Betsy Bates

LA JOLLA, CALIF. — “Diabesity,” as Dr. David Heber calls type 2 diabetes, is a lifestyle disease, not a diagnosis that necessarily requires heavy lifting of the prescription pad.

Too many physicians begin and end the conversation by saying, “You have diabetes and I have a drug for you,” he said at Perspectives in Women's Health, sponsored by FAMILY PRACTICE NEWS, OB.GYN. NEWS, and INTERNAL MEDICINE NEWS.

Obesity, which packs proinflammatory adipocytes around the heart, liver, and intestines, stands as the greatest threat to women's health in the modern world, said Dr. Heber, professor of medicine, and director of the University of California at Los Angeles Center for Human Nutrition.

It costs $130 billion in the United States each year, impacting nearly every organ system in the body, including the reproductive system (Dr. Heber calls polycystic ovary syndrome “diabetes of the ovary”), musculoskeletal system, and the hepatic system, rapidly becoming a leading cause of liver transplantation.

Dr. Heber emphasized that judging patients by appearance alone, or even body mass index, will miss many women at increased risk for cardiovascular disease and diabetes because of abdominal fat.

“Women have higher body fat than men at every BMI,” he said, quoting one study that found that 45% of women with normal BMIs had excess internal fat.

In his office, he uses a bioelectrical impedance meter to measure skeletal muscle versus fat tissue mass, from which calculations can be made for the number of calories per day required to reduce weight in a certain period of time. The devices cost about $500, and provide an excellent opportunity for patient education as well as an accurate assessment of diabetes risk, he said.

The next step is to discuss with patients the need for lifestyle modification to preserve health in a way that they can envision. For example, he explains, “It takes a lot of exercise to make up for a little dietary indiscretion.” To burn off 2 ounces of potato chips, it takes a 3-mile run in 30 minutes. Drinking two regular sodas instead of diet sodas is fine, as long as you want to bicycle 3 miles in 30 minutes.

While most people can be convinced to institute 30 minutes a day of exercise, they certainly won't want to sign up for 90 minutes a day to account for a bag of chips and a couple of sodas.

Unfortunately, both emotions and nature work in opposition to weight loss, since “psychology trumps physiology every time. You eat when you are not hungry. Nature wants you to hold onto calories.” Diabetes, he said, “is great genes in the wrong century.”

For many people, then, a whole restructuring of views about food must counteract impulses and a food industry that has conditioned us to crave foods that are sweet, bland, oily, and creamy “so that you can consume a large amount of food without realizing it,” Dr. Heber said.

Focusing on fruits and vegetables, whole grains, fish, spices, and nuts in a color-coordinated diet (see box) can provide fewer calories and fewer proinflammatory foods, as described in Dr. Heber's book for lay audiences, “What Color is Your Diet?” (New York: HarperCollins Publishers, 2001).

Replacing two meals a day (one per day for weight maintenance after weight loss) with high-protein, low-calorie, meal replacement shakes makes the transition even easier.

Drinking thick shakes for two meals makes people want chewy, crunchy, colorful foods for snacks and the third meal of the day, he explained. Fruits and vegetables fit that bill.

The strategy also helps patients learn to self-monitor their eating and to better gauge portion sizes and estimate calories. Planning just one meal a day reduces the amount of food brought into the home and simplifies the task of preparing a healthy, attractive meal.

The payoff, he promised, can be immense, not only because patients will pay cash for supervised weight loss, but also because the health benefits are profound.

Controlled studies document that modest weight reduction modifies every element of the metabolic syndrome and can prevent conversion to type 2 diabetes in people who are glucose intolerant.

FAMILY PRACTICE NEWS is published by the International Medical News Group, a division of Elsevier.

Color Palate for Healthy Eating

Dr. Heber encourages his diabetes patients to eat from the following color groups of fruits and vegetables:

▸ Red. Tomato products, soups, sauces, juices (contain lycopene).

▸ Red/purple. Red wine, grapes, berries, plums (contain anthocyanins, ellagitannins).

▸ Orange. Carrots, mango, apricot, sweet potato (contain β-carotene/α-carotene).

▸ Orange/yellow. Citrus fruits, papaya, peaches (contain citrus flavonoids).

▸ Yellow/green. Spinach, corn, avocado, green beans (contain lutein/zeaxanthin).

▸ Green. Broccoli, Brussels sprouts, cabbage (contain glucosinolates, indoles).

▸ White/green. Garlic, onions, chives, asparagus (contain allyl sulfides).

Dr. Heber tells his patients to avoid white and beige foods, such as white bread.

LA JOLLA, CALIF. — “Diabesity,” as Dr. David Heber calls type 2 diabetes, is a lifestyle disease, not a diagnosis that necessarily requires heavy lifting of the prescription pad.

Too many physicians begin and end the conversation by saying, “You have diabetes and I have a drug for you,” he said at Perspectives in Women's Health, sponsored by FAMILY PRACTICE NEWS, OB.GYN. NEWS, and INTERNAL MEDICINE NEWS.

Obesity, which packs proinflammatory adipocytes around the heart, liver, and intestines, stands as the greatest threat to women's health in the modern world, said Dr. Heber, professor of medicine, and director of the University of California at Los Angeles Center for Human Nutrition.

It costs $130 billion in the United States each year, impacting nearly every organ system in the body, including the reproductive system (Dr. Heber calls polycystic ovary syndrome “diabetes of the ovary”), musculoskeletal system, and the hepatic system, rapidly becoming a leading cause of liver transplantation.

Dr. Heber emphasized that judging patients by appearance alone, or even body mass index, will miss many women at increased risk for cardiovascular disease and diabetes because of abdominal fat.

“Women have higher body fat than men at every BMI,” he said, quoting one study that found that 45% of women with normal BMIs had excess internal fat.

In his office, he uses a bioelectrical impedance meter to measure skeletal muscle versus fat tissue mass, from which calculations can be made for the number of calories per day required to reduce weight in a certain period of time. The devices cost about $500, and provide an excellent opportunity for patient education as well as an accurate assessment of diabetes risk, he said.

The next step is to discuss with patients the need for lifestyle modification to preserve health in a way that they can envision. For example, he explains, “It takes a lot of exercise to make up for a little dietary indiscretion.” To burn off 2 ounces of potato chips, it takes a 3-mile run in 30 minutes. Drinking two regular sodas instead of diet sodas is fine, as long as you want to bicycle 3 miles in 30 minutes.

While most people can be convinced to institute 30 minutes a day of exercise, they certainly won't want to sign up for 90 minutes a day to account for a bag of chips and a couple of sodas.

Unfortunately, both emotions and nature work in opposition to weight loss, since “psychology trumps physiology every time. You eat when you are not hungry. Nature wants you to hold onto calories.” Diabetes, he said, “is great genes in the wrong century.”

For many people, then, a whole restructuring of views about food must counteract impulses and a food industry that has conditioned us to crave foods that are sweet, bland, oily, and creamy “so that you can consume a large amount of food without realizing it,” Dr. Heber said.

Focusing on fruits and vegetables, whole grains, fish, spices, and nuts in a color-coordinated diet (see box) can provide fewer calories and fewer proinflammatory foods, as described in Dr. Heber's book for lay audiences, “What Color is Your Diet?” (New York: HarperCollins Publishers, 2001).

Replacing two meals a day (one per day for weight maintenance after weight loss) with high-protein, low-calorie, meal replacement shakes makes the transition even easier.

Drinking thick shakes for two meals makes people want chewy, crunchy, colorful foods for snacks and the third meal of the day, he explained. Fruits and vegetables fit that bill.

The strategy also helps patients learn to self-monitor their eating and to better gauge portion sizes and estimate calories. Planning just one meal a day reduces the amount of food brought into the home and simplifies the task of preparing a healthy, attractive meal.

The payoff, he promised, can be immense, not only because patients will pay cash for supervised weight loss, but also because the health benefits are profound.

Controlled studies document that modest weight reduction modifies every element of the metabolic syndrome and can prevent conversion to type 2 diabetes in people who are glucose intolerant.

FAMILY PRACTICE NEWS is published by the International Medical News Group, a division of Elsevier.

Color Palate for Healthy Eating

Dr. Heber encourages his diabetes patients to eat from the following color groups of fruits and vegetables:

▸ Red. Tomato products, soups, sauces, juices (contain lycopene).

▸ Red/purple. Red wine, grapes, berries, plums (contain anthocyanins, ellagitannins).

▸ Orange. Carrots, mango, apricot, sweet potato (contain β-carotene/α-carotene).

▸ Orange/yellow. Citrus fruits, papaya, peaches (contain citrus flavonoids).

▸ Yellow/green. Spinach, corn, avocado, green beans (contain lutein/zeaxanthin).

▸ Green. Broccoli, Brussels sprouts, cabbage (contain glucosinolates, indoles).

▸ White/green. Garlic, onions, chives, asparagus (contain allyl sulfides).

Dr. Heber tells his patients to avoid white and beige foods, such as white bread.

LA JOLLA, CALIF. — “Diabesity,” as Dr. David Heber calls type 2 diabetes, is a lifestyle disease, not a diagnosis that necessarily requires heavy lifting of the prescription pad.

Too many physicians begin and end the conversation by saying, “You have diabetes and I have a drug for you,” he said at Perspectives in Women's Health, sponsored by FAMILY PRACTICE NEWS, OB.GYN. NEWS, and INTERNAL MEDICINE NEWS.

Obesity, which packs proinflammatory adipocytes around the heart, liver, and intestines, stands as the greatest threat to women's health in the modern world, said Dr. Heber, professor of medicine, and director of the University of California at Los Angeles Center for Human Nutrition.

It costs $130 billion in the United States each year, impacting nearly every organ system in the body, including the reproductive system (Dr. Heber calls polycystic ovary syndrome “diabetes of the ovary”), musculoskeletal system, and the hepatic system, rapidly becoming a leading cause of liver transplantation.

Dr. Heber emphasized that judging patients by appearance alone, or even body mass index, will miss many women at increased risk for cardiovascular disease and diabetes because of abdominal fat.

“Women have higher body fat than men at every BMI,” he said, quoting one study that found that 45% of women with normal BMIs had excess internal fat.

In his office, he uses a bioelectrical impedance meter to measure skeletal muscle versus fat tissue mass, from which calculations can be made for the number of calories per day required to reduce weight in a certain period of time. The devices cost about $500, and provide an excellent opportunity for patient education as well as an accurate assessment of diabetes risk, he said.

The next step is to discuss with patients the need for lifestyle modification to preserve health in a way that they can envision. For example, he explains, “It takes a lot of exercise to make up for a little dietary indiscretion.” To burn off 2 ounces of potato chips, it takes a 3-mile run in 30 minutes. Drinking two regular sodas instead of diet sodas is fine, as long as you want to bicycle 3 miles in 30 minutes.

While most people can be convinced to institute 30 minutes a day of exercise, they certainly won't want to sign up for 90 minutes a day to account for a bag of chips and a couple of sodas.

Unfortunately, both emotions and nature work in opposition to weight loss, since “psychology trumps physiology every time. You eat when you are not hungry. Nature wants you to hold onto calories.” Diabetes, he said, “is great genes in the wrong century.”

For many people, then, a whole restructuring of views about food must counteract impulses and a food industry that has conditioned us to crave foods that are sweet, bland, oily, and creamy “so that you can consume a large amount of food without realizing it,” Dr. Heber said.

Focusing on fruits and vegetables, whole grains, fish, spices, and nuts in a color-coordinated diet (see box) can provide fewer calories and fewer proinflammatory foods, as described in Dr. Heber's book for lay audiences, “What Color is Your Diet?” (New York: HarperCollins Publishers, 2001).

