Damian McNamara

ORLANDO – A first-of-its-kind program to screen and treat HIV-infected women for cervical cancer in Zambia was heralded as a potential platform for low-cost, human papillomavirus–based screening programs at this year’s annual meeting of the Society of Gynecologic Oncologists.

More than 20,000 residents of the impoverished, south-central African nation were screened in the first 3 years, according to a study. Just over half of the 6,572 women with known HIV infection at the time of presentation screened positive for cervical cancer, Dr. Groesbeck Parham said.

Although initially designed for HIV-positive women, the program expanded to generalized cervical cancer prevention when word of the services spread.

Dr. Parham and his colleagues analyzed data from 21,010 women who were screened for cervical cancer in 2006, 2007, and 2008. About one-third each were HIV positive (6,572), HIV negative (7,238 women), or of uncertain status at presentation (7,200).

In the HIV-positive cohort, 3,523 of the screened women (54%) had detectable cervical lesions that were seen via visual inspection with acetic acid (VIA). Of those with positive VIA findings, 2,061 were eligible for cryotherapy and about 70% of those underwent this treatment. "The remainder declined cryotherapy, saying they needed to confer with their families and husbands; [they] did not return. That is a problem," said Dr. Parham, a gynecologic oncologist at the University of Alabama at Birmingham.He is also affiliated with the Center for Infectious Disease Research in Zambia (CIDRZ).

A total of 1,462 women had complex lesions that clinicians felt required excision and histologic evaluation. In this group, 1,095 had histology done and 367 did not. "That [also] is a problem," Dr. Parham said.

An available 715 pathology reports revealed 151 women with benign histology (21%) and 449 with precancerous lesions (214 women with cervical intraepithelial neoplasia [CIN] 1 and 235 women with CIN 2 or 3). "We found 115 had invasive cancer. About 70% of the invasive cancers were early (stage IA, IB), almost the opposite of what we see when women do not come into the university through a cervical cancer–screening program."

VIA and cryotherapy-based, screen-and-treat programs "in a low-income African nation can prevent deaths from cervical cancer in HIV-infected women," Dr. Parham said.

The researchers used a "conditional probability model" to calculate mortality prevention. Dr. Parham said, "In our best estimate, we prevented 142 cervical cancer deaths, and thus one death was prevented for every 46 HIV-positive women we screened – a high intervention-to-impact ratio."

This "demonstrates how a small group of people committed to a single cause – even with very few resources, if [they are] willing to make personal sacrifices – can have profound impact on improving the care of women with gynecologic cancers," said Dr. Robert E. Bristow, director of gynecologic oncology services at the University of California, Irvine, Medical Center.

Rationale and funding for the program stemmed from previous research by Dr. Parham and his colleagues (Gynecol. Oncol. 2006:103:1017-22). They found cytologic evidence of invasive cervical cancer in almost 20% of 150 consecutive, HIV-positive women who were screened in Zambia. The findings convinced the government to support screening.

Since the onset of the HIV/AIDS pandemic in 1985, the life expectancy of the 12 million people in Zambia has dropped from 52 years to 38 years. The HIV prevalence is 16% nationally and 22% in the capital city of Lusaka. The cervical cancer incidence is 52 per 100,000, and associated deaths are 38 per 100,000.

"According to the World Health Organization, Zambia has the second highest cervical cancer incidence and mortality rates in the world," Dr. Parham said.

The clinic programs began in Lusaka, where 24 public health clinics and one tertiary hospital serve 2 million residents. There are five gynecologists at the hospital and only 15 gynecologists in the entire country, Dr. Parham said.

"When you start making rounds on the gynecology unit, you quickly discover that about 80% of beds are occupied by women who have invasive cervical cancer, most with very advanced stages," Dr. Parham said. "You will also see a significant number of women [aged 20-30 years] who are HIV infected."

It is not uncommon to see unusual clinical manifestations of cervical cancer in this immunosuppressed population "because of this sordid relationship between HIV and cervical carcinogenesis," Dr. Parham said. Higher prevalence rates of human papillomavirus (HPV) infections, CIN, and invasive cancers result. These patients typically experience faster progression to advanced stages and grades of cancer, as well as higher recurrence and persistence rates.

The screening program faced some additional challenges. For example, the low socioeconomic status of women in Zambia prevented most from returning for multiple evaluations. "We decided to use the only alternative available at that time, which is visual inspection with acetic acid. We think it’s as good as colposcopy and much less expensive."

Nurses were trained to screen and read results visually within a few minutes. Women with visible lesions were offered cryotherapy during the same visit, or were referred for histologic evaluation. Patients with invasive cervical cancer were referred for surgery or radiation.

If nurses are uncertain about a suspicious lesion, they take digital photos, upload them to a website, and await feedback from a physician who has been alerted via text message. Dr. Parham explained the telemedicine aspect: "As we expanded from 4 to 8 to 18 clinics, we just could not make it around physically to answer all the questions."

Shortcomings of the test include a potential for both false negatives (which can lead to undiagnosed disease) and false positives (which can lead to unnecessary medical intervention, costs, and undue anxiety), he said.

Because of a low level of awareness of cervical cancer in the poor communities, Dr. Parham and his associates developed a team of local women to promote cervical cancer screening. "We call them ‘peer educators.’ They are very effective."

A study limitation was a substantial loss to follow-up. To meet this challenge, they implemented a system in which young people in the community use cell phones to call women who miss appointments. "Our follow-up rates have moved from 20% to more than 80%. There is something about getting a phone call that these women really appreciate."

A national expansion is underway, Dr. Parham said. "The Zambian government has embraced our program. We’ve already started rolling out in rural areas. We would like to incorporate HPV DNA–based screening when it becomes available and cost effective."

Screening has also expanded beyond the national border. About a year and half ago, the program’s staff trained 61 health care practitioners from 10 African nations and the People’s Republic of China on how to use the Zambian model. "In Cameroon, they took our model, screened more than 8,000 women, and [have] already started an HPV screening program." To date, Dr. Parham said, cervical cancer screening has reached approximately 1,500 women in Botswana, 1,200 more in Nigeria, and 1,000 in Zimbabwe.

At the meeting, Dr. Parham was presented the Hugh R.K. Barber, M.D., Presidential Lecture Award for his work. Dr. Parham had no relevant disclosures.

ORLANDO – A first-of-its-kind program to screen and treat HIV-infected women for cervical cancer in Zambia was heralded as a potential platform for low-cost, human papillomavirus–based screening programs at this year’s annual meeting of the Society of Gynecologic Oncologists.

More than 20,000 residents of the impoverished, south-central African nation were screened in the first 3 years, according to a study. Just over half of the 6,572 women with known HIV infection at the time of presentation screened positive for cervical cancer, Dr. Groesbeck Parham said.

Although initially designed for HIV-positive women, the program expanded to generalized cervical cancer prevention when word of the services spread.

Dr. Parham and his colleagues analyzed data from 21,010 women who were screened for cervical cancer in 2006, 2007, and 2008. About one-third each were HIV positive (6,572), HIV negative (7,238 women), or of uncertain status at presentation (7,200).

In the HIV-positive cohort, 3,523 of the screened women (54%) had detectable cervical lesions that were seen via visual inspection with acetic acid (VIA). Of those with positive VIA findings, 2,061 were eligible for cryotherapy and about 70% of those underwent this treatment. "The remainder declined cryotherapy, saying they needed to confer with their families and husbands; [they] did not return. That is a problem," said Dr. Parham, a gynecologic oncologist at the University of Alabama at Birmingham.He is also affiliated with the Center for Infectious Disease Research in Zambia (CIDRZ).

A total of 1,462 women had complex lesions that clinicians felt required excision and histologic evaluation. In this group, 1,095 had histology done and 367 did not. "That [also] is a problem," Dr. Parham said.

An available 715 pathology reports revealed 151 women with benign histology (21%) and 449 with precancerous lesions (214 women with cervical intraepithelial neoplasia [CIN] 1 and 235 women with CIN 2 or 3). "We found 115 had invasive cancer. About 70% of the invasive cancers were early (stage IA, IB), almost the opposite of what we see when women do not come into the university through a cervical cancer–screening program."

VIA and cryotherapy-based, screen-and-treat programs "in a low-income African nation can prevent deaths from cervical cancer in HIV-infected women," Dr. Parham said.

The researchers used a "conditional probability model" to calculate mortality prevention. Dr. Parham said, "In our best estimate, we prevented 142 cervical cancer deaths, and thus one death was prevented for every 46 HIV-positive women we screened – a high intervention-to-impact ratio."

This "demonstrates how a small group of people committed to a single cause – even with very few resources, if [they are] willing to make personal sacrifices – can have profound impact on improving the care of women with gynecologic cancers," said Dr. Robert E. Bristow, director of gynecologic oncology services at the University of California, Irvine, Medical Center.

Rationale and funding for the program stemmed from previous research by Dr. Parham and his colleagues (Gynecol. Oncol. 2006:103:1017-22). They found cytologic evidence of invasive cervical cancer in almost 20% of 150 consecutive, HIV-positive women who were screened in Zambia. The findings convinced the government to support screening.

Since the onset of the HIV/AIDS pandemic in 1985, the life expectancy of the 12 million people in Zambia has dropped from 52 years to 38 years. The HIV prevalence is 16% nationally and 22% in the capital city of Lusaka. The cervical cancer incidence is 52 per 100,000, and associated deaths are 38 per 100,000.

"According to the World Health Organization, Zambia has the second highest cervical cancer incidence and mortality rates in the world," Dr. Parham said.

The clinic programs began in Lusaka, where 24 public health clinics and one tertiary hospital serve 2 million residents. There are five gynecologists at the hospital and only 15 gynecologists in the entire country, Dr. Parham said.

"When you start making rounds on the gynecology unit, you quickly discover that about 80% of beds are occupied by women who have invasive cervical cancer, most with very advanced stages," Dr. Parham said. "You will also see a significant number of women [aged 20-30 years] who are HIV infected."

It is not uncommon to see unusual clinical manifestations of cervical cancer in this immunosuppressed population "because of this sordid relationship between HIV and cervical carcinogenesis," Dr. Parham said. Higher prevalence rates of human papillomavirus (HPV) infections, CIN, and invasive cancers result. These patients typically experience faster progression to advanced stages and grades of cancer, as well as higher recurrence and persistence rates.

The screening program faced some additional challenges. For example, the low socioeconomic status of women in Zambia prevented most from returning for multiple evaluations. "We decided to use the only alternative available at that time, which is visual inspection with acetic acid. We think it’s as good as colposcopy and much less expensive."

Nurses were trained to screen and read results visually within a few minutes. Women with visible lesions were offered cryotherapy during the same visit, or were referred for histologic evaluation. Patients with invasive cervical cancer were referred for surgery or radiation.

If nurses are uncertain about a suspicious lesion, they take digital photos, upload them to a website, and await feedback from a physician who has been alerted via text message. Dr. Parham explained the telemedicine aspect: "As we expanded from 4 to 8 to 18 clinics, we just could not make it around physically to answer all the questions."

Shortcomings of the test include a potential for both false negatives (which can lead to undiagnosed disease) and false positives (which can lead to unnecessary medical intervention, costs, and undue anxiety), he said.

Because of a low level of awareness of cervical cancer in the poor communities, Dr. Parham and his associates developed a team of local women to promote cervical cancer screening. "We call them ‘peer educators.’ They are very effective."

A study limitation was a substantial loss to follow-up. To meet this challenge, they implemented a system in which young people in the community use cell phones to call women who miss appointments. "Our follow-up rates have moved from 20% to more than 80%. There is something about getting a phone call that these women really appreciate."

A national expansion is underway, Dr. Parham said. "The Zambian government has embraced our program. We’ve already started rolling out in rural areas. We would like to incorporate HPV DNA–based screening when it becomes available and cost effective."

Screening has also expanded beyond the national border. About a year and half ago, the program’s staff trained 61 health care practitioners from 10 African nations and the People’s Republic of China on how to use the Zambian model. "In Cameroon, they took our model, screened more than 8,000 women, and [have] already started an HPV screening program." To date, Dr. Parham said, cervical cancer screening has reached approximately 1,500 women in Botswana, 1,200 more in Nigeria, and 1,000 in Zimbabwe.

At the meeting, Dr. Parham was presented the Hugh R.K. Barber, M.D., Presidential Lecture Award for his work. Dr. Parham had no relevant disclosures.

ORLANDO – A first-of-its-kind program to screen and treat HIV-infected women for cervical cancer in Zambia was heralded as a potential platform for low-cost, human papillomavirus–based screening programs at this year’s annual meeting of the Society of Gynecologic Oncologists.

More than 20,000 residents of the impoverished, south-central African nation were screened in the first 3 years, according to a study. Just over half of the 6,572 women with known HIV infection at the time of presentation screened positive for cervical cancer, Dr. Groesbeck Parham said.

Although initially designed for HIV-positive women, the program expanded to generalized cervical cancer prevention when word of the services spread.

Dr. Parham and his colleagues analyzed data from 21,010 women who were screened for cervical cancer in 2006, 2007, and 2008. About one-third each were HIV positive (6,572), HIV negative (7,238 women), or of uncertain status at presentation (7,200).

In the HIV-positive cohort, 3,523 of the screened women (54%) had detectable cervical lesions that were seen via visual inspection with acetic acid (VIA). Of those with positive VIA findings, 2,061 were eligible for cryotherapy and about 70% of those underwent this treatment. "The remainder declined cryotherapy, saying they needed to confer with their families and husbands; [they] did not return. That is a problem," said Dr. Parham, a gynecologic oncologist at the University of Alabama at Birmingham.He is also affiliated with the Center for Infectious Disease Research in Zambia (CIDRZ).

A total of 1,462 women had complex lesions that clinicians felt required excision and histologic evaluation. In this group, 1,095 had histology done and 367 did not. "That [also] is a problem," Dr. Parham said.

An available 715 pathology reports revealed 151 women with benign histology (21%) and 449 with precancerous lesions (214 women with cervical intraepithelial neoplasia [CIN] 1 and 235 women with CIN 2 or 3). "We found 115 had invasive cancer. About 70% of the invasive cancers were early (stage IA, IB), almost the opposite of what we see when women do not come into the university through a cervical cancer–screening program."

VIA and cryotherapy-based, screen-and-treat programs "in a low-income African nation can prevent deaths from cervical cancer in HIV-infected women," Dr. Parham said.

The researchers used a "conditional probability model" to calculate mortality prevention. Dr. Parham said, "In our best estimate, we prevented 142 cervical cancer deaths, and thus one death was prevented for every 46 HIV-positive women we screened – a high intervention-to-impact ratio."

This "demonstrates how a small group of people committed to a single cause – even with very few resources, if [they are] willing to make personal sacrifices – can have profound impact on improving the care of women with gynecologic cancers," said Dr. Robert E. Bristow, director of gynecologic oncology services at the University of California, Irvine, Medical Center.

Rationale and funding for the program stemmed from previous research by Dr. Parham and his colleagues (Gynecol. Oncol. 2006:103:1017-22). They found cytologic evidence of invasive cervical cancer in almost 20% of 150 consecutive, HIV-positive women who were screened in Zambia. The findings convinced the government to support screening.

Since the onset of the HIV/AIDS pandemic in 1985, the life expectancy of the 12 million people in Zambia has dropped from 52 years to 38 years. The HIV prevalence is 16% nationally and 22% in the capital city of Lusaka. The cervical cancer incidence is 52 per 100,000, and associated deaths are 38 per 100,000.

"According to the World Health Organization, Zambia has the second highest cervical cancer incidence and mortality rates in the world," Dr. Parham said.

The clinic programs began in Lusaka, where 24 public health clinics and one tertiary hospital serve 2 million residents. There are five gynecologists at the hospital and only 15 gynecologists in the entire country, Dr. Parham said.

"When you start making rounds on the gynecology unit, you quickly discover that about 80% of beds are occupied by women who have invasive cervical cancer, most with very advanced stages," Dr. Parham said. "You will also see a significant number of women [aged 20-30 years] who are HIV infected."

