to modernizing our health care system."
As of the end of April, more than 291,000 physicians and other eligible professionals received incentive payments from the Medicare and Medicaid EHR Incentive Programs. This is a significant jump in adoption since the incentives were created under the 2009 Recovery Act. In 2008, only 17% of office-based physicians reported that they had a basic EHR system and 4.4% had a fully functional system, according to the Centers for Disease Control and Prevention.
The number of hospitals using EHRs is also reaching critical mass, according to HHS. More than 3,800 facilities have received incentive payments for their EHR use as of the end of April.
Under the Medicare program, physicians can earn up to $44,000 in bonus payments from the government over 5 years by using electronic systems to meet and report on a set of quality measures. Under Medicaid, the bonus payments add up to $63,750 over 6 years.
New test beats PSA in predicting significant prostate Ca
SAN DIEGO – A blood test that detects the –2proPSA isoform of prostate-specific antigen may provide a way to reduce the number of unneeded prostate biopsies, results from a multicenter study showed.
Using a Prostate Health Index (phi) level of 27 as a threshold for selecting men for prostate cancer could eliminate unnecessary biopsies in 26% of men when total PSA is 4-10 ng/mL, said Dr. Martin G. Sanda, chief of urology at Emory University in Atlanta, during a press briefing at the annual meeting of the American Urological Association.
"This is a substantial portion of the population who may undergo PSA testing. [The index] would allow the ability to detect aggressive prostate cancer while having an acceptable false-negative rate. The Prostate Health Index has the potential to mitigate harms of overdetection/overtreatment of indolent cancers while retaining benefits of detecting aggressive prostate cancer which warrants treatment," he said.
The Prostate Health Index (phi), developed by Beckman Coulter and granted premarket approval from the Food and Drug Administration in June 2012, is a simple, noninvasive blood test that is 2.5 times more specific in detecting prostate cancer than PSA in patients with PSA values in the 4- to 10-ng/mL range and is shown to reduce the number of prostate biopsies.
"The Achilles’ heel of PSA detection in its current form is the overdetection and subsequently the downstream overtreatment of indolent prostate cancers," Dr. Sanda said. "The phi is a manner of reporting the detection of the –2proPSA isoform of PSA. This is a small subset of the PSA molecules, as opposed to the routine total PSA test that we are familiar with."
For the current study Dr. Sanda and his associates investigated whether the use of phi, compared with total PSA and the ratio of free to total PSA (%fPSA), could reduce unnecessary biopsies and overdetection of indolent prostate cancer while improving the detection of aggressive prostate cancer. He reported results from 658 men whose PSA was 4-10 ng/mL. Of these 658 men, 324 had prostate cancer. Among these 324 cancers, 160 were aggressive (meaning a Gleason score of 7 or greater) and 164 were indolent cancers.
Dr. Sanda reported that at 90% sensitivity, the specificity of phi was 31.1%, compared with 19.8% for %fPSA (P = .024) and 10.8% for PSA (P less than .001). When the phi ranged from 0 to 26.9, the probability of significant prostate cancer was 3.9% and rose sequentially with increasing range of phi. Specifically, the probability of significant prostate cancer was 8.5% for those with a phi of 27.0-35.9, 14.4% for those in the range of 36.0-54.9, and 28.9% for those with a phi level of 55 or higher.
"When phi is less than 27, the probability of one of these cancers being a Gleason score of 7 or higher was under 4%," said Dr. Sanda, who also directs the university’s Prostate Cancer Center. "With that particular threshold, we would be able to retain the benefits of being able to detect aggressive cancers in patients who had a biopsy when their phi was higher than 27 while avoiding unnecessary [biopsies] in about 26% of the men, substantially reducing the number of indolent cancers diagnosed and the number of unnecessary biopsies performed."
The false-positive rate was "in an acceptable range," he added. Only 4 out of 109 Gleason 3 + 4 cancers were missed (3.7%), and only 1 out of 35 Gleason 4 + 3 cancers was missed (2.9%).
"Because this is a straightforward serum assay, phi does have the potential to have a favorable cost profile relative to some of the genetic marker testing that’s coming down the pipeline," Dr. Sanda commented. "The next step is to validate these findings in a larger and separate cohort." That effort is currently underway with the Early Detection Research Network, a cohort study funded by the National Cancer Institute.
The study was funded by Beckman Coulter. Dr. Sanda disclosed that he is an investigator for the company. He also reported affiliations with Medicametrix, Accuray, and other companies.
SAN DIEGO – A blood test that detects the –2proPSA isoform of prostate-specific antigen may provide a way to reduce the number of unneeded prostate biopsies, results from a multicenter study showed.