Replacing two meals a day (one per day for weight maintenance after weight loss) with high-protein, low-calorie, meal replacement shakes makes the transition even easier.

Drinking thick shakes for two meals makes people want chewy, crunchy, colorful foods for snacks and the third meal of the day, he explained. Fruits and vegetables fit that bill.

The strategy also helps patients learn to self-monitor their eating and to better gauge portion sizes and estimate calories. Planning just one meal a day reduces the amount of food brought into the home and simplifies the task of preparing a healthy, attractive meal.

The payoff, he promised, can be immense, not only because patients will pay cash for supervised weight loss, but also because the health benefits are profound.

Controlled studies document that modest weight reduction modifies every element of the metabolic syndrome and can prevent conversion to type 2 diabetes in people who are glucose intolerant.

FAMILY PRACTICE NEWS is published by the International Medical News Group, a division of Elsevier.

Color Palate for Healthy Eating

Dr. Heber encourages his diabetes patients to eat from the following color groups of fruits and vegetables:

▸ Red. Tomato products, soups, sauces, juices (contain lycopene).

▸ Red/purple. Red wine, grapes, berries, plums (contain anthocyanins, ellagitannins).

▸ Orange. Carrots, mango, apricot, sweet potato (contain β-carotene/α-carotene).

▸ Orange/yellow. Citrus fruits, papaya, peaches (contain citrus flavonoids).

▸ Yellow/green. Spinach, corn, avocado, green beans (contain lutein/zeaxanthin).

▸ Green. Broccoli, Brussels sprouts, cabbage (contain glucosinolates, indoles).

▸ White/green. Garlic, onions, chives, asparagus (contain allyl sulfides).

Dr. Heber tells his patients to avoid white and beige foods, such as white bread.

VANCOUVER, B.C. – Women appear to experience a 2- to 5-day period of heightened withdrawal and craving symptoms just prior to smoking relapse, offering what could be a golden opportunity for intervention, researchers reported at the annual meeting of the North American Primary Care Research Group.

The finding was a serendipitous discovery from a larger trial investigating associations between the menstrual cycle and smoking withdrawal, explained Dr. Bruce A. Center of the department of family practice and community health at the University of Minnesota, Minneapolis.

Participants included 137 female smokers aged 18–40 years who completed an intensive, month-long study as part of a larger, longitudinal smoking cessation trial sponsored by the National Institutes of Health. At baseline and for 30 days following an assigned quit date, they completed daily logs of specific symptoms of withdrawal, nicotine craving, and smoking urges, as well as negative affect.

Despite education, phone counseling, and monitoring, 111 enrollees relapsed over the course of the study.

The intensity of craving, withdrawal, and smoking urges rose quite precipitously during the 2–5 days prior to relapse, when it peaked. All of the symptoms declined after relapse occurred.

“Frankly, I didn't think there would be a window [of symptom escalation], or if there was, it would be 15 minutes,” Dr. Center said. The next step will be to design and test an intervention that educates women in how to recognize and monitor their symptoms and take steps to prevent relapse once they recognize an escalation.

More work will be necessary to determine the most effective tools for staving off relapse when an uptick in symptoms is recognized, Dr. Center said.

VANCOUVER, B.C. – Women appear to experience a 2- to 5-day period of heightened withdrawal and craving symptoms just prior to smoking relapse, offering what could be a golden opportunity for intervention, researchers reported at the annual meeting of the North American Primary Care Research Group.

The finding was a serendipitous discovery from a larger trial investigating associations between the menstrual cycle and smoking withdrawal, explained Dr. Bruce A. Center of the department of family practice and community health at the University of Minnesota, Minneapolis.

Participants included 137 female smokers aged 18–40 years who completed an intensive, month-long study as part of a larger, longitudinal smoking cessation trial sponsored by the National Institutes of Health. At baseline and for 30 days following an assigned quit date, they completed daily logs of specific symptoms of withdrawal, nicotine craving, and smoking urges, as well as negative affect.

Despite education, phone counseling, and monitoring, 111 enrollees relapsed over the course of the study.

The intensity of craving, withdrawal, and smoking urges rose quite precipitously during the 2–5 days prior to relapse, when it peaked. All of the symptoms declined after relapse occurred.

“Frankly, I didn't think there would be a window [of symptom escalation], or if there was, it would be 15 minutes,” Dr. Center said. The next step will be to design and test an intervention that educates women in how to recognize and monitor their symptoms and take steps to prevent relapse once they recognize an escalation.

More work will be necessary to determine the most effective tools for staving off relapse when an uptick in symptoms is recognized, Dr. Center said.

VANCOUVER, B.C. – Women appear to experience a 2- to 5-day period of heightened withdrawal and craving symptoms just prior to smoking relapse, offering what could be a golden opportunity for intervention, researchers reported at the annual meeting of the North American Primary Care Research Group.

The finding was a serendipitous discovery from a larger trial investigating associations between the menstrual cycle and smoking withdrawal, explained Dr. Bruce A. Center of the department of family practice and community health at the University of Minnesota, Minneapolis.

Participants included 137 female smokers aged 18–40 years who completed an intensive, month-long study as part of a larger, longitudinal smoking cessation trial sponsored by the National Institutes of Health. At baseline and for 30 days following an assigned quit date, they completed daily logs of specific symptoms of withdrawal, nicotine craving, and smoking urges, as well as negative affect.

Despite education, phone counseling, and monitoring, 111 enrollees relapsed over the course of the study.

The intensity of craving, withdrawal, and smoking urges rose quite precipitously during the 2–5 days prior to relapse, when it peaked. All of the symptoms declined after relapse occurred.

“Frankly, I didn't think there would be a window [of symptom escalation], or if there was, it would be 15 minutes,” Dr. Center said. The next step will be to design and test an intervention that educates women in how to recognize and monitor their symptoms and take steps to prevent relapse once they recognize an escalation.

More work will be necessary to determine the most effective tools for staving off relapse when an uptick in symptoms is recognized, Dr. Center said.

MONTEREY, CALIF. — The initial preoperative diagnoses of nail lesions that prove to be squamous cell carcinoma run the gamut from onychomycosis to subungual verruca, Dr. Phoebe Rich said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

In her own practice, one such lesion was oozing and appeared onycholytic, she explained, displaying a slide of the crusty lesion at the nail edge.

"It doesn't look like much," said Dr. Rich, director of the nail center at Oregon Health and Science University, Portland.

Among 13 SCC cases diagnosed by Dr. Rich, who is also in private practice, six appeared verrucous and six eczematoid, in addition to the onycholytic case.

Earlier this year, a clinicopathological review of SCC of the nail apparatus by French researchers revealed that subungual SCC was the preoperative diagnosis in only 10 of 35 patients (Br. J. Dermatol. 2007;156:871-4). Nine cases were originally thought to be onychomycosis, five were diagnosed as subungual verruca, and five were thought to be "longitudinal melanonychia (nevus, melanoma)." Six cases carried a variety of other preoperative diagnoses, including exostosis and onychomatricoma.

The lesson is to always be thinking of SCC of the nail as a possibility, she stressed.

MONTEREY, CALIF. — The initial preoperative diagnoses of nail lesions that prove to be squamous cell carcinoma run the gamut from onychomycosis to subungual verruca, Dr. Phoebe Rich said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

In her own practice, one such lesion was oozing and appeared onycholytic, she explained, displaying a slide of the crusty lesion at the nail edge.

"It doesn't look like much," said Dr. Rich, director of the nail center at Oregon Health and Science University, Portland.

Among 13 SCC cases diagnosed by Dr. Rich, who is also in private practice, six appeared verrucous and six eczematoid, in addition to the onycholytic case.

Earlier this year, a clinicopathological review of SCC of the nail apparatus by French researchers revealed that subungual SCC was the preoperative diagnosis in only 10 of 35 patients (Br. J. Dermatol. 2007;156:871-4). Nine cases were originally thought to be onychomycosis, five were diagnosed as subungual verruca, and five were thought to be "longitudinal melanonychia (nevus, melanoma)." Six cases carried a variety of other preoperative diagnoses, including exostosis and onychomatricoma.

The lesson is to always be thinking of SCC of the nail as a possibility, she stressed.

MONTEREY, CALIF. — The initial preoperative diagnoses of nail lesions that prove to be squamous cell carcinoma run the gamut from onychomycosis to subungual verruca, Dr. Phoebe Rich said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

In her own practice, one such lesion was oozing and appeared onycholytic, she explained, displaying a slide of the crusty lesion at the nail edge.

"It doesn't look like much," said Dr. Rich, director of the nail center at Oregon Health and Science University, Portland.

Among 13 SCC cases diagnosed by Dr. Rich, who is also in private practice, six appeared verrucous and six eczematoid, in addition to the onycholytic case.

Earlier this year, a clinicopathological review of SCC of the nail apparatus by French researchers revealed that subungual SCC was the preoperative diagnosis in only 10 of 35 patients (Br. J. Dermatol. 2007;156:871-4). Nine cases were originally thought to be onychomycosis, five were diagnosed as subungual verruca, and five were thought to be "longitudinal melanonychia (nevus, melanoma)." Six cases carried a variety of other preoperative diagnoses, including exostosis and onychomatricoma.

The lesson is to always be thinking of SCC of the nail as a possibility, she stressed.

MONTEREY, CALIF. — Proper management and orientation of nail biopsy specimens will help ensure that the ensuing diagnosis is accurate, Dr. Phoebe Rich advised colleagues at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

"If you send these in and they're sectioned wrong, you're going to get the wrong answer or you're not going to get an answer at all," said Dr. Rich, director of the nail center at Oregon Health and Science University in Portland.

She places the properly oriented specimen on a piece of paper that contains a photocopied template of a nail. "I orient it the way that I want the pathologist to look at it," she said.

As an example, she showed how she oriented the biopsy specimen from a lesion suspicious for melanoma in which she took the nail plate, matrix, part of the nail fold, and the nail bed. The tissue was placed directly on the diagram of the nail, and the nail plate was sent to the pathologist as well.

"The pathologist knows to section this in a longitudinal way. If you were to 'breadloaf' this, you're probably not going to get your answer," she said.

The pathologist sections right through the specimen and the paper, preserving the orientation.

There is no need to affix the specimen to the paper. "If you put it down right away on the paper, it actually sticks. I let it sit there for a few minutes before I put it in the formalin and it actually will adhere to the paper," Dr. Rich explained.

She noted that in many cases, an accurate diagnosis will not require removal of the entire nail plate.

"I tell the residents: 'Unless the nail plate is deformed by the tumor, you're not dealing with a deep lesion. You can really just take off the top part and you're still going to get your answer very, very nicely,'" she said.

Biopsy any unexplained pigmented lesion at the origin of the band by cutting along and peeling back the affected part of the nail as necessary, saucerizing the lesion, and scoring around it, she explained.

The distal plate can often be preserved, she said.

In response to a question from the audience, Dr. Rich acknowledged the difficulty in knowing whether or when to biopsy a pigmented nail in a person with naturally pigmented nails, such as is often the case in African American patients.

Look for pigment that is different from that in the other nails, changing, or larger than the norm for that patient, she recommended.

"Just like in patients with a lot of moles, you look for the ugly duckling."

MONTEREY, CALIF. — Proper management and orientation of nail biopsy specimens will help ensure that the ensuing diagnosis is accurate, Dr. Phoebe Rich advised colleagues at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

"If you send these in and they're sectioned wrong, you're going to get the wrong answer or you're not going to get an answer at all," said Dr. Rich, director of the nail center at Oregon Health and Science University in Portland.

She places the properly oriented specimen on a piece of paper that contains a photocopied template of a nail. "I orient it the way that I want the pathologist to look at it," she said.