It is not uncommon to see unusual clinical manifestations of cervical cancer in this immunosuppressed population "because of this sordid relationship between HIV and cervical carcinogenesis," Dr. Parham said. Higher prevalence rates of human papillomavirus (HPV) infections, CIN, and invasive cancers result. These patients typically experience faster progression to advanced stages and grades of cancer, as well as higher recurrence and persistence rates.

The screening program faced some additional challenges. For example, the low socioeconomic status of women in Zambia prevented most from returning for multiple evaluations. "We decided to use the only alternative available at that time, which is visual inspection with acetic acid. We think it’s as good as colposcopy and much less expensive."

Nurses were trained to screen and read results visually within a few minutes. Women with visible lesions were offered cryotherapy during the same visit, or were referred for histologic evaluation. Patients with invasive cervical cancer were referred for surgery or radiation.

If nurses are uncertain about a suspicious lesion, they take digital photos, upload them to a website, and await feedback from a physician who has been alerted via text message. Dr. Parham explained the telemedicine aspect: "As we expanded from 4 to 8 to 18 clinics, we just could not make it around physically to answer all the questions."

Shortcomings of the test include a potential for both false negatives (which can lead to undiagnosed disease) and false positives (which can lead to unnecessary medical intervention, costs, and undue anxiety), he said.

Because of a low level of awareness of cervical cancer in the poor communities, Dr. Parham and his associates developed a team of local women to promote cervical cancer screening. "We call them ‘peer educators.’ They are very effective."

A study limitation was a substantial loss to follow-up. To meet this challenge, they implemented a system in which young people in the community use cell phones to call women who miss appointments. "Our follow-up rates have moved from 20% to more than 80%. There is something about getting a phone call that these women really appreciate."

A national expansion is underway, Dr. Parham said. "The Zambian government has embraced our program. We’ve already started rolling out in rural areas. We would like to incorporate HPV DNA–based screening when it becomes available and cost effective."

Screening has also expanded beyond the national border. About a year and half ago, the program’s staff trained 61 health care practitioners from 10 African nations and the People’s Republic of China on how to use the Zambian model. "In Cameroon, they took our model, screened more than 8,000 women, and [have] already started an HPV screening program." To date, Dr. Parham said, cervical cancer screening has reached approximately 1,500 women in Botswana, 1,200 more in Nigeria, and 1,000 in Zimbabwe.

At the meeting, Dr. Parham was presented the Hugh R.K. Barber, M.D., Presidential Lecture Award for his work. Dr. Parham had no relevant disclosures.

ORLANDO – A first-of-its-kind program to screen and treat HIV-infected women for cervical cancer in Zambia was heralded as a potential platform for low-cost, human papillomavirus–based screening programs at this year’s annual meeting of the Society of Gynecologic Oncologists.

More than 20,000 residents of the impoverished, south-central African nation were screened in the first 3 years, according to a study. Just over half of the 6,572 women with known HIV infection at the time of presentation screened positive for cervical cancer, Dr. Groesbeck Parham said.

Although initially designed for HIV-positive women, the program expanded to generalized cervical cancer prevention when word of the services spread.

Dr. Parham and his colleagues analyzed data from 21,010 women who were screened for cervical cancer in 2006, 2007, and 2008. About one-third each were HIV positive (6,572), HIV negative (7,238 women), or of uncertain status at presentation (7,200).

In the HIV-positive cohort, 3,523 of the screened women (54%) had detectable cervical lesions that were seen via visual inspection with acetic acid (VIA). Of those with positive VIA findings, 2,061 were eligible for cryotherapy and about 70% of those underwent this treatment. "The remainder declined cryotherapy, saying they needed to confer with their families and husbands; [they] did not return. That is a problem," said Dr. Parham, a gynecologic oncologist at the University of Alabama at Birmingham.He is also affiliated with the Center for Infectious Disease Research in Zambia (CIDRZ).

A total of 1,462 women had complex lesions that clinicians felt required excision and histologic evaluation. In this group, 1,095 had histology done and 367 did not. "That [also] is a problem," Dr. Parham said.

An available 715 pathology reports revealed 151 women with benign histology (21%) and 449 with precancerous lesions (214 women with cervical intraepithelial neoplasia [CIN] 1 and 235 women with CIN 2 or 3). "We found 115 had invasive cancer. About 70% of the invasive cancers were early (stage IA, IB), almost the opposite of what we see when women do not come into the university through a cervical cancer–screening program."

VIA and cryotherapy-based, screen-and-treat programs "in a low-income African nation can prevent deaths from cervical cancer in HIV-infected women," Dr. Parham said.

The researchers used a "conditional probability model" to calculate mortality prevention. Dr. Parham said, "In our best estimate, we prevented 142 cervical cancer deaths, and thus one death was prevented for every 46 HIV-positive women we screened – a high intervention-to-impact ratio."

This "demonstrates how a small group of people committed to a single cause – even with very few resources, if [they are] willing to make personal sacrifices – can have profound impact on improving the care of women with gynecologic cancers," said Dr. Robert E. Bristow, director of gynecologic oncology services at the University of California, Irvine, Medical Center.

Rationale and funding for the program stemmed from previous research by Dr. Parham and his colleagues (Gynecol. Oncol. 2006:103:1017-22). They found cytologic evidence of invasive cervical cancer in almost 20% of 150 consecutive, HIV-positive women who were screened in Zambia. The findings convinced the government to support screening.

Since the onset of the HIV/AIDS pandemic in 1985, the life expectancy of the 12 million people in Zambia has dropped from 52 years to 38 years. The HIV prevalence is 16% nationally and 22% in the capital city of Lusaka. The cervical cancer incidence is 52 per 100,000, and associated deaths are 38 per 100,000.

"According to the World Health Organization, Zambia has the second highest cervical cancer incidence and mortality rates in the world," Dr. Parham said.

The clinic programs began in Lusaka, where 24 public health clinics and one tertiary hospital serve 2 million residents. There are five gynecologists at the hospital and only 15 gynecologists in the entire country, Dr. Parham said.

"When you start making rounds on the gynecology unit, you quickly discover that about 80% of beds are occupied by women who have invasive cervical cancer, most with very advanced stages," Dr. Parham said. "You will also see a significant number of women [aged 20-30 years] who are HIV infected."

It is not uncommon to see unusual clinical manifestations of cervical cancer in this immunosuppressed population "because of this sordid relationship between HIV and cervical carcinogenesis," Dr. Parham said. Higher prevalence rates of human papillomavirus (HPV) infections, CIN, and invasive cancers result. These patients typically experience faster progression to advanced stages and grades of cancer, as well as higher recurrence and persistence rates.

The screening program faced some additional challenges. For example, the low socioeconomic status of women in Zambia prevented most from returning for multiple evaluations. "We decided to use the only alternative available at that time, which is visual inspection with acetic acid. We think it’s as good as colposcopy and much less expensive."

Nurses were trained to screen and read results visually within a few minutes. Women with visible lesions were offered cryotherapy during the same visit, or were referred for histologic evaluation. Patients with invasive cervical cancer were referred for surgery or radiation.

If nurses are uncertain about a suspicious lesion, they take digital photos, upload them to a website, and await feedback from a physician who has been alerted via text message. Dr. Parham explained the telemedicine aspect: "As we expanded from 4 to 8 to 18 clinics, we just could not make it around physically to answer all the questions."

Shortcomings of the test include a potential for both false negatives (which can lead to undiagnosed disease) and false positives (which can lead to unnecessary medical intervention, costs, and undue anxiety), he said.

Because of a low level of awareness of cervical cancer in the poor communities, Dr. Parham and his associates developed a team of local women to promote cervical cancer screening. "We call them ‘peer educators.’ They are very effective."

A study limitation was a substantial loss to follow-up. To meet this challenge, they implemented a system in which young people in the community use cell phones to call women who miss appointments. "Our follow-up rates have moved from 20% to more than 80%. There is something about getting a phone call that these women really appreciate."

A national expansion is underway, Dr. Parham said. "The Zambian government has embraced our program. We’ve already started rolling out in rural areas. We would like to incorporate HPV DNA–based screening when it becomes available and cost effective."

Screening has also expanded beyond the national border. About a year and half ago, the program’s staff trained 61 health care practitioners from 10 African nations and the People’s Republic of China on how to use the Zambian model. "In Cameroon, they took our model, screened more than 8,000 women, and [have] already started an HPV screening program." To date, Dr. Parham said, cervical cancer screening has reached approximately 1,500 women in Botswana, 1,200 more in Nigeria, and 1,000 in Zimbabwe.

At the meeting, Dr. Parham was presented the Hugh R.K. Barber, M.D., Presidential Lecture Award for his work. Dr. Parham had no relevant disclosures.

ORLANDO – A first-of-its-kind program to screen and treat HIV-infected women for cervical cancer in Zambia was heralded as a potential platform for low-cost, human papillomavirus–based screening programs at this year’s annual meeting of the Society of Gynecologic Oncologists.

More than 20,000 residents of the impoverished, south-central African nation were screened in the first 3 years, according to a study. Just over half of the 6,572 women with known HIV infection at the time of presentation screened positive for cervical cancer, Dr. Groesbeck Parham said.

Although initially designed for HIV-positive women, the program expanded to generalized cervical cancer prevention when word of the services spread.

Dr. Parham and his colleagues analyzed data from 21,010 women who were screened for cervical cancer in 2006, 2007, and 2008. About one-third each were HIV positive (6,572), HIV negative (7,238 women), or of uncertain status at presentation (7,200).

In the HIV-positive cohort, 3,523 of the screened women (54%) had detectable cervical lesions that were seen via visual inspection with acetic acid (VIA). Of those with positive VIA findings, 2,061 were eligible for cryotherapy and about 70% of those underwent this treatment. "The remainder declined cryotherapy, saying they needed to confer with their families and husbands; [they] did not return. That is a problem," said Dr. Parham, a gynecologic oncologist at the University of Alabama at Birmingham.He is also affiliated with the Center for Infectious Disease Research in Zambia (CIDRZ).

A total of 1,462 women had complex lesions that clinicians felt required excision and histologic evaluation. In this group, 1,095 had histology done and 367 did not. "That [also] is a problem," Dr. Parham said.

An available 715 pathology reports revealed 151 women with benign histology (21%) and 449 with precancerous lesions (214 women with cervical intraepithelial neoplasia [CIN] 1 and 235 women with CIN 2 or 3). "We found 115 had invasive cancer. About 70% of the invasive cancers were early (stage IA, IB), almost the opposite of what we see when women do not come into the university through a cervical cancer–screening program."

VIA and cryotherapy-based, screen-and-treat programs "in a low-income African nation can prevent deaths from cervical cancer in HIV-infected women," Dr. Parham said.

The researchers used a "conditional probability model" to calculate mortality prevention. Dr. Parham said, "In our best estimate, we prevented 142 cervical cancer deaths, and thus one death was prevented for every 46 HIV-positive women we screened – a high intervention-to-impact ratio."

This "demonstrates how a small group of people committed to a single cause – even with very few resources, if [they are] willing to make personal sacrifices – can have profound impact on improving the care of women with gynecologic cancers," said Dr. Robert E. Bristow, director of gynecologic oncology services at the University of California, Irvine, Medical Center.

Rationale and funding for the program stemmed from previous research by Dr. Parham and his colleagues (Gynecol. Oncol. 2006:103:1017-22). They found cytologic evidence of invasive cervical cancer in almost 20% of 150 consecutive, HIV-positive women who were screened in Zambia. The findings convinced the government to support screening.

Since the onset of the HIV/AIDS pandemic in 1985, the life expectancy of the 12 million people in Zambia has dropped from 52 years to 38 years. The HIV prevalence is 16% nationally and 22% in the capital city of Lusaka. The cervical cancer incidence is 52 per 100,000, and associated deaths are 38 per 100,000.

"According to the World Health Organization, Zambia has the second highest cervical cancer incidence and mortality rates in the world," Dr. Parham said.

The clinic programs began in Lusaka, where 24 public health clinics and one tertiary hospital serve 2 million residents. There are five gynecologists at the hospital and only 15 gynecologists in the entire country, Dr. Parham said.

"When you start making rounds on the gynecology unit, you quickly discover that about 80% of beds are occupied by women who have invasive cervical cancer, most with very advanced stages," Dr. Parham said. "You will also see a significant number of women [aged 20-30 years] who are HIV infected."

It is not uncommon to see unusual clinical manifestations of cervical cancer in this immunosuppressed population "because of this sordid relationship between HIV and cervical carcinogenesis," Dr. Parham said. Higher prevalence rates of human papillomavirus (HPV) infections, CIN, and invasive cancers result. These patients typically experience faster progression to advanced stages and grades of cancer, as well as higher recurrence and persistence rates.

The screening program faced some additional challenges. For example, the low socioeconomic status of women in Zambia prevented most from returning for multiple evaluations. "We decided to use the only alternative available at that time, which is visual inspection with acetic acid. We think it’s as good as colposcopy and much less expensive."

Nurses were trained to screen and read results visually within a few minutes. Women with visible lesions were offered cryotherapy during the same visit, or were referred for histologic evaluation. Patients with invasive cervical cancer were referred for surgery or radiation.

If nurses are uncertain about a suspicious lesion, they take digital photos, upload them to a website, and await feedback from a physician who has been alerted via text message. Dr. Parham explained the telemedicine aspect: "As we expanded from 4 to 8 to 18 clinics, we just could not make it around physically to answer all the questions."

Shortcomings of the test include a potential for both false negatives (which can lead to undiagnosed disease) and false positives (which can lead to unnecessary medical intervention, costs, and undue anxiety), he said.

Because of a low level of awareness of cervical cancer in the poor communities, Dr. Parham and his associates developed a team of local women to promote cervical cancer screening. "We call them ‘peer educators.’ They are very effective."

A study limitation was a substantial loss to follow-up. To meet this challenge, they implemented a system in which young people in the community use cell phones to call women who miss appointments. "Our follow-up rates have moved from 20% to more than 80%. There is something about getting a phone call that these women really appreciate."

A national expansion is underway, Dr. Parham said. "The Zambian government has embraced our program. We’ve already started rolling out in rural areas. We would like to incorporate HPV DNA–based screening when it becomes available and cost effective."

Screening has also expanded beyond the national border. About a year and half ago, the program’s staff trained 61 health care practitioners from 10 African nations and the People’s Republic of China on how to use the Zambian model. "In Cameroon, they took our model, screened more than 8,000 women, and [have] already started an HPV screening program." To date, Dr. Parham said, cervical cancer screening has reached approximately 1,500 women in Botswana, 1,200 more in Nigeria, and 1,000 in Zimbabwe.

At the meeting, Dr. Parham was presented the Hugh R.K. Barber, M.D., Presidential Lecture Award for his work. Dr. Parham had no relevant disclosures.

ORLANDO – A first-of-its-kind program to screen and treat HIV-infected women for cervical cancer in Zambia was heralded as a potential platform for low-cost, human papillomavirus–based screening programs at this year’s annual meeting of the Society of Gynecologic Oncologists.

More than 20,000 residents of the impoverished, south-central African nation were screened in the first 3 years, according to a study. Just over half of the 6,572 women with known HIV infection at the time of presentation screened positive for cervical cancer, Dr. Groesbeck Parham said.

Although initially designed for HIV-positive women, the program expanded to generalized cervical cancer prevention when word of the services spread.

Dr. Parham and his colleagues analyzed data from 21,010 women who were screened for cervical cancer in 2006, 2007, and 2008. About one-third each were HIV positive (6,572), HIV negative (7,238 women), or of uncertain status at presentation (7,200).

In the HIV-positive cohort, 3,523 of the screened women (54%) had detectable cervical lesions that were seen via visual inspection with acetic acid (VIA). Of those with positive VIA findings, 2,061 were eligible for cryotherapy and about 70% of those underwent this treatment. "The remainder declined cryotherapy, saying they needed to confer with their families and husbands; [they] did not return. That is a problem," said Dr. Parham, a gynecologic oncologist at the University of Alabama at Birmingham.He is also affiliated with the Center for Infectious Disease Research in Zambia (CIDRZ).