Using a Prostate Health Index (phi) level of 27 as a threshold for selecting men for prostate cancer could eliminate unnecessary biopsies in 26% of men when total PSA is 4-10 ng/mL, said Dr. Martin G. Sanda, chief of urology at Emory University in Atlanta, during a press briefing at the annual meeting of the American Urological Association.
"This is a substantial portion of the population who may undergo PSA testing. [The index] would allow the ability to detect aggressive prostate cancer while having an acceptable false-negative rate. The Prostate Health Index has the potential to mitigate harms of overdetection/overtreatment of indolent cancers while retaining benefits of detecting aggressive prostate cancer which warrants treatment," he said.
The Prostate Health Index (phi), developed by Beckman Coulter and granted premarket approval from the Food and Drug Administration in June 2012, is a simple, noninvasive blood test that is 2.5 times more specific in detecting prostate cancer than PSA in patients with PSA values in the 4- to 10-ng/mL range and is shown to reduce the number of prostate biopsies.
"The Achilles’ heel of PSA detection in its current form is the overdetection and subsequently the downstream overtreatment of indolent prostate cancers," Dr. Sanda said. "The phi is a manner of reporting the detection of the –2proPSA isoform of PSA. This is a small subset of the PSA molecules, as opposed to the routine total PSA test that we are familiar with."
For the current study Dr. Sanda and his associates investigated whether the use of phi, compared with total PSA and the ratio of free to total PSA (%fPSA), could reduce unnecessary biopsies and overdetection of indolent prostate cancer while improving the detection of aggressive prostate cancer. He reported results from 658 men whose PSA was 4-10 ng/mL. Of these 658 men, 324 had prostate cancer. Among these 324 cancers, 160 were aggressive (meaning a Gleason score of 7 or greater) and 164 were indolent cancers.
Dr. Sanda reported that at 90% sensitivity, the specificity of phi was 31.1%, compared with 19.8% for %fPSA (P = .024) and 10.8% for PSA (P less than .001). When the phi ranged from 0 to 26.9, the probability of significant prostate cancer was 3.9% and rose sequentially with increasing range of phi. Specifically, the probability of significant prostate cancer was 8.5% for those with a phi of 27.0-35.9, 14.4% for those in the range of 36.0-54.9, and 28.9% for those with a phi level of 55 or higher.
"When phi is less than 27, the probability of one of these cancers being a Gleason score of 7 or higher was under 4%," said Dr. Sanda, who also directs the university’s Prostate Cancer Center. "With that particular threshold, we would be able to retain the benefits of being able to detect aggressive cancers in patients who had a biopsy when their phi was higher than 27 while avoiding unnecessary [biopsies] in about 26% of the men, substantially reducing the number of indolent cancers diagnosed and the number of unnecessary biopsies performed."
The false-positive rate was "in an acceptable range," he added. Only 4 out of 109 Gleason 3 + 4 cancers were missed (3.7%), and only 1 out of 35 Gleason 4 + 3 cancers was missed (2.9%).
"Because this is a straightforward serum assay, phi does have the potential to have a favorable cost profile relative to some of the genetic marker testing that’s coming down the pipeline," Dr. Sanda commented. "The next step is to validate these findings in a larger and separate cohort." That effort is currently underway with the Early Detection Research Network, a cohort study funded by the National Cancer Institute.
The study was funded by Beckman Coulter. Dr. Sanda disclosed that he is an investigator for the company. He also reported affiliations with Medicametrix, Accuray, and other companies.
SAN DIEGO – A blood test that detects the –2proPSA isoform of prostate-specific antigen may provide a way to reduce the number of unneeded prostate biopsies, results from a multicenter study showed.
Using a Prostate Health Index (phi) level of 27 as a threshold for selecting men for prostate cancer could eliminate unnecessary biopsies in 26% of men when total PSA is 4-10 ng/mL, said Dr. Martin G. Sanda, chief of urology at Emory University in Atlanta, during a press briefing at the annual meeting of the American Urological Association.
"This is a substantial portion of the population who may undergo PSA testing. [The index] would allow the ability to detect aggressive prostate cancer while having an acceptable false-negative rate. The Prostate Health Index has the potential to mitigate harms of overdetection/overtreatment of indolent cancers while retaining benefits of detecting aggressive prostate cancer which warrants treatment," he said.
The Prostate Health Index (phi), developed by Beckman Coulter and granted premarket approval from the Food and Drug Administration in June 2012, is a simple, noninvasive blood test that is 2.5 times more specific in detecting prostate cancer than PSA in patients with PSA values in the 4- to 10-ng/mL range and is shown to reduce the number of prostate biopsies.
"The Achilles’ heel of PSA detection in its current form is the overdetection and subsequently the downstream overtreatment of indolent prostate cancers," Dr. Sanda said. "The phi is a manner of reporting the detection of the –2proPSA isoform of PSA. This is a small subset of the PSA molecules, as opposed to the routine total PSA test that we are familiar with."