As an example, she showed how she oriented the biopsy specimen from a lesion suspicious for melanoma in which she took the nail plate, matrix, part of the nail fold, and the nail bed. The tissue was placed directly on the diagram of the nail, and the nail plate was sent to the pathologist as well.

"The pathologist knows to section this in a longitudinal way. If you were to 'breadloaf' this, you're probably not going to get your answer," she said.

The pathologist sections right through the specimen and the paper, preserving the orientation.

There is no need to affix the specimen to the paper. "If you put it down right away on the paper, it actually sticks. I let it sit there for a few minutes before I put it in the formalin and it actually will adhere to the paper," Dr. Rich explained.

She noted that in many cases, an accurate diagnosis will not require removal of the entire nail plate.

"I tell the residents: 'Unless the nail plate is deformed by the tumor, you're not dealing with a deep lesion. You can really just take off the top part and you're still going to get your answer very, very nicely,'" she said.

Biopsy any unexplained pigmented lesion at the origin of the band by cutting along and peeling back the affected part of the nail as necessary, saucerizing the lesion, and scoring around it, she explained.

The distal plate can often be preserved, she said.

In response to a question from the audience, Dr. Rich acknowledged the difficulty in knowing whether or when to biopsy a pigmented nail in a person with naturally pigmented nails, such as is often the case in African American patients.

Look for pigment that is different from that in the other nails, changing, or larger than the norm for that patient, she recommended.

"Just like in patients with a lot of moles, you look for the ugly duckling."

MONTEREY, CALIF. — Proper management and orientation of nail biopsy specimens will help ensure that the ensuing diagnosis is accurate, Dr. Phoebe Rich advised colleagues at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

"If you send these in and they're sectioned wrong, you're going to get the wrong answer or you're not going to get an answer at all," said Dr. Rich, director of the nail center at Oregon Health and Science University in Portland.

She places the properly oriented specimen on a piece of paper that contains a photocopied template of a nail. "I orient it the way that I want the pathologist to look at it," she said.

As an example, she showed how she oriented the biopsy specimen from a lesion suspicious for melanoma in which she took the nail plate, matrix, part of the nail fold, and the nail bed. The tissue was placed directly on the diagram of the nail, and the nail plate was sent to the pathologist as well.

"The pathologist knows to section this in a longitudinal way. If you were to 'breadloaf' this, you're probably not going to get your answer," she said.

The pathologist sections right through the specimen and the paper, preserving the orientation.

There is no need to affix the specimen to the paper. "If you put it down right away on the paper, it actually sticks. I let it sit there for a few minutes before I put it in the formalin and it actually will adhere to the paper," Dr. Rich explained.

She noted that in many cases, an accurate diagnosis will not require removal of the entire nail plate.

"I tell the residents: 'Unless the nail plate is deformed by the tumor, you're not dealing with a deep lesion. You can really just take off the top part and you're still going to get your answer very, very nicely,'" she said.

Biopsy any unexplained pigmented lesion at the origin of the band by cutting along and peeling back the affected part of the nail as necessary, saucerizing the lesion, and scoring around it, she explained.

The distal plate can often be preserved, she said.

In response to a question from the audience, Dr. Rich acknowledged the difficulty in knowing whether or when to biopsy a pigmented nail in a person with naturally pigmented nails, such as is often the case in African American patients.

Look for pigment that is different from that in the other nails, changing, or larger than the norm for that patient, she recommended.

"Just like in patients with a lot of moles, you look for the ugly duckling."

VANCOUVER, B.C. — More than a third of primary care patients with health insurance reported delaying or foregoing recommended medical care because they could not afford copays or deductibles in according to findings in a study conducted at 37 clinics in Colorado.

Thirty percent of 1,133 English- and Spanish-speaking patients who attended family medicine and internal medicine clinics were underinsured, including 10% who had no health insurance, reported Dr. Kent Voorhees, who is in the department of family medicine at the University of Colorado Health Sciences Center in Denver.

The investigators defined underinsurance as being unable to comply with medical advice in the previous 12 months by patients who have medical insurance but cannot absorb the cost burden of copays or deductibles.

The patients included newborns and those aged up to 89 years.

Among 90% of patients with some form of insurance, 36% were underinsured.

“Even patients with Medicare and Medicaid—groups excluded from previous underinsurance studies—reported being underinsured at a rate of 19.2% and 34.6%, respectively,” reported Dr. Voorhees and associates in a poster at the annual meeting of the North American Primary Care Research Group.

Half of all underinsured patients said they felt their health had suffered because they could not afford to follow physicians' advice to obtain tests, specialist care, or prescriptions.

An equal percentage of patients with no insurance coverage said their health had suffered for the same reason.

The underinsurance phenomenon is symptomatic of a creeping pattern of cost shifting from payers to patients, resulting in hidden compromises in health care, said Dr. Voorhees in an interview at the meeting.

“If patients are healthy, then they may not even know they're underinsured,” he added.

The issue lurks under the radar in health policy research, as well as in studies of compliance, yet the Colorado findings are likely to be generalizable to much of the country, according to Dr. Voorhees.

“To adequately meet the health care needs in the [United States], we need to look beyond the problem of the uninsured to create a system that also solves the problem of underinsurance,” the authors concluded.

“This will improve overall health and health-related outcomes to an acceptable level,” they argued.

VANCOUVER, B.C. — More than a third of primary care patients with health insurance reported delaying or foregoing recommended medical care because they could not afford copays or deductibles in according to findings in a study conducted at 37 clinics in Colorado.

Thirty percent of 1,133 English- and Spanish-speaking patients who attended family medicine and internal medicine clinics were underinsured, including 10% who had no health insurance, reported Dr. Kent Voorhees, who is in the department of family medicine at the University of Colorado Health Sciences Center in Denver.

The investigators defined underinsurance as being unable to comply with medical advice in the previous 12 months by patients who have medical insurance but cannot absorb the cost burden of copays or deductibles.

The patients included newborns and those aged up to 89 years.

Among 90% of patients with some form of insurance, 36% were underinsured.

“Even patients with Medicare and Medicaid—groups excluded from previous underinsurance studies—reported being underinsured at a rate of 19.2% and 34.6%, respectively,” reported Dr. Voorhees and associates in a poster at the annual meeting of the North American Primary Care Research Group.

Half of all underinsured patients said they felt their health had suffered because they could not afford to follow physicians' advice to obtain tests, specialist care, or prescriptions.

An equal percentage of patients with no insurance coverage said their health had suffered for the same reason.

The underinsurance phenomenon is symptomatic of a creeping pattern of cost shifting from payers to patients, resulting in hidden compromises in health care, said Dr. Voorhees in an interview at the meeting.

“If patients are healthy, then they may not even know they're underinsured,” he added.

The issue lurks under the radar in health policy research, as well as in studies of compliance, yet the Colorado findings are likely to be generalizable to much of the country, according to Dr. Voorhees.

“To adequately meet the health care needs in the [United States], we need to look beyond the problem of the uninsured to create a system that also solves the problem of underinsurance,” the authors concluded.

“This will improve overall health and health-related outcomes to an acceptable level,” they argued.

VANCOUVER, B.C. — More than a third of primary care patients with health insurance reported delaying or foregoing recommended medical care because they could not afford copays or deductibles in according to findings in a study conducted at 37 clinics in Colorado.

Thirty percent of 1,133 English- and Spanish-speaking patients who attended family medicine and internal medicine clinics were underinsured, including 10% who had no health insurance, reported Dr. Kent Voorhees, who is in the department of family medicine at the University of Colorado Health Sciences Center in Denver.

The investigators defined underinsurance as being unable to comply with medical advice in the previous 12 months by patients who have medical insurance but cannot absorb the cost burden of copays or deductibles.

The patients included newborns and those aged up to 89 years.

Among 90% of patients with some form of insurance, 36% were underinsured.

“Even patients with Medicare and Medicaid—groups excluded from previous underinsurance studies—reported being underinsured at a rate of 19.2% and 34.6%, respectively,” reported Dr. Voorhees and associates in a poster at the annual meeting of the North American Primary Care Research Group.

Half of all underinsured patients said they felt their health had suffered because they could not afford to follow physicians' advice to obtain tests, specialist care, or prescriptions.

An equal percentage of patients with no insurance coverage said their health had suffered for the same reason.

The underinsurance phenomenon is symptomatic of a creeping pattern of cost shifting from payers to patients, resulting in hidden compromises in health care, said Dr. Voorhees in an interview at the meeting.

“If patients are healthy, then they may not even know they're underinsured,” he added.

The issue lurks under the radar in health policy research, as well as in studies of compliance, yet the Colorado findings are likely to be generalizable to much of the country, according to Dr. Voorhees.

“To adequately meet the health care needs in the [United States], we need to look beyond the problem of the uninsured to create a system that also solves the problem of underinsurance,” the authors concluded.

“This will improve overall health and health-related outcomes to an acceptable level,” they argued.

MONTEREY, CALIF. — Although most physicians are familiar with the basic facts concerning the newly introduced Gardasil and Zostavax vaccines, questions still surround their use.

Zostavax, a 14-fold concentrated version of Varivax, the varicella zoster vaccine to prevent chicken pox in children, was approved by the Food and Drug Administration in May 2006 for adults aged 60 years and older. A month later, approval was issued for Gardasil in girls and young women aged 9–26 years to prevent cervical cancer, precancerous genital lesions, and genital warts caused by HPV types 6, 11, 16, and 18.

Dr. Stephen K. Tyring, professor of dermatology at the University of Texas Health Sciences Center in Houston, discussed commonly asked patient questions about the vaccines at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Gardasil

▸ “I'm 30, and I'm in the dating scene. Should I get the Gardasil vaccine even though it's only approved for ages 9–26?” The vaccine was studied in younger women, but there's no reason that older women who are sexually active shouldn't receive the vaccine, Dr. Tyring said. Yet most insurers probably will not cover the cost of the vaccine in those outside of the FDA-specified age groups.

▸ “Shouldn't we be vaccinating boys and young men, too?” Men obviously play a role in the spread of oncogenic papilloma viruses, but women suffered more anogenital malignancies in countries where the vaccine was studied, so they were included in the trials, he said. Ongoing studies will establish “the safety if not the efficacy” of the vaccine in males.

▸ “Why isn't Gardasil being used to treat cervical cancer?” The few published studies of Gardasil's efficacy in treating cervical cancer have had unimpressive results, so its role remains preventive.

▸ “How long will the viral protection last?” “We don't know,” Dr. Tyring said. The duration of protection was at least 5 years in trial participants. “We hope it's a lifetime.”

▸ “I've already had genital warts. What would be the point of my getting the vaccine now?” If a physician can show that a patient has been exposed only to HPV types 6 and 11, she could still receive protection against HPV types 16 and 18, which cause cervical cancer. The American Cancer Society predicts more than 11,000 women will be diagnosed with cervical cancer in the United States this year, and nearly 3,700 will die of the disease.

Zostavax

▸ “I've heard the Zostavax vaccine isn't very effective. Why should I get it?” In a pivotal trial, the Zostavax vaccine prevented herpes zoster in 51% of adults aged 60 and older, an impressive result considering it was being used to do something quite extraordinary: prevent reemergence of a virus that had been lying dormant in the dorsal root ganglia for decades, Dr. Tyring said. Among those who did get shingles after receiving the vaccine, the rate of postherpetic neuralgia was reduced by two-thirds.

▸ “I'm 55, but I've seen what shingles was like in my dad, and I don't want to get it. Should I get the vaccine?” Dr. Tyring and associates have given the vaccine to people in their 50s and found that their immunogenicity is superior to that of older adults. Pending trials may lead to approval in younger adults, but until that time, there may be no reimbursement for what appears to be a safe and effective vaccine.

