Damian McNamara

ORLANDO — Intraoperative glucose levels were often “undesirably high” among orthotopic liver transplant recipients in a 5-year, retrospective study at Tufts Medical Center in Boston.

These glucose levels, and their fluctuations, directly affected the probability of mortality and the length of stay in the surgical ICU, the researchers found.

In addition, “these effects were pronounced in diabetics,” Dr. Roman Schumann said. The analysis included 86 liver transplant recipients, 20 of whom had a history of diabetes mellitus.

Although control of glucose levels during cardiac surgery is well studied (Anesth. Analg. 2008;107:51–8; Ann. Intern. Med. 2007;146:233–43), data are limited regarding links between glycemic control and outcomes in patients undergoing orthotopic liver transplantation.

For that reason, Dr. Schumann and his colleagues looked at mean and peak glucose levels and variability of glucose levels, as well as insulin administration, in the years prior to adoption of an intraoperative glucose control protocol at Tufts.

They found a mean intraoperative glucose level of 187 mg/dL among nondiabetic recipients and 213 mg/dL among the diabetic patients; the difference was statistically significant. Mean peak glucose levels, however, did not differ significantly: 262 mg/dL among nondiabetic patients and 281 mg/dL for diabetic patients.

“Mean glucoses were fairly high for all patients, and peak glucoses were very high, I would say,” Dr. Schumann noted at the annual meeting of the American Society of Anesthesiologists.

“It turned out that peak glucose and variability were important for length of stay in the ICU,” Dr. Schumann said. Mean glucose levels, in contrast, were not significantly associated with a longer length of ICU stay. None of these factors was significantly associated with length of hospital stay.

Dr. Schumann was an anesthesiologist at Tufts at the time of the study. He currently works at Beth Israel Deaconess Medical Center, also in Boston.

Mean fluctuations in intraoperative glucose did not differ significantly between groups: 138 mg/dL among nondiabetic patients vs. 142 mg/dL among diabetic patients.

Not surprisingly, a lower percentage of nondiabetic patients, 38%, received intraoperative insulin, compared with 65% of diabetic patients. Length of hospital stay, time to extubation, and probability of hospital mortality did not differ significantly between those who received insulin and those who did not.

The study included 61 men and 25 women with a mean age of 52 years. Average body mass index was 28 kg/m

Glycemic control was managed at the discretion of the anesthesia team. Glucose determinations were performed hourly at a satellite laboratory in the operating room.

Dr. Schumann and his associates used a surrogate measure for probability of hospital mortality, the Simplified Acute Physiology Score (SAPS) II. They found that increasing patient age and Model for End-Stage Liver Disease (MELD) score were each significantly associated with increased probability of mortality. “All glucose values, as they increased, adversely affected SAPS score,” he said.

Three patients died, Dr. Schumann said in response to a meeting attendee's question. “Only three died over 5 years?” the attendee asked. “Yes, this was a small number of patients,” Dr. Schumann replied.

The retrospective design was a limitation, Dr. Schumann said during a question-and-answer session. Another limitation was that the researchers considered only intraoperative glucose levels. “There are a lot of factors besides glucose that can affect these factors, so it's a bit bold to say glucose is involved to the extent we think it may be,” he said.

The study results support use of protocol-driven glycemic control during orthotopic liver transplantation, Dr. Schumann said. Precise target values remain unknown, however. Future prospective studies may be able to determine the ideal target levels, he added.

ORLANDO — Intraoperative glucose levels were often “undesirably high” among orthotopic liver transplant recipients in a 5-year, retrospective study at Tufts Medical Center in Boston.

These glucose levels, and their fluctuations, directly affected the probability of mortality and the length of stay in the surgical ICU, the researchers found.

In addition, “these effects were pronounced in diabetics,” Dr. Roman Schumann said. The analysis included 86 liver transplant recipients, 20 of whom had a history of diabetes mellitus.

Although control of glucose levels during cardiac surgery is well studied (Anesth. Analg. 2008;107:51–8; Ann. Intern. Med. 2007;146:233–43), data are limited regarding links between glycemic control and outcomes in patients undergoing orthotopic liver transplantation.

For that reason, Dr. Schumann and his colleagues looked at mean and peak glucose levels and variability of glucose levels, as well as insulin administration, in the years prior to adoption of an intraoperative glucose control protocol at Tufts.

They found a mean intraoperative glucose level of 187 mg/dL among nondiabetic recipients and 213 mg/dL among the diabetic patients; the difference was statistically significant. Mean peak glucose levels, however, did not differ significantly: 262 mg/dL among nondiabetic patients and 281 mg/dL for diabetic patients.

“Mean glucoses were fairly high for all patients, and peak glucoses were very high, I would say,” Dr. Schumann noted at the annual meeting of the American Society of Anesthesiologists.

“It turned out that peak glucose and variability were important for length of stay in the ICU,” Dr. Schumann said. Mean glucose levels, in contrast, were not significantly associated with a longer length of ICU stay. None of these factors was significantly associated with length of hospital stay.

Dr. Schumann was an anesthesiologist at Tufts at the time of the study. He currently works at Beth Israel Deaconess Medical Center, also in Boston.

Mean fluctuations in intraoperative glucose did not differ significantly between groups: 138 mg/dL among nondiabetic patients vs. 142 mg/dL among diabetic patients.

Not surprisingly, a lower percentage of nondiabetic patients, 38%, received intraoperative insulin, compared with 65% of diabetic patients. Length of hospital stay, time to extubation, and probability of hospital mortality did not differ significantly between those who received insulin and those who did not.

The study included 61 men and 25 women with a mean age of 52 years. Average body mass index was 28 kg/m

Glycemic control was managed at the discretion of the anesthesia team. Glucose determinations were performed hourly at a satellite laboratory in the operating room.

Dr. Schumann and his associates used a surrogate measure for probability of hospital mortality, the Simplified Acute Physiology Score (SAPS) II. They found that increasing patient age and Model for End-Stage Liver Disease (MELD) score were each significantly associated with increased probability of mortality. “All glucose values, as they increased, adversely affected SAPS score,” he said.

Three patients died, Dr. Schumann said in response to a meeting attendee's question. “Only three died over 5 years?” the attendee asked. “Yes, this was a small number of patients,” Dr. Schumann replied.

The retrospective design was a limitation, Dr. Schumann said during a question-and-answer session. Another limitation was that the researchers considered only intraoperative glucose levels. “There are a lot of factors besides glucose that can affect these factors, so it's a bit bold to say glucose is involved to the extent we think it may be,” he said.

The study results support use of protocol-driven glycemic control during orthotopic liver transplantation, Dr. Schumann said. Precise target values remain unknown, however. Future prospective studies may be able to determine the ideal target levels, he added.

ORLANDO — Intraoperative glucose levels were often “undesirably high” among orthotopic liver transplant recipients in a 5-year, retrospective study at Tufts Medical Center in Boston.

These glucose levels, and their fluctuations, directly affected the probability of mortality and the length of stay in the surgical ICU, the researchers found.

In addition, “these effects were pronounced in diabetics,” Dr. Roman Schumann said. The analysis included 86 liver transplant recipients, 20 of whom had a history of diabetes mellitus.

Although control of glucose levels during cardiac surgery is well studied (Anesth. Analg. 2008;107:51–8; Ann. Intern. Med. 2007;146:233–43), data are limited regarding links between glycemic control and outcomes in patients undergoing orthotopic liver transplantation.

For that reason, Dr. Schumann and his colleagues looked at mean and peak glucose levels and variability of glucose levels, as well as insulin administration, in the years prior to adoption of an intraoperative glucose control protocol at Tufts.

They found a mean intraoperative glucose level of 187 mg/dL among nondiabetic recipients and 213 mg/dL among the diabetic patients; the difference was statistically significant. Mean peak glucose levels, however, did not differ significantly: 262 mg/dL among nondiabetic patients and 281 mg/dL for diabetic patients.

“Mean glucoses were fairly high for all patients, and peak glucoses were very high, I would say,” Dr. Schumann noted at the annual meeting of the American Society of Anesthesiologists.