A total of 1,462 women had complex lesions that clinicians felt required excision and histologic evaluation. In this group, 1,095 had histology done and 367 did not. "That [also] is a problem," Dr. Parham said.

An available 715 pathology reports revealed 151 women with benign histology (21%) and 449 with precancerous lesions (214 women with cervical intraepithelial neoplasia [CIN] 1 and 235 women with CIN 2 or 3). "We found 115 had invasive cancer. About 70% of the invasive cancers were early (stage IA, IB), almost the opposite of what we see when women do not come into the university through a cervical cancer–screening program."

VIA and cryotherapy-based, screen-and-treat programs "in a low-income African nation can prevent deaths from cervical cancer in HIV-infected women," Dr. Parham said.

The researchers used a "conditional probability model" to calculate mortality prevention. Dr. Parham said, "In our best estimate, we prevented 142 cervical cancer deaths, and thus one death was prevented for every 46 HIV-positive women we screened – a high intervention-to-impact ratio."

This "demonstrates how a small group of people committed to a single cause – even with very few resources, if [they are] willing to make personal sacrifices – can have profound impact on improving the care of women with gynecologic cancers," said Dr. Robert E. Bristow, director of gynecologic oncology services at the University of California, Irvine, Medical Center.

Rationale and funding for the program stemmed from previous research by Dr. Parham and his colleagues (Gynecol. Oncol. 2006:103:1017-22). They found cytologic evidence of invasive cervical cancer in almost 20% of 150 consecutive, HIV-positive women who were screened in Zambia. The findings convinced the government to support screening.

Since the onset of the HIV/AIDS pandemic in 1985, the life expectancy of the 12 million people in Zambia has dropped from 52 years to 38 years. The HIV prevalence is 16% nationally and 22% in the capital city of Lusaka. The cervical cancer incidence is 52 per 100,000, and associated deaths are 38 per 100,000.

"According to the World Health Organization, Zambia has the second highest cervical cancer incidence and mortality rates in the world," Dr. Parham said.

The clinic programs began in Lusaka, where 24 public health clinics and one tertiary hospital serve 2 million residents. There are five gynecologists at the hospital and only 15 gynecologists in the entire country, Dr. Parham said.

"When you start making rounds on the gynecology unit, you quickly discover that about 80% of beds are occupied by women who have invasive cervical cancer, most with very advanced stages," Dr. Parham said. "You will also see a significant number of women [aged 20-30 years] who are HIV infected."

It is not uncommon to see unusual clinical manifestations of cervical cancer in this immunosuppressed population "because of this sordid relationship between HIV and cervical carcinogenesis," Dr. Parham said. Higher prevalence rates of human papillomavirus (HPV) infections, CIN, and invasive cancers result. These patients typically experience faster progression to advanced stages and grades of cancer, as well as higher recurrence and persistence rates.

The screening program faced some additional challenges. For example, the low socioeconomic status of women in Zambia prevented most from returning for multiple evaluations. "We decided to use the only alternative available at that time, which is visual inspection with acetic acid. We think it’s as good as colposcopy and much less expensive."

Nurses were trained to screen and read results visually within a few minutes. Women with visible lesions were offered cryotherapy during the same visit, or were referred for histologic evaluation. Patients with invasive cervical cancer were referred for surgery or radiation.

If nurses are uncertain about a suspicious lesion, they take digital photos, upload them to a website, and await feedback from a physician who has been alerted via text message. Dr. Parham explained the telemedicine aspect: "As we expanded from 4 to 8 to 18 clinics, we just could not make it around physically to answer all the questions."

Shortcomings of the test include a potential for both false negatives (which can lead to undiagnosed disease) and false positives (which can lead to unnecessary medical intervention, costs, and undue anxiety), he said.

Because of a low level of awareness of cervical cancer in the poor communities, Dr. Parham and his associates developed a team of local women to promote cervical cancer screening. "We call them ‘peer educators.’ They are very effective."

A study limitation was a substantial loss to follow-up. To meet this challenge, they implemented a system in which young people in the community use cell phones to call women who miss appointments. "Our follow-up rates have moved from 20% to more than 80%. There is something about getting a phone call that these women really appreciate."

A national expansion is underway, Dr. Parham said. "The Zambian government has embraced our program. We’ve already started rolling out in rural areas. We would like to incorporate HPV DNA–based screening when it becomes available and cost effective."

Screening has also expanded beyond the national border. About a year and half ago, the program’s staff trained 61 health care practitioners from 10 African nations and the People’s Republic of China on how to use the Zambian model. "In Cameroon, they took our model, screened more than 8,000 women, and [have] already started an HPV screening program." To date, Dr. Parham said, cervical cancer screening has reached approximately 1,500 women in Botswana, 1,200 more in Nigeria, and 1,000 in Zimbabwe.

At the meeting, Dr. Parham was presented the Hugh R.K. Barber, M.D., Presidential Lecture Award for his work. Dr. Parham had no relevant disclosures.

ORLANDO – A first-of-its-kind program to screen and treat HIV-infected women for cervical cancer in Zambia was heralded as a potential platform for low-cost, human papillomavirus–based screening programs at this year’s annual meeting of the Society of Gynecologic Oncologists.

More than 20,000 residents of the impoverished, south-central African nation were screened in the first 3 years, according to a study. Just over half of the 6,572 women with known HIV infection at the time of presentation screened positive for cervical cancer, Dr. Groesbeck Parham said.

Although initially designed for HIV-positive women, the program expanded to generalized cervical cancer prevention when word of the services spread.

Dr. Parham and his colleagues analyzed data from 21,010 women who were screened for cervical cancer in 2006, 2007, and 2008. About one-third each were HIV positive (6,572), HIV negative (7,238 women), or of uncertain status at presentation (7,200).

In the HIV-positive cohort, 3,523 of the screened women (54%) had detectable cervical lesions that were seen via visual inspection with acetic acid (VIA). Of those with positive VIA findings, 2,061 were eligible for cryotherapy and about 70% of those underwent this treatment. "The remainder declined cryotherapy, saying they needed to confer with their families and husbands; [they] did not return. That is a problem," said Dr. Parham, a gynecologic oncologist at the University of Alabama at Birmingham.He is also affiliated with the Center for Infectious Disease Research in Zambia (CIDRZ).

A total of 1,462 women had complex lesions that clinicians felt required excision and histologic evaluation. In this group, 1,095 had histology done and 367 did not. "That [also] is a problem," Dr. Parham said.

An available 715 pathology reports revealed 151 women with benign histology (21%) and 449 with precancerous lesions (214 women with cervical intraepithelial neoplasia [CIN] 1 and 235 women with CIN 2 or 3). "We found 115 had invasive cancer. About 70% of the invasive cancers were early (stage IA, IB), almost the opposite of what we see when women do not come into the university through a cervical cancer–screening program."

VIA and cryotherapy-based, screen-and-treat programs "in a low-income African nation can prevent deaths from cervical cancer in HIV-infected women," Dr. Parham said.

The researchers used a "conditional probability model" to calculate mortality prevention. Dr. Parham said, "In our best estimate, we prevented 142 cervical cancer deaths, and thus one death was prevented for every 46 HIV-positive women we screened – a high intervention-to-impact ratio."

This "demonstrates how a small group of people committed to a single cause – even with very few resources, if [they are] willing to make personal sacrifices – can have profound impact on improving the care of women with gynecologic cancers," said Dr. Robert E. Bristow, director of gynecologic oncology services at the University of California, Irvine, Medical Center.

Rationale and funding for the program stemmed from previous research by Dr. Parham and his colleagues (Gynecol. Oncol. 2006:103:1017-22). They found cytologic evidence of invasive cervical cancer in almost 20% of 150 consecutive, HIV-positive women who were screened in Zambia. The findings convinced the government to support screening.

Since the onset of the HIV/AIDS pandemic in 1985, the life expectancy of the 12 million people in Zambia has dropped from 52 years to 38 years. The HIV prevalence is 16% nationally and 22% in the capital city of Lusaka. The cervical cancer incidence is 52 per 100,000, and associated deaths are 38 per 100,000.

"According to the World Health Organization, Zambia has the second highest cervical cancer incidence and mortality rates in the world," Dr. Parham said.

The clinic programs began in Lusaka, where 24 public health clinics and one tertiary hospital serve 2 million residents. There are five gynecologists at the hospital and only 15 gynecologists in the entire country, Dr. Parham said.

"When you start making rounds on the gynecology unit, you quickly discover that about 80% of beds are occupied by women who have invasive cervical cancer, most with very advanced stages," Dr. Parham said. "You will also see a significant number of women [aged 20-30 years] who are HIV infected."

It is not uncommon to see unusual clinical manifestations of cervical cancer in this immunosuppressed population "because of this sordid relationship between HIV and cervical carcinogenesis," Dr. Parham said. Higher prevalence rates of human papillomavirus (HPV) infections, CIN, and invasive cancers result. These patients typically experience faster progression to advanced stages and grades of cancer, as well as higher recurrence and persistence rates.

The screening program faced some additional challenges. For example, the low socioeconomic status of women in Zambia prevented most from returning for multiple evaluations. "We decided to use the only alternative available at that time, which is visual inspection with acetic acid. We think it’s as good as colposcopy and much less expensive."

Nurses were trained to screen and read results visually within a few minutes. Women with visible lesions were offered cryotherapy during the same visit, or were referred for histologic evaluation. Patients with invasive cervical cancer were referred for surgery or radiation.

If nurses are uncertain about a suspicious lesion, they take digital photos, upload them to a website, and await feedback from a physician who has been alerted via text message. Dr. Parham explained the telemedicine aspect: "As we expanded from 4 to 8 to 18 clinics, we just could not make it around physically to answer all the questions."

Shortcomings of the test include a potential for both false negatives (which can lead to undiagnosed disease) and false positives (which can lead to unnecessary medical intervention, costs, and undue anxiety), he said.

Because of a low level of awareness of cervical cancer in the poor communities, Dr. Parham and his associates developed a team of local women to promote cervical cancer screening. "We call them ‘peer educators.’ They are very effective."

A study limitation was a substantial loss to follow-up. To meet this challenge, they implemented a system in which young people in the community use cell phones to call women who miss appointments. "Our follow-up rates have moved from 20% to more than 80%. There is something about getting a phone call that these women really appreciate."

A national expansion is underway, Dr. Parham said. "The Zambian government has embraced our program. We’ve already started rolling out in rural areas. We would like to incorporate HPV DNA–based screening when it becomes available and cost effective."

Screening has also expanded beyond the national border. About a year and half ago, the program’s staff trained 61 health care practitioners from 10 African nations and the People’s Republic of China on how to use the Zambian model. "In Cameroon, they took our model, screened more than 8,000 women, and [have] already started an HPV screening program." To date, Dr. Parham said, cervical cancer screening has reached approximately 1,500 women in Botswana, 1,200 more in Nigeria, and 1,000 in Zimbabwe.

At the meeting, Dr. Parham was presented the Hugh R.K. Barber, M.D., Presidential Lecture Award for his work. Dr. Parham had no relevant disclosures.

ORLANDO – A first-of-its-kind program to screen and treat HIV-infected women for cervical cancer in Zambia was heralded as a potential platform for low-cost, human papillomavirus–based screening programs at this year’s annual meeting of the Society of Gynecologic Oncologists.

More than 20,000 residents of the impoverished, south-central African nation were screened in the first 3 years, according to a study. Just over half of the 6,572 women with known HIV infection at the time of presentation screened positive for cervical cancer, Dr. Groesbeck Parham said.

Although initially designed for HIV-positive women, the program expanded to generalized cervical cancer prevention when word of the services spread.

Dr. Parham and his colleagues analyzed data from 21,010 women who were screened for cervical cancer in 2006, 2007, and 2008. About one-third each were HIV positive (6,572), HIV negative (7,238 women), or of uncertain status at presentation (7,200).

In the HIV-positive cohort, 3,523 of the screened women (54%) had detectable cervical lesions that were seen via visual inspection with acetic acid (VIA). Of those with positive VIA findings, 2,061 were eligible for cryotherapy and about 70% of those underwent this treatment. "The remainder declined cryotherapy, saying they needed to confer with their families and husbands; [they] did not return. That is a problem," said Dr. Parham, a gynecologic oncologist at the University of Alabama at Birmingham.He is also affiliated with the Center for Infectious Disease Research in Zambia (CIDRZ).

A total of 1,462 women had complex lesions that clinicians felt required excision and histologic evaluation. In this group, 1,095 had histology done and 367 did not. "That [also] is a problem," Dr. Parham said.

An available 715 pathology reports revealed 151 women with benign histology (21%) and 449 with precancerous lesions (214 women with cervical intraepithelial neoplasia [CIN] 1 and 235 women with CIN 2 or 3). "We found 115 had invasive cancer. About 70% of the invasive cancers were early (stage IA, IB), almost the opposite of what we see when women do not come into the university through a cervical cancer–screening program."

VIA and cryotherapy-based, screen-and-treat programs "in a low-income African nation can prevent deaths from cervical cancer in HIV-infected women," Dr. Parham said.

The researchers used a "conditional probability model" to calculate mortality prevention. Dr. Parham said, "In our best estimate, we prevented 142 cervical cancer deaths, and thus one death was prevented for every 46 HIV-positive women we screened – a high intervention-to-impact ratio."

This "demonstrates how a small group of people committed to a single cause – even with very few resources, if [they are] willing to make personal sacrifices – can have profound impact on improving the care of women with gynecologic cancers," said Dr. Robert E. Bristow, director of gynecologic oncology services at the University of California, Irvine, Medical Center.

Rationale and funding for the program stemmed from previous research by Dr. Parham and his colleagues (Gynecol. Oncol. 2006:103:1017-22). They found cytologic evidence of invasive cervical cancer in almost 20% of 150 consecutive, HIV-positive women who were screened in Zambia. The findings convinced the government to support screening.

Since the onset of the HIV/AIDS pandemic in 1985, the life expectancy of the 12 million people in Zambia has dropped from 52 years to 38 years. The HIV prevalence is 16% nationally and 22% in the capital city of Lusaka. The cervical cancer incidence is 52 per 100,000, and associated deaths are 38 per 100,000.

"According to the World Health Organization, Zambia has the second highest cervical cancer incidence and mortality rates in the world," Dr. Parham said.

The clinic programs began in Lusaka, where 24 public health clinics and one tertiary hospital serve 2 million residents. There are five gynecologists at the hospital and only 15 gynecologists in the entire country, Dr. Parham said.

"When you start making rounds on the gynecology unit, you quickly discover that about 80% of beds are occupied by women who have invasive cervical cancer, most with very advanced stages," Dr. Parham said. "You will also see a significant number of women [aged 20-30 years] who are HIV infected."

It is not uncommon to see unusual clinical manifestations of cervical cancer in this immunosuppressed population "because of this sordid relationship between HIV and cervical carcinogenesis," Dr. Parham said. Higher prevalence rates of human papillomavirus (HPV) infections, CIN, and invasive cancers result. These patients typically experience faster progression to advanced stages and grades of cancer, as well as higher recurrence and persistence rates.

The screening program faced some additional challenges. For example, the low socioeconomic status of women in Zambia prevented most from returning for multiple evaluations. "We decided to use the only alternative available at that time, which is visual inspection with acetic acid. We think it’s as good as colposcopy and much less expensive."

Nurses were trained to screen and read results visually within a few minutes. Women with visible lesions were offered cryotherapy during the same visit, or were referred for histologic evaluation. Patients with invasive cervical cancer were referred for surgery or radiation.

If nurses are uncertain about a suspicious lesion, they take digital photos, upload them to a website, and await feedback from a physician who has been alerted via text message. Dr. Parham explained the telemedicine aspect: "As we expanded from 4 to 8 to 18 clinics, we just could not make it around physically to answer all the questions."