▸ “I have had shingles, and I never want to go through it again. Will the disease prevent recurrence?” Even without the vaccine, an immunocompetent person has only a 5% chance of getting shingles a second time.

▸ “I don't think I even had chicken pox as a child, so would the vaccine be unnecessary?” Fully 99% of people over age 60 are seropositive, whether or not they recall having scratchy bumps, and can be presumed to be at risk for shingles, he said.

Dr. Tyring receives research support and has served on the speaker's bureau and as a consultant to Merck, maker of both vaccines.

MONTEREY, CALIF. — Although most physicians are familiar with the basic facts concerning the newly introduced Gardasil and Zostavax vaccines, questions still surround their use.

Zostavax, a 14-fold concentrated version of Varivax, the varicella zoster vaccine to prevent chicken pox in children, was approved by the Food and Drug Administration in May 2006 for adults aged 60 years and older. A month later, approval was issued for Gardasil in girls and young women aged 9–26 years to prevent cervical cancer, precancerous genital lesions, and genital warts caused by HPV types 6, 11, 16, and 18.

Dr. Stephen K. Tyring, professor of dermatology at the University of Texas Health Sciences Center in Houston, discussed commonly asked patient questions about the vaccines at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Gardasil

▸ “I'm 30, and I'm in the dating scene. Should I get the Gardasil vaccine even though it's only approved for ages 9–26?” The vaccine was studied in younger women, but there's no reason that older women who are sexually active shouldn't receive the vaccine, Dr. Tyring said. Yet most insurers probably will not cover the cost of the vaccine in those outside of the FDA-specified age groups.

▸ “Shouldn't we be vaccinating boys and young men, too?” Men obviously play a role in the spread of oncogenic papilloma viruses, but women suffered more anogenital malignancies in countries where the vaccine was studied, so they were included in the trials, he said. Ongoing studies will establish “the safety if not the efficacy” of the vaccine in males.

▸ “Why isn't Gardasil being used to treat cervical cancer?” The few published studies of Gardasil's efficacy in treating cervical cancer have had unimpressive results, so its role remains preventive.

▸ “How long will the viral protection last?” “We don't know,” Dr. Tyring said. The duration of protection was at least 5 years in trial participants. “We hope it's a lifetime.”

▸ “I've already had genital warts. What would be the point of my getting the vaccine now?” If a physician can show that a patient has been exposed only to HPV types 6 and 11, she could still receive protection against HPV types 16 and 18, which cause cervical cancer. The American Cancer Society predicts more than 11,000 women will be diagnosed with cervical cancer in the United States this year, and nearly 3,700 will die of the disease.

Zostavax

▸ “I've heard the Zostavax vaccine isn't very effective. Why should I get it?” In a pivotal trial, the Zostavax vaccine prevented herpes zoster in 51% of adults aged 60 and older, an impressive result considering it was being used to do something quite extraordinary: prevent reemergence of a virus that had been lying dormant in the dorsal root ganglia for decades, Dr. Tyring said. Among those who did get shingles after receiving the vaccine, the rate of postherpetic neuralgia was reduced by two-thirds.

▸ “I'm 55, but I've seen what shingles was like in my dad, and I don't want to get it. Should I get the vaccine?” Dr. Tyring and associates have given the vaccine to people in their 50s and found that their immunogenicity is superior to that of older adults. Pending trials may lead to approval in younger adults, but until that time, there may be no reimbursement for what appears to be a safe and effective vaccine.

▸ “I have had shingles, and I never want to go through it again. Will the disease prevent recurrence?” Even without the vaccine, an immunocompetent person has only a 5% chance of getting shingles a second time.

▸ “I don't think I even had chicken pox as a child, so would the vaccine be unnecessary?” Fully 99% of people over age 60 are seropositive, whether or not they recall having scratchy bumps, and can be presumed to be at risk for shingles, he said.

Dr. Tyring receives research support and has served on the speaker's bureau and as a consultant to Merck, maker of both vaccines.

MONTEREY, CALIF. — Although most physicians are familiar with the basic facts concerning the newly introduced Gardasil and Zostavax vaccines, questions still surround their use.

Zostavax, a 14-fold concentrated version of Varivax, the varicella zoster vaccine to prevent chicken pox in children, was approved by the Food and Drug Administration in May 2006 for adults aged 60 years and older. A month later, approval was issued for Gardasil in girls and young women aged 9–26 years to prevent cervical cancer, precancerous genital lesions, and genital warts caused by HPV types 6, 11, 16, and 18.

Dr. Stephen K. Tyring, professor of dermatology at the University of Texas Health Sciences Center in Houston, discussed commonly asked patient questions about the vaccines at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Gardasil

▸ “I'm 30, and I'm in the dating scene. Should I get the Gardasil vaccine even though it's only approved for ages 9–26?” The vaccine was studied in younger women, but there's no reason that older women who are sexually active shouldn't receive the vaccine, Dr. Tyring said. Yet most insurers probably will not cover the cost of the vaccine in those outside of the FDA-specified age groups.

▸ “Shouldn't we be vaccinating boys and young men, too?” Men obviously play a role in the spread of oncogenic papilloma viruses, but women suffered more anogenital malignancies in countries where the vaccine was studied, so they were included in the trials, he said. Ongoing studies will establish “the safety if not the efficacy” of the vaccine in males.

▸ “Why isn't Gardasil being used to treat cervical cancer?” The few published studies of Gardasil's efficacy in treating cervical cancer have had unimpressive results, so its role remains preventive.

▸ “How long will the viral protection last?” “We don't know,” Dr. Tyring said. The duration of protection was at least 5 years in trial participants. “We hope it's a lifetime.”

▸ “I've already had genital warts. What would be the point of my getting the vaccine now?” If a physician can show that a patient has been exposed only to HPV types 6 and 11, she could still receive protection against HPV types 16 and 18, which cause cervical cancer. The American Cancer Society predicts more than 11,000 women will be diagnosed with cervical cancer in the United States this year, and nearly 3,700 will die of the disease.

Zostavax

▸ “I've heard the Zostavax vaccine isn't very effective. Why should I get it?” In a pivotal trial, the Zostavax vaccine prevented herpes zoster in 51% of adults aged 60 and older, an impressive result considering it was being used to do something quite extraordinary: prevent reemergence of a virus that had been lying dormant in the dorsal root ganglia for decades, Dr. Tyring said. Among those who did get shingles after receiving the vaccine, the rate of postherpetic neuralgia was reduced by two-thirds.

▸ “I'm 55, but I've seen what shingles was like in my dad, and I don't want to get it. Should I get the vaccine?” Dr. Tyring and associates have given the vaccine to people in their 50s and found that their immunogenicity is superior to that of older adults. Pending trials may lead to approval in younger adults, but until that time, there may be no reimbursement for what appears to be a safe and effective vaccine.

▸ “I have had shingles, and I never want to go through it again. Will the disease prevent recurrence?” Even without the vaccine, an immunocompetent person has only a 5% chance of getting shingles a second time.

▸ “I don't think I even had chicken pox as a child, so would the vaccine be unnecessary?” Fully 99% of people over age 60 are seropositive, whether or not they recall having scratchy bumps, and can be presumed to be at risk for shingles, he said.

Dr. Tyring receives research support and has served on the speaker's bureau and as a consultant to Merck, maker of both vaccines.

MONTEREY, CALIF. — Cutaneous squamous cell carcinoma can take many forms, with vastly different biologic behaviors and risk profiles.

Yet, “with relatively few exceptions, they have a tendency to simply be lumped by the nondermatologist clinician, the general surgeon, and the general pathologist,” said Dr. Ronald Barr in calling for a comprehensive clinicopathologic classification of cutaneous SCC subtypes based on malignant potential.

Subtypes of SCC are not “histological curiosities,” but distinct entities that offer important clues as to management and prognosis of individual patients, maintained Dr. Barr during a presentation to the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

A system of histologic subtypes of SCC has been proposed by Dr. Barr, professor emeritus of dermatology and pathology at the University of California, Irvine, and his colleagues (J. Cutan. Pathol. 2006;33:191–206, 261–79). The suggested subtypes include low-risk SCCs, which carry a less than 3% risk of metastasis; intermediate-risk SCCs, which have a 3%–10% risk of metastasis; high-risk SCCs, with a greater than 10% risk of metastasis; and SCCs of indeterminate malignant potential, explained Dr. Barr.

These subtype categories would include:

▸ Low-risk, invasive SCCs. This category would include SCCs arising in sun-damaged skin of elderly patients (95% of cases), verrucous carcinoma and other human papillomavirus-related SCCs in immunocompetent patients, spindle cell SCC (unrelated to radiation exposure), and trichilemmal carcinoma.

▸ Intermediate-risk SCCs. Suggested category inclusions are acantholytic SCC, lymphoepitheliomalike carcinoma of the skin (LELCS), intraepidermal epithelioma (IEE), and Borst-Jadassohn tumor with invasion.

▸ High-risk SCCs. This subtype category would include invasive Bowen's disease; desmoplastic SCCs; malignant proliferating pilar tumor/cyst; de novo SCC; adenosquamous cell carcinoma; and SCC arising in association with radiation, burn scars, chronic conditions, or immunosuppression.

▸ SCCs of indeterminate malignant potential. Proposed subtypes for this category include signet-ring and clear cell SCC; pigmented, papillary, and follicular SCC; SCC arising in adnexal cysts; and possibly keratoacanthoma.

Dr. Barr acknowledged that many of the tumors he categorized as intermediate- or high-risk are rare, and there have been few studies to accurately determine their malignant potential. However, this classification system would help to structure research by subtype and help to clarify future research by separating out entities that carry a higher risk potential than a superficially invasive, well-differentiated SCC arising within actinic keratoses on sun-damaged skin.

In addition to histologic subtypes, he called for more pathologic reporting of prognostic factors in individual SCC cases including the grade of differentiation (Broders' grades I-IV), size of the tumor and depth of tumor invasion, and presence or absence of perineural or hematolymphatic invasion. “These are important,” he said.

Fewer than 35% of patients with metastatic SCC survive for 5 years, in stark contrast to the generally excellent prognosis of SCC. “When squamous cell carcinoma metastasizes, the literature just clumps [these cases],” but clearly, individual characteristics make a difference, he said.

With regard to depth of invasion, data from one study showed that tumors that were less than 2 mm thick never metastasized, those 2 mm to 6 mm metastasized at a rate of 4.5%, and those deeper than 6 mm metastasized at a rate of 15% (Am. J. Clin. Pathol. 1990;94:624–7).

Low- versus high-grade differentiation carries a highly variable rate of metastasis as well (33% vs. 9%), Dr. Barr added, noting that perineural invasion has been associated with rates of metastasis between 35% and 80%.

MONTEREY, CALIF. — Cutaneous squamous cell carcinoma can take many forms, with vastly different biologic behaviors and risk profiles.

Yet, “with relatively few exceptions, they have a tendency to simply be lumped by the nondermatologist clinician, the general surgeon, and the general pathologist,” said Dr. Ronald Barr in calling for a comprehensive clinicopathologic classification of cutaneous SCC subtypes based on malignant potential.

Subtypes of SCC are not “histological curiosities,” but distinct entities that offer important clues as to management and prognosis of individual patients, maintained Dr. Barr during a presentation to the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

A system of histologic subtypes of SCC has been proposed by Dr. Barr, professor emeritus of dermatology and pathology at the University of California, Irvine, and his colleagues (J. Cutan. Pathol. 2006;33:191–206, 261–79). The suggested subtypes include low-risk SCCs, which carry a less than 3% risk of metastasis; intermediate-risk SCCs, which have a 3%–10% risk of metastasis; high-risk SCCs, with a greater than 10% risk of metastasis; and SCCs of indeterminate malignant potential, explained Dr. Barr.