“It turned out that peak glucose and variability were important for length of stay in the ICU,” Dr. Schumann said. Mean glucose levels, in contrast, were not significantly associated with a longer length of ICU stay. None of these factors was significantly associated with length of hospital stay.

Dr. Schumann was an anesthesiologist at Tufts at the time of the study. He currently works at Beth Israel Deaconess Medical Center, also in Boston.

Mean fluctuations in intraoperative glucose did not differ significantly between groups: 138 mg/dL among nondiabetic patients vs. 142 mg/dL among diabetic patients.

Not surprisingly, a lower percentage of nondiabetic patients, 38%, received intraoperative insulin, compared with 65% of diabetic patients. Length of hospital stay, time to extubation, and probability of hospital mortality did not differ significantly between those who received insulin and those who did not.

The study included 61 men and 25 women with a mean age of 52 years. Average body mass index was 28 kg/m

Glycemic control was managed at the discretion of the anesthesia team. Glucose determinations were performed hourly at a satellite laboratory in the operating room.

Dr. Schumann and his associates used a surrogate measure for probability of hospital mortality, the Simplified Acute Physiology Score (SAPS) II. They found that increasing patient age and Model for End-Stage Liver Disease (MELD) score were each significantly associated with increased probability of mortality. “All glucose values, as they increased, adversely affected SAPS score,” he said.

Three patients died, Dr. Schumann said in response to a meeting attendee's question. “Only three died over 5 years?” the attendee asked. “Yes, this was a small number of patients,” Dr. Schumann replied.

The retrospective design was a limitation, Dr. Schumann said during a question-and-answer session. Another limitation was that the researchers considered only intraoperative glucose levels. “There are a lot of factors besides glucose that can affect these factors, so it's a bit bold to say glucose is involved to the extent we think it may be,” he said.

The study results support use of protocol-driven glycemic control during orthotopic liver transplantation, Dr. Schumann said. Precise target values remain unknown, however. Future prospective studies may be able to determine the ideal target levels, he added.

People with sleep-disordered breathing were less likely to experience a normal nighttime decrease in systolic blood pressure and were at increased risk of adverse cardiac and other outcomes, according to a new prospective study.

Data from a previous study showed that most people experience a 10%–20% dip in blood pressure at nighttime (Hypertension 1995;26:60-9). Other data have shown an association between sleep apnea syndrome and a failure to experience the beneficial nighttime decrease in blood pressure, but the evidence is limited to cross-sectional studies (Am. J. Hypertens. 2001;14:887-92; Chest 2002;122:1148-55).

The current study's findings are important because “nocturnal nondipping” associated with sleep-disordered breathing (SDB) has been linked in earlier studies to target organ damage and a poor cardiovascular prognosis (Can. J. Cardiol. 2007;23:132-8; JAMA 1999;282:539-46).

Dr. Khin Mae Hla and her associates of the departments of medicine and population health sciences at the University of Wisconsin, Madison, assessed 328 adults in the ongoing Wisconsin Sleep Cohort Study. Mean patient age was 49 years, 63% were men, and the mean body mass index was 29 kg/m

The chances of developing systolic non-dipping were significantly correlated with baseline SDBseverity in a dose-response fashion. Patients scoring less than 5 on the Apnea-Hypopnea Index (no or minimal SDB) were used as a reference group. Those with mild SDB (score of 5 to 15) were three times as likely to develop systolic nondipping (adjusted odds ratio, 3.1), and those with moderate to severe SDB (score of 15 or greater) were more than four times as likely to develop systolic nondipping (OR, 4.4). The researchers controlled for possible confounders, including age, gender, body mass index, smoking, and alcohol use. Use of continuous positive airway pressure (CPAP) by 11 patients, antihypertensive medication use (42 patients), and inclusion of 8 patients with a history of cardiovascular disease did not significantly alter the findings, though inclusion of the CPAP patients was a possible limitation of the study, said the researchers. Grants from the National Institutes of Health helped fund the study.

People with sleep-disordered breathing were less likely to experience a normal nighttime decrease in systolic blood pressure and were at increased risk of adverse cardiac and other outcomes, according to a new prospective study.

Data from a previous study showed that most people experience a 10%–20% dip in blood pressure at nighttime (Hypertension 1995;26:60-9). Other data have shown an association between sleep apnea syndrome and a failure to experience the beneficial nighttime decrease in blood pressure, but the evidence is limited to cross-sectional studies (Am. J. Hypertens. 2001;14:887-92; Chest 2002;122:1148-55).

The current study's findings are important because “nocturnal nondipping” associated with sleep-disordered breathing (SDB) has been linked in earlier studies to target organ damage and a poor cardiovascular prognosis (Can. J. Cardiol. 2007;23:132-8; JAMA 1999;282:539-46).

Dr. Khin Mae Hla and her associates of the departments of medicine and population health sciences at the University of Wisconsin, Madison, assessed 328 adults in the ongoing Wisconsin Sleep Cohort Study. Mean patient age was 49 years, 63% were men, and the mean body mass index was 29 kg/m

The chances of developing systolic non-dipping were significantly correlated with baseline SDBseverity in a dose-response fashion. Patients scoring less than 5 on the Apnea-Hypopnea Index (no or minimal SDB) were used as a reference group. Those with mild SDB (score of 5 to 15) were three times as likely to develop systolic nondipping (adjusted odds ratio, 3.1), and those with moderate to severe SDB (score of 15 or greater) were more than four times as likely to develop systolic nondipping (OR, 4.4). The researchers controlled for possible confounders, including age, gender, body mass index, smoking, and alcohol use. Use of continuous positive airway pressure (CPAP) by 11 patients, antihypertensive medication use (42 patients), and inclusion of 8 patients with a history of cardiovascular disease did not significantly alter the findings, though inclusion of the CPAP patients was a possible limitation of the study, said the researchers. Grants from the National Institutes of Health helped fund the study.

People with sleep-disordered breathing were less likely to experience a normal nighttime decrease in systolic blood pressure and were at increased risk of adverse cardiac and other outcomes, according to a new prospective study.

Data from a previous study showed that most people experience a 10%–20% dip in blood pressure at nighttime (Hypertension 1995;26:60-9). Other data have shown an association between sleep apnea syndrome and a failure to experience the beneficial nighttime decrease in blood pressure, but the evidence is limited to cross-sectional studies (Am. J. Hypertens. 2001;14:887-92; Chest 2002;122:1148-55).

The current study's findings are important because “nocturnal nondipping” associated with sleep-disordered breathing (SDB) has been linked in earlier studies to target organ damage and a poor cardiovascular prognosis (Can. J. Cardiol. 2007;23:132-8; JAMA 1999;282:539-46).

Dr. Khin Mae Hla and her associates of the departments of medicine and population health sciences at the University of Wisconsin, Madison, assessed 328 adults in the ongoing Wisconsin Sleep Cohort Study. Mean patient age was 49 years, 63% were men, and the mean body mass index was 29 kg/m

The chances of developing systolic non-dipping were significantly correlated with baseline SDBseverity in a dose-response fashion. Patients scoring less than 5 on the Apnea-Hypopnea Index (no or minimal SDB) were used as a reference group. Those with mild SDB (score of 5 to 15) were three times as likely to develop systolic nondipping (adjusted odds ratio, 3.1), and those with moderate to severe SDB (score of 15 or greater) were more than four times as likely to develop systolic nondipping (OR, 4.4). The researchers controlled for possible confounders, including age, gender, body mass index, smoking, and alcohol use. Use of continuous positive airway pressure (CPAP) by 11 patients, antihypertensive medication use (42 patients), and inclusion of 8 patients with a history of cardiovascular disease did not significantly alter the findings, though inclusion of the CPAP patients was a possible limitation of the study, said the researchers. Grants from the National Institutes of Health helped fund the study.

ORLANDO — Racial differences in prevalence of erectile dysfunction in a large study were independent of traditional risk factors, including age, medical comorbidity, current tobacco use, and obesity.