For the current study Dr. Sanda and his associates investigated whether the use of phi, compared with total PSA and the ratio of free to total PSA (%fPSA), could reduce unnecessary biopsies and overdetection of indolent prostate cancer while improving the detection of aggressive prostate cancer. He reported results from 658 men whose PSA was 4-10 ng/mL. Of these 658 men, 324 had prostate cancer. Among these 324 cancers, 160 were aggressive (meaning a Gleason score of 7 or greater) and 164 were indolent cancers.
Dr. Sanda reported that at 90% sensitivity, the specificity of phi was 31.1%, compared with 19.8% for %fPSA (P = .024) and 10.8% for PSA (P less than .001). When the phi ranged from 0 to 26.9, the probability of significant prostate cancer was 3.9% and rose sequentially with increasing range of phi. Specifically, the probability of significant prostate cancer was 8.5% for those with a phi of 27.0-35.9, 14.4% for those in the range of 36.0-54.9, and 28.9% for those with a phi level of 55 or higher.
"When phi is less than 27, the probability of one of these cancers being a Gleason score of 7 or higher was under 4%," said Dr. Sanda, who also directs the university’s Prostate Cancer Center. "With that particular threshold, we would be able to retain the benefits of being able to detect aggressive cancers in patients who had a biopsy when their phi was higher than 27 while avoiding unnecessary [biopsies] in about 26% of the men, substantially reducing the number of indolent cancers diagnosed and the number of unnecessary biopsies performed."
The false-positive rate was "in an acceptable range," he added. Only 4 out of 109 Gleason 3 + 4 cancers were missed (3.7%), and only 1 out of 35 Gleason 4 + 3 cancers was missed (2.9%).
"Because this is a straightforward serum assay, phi does have the potential to have a favorable cost profile relative to some of the genetic marker testing that’s coming down the pipeline," Dr. Sanda commented. "The next step is to validate these findings in a larger and separate cohort." That effort is currently underway with the Early Detection Research Network, a cohort study funded by the National Cancer Institute.
The study was funded by Beckman Coulter. Dr. Sanda disclosed that he is an investigator for the company. He also reported affiliations with Medicametrix, Accuray, and other companies.
AT THE AUA ANNUAL MEETING
Major finding: The probability of significant prostate cancer was 8.5% for men with a Prostate Health Index (phi) level of 27.0-35.9, 14.4% for those with a phi level of 36.0-54.9, and 28.9% for those with a level of 55 or higher.
Data source: A multicenter study of 658 men whose PSA was 4-10 ng/mL.
Disclosures: The study was funded by Beckman Coulter. Dr. Sanda disclosed that he is an investigator for the company. He also reported affiliations with Medicametrix, Accuray, and other companies.
Better endografts mean fewer reinterventions for endovascular AAA
INDIANAPOLIS – Reintervention rates following endovascular repair of abdominal aortic aneurysms have fallen steadily with the introduction of each successive generation of endografts, while reintervention rates after open surgical repair remained stable during a recent 15-year period.
This was among the key findings from the first in-depth analysis of reinterventions occurring in contemporaneous cohorts of abdominal aortic aneurysm (AAA) patients undergoing endovascular aneurysm repair (EVAR) or open repair. The large single-center retrospective study demonstrated major differences between the two treatment strategies in terms of the incidence, nature, timing, and mortality associated with complications requiring reintervention, Dr. Mustafa Al-Jubouri said at the annual meeting of the American Surgical Association.
Dr. Al-Jubouri of Jobst Vascular Institute, Toledo, Ohio, reported on the 1,144 patients who underwent AAA repair there during 1996-2011. Forty-nine percent had EVAR, 51% open surgical repair. Beginning in 2003, more EVARs than open repairs were done annually at the Toledo institute, consistent with the experience at many major centers in the United States and elsewhere, where EVAR has become the first-line treatment based upon evidence that it offers lower operative mortality, less blood loss, and shorter ICU and hospital lengths of stay.
These advantages come at a cost, however: namely, a greater rate of secondary interventions, mainly due to device migration, failure, or endoleaks. The purpose of Dr. Al-Jubouri’s study was to evaluate the rates and reasons for reintervention over time in the two cohorts, as well as the impact of reintervention on long-term survival.
Reintervention was required in 13.6% of the EVAR group during a mean follow-up of 4.58 years, and in 5.1% of the open surgery group during 6.58 years. A single reintervention occurred in 7.9% of EVAR patients and 3.6% of the open repair group. More than one reintervention was required in 5.8% of EVAR patients compared to just 1.6% of the open repair group.