These subtype categories would include:

▸ Low-risk, invasive SCCs. This category would include SCCs arising in sun-damaged skin of elderly patients (95% of cases), verrucous carcinoma and other human papillomavirus-related SCCs in immunocompetent patients, spindle cell SCC (unrelated to radiation exposure), and trichilemmal carcinoma.

▸ Intermediate-risk SCCs. Suggested category inclusions are acantholytic SCC, lymphoepitheliomalike carcinoma of the skin (LELCS), intraepidermal epithelioma (IEE), and Borst-Jadassohn tumor with invasion.

▸ High-risk SCCs. This subtype category would include invasive Bowen's disease; desmoplastic SCCs; malignant proliferating pilar tumor/cyst; de novo SCC; adenosquamous cell carcinoma; and SCC arising in association with radiation, burn scars, chronic conditions, or immunosuppression.

▸ SCCs of indeterminate malignant potential. Proposed subtypes for this category include signet-ring and clear cell SCC; pigmented, papillary, and follicular SCC; SCC arising in adnexal cysts; and possibly keratoacanthoma.

Dr. Barr acknowledged that many of the tumors he categorized as intermediate- or high-risk are rare, and there have been few studies to accurately determine their malignant potential. However, this classification system would help to structure research by subtype and help to clarify future research by separating out entities that carry a higher risk potential than a superficially invasive, well-differentiated SCC arising within actinic keratoses on sun-damaged skin.

In addition to histologic subtypes, he called for more pathologic reporting of prognostic factors in individual SCC cases including the grade of differentiation (Broders' grades I-IV), size of the tumor and depth of tumor invasion, and presence or absence of perineural or hematolymphatic invasion. “These are important,” he said.

Fewer than 35% of patients with metastatic SCC survive for 5 years, in stark contrast to the generally excellent prognosis of SCC. “When squamous cell carcinoma metastasizes, the literature just clumps [these cases],” but clearly, individual characteristics make a difference, he said.

With regard to depth of invasion, data from one study showed that tumors that were less than 2 mm thick never metastasized, those 2 mm to 6 mm metastasized at a rate of 4.5%, and those deeper than 6 mm metastasized at a rate of 15% (Am. J. Clin. Pathol. 1990;94:624–7).

Low- versus high-grade differentiation carries a highly variable rate of metastasis as well (33% vs. 9%), Dr. Barr added, noting that perineural invasion has been associated with rates of metastasis between 35% and 80%.

MONTEREY, CALIF. — Cutaneous squamous cell carcinoma can take many forms, with vastly different biologic behaviors and risk profiles.

Yet, “with relatively few exceptions, they have a tendency to simply be lumped by the nondermatologist clinician, the general surgeon, and the general pathologist,” said Dr. Ronald Barr in calling for a comprehensive clinicopathologic classification of cutaneous SCC subtypes based on malignant potential.

Subtypes of SCC are not “histological curiosities,” but distinct entities that offer important clues as to management and prognosis of individual patients, maintained Dr. Barr during a presentation to the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

A system of histologic subtypes of SCC has been proposed by Dr. Barr, professor emeritus of dermatology and pathology at the University of California, Irvine, and his colleagues (J. Cutan. Pathol. 2006;33:191–206, 261–79). The suggested subtypes include low-risk SCCs, which carry a less than 3% risk of metastasis; intermediate-risk SCCs, which have a 3%–10% risk of metastasis; high-risk SCCs, with a greater than 10% risk of metastasis; and SCCs of indeterminate malignant potential, explained Dr. Barr.

These subtype categories would include:

▸ Low-risk, invasive SCCs. This category would include SCCs arising in sun-damaged skin of elderly patients (95% of cases), verrucous carcinoma and other human papillomavirus-related SCCs in immunocompetent patients, spindle cell SCC (unrelated to radiation exposure), and trichilemmal carcinoma.

▸ Intermediate-risk SCCs. Suggested category inclusions are acantholytic SCC, lymphoepitheliomalike carcinoma of the skin (LELCS), intraepidermal epithelioma (IEE), and Borst-Jadassohn tumor with invasion.

▸ High-risk SCCs. This subtype category would include invasive Bowen's disease; desmoplastic SCCs; malignant proliferating pilar tumor/cyst; de novo SCC; adenosquamous cell carcinoma; and SCC arising in association with radiation, burn scars, chronic conditions, or immunosuppression.

▸ SCCs of indeterminate malignant potential. Proposed subtypes for this category include signet-ring and clear cell SCC; pigmented, papillary, and follicular SCC; SCC arising in adnexal cysts; and possibly keratoacanthoma.

Dr. Barr acknowledged that many of the tumors he categorized as intermediate- or high-risk are rare, and there have been few studies to accurately determine their malignant potential. However, this classification system would help to structure research by subtype and help to clarify future research by separating out entities that carry a higher risk potential than a superficially invasive, well-differentiated SCC arising within actinic keratoses on sun-damaged skin.

In addition to histologic subtypes, he called for more pathologic reporting of prognostic factors in individual SCC cases including the grade of differentiation (Broders' grades I-IV), size of the tumor and depth of tumor invasion, and presence or absence of perineural or hematolymphatic invasion. “These are important,” he said.

Fewer than 35% of patients with metastatic SCC survive for 5 years, in stark contrast to the generally excellent prognosis of SCC. “When squamous cell carcinoma metastasizes, the literature just clumps [these cases],” but clearly, individual characteristics make a difference, he said.

With regard to depth of invasion, data from one study showed that tumors that were less than 2 mm thick never metastasized, those 2 mm to 6 mm metastasized at a rate of 4.5%, and those deeper than 6 mm metastasized at a rate of 15% (Am. J. Clin. Pathol. 1990;94:624–7).

Low- versus high-grade differentiation carries a highly variable rate of metastasis as well (33% vs. 9%), Dr. Barr added, noting that perineural invasion has been associated with rates of metastasis between 35% and 80%.

VANCOUVER, B.C. — Thromboprophylaxis using warfarin produced a “huge, highly significant, 50% reduction” in death and major disability from stroke in elderly patients with a history of atrial fibrillation, roundly outperforming aspirin prophylaxis in a randomized trial, Dr. Richard Hobbs reported at the annual meeting of the North American Primary Care Research Group.

Feared bleeding complications were no higher than with aspirin therapy in the Birmingham Atrial Fibrillation Treatment of the Aged (BAFTA) trial, conducted in 262 general practices in England and Wales.

“We think warfarin should be routinely prescribed to any patient presenting with atrial fibrillation, regardless of age,” declared Dr. Hobbs, lead investigator for the trial and professor and head of primary care and general practice at the University of Birmingham (England) School of Medicine.

The prevalence of atrial fibrillation increases with age, and 50% of all cases are in patients older than 75 years. It raises the risk of stroke fivefold and accounts for a third of all strokes in the elderly, explained Dr. Hobbs during an oral paper presentation at the meeting.

However, existing trial data supporting warfarin as a prophylaxis focused heavily on younger patients with atrial fibrillation who are believed to have a very different risk-benefit profile than patients older than 75. Indeed, among the few elderly patients enrolled in large-scale trials, the risk of bleeding events was high enough that the number needed to treat (46) was close to the number needed to harm (55).

“As a consequence of that, many physicians around the world were in equipoise about whether you should treat patients over 75 with warfarin or give them aspirin. Hence, this trial,” Dr. Hobbs said.

The BAFTA trial identified more than 58,000 adults over the age of 75 who had been diagnosed with atrial fibrillation or screened for the condition based on an irregular pulse. Of a total of 973 men and women, 488 were randomized to receive warfarin, and 485 were assigned to receive aspirin. They were followed for a mean of 2.7 years.

The trial differed from original large-scale warfarin/aspirin studies in several ways. Patients, obviously, were much older (mean age 81, compared with about 60). Reflecting their advanced age, they were also less healthy, with many comorbidities and a relatively high mean CHADS2 score (28% with a score from 3–6 on the stroke risk scale for AF patients of 0–6 points), which reflected an elevated baseline risk of stroke.

Few exclusions prohibited entry into the study “because we wanted it to be relevant to most providers' practices,” he said.

Patients were not enrolled if they had active peptic ulcer disease, a history of rheumatic heart disease or intracranial hemorrhage, or a major nontraumatic hemorrhage in the past 5 years.

The primary outcome was specified as a fatal or disabling stroke, the latter defined as a stroke resulting in persistent symptoms after 48 hours, intracranial hemorrhage, or significant arterial embolism. Secondary outcomes included major extracranial hemorrhages or major nonstroke vascular events.

Aspirin was given at a dosage of 75 mg/day, and warfarin was prescribed at a target international normalized ratio (INR) of 2.5 within a range of 2–3. Dosages of both drugs were lower than those used in major trials and commonly prescribed by U.S. physicians, Dr. Hobbs said.

The results were clear, he said. “We showed a huge, highly significant, 50% reduction in the primary end point, in terms of death or major disabling stroke,” he said.

The patient group receiving warfarin had 1.8 strokes per year, compared with 3.8 per year in the group receiving aspirin. One fatal or disabling stroke per year was prevented for every 50 patients receiving warfarin. “A very important question is, was that at the expense of bleeding?” he asked.

The answer was no, with every major bleeding variable equal between the two groups. A multivariate analysis showed that the results persisted when investigators controlled for age, gender, previous warfarin use, enrollment type (screening or previous atrial fibrillation diagnosis), CHADS2 score, and comorbidities.

A crucial element in the study was the low INR used to guide warfarin therapy, because bleeding risk rises sharply at an INR of 3.5 or higher, he added.

The absolute risk of a major adverse event was 1.9% for patients taking warfarin and 2% for those taking aspirin. Because there was no placebo group, it is unknown whether those events were related to the drugs or were reflective of the background event rate in that population, Dr. Hobbs said in an interview.

The BAFTA study was funded by the Medical Research Council.

ELSEVIER GLOBAL MEDICAL NEWS

VANCOUVER, B.C. — Thromboprophylaxis using warfarin produced a “huge, highly significant, 50% reduction” in death and major disability from stroke in elderly patients with a history of atrial fibrillation, roundly outperforming aspirin prophylaxis in a randomized trial, Dr. Richard Hobbs reported at the annual meeting of the North American Primary Care Research Group.

Feared bleeding complications were no higher than with aspirin therapy in the Birmingham Atrial Fibrillation Treatment of the Aged (BAFTA) trial, conducted in 262 general practices in England and Wales.

“We think warfarin should be routinely prescribed to any patient presenting with atrial fibrillation, regardless of age,” declared Dr. Hobbs, lead investigator for the trial and professor and head of primary care and general practice at the University of Birmingham (England) School of Medicine.

The prevalence of atrial fibrillation increases with age, and 50% of all cases are in patients older than 75 years. It raises the risk of stroke fivefold and accounts for a third of all strokes in the elderly, explained Dr. Hobbs during an oral paper presentation at the meeting.

However, existing trial data supporting warfarin as a prophylaxis focused heavily on younger patients with atrial fibrillation who are believed to have a very different risk-benefit profile than patients older than 75. Indeed, among the few elderly patients enrolled in large-scale trials, the risk of bleeding events was high enough that the number needed to treat (46) was close to the number needed to harm (55).

“As a consequence of that, many physicians around the world were in equipoise about whether you should treat patients over 75 with warfarin or give them aspirin. Hence, this trial,” Dr. Hobbs said.