Increased cardiovascular disease and diabetes risk in some racial groups prompted the study. Using Kaiser Permanente data, researchers for the California Men's Health Study assessed 81,426 men who self-reported African American, Hispanic, Asian/Pacific Islander, white, or other/multiple ethnicity and compared prevalence rates of erectile dysfunction (ED). Men of ethnic minorities were oversampled and represented 35% of the cohort.

Dr. James F. Smith and his associates found elevated ED prevalence in all other groups, compared with the white group. In a multivariate model, race data were adjusted for age, medical comorbidity, obesity, tobacco use, education, and income. Compared with a reference group of white men (odds ratio, 1.0), Asian/Pacific Islander men had a slight, nonsignificant increase in ED prevalence (OR, 1.06). However, African American (OR, 1.09), other/multiple ethnicity (OR, 1.16), and Hispanic men (OR, 1.19) had significantly higher prevalence rates.

“Small prevalence differences may have significant public health implications,” said Dr. Smith, an andrology fellow in the department of urology, University of California, San Francisco.

There was an inverse linear relationship between ED and higher income. For example, risk of ED was almost 50% higher for those who earned $20,000 or less versus men who earned $100,000 or more.

“We need to tell our patients to stop smoking, to lose weight, and to make a lot of money,” Dr. Smith said at the annual meeting of the American Urological Association. The study was funded by the California Cancer Research Program.

The researchers also confirmed clear associations between ED and traditional risk factors including older age, tobacco use, increased body mass index, cardiovascular disease, and diabetes. Men with diabetes were more likely to have ED (OR, 2.4), as were those with cardiovascular disease (OR, 1.7) or who currently used tobacco (OR, 1.4).

“There were clear associations between age and ED,” Dr. Smith said. For every 10-year increase in age, there was a 2.2 OR increase in risk of ED. Overall, ED prevalence rose from 13% of men aged 45–49 years, to 24% for men aged 50–59 years, to 44% for men aged 60–69 years. Similar increases with age were seen in all racial groups.

ELSEVIER GLOBAL MEDICAL NEWS

ORLANDO — Racial differences in prevalence of erectile dysfunction in a large study were independent of traditional risk factors, including age, medical comorbidity, current tobacco use, and obesity.

Increased cardiovascular disease and diabetes risk in some racial groups prompted the study. Using Kaiser Permanente data, researchers for the California Men's Health Study assessed 81,426 men who self-reported African American, Hispanic, Asian/Pacific Islander, white, or other/multiple ethnicity and compared prevalence rates of erectile dysfunction (ED). Men of ethnic minorities were oversampled and represented 35% of the cohort.

Dr. James F. Smith and his associates found elevated ED prevalence in all other groups, compared with the white group. In a multivariate model, race data were adjusted for age, medical comorbidity, obesity, tobacco use, education, and income. Compared with a reference group of white men (odds ratio, 1.0), Asian/Pacific Islander men had a slight, nonsignificant increase in ED prevalence (OR, 1.06). However, African American (OR, 1.09), other/multiple ethnicity (OR, 1.16), and Hispanic men (OR, 1.19) had significantly higher prevalence rates.

“Small prevalence differences may have significant public health implications,” said Dr. Smith, an andrology fellow in the department of urology, University of California, San Francisco.

There was an inverse linear relationship between ED and higher income. For example, risk of ED was almost 50% higher for those who earned $20,000 or less versus men who earned $100,000 or more.

“We need to tell our patients to stop smoking, to lose weight, and to make a lot of money,” Dr. Smith said at the annual meeting of the American Urological Association. The study was funded by the California Cancer Research Program.

The researchers also confirmed clear associations between ED and traditional risk factors including older age, tobacco use, increased body mass index, cardiovascular disease, and diabetes. Men with diabetes were more likely to have ED (OR, 2.4), as were those with cardiovascular disease (OR, 1.7) or who currently used tobacco (OR, 1.4).

“There were clear associations between age and ED,” Dr. Smith said. For every 10-year increase in age, there was a 2.2 OR increase in risk of ED. Overall, ED prevalence rose from 13% of men aged 45–49 years, to 24% for men aged 50–59 years, to 44% for men aged 60–69 years. Similar increases with age were seen in all racial groups.

ELSEVIER GLOBAL MEDICAL NEWS

ORLANDO — Racial differences in prevalence of erectile dysfunction in a large study were independent of traditional risk factors, including age, medical comorbidity, current tobacco use, and obesity.

Increased cardiovascular disease and diabetes risk in some racial groups prompted the study. Using Kaiser Permanente data, researchers for the California Men's Health Study assessed 81,426 men who self-reported African American, Hispanic, Asian/Pacific Islander, white, or other/multiple ethnicity and compared prevalence rates of erectile dysfunction (ED). Men of ethnic minorities were oversampled and represented 35% of the cohort.

Dr. James F. Smith and his associates found elevated ED prevalence in all other groups, compared with the white group. In a multivariate model, race data were adjusted for age, medical comorbidity, obesity, tobacco use, education, and income. Compared with a reference group of white men (odds ratio, 1.0), Asian/Pacific Islander men had a slight, nonsignificant increase in ED prevalence (OR, 1.06). However, African American (OR, 1.09), other/multiple ethnicity (OR, 1.16), and Hispanic men (OR, 1.19) had significantly higher prevalence rates.

“Small prevalence differences may have significant public health implications,” said Dr. Smith, an andrology fellow in the department of urology, University of California, San Francisco.

There was an inverse linear relationship between ED and higher income. For example, risk of ED was almost 50% higher for those who earned $20,000 or less versus men who earned $100,000 or more.

“We need to tell our patients to stop smoking, to lose weight, and to make a lot of money,” Dr. Smith said at the annual meeting of the American Urological Association. The study was funded by the California Cancer Research Program.

The researchers also confirmed clear associations between ED and traditional risk factors including older age, tobacco use, increased body mass index, cardiovascular disease, and diabetes. Men with diabetes were more likely to have ED (OR, 2.4), as were those with cardiovascular disease (OR, 1.7) or who currently used tobacco (OR, 1.4).

“There were clear associations between age and ED,” Dr. Smith said. For every 10-year increase in age, there was a 2.2 OR increase in risk of ED. Overall, ED prevalence rose from 13% of men aged 45–49 years, to 24% for men aged 50–59 years, to 44% for men aged 60–69 years. Similar increases with age were seen in all racial groups.

ELSEVIER GLOBAL MEDICAL NEWS

ORLANDO — Gastric bypass surgery leads to significant improvement in the sexual dysfunction experienced by many morbidly obese men, a recent study found.

The effects of surgical weight loss on sexual function are not well studied, although dramatic improvements in diabetes, hypertension, and cardiovascular disease risk have been associated with gastric bypass surgery in previous studies.

“The reason this is newsworthy is we have an increasing problem with obesity worldwide,” said Dr. Ira Sharlip, moderator of a press briefing at the annual meeting of the American Urological Association. “One of the problems that arise[s] with morbid obesity is sexual dysfunction.” Dr. Sharlip practices internal medicine and urology in San Francisco.

The decrease in sexual function can be considerable. “A male—obese or morbidly obese—has the same amount of sexual dysfunction as a male 20 years older than him,” coauthor Dr. Jason A. Smith said.

Participants had substantially lower sexual function scores before surgery than did normal-weight men, said Dr. Smith, a urology resident at Albert Einstein Medical Center in Philadelphia. The researchers used sexual function scores from a reference group of normal-weight men who participated in a previous study (J. Urol. 2007;177:1438-42).

“So far, only 20% of patients seeking [gastric bypass surgery] treatment are men,” Dr. Smith said. “We think there are more social pressures for women. We believe sex life is important to men, so this will be an incentive for men to seek gastric bypass.”

Dr. Smith, with lead author Dr. Ramsey M. Dallal, a bariatric surgeon in Elkins Park, Pa., and their associates, assessed sexual function among 95 morbidly obese men before and after Roux-en-Y gastric bypass surgery. Their mean body mass index was 51 kg/m

Participants rated their preoperative and postoperative sexual function using the 11-question Brief Sexual Inventory. This instrument addresses multiple domains including sexual drive, erectile dysfunction, and overall sexual satisfaction.