The types and timing of complications leading to reintervention were very different in the two groups. Sixty-eight percent of reinterventions in the EVAR group were for treatment of endoleaks. Another 11.5% were to address device migration, and an equal number were for occlusion.
In contrast, the three most frequent causes of reintervention in the open repair group were colonic ischemia, accounting for 30.4% of reintervention procedures; severe bleeding, 21.7%; and incisional hernia, which triggered another 21.7% of reinterventions.
Notably, 60% of all reinterventions in the open repair group occurred during the initial hospitalization, while less than 7% of reinterventions in the EVAR patients happened within 1 month of the index procedure and only one-third within the first year, the surgeon continued.
Thirty-day mortality in EVAR patients who underwent reintervention within the first month was zero, compared to a 23.3% mortality rate in open repair patients requiring reintervention within 1 month. However, when patients did not require early reintervention, 30-day mortality rates in the two groups did not differ significantly: 1.9% in EVAR group and in the open repair group. That means when patients in the open surgery group required early reintervention, their mortality rate shot up sevenfold.
After the first 30 days post-index procedure, long-term survival rates in the two groups were similar.
Need for reintervention in the open repair group was strongly related to larger aneurysm size. In contrast, reintervention rates were similar in the EVAR group regardless of aneurysm size.
A first reintervention after EVAR occurred in 23.7% of patients who received a first-generation endograft, such as the Ancure or Talent; in 16.2% of those who got the second-generation AneuRx endograft; and in 9.1% with a third-generation endograft, such as the Excluder, Endurant, Powerlink, or Zenith. The annualized rate of reintervention during the first 3 years of follow-up was 6.8% per year with first-generation devices, 7.2% per year with second-generation endografts, and significantly lower at 3.4% per year with the third-generation.
One major reason reintervention rates in EVAR patients have declined over time is that each newer generation of endograft is lower-profile, easier to deploy, and more durable. Also, many of the surgeons now putting in third-generation endografts were performing EVAR 15 years ago; they’re very experienced operators, Dr. Al-Jubouri noted.
Discussant Dr. James R. Debord proposed another explanation for the decrease in EVAR reinterventions over time.
"Isn’t it much more likely that it’s due to recognition of the fact that many of these type 2 endoleaks that we used to intervene on early on don’t require reintervention unless there’s sac enlargement?" commented Dr. Debord, professor of clinical surgery and chief of vascular surgery at the University of Illinois at Peoria.
Dr. Al-Jubouri concurred that this is an important factor in the declining rate of EVAR reinterventions.
"We saw a significant decrease in reinterventions for type 2 endoleaks between the first, second, and third generations," he said.
Asked how his study findings have changed the follow-up protocols at Jobst Vascular Institute, the surgeon replied that in the early years of the series EVAR patients got a CT scan at 6 weeks, 6 months, 1 year, and annually thereafter. This evaluation has evolved over time. Now EVAR patients get a CT scan at 6-12 weeks, and duplex ultrasounds at 6 months, 1 year, and annually thereafter.
"There is no standardized follow-up for open repair patients. However, most [patients] get an annual duplex ultrasound for their follow-up. A CT scan is not part of the follow-up of patients with open repair. But most if not all of the complications that developed in the open repair group were symptomatic," he explained.
He reported having no financial conflicts.
Dr. Mustafa Al-Jubouri and his colleagues assessed reinterventions and outcomes after EVAR and open AAA repair over a long time period, and found decreasing rates of reintervention after EVAR, which they attribute to improvements in technology from first to third and later-generation devices. I would concur with the one discussant, that some of the decrease may also be due to the understanding that not all type II endoleaks require repair. Further, much of the decrease may be due to physician experience – both with appropriate patient and device selection, and technical expertise, including with deployment. However, regardless of the underlying reason for the improvement in the reintervention rate, it is heartening that reintervention is decreasing as physicians become more facile, and industry provides technological improvements to the devices.
Dr. Linda Harris, FACS, is division chief and program director of vascular surgery at State University of New York, Buffalo. Dr. Harris has no disclosures
Dr. Mustafa Al-Jubouri and his colleagues assessed reinterventions and outcomes after EVAR and open AAA repair over a long time period, and found decreasing rates of reintervention after EVAR, which they attribute to improvements in technology from first to third and later-generation devices. I would concur with the one discussant, that some of the decrease may also be due to the understanding that not all type II endoleaks require repair. Further, much of the decrease may be due to physician experience – both with appropriate patient and device selection, and technical expertise, including with deployment. However, regardless of the underlying reason for the improvement in the reintervention rate, it is heartening that reintervention is decreasing as physicians become more facile, and industry provides technological improvements to the devices.