The BAFTA trial identified more than 58,000 adults over the age of 75 who had been diagnosed with atrial fibrillation or screened for the condition based on an irregular pulse. Of a total of 973 men and women, 488 were randomized to receive warfarin, and 485 were assigned to receive aspirin. They were followed for a mean of 2.7 years.

The trial differed from original large-scale warfarin/aspirin studies in several ways. Patients, obviously, were much older (mean age 81, compared with about 60). Reflecting their advanced age, they were also less healthy, with many comorbidities and a relatively high mean CHADS2 score (28% with a score from 3–6 on the stroke risk scale for AF patients of 0–6 points), which reflected an elevated baseline risk of stroke.

Few exclusions prohibited entry into the study “because we wanted it to be relevant to most providers' practices,” he said.

Patients were not enrolled if they had active peptic ulcer disease, a history of rheumatic heart disease or intracranial hemorrhage, or a major nontraumatic hemorrhage in the past 5 years.

The primary outcome was specified as a fatal or disabling stroke, the latter defined as a stroke resulting in persistent symptoms after 48 hours, intracranial hemorrhage, or significant arterial embolism. Secondary outcomes included major extracranial hemorrhages or major nonstroke vascular events.

Aspirin was given at a dosage of 75 mg/day, and warfarin was prescribed at a target international normalized ratio (INR) of 2.5 within a range of 2–3. Dosages of both drugs were lower than those used in major trials and commonly prescribed by U.S. physicians, Dr. Hobbs said.

The results were clear, he said. “We showed a huge, highly significant, 50% reduction in the primary end point, in terms of death or major disabling stroke,” he said.

The patient group receiving warfarin had 1.8 strokes per year, compared with 3.8 per year in the group receiving aspirin. One fatal or disabling stroke per year was prevented for every 50 patients receiving warfarin. “A very important question is, was that at the expense of bleeding?” he asked.

The answer was no, with every major bleeding variable equal between the two groups. A multivariate analysis showed that the results persisted when investigators controlled for age, gender, previous warfarin use, enrollment type (screening or previous atrial fibrillation diagnosis), CHADS2 score, and comorbidities.

A crucial element in the study was the low INR used to guide warfarin therapy, because bleeding risk rises sharply at an INR of 3.5 or higher, he added.

The absolute risk of a major adverse event was 1.9% for patients taking warfarin and 2% for those taking aspirin. Because there was no placebo group, it is unknown whether those events were related to the drugs or were reflective of the background event rate in that population, Dr. Hobbs said in an interview.

The BAFTA study was funded by the Medical Research Council.

ELSEVIER GLOBAL MEDICAL NEWS

VANCOUVER, B.C. — Thromboprophylaxis using warfarin produced a “huge, highly significant, 50% reduction” in death and major disability from stroke in elderly patients with a history of atrial fibrillation, roundly outperforming aspirin prophylaxis in a randomized trial, Dr. Richard Hobbs reported at the annual meeting of the North American Primary Care Research Group.

Feared bleeding complications were no higher than with aspirin therapy in the Birmingham Atrial Fibrillation Treatment of the Aged (BAFTA) trial, conducted in 262 general practices in England and Wales.

“We think warfarin should be routinely prescribed to any patient presenting with atrial fibrillation, regardless of age,” declared Dr. Hobbs, lead investigator for the trial and professor and head of primary care and general practice at the University of Birmingham (England) School of Medicine.

The prevalence of atrial fibrillation increases with age, and 50% of all cases are in patients older than 75 years. It raises the risk of stroke fivefold and accounts for a third of all strokes in the elderly, explained Dr. Hobbs during an oral paper presentation at the meeting.

However, existing trial data supporting warfarin as a prophylaxis focused heavily on younger patients with atrial fibrillation who are believed to have a very different risk-benefit profile than patients older than 75. Indeed, among the few elderly patients enrolled in large-scale trials, the risk of bleeding events was high enough that the number needed to treat (46) was close to the number needed to harm (55).

“As a consequence of that, many physicians around the world were in equipoise about whether you should treat patients over 75 with warfarin or give them aspirin. Hence, this trial,” Dr. Hobbs said.

The BAFTA trial identified more than 58,000 adults over the age of 75 who had been diagnosed with atrial fibrillation or screened for the condition based on an irregular pulse. Of a total of 973 men and women, 488 were randomized to receive warfarin, and 485 were assigned to receive aspirin. They were followed for a mean of 2.7 years.

The trial differed from original large-scale warfarin/aspirin studies in several ways. Patients, obviously, were much older (mean age 81, compared with about 60). Reflecting their advanced age, they were also less healthy, with many comorbidities and a relatively high mean CHADS2 score (28% with a score from 3–6 on the stroke risk scale for AF patients of 0–6 points), which reflected an elevated baseline risk of stroke.

Few exclusions prohibited entry into the study “because we wanted it to be relevant to most providers' practices,” he said.

Patients were not enrolled if they had active peptic ulcer disease, a history of rheumatic heart disease or intracranial hemorrhage, or a major nontraumatic hemorrhage in the past 5 years.

The primary outcome was specified as a fatal or disabling stroke, the latter defined as a stroke resulting in persistent symptoms after 48 hours, intracranial hemorrhage, or significant arterial embolism. Secondary outcomes included major extracranial hemorrhages or major nonstroke vascular events.

Aspirin was given at a dosage of 75 mg/day, and warfarin was prescribed at a target international normalized ratio (INR) of 2.5 within a range of 2–3. Dosages of both drugs were lower than those used in major trials and commonly prescribed by U.S. physicians, Dr. Hobbs said.

The results were clear, he said. “We showed a huge, highly significant, 50% reduction in the primary end point, in terms of death or major disabling stroke,” he said.

The patient group receiving warfarin had 1.8 strokes per year, compared with 3.8 per year in the group receiving aspirin. One fatal or disabling stroke per year was prevented for every 50 patients receiving warfarin. “A very important question is, was that at the expense of bleeding?” he asked.

The answer was no, with every major bleeding variable equal between the two groups. A multivariate analysis showed that the results persisted when investigators controlled for age, gender, previous warfarin use, enrollment type (screening or previous atrial fibrillation diagnosis), CHADS2 score, and comorbidities.

A crucial element in the study was the low INR used to guide warfarin therapy, because bleeding risk rises sharply at an INR of 3.5 or higher, he added.

The absolute risk of a major adverse event was 1.9% for patients taking warfarin and 2% for those taking aspirin. Because there was no placebo group, it is unknown whether those events were related to the drugs or were reflective of the background event rate in that population, Dr. Hobbs said in an interview.

The BAFTA study was funded by the Medical Research Council.

ELSEVIER GLOBAL MEDICAL NEWS

MONTEREY, CALIF. — Cutaneous squamous cell carcinoma can take many forms, with vastly different biological behaviors and risk profiles.

Yet, "with relatively few exceptions, they have a tendency to simply be lumped by the nondermatologist clinician, the general surgeon, and the general pathologist," said Dr. Ronald Barr in calling for a comprehensive clinicopathologic classification of cutaneous SCC subtypes based on malignant potential.

Subtypes of SCC are not "histological curiosities," but distinct entities that offer important clues as to management and prognosis of individual patients, maintained Dr. Barr during a presentation to the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

A system of histologic subtypes of SCC has been proposed by Dr. Barr, professor emeritus of dermatology and pathology at the University of California, Irvine, and his colleagues (J. Cutan. Pathol. 2006;33:191-206, 261-79). The suggested subtypes include low-risk SCCs, which carry a less than 3% risk of metastasis; intermediate-risk SCCs, which have a 3%-10% risk of metastasis; high-risk SCCs, with a greater than 10% risk of metastasis; and SCCs of indeterminate malignant potential, explained Dr. Barr.

These subtype categories would include:

▸ Low-risk, invasive SCCs. These would include SCCs arising in sun-damaged skin of elderly patients (95% of cases), verrucous carcinoma and other human papillomavirus-related SCCs in immunocompetent patients, spindle cell SCC (unrelated to radiation exposure), and trichilemmal carcinoma.

▸ Intermediate-risk SCCs. Suggested category inclusions are acantholytic SCC, lymphoepitheliomalike carcinoma of the skin (LELCS), intraepidermal epithelioma (IEE), and Borst-Jadassohn tumor with invasion.

▸ High-risk SCCs. This subtype category would include invasive Bowen's disease; desmoplastic SCCs; malignant proliferating pilar tumor/cyst; de novo SCC; adenosquamous cell carcinoma; and SCC arising in association with radiation, burn scars, chronic conditions, or immunosuppression.

▸ SCCs of indeterminate malignant potential. Proposed subtypes for this category include signet-ring and clear cell SCC; pigmented, papillary, and follicular SCC; SCC arising in adnexal cysts; and possibly keratoacanthoma.

Dr. Barr acknowledged that many of the tumors he categorized as intermediate- or high-risk are rare, and there have been few studies to accurately determine their malignant poten- tial. However, this classification system would help to structure research by subtype and help to clarify future research by separating out entities that carry a higher risk potential than a superficially invasive, well-differentiated SCC arising within actinic keratoses on sun-damaged skin.

In addition to histologic subtypes, he called for more pathologic reporting of prognostic factors in individual SCC cases including the grade of differentiation (Broders' grades I-IV), tumor size and depth of invasion, and presence or absence of perineural or hematolymphatic invasion.

Fewer than 35% of patients with metastatic SCC survive for 5 years, in stark contrast to the generally excellent prognosis of SCC. "When squamous cell carcinoma metastasizes, the literature just clumps [these cases]," but clearly, individual characteristics make a difference, he said.

With regard to depth of invasion, one study found that tumors less than 2 mm thick never metastasized, those 2 mm to 6 mm metastasized at a rate of 4.5%, and those deeper than 6 mm metastasized at a rate of 15% (Am. J. Clin. Pathol. 1990;94:624-7). Low- versus high-grade differentiation carries a highly variable rate of metastasis as well (33% vs. 9%), Dr. Barr said. Perineural invasion is associated with rates of metastasis between 35% and 80%.

MONTEREY, CALIF. — Cutaneous squamous cell carcinoma can take many forms, with vastly different biological behaviors and risk profiles.

Yet, "with relatively few exceptions, they have a tendency to simply be lumped by the nondermatologist clinician, the general surgeon, and the general pathologist," said Dr. Ronald Barr in calling for a comprehensive clinicopathologic classification of cutaneous SCC subtypes based on malignant potential.

Subtypes of SCC are not "histological curiosities," but distinct entities that offer important clues as to management and prognosis of individual patients, maintained Dr. Barr during a presentation to the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

A system of histologic subtypes of SCC has been proposed by Dr. Barr, professor emeritus of dermatology and pathology at the University of California, Irvine, and his colleagues (J. Cutan. Pathol. 2006;33:191-206, 261-79). The suggested subtypes include low-risk SCCs, which carry a less than 3% risk of metastasis; intermediate-risk SCCs, which have a 3%-10% risk of metastasis; high-risk SCCs, with a greater than 10% risk of metastasis; and SCCs of indeterminate malignant potential, explained Dr. Barr.

These subtype categories would include:

▸ Low-risk, invasive SCCs. These would include SCCs arising in sun-damaged skin of elderly patients (95% of cases), verrucous carcinoma and other human papillomavirus-related SCCs in immunocompetent patients, spindle cell SCC (unrelated to radiation exposure), and trichilemmal carcinoma.

▸ Intermediate-risk SCCs. Suggested category inclusions are acantholytic SCC, lymphoepitheliomalike carcinoma of the skin (LELCS), intraepidermal epithelioma (IEE), and Borst-Jadassohn tumor with invasion.

▸ High-risk SCCs. This subtype category would include invasive Bowen's disease; desmoplastic SCCs; malignant proliferating pilar tumor/cyst; de novo SCC; adenosquamous cell carcinoma; and SCC arising in association with radiation, burn scars, chronic conditions, or immunosuppression.