Postoperative assessment was conducted at a mean of 19 months after surgery. “Overall, in all sexual domains, all improved. This is what we expected to find,” Dr. Smith said. But “the degree to which they improved exceeded our expectations.”

Sexual drive scores, for example, improved from 3.9 to 5.4 (scale of 0–8) in a bivariate analysis. Erectile dysfunction scores improved from 6.3 to 8.9 (scale of 0–12), ejaculatory function improved from 4.9 to 6.3 (scale of 0–8), problem assessment improved from 7.4 to 9.5 (scale of 0–12), and sexual satisfaction improved from 1.6 to 2.2 (scale of 0–4). All of these changes were statistically significant.

The amount of weight loss predicted the enhancement in all sexual function domains in a multivariate analysis that controlled for age, diabetes, hypertension, and cigarette smoking.

On average, participants had a 67% excess weight loss after 1 year. Their mean weight decreased from 155 kg (342 pounds) to 102 kg (225 pounds). Because the researchers controlled for confounders, “weight alone was responsible for sexual dysfunction [preoperatively], and weight loss alone was responsible for improvement in scores,” Dr. Smith said.

Sexual dysfunction “should be considered one of the numerous reversible conditions in the morbidly obese,” Dr. Smith said, adding that this is the first study to look at sexual function in men after Roux-en-Y gastric bypass. Previous research assessed only nonsurgical weight loss options, with inconsistent results.

Dr. Richard Harkaway, another coauthor, said, “We are fortunate to have one of the few academic bariatric surgery centers that keeps a large database and was willing to work with urologists.” The findings will be very easy to verify, he added.

Not stratifying patients according to prior use of PDE5 inhibitors is a potential limitation of the study, said Dr. Harkaway, a urologist who practices in Philadelphia. Also, the researchers did not account for psychogenic impotence, “which is supposed to be about 20% in all [impotent] men, but could be higher in obese men because body image plays a role.” The researchers plan to do a similar study on women as well.

ORLANDO — Gastric bypass surgery leads to significant improvement in the sexual dysfunction experienced by many morbidly obese men, a recent study found.

The effects of surgical weight loss on sexual function are not well studied, although dramatic improvements in diabetes, hypertension, and cardiovascular disease risk have been associated with gastric bypass surgery in previous studies.

“The reason this is newsworthy is we have an increasing problem with obesity worldwide,” said Dr. Ira Sharlip, moderator of a press briefing at the annual meeting of the American Urological Association. “One of the problems that arise[s] with morbid obesity is sexual dysfunction.” Dr. Sharlip practices internal medicine and urology in San Francisco.

The decrease in sexual function can be considerable. “A male—obese or morbidly obese—has the same amount of sexual dysfunction as a male 20 years older than him,” coauthor Dr. Jason A. Smith said.

Participants had substantially lower sexual function scores before surgery than did normal-weight men, said Dr. Smith, a urology resident at Albert Einstein Medical Center in Philadelphia. The researchers used sexual function scores from a reference group of normal-weight men who participated in a previous study (J. Urol. 2007;177:1438-42).

“So far, only 20% of patients seeking [gastric bypass surgery] treatment are men,” Dr. Smith said. “We think there are more social pressures for women. We believe sex life is important to men, so this will be an incentive for men to seek gastric bypass.”

Dr. Smith, with lead author Dr. Ramsey M. Dallal, a bariatric surgeon in Elkins Park, Pa., and their associates, assessed sexual function among 95 morbidly obese men before and after Roux-en-Y gastric bypass surgery. Their mean body mass index was 51 kg/m

Participants rated their preoperative and postoperative sexual function using the 11-question Brief Sexual Inventory. This instrument addresses multiple domains including sexual drive, erectile dysfunction, and overall sexual satisfaction.

Postoperative assessment was conducted at a mean of 19 months after surgery. “Overall, in all sexual domains, all improved. This is what we expected to find,” Dr. Smith said. But “the degree to which they improved exceeded our expectations.”

Sexual drive scores, for example, improved from 3.9 to 5.4 (scale of 0–8) in a bivariate analysis. Erectile dysfunction scores improved from 6.3 to 8.9 (scale of 0–12), ejaculatory function improved from 4.9 to 6.3 (scale of 0–8), problem assessment improved from 7.4 to 9.5 (scale of 0–12), and sexual satisfaction improved from 1.6 to 2.2 (scale of 0–4). All of these changes were statistically significant.

The amount of weight loss predicted the enhancement in all sexual function domains in a multivariate analysis that controlled for age, diabetes, hypertension, and cigarette smoking.

On average, participants had a 67% excess weight loss after 1 year. Their mean weight decreased from 155 kg (342 pounds) to 102 kg (225 pounds). Because the researchers controlled for confounders, “weight alone was responsible for sexual dysfunction [preoperatively], and weight loss alone was responsible for improvement in scores,” Dr. Smith said.

Sexual dysfunction “should be considered one of the numerous reversible conditions in the morbidly obese,” Dr. Smith said, adding that this is the first study to look at sexual function in men after Roux-en-Y gastric bypass. Previous research assessed only nonsurgical weight loss options, with inconsistent results.

Dr. Richard Harkaway, another coauthor, said, “We are fortunate to have one of the few academic bariatric surgery centers that keeps a large database and was willing to work with urologists.” The findings will be very easy to verify, he added.

Not stratifying patients according to prior use of PDE5 inhibitors is a potential limitation of the study, said Dr. Harkaway, a urologist who practices in Philadelphia. Also, the researchers did not account for psychogenic impotence, “which is supposed to be about 20% in all [impotent] men, but could be higher in obese men because body image plays a role.” The researchers plan to do a similar study on women as well.

ORLANDO — Gastric bypass surgery leads to significant improvement in the sexual dysfunction experienced by many morbidly obese men, a recent study found.

The effects of surgical weight loss on sexual function are not well studied, although dramatic improvements in diabetes, hypertension, and cardiovascular disease risk have been associated with gastric bypass surgery in previous studies.

“The reason this is newsworthy is we have an increasing problem with obesity worldwide,” said Dr. Ira Sharlip, moderator of a press briefing at the annual meeting of the American Urological Association. “One of the problems that arise[s] with morbid obesity is sexual dysfunction.” Dr. Sharlip practices internal medicine and urology in San Francisco.

The decrease in sexual function can be considerable. “A male—obese or morbidly obese—has the same amount of sexual dysfunction as a male 20 years older than him,” coauthor Dr. Jason A. Smith said.

Participants had substantially lower sexual function scores before surgery than did normal-weight men, said Dr. Smith, a urology resident at Albert Einstein Medical Center in Philadelphia. The researchers used sexual function scores from a reference group of normal-weight men who participated in a previous study (J. Urol. 2007;177:1438-42).

“So far, only 20% of patients seeking [gastric bypass surgery] treatment are men,” Dr. Smith said. “We think there are more social pressures for women. We believe sex life is important to men, so this will be an incentive for men to seek gastric bypass.”

Dr. Smith, with lead author Dr. Ramsey M. Dallal, a bariatric surgeon in Elkins Park, Pa., and their associates, assessed sexual function among 95 morbidly obese men before and after Roux-en-Y gastric bypass surgery. Their mean body mass index was 51 kg/m

Participants rated their preoperative and postoperative sexual function using the 11-question Brief Sexual Inventory. This instrument addresses multiple domains including sexual drive, erectile dysfunction, and overall sexual satisfaction.

Postoperative assessment was conducted at a mean of 19 months after surgery. “Overall, in all sexual domains, all improved. This is what we expected to find,” Dr. Smith said. But “the degree to which they improved exceeded our expectations.”

Sexual drive scores, for example, improved from 3.9 to 5.4 (scale of 0–8) in a bivariate analysis. Erectile dysfunction scores improved from 6.3 to 8.9 (scale of 0–12), ejaculatory function improved from 4.9 to 6.3 (scale of 0–8), problem assessment improved from 7.4 to 9.5 (scale of 0–12), and sexual satisfaction improved from 1.6 to 2.2 (scale of 0–4). All of these changes were statistically significant.

The amount of weight loss predicted the enhancement in all sexual function domains in a multivariate analysis that controlled for age, diabetes, hypertension, and cigarette smoking.