Dr. Linda Harris, FACS, is division chief and program director of vascular surgery at State University of New York, Buffalo. Dr. Harris has no disclosures
Dr. Mustafa Al-Jubouri and his colleagues assessed reinterventions and outcomes after EVAR and open AAA repair over a long time period, and found decreasing rates of reintervention after EVAR, which they attribute to improvements in technology from first to third and later-generation devices. I would concur with the one discussant, that some of the decrease may also be due to the understanding that not all type II endoleaks require repair. Further, much of the decrease may be due to physician experience – both with appropriate patient and device selection, and technical expertise, including with deployment. However, regardless of the underlying reason for the improvement in the reintervention rate, it is heartening that reintervention is decreasing as physicians become more facile, and industry provides technological improvements to the devices.
Dr. Linda Harris, FACS, is division chief and program director of vascular surgery at State University of New York, Buffalo. Dr. Harris has no disclosures
INDIANAPOLIS – Reintervention rates following endovascular repair of abdominal aortic aneurysms have fallen steadily with the introduction of each successive generation of endografts, while reintervention rates after open surgical repair remained stable during a recent 15-year period.
This was among the key findings from the first in-depth analysis of reinterventions occurring in contemporaneous cohorts of abdominal aortic aneurysm (AAA) patients undergoing endovascular aneurysm repair (EVAR) or open repair. The large single-center retrospective study demonstrated major differences between the two treatment strategies in terms of the incidence, nature, timing, and mortality associated with complications requiring reintervention, Dr. Mustafa Al-Jubouri said at the annual meeting of the American Surgical Association.
Dr. Al-Jubouri of Jobst Vascular Institute, Toledo, Ohio, reported on the 1,144 patients who underwent AAA repair there during 1996-2011. Forty-nine percent had EVAR, 51% open surgical repair. Beginning in 2003, more EVARs than open repairs were done annually at the Toledo institute, consistent with the experience at many major centers in the United States and elsewhere, where EVAR has become the first-line treatment based upon evidence that it offers lower operative mortality, less blood loss, and shorter ICU and hospital lengths of stay.
These advantages come at a cost, however: namely, a greater rate of secondary interventions, mainly due to device migration, failure, or endoleaks. The purpose of Dr. Al-Jubouri’s study was to evaluate the rates and reasons for reintervention over time in the two cohorts, as well as the impact of reintervention on long-term survival.
Reintervention was required in 13.6% of the EVAR group during a mean follow-up of 4.58 years, and in 5.1% of the open surgery group during 6.58 years. A single reintervention occurred in 7.9% of EVAR patients and 3.6% of the open repair group. More than one reintervention was required in 5.8% of EVAR patients compared to just 1.6% of the open repair group.
The types and timing of complications leading to reintervention were very different in the two groups. Sixty-eight percent of reinterventions in the EVAR group were for treatment of endoleaks. Another 11.5% were to address device migration, and an equal number were for occlusion.
In contrast, the three most frequent causes of reintervention in the open repair group were colonic ischemia, accounting for 30.4% of reintervention procedures; severe bleeding, 21.7%; and incisional hernia, which triggered another 21.7% of reinterventions.
Notably, 60% of all reinterventions in the open repair group occurred during the initial hospitalization, while less than 7% of reinterventions in the EVAR patients happened within 1 month of the index procedure and only one-third within the first year, the surgeon continued.
Thirty-day mortality in EVAR patients who underwent reintervention within the first month was zero, compared to a 23.3% mortality rate in open repair patients requiring reintervention within 1 month. However, when patients did not require early reintervention, 30-day mortality rates in the two groups did not differ significantly: 1.9% in EVAR group and in the open repair group. That means when patients in the open surgery group required early reintervention, their mortality rate shot up sevenfold.
After the first 30 days post-index procedure, long-term survival rates in the two groups were similar.
Need for reintervention in the open repair group was strongly related to larger aneurysm size. In contrast, reintervention rates were similar in the EVAR group regardless of aneurysm size.
A first reintervention after EVAR occurred in 23.7% of patients who received a first-generation endograft, such as the Ancure or Talent; in 16.2% of those who got the second-generation AneuRx endograft; and in 9.1% with a third-generation endograft, such as the Excluder, Endurant, Powerlink, or Zenith. The annualized rate of reintervention during the first 3 years of follow-up was 6.8% per year with first-generation devices, 7.2% per year with second-generation endografts, and significantly lower at 3.4% per year with the third-generation.
One major reason reintervention rates in EVAR patients have declined over time is that each newer generation of endograft is lower-profile, easier to deploy, and more durable. Also, many of the surgeons now putting in third-generation endografts were performing EVAR 15 years ago; they’re very experienced operators, Dr. Al-Jubouri noted.
Discussant Dr. James R. Debord proposed another explanation for the decrease in EVAR reinterventions over time.