▸ SCCs of indeterminate malignant potential. Proposed subtypes for this category include signet-ring and clear cell SCC; pigmented, papillary, and follicular SCC; SCC arising in adnexal cysts; and possibly keratoacanthoma.

Dr. Barr acknowledged that many of the tumors he categorized as intermediate- or high-risk are rare, and there have been few studies to accurately determine their malignant poten- tial. However, this classification system would help to structure research by subtype and help to clarify future research by separating out entities that carry a higher risk potential than a superficially invasive, well-differentiated SCC arising within actinic keratoses on sun-damaged skin.

In addition to histologic subtypes, he called for more pathologic reporting of prognostic factors in individual SCC cases including the grade of differentiation (Broders' grades I-IV), tumor size and depth of invasion, and presence or absence of perineural or hematolymphatic invasion.

Fewer than 35% of patients with metastatic SCC survive for 5 years, in stark contrast to the generally excellent prognosis of SCC. "When squamous cell carcinoma metastasizes, the literature just clumps [these cases]," but clearly, individual characteristics make a difference, he said.

With regard to depth of invasion, one study found that tumors less than 2 mm thick never metastasized, those 2 mm to 6 mm metastasized at a rate of 4.5%, and those deeper than 6 mm metastasized at a rate of 15% (Am. J. Clin. Pathol. 1990;94:624-7). Low- versus high-grade differentiation carries a highly variable rate of metastasis as well (33% vs. 9%), Dr. Barr said. Perineural invasion is associated with rates of metastasis between 35% and 80%.

MONTEREY, CALIF. — Cutaneous squamous cell carcinoma can take many forms, with vastly different biological behaviors and risk profiles.

Yet, "with relatively few exceptions, they have a tendency to simply be lumped by the nondermatologist clinician, the general surgeon, and the general pathologist," said Dr. Ronald Barr in calling for a comprehensive clinicopathologic classification of cutaneous SCC subtypes based on malignant potential.

Subtypes of SCC are not "histological curiosities," but distinct entities that offer important clues as to management and prognosis of individual patients, maintained Dr. Barr during a presentation to the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

A system of histologic subtypes of SCC has been proposed by Dr. Barr, professor emeritus of dermatology and pathology at the University of California, Irvine, and his colleagues (J. Cutan. Pathol. 2006;33:191-206, 261-79). The suggested subtypes include low-risk SCCs, which carry a less than 3% risk of metastasis; intermediate-risk SCCs, which have a 3%-10% risk of metastasis; high-risk SCCs, with a greater than 10% risk of metastasis; and SCCs of indeterminate malignant potential, explained Dr. Barr.

These subtype categories would include:

▸ Low-risk, invasive SCCs. These would include SCCs arising in sun-damaged skin of elderly patients (95% of cases), verrucous carcinoma and other human papillomavirus-related SCCs in immunocompetent patients, spindle cell SCC (unrelated to radiation exposure), and trichilemmal carcinoma.

▸ Intermediate-risk SCCs. Suggested category inclusions are acantholytic SCC, lymphoepitheliomalike carcinoma of the skin (LELCS), intraepidermal epithelioma (IEE), and Borst-Jadassohn tumor with invasion.

▸ High-risk SCCs. This subtype category would include invasive Bowen's disease; desmoplastic SCCs; malignant proliferating pilar tumor/cyst; de novo SCC; adenosquamous cell carcinoma; and SCC arising in association with radiation, burn scars, chronic conditions, or immunosuppression.

▸ SCCs of indeterminate malignant potential. Proposed subtypes for this category include signet-ring and clear cell SCC; pigmented, papillary, and follicular SCC; SCC arising in adnexal cysts; and possibly keratoacanthoma.

Dr. Barr acknowledged that many of the tumors he categorized as intermediate- or high-risk are rare, and there have been few studies to accurately determine their malignant poten- tial. However, this classification system would help to structure research by subtype and help to clarify future research by separating out entities that carry a higher risk potential than a superficially invasive, well-differentiated SCC arising within actinic keratoses on sun-damaged skin.

In addition to histologic subtypes, he called for more pathologic reporting of prognostic factors in individual SCC cases including the grade of differentiation (Broders' grades I-IV), tumor size and depth of invasion, and presence or absence of perineural or hematolymphatic invasion.

Fewer than 35% of patients with metastatic SCC survive for 5 years, in stark contrast to the generally excellent prognosis of SCC. "When squamous cell carcinoma metastasizes, the literature just clumps [these cases]," but clearly, individual characteristics make a difference, he said.

With regard to depth of invasion, one study found that tumors less than 2 mm thick never metastasized, those 2 mm to 6 mm metastasized at a rate of 4.5%, and those deeper than 6 mm metastasized at a rate of 15% (Am. J. Clin. Pathol. 1990;94:624-7). Low- versus high-grade differentiation carries a highly variable rate of metastasis as well (33% vs. 9%), Dr. Barr said. Perineural invasion is associated with rates of metastasis between 35% and 80%.

Arthritis creates work limitations for about a third of the working-age adults with the disease, impacting nearly 7% of the total U.S. workforce, according to a state-by-state study by the Centers for Disease Control. The first-of-its-kind survey, drawing on data from the Behavioral Risk Factor Surveillance System, may foreshadow a profound challenge to the economy as the population ages. Arthritis today affects 46 million Americans, with an estimated economic toll of $128 billion a year, according to the Arthritis Foundation.

The random digit-dialed telephone survey of more than 200,000 households queried working-age adults in every state, Washington, Guam, Puerto Rico, and the U.S. Virgin Islands about whether they had been diagnosed with arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia.

Respondents with arthritis were asked whether arthritis or joint symptoms currently affected whether they were employed and the type and amount of work they could do.

The responses are weighted to represent the adult population in each state.

A high degree of variability was found in the state-specific prevalence of arthritis-related work limitations among all adults between 18 and 64 years of age, from 3.4% of adults in Hawaii to 15% in Kentucky, reported Kristina A. Theis and associates at the National Center for Chronic Disease Prevention and the National Center on Birth Defects and Developmental Disability at the CDC (MMWR 2007;56:1045–9).

Among adults reporting physician-diagnosed arthritis and related conditions, work limitations were reported by a median 33%, ranging from 25.1% in Nevada to 51.3% in Kentucky.

“That's huge,” said Ms. Theis in a telephone interview. “In Kentucky, that represents every other person with arthritis a doctor might be seeing.”

Preventing or minimizing work-related limitations through timely therapy, rehabilitation, and workplace accommodation impacts not only the economy as a whole, but the individual patients' independence, self-esteem, and financial well-being, she stressed.

“It is not always on the physicians' radar screen to inquire, 'How's your function? How's your pain? And by the way, how is that function and pain impacting you at work?'” said Ms. Theis.

Rheumatologists in the states bookending statistics about work limitations among adults with arthritis said that patient characteristics and the availability of services may play into differences seen across populations.

In Elizabethtown, Ky., rheumatologist Daksha Mehta said that some patients travel more than 100 miles to see her.

Although there is a nationwide shortage of board-certified rheumatologists, “I'm sure it's worse in Kentucky,” she said.

Access to medical specialists, as well as experts in occupational therapy and workplace ergonomics, may be limited in small, isolated rural communities. In addition, many patients still do not recognize the need for early diagnosis and treatment, despite educational efforts by rheumatology groups statewide, she said.

“Personally, I have patients with arthritis who are still working at their factory jobs, still farming, but that's with appropriate therapy … optimizing medications, having physical and occupational therapy, doing home strengthening exercises,” said Dr. Mehta of the Center for Arthritis and Osteoporosis.

Dr. Rex Adams, a rheumatologist at Arthritis Associates of Nevada in Reno said he doubted that the types of jobs performed in his state differ much from those practiced in Kentucky, which has doubled the prevalence of work-related limitations reported by working-aged adults with arthritis.

“Mining is big in Nevada, and there are a lot of service industry workers here. There is a lot of physical work,” he said.

Dr. Adams speculated that the variation might be explained by systemic factors, such as differences in state disability program formats, or perhaps populations. Nevada draws a “pretty young, healthy population” with a large percentage of workers who have recently moved from other locations, whereas Kentucky's population may be older and more stationary.

In both states, rheumatologists said they advocate a team approach to arthritis management, with an emphasis on therapy and lifestyle modifications as well as medication. Occupational and physical therapy are offered on-site in a growing number of group rheumatology practices.

Such trends could make a difference in patients' being able to maintain their ability to perform their jobs, said Ms. Theis from the CDC's Division of Adult and Community Health.

Preliminary findings from a separate study by the CDC build on a growing body of published research suggesting that physician recommendations concerning arthritis management are highly influential in terms of patient behavior, she explained.

When a physician recommends weight loss, an arthritis-focused exercise program, or workplace accommodations in conjunction with the Americans with Disabilities Act, for example, patients are much more likely to attempt to follow that advice.

“We're hoping physicians will say, 'I have a really important voice that carries a lot of weight on a lot of levels,'” said Ms. Theis. “We see them as one of our most important audiences.”

Sometimes, the physician's role on minimizing work limitations is direct, perhaps by prescribing traditional therapy regimens and even biologic therapy to patients early enough in the course of their disease to preserve function.

Other times, a physician may refer a patient to physical or occupational therapy, or to a hand surgeon for a customized thumb or wrist splint that permits normal workplace activities, said Diana Baldwin, who is an occupational therapist at the Missouri Arthritis Rehabilitation and Training Center.

“We've found that it isn't enough to tell people, 'Cut back on your hours,' or 'Be more flexible,' or 'Don't do things that hurt,' '' she said. “For the average working person with arthritis, that is not useful [advice].”

What does seem to make a difference is when physicians explain to arthritis patients early on that their joints are more vulnerable to common workplace conditions such as tendonitis or lower back pain, and provide a reasonable rationale for them to implement protective strategies, she said.

The Missouri Training Center in Columbia is currently completing a federally funded study that has randomized 84 adults with arthritis to receive either written materials about arthritis in the workplace or interventions conducted by Ms. Baldwin in the work setting, be it a manufacturing workshop, business office, or classroom.

She has spent 1.5–2 hours interviewing these workers with arthritis and then has studied them as they work, taking pictures that she will later diagram to show movements that stress the joints including twisting, grabbing, reaching, and bending.

She has investigated ergonomic surgical tools to aid an anesthesiologist, adapted the car of a traveling salesman, and added a step stool to ease a manufacturing specialist's reach to a drill press.

Making such changes early on appears to keep people in the workplace longer, working more effectively and in less pain, she said.

But economic realities have proved to be a barrier to early workplace interventions, particularly in the lower paying, rigorous jobs that put the greatest stress on joints.

No janitors have agreed to allow Ms. Baldwin to come to their workplaces to identify practices that might be exacerbating their arthritis, for example.

“They're not going to expose the fact that they have arthritis on the job,” she said.

Before the height of this cart was modified, the user had to bend forward to push it around the workplace.

With a raised handle on the cart, the user can stand upright and move it more easily. Photos courtesy Diana Baldwin

Arthritis creates work limitations for about a third of the working-age adults with the disease, impacting nearly 7% of the total U.S. workforce, according to a state-by-state study by the Centers for Disease Control. The first-of-its-kind survey, drawing on data from the Behavioral Risk Factor Surveillance System, may foreshadow a profound challenge to the economy as the population ages. Arthritis today affects 46 million Americans, with an estimated economic toll of $128 billion a year, according to the Arthritis Foundation.

The random digit-dialed telephone survey of more than 200,000 households queried working-age adults in every state, Washington, Guam, Puerto Rico, and the U.S. Virgin Islands about whether they had been diagnosed with arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia.