Shortcomings of the test include a potential for both false negatives (which can lead to undiagnosed disease) and false positives (which can lead to unnecessary medical intervention, costs, and undue anxiety), he said.

Because of a low level of awareness of cervical cancer in the poor communities, Dr. Parham and his associates developed a team of local women to promote cervical cancer screening. "We call them ‘peer educators.’ They are very effective."

A study limitation was a substantial loss to follow-up. To meet this challenge, they implemented a system in which young people in the community use cell phones to call women who miss appointments. "Our follow-up rates have moved from 20% to more than 80%. There is something about getting a phone call that these women really appreciate."

A national expansion is underway, Dr. Parham said. "The Zambian government has embraced our program. We’ve already started rolling out in rural areas. We would like to incorporate HPV DNA–based screening when it becomes available and cost effective."

Screening has also expanded beyond the national border. About a year and half ago, the program’s staff trained 61 health care practitioners from 10 African nations and the People’s Republic of China on how to use the Zambian model. "In Cameroon, they took our model, screened more than 8,000 women, and [have] already started an HPV screening program." To date, Dr. Parham said, cervical cancer screening has reached approximately 1,500 women in Botswana, 1,200 more in Nigeria, and 1,000 in Zimbabwe.

At the meeting, Dr. Parham was presented the Hugh R.K. Barber, M.D., Presidential Lecture Award for his work. Dr. Parham had no relevant disclosures.

ORLANDO – A first-of-its-kind program to screen and treat HIV-infected women for cervical cancer in Zambia was heralded as a potential platform for low-cost, human papillomavirus–based screening programs at this year’s annual meeting of the Society of Gynecologic Oncologists.

More than 20,000 residents of the impoverished, south-central African nation were screened in the first 3 years, according to a study. Just over half of the 6,572 women with known HIV infection at the time of presentation screened positive for cervical cancer, Dr. Groesbeck Parham said.

Although initially designed for HIV-positive women, the program expanded to generalized cervical cancer prevention when word of the services spread.

Dr. Parham and his colleagues analyzed data from 21,010 women who were screened for cervical cancer in 2006, 2007, and 2008. About one-third each were HIV positive (6,572), HIV negative (7,238 women), or of uncertain status at presentation (7,200).

In the HIV-positive cohort, 3,523 of the screened women (54%) had detectable cervical lesions that were seen via visual inspection with acetic acid (VIA). Of those with positive VIA findings, 2,061 were eligible for cryotherapy and about 70% of those underwent this treatment. "The remainder declined cryotherapy, saying they needed to confer with their families and husbands; [they] did not return. That is a problem," said Dr. Parham, a gynecologic oncologist at the University of Alabama at Birmingham.He is also affiliated with the Center for Infectious Disease Research in Zambia (CIDRZ).

A total of 1,462 women had complex lesions that clinicians felt required excision and histologic evaluation. In this group, 1,095 had histology done and 367 did not. "That [also] is a problem," Dr. Parham said.

An available 715 pathology reports revealed 151 women with benign histology (21%) and 449 with precancerous lesions (214 women with cervical intraepithelial neoplasia [CIN] 1 and 235 women with CIN 2 or 3). "We found 115 had invasive cancer. About 70% of the invasive cancers were early (stage IA, IB), almost the opposite of what we see when women do not come into the university through a cervical cancer–screening program."

VIA and cryotherapy-based, screen-and-treat programs "in a low-income African nation can prevent deaths from cervical cancer in HIV-infected women," Dr. Parham said.

The researchers used a "conditional probability model" to calculate mortality prevention. Dr. Parham said, "In our best estimate, we prevented 142 cervical cancer deaths, and thus one death was prevented for every 46 HIV-positive women we screened – a high intervention-to-impact ratio."

This "demonstrates how a small group of people committed to a single cause – even with very few resources, if [they are] willing to make personal sacrifices – can have profound impact on improving the care of women with gynecologic cancers," said Dr. Robert E. Bristow, director of gynecologic oncology services at the University of California, Irvine, Medical Center.

Rationale and funding for the program stemmed from previous research by Dr. Parham and his colleagues (Gynecol. Oncol. 2006:103:1017-22). They found cytologic evidence of invasive cervical cancer in almost 20% of 150 consecutive, HIV-positive women who were screened in Zambia. The findings convinced the government to support screening.

Since the onset of the HIV/AIDS pandemic in 1985, the life expectancy of the 12 million people in Zambia has dropped from 52 years to 38 years. The HIV prevalence is 16% nationally and 22% in the capital city of Lusaka. The cervical cancer incidence is 52 per 100,000, and associated deaths are 38 per 100,000.

"According to the World Health Organization, Zambia has the second highest cervical cancer incidence and mortality rates in the world," Dr. Parham said.

The clinic programs began in Lusaka, where 24 public health clinics and one tertiary hospital serve 2 million residents. There are five gynecologists at the hospital and only 15 gynecologists in the entire country, Dr. Parham said.

"When you start making rounds on the gynecology unit, you quickly discover that about 80% of beds are occupied by women who have invasive cervical cancer, most with very advanced stages," Dr. Parham said. "You will also see a significant number of women [aged 20-30 years] who are HIV infected."

It is not uncommon to see unusual clinical manifestations of cervical cancer in this immunosuppressed population "because of this sordid relationship between HIV and cervical carcinogenesis," Dr. Parham said. Higher prevalence rates of human papillomavirus (HPV) infections, CIN, and invasive cancers result. These patients typically experience faster progression to advanced stages and grades of cancer, as well as higher recurrence and persistence rates.

The screening program faced some additional challenges. For example, the low socioeconomic status of women in Zambia prevented most from returning for multiple evaluations. "We decided to use the only alternative available at that time, which is visual inspection with acetic acid. We think it’s as good as colposcopy and much less expensive."

Nurses were trained to screen and read results visually within a few minutes. Women with visible lesions were offered cryotherapy during the same visit, or were referred for histologic evaluation. Patients with invasive cervical cancer were referred for surgery or radiation.

If nurses are uncertain about a suspicious lesion, they take digital photos, upload them to a website, and await feedback from a physician who has been alerted via text message. Dr. Parham explained the telemedicine aspect: "As we expanded from 4 to 8 to 18 clinics, we just could not make it around physically to answer all the questions."

Shortcomings of the test include a potential for both false negatives (which can lead to undiagnosed disease) and false positives (which can lead to unnecessary medical intervention, costs, and undue anxiety), he said.

Because of a low level of awareness of cervical cancer in the poor communities, Dr. Parham and his associates developed a team of local women to promote cervical cancer screening. "We call them ‘peer educators.’ They are very effective."

A study limitation was a substantial loss to follow-up. To meet this challenge, they implemented a system in which young people in the community use cell phones to call women who miss appointments. "Our follow-up rates have moved from 20% to more than 80%. There is something about getting a phone call that these women really appreciate."

A national expansion is underway, Dr. Parham said. "The Zambian government has embraced our program. We’ve already started rolling out in rural areas. We would like to incorporate HPV DNA–based screening when it becomes available and cost effective."

Screening has also expanded beyond the national border. About a year and half ago, the program’s staff trained 61 health care practitioners from 10 African nations and the People’s Republic of China on how to use the Zambian model. "In Cameroon, they took our model, screened more than 8,000 women, and [have] already started an HPV screening program." To date, Dr. Parham said, cervical cancer screening has reached approximately 1,500 women in Botswana, 1,200 more in Nigeria, and 1,000 in Zimbabwe.

At the meeting, Dr. Parham was presented the Hugh R.K. Barber, M.D., Presidential Lecture Award for his work. Dr. Parham had no relevant disclosures.

MIAMI BEACH – You may soon be able to "pump up the volume" with a new facial filler, according to Dr. Nowell Solish.

Dr. Solish reported his experience with a low-molecular-weight, hyaluronic acid filler at the South Beach Symposium.

Allergan Inc.’s Voluma is already available in Canada and is expected to be available in the United States this year. This viscous formulation of the Juvéderm product line "is really for deeper injections and really for facial volume."

Appropriate use includes injections of the cheek, submalar region, and chin. "This is really for volume replacement in patients whose faces have become ‘bottom heavy,’ " said Dr. Solish of the division of dermatology at the University of Toronto.

"I use this in the midface mostly. It all depends on the age of the patient," he said. He tends to inject more filler medially for older patients and more laterally on the face for his younger patients.

Dr. Solish recommended injection planning using markings to ensure symmetrical placement of the filler. For example, he explained how a triangle on the midface created by the intersection of three straight lines could be used as a guide. One line would go from the lateral canthus to the corner of the patient’s mouth, the second from the upper part of the tragus to the alar lobule, and the third from the lateral canthus to the lower tragus.

Subcutaneous injections are made to the deep dermis and above the periosteum. Do not overcorrect your patient and always massage the area post injection to ensure even distribution, he said.

Voluma is expected to contain lidocaine when it is marketed in the United States. "I mix this filler with lidocaine. Voluma does not come with lidocaine in Canada," Dr. Solish said. He said that the addition of lidocaine with epinephrine makes the filler less viscous and easier to inject through a 28-gauge needle.

Results can last up to a year or longer. His patients typically return for subsequent treatment in 9-12 months. "We are finding they need about half as much product as their initial treatment," he said.

Dr. Solish reported side effects similar to other hyaluronic acid fillers, including bruising, swelling, and discomfort.

"But some patients have a foreign body–like reaction that requires draining and hyaluronidase," Dr. Solish said. "We’ve seen a few cases in Canada."

The low-molecular-weight hyaluronic acid is composed of 90% short molecular chains and 10% of the chains "you are used to with regular Juvéderm," Dr. Solish said.

The term "molecular weight" refers to the length of the molecular chains (number of repeating chains). Greater cross-linking with these shorter chains increases the product’s viscosity.

Dr. Solish disclosed being a consultant and researcher for Allergan.

MIAMI BEACH – You may soon be able to "pump up the volume" with a new facial filler, according to Dr. Nowell Solish.

Dr. Solish reported his experience with a low-molecular-weight, hyaluronic acid filler at the South Beach Symposium.

Allergan Inc.’s Voluma is already available in Canada and is expected to be available in the United States this year. This viscous formulation of the Juvéderm product line "is really for deeper injections and really for facial volume."

Appropriate use includes injections of the cheek, submalar region, and chin. "This is really for volume replacement in patients whose faces have become ‘bottom heavy,’ " said Dr. Solish of the division of dermatology at the University of Toronto.

"I use this in the midface mostly. It all depends on the age of the patient," he said. He tends to inject more filler medially for older patients and more laterally on the face for his younger patients.

Dr. Solish recommended injection planning using markings to ensure symmetrical placement of the filler. For example, he explained how a triangle on the midface created by the intersection of three straight lines could be used as a guide. One line would go from the lateral canthus to the corner of the patient’s mouth, the second from the upper part of the tragus to the alar lobule, and the third from the lateral canthus to the lower tragus.

Subcutaneous injections are made to the deep dermis and above the periosteum. Do not overcorrect your patient and always massage the area post injection to ensure even distribution, he said.

Voluma is expected to contain lidocaine when it is marketed in the United States. "I mix this filler with lidocaine. Voluma does not come with lidocaine in Canada," Dr. Solish said. He said that the addition of lidocaine with epinephrine makes the filler less viscous and easier to inject through a 28-gauge needle.

Results can last up to a year or longer. His patients typically return for subsequent treatment in 9-12 months. "We are finding they need about half as much product as their initial treatment," he said.

Dr. Solish reported side effects similar to other hyaluronic acid fillers, including bruising, swelling, and discomfort.

"But some patients have a foreign body–like reaction that requires draining and hyaluronidase," Dr. Solish said. "We’ve seen a few cases in Canada."

The low-molecular-weight hyaluronic acid is composed of 90% short molecular chains and 10% of the chains "you are used to with regular Juvéderm," Dr. Solish said.

The term "molecular weight" refers to the length of the molecular chains (number of repeating chains). Greater cross-linking with these shorter chains increases the product’s viscosity.

Dr. Solish disclosed being a consultant and researcher for Allergan.

MIAMI BEACH – You may soon be able to "pump up the volume" with a new facial filler, according to Dr. Nowell Solish.

Dr. Solish reported his experience with a low-molecular-weight, hyaluronic acid filler at the South Beach Symposium.

Allergan Inc.’s Voluma is already available in Canada and is expected to be available in the United States this year. This viscous formulation of the Juvéderm product line "is really for deeper injections and really for facial volume."

Appropriate use includes injections of the cheek, submalar region, and chin. "This is really for volume replacement in patients whose faces have become ‘bottom heavy,’ " said Dr. Solish of the division of dermatology at the University of Toronto.

"I use this in the midface mostly. It all depends on the age of the patient," he said. He tends to inject more filler medially for older patients and more laterally on the face for his younger patients.

Dr. Solish recommended injection planning using markings to ensure symmetrical placement of the filler. For example, he explained how a triangle on the midface created by the intersection of three straight lines could be used as a guide. One line would go from the lateral canthus to the corner of the patient’s mouth, the second from the upper part of the tragus to the alar lobule, and the third from the lateral canthus to the lower tragus.

Subcutaneous injections are made to the deep dermis and above the periosteum. Do not overcorrect your patient and always massage the area post injection to ensure even distribution, he said.

Voluma is expected to contain lidocaine when it is marketed in the United States. "I mix this filler with lidocaine. Voluma does not come with lidocaine in Canada," Dr. Solish said. He said that the addition of lidocaine with epinephrine makes the filler less viscous and easier to inject through a 28-gauge needle.

Results can last up to a year or longer. His patients typically return for subsequent treatment in 9-12 months. "We are finding they need about half as much product as their initial treatment," he said.

Dr. Solish reported side effects similar to other hyaluronic acid fillers, including bruising, swelling, and discomfort.

"But some patients have a foreign body–like reaction that requires draining and hyaluronidase," Dr. Solish said. "We’ve seen a few cases in Canada."

The low-molecular-weight hyaluronic acid is composed of 90% short molecular chains and 10% of the chains "you are used to with regular Juvéderm," Dr. Solish said.

The term "molecular weight" refers to the length of the molecular chains (number of repeating chains). Greater cross-linking with these shorter chains increases the product’s viscosity.

Dr. Solish disclosed being a consultant and researcher for Allergan.

ORLANDO - A new analysis finds that bevacizumab was an independent risk factor for gastrointestinal adverse events in a pivotal phase III trial supporting addition of the antiangiogenic therapy to front-line chemotherapy for advanced ovarian cancer and related malignancies.

Adjuvant bevacizumab (Avastin) approximately doubled the risk of perforation, fistulae, necrosis, or hemorrhage in women with newly diagnosed epithelial ovarian, primary peritoneal, or fallopian tube cancers in the Gynecologic Oncology Group (GOG) 218 protocol (odds ratio, 2.15), Dr. Robert A. Burger reported at the annual meeting of the Society of Gynecologic Oncologists.

A history of inflammatory bowel disease (IBD) or large-bowel resection at the time of primary surgery also significantly increased a woman’s chance of developing a GI event, he said; such a history does not rule out treatment with bevacizumab, but patients should be informed of their risk factors.

"The clinical impact of any of these [GI] events cannot be minimized, even though they are uncommon. When you get one, it can be disastrous," said Dr. Burger, director of the women’s cancer center and attending surgeon in gynecologic oncology at Fox Chase Cancer Center in Philadelphia.

At the plenary session during the 2010 annual meeting of the American Society of Clinical Oncology, Dr. Burger had reported that bevacizumab increased median progression-free survival by 3.8 months in the trial (that is, 14.1 months with the addition of bevacizumab to standard chemotherapy followed by maintenance bevacizumab vs. 10.3 months with standard chemotherapy and placebo).

Preliminary results from a second phase III trial – the ICON-7 study that was presented at the European Society of Clinical Oncology annual meeting this past fall – also showed an improvement: Median progression-free survival increased from 17.3 months with standard first-line chemotherapy to 19 months with the addition of bevacizumab.