On average, participants had a 67% excess weight loss after 1 year. Their mean weight decreased from 155 kg (342 pounds) to 102 kg (225 pounds). Because the researchers controlled for confounders, “weight alone was responsible for sexual dysfunction [preoperatively], and weight loss alone was responsible for improvement in scores,” Dr. Smith said.

Sexual dysfunction “should be considered one of the numerous reversible conditions in the morbidly obese,” Dr. Smith said, adding that this is the first study to look at sexual function in men after Roux-en-Y gastric bypass. Previous research assessed only nonsurgical weight loss options, with inconsistent results.

Dr. Richard Harkaway, another coauthor, said, “We are fortunate to have one of the few academic bariatric surgery centers that keeps a large database and was willing to work with urologists.” The findings will be very easy to verify, he added.

Not stratifying patients according to prior use of PDE5 inhibitors is a potential limitation of the study, said Dr. Harkaway, a urologist who practices in Philadelphia. Also, the researchers did not account for psychogenic impotence, “which is supposed to be about 20% in all [impotent] men, but could be higher in obese men because body image plays a role.” The researchers plan to do a similar study on women as well.

ORLANDO — With increasing use of androgen deprivation hormone therapy for men with prostate cancer come growing concerns about an increased risk of diabetes, cardiovascular morbidity, and other adverse treatment effects.

Consider these risks when prescribing gonadotropin-releasing hormone agonist therapy for men with prostate cancer, and screen for comorbidities, Dr. Matthew Smith advised. Educate patients about adverse treatment effects and counsel them on lifestyle modifications that could ultimately decrease these risks, he added.

A gradual improvement in prostate cancer-specific mortality since the early 1990s has been accompanied by the rising use of GnRH agonists in the United States, so physicians might start seeing more patients with adverse effects from these agents. About 3% of the entire male Medicare population and one-third of approximately 2 million prostate cancer survivors now take GnRH agonists, Dr. Smith said at the annual meeting of the American Urological Association.

Loss of libido, vasomotor flushing, fatigue, anemia, and increased risk of osteoporosis are among the adverse events associated with androgen deprivation, said Dr. Smith, director of genitourinary medical oncology at Massachusetts General Hospital in Boston.

“GnRH agonists also make a common problem—obesity—worse,” Dr. Smith said. These agents decrease muscle mass and increase fat mass, according to a previous study by Dr. Smith and his associates (J. Clin. Endocrinol. Metab. 2002;87:599-603).

Changes can become apparent as soon as 12 weeks after initiating therapy, Dr. Smith said. Also, 2- to 3-kg muscle loss and 3-kg fat accumulation can occur in 1 year, he and his associates reported (Cancer 2008;112:2188-94). These agents selectively increase subcutaneous fat mass, with approximately 94% of the fat accumulation occurring in the abdomen. Because accumulation of abdominal fat is often associated with adverse health outcomes, “it's not just a cosmetic issue.”

Lipid changes are more prevalent among men treated with GnRH agonists, compared with those not treated with these agents, according to a cross-sectional study by other researchers (Int. J. Impot. Res. 2006;18:494-8).

Dr. Smith said lipid changes can occur rapidly, in as little as 3 months after initiation of GnRH agonist therapy. However, overall cardiovascular risk is less clear because patients can experience increases in total cholesterol, LDL cholesterol, and triglyceride levels as well as increases in HDL cholesterol. “Overall cardiovascular risk effect warrants further study.”

Also consider monitoring patients for changes in insulin sensitivity during GnRH agonist therapy, Dr. Smith said. In one study, there was a “fairly dramatic rise in compensatory insulin levels in nondiabetic men—changes consistent with nondiabetic insulin resistance” (J. Clin. Endocrinol. Metab. 2006;91:1305-8).

A 44% excess risk for diabetes and 16% excess risk for coronary heart disease were among the findings of another study by Dr. Smith and colleagues (J. Clin. Oncol. 2006;24:4448-56). More than one-third of 73,196 Medicare enrollees aged 66 years and older received androgen deprivation therapy in this Surveillance Epidemiology and End Results (SEER) database study. After controlling for baseline covariates, GnRH agonist exposure was associated with a greater risk for diagnosis of incident diabetes (hazard ratio, 1.44), coronary heart disease (HR, 1.16), myocardial infarction (HR, 1.11), and sudden death (HR, 1.16), Dr. Smith said.

Even slightly elevated risks associated with GnRH agonist treatment are clinically relevant given the increased risks already associated with advanced age in the prostate cancer population, Dr. Smith said.

What is less clear is whether GnRH agonists alter cardiovascular mortality. Dr. Smith said, “It's premature to conclude that GnRH agonists increase cardiovascular disease mortality. More studies are needed.”

ORLANDO — With increasing use of androgen deprivation hormone therapy for men with prostate cancer come growing concerns about an increased risk of diabetes, cardiovascular morbidity, and other adverse treatment effects.

Consider these risks when prescribing gonadotropin-releasing hormone agonist therapy for men with prostate cancer, and screen for comorbidities, Dr. Matthew Smith advised. Educate patients about adverse treatment effects and counsel them on lifestyle modifications that could ultimately decrease these risks, he added.

A gradual improvement in prostate cancer-specific mortality since the early 1990s has been accompanied by the rising use of GnRH agonists in the United States, so physicians might start seeing more patients with adverse effects from these agents. About 3% of the entire male Medicare population and one-third of approximately 2 million prostate cancer survivors now take GnRH agonists, Dr. Smith said at the annual meeting of the American Urological Association.

Loss of libido, vasomotor flushing, fatigue, anemia, and increased risk of osteoporosis are among the adverse events associated with androgen deprivation, said Dr. Smith, director of genitourinary medical oncology at Massachusetts General Hospital in Boston.

“GnRH agonists also make a common problem—obesity—worse,” Dr. Smith said. These agents decrease muscle mass and increase fat mass, according to a previous study by Dr. Smith and his associates (J. Clin. Endocrinol. Metab. 2002;87:599-603).

Changes can become apparent as soon as 12 weeks after initiating therapy, Dr. Smith said. Also, 2- to 3-kg muscle loss and 3-kg fat accumulation can occur in 1 year, he and his associates reported (Cancer 2008;112:2188-94). These agents selectively increase subcutaneous fat mass, with approximately 94% of the fat accumulation occurring in the abdomen. Because accumulation of abdominal fat is often associated with adverse health outcomes, “it's not just a cosmetic issue.”

Lipid changes are more prevalent among men treated with GnRH agonists, compared with those not treated with these agents, according to a cross-sectional study by other researchers (Int. J. Impot. Res. 2006;18:494-8).

Dr. Smith said lipid changes can occur rapidly, in as little as 3 months after initiation of GnRH agonist therapy. However, overall cardiovascular risk is less clear because patients can experience increases in total cholesterol, LDL cholesterol, and triglyceride levels as well as increases in HDL cholesterol. “Overall cardiovascular risk effect warrants further study.”

Also consider monitoring patients for changes in insulin sensitivity during GnRH agonist therapy, Dr. Smith said. In one study, there was a “fairly dramatic rise in compensatory insulin levels in nondiabetic men—changes consistent with nondiabetic insulin resistance” (J. Clin. Endocrinol. Metab. 2006;91:1305-8).

A 44% excess risk for diabetes and 16% excess risk for coronary heart disease were among the findings of another study by Dr. Smith and colleagues (J. Clin. Oncol. 2006;24:4448-56). More than one-third of 73,196 Medicare enrollees aged 66 years and older received androgen deprivation therapy in this Surveillance Epidemiology and End Results (SEER) database study. After controlling for baseline covariates, GnRH agonist exposure was associated with a greater risk for diagnosis of incident diabetes (hazard ratio, 1.44), coronary heart disease (HR, 1.16), myocardial infarction (HR, 1.11), and sudden death (HR, 1.16), Dr. Smith said.

Even slightly elevated risks associated with GnRH agonist treatment are clinically relevant given the increased risks already associated with advanced age in the prostate cancer population, Dr. Smith said.