Respondents with arthritis were asked whether arthritis or joint symptoms currently affected whether they were employed and the type and amount of work they could do.

The responses are weighted to represent the adult population in each state.

A high degree of variability was found in the state-specific prevalence of arthritis-related work limitations among all adults between 18 and 64 years of age, from 3.4% of adults in Hawaii to 15% in Kentucky, reported Kristina A. Theis and associates at the National Center for Chronic Disease Prevention and the National Center on Birth Defects and Developmental Disability at the CDC (MMWR 2007;56:1045–9).

Among adults reporting physician-diagnosed arthritis and related conditions, work limitations were reported by a median 33%, ranging from 25.1% in Nevada to 51.3% in Kentucky.

“That's huge,” said Ms. Theis in a telephone interview. “In Kentucky, that represents every other person with arthritis a doctor might be seeing.”

Preventing or minimizing work-related limitations through timely therapy, rehabilitation, and workplace accommodation impacts not only the economy as a whole, but the individual patients' independence, self-esteem, and financial well-being, she stressed.

“It is not always on the physicians' radar screen to inquire, 'How's your function? How's your pain? And by the way, how is that function and pain impacting you at work?'” said Ms. Theis.

Rheumatologists in the states bookending statistics about work limitations among adults with arthritis said that patient characteristics and the availability of services may play into differences seen across populations.

In Elizabethtown, Ky., rheumatologist Daksha Mehta said that some patients travel more than 100 miles to see her.

Although there is a nationwide shortage of board-certified rheumatologists, “I'm sure it's worse in Kentucky,” she said.

Access to medical specialists, as well as experts in occupational therapy and workplace ergonomics, may be limited in small, isolated rural communities. In addition, many patients still do not recognize the need for early diagnosis and treatment, despite educational efforts by rheumatology groups statewide, she said.

“Personally, I have patients with arthritis who are still working at their factory jobs, still farming, but that's with appropriate therapy … optimizing medications, having physical and occupational therapy, doing home strengthening exercises,” said Dr. Mehta of the Center for Arthritis and Osteoporosis.

Dr. Rex Adams, a rheumatologist at Arthritis Associates of Nevada in Reno said he doubted that the types of jobs performed in his state differ much from those practiced in Kentucky, which has doubled the prevalence of work-related limitations reported by working-aged adults with arthritis.

“Mining is big in Nevada, and there are a lot of service industry workers here. There is a lot of physical work,” he said.

Dr. Adams speculated that the variation might be explained by systemic factors, such as differences in state disability program formats, or perhaps populations. Nevada draws a “pretty young, healthy population” with a large percentage of workers who have recently moved from other locations, whereas Kentucky's population may be older and more stationary.

In both states, rheumatologists said they advocate a team approach to arthritis management, with an emphasis on therapy and lifestyle modifications as well as medication. Occupational and physical therapy are offered on-site in a growing number of group rheumatology practices.

Such trends could make a difference in patients' being able to maintain their ability to perform their jobs, said Ms. Theis from the CDC's Division of Adult and Community Health.

Preliminary findings from a separate study by the CDC build on a growing body of published research suggesting that physician recommendations concerning arthritis management are highly influential in terms of patient behavior, she explained.

When a physician recommends weight loss, an arthritis-focused exercise program, or workplace accommodations in conjunction with the Americans with Disabilities Act, for example, patients are much more likely to attempt to follow that advice.

“We're hoping physicians will say, 'I have a really important voice that carries a lot of weight on a lot of levels,'” said Ms. Theis. “We see them as one of our most important audiences.”

Sometimes, the physician's role on minimizing work limitations is direct, perhaps by prescribing traditional therapy regimens and even biologic therapy to patients early enough in the course of their disease to preserve function.

Other times, a physician may refer a patient to physical or occupational therapy, or to a hand surgeon for a customized thumb or wrist splint that permits normal workplace activities, said Diana Baldwin, who is an occupational therapist at the Missouri Arthritis Rehabilitation and Training Center.

“We've found that it isn't enough to tell people, 'Cut back on your hours,' or 'Be more flexible,' or 'Don't do things that hurt,' '' she said. “For the average working person with arthritis, that is not useful [advice].”

What does seem to make a difference is when physicians explain to arthritis patients early on that their joints are more vulnerable to common workplace conditions such as tendonitis or lower back pain, and provide a reasonable rationale for them to implement protective strategies, she said.

The Missouri Training Center in Columbia is currently completing a federally funded study that has randomized 84 adults with arthritis to receive either written materials about arthritis in the workplace or interventions conducted by Ms. Baldwin in the work setting, be it a manufacturing workshop, business office, or classroom.

She has spent 1.5–2 hours interviewing these workers with arthritis and then has studied them as they work, taking pictures that she will later diagram to show movements that stress the joints including twisting, grabbing, reaching, and bending.

She has investigated ergonomic surgical tools to aid an anesthesiologist, adapted the car of a traveling salesman, and added a step stool to ease a manufacturing specialist's reach to a drill press.

Making such changes early on appears to keep people in the workplace longer, working more effectively and in less pain, she said.

But economic realities have proved to be a barrier to early workplace interventions, particularly in the lower paying, rigorous jobs that put the greatest stress on joints.

No janitors have agreed to allow Ms. Baldwin to come to their workplaces to identify practices that might be exacerbating their arthritis, for example.

“They're not going to expose the fact that they have arthritis on the job,” she said.

Before the height of this cart was modified, the user had to bend forward to push it around the workplace.

With a raised handle on the cart, the user can stand upright and move it more easily. Photos courtesy Diana Baldwin

Arthritis creates work limitations for about a third of the working-age adults with the disease, impacting nearly 7% of the total U.S. workforce, according to a state-by-state study by the Centers for Disease Control. The first-of-its-kind survey, drawing on data from the Behavioral Risk Factor Surveillance System, may foreshadow a profound challenge to the economy as the population ages. Arthritis today affects 46 million Americans, with an estimated economic toll of $128 billion a year, according to the Arthritis Foundation.

The random digit-dialed telephone survey of more than 200,000 households queried working-age adults in every state, Washington, Guam, Puerto Rico, and the U.S. Virgin Islands about whether they had been diagnosed with arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia.

Respondents with arthritis were asked whether arthritis or joint symptoms currently affected whether they were employed and the type and amount of work they could do.

The responses are weighted to represent the adult population in each state.

A high degree of variability was found in the state-specific prevalence of arthritis-related work limitations among all adults between 18 and 64 years of age, from 3.4% of adults in Hawaii to 15% in Kentucky, reported Kristina A. Theis and associates at the National Center for Chronic Disease Prevention and the National Center on Birth Defects and Developmental Disability at the CDC (MMWR 2007;56:1045–9).

Among adults reporting physician-diagnosed arthritis and related conditions, work limitations were reported by a median 33%, ranging from 25.1% in Nevada to 51.3% in Kentucky.

“That's huge,” said Ms. Theis in a telephone interview. “In Kentucky, that represents every other person with arthritis a doctor might be seeing.”

Preventing or minimizing work-related limitations through timely therapy, rehabilitation, and workplace accommodation impacts not only the economy as a whole, but the individual patients' independence, self-esteem, and financial well-being, she stressed.

“It is not always on the physicians' radar screen to inquire, 'How's your function? How's your pain? And by the way, how is that function and pain impacting you at work?'” said Ms. Theis.

Rheumatologists in the states bookending statistics about work limitations among adults with arthritis said that patient characteristics and the availability of services may play into differences seen across populations.

In Elizabethtown, Ky., rheumatologist Daksha Mehta said that some patients travel more than 100 miles to see her.

Although there is a nationwide shortage of board-certified rheumatologists, “I'm sure it's worse in Kentucky,” she said.

Access to medical specialists, as well as experts in occupational therapy and workplace ergonomics, may be limited in small, isolated rural communities. In addition, many patients still do not recognize the need for early diagnosis and treatment, despite educational efforts by rheumatology groups statewide, she said.

“Personally, I have patients with arthritis who are still working at their factory jobs, still farming, but that's with appropriate therapy … optimizing medications, having physical and occupational therapy, doing home strengthening exercises,” said Dr. Mehta of the Center for Arthritis and Osteoporosis.

Dr. Rex Adams, a rheumatologist at Arthritis Associates of Nevada in Reno said he doubted that the types of jobs performed in his state differ much from those practiced in Kentucky, which has doubled the prevalence of work-related limitations reported by working-aged adults with arthritis.

“Mining is big in Nevada, and there are a lot of service industry workers here. There is a lot of physical work,” he said.

Dr. Adams speculated that the variation might be explained by systemic factors, such as differences in state disability program formats, or perhaps populations. Nevada draws a “pretty young, healthy population” with a large percentage of workers who have recently moved from other locations, whereas Kentucky's population may be older and more stationary.

In both states, rheumatologists said they advocate a team approach to arthritis management, with an emphasis on therapy and lifestyle modifications as well as medication. Occupational and physical therapy are offered on-site in a growing number of group rheumatology practices.

Such trends could make a difference in patients' being able to maintain their ability to perform their jobs, said Ms. Theis from the CDC's Division of Adult and Community Health.

Preliminary findings from a separate study by the CDC build on a growing body of published research suggesting that physician recommendations concerning arthritis management are highly influential in terms of patient behavior, she explained.

When a physician recommends weight loss, an arthritis-focused exercise program, or workplace accommodations in conjunction with the Americans with Disabilities Act, for example, patients are much more likely to attempt to follow that advice.

“We're hoping physicians will say, 'I have a really important voice that carries a lot of weight on a lot of levels,'” said Ms. Theis. “We see them as one of our most important audiences.”

Sometimes, the physician's role on minimizing work limitations is direct, perhaps by prescribing traditional therapy regimens and even biologic therapy to patients early enough in the course of their disease to preserve function.

Other times, a physician may refer a patient to physical or occupational therapy, or to a hand surgeon for a customized thumb or wrist splint that permits normal workplace activities, said Diana Baldwin, who is an occupational therapist at the Missouri Arthritis Rehabilitation and Training Center.

“We've found that it isn't enough to tell people, 'Cut back on your hours,' or 'Be more flexible,' or 'Don't do things that hurt,' '' she said. “For the average working person with arthritis, that is not useful [advice].”

What does seem to make a difference is when physicians explain to arthritis patients early on that their joints are more vulnerable to common workplace conditions such as tendonitis or lower back pain, and provide a reasonable rationale for them to implement protective strategies, she said.

The Missouri Training Center in Columbia is currently completing a federally funded study that has randomized 84 adults with arthritis to receive either written materials about arthritis in the workplace or interventions conducted by Ms. Baldwin in the work setting, be it a manufacturing workshop, business office, or classroom.

She has spent 1.5–2 hours interviewing these workers with arthritis and then has studied them as they work, taking pictures that she will later diagram to show movements that stress the joints including twisting, grabbing, reaching, and bending.

She has investigated ergonomic surgical tools to aid an anesthesiologist, adapted the car of a traveling salesman, and added a step stool to ease a manufacturing specialist's reach to a drill press.

Making such changes early on appears to keep people in the workplace longer, working more effectively and in less pain, she said.

But economic realities have proved to be a barrier to early workplace interventions, particularly in the lower paying, rigorous jobs that put the greatest stress on joints.

No janitors have agreed to allow Ms. Baldwin to come to their workplaces to identify practices that might be exacerbating their arthritis, for example.

“They're not going to expose the fact that they have arthritis on the job,” she said.

Before the height of this cart was modified, the user had to bend forward to push it around the workplace.

With a raised handle on the cart, the user can stand upright and move it more easily. Photos courtesy Diana Baldwin