"Isn’t it much more likely that it’s due to recognition of the fact that many of these type 2 endoleaks that we used to intervene on early on don’t require reintervention unless there’s sac enlargement?" commented Dr. Debord, professor of clinical surgery and chief of vascular surgery at the University of Illinois at Peoria.
Dr. Al-Jubouri concurred that this is an important factor in the declining rate of EVAR reinterventions.
"We saw a significant decrease in reinterventions for type 2 endoleaks between the first, second, and third generations," he said.
Asked how his study findings have changed the follow-up protocols at Jobst Vascular Institute, the surgeon replied that in the early years of the series EVAR patients got a CT scan at 6 weeks, 6 months, 1 year, and annually thereafter. This evaluation has evolved over time. Now EVAR patients get a CT scan at 6-12 weeks, and duplex ultrasounds at 6 months, 1 year, and annually thereafter.
"There is no standardized follow-up for open repair patients. However, most [patients] get an annual duplex ultrasound for their follow-up. A CT scan is not part of the follow-up of patients with open repair. But most if not all of the complications that developed in the open repair group were symptomatic," he explained.
He reported having no financial conflicts.
INDIANAPOLIS – Reintervention rates following endovascular repair of abdominal aortic aneurysms have fallen steadily with the introduction of each successive generation of endografts, while reintervention rates after open surgical repair remained stable during a recent 15-year period.
This was among the key findings from the first in-depth analysis of reinterventions occurring in contemporaneous cohorts of abdominal aortic aneurysm (AAA) patients undergoing endovascular aneurysm repair (EVAR) or open repair. The large single-center retrospective study demonstrated major differences between the two treatment strategies in terms of the incidence, nature, timing, and mortality associated with complications requiring reintervention, Dr. Mustafa Al-Jubouri said at the annual meeting of the American Surgical Association.
Dr. Al-Jubouri of Jobst Vascular Institute, Toledo, Ohio, reported on the 1,144 patients who underwent AAA repair there during 1996-2011. Forty-nine percent had EVAR, 51% open surgical repair. Beginning in 2003, more EVARs than open repairs were done annually at the Toledo institute, consistent with the experience at many major centers in the United States and elsewhere, where EVAR has become the first-line treatment based upon evidence that it offers lower operative mortality, less blood loss, and shorter ICU and hospital lengths of stay.
These advantages come at a cost, however: namely, a greater rate of secondary interventions, mainly due to device migration, failure, or endoleaks. The purpose of Dr. Al-Jubouri’s study was to evaluate the rates and reasons for reintervention over time in the two cohorts, as well as the impact of reintervention on long-term survival.
Reintervention was required in 13.6% of the EVAR group during a mean follow-up of 4.58 years, and in 5.1% of the open surgery group during 6.58 years. A single reintervention occurred in 7.9% of EVAR patients and 3.6% of the open repair group. More than one reintervention was required in 5.8% of EVAR patients compared to just 1.6% of the open repair group.
The types and timing of complications leading to reintervention were very different in the two groups. Sixty-eight percent of reinterventions in the EVAR group were for treatment of endoleaks. Another 11.5% were to address device migration, and an equal number were for occlusion.
In contrast, the three most frequent causes of reintervention in the open repair group were colonic ischemia, accounting for 30.4% of reintervention procedures; severe bleeding, 21.7%; and incisional hernia, which triggered another 21.7% of reinterventions.
Notably, 60% of all reinterventions in the open repair group occurred during the initial hospitalization, while less than 7% of reinterventions in the EVAR patients happened within 1 month of the index procedure and only one-third within the first year, the surgeon continued.
Thirty-day mortality in EVAR patients who underwent reintervention within the first month was zero, compared to a 23.3% mortality rate in open repair patients requiring reintervention within 1 month. However, when patients did not require early reintervention, 30-day mortality rates in the two groups did not differ significantly: 1.9% in EVAR group and in the open repair group. That means when patients in the open surgery group required early reintervention, their mortality rate shot up sevenfold.
After the first 30 days post-index procedure, long-term survival rates in the two groups were similar.
Need for reintervention in the open repair group was strongly related to larger aneurysm size. In contrast, reintervention rates were similar in the EVAR group regardless of aneurysm size.
A first reintervention after EVAR occurred in 23.7% of patients who received a first-generation endograft, such as the Ancure or Talent; in 16.2% of those who got the second-generation AneuRx endograft; and in 9.1% with a third-generation endograft, such as the Excluder, Endurant, Powerlink, or Zenith. The annualized rate of reintervention during the first 3 years of follow-up was 6.8% per year with first-generation devices, 7.2% per year with second-generation endografts, and significantly lower at 3.4% per year with the third-generation.