Bevacizumab is not currently indicated for ovarian cancer, but Roche announced that it has applied for marketing approval in Europe and plans to apply in the United States this year. A study published March 7 in the Journal of Clinical Oncology concluded that adding bevacizumab to standard chemotherapy for advanced ovarian cancer is not cost effective (J. Clin. Oncol. 2011 March 7 [doi:10.1200/JCO.2010.32.1075]).

The GOG 218 trial randomized 1,873 women to three first-line treatment regimens. Participants had stage III or IV cancer, were treatment naive, and underwent tumor debulking prior to randomization.

All participants received six cycles of platinum-taxane chemotherapy. Patients in arm 1 also received a placebo for cycles 2-22; patients in arm 2 also received bevacizumab (15 mg/kg) for cycles 2-6 and then placebo for cycles 7-22; and patients in arm 3 also received the same dose of bevacizumab for cycles 2-22.

In the new analysis, Dr. Burger and his associates assessed patient history for multiple factors, including GI disorders; chronic corticosteroid or NSAID use for any indication; small- or large-bowel resection at time of primary surgery or with anastomosis; cardiovascular disease; diabetes; smoking; and autoimmune disease. Complete history was available for 1,759 patients.

A total of 50 women (2.8%) experienced a grade 2 or greater GI adverse event, said Dr. Burger. These adverse events occurred in 1.7% (10 of 587) women who were treated only with standard therapies, compared with 3.4% of the two bevacizumab arms (20 of 587 women in arm 2, and 20 of 585 women in arm 3).

"Overall, 92% of GI adverse events occurred during the cytotoxic phase, most by cycle 4," Dr. Burger said.

IBD treatment, small-bowel resection, and large-bowel resection were each significantly associated with higher likelihood of a GI adverse event in univariate analyses. There were no associations with age, baseline performance status, stage, or residual disease after debulking surgery.

In a multivariate analysis, treatment of IBD (OR, 13.4) and large-bowel resection at time of primary surgery (OR, 2.05) remained significantly associated with GI adverse events, but small-bowel resection at time of primary surgery (OR, 1.95) was no longer significant. After controlling for these factors, researchers found that the risk of a GI adverse event more than doubled with receipt of bevacizumab (OR, 2.15) when both bevacizumab arms were combined, compared with placebo.

"This is an interesting and thought-provoking study. It addresses a very relevant question we all face with patients with advanced ovarian cancer," commented Dr. David O’Malley of the Ohio State University, Columbus, in an invited discussion of the study.

GI side effects are "still a relatively rare event, with only 50 GI adverse events identified," he noted, but he also cited a 2.5% overall incidence of fatal adverse events associated with bevacizumab that was reported in a recent meta-analysis (JAMA 2011:305:487-94).

Given that the majority of GI events occurred during initial chemotherapy treatment, Dr. O’Malley asked whether bevacizumab should be included in future trials only as maintenance therapy.

"Point well taken," Dr. Burger replied. "We really do not know the absolute importance of combining [antiangiogenic and cytotoxic therapies] in the front-line setting at all."

"We can safely say we should inform our patients ... of the risk factors that may increase the probability of a severe gastrointestinal event," Dr. Burger said. "I don’t think we can come to a conclusion that patients should be excluded based on bowel resection or history of IBD," because confidence limits were fairly large for some of these relatively rare risks.

Dr. Burger said he would be more cautious, however, with prescription of bevacizumab in a patient who has other risk factors. "If a patient has two independent risk factors, those risks need to be multiplied," he said.

Strengths of the study include a large patient population and being the first prospective evaluation of GI adverse events associated with bevacizumab in advanced gynecologic cancer, Dr. O’Malley said. However, there was less than 1 month’s difference in progression-free survival between the control arm and treatment arm 1, he said. "When looking at bevacizumab as adjuvant therapy during these first six cycles, we need to keep this in mind."

The Gynecologic Oncology Group, National Cancer Institute, and Genentech supported this trial. Dr. Burger disclosed that he has served on advisory boards for Genentech and Roche but did not receive honoraria. Dr. O’Malley said he receives research support from Genentech.

ORLANDO - A new analysis finds that bevacizumab was an independent risk factor for gastrointestinal adverse events in a pivotal phase III trial supporting addition of the antiangiogenic therapy to front-line chemotherapy for advanced ovarian cancer and related malignancies.

Adjuvant bevacizumab (Avastin) approximately doubled the risk of perforation, fistulae, necrosis, or hemorrhage in women with newly diagnosed epithelial ovarian, primary peritoneal, or fallopian tube cancers in the Gynecologic Oncology Group (GOG) 218 protocol (odds ratio, 2.15), Dr. Robert A. Burger reported at the annual meeting of the Society of Gynecologic Oncologists.

A history of inflammatory bowel disease (IBD) or large-bowel resection at the time of primary surgery also significantly increased a woman’s chance of developing a GI event, he said; such a history does not rule out treatment with bevacizumab, but patients should be informed of their risk factors.

"The clinical impact of any of these [GI] events cannot be minimized, even though they are uncommon. When you get one, it can be disastrous," said Dr. Burger, director of the women’s cancer center and attending surgeon in gynecologic oncology at Fox Chase Cancer Center in Philadelphia.

At the plenary session during the 2010 annual meeting of the American Society of Clinical Oncology, Dr. Burger had reported that bevacizumab increased median progression-free survival by 3.8 months in the trial (that is, 14.1 months with the addition of bevacizumab to standard chemotherapy followed by maintenance bevacizumab vs. 10.3 months with standard chemotherapy and placebo).

Preliminary results from a second phase III trial – the ICON-7 study that was presented at the European Society of Clinical Oncology annual meeting this past fall – also showed an improvement: Median progression-free survival increased from 17.3 months with standard first-line chemotherapy to 19 months with the addition of bevacizumab.

Bevacizumab is not currently indicated for ovarian cancer, but Roche announced that it has applied for marketing approval in Europe and plans to apply in the United States this year. A study published March 7 in the Journal of Clinical Oncology concluded that adding bevacizumab to standard chemotherapy for advanced ovarian cancer is not cost effective (J. Clin. Oncol. 2011 March 7 [doi:10.1200/JCO.2010.32.1075]).

The GOG 218 trial randomized 1,873 women to three first-line treatment regimens. Participants had stage III or IV cancer, were treatment naive, and underwent tumor debulking prior to randomization.

All participants received six cycles of platinum-taxane chemotherapy. Patients in arm 1 also received a placebo for cycles 2-22; patients in arm 2 also received bevacizumab (15 mg/kg) for cycles 2-6 and then placebo for cycles 7-22; and patients in arm 3 also received the same dose of bevacizumab for cycles 2-22.

In the new analysis, Dr. Burger and his associates assessed patient history for multiple factors, including GI disorders; chronic corticosteroid or NSAID use for any indication; small- or large-bowel resection at time of primary surgery or with anastomosis; cardiovascular disease; diabetes; smoking; and autoimmune disease. Complete history was available for 1,759 patients.

A total of 50 women (2.8%) experienced a grade 2 or greater GI adverse event, said Dr. Burger. These adverse events occurred in 1.7% (10 of 587) women who were treated only with standard therapies, compared with 3.4% of the two bevacizumab arms (20 of 587 women in arm 2, and 20 of 585 women in arm 3).

"Overall, 92% of GI adverse events occurred during the cytotoxic phase, most by cycle 4," Dr. Burger said.

IBD treatment, small-bowel resection, and large-bowel resection were each significantly associated with higher likelihood of a GI adverse event in univariate analyses. There were no associations with age, baseline performance status, stage, or residual disease after debulking surgery.

In a multivariate analysis, treatment of IBD (OR, 13.4) and large-bowel resection at time of primary surgery (OR, 2.05) remained significantly associated with GI adverse events, but small-bowel resection at time of primary surgery (OR, 1.95) was no longer significant. After controlling for these factors, researchers found that the risk of a GI adverse event more than doubled with receipt of bevacizumab (OR, 2.15) when both bevacizumab arms were combined, compared with placebo.

"This is an interesting and thought-provoking study. It addresses a very relevant question we all face with patients with advanced ovarian cancer," commented Dr. David O’Malley of the Ohio State University, Columbus, in an invited discussion of the study.

GI side effects are "still a relatively rare event, with only 50 GI adverse events identified," he noted, but he also cited a 2.5% overall incidence of fatal adverse events associated with bevacizumab that was reported in a recent meta-analysis (JAMA 2011:305:487-94).

Given that the majority of GI events occurred during initial chemotherapy treatment, Dr. O’Malley asked whether bevacizumab should be included in future trials only as maintenance therapy.

"Point well taken," Dr. Burger replied. "We really do not know the absolute importance of combining [antiangiogenic and cytotoxic therapies] in the front-line setting at all."

"We can safely say we should inform our patients ... of the risk factors that may increase the probability of a severe gastrointestinal event," Dr. Burger said. "I don’t think we can come to a conclusion that patients should be excluded based on bowel resection or history of IBD," because confidence limits were fairly large for some of these relatively rare risks.

Dr. Burger said he would be more cautious, however, with prescription of bevacizumab in a patient who has other risk factors. "If a patient has two independent risk factors, those risks need to be multiplied," he said.

Strengths of the study include a large patient population and being the first prospective evaluation of GI adverse events associated with bevacizumab in advanced gynecologic cancer, Dr. O’Malley said. However, there was less than 1 month’s difference in progression-free survival between the control arm and treatment arm 1, he said. "When looking at bevacizumab as adjuvant therapy during these first six cycles, we need to keep this in mind."

The Gynecologic Oncology Group, National Cancer Institute, and Genentech supported this trial. Dr. Burger disclosed that he has served on advisory boards for Genentech and Roche but did not receive honoraria. Dr. O’Malley said he receives research support from Genentech.

ORLANDO - A new analysis finds that bevacizumab was an independent risk factor for gastrointestinal adverse events in a pivotal phase III trial supporting addition of the antiangiogenic therapy to front-line chemotherapy for advanced ovarian cancer and related malignancies.

Adjuvant bevacizumab (Avastin) approximately doubled the risk of perforation, fistulae, necrosis, or hemorrhage in women with newly diagnosed epithelial ovarian, primary peritoneal, or fallopian tube cancers in the Gynecologic Oncology Group (GOG) 218 protocol (odds ratio, 2.15), Dr. Robert A. Burger reported at the annual meeting of the Society of Gynecologic Oncologists.

A history of inflammatory bowel disease (IBD) or large-bowel resection at the time of primary surgery also significantly increased a woman’s chance of developing a GI event, he said; such a history does not rule out treatment with bevacizumab, but patients should be informed of their risk factors.

"The clinical impact of any of these [GI] events cannot be minimized, even though they are uncommon. When you get one, it can be disastrous," said Dr. Burger, director of the women’s cancer center and attending surgeon in gynecologic oncology at Fox Chase Cancer Center in Philadelphia.

At the plenary session during the 2010 annual meeting of the American Society of Clinical Oncology, Dr. Burger had reported that bevacizumab increased median progression-free survival by 3.8 months in the trial (that is, 14.1 months with the addition of bevacizumab to standard chemotherapy followed by maintenance bevacizumab vs. 10.3 months with standard chemotherapy and placebo).

Preliminary results from a second phase III trial – the ICON-7 study that was presented at the European Society of Clinical Oncology annual meeting this past fall – also showed an improvement: Median progression-free survival increased from 17.3 months with standard first-line chemotherapy to 19 months with the addition of bevacizumab.

Bevacizumab is not currently indicated for ovarian cancer, but Roche announced that it has applied for marketing approval in Europe and plans to apply in the United States this year. A study published March 7 in the Journal of Clinical Oncology concluded that adding bevacizumab to standard chemotherapy for advanced ovarian cancer is not cost effective (J. Clin. Oncol. 2011 March 7 [doi:10.1200/JCO.2010.32.1075]).

The GOG 218 trial randomized 1,873 women to three first-line treatment regimens. Participants had stage III or IV cancer, were treatment naive, and underwent tumor debulking prior to randomization.

All participants received six cycles of platinum-taxane chemotherapy. Patients in arm 1 also received a placebo for cycles 2-22; patients in arm 2 also received bevacizumab (15 mg/kg) for cycles 2-6 and then placebo for cycles 7-22; and patients in arm 3 also received the same dose of bevacizumab for cycles 2-22.

In the new analysis, Dr. Burger and his associates assessed patient history for multiple factors, including GI disorders; chronic corticosteroid or NSAID use for any indication; small- or large-bowel resection at time of primary surgery or with anastomosis; cardiovascular disease; diabetes; smoking; and autoimmune disease. Complete history was available for 1,759 patients.

A total of 50 women (2.8%) experienced a grade 2 or greater GI adverse event, said Dr. Burger. These adverse events occurred in 1.7% (10 of 587) women who were treated only with standard therapies, compared with 3.4% of the two bevacizumab arms (20 of 587 women in arm 2, and 20 of 585 women in arm 3).

"Overall, 92% of GI adverse events occurred during the cytotoxic phase, most by cycle 4," Dr. Burger said.

IBD treatment, small-bowel resection, and large-bowel resection were each significantly associated with higher likelihood of a GI adverse event in univariate analyses. There were no associations with age, baseline performance status, stage, or residual disease after debulking surgery.

In a multivariate analysis, treatment of IBD (OR, 13.4) and large-bowel resection at time of primary surgery (OR, 2.05) remained significantly associated with GI adverse events, but small-bowel resection at time of primary surgery (OR, 1.95) was no longer significant. After controlling for these factors, researchers found that the risk of a GI adverse event more than doubled with receipt of bevacizumab (OR, 2.15) when both bevacizumab arms were combined, compared with placebo.

"This is an interesting and thought-provoking study. It addresses a very relevant question we all face with patients with advanced ovarian cancer," commented Dr. David O’Malley of the Ohio State University, Columbus, in an invited discussion of the study.

GI side effects are "still a relatively rare event, with only 50 GI adverse events identified," he noted, but he also cited a 2.5% overall incidence of fatal adverse events associated with bevacizumab that was reported in a recent meta-analysis (JAMA 2011:305:487-94).

Given that the majority of GI events occurred during initial chemotherapy treatment, Dr. O’Malley asked whether bevacizumab should be included in future trials only as maintenance therapy.

"Point well taken," Dr. Burger replied. "We really do not know the absolute importance of combining [antiangiogenic and cytotoxic therapies] in the front-line setting at all."

"We can safely say we should inform our patients ... of the risk factors that may increase the probability of a severe gastrointestinal event," Dr. Burger said. "I don’t think we can come to a conclusion that patients should be excluded based on bowel resection or history of IBD," because confidence limits were fairly large for some of these relatively rare risks.

Dr. Burger said he would be more cautious, however, with prescription of bevacizumab in a patient who has other risk factors. "If a patient has two independent risk factors, those risks need to be multiplied," he said.

Strengths of the study include a large patient population and being the first prospective evaluation of GI adverse events associated with bevacizumab in advanced gynecologic cancer, Dr. O’Malley said. However, there was less than 1 month’s difference in progression-free survival between the control arm and treatment arm 1, he said. "When looking at bevacizumab as adjuvant therapy during these first six cycles, we need to keep this in mind."

The Gynecologic Oncology Group, National Cancer Institute, and Genentech supported this trial. Dr. Burger disclosed that he has served on advisory boards for Genentech and Roche but did not receive honoraria. Dr. O’Malley said he receives research support from Genentech.

ORLANDO - A new analysis finds that bevacizumab was an independent risk factor for gastrointestinal adverse events in a pivotal phase III trial supporting addition of the antiangiogenic therapy to front-line chemotherapy for advanced ovarian cancer and related malignancies.