What is less clear is whether GnRH agonists alter cardiovascular mortality. Dr. Smith said, “It's premature to conclude that GnRH agonists increase cardiovascular disease mortality. More studies are needed.”

ORLANDO — With increasing use of androgen deprivation hormone therapy for men with prostate cancer come growing concerns about an increased risk of diabetes, cardiovascular morbidity, and other adverse treatment effects.

Consider these risks when prescribing gonadotropin-releasing hormone agonist therapy for men with prostate cancer, and screen for comorbidities, Dr. Matthew Smith advised. Educate patients about adverse treatment effects and counsel them on lifestyle modifications that could ultimately decrease these risks, he added.

A gradual improvement in prostate cancer-specific mortality since the early 1990s has been accompanied by the rising use of GnRH agonists in the United States, so physicians might start seeing more patients with adverse effects from these agents. About 3% of the entire male Medicare population and one-third of approximately 2 million prostate cancer survivors now take GnRH agonists, Dr. Smith said at the annual meeting of the American Urological Association.

Loss of libido, vasomotor flushing, fatigue, anemia, and increased risk of osteoporosis are among the adverse events associated with androgen deprivation, said Dr. Smith, director of genitourinary medical oncology at Massachusetts General Hospital in Boston.

“GnRH agonists also make a common problem—obesity—worse,” Dr. Smith said. These agents decrease muscle mass and increase fat mass, according to a previous study by Dr. Smith and his associates (J. Clin. Endocrinol. Metab. 2002;87:599-603).

Changes can become apparent as soon as 12 weeks after initiating therapy, Dr. Smith said. Also, 2- to 3-kg muscle loss and 3-kg fat accumulation can occur in 1 year, he and his associates reported (Cancer 2008;112:2188-94). These agents selectively increase subcutaneous fat mass, with approximately 94% of the fat accumulation occurring in the abdomen. Because accumulation of abdominal fat is often associated with adverse health outcomes, “it's not just a cosmetic issue.”

Lipid changes are more prevalent among men treated with GnRH agonists, compared with those not treated with these agents, according to a cross-sectional study by other researchers (Int. J. Impot. Res. 2006;18:494-8).

Dr. Smith said lipid changes can occur rapidly, in as little as 3 months after initiation of GnRH agonist therapy. However, overall cardiovascular risk is less clear because patients can experience increases in total cholesterol, LDL cholesterol, and triglyceride levels as well as increases in HDL cholesterol. “Overall cardiovascular risk effect warrants further study.”

Also consider monitoring patients for changes in insulin sensitivity during GnRH agonist therapy, Dr. Smith said. In one study, there was a “fairly dramatic rise in compensatory insulin levels in nondiabetic men—changes consistent with nondiabetic insulin resistance” (J. Clin. Endocrinol. Metab. 2006;91:1305-8).

A 44% excess risk for diabetes and 16% excess risk for coronary heart disease were among the findings of another study by Dr. Smith and colleagues (J. Clin. Oncol. 2006;24:4448-56). More than one-third of 73,196 Medicare enrollees aged 66 years and older received androgen deprivation therapy in this Surveillance Epidemiology and End Results (SEER) database study. After controlling for baseline covariates, GnRH agonist exposure was associated with a greater risk for diagnosis of incident diabetes (hazard ratio, 1.44), coronary heart disease (HR, 1.16), myocardial infarction (HR, 1.11), and sudden death (HR, 1.16), Dr. Smith said.

Even slightly elevated risks associated with GnRH agonist treatment are clinically relevant given the increased risks already associated with advanced age in the prostate cancer population, Dr. Smith said.

What is less clear is whether GnRH agonists alter cardiovascular mortality. Dr. Smith said, “It's premature to conclude that GnRH agonists increase cardiovascular disease mortality. More studies are needed.”

ORLANDO — Adjuvant radiotherapy following prostate cancer surgery significantly improved overall and metastatic disease-free survival, compared with surgery alone, according to 12-year results of an ongoing, randomized prospective study.

Adjuvant radiotherapy also increased biochemical control, avoided the need for androgen ablation, decreased detectable local failures, and decreased metastatic disease.

“It improved every parameter of which we know,” Dr. Gregory Swanson said during a late-breaking science forum at the annual meeting of the American Urological Association.

Dr. Swanson and fellow researchers with the Southwest Oncology Group (SWOG) Genitourinary Committee assessed 425 men with pathology-proven pT3 prostate cancer. All of the men had surgical margins positive for cancer following radical prostatectomy, placing them at high risk for recurrence. The mean age was about 65 years. Radiotherapy was 60–64 Gy directed at the prostate fossa.

A total of 214 men were randomized to surgery and radiation and 211 received surgery alone. Median follow-up is now longer than 12 years, said Dr. Swanson of the departments of radiation oncology and urology at the University of Texas at San Antonio.

Previously reported, 10-year median follow-up results showed significantly improved biochemical control and decreased local failure in the radiation group, but only a trend toward improved metastatic-free and overall survival.

“Metastatic-free survival is now statistically significant. So the finding is positive that radiation does improve metastasis-free survival for high-risk patients,” Dr. Swanson said.

The 15-year metastatic-free survival is 46% in the radiation group, compared with 38% in the observation group (hazard ratio, 0.74). The 15-year overall survival rates were similar—47% in the radiation group, compared with 37% in the observation group (HR, 0.76).

However, the trade-off for improved outcomes was greater morbidity in the adjuvant radiotherapy group, Dr. Swanson reported. A review of records showed that urethral stricture occurred in 38 patients (18%) in the radiation group, compared with 20 patients (10%) in the observation group.

Likewise, incontinence occurred more often in the radiation group (14 patients, 7%) than it did in the observation group (6 patients, 3%). Proctitis occurred in seven patients (3%) of the radiation group but in none of the observation group.

The SWOG researchers also tracked complications prospectively. Compared with baseline, they found that there was a significantly higher rate of complications at 6 weeks in the radiation than in the observation groups. For example, 71% of patients in the radiation group and 43% of the patients in the observation groups reported an unpleasant quality of life; 37% and 18%, respectively, reported increased urinary frequency; and 59% and 7%, respectively, reported bowel tenderness.

At 2 years' follow-up, only increased urinary frequency (24%, compared with 13%) and bowel tenderness (19%, compared with 4%) remained significantly more common in the radiation group.

At 5 years, complications were no longer significantly different between groups. “There is increased morbidity, but it's manageable and reduces over time,” Dr. Swanson said.

On the basis of these findings, adjuvant radiotherapy should be offered to all high-risk postsurgery patients, he said. “We can significantly reduce recurrence by all parameters with adjuvant radiation.”

A meeting attendee asked if any patients opted out of radiation therapy. “There were four in each arm who did not get the treatment they were assigned to,” Dr. Swanson said.

Another attendee asked if postoperative prostate-specific antigen levels were 0 in all patients after surgery. Dr. Swanson replied that 98% were below 1.0 ng/mL.

“But you are right—not all were 0 PSA.” The investigators previously reported that adjuvant radiation reduces the risk of biochemical failure at all postsurgical PSA levels at a follow-up of 10 years (J. Clin. Oncol. 2007;25:2225–9).

ORLANDO — Adjuvant radiotherapy following prostate cancer surgery significantly improved overall and metastatic disease-free survival, compared with surgery alone, according to 12-year results of an ongoing, randomized prospective study.

Adjuvant radiotherapy also increased biochemical control, avoided the need for androgen ablation, decreased detectable local failures, and decreased metastatic disease.

“It improved every parameter of which we know,” Dr. Gregory Swanson said during a late-breaking science forum at the annual meeting of the American Urological Association.

Dr. Swanson and fellow researchers with the Southwest Oncology Group (SWOG) Genitourinary Committee assessed 425 men with pathology-proven pT3 prostate cancer. All of the men had surgical margins positive for cancer following radical prostatectomy, placing them at high risk for recurrence. The mean age was about 65 years. Radiotherapy was 60–64 Gy directed at the prostate fossa.

A total of 214 men were randomized to surgery and radiation and 211 received surgery alone. Median follow-up is now longer than 12 years, said Dr. Swanson of the departments of radiation oncology and urology at the University of Texas at San Antonio.