One major reason reintervention rates in EVAR patients have declined over time is that each newer generation of endograft is lower-profile, easier to deploy, and more durable. Also, many of the surgeons now putting in third-generation endografts were performing EVAR 15 years ago; they’re very experienced operators, Dr. Al-Jubouri noted.
Discussant Dr. James R. Debord proposed another explanation for the decrease in EVAR reinterventions over time.
"Isn’t it much more likely that it’s due to recognition of the fact that many of these type 2 endoleaks that we used to intervene on early on don’t require reintervention unless there’s sac enlargement?" commented Dr. Debord, professor of clinical surgery and chief of vascular surgery at the University of Illinois at Peoria.
Dr. Al-Jubouri concurred that this is an important factor in the declining rate of EVAR reinterventions.
"We saw a significant decrease in reinterventions for type 2 endoleaks between the first, second, and third generations," he said.
Asked how his study findings have changed the follow-up protocols at Jobst Vascular Institute, the surgeon replied that in the early years of the series EVAR patients got a CT scan at 6 weeks, 6 months, 1 year, and annually thereafter. This evaluation has evolved over time. Now EVAR patients get a CT scan at 6-12 weeks, and duplex ultrasounds at 6 months, 1 year, and annually thereafter.
"There is no standardized follow-up for open repair patients. However, most [patients] get an annual duplex ultrasound for their follow-up. A CT scan is not part of the follow-up of patients with open repair. But most if not all of the complications that developed in the open repair group were symptomatic," he explained.
He reported having no financial conflicts.
AT THE ASA ANNUAL MEETING
Major Finding: Reintervention rates were markedly higher following endovascular repair compared with open surgical repair of abdominal aortic aneurysms, but the adverse effects associated with reintervention after open repair were far more serious.
Data Source: A retrospective study of the 15-year experience at a large-volume vascular surgery. It encompassed 1,144 patients who underwent abdominal aortic aneurysm repair and their subsequent reintervention rates.
Disclosures: The presenter reported having no conflicts of interest.
Consequences of not screening for prostate cancer prove dire
SAN DIEGO – The mean survival of men who initially presented with a prostate-specific antigen score of 100 ng/mL or greater was just 18 months, results from a single-center study showed.
In an effort to provide insight into the consequences of not screening for prostate cancer, researchers at Santa Clara Valley Medical Center, San Jose, Calif., – a county hospital affiliated with the Stanford (Calif.) University that serves a large underinsured population – evaluated the impact of initial prostate-specific antigen (PSA) levels of 100 ng/mL or greater on patient morbidity and mortality. "What we hypothesized is that they would do pretty well because with newer forms of treatment, and once they get into our system, we have comprehensive care that we can provide to them," Dr. Jeffrey H. Reese, chief of the division of urology at Santa Clara Valley Medical Center, said during a press briefing at the annual meeting of the American Urological Association. However, "what we found is that they did not do well at all."
Dr. Reese reported results from 71 men with a mean age of 67 years who presented with a mean PSA score of 100 ng/mL or greater between 1998 and 2008 – none of whom had received a prior prostate cancer screening at the medical center. The median PSA at presentation was 399 ng/mL, and the median survival was 18 months. "These patients did profoundly worse than what we would have expected," Dr. Reese said. Only 9.6% of the patients survived beyond 3 years.
About 80% of patients had chronic pain from their disease. Common comorbidities included hospitalization (64%), chronic catheterization (29%), spinal cord compression (19%), and compression fracture (17%).
"There are a variety of reasons why [these men] are not being screened," Dr. Reese said. "This is a population that either has no health insurance or minimal health insurance. Some were brought in by concerned family members. Some were immigrants. I think our public hospitals represent a snapshot of what prostate cancer was like before PSA screening. It was not uncommon to have these patients come in with widely metastatic disease. There would be consequences to not screening for PSA, if we were just to abandon it entirely."
He described death from prostate cancer as "a really bad way to die. It’s painful and prolonged. There’s a profound price to pay for this disease."
Study coauthor Dr. Winifred Adams, a urology fellow at the Stanford University, acknowledged that the relatively small sample of 71 patients was a limitation. "We wonder: Is this just a problem of metastatic disease, or is it more of a PSA issue of over 100? So we need to go back and look at all patients with metastatic disease versus those who have PSA over 100 and see if the outcome is the same," Dr. Adams said.
The researchers reported having no relevant financial conflicts to disclose.
SAN DIEGO – The mean survival of men who initially presented with a prostate-specific antigen score of 100 ng/mL or greater was just 18 months, results from a single-center study showed.