Adjuvant bevacizumab (Avastin) approximately doubled the risk of perforation, fistulae, necrosis, or hemorrhage in women with newly diagnosed epithelial ovarian, primary peritoneal, or fallopian tube cancers in the Gynecologic Oncology Group (GOG) 218 protocol (odds ratio, 2.15), Dr. Robert A. Burger reported at the annual meeting of the Society of Gynecologic Oncologists.

A history of inflammatory bowel disease (IBD) or large-bowel resection at the time of primary surgery also significantly increased a woman’s chance of developing a GI event, he said; such a history does not rule out treatment with bevacizumab, but patients should be informed of their risk factors.

"The clinical impact of any of these [GI] events cannot be minimized, even though they are uncommon. When you get one, it can be disastrous," said Dr. Burger, director of the women’s cancer center and attending surgeon in gynecologic oncology at Fox Chase Cancer Center in Philadelphia.

At the plenary session during the 2010 annual meeting of the American Society of Clinical Oncology, Dr. Burger had reported that bevacizumab increased median progression-free survival by 3.8 months in the trial (that is, 14.1 months with the addition of bevacizumab to standard chemotherapy followed by maintenance bevacizumab vs. 10.3 months with standard chemotherapy and placebo).

Preliminary results from a second phase III trial – the ICON-7 study that was presented at the European Society of Clinical Oncology annual meeting this past fall – also showed an improvement: Median progression-free survival increased from 17.3 months with standard first-line chemotherapy to 19 months with the addition of bevacizumab.

Bevacizumab is not currently indicated for ovarian cancer, but Roche announced that it has applied for marketing approval in Europe and plans to apply in the United States this year. A study published March 7 in the Journal of Clinical Oncology concluded that adding bevacizumab to standard chemotherapy for advanced ovarian cancer is not cost effective (J. Clin. Oncol. 2011 March 7 [doi:10.1200/JCO.2010.32.1075]).

The GOG 218 trial randomized 1,873 women to three first-line treatment regimens. Participants had stage III or IV cancer, were treatment naive, and underwent tumor debulking prior to randomization.

All participants received six cycles of platinum-taxane chemotherapy. Patients in arm 1 also received a placebo for cycles 2-22; patients in arm 2 also received bevacizumab (15 mg/kg) for cycles 2-6 and then placebo for cycles 7-22; and patients in arm 3 also received the same dose of bevacizumab for cycles 2-22.

In the new analysis, Dr. Burger and his associates assessed patient history for multiple factors, including GI disorders; chronic corticosteroid or NSAID use for any indication; small- or large-bowel resection at time of primary surgery or with anastomosis; cardiovascular disease; diabetes; smoking; and autoimmune disease. Complete history was available for 1,759 patients.

A total of 50 women (2.8%) experienced a grade 2 or greater GI adverse event, said Dr. Burger. These adverse events occurred in 1.7% (10 of 587) women who were treated only with standard therapies, compared with 3.4% of the two bevacizumab arms (20 of 587 women in arm 2, and 20 of 585 women in arm 3).

"Overall, 92% of GI adverse events occurred during the cytotoxic phase, most by cycle 4," Dr. Burger said.

IBD treatment, small-bowel resection, and large-bowel resection were each significantly associated with higher likelihood of a GI adverse event in univariate analyses. There were no associations with age, baseline performance status, stage, or residual disease after debulking surgery.

In a multivariate analysis, treatment of IBD (OR, 13.4) and large-bowel resection at time of primary surgery (OR, 2.05) remained significantly associated with GI adverse events, but small-bowel resection at time of primary surgery (OR, 1.95) was no longer significant. After controlling for these factors, researchers found that the risk of a GI adverse event more than doubled with receipt of bevacizumab (OR, 2.15) when both bevacizumab arms were combined, compared with placebo.

"This is an interesting and thought-provoking study. It addresses a very relevant question we all face with patients with advanced ovarian cancer," commented Dr. David O’Malley of the Ohio State University, Columbus, in an invited discussion of the study.

GI side effects are "still a relatively rare event, with only 50 GI adverse events identified," he noted, but he also cited a 2.5% overall incidence of fatal adverse events associated with bevacizumab that was reported in a recent meta-analysis (JAMA 2011:305:487-94).

Given that the majority of GI events occurred during initial chemotherapy treatment, Dr. O’Malley asked whether bevacizumab should be included in future trials only as maintenance therapy.

"Point well taken," Dr. Burger replied. "We really do not know the absolute importance of combining [antiangiogenic and cytotoxic therapies] in the front-line setting at all."

"We can safely say we should inform our patients ... of the risk factors that may increase the probability of a severe gastrointestinal event," Dr. Burger said. "I don’t think we can come to a conclusion that patients should be excluded based on bowel resection or history of IBD," because confidence limits were fairly large for some of these relatively rare risks.

Dr. Burger said he would be more cautious, however, with prescription of bevacizumab in a patient who has other risk factors. "If a patient has two independent risk factors, those risks need to be multiplied," he said.

Strengths of the study include a large patient population and being the first prospective evaluation of GI adverse events associated with bevacizumab in advanced gynecologic cancer, Dr. O’Malley said. However, there was less than 1 month’s difference in progression-free survival between the control arm and treatment arm 1, he said. "When looking at bevacizumab as adjuvant therapy during these first six cycles, we need to keep this in mind."

The Gynecologic Oncology Group, National Cancer Institute, and Genentech supported this trial. Dr. Burger disclosed that he has served on advisory boards for Genentech and Roche but did not receive honoraria. Dr. O’Malley said he receives research support from Genentech.

ORLANDO - A new analysis finds that bevacizumab was an independent risk factor for gastrointestinal adverse events in a pivotal phase III trial supporting addition of the antiangiogenic therapy to front-line chemotherapy for advanced ovarian cancer and related malignancies.

Adjuvant bevacizumab (Avastin) approximately doubled the risk of perforation, fistulae, necrosis, or hemorrhage in women with newly diagnosed epithelial ovarian, primary peritoneal, or fallopian tube cancers in the Gynecologic Oncology Group (GOG) 218 protocol (odds ratio, 2.15), Dr. Robert A. Burger reported at the annual meeting of the Society of Gynecologic Oncologists.

A history of inflammatory bowel disease (IBD) or large-bowel resection at the time of primary surgery also significantly increased a woman’s chance of developing a GI event, he said; such a history does not rule out treatment with bevacizumab, but patients should be informed of their risk factors.

"The clinical impact of any of these [GI] events cannot be minimized, even though they are uncommon. When you get one, it can be disastrous," said Dr. Burger, director of the women’s cancer center and attending surgeon in gynecologic oncology at Fox Chase Cancer Center in Philadelphia.

At the plenary session during the 2010 annual meeting of the American Society of Clinical Oncology, Dr. Burger had reported that bevacizumab increased median progression-free survival by 3.8 months in the trial (that is, 14.1 months with the addition of bevacizumab to standard chemotherapy followed by maintenance bevacizumab vs. 10.3 months with standard chemotherapy and placebo).

Preliminary results from a second phase III trial – the ICON-7 study that was presented at the European Society of Clinical Oncology annual meeting this past fall – also showed an improvement: Median progression-free survival increased from 17.3 months with standard first-line chemotherapy to 19 months with the addition of bevacizumab.

Bevacizumab is not currently indicated for ovarian cancer, but Roche announced that it has applied for marketing approval in Europe and plans to apply in the United States this year. A study published March 7 in the Journal of Clinical Oncology concluded that adding bevacizumab to standard chemotherapy for advanced ovarian cancer is not cost effective (J. Clin. Oncol. 2011 March 7 [doi:10.1200/JCO.2010.32.1075]).

The GOG 218 trial randomized 1,873 women to three first-line treatment regimens. Participants had stage III or IV cancer, were treatment naive, and underwent tumor debulking prior to randomization.

All participants received six cycles of platinum-taxane chemotherapy. Patients in arm 1 also received a placebo for cycles 2-22; patients in arm 2 also received bevacizumab (15 mg/kg) for cycles 2-6 and then placebo for cycles 7-22; and patients in arm 3 also received the same dose of bevacizumab for cycles 2-22.

In the new analysis, Dr. Burger and his associates assessed patient history for multiple factors, including GI disorders; chronic corticosteroid or NSAID use for any indication; small- or large-bowel resection at time of primary surgery or with anastomosis; cardiovascular disease; diabetes; smoking; and autoimmune disease. Complete history was available for 1,759 patients.

A total of 50 women (2.8%) experienced a grade 2 or greater GI adverse event, said Dr. Burger. These adverse events occurred in 1.7% (10 of 587) women who were treated only with standard therapies, compared with 3.4% of the two bevacizumab arms (20 of 587 women in arm 2, and 20 of 585 women in arm 3).

"Overall, 92% of GI adverse events occurred during the cytotoxic phase, most by cycle 4," Dr. Burger said.

IBD treatment, small-bowel resection, and large-bowel resection were each significantly associated with higher likelihood of a GI adverse event in univariate analyses. There were no associations with age, baseline performance status, stage, or residual disease after debulking surgery.

In a multivariate analysis, treatment of IBD (OR, 13.4) and large-bowel resection at time of primary surgery (OR, 2.05) remained significantly associated with GI adverse events, but small-bowel resection at time of primary surgery (OR, 1.95) was no longer significant. After controlling for these factors, researchers found that the risk of a GI adverse event more than doubled with receipt of bevacizumab (OR, 2.15) when both bevacizumab arms were combined, compared with placebo.

"This is an interesting and thought-provoking study. It addresses a very relevant question we all face with patients with advanced ovarian cancer," commented Dr. David O’Malley of the Ohio State University, Columbus, in an invited discussion of the study.

GI side effects are "still a relatively rare event, with only 50 GI adverse events identified," he noted, but he also cited a 2.5% overall incidence of fatal adverse events associated with bevacizumab that was reported in a recent meta-analysis (JAMA 2011:305:487-94).

Given that the majority of GI events occurred during initial chemotherapy treatment, Dr. O’Malley asked whether bevacizumab should be included in future trials only as maintenance therapy.

"Point well taken," Dr. Burger replied. "We really do not know the absolute importance of combining [antiangiogenic and cytotoxic therapies] in the front-line setting at all."

"We can safely say we should inform our patients ... of the risk factors that may increase the probability of a severe gastrointestinal event," Dr. Burger said. "I don’t think we can come to a conclusion that patients should be excluded based on bowel resection or history of IBD," because confidence limits were fairly large for some of these relatively rare risks.

Dr. Burger said he would be more cautious, however, with prescription of bevacizumab in a patient who has other risk factors. "If a patient has two independent risk factors, those risks need to be multiplied," he said.

Strengths of the study include a large patient population and being the first prospective evaluation of GI adverse events associated with bevacizumab in advanced gynecologic cancer, Dr. O’Malley said. However, there was less than 1 month’s difference in progression-free survival between the control arm and treatment arm 1, he said. "When looking at bevacizumab as adjuvant therapy during these first six cycles, we need to keep this in mind."

The Gynecologic Oncology Group, National Cancer Institute, and Genentech supported this trial. Dr. Burger disclosed that he has served on advisory boards for Genentech and Roche but did not receive honoraria. Dr. O’Malley said he receives research support from Genentech.

ORLANDO - A new analysis finds that bevacizumab was an independent risk factor for gastrointestinal adverse events in a pivotal phase III trial supporting addition of the antiangiogenic therapy to front-line chemotherapy for advanced ovarian cancer and related malignancies.

Adjuvant bevacizumab (Avastin) approximately doubled the risk of perforation, fistulae, necrosis, or hemorrhage in women with newly diagnosed epithelial ovarian, primary peritoneal, or fallopian tube cancers in the Gynecologic Oncology Group (GOG) 218 protocol (odds ratio, 2.15), Dr. Robert A. Burger reported at the annual meeting of the Society of Gynecologic Oncologists.

A history of inflammatory bowel disease (IBD) or large-bowel resection at the time of primary surgery also significantly increased a woman’s chance of developing a GI event, he said; such a history does not rule out treatment with bevacizumab, but patients should be informed of their risk factors.

"The clinical impact of any of these [GI] events cannot be minimized, even though they are uncommon. When you get one, it can be disastrous," said Dr. Burger, director of the women’s cancer center and attending surgeon in gynecologic oncology at Fox Chase Cancer Center in Philadelphia.

At the plenary session during the 2010 annual meeting of the American Society of Clinical Oncology, Dr. Burger had reported that bevacizumab increased median progression-free survival by 3.8 months in the trial (that is, 14.1 months with the addition of bevacizumab to standard chemotherapy followed by maintenance bevacizumab vs. 10.3 months with standard chemotherapy and placebo).

Preliminary results from a second phase III trial – the ICON-7 study that was presented at the European Society of Clinical Oncology annual meeting this past fall – also showed an improvement: Median progression-free survival increased from 17.3 months with standard first-line chemotherapy to 19 months with the addition of bevacizumab.

Bevacizumab is not currently indicated for ovarian cancer, but Roche announced that it has applied for marketing approval in Europe and plans to apply in the United States this year. A study published March 7 in the Journal of Clinical Oncology concluded that adding bevacizumab to standard chemotherapy for advanced ovarian cancer is not cost effective (J. Clin. Oncol. 2011 March 7 [doi:10.1200/JCO.2010.32.1075]).

The GOG 218 trial randomized 1,873 women to three first-line treatment regimens. Participants had stage III or IV cancer, were treatment naive, and underwent tumor debulking prior to randomization.

All participants received six cycles of platinum-taxane chemotherapy. Patients in arm 1 also received a placebo for cycles 2-22; patients in arm 2 also received bevacizumab (15 mg/kg) for cycles 2-6 and then placebo for cycles 7-22; and patients in arm 3 also received the same dose of bevacizumab for cycles 2-22.

In the new analysis, Dr. Burger and his associates assessed patient history for multiple factors, including GI disorders; chronic corticosteroid or NSAID use for any indication; small- or large-bowel resection at time of primary surgery or with anastomosis; cardiovascular disease; diabetes; smoking; and autoimmune disease. Complete history was available for 1,759 patients.

A total of 50 women (2.8%) experienced a grade 2 or greater GI adverse event, said Dr. Burger. These adverse events occurred in 1.7% (10 of 587) women who were treated only with standard therapies, compared with 3.4% of the two bevacizumab arms (20 of 587 women in arm 2, and 20 of 585 women in arm 3).

"Overall, 92% of GI adverse events occurred during the cytotoxic phase, most by cycle 4," Dr. Burger said.

IBD treatment, small-bowel resection, and large-bowel resection were each significantly associated with higher likelihood of a GI adverse event in univariate analyses. There were no associations with age, baseline performance status, stage, or residual disease after debulking surgery.

In a multivariate analysis, treatment of IBD (OR, 13.4) and large-bowel resection at time of primary surgery (OR, 2.05) remained significantly associated with GI adverse events, but small-bowel resection at time of primary surgery (OR, 1.95) was no longer significant. After controlling for these factors, researchers found that the risk of a GI adverse event more than doubled with receipt of bevacizumab (OR, 2.15) when both bevacizumab arms were combined, compared with placebo.

"This is an interesting and thought-provoking study. It addresses a very relevant question we all face with patients with advanced ovarian cancer," commented Dr. David O’Malley of the Ohio State University, Columbus, in an invited discussion of the study.

GI side effects are "still a relatively rare event, with only 50 GI adverse events identified," he noted, but he also cited a 2.5% overall incidence of fatal adverse events associated with bevacizumab that was reported in a recent meta-analysis (JAMA 2011:305:487-94).

Given that the majority of GI events occurred during initial chemotherapy treatment, Dr. O’Malley asked whether bevacizumab should be included in future trials only as maintenance therapy.

"Point well taken," Dr. Burger replied. "We really do not know the absolute importance of combining [antiangiogenic and cytotoxic therapies] in the front-line setting at all."

"We can safely say we should inform our patients ... of the risk factors that may increase the probability of a severe gastrointestinal event," Dr. Burger said. "I don’t think we can come to a conclusion that patients should be excluded based on bowel resection or history of IBD," because confidence limits were fairly large for some of these relatively rare risks.