Previously reported, 10-year median follow-up results showed significantly improved biochemical control and decreased local failure in the radiation group, but only a trend toward improved metastatic-free and overall survival.

“Metastatic-free survival is now statistically significant. So the finding is positive that radiation does improve metastasis-free survival for high-risk patients,” Dr. Swanson said.

The 15-year metastatic-free survival is 46% in the radiation group, compared with 38% in the observation group (hazard ratio, 0.74). The 15-year overall survival rates were similar—47% in the radiation group, compared with 37% in the observation group (HR, 0.76).

However, the trade-off for improved outcomes was greater morbidity in the adjuvant radiotherapy group, Dr. Swanson reported. A review of records showed that urethral stricture occurred in 38 patients (18%) in the radiation group, compared with 20 patients (10%) in the observation group.

Likewise, incontinence occurred more often in the radiation group (14 patients, 7%) than it did in the observation group (6 patients, 3%). Proctitis occurred in seven patients (3%) of the radiation group but in none of the observation group.

The SWOG researchers also tracked complications prospectively. Compared with baseline, they found that there was a significantly higher rate of complications at 6 weeks in the radiation than in the observation groups. For example, 71% of patients in the radiation group and 43% of the patients in the observation groups reported an unpleasant quality of life; 37% and 18%, respectively, reported increased urinary frequency; and 59% and 7%, respectively, reported bowel tenderness.

At 2 years' follow-up, only increased urinary frequency (24%, compared with 13%) and bowel tenderness (19%, compared with 4%) remained significantly more common in the radiation group.

At 5 years, complications were no longer significantly different between groups. “There is increased morbidity, but it's manageable and reduces over time,” Dr. Swanson said.

On the basis of these findings, adjuvant radiotherapy should be offered to all high-risk postsurgery patients, he said. “We can significantly reduce recurrence by all parameters with adjuvant radiation.”

A meeting attendee asked if any patients opted out of radiation therapy. “There were four in each arm who did not get the treatment they were assigned to,” Dr. Swanson said.

Another attendee asked if postoperative prostate-specific antigen levels were 0 in all patients after surgery. Dr. Swanson replied that 98% were below 1.0 ng/mL.

“But you are right—not all were 0 PSA.” The investigators previously reported that adjuvant radiation reduces the risk of biochemical failure at all postsurgical PSA levels at a follow-up of 10 years (J. Clin. Oncol. 2007;25:2225–9).

ORLANDO — Adjuvant radiotherapy following prostate cancer surgery significantly improved overall and metastatic disease-free survival, compared with surgery alone, according to 12-year results of an ongoing, randomized prospective study.

Adjuvant radiotherapy also increased biochemical control, avoided the need for androgen ablation, decreased detectable local failures, and decreased metastatic disease.

“It improved every parameter of which we know,” Dr. Gregory Swanson said during a late-breaking science forum at the annual meeting of the American Urological Association.

Dr. Swanson and fellow researchers with the Southwest Oncology Group (SWOG) Genitourinary Committee assessed 425 men with pathology-proven pT3 prostate cancer. All of the men had surgical margins positive for cancer following radical prostatectomy, placing them at high risk for recurrence. The mean age was about 65 years. Radiotherapy was 60–64 Gy directed at the prostate fossa.

A total of 214 men were randomized to surgery and radiation and 211 received surgery alone. Median follow-up is now longer than 12 years, said Dr. Swanson of the departments of radiation oncology and urology at the University of Texas at San Antonio.

Previously reported, 10-year median follow-up results showed significantly improved biochemical control and decreased local failure in the radiation group, but only a trend toward improved metastatic-free and overall survival.

“Metastatic-free survival is now statistically significant. So the finding is positive that radiation does improve metastasis-free survival for high-risk patients,” Dr. Swanson said.

The 15-year metastatic-free survival is 46% in the radiation group, compared with 38% in the observation group (hazard ratio, 0.74). The 15-year overall survival rates were similar—47% in the radiation group, compared with 37% in the observation group (HR, 0.76).

However, the trade-off for improved outcomes was greater morbidity in the adjuvant radiotherapy group, Dr. Swanson reported. A review of records showed that urethral stricture occurred in 38 patients (18%) in the radiation group, compared with 20 patients (10%) in the observation group.

Likewise, incontinence occurred more often in the radiation group (14 patients, 7%) than it did in the observation group (6 patients, 3%). Proctitis occurred in seven patients (3%) of the radiation group but in none of the observation group.

The SWOG researchers also tracked complications prospectively. Compared with baseline, they found that there was a significantly higher rate of complications at 6 weeks in the radiation than in the observation groups. For example, 71% of patients in the radiation group and 43% of the patients in the observation groups reported an unpleasant quality of life; 37% and 18%, respectively, reported increased urinary frequency; and 59% and 7%, respectively, reported bowel tenderness.

At 2 years' follow-up, only increased urinary frequency (24%, compared with 13%) and bowel tenderness (19%, compared with 4%) remained significantly more common in the radiation group.

At 5 years, complications were no longer significantly different between groups. “There is increased morbidity, but it's manageable and reduces over time,” Dr. Swanson said.

On the basis of these findings, adjuvant radiotherapy should be offered to all high-risk postsurgery patients, he said. “We can significantly reduce recurrence by all parameters with adjuvant radiation.”

A meeting attendee asked if any patients opted out of radiation therapy. “There were four in each arm who did not get the treatment they were assigned to,” Dr. Swanson said.

Another attendee asked if postoperative prostate-specific antigen levels were 0 in all patients after surgery. Dr. Swanson replied that 98% were below 1.0 ng/mL.

“But you are right—not all were 0 PSA.” The investigators previously reported that adjuvant radiation reduces the risk of biochemical failure at all postsurgical PSA levels at a follow-up of 10 years (J. Clin. Oncol. 2007;25:2225–9).

ORLANDO — Men who have surgery to remove prostate cancer experience better long-term survival, compared with patients who have radiation therapy or watchful waiting, according to a retrospective study of African American and white men.

Researchers assessed survival in a cohort of 23,811 men diagnosed with prostate cancer enrolled in the HMO Cancer Research Network in which 12 health maintenance organizations nationwide participate.

This source of data has an advantage compared with previous, population-based studies that assessed possible racial differences in outcomes, said Dr. Gerald Y. Tan. “Comparisons using HMO data may control for treatment selection biases across racial groups. Black men have equal access to care when you use an HMO database versus a population database,” said Dr. Tan of the department of urology at New York Weill Cornell Medical Center, New York.

A total of 10,450 men chose watchful waiting for their prostate cancer management, 6,804 chose radical prostatectomy, and 6,557 chose radiation therapy.

The cohort comprised 3,613 African Americans, 17,345 whites, and 2,853 patients who reported their race as “other.” The researchers looked for differences between African American and white men.

A total of 44% of the African American and white men chose watchful waiting. In the remaining African American and white men, 30% and 28%, respectively, chose surgery, and 26% and 28% chose radiation.

Men treated with surgery lived longer than did men in the other two groups, Dr. Tan said at the annual meeting of the American Urological Association. After a mean follow-up of 6.6 years, 37% of the watchful waiting group, 15% of the surgery group, and 24% of the radiation group had died.

The prostate cancer-specific death rate was highest in the conservative treatment group, regardless of race, and better for African American men, compared with white men in the radiation and surgery groups, said Dr. Tan, who presented results on behalf of the principal investigator, Dr. Robert A. Leung, a urologist at the same institution. The retrospective design and unavailability of data regarding family history of prostate cancer were potential limitations of the study, Dr. Tan said.

ORLANDO — Men who have surgery to remove prostate cancer experience better long-term survival, compared with patients who have radiation therapy or watchful waiting, according to a retrospective study of African American and white men.

Researchers assessed survival in a cohort of 23,811 men diagnosed with prostate cancer enrolled in the HMO Cancer Research Network in which 12 health maintenance organizations nationwide participate.