In an effort to provide insight into the consequences of not screening for prostate cancer, researchers at Santa Clara Valley Medical Center, San Jose, Calif., – a county hospital affiliated with the Stanford (Calif.) University that serves a large underinsured population – evaluated the impact of initial prostate-specific antigen (PSA) levels of 100 ng/mL or greater on patient morbidity and mortality. "What we hypothesized is that they would do pretty well because with newer forms of treatment, and once they get into our system, we have comprehensive care that we can provide to them," Dr. Jeffrey H. Reese, chief of the division of urology at Santa Clara Valley Medical Center, said during a press briefing at the annual meeting of the American Urological Association. However, "what we found is that they did not do well at all."
Dr. Reese reported results from 71 men with a mean age of 67 years who presented with a mean PSA score of 100 ng/mL or greater between 1998 and 2008 – none of whom had received a prior prostate cancer screening at the medical center. The median PSA at presentation was 399 ng/mL, and the median survival was 18 months. "These patients did profoundly worse than what we would have expected," Dr. Reese said. Only 9.6% of the patients survived beyond 3 years.
About 80% of patients had chronic pain from their disease. Common comorbidities included hospitalization (64%), chronic catheterization (29%), spinal cord compression (19%), and compression fracture (17%).
"There are a variety of reasons why [these men] are not being screened," Dr. Reese said. "This is a population that either has no health insurance or minimal health insurance. Some were brought in by concerned family members. Some were immigrants. I think our public hospitals represent a snapshot of what prostate cancer was like before PSA screening. It was not uncommon to have these patients come in with widely metastatic disease. There would be consequences to not screening for PSA, if we were just to abandon it entirely."
He described death from prostate cancer as "a really bad way to die. It’s painful and prolonged. There’s a profound price to pay for this disease."
Study coauthor Dr. Winifred Adams, a urology fellow at the Stanford University, acknowledged that the relatively small sample of 71 patients was a limitation. "We wonder: Is this just a problem of metastatic disease, or is it more of a PSA issue of over 100? So we need to go back and look at all patients with metastatic disease versus those who have PSA over 100 and see if the outcome is the same," Dr. Adams said.
The researchers reported having no relevant financial conflicts to disclose.
SAN DIEGO – The mean survival of men who initially presented with a prostate-specific antigen score of 100 ng/mL or greater was just 18 months, results from a single-center study showed.
In an effort to provide insight into the consequences of not screening for prostate cancer, researchers at Santa Clara Valley Medical Center, San Jose, Calif., – a county hospital affiliated with the Stanford (Calif.) University that serves a large underinsured population – evaluated the impact of initial prostate-specific antigen (PSA) levels of 100 ng/mL or greater on patient morbidity and mortality. "What we hypothesized is that they would do pretty well because with newer forms of treatment, and once they get into our system, we have comprehensive care that we can provide to them," Dr. Jeffrey H. Reese, chief of the division of urology at Santa Clara Valley Medical Center, said during a press briefing at the annual meeting of the American Urological Association. However, "what we found is that they did not do well at all."
Dr. Reese reported results from 71 men with a mean age of 67 years who presented with a mean PSA score of 100 ng/mL or greater between 1998 and 2008 – none of whom had received a prior prostate cancer screening at the medical center. The median PSA at presentation was 399 ng/mL, and the median survival was 18 months. "These patients did profoundly worse than what we would have expected," Dr. Reese said. Only 9.6% of the patients survived beyond 3 years.
About 80% of patients had chronic pain from their disease. Common comorbidities included hospitalization (64%), chronic catheterization (29%), spinal cord compression (19%), and compression fracture (17%).
"There are a variety of reasons why [these men] are not being screened," Dr. Reese said. "This is a population that either has no health insurance or minimal health insurance. Some were brought in by concerned family members. Some were immigrants. I think our public hospitals represent a snapshot of what prostate cancer was like before PSA screening. It was not uncommon to have these patients come in with widely metastatic disease. There would be consequences to not screening for PSA, if we were just to abandon it entirely."
He described death from prostate cancer as "a really bad way to die. It’s painful and prolonged. There’s a profound price to pay for this disease."
Study coauthor Dr. Winifred Adams, a urology fellow at the Stanford University, acknowledged that the relatively small sample of 71 patients was a limitation. "We wonder: Is this just a problem of metastatic disease, or is it more of a PSA issue of over 100? So we need to go back and look at all patients with metastatic disease versus those who have PSA over 100 and see if the outcome is the same," Dr. Adams said.
The researchers reported having no relevant financial conflicts to disclose.
AT THE AUA ANNUAL MEETING
Major finding: Men who first presented with a PSA score of 100 ng/mL or greater survived a median of just 18 months.
Data source: A study of 71 men with a mean age of 67 years who presented to Santa Clara Valley Medical Center between 1998 and 2008.
Disclosures: The researchers reported having no relevant financial conflicts to disclose.