Dr. Burger said he would be more cautious, however, with prescription of bevacizumab in a patient who has other risk factors. "If a patient has two independent risk factors, those risks need to be multiplied," he said.

Strengths of the study include a large patient population and being the first prospective evaluation of GI adverse events associated with bevacizumab in advanced gynecologic cancer, Dr. O’Malley said. However, there was less than 1 month’s difference in progression-free survival between the control arm and treatment arm 1, he said. "When looking at bevacizumab as adjuvant therapy during these first six cycles, we need to keep this in mind."

The Gynecologic Oncology Group, National Cancer Institute, and Genentech supported this trial. Dr. Burger disclosed that he has served on advisory boards for Genentech and Roche but did not receive honoraria. Dr. O’Malley said he receives research support from Genentech.

NEW ORLEANS – Patch testing and prescription of fragrance-free skin care regimens might be indicated for children with moderate to severe atopic dermatitis.

In a study of 101 children, 88% of 54 with atopic dermatitis had a positive patch test result for one or more allergens, compared with 66% of 47 participants without atopic dermatitis, a statistically significant difference.

Dr. Elise Herro and her associates also found a correlation regarding the severity of both conditions. "EASI [Eczema Area and Severity Index] scores greater than 10 also statistically correlated with a higher probability of greater than 3 positive patch tests," she said at the annual meeting of the American Contact Dermatitis Society.

Study participants were 6-18 years old. Of the total 101 patients patch tested, 79 had at least one reactive test result. The 54 children classified as atopic met Hanifin-Rajka criteria.

Nickel, balsam of Peru, and fragrance were the most common allergens in the study. Positive reactions were significantly more common in children with atopy versus children without atopy for nickel (35% vs. 26%), balsam of Peru (20% vs. 2%), and fragrance mix (19% vs. 0%).

"We [also] found contact allergens whose high prevalence was unique to our patient population," said Dr. Herro of Rady Children's Hospital and the University of California, San Diego.

Dr. Herro and her colleagues identified children reactive to tixocortol pivalate, and para-tertiary-butylphenol-formaldehyde resin, a component of sports gear that can cause dermatitis. Positive tixocortol pivalate patch test reactions "could be related to the high percentage of atopic patients who have used topical corticosteroids."

Dr. Herro also reviewed previous studies that included patients with both atopic dermatitis and allergic contact dermatitis (Contact Dermatitis 2008;58:188-9; Arch. Dermatol. 2008;144;1329-36; and J. Clin. Aesthet. Dermatol. 2010;3:29-35).

This research "shows us that allergic contact dermatitis is commonly associated with atopic dermatitis, both when you look at frequency of allergic contact dermatitis among patients with atopic dermatitis and the frequency of atopic dermatitis among patients with allergic contact dermatitis," Dr. Herro said.

She said that she had no relevant financial disclosures.

NEW ORLEANS – Patch testing and prescription of fragrance-free skin care regimens might be indicated for children with moderate to severe atopic dermatitis.

In a study of 101 children, 88% of 54 with atopic dermatitis had a positive patch test result for one or more allergens, compared with 66% of 47 participants without atopic dermatitis, a statistically significant difference.

Dr. Elise Herro and her associates also found a correlation regarding the severity of both conditions. "EASI [Eczema Area and Severity Index] scores greater than 10 also statistically correlated with a higher probability of greater than 3 positive patch tests," she said at the annual meeting of the American Contact Dermatitis Society.

Study participants were 6-18 years old. Of the total 101 patients patch tested, 79 had at least one reactive test result. The 54 children classified as atopic met Hanifin-Rajka criteria.

Nickel, balsam of Peru, and fragrance were the most common allergens in the study. Positive reactions were significantly more common in children with atopy versus children without atopy for nickel (35% vs. 26%), balsam of Peru (20% vs. 2%), and fragrance mix (19% vs. 0%).

"We [also] found contact allergens whose high prevalence was unique to our patient population," said Dr. Herro of Rady Children's Hospital and the University of California, San Diego.

Dr. Herro and her colleagues identified children reactive to tixocortol pivalate, and para-tertiary-butylphenol-formaldehyde resin, a component of sports gear that can cause dermatitis. Positive tixocortol pivalate patch test reactions "could be related to the high percentage of atopic patients who have used topical corticosteroids."

Dr. Herro also reviewed previous studies that included patients with both atopic dermatitis and allergic contact dermatitis (Contact Dermatitis 2008;58:188-9; Arch. Dermatol. 2008;144;1329-36; and J. Clin. Aesthet. Dermatol. 2010;3:29-35).

This research "shows us that allergic contact dermatitis is commonly associated with atopic dermatitis, both when you look at frequency of allergic contact dermatitis among patients with atopic dermatitis and the frequency of atopic dermatitis among patients with allergic contact dermatitis," Dr. Herro said.

She said that she had no relevant financial disclosures.

NEW ORLEANS – Patch testing and prescription of fragrance-free skin care regimens might be indicated for children with moderate to severe atopic dermatitis.

In a study of 101 children, 88% of 54 with atopic dermatitis had a positive patch test result for one or more allergens, compared with 66% of 47 participants without atopic dermatitis, a statistically significant difference.

Dr. Elise Herro and her associates also found a correlation regarding the severity of both conditions. "EASI [Eczema Area and Severity Index] scores greater than 10 also statistically correlated with a higher probability of greater than 3 positive patch tests," she said at the annual meeting of the American Contact Dermatitis Society.

Study participants were 6-18 years old. Of the total 101 patients patch tested, 79 had at least one reactive test result. The 54 children classified as atopic met Hanifin-Rajka criteria.

Nickel, balsam of Peru, and fragrance were the most common allergens in the study. Positive reactions were significantly more common in children with atopy versus children without atopy for nickel (35% vs. 26%), balsam of Peru (20% vs. 2%), and fragrance mix (19% vs. 0%).

"We [also] found contact allergens whose high prevalence was unique to our patient population," said Dr. Herro of Rady Children's Hospital and the University of California, San Diego.

Dr. Herro and her colleagues identified children reactive to tixocortol pivalate, and para-tertiary-butylphenol-formaldehyde resin, a component of sports gear that can cause dermatitis. Positive tixocortol pivalate patch test reactions "could be related to the high percentage of atopic patients who have used topical corticosteroids."

Dr. Herro also reviewed previous studies that included patients with both atopic dermatitis and allergic contact dermatitis (Contact Dermatitis 2008;58:188-9; Arch. Dermatol. 2008;144;1329-36; and J. Clin. Aesthet. Dermatol. 2010;3:29-35).

This research "shows us that allergic contact dermatitis is commonly associated with atopic dermatitis, both when you look at frequency of allergic contact dermatitis among patients with atopic dermatitis and the frequency of atopic dermatitis among patients with allergic contact dermatitis," Dr. Herro said.

She said that she had no relevant financial disclosures.

NEW ORLEANS – Patch testing and prescription of fragrance-free skin care regimens might be indicated for children with moderate to severe atopic dermatitis.

In a study of 101 children, 88% of 54 with atopic dermatitis had a positive patch test result for one or more allergens, compared with 66% of 47 participants without atopic dermatitis, a statistically significant difference.

Dr. Elise Herro and her associates also found a correlation regarding the severity of both conditions. "EASI [Eczema Area and Severity Index] scores greater than 10 also statistically correlated with a higher probability of greater than 3 positive patch tests," she said at the annual meeting of the American Contact Dermatitis Society.

Study participants were 6-18 years old. Of the total 101 patients patch tested, 79 had at least one reactive test result. The 54 children classified as atopic met Hanifin-Rajka criteria.

Nickel, balsam of Peru, and fragrance were the most common allergens in the study. Positive reactions were significantly more common in children with atopy versus children without atopy for nickel (35% vs. 26%), balsam of Peru (20% vs. 2%), and fragrance mix (19% vs. 0%).

"We [also] found contact allergens whose high prevalence was unique to our patient population," said Dr. Herro of Rady Children’s Hospital and the University of California, San Diego.

Dr. Herro and her colleagues identified children reactive to tixocortol pivalate, and para-tertiary-butylphenol-formaldehyde resin, a component of sports gear that can cause dermatitis. Positive tixocortol pivalate patch test reactions "could be related to the high percentage of atopic patients who have used topical corticosteroids."

Dr. Herro also reviewed previous studies that included patients with both atopic dermatitis and allergic contact dermatitis (Contact Dermatitis 2008;58:188-9; Arch. Dermatol. 2008;144;1329-36; and J. Clin. Aesthet. Dermatol. 2010;3:29-35).

This research "shows us that allergic contact dermatitis is commonly associated with atopic dermatitis, both when you look at frequency of allergic contact dermatitis among patients with atopic dermatitis and the frequency of atopic dermatitis among patients with allergic contact dermatitis," Dr. Herro said.

She said that she had no relevant financial disclosures.

NEW ORLEANS – Patch testing and prescription of fragrance-free skin care regimens might be indicated for children with moderate to severe atopic dermatitis.

In a study of 101 children, 88% of 54 with atopic dermatitis had a positive patch test result for one or more allergens, compared with 66% of 47 participants without atopic dermatitis, a statistically significant difference.

Dr. Elise Herro and her associates also found a correlation regarding the severity of both conditions. "EASI [Eczema Area and Severity Index] scores greater than 10 also statistically correlated with a higher probability of greater than 3 positive patch tests," she said at the annual meeting of the American Contact Dermatitis Society.

Study participants were 6-18 years old. Of the total 101 patients patch tested, 79 had at least one reactive test result. The 54 children classified as atopic met Hanifin-Rajka criteria.

Nickel, balsam of Peru, and fragrance were the most common allergens in the study. Positive reactions were significantly more common in children with atopy versus children without atopy for nickel (35% vs. 26%), balsam of Peru (20% vs. 2%), and fragrance mix (19% vs. 0%).

"We [also] found contact allergens whose high prevalence was unique to our patient population," said Dr. Herro of Rady Children’s Hospital and the University of California, San Diego.

Dr. Herro and her colleagues identified children reactive to tixocortol pivalate, and para-tertiary-butylphenol-formaldehyde resin, a component of sports gear that can cause dermatitis. Positive tixocortol pivalate patch test reactions "could be related to the high percentage of atopic patients who have used topical corticosteroids."

Dr. Herro also reviewed previous studies that included patients with both atopic dermatitis and allergic contact dermatitis (Contact Dermatitis 2008;58:188-9; Arch. Dermatol. 2008;144;1329-36; and J. Clin. Aesthet. Dermatol. 2010;3:29-35).

This research "shows us that allergic contact dermatitis is commonly associated with atopic dermatitis, both when you look at frequency of allergic contact dermatitis among patients with atopic dermatitis and the frequency of atopic dermatitis among patients with allergic contact dermatitis," Dr. Herro said.

She said that she had no relevant financial disclosures.

NEW ORLEANS – Patch testing and prescription of fragrance-free skin care regimens might be indicated for children with moderate to severe atopic dermatitis.

In a study of 101 children, 88% of 54 with atopic dermatitis had a positive patch test result for one or more allergens, compared with 66% of 47 participants without atopic dermatitis, a statistically significant difference.

Dr. Elise Herro and her associates also found a correlation regarding the severity of both conditions. "EASI [Eczema Area and Severity Index] scores greater than 10 also statistically correlated with a higher probability of greater than 3 positive patch tests," she said at the annual meeting of the American Contact Dermatitis Society.

Study participants were 6-18 years old. Of the total 101 patients patch tested, 79 had at least one reactive test result. The 54 children classified as atopic met Hanifin-Rajka criteria.

Nickel, balsam of Peru, and fragrance were the most common allergens in the study. Positive reactions were significantly more common in children with atopy versus children without atopy for nickel (35% vs. 26%), balsam of Peru (20% vs. 2%), and fragrance mix (19% vs. 0%).

"We [also] found contact allergens whose high prevalence was unique to our patient population," said Dr. Herro of Rady Children’s Hospital and the University of California, San Diego.

Dr. Herro and her colleagues identified children reactive to tixocortol pivalate, and para-tertiary-butylphenol-formaldehyde resin, a component of sports gear that can cause dermatitis. Positive tixocortol pivalate patch test reactions "could be related to the high percentage of atopic patients who have used topical corticosteroids."

Dr. Herro also reviewed previous studies that included patients with both atopic dermatitis and allergic contact dermatitis (Contact Dermatitis 2008;58:188-9; Arch. Dermatol. 2008;144;1329-36; and J. Clin. Aesthet. Dermatol. 2010;3:29-35).

This research "shows us that allergic contact dermatitis is commonly associated with atopic dermatitis, both when you look at frequency of allergic contact dermatitis among patients with atopic dermatitis and the frequency of atopic dermatitis among patients with allergic contact dermatitis," Dr. Herro said.

She said that she had no relevant financial disclosures.

NEW ORLEANS – Patch testing and prescription of fragrance-free skin care regimens might be indicated for children with moderate to severe atopic dermatitis.

In a study of 101 children, 88% of 54 with atopic dermatitis had a positive patch test result for one or more allergens, compared with 66% of 47 participants without atopic dermatitis, a statistically significant difference.

Dr. Elise Herro and her associates also found a correlation regarding the severity of both conditions. "EASI [Eczema Area and Severity Index] scores greater than 10 also statistically correlated with a higher probability of greater than 3 positive patch tests," she said at the annual meeting of the American Contact Dermatitis Society.

Study participants were 6-18 years old. Of the total 101 patients patch tested, 79 had at least one reactive test result. The 54 children classified as atopic met Hanifin-Rajka criteria.

Nickel, balsam of Peru, and fragrance were the most common allergens in the study. Positive reactions were significantly more common in children with atopy versus children without atopy for nickel (35% vs. 26%), balsam of Peru (20% vs. 2%), and fragrance mix (19% vs. 0%).

"We [also] found contact allergens whose high prevalence was unique to our patient population," said Dr. Herro of Rady Children’s Hospital and the University of California, San Diego.

Dr. Herro and her colleagues identified children reactive to tixocortol pivalate, and para-tertiary-butylphenol-formaldehyde resin, a component of sports gear that can cause dermatitis. Positive tixocortol pivalate patch test reactions "could be related to the high percentage of atopic patients who have used topical corticosteroids."

Dr. Herro also reviewed previous studies that included patients with both atopic dermatitis and allergic contact dermatitis (Contact Dermatitis 2008;58:188-9; Arch. Dermatol. 2008;144;1329-36; and J. Clin. Aesthet. Dermatol. 2010;3:29-35).

This research "shows us that allergic contact dermatitis is commonly associated with atopic dermatitis, both when you look at frequency of allergic contact dermatitis among patients with atopic dermatitis and the frequency of atopic dermatitis among patients with allergic contact dermatitis," Dr. Herro said.

She said that she had no relevant financial disclosures.

NEW ORLEANS – Patch testing and prescription of fragrance-free skin care regimens might be indicated for children with moderate to severe atopic dermatitis.

In a study of 101 children, 88% of 54 with atopic dermatitis had a positive patch test result for one or more allergens, compared with 66% of 47 participants without atopic dermatitis, a statistically significant difference.

Dr. Elise Herro and her associates also found a correlation regarding the severity of both conditions. "EASI [Eczema Area and Severity Index] scores greater than 10 also statistically correlated with a higher probability of greater than 3 positive patch tests," she said at the annual meeting of the American Contact Dermatitis Society.

Study participants were 6-18 years old. Of the total 101 patients patch tested, 79 had at least one reactive test result. The 54 children classified as atopic met Hanifin-Rajka criteria.

Nickel, balsam of Peru, and fragrance were the most common allergens in the study. Positive reactions were significantly more common in children with atopy versus children without atopy for nickel (35% vs. 26%), balsam of Peru (20% vs. 2%), and fragrance mix (19% vs. 0%).

"We [also] found contact allergens whose high prevalence was unique to our patient population," said Dr. Herro of Rady Children’s Hospital and the University of California, San Diego.

Dr. Herro and her colleagues identified children reactive to tixocortol pivalate, and para-tertiary-butylphenol-formaldehyde resin, a component of sports gear that can cause dermatitis. Positive tixocortol pivalate patch test reactions "could be related to the high percentage of atopic patients who have used topical corticosteroids."

Dr. Herro also reviewed previous studies that included patients with both atopic dermatitis and allergic contact dermatitis (Contact Dermatitis 2008;58:188-9; Arch. Dermatol. 2008;144;1329-36; and J. Clin. Aesthet. Dermatol. 2010;3:29-35).

This research "shows us that allergic contact dermatitis is commonly associated with atopic dermatitis, both when you look at frequency of allergic contact dermatitis among patients with atopic dermatitis and the frequency of atopic dermatitis among patients with allergic contact dermatitis," Dr. Herro said.

She said that she had no relevant financial disclosures.

NEW ORLEANS – Patch testing and prescription of fragrance-free skin care regimens might be indicated for children with moderate to severe atopic dermatitis.

In a study of 101 children, 88% of 54 with atopic dermatitis had a positive patch test result for one or more allergens, compared with 66% of 47 participants without atopic dermatitis, a statistically significant difference.

Dr. Elise Herro and her associates also found a correlation regarding the severity of both conditions. "EASI [Eczema Area and Severity Index] scores greater than 10 also statistically correlated with a higher probability of greater than 3 positive patch tests," she said at the annual meeting of the American Contact Dermatitis Society.

Study participants were 6-18 years old. Of the total 101 patients patch tested, 79 had at least one reactive test result. The 54 children classified as atopic met Hanifin-Rajka criteria.

Nickel, balsam of Peru, and fragrance were the most common allergens in the study. Positive reactions were significantly more common in children with atopy versus children without atopy for nickel (35% vs. 26%), balsam of Peru (20% vs. 2%), and fragrance mix (19% vs. 0%).

"We [also] found contact allergens whose high prevalence was unique to our patient population," said Dr. Herro of Rady Children’s Hospital and the University of California, San Diego.

Dr. Herro and her colleagues identified children reactive to tixocortol pivalate, and para-tertiary-butylphenol-formaldehyde resin, a component of sports gear that can cause dermatitis. Positive tixocortol pivalate patch test reactions "could be related to the high percentage of atopic patients who have used topical corticosteroids."

Dr. Herro also reviewed previous studies that included patients with both atopic dermatitis and allergic contact dermatitis (Contact Dermatitis 2008;58:188-9; Arch. Dermatol. 2008;144;1329-36; and J. Clin. Aesthet. Dermatol. 2010;3:29-35).

This research "shows us that allergic contact dermatitis is commonly associated with atopic dermatitis, both when you look at frequency of allergic contact dermatitis among patients with atopic dermatitis and the frequency of atopic dermatitis among patients with allergic contact dermatitis," Dr. Herro said.

She said that she had no relevant financial disclosures.

NEW ORLEANS - When a patient presents with patches of lighter skin and you immediately go through the most likely clinical culprits in your head, don't forget to include hypochromia in your differential diagnosis among the common hypopigmentation disorders, Dr. James J. Nordlund said.

Although most diagnoses will not be definitive without a biopsy, your clinical suspicions are essential to alert your pathologist to look for subtle signs that in some cases can make a big difference in clinical treatment and outcomes, Dr. Nordlund said.

Mycosis fungoides, progressive macular hypomelanosis, sarcoidosis, and pityriasis alba are true hypopigmentation disorders characterized by decreases in melanin in the skin. In contrast, hypochromia or patches of light- or white-colored skin, can throw you off until the pathology report reveals normal melanin levels.

"These are some of the problems I struggle with. They are common and I see them every day, and I certainly have some successes and failures," Dr. Nordlund said at the annual meeting of the American Society of Dermatology.

A misdiagnosis of hypopigmentation "is probably the biggest problem when we don't get a great response in patients. You have to ask yourself if the condition is related to a melanin decrease," said Dr. Nordlund, professor of clinical dermatology at Wright State University in Dayton, Ohio.

Nevus anemicus is an example of hypochromia. This vascular anomaly often mimics hypopigmentation, Dr. Nordlund said. Scars also can cause hypochromia. A Wood's lamp might reveal excessive collagen in the dermis and decreased vascularity with scar tissue. "It appears to be depigmentation but it's not."

Mycosis fungoides, in contrast, is a true hypopigmentation disorder. The ultraviolet glow of a Wood's lamp, however, will be insufficient for most diagnoses. The clinical presentation is vague, so a biopsy helps to identify this condition, Dr. Nordlund said. He performs longitudinal shave biopsies if there is any doubt.

"It's important to keep hypopigmentation mycosis fungoides in mind as a cause of hypopigmentation on the trunk and extremities," Dr. Nordlund said. "Alert your pathologist to this possible diagnosis so they can look for the subtle signs."

Mycosis fungoides is more common in darker skin, affects both children and adults, and generally has a good prognosis. Treatment response generally is better with narrow-band ultraviolet B phototherapy or psoralen and ultraviolet A (PUVA) therapy than with topical steroids.

You also may see hypopigmentation in association with sarcoidosis, a granulomatous inflammation that most often presents as red, indurated nodules on the skin, although it can affect any or all organs. A punch biopsy can confirm if a lesion is sarcoid, Dr. Nordlund said. "You really cannot be sure except with histology."

A biopsy also helps to distinguish mycosis fungoides or sarcoidosis from a third hypopigmentation disorder called progressive macular hypomelanosis. Ill-defined macules typically begin on the back and spread, sparing the face, in darker-skinned patients. A meeting attendee asked if there are diagnostic studies for this condition. Dr. Nordlund said no. "I biopsy them, because I don't think it's distinguishable from mycosis fungoides or sarcoidosis. That is all I do, biopsy." Pathology generally reveals a mild-to-moderate deficiency of melanin.

This is "one disorder I see too often for my own desires. It's hard to treat," Dr. Nordlund said. PUVA is an option, but the hypopigmentation can return after treatment is discontinued. Some researchers suggest the condition is a form of Pityrosporum (now called Malassezia) infection, he added. "Minocycline 100 mg with benzoyl peroxide - I've tried this off-label approach - and sometimes I get a response."

There also is an idiopathic form. In idiopathic guttate hypomelanosis, melanocytes usually are present but melanization is suppressed. The epidermis will appear normal to slightly atrophic. Pathogenesis might be genetic and/or due to exposure to sunlight, "but I can't convince myself of the sunlight etiology," Dr. Nordlund said.

Also consider pityriasis alba, characterized by hypopigmentation with slight scaling but no pruritus, in your differential diagnosis. This condition is very common in children and young adults.

"From my own experience, UV light is not very helpful," Dr. Nordlund said.

"Oftentimes the mistake is to use high-potency steroids, which also suppress melanin. You essentially turn off melanin production and don't get a good response." Instead, he recommended long-term, mild steroid treatment with a product such as Desonide Lotion (available as a generic).

Tinea versicolor is a common infection that also causes hypopigmentation. The yeastlike Malassezia furfur fungus infects the stratum corneum. The condition is easily treated with topical or oral ketoconazole, Dr. Nordlund said, but complete response can take time. "Warn patients that hypopigmentation can persist for months."

Dr. Nordlund said that he had no relevant financial disclosures.

NEW ORLEANS - When a patient presents with patches of lighter skin and you immediately go through the most likely clinical culprits in your head, don't forget to include hypochromia in your differential diagnosis among the common hypopigmentation disorders, Dr. James J. Nordlund said.

Although most diagnoses will not be definitive without a biopsy, your clinical suspicions are essential to alert your pathologist to look for subtle signs that in some cases can make a big difference in clinical treatment and outcomes, Dr. Nordlund said.

Mycosis fungoides, progressive macular hypomelanosis, sarcoidosis, and pityriasis alba are true hypopigmentation disorders characterized by decreases in melanin in the skin. In contrast, hypochromia or patches of light- or white-colored skin, can throw you off until the pathology report reveals normal melanin levels.

"These are some of the problems I struggle with. They are common and I see them every day, and I certainly have some successes and failures," Dr. Nordlund said at the annual meeting of the American Society of Dermatology.

A misdiagnosis of hypopigmentation "is probably the biggest problem when we don't get a great response in patients. You have to ask yourself if the condition is related to a melanin decrease," said Dr. Nordlund, professor of clinical dermatology at Wright State University in Dayton, Ohio.

Nevus anemicus is an example of hypochromia. This vascular anomaly often mimics hypopigmentation, Dr. Nordlund said. Scars also can cause hypochromia. A Wood's lamp might reveal excessive collagen in the dermis and decreased vascularity with scar tissue. "It appears to be depigmentation but it's not."

Mycosis fungoides, in contrast, is a true hypopigmentation disorder. The ultraviolet glow of a Wood's lamp, however, will be insufficient for most diagnoses. The clinical presentation is vague, so a biopsy helps to identify this condition, Dr. Nordlund said. He performs longitudinal shave biopsies if there is any doubt.

"It's important to keep hypopigmentation mycosis fungoides in mind as a cause of hypopigmentation on the trunk and extremities," Dr. Nordlund said. "Alert your pathologist to this possible diagnosis so they can look for the subtle signs."

Mycosis fungoides is more common in darker skin, affects both children and adults, and generally has a good prognosis. Treatment response generally is better with narrow-band ultraviolet B phototherapy or psoralen and ultraviolet A (PUVA) therapy than with topical steroids.

You also may see hypopigmentation in association with sarcoidosis, a granulomatous inflammation that most often presents as red, indurated nodules on the skin, although it can affect any or all organs. A punch biopsy can confirm if a lesion is sarcoid, Dr. Nordlund said. "You really cannot be sure except with histology."

A biopsy also helps to distinguish mycosis fungoides or sarcoidosis from a third hypopigmentation disorder called progressive macular hypomelanosis. Ill-defined macules typically begin on the back and spread, sparing the face, in darker-skinned patients. A meeting attendee asked if there are diagnostic studies for this condition. Dr. Nordlund said no. "I biopsy them, because I don't think it's distinguishable from mycosis fungoides or sarcoidosis. That is all I do, biopsy." Pathology generally reveals a mild-to-moderate deficiency of melanin.

This is "one disorder I see too often for my own desires. It's hard to treat," Dr. Nordlund said. PUVA is an option, but the hypopigmentation can return after treatment is discontinued. Some researchers suggest the condition is a form of Pityrosporum (now called Malassezia) infection, he added. "Minocycline 100 mg with benzoyl peroxide - I've tried this off-label approach - and sometimes I get a response."

There also is an idiopathic form. In idiopathic guttate hypomelanosis, melanocytes usually are present but melanization is suppressed. The epidermis will appear normal to slightly atrophic. Pathogenesis might be genetic and/or due to exposure to sunlight, "but I can't convince myself of the sunlight etiology," Dr. Nordlund said.

Also consider pityriasis alba, characterized by hypopigmentation with slight scaling but no pruritus, in your differential diagnosis. This condition is very common in children and young adults.

"From my own experience, UV light is not very helpful," Dr. Nordlund said.

"Oftentimes the mistake is to use high-potency steroids, which also suppress melanin. You essentially turn off melanin production and don't get a good response." Instead, he recommended long-term, mild steroid treatment with a product such as Desonide Lotion (available as a generic).

Tinea versicolor is a common infection that also causes hypopigmentation. The yeastlike Malassezia furfur fungus infects the stratum corneum. The condition is easily treated with topical or oral ketoconazole, Dr. Nordlund said, but complete response can take time. "Warn patients that hypopigmentation can persist for months."

Dr. Nordlund said that he had no relevant financial disclosures.

NEW ORLEANS - When a patient presents with patches of lighter skin and you immediately go through the most likely clinical culprits in your head, don't forget to include hypochromia in your differential diagnosis among the common hypopigmentation disorders, Dr. James J. Nordlund said.

Although most diagnoses will not be definitive without a biopsy, your clinical suspicions are essential to alert your pathologist to look for subtle signs that in some cases can make a big difference in clinical treatment and outcomes, Dr. Nordlund said.

Mycosis fungoides, progressive macular hypomelanosis, sarcoidosis, and pityriasis alba are true hypopigmentation disorders characterized by decreases in melanin in the skin. In contrast, hypochromia or patches of light- or white-colored skin, can throw you off until the pathology report reveals normal melanin levels.

"These are some of the problems I struggle with. They are common and I see them every day, and I certainly have some successes and failures," Dr. Nordlund said at the annual meeting of the American Society of Dermatology.

A misdiagnosis of hypopigmentation "is probably the biggest problem when we don't get a great response in patients. You have to ask yourself if the condition is related to a melanin decrease," said Dr. Nordlund, professor of clinical dermatology at Wright State University in Dayton, Ohio.

Nevus anemicus is an example of hypochromia. This vascular anomaly often mimics hypopigmentation, Dr. Nordlund said. Scars also can cause hypochromia. A Wood's lamp might reveal excessive collagen in the dermis and decreased vascularity with scar tissue. "It appears to be depigmentation but it's not."

Mycosis fungoides, in contrast, is a true hypopigmentation disorder. The ultraviolet glow of a Wood's lamp, however, will be insufficient for most diagnoses. The clinical presentation is vague, so a biopsy helps to identify this condition, Dr. Nordlund said. He performs longitudinal shave biopsies if there is any doubt.

"It's important to keep hypopigmentation mycosis fungoides in mind as a cause of hypopigmentation on the trunk and extremities," Dr. Nordlund said. "Alert your pathologist to this possible diagnosis so they can look for the subtle signs."

Mycosis fungoides is more common in darker skin, affects both children and adults, and generally has a good prognosis. Treatment response generally is better with narrow-band ultraviolet B phototherapy or psoralen and ultraviolet A (PUVA) therapy than with topical steroids.

You also may see hypopigmentation in association with sarcoidosis, a granulomatous inflammation that most often presents as red, indurated nodules on the skin, although it can affect any or all organs. A punch biopsy can confirm if a lesion is sarcoid, Dr. Nordlund said. "You really cannot be sure except with histology."

A biopsy also helps to distinguish mycosis fungoides or sarcoidosis from a third hypopigmentation disorder called progressive macular hypomelanosis. Ill-defined macules typically begin on the back and spread, sparing the face, in darker-skinned patients. A meeting attendee asked if there are diagnostic studies for this condition. Dr. Nordlund said no. "I biopsy them, because I don't think it's distinguishable from mycosis fungoides or sarcoidosis. That is all I do, biopsy." Pathology generally reveals a mild-to-moderate deficiency of melanin.

This is "one disorder I see too often for my own desires. It's hard to treat," Dr. Nordlund said. PUVA is an option, but the hypopigmentation can return after treatment is discontinued. Some researchers suggest the condition is a form of Pityrosporum (now called Malassezia) infection, he added. "Minocycline 100 mg with benzoyl peroxide - I've tried this off-label approach - and sometimes I get a response."

There also is an idiopathic form. In idiopathic guttate hypomelanosis, melanocytes usually are present but melanization is suppressed. The epidermis will appear normal to slightly atrophic. Pathogenesis might be genetic and/or due to exposure to sunlight, "but I can't convince myself of the sunlight etiology," Dr. Nordlund said.

Also consider pityriasis alba, characterized by hypopigmentation with slight scaling but no pruritus, in your differential diagnosis. This condition is very common in children and young adults.

"From my own experience, UV light is not very helpful," Dr. Nordlund said.

"Oftentimes the mistake is to use high-potency steroids, which also suppress melanin. You essentially turn off melanin production and don't get a good response." Instead, he recommended long-term, mild steroid treatment with a product such as Desonide Lotion (available as a generic).

Tinea versicolor is a common infection that also causes hypopigmentation. The yeastlike Malassezia furfur fungus infects the stratum corneum. The condition is easily treated with topical or oral ketoconazole, Dr. Nordlund said, but complete response can take time. "Warn patients that hypopigmentation can persist for months."

Dr. Nordlund said that he had no relevant financial disclosures.