This source of data has an advantage compared with previous, population-based studies that assessed possible racial differences in outcomes, said Dr. Gerald Y. Tan. “Comparisons using HMO data may control for treatment selection biases across racial groups. Black men have equal access to care when you use an HMO database versus a population database,” said Dr. Tan of the department of urology at New York Weill Cornell Medical Center, New York.

A total of 10,450 men chose watchful waiting for their prostate cancer management, 6,804 chose radical prostatectomy, and 6,557 chose radiation therapy.

The cohort comprised 3,613 African Americans, 17,345 whites, and 2,853 patients who reported their race as “other.” The researchers looked for differences between African American and white men.

A total of 44% of the African American and white men chose watchful waiting. In the remaining African American and white men, 30% and 28%, respectively, chose surgery, and 26% and 28% chose radiation.

Men treated with surgery lived longer than did men in the other two groups, Dr. Tan said at the annual meeting of the American Urological Association. After a mean follow-up of 6.6 years, 37% of the watchful waiting group, 15% of the surgery group, and 24% of the radiation group had died.

The prostate cancer-specific death rate was highest in the conservative treatment group, regardless of race, and better for African American men, compared with white men in the radiation and surgery groups, said Dr. Tan, who presented results on behalf of the principal investigator, Dr. Robert A. Leung, a urologist at the same institution. The retrospective design and unavailability of data regarding family history of prostate cancer were potential limitations of the study, Dr. Tan said.

ORLANDO — Men who have surgery to remove prostate cancer experience better long-term survival, compared with patients who have radiation therapy or watchful waiting, according to a retrospective study of African American and white men.

Researchers assessed survival in a cohort of 23,811 men diagnosed with prostate cancer enrolled in the HMO Cancer Research Network in which 12 health maintenance organizations nationwide participate.

This source of data has an advantage compared with previous, population-based studies that assessed possible racial differences in outcomes, said Dr. Gerald Y. Tan. “Comparisons using HMO data may control for treatment selection biases across racial groups. Black men have equal access to care when you use an HMO database versus a population database,” said Dr. Tan of the department of urology at New York Weill Cornell Medical Center, New York.

A total of 10,450 men chose watchful waiting for their prostate cancer management, 6,804 chose radical prostatectomy, and 6,557 chose radiation therapy.

The cohort comprised 3,613 African Americans, 17,345 whites, and 2,853 patients who reported their race as “other.” The researchers looked for differences between African American and white men.

A total of 44% of the African American and white men chose watchful waiting. In the remaining African American and white men, 30% and 28%, respectively, chose surgery, and 26% and 28% chose radiation.

Men treated with surgery lived longer than did men in the other two groups, Dr. Tan said at the annual meeting of the American Urological Association. After a mean follow-up of 6.6 years, 37% of the watchful waiting group, 15% of the surgery group, and 24% of the radiation group had died.

The prostate cancer-specific death rate was highest in the conservative treatment group, regardless of race, and better for African American men, compared with white men in the radiation and surgery groups, said Dr. Tan, who presented results on behalf of the principal investigator, Dr. Robert A. Leung, a urologist at the same institution. The retrospective design and unavailability of data regarding family history of prostate cancer were potential limitations of the study, Dr. Tan said.

ORLANDO — Among men who have a baseline prostate-specific antigen level above the median for their age, being African American and having a positive family history are predictive of future cancer. However, a baseline reading above the median was a more powerful overall predictor than were these two other factors, according to a study of 26,111 men.

“Our results demonstrated that the effect of [elevated] baseline PSA is so strong that it even holds true for men with two risk factors,” Dana M. Mondo said during a press briefing at the annual meeting of the American Urological Association. Compared with both race and family history, “baseline PSA reading is a more powerful clinical tool when it comes to predicting future risk of prostate cancer.”

It is widely accepted that African American men and those with a strong family history of prostate cancer are at increased risk (Prostate Cancer Prostatic Dis. 2008 Feb. 12 Epub ahead of print; J. Urol. 2007;177:444–9). “Having a baseline PSA level above the age-specific median has also been shown to increase risk, but has not been incorporated into most prostate cancer guidelines,” Ms. Mondo said.

The aim of the study was to determine if race, family history, or PSA was the most important predictor of risk. “This is a timely study,” said Dr. Stephen J. Freedland, moderator of the press briefing. “We know prostate cancer is a very common disease. Three standard risk factors are age, race, and family history. And we are learning more and more about PSA values and how to use that to predict who will develop prostate cancer.”

The participants volunteered in 1991–2001 for PSA testing and a digital rectal examination. Researchers assessed both African American men and white men with and without family histories of prostate cancer and then stratified them by age. In all, 329 men both were African American and reported a positive family history.

Researchers compared outcomes for three groups: men in their 40s, 50s, and 60 and older. Mean follow-up was 20 months, 71 months, and 81 months, respectively, in these age groups. There were equal numbers of men in each group with a baseline PSA above and below their age-specific median—0.7 ng/mL for men in their 40s, 0.9 ng/mL for men in their 50s, and 1.4 ng/mL for men in their 60s and older, said Ms. Mondo, a medical student at Northwestern University, Chicago.

Results of the study show that men who both are African American and have “a family history of prostate cancer and a baseline [PSA] below the median had a very low prevalence of prostate cancer,” Ms. Mondo said.

There were no cancers in patients with both risk factors and a lower PSA level in the 40- and 50-year-old age groups. However, three (14%) men aged 60 years or older developed prostate cancer during follow-up.

In contrast, in men with both risk factors and a PSA level above the median, cancer prevalence rates increased with age: 8% for men in their 40s, 16% for men in their 50s, and 30% for men aged 60 and older.

The findings could lead to highly individualized screening for prostate cancer based on a man's baseline PSA value and how it relates to established, age-specific medians, Ms. Mondo said.

Nine major professional organizations issue prostate cancer-screening guidelines, but only the National Comprehensive Cancer Network (NCCN) currently recommends a baseline PSA test beginning at age 40. “We believe all men starting at age 40 should have a baseline PSA measured,” Ms. Mondo said.

Other organizations should consider instituting baseline PSA readings, she said. The American Urological Association PSA Best Practice Guidelines from 2000 recommend PSA screening beginning at age 50, although a lower minimum age is under consideration for an update to be released this year, Dr. Kristen L. Greene said during a different presentation at the meeting. Dr. Greene is on the urology faculty at the University of California, San Francisco.

“If you can know one fact about the patient, the PSA is what you want to know,” said Dr. Freedland of the division of urologic surgery at Duke University, Durham, N.C. “I agree that the NCCN is on the forefront of where we need to go. And if you are low at age 40, you may not need to repeat it for 5 years.

ORLANDO — Among men who have a baseline prostate-specific antigen level above the median for their age, being African American and having a positive family history are predictive of future cancer. However, a baseline reading above the median was a more powerful overall predictor than were these two other factors, according to a study of 26,111 men.

“Our results demonstrated that the effect of [elevated] baseline PSA is so strong that it even holds true for men with two risk factors,” Dana M. Mondo said during a press briefing at the annual meeting of the American Urological Association. Compared with both race and family history, “baseline PSA reading is a more powerful clinical tool when it comes to predicting future risk of prostate cancer.”

It is widely accepted that African American men and those with a strong family history of prostate cancer are at increased risk (Prostate Cancer Prostatic Dis. 2008 Feb. 12 Epub ahead of print; J. Urol. 2007;177:444–9). “Having a baseline PSA level above the age-specific median has also been shown to increase risk, but has not been incorporated into most prostate cancer guidelines,” Ms. Mondo said.

The aim of the study was to determine if race, family history, or PSA was the most important predictor of risk. “This is a timely study,” said Dr. Stephen J. Freedland, moderator of the press briefing. “We know prostate cancer is a very common disease. Three standard risk factors are age, race, and family history. And we are learning more and more about PSA values and how to use that to predict who will develop prostate cancer.”

The participants volunteered in 1991–2001 for PSA testing and a digital rectal examination. Researchers assessed both African American men and white men with and without family histories of prostate cancer and then stratified them by age. In all, 329 men both were African American and reported a positive family history.

Researchers compared outcomes for three groups: men in their 40s, 50s, and 60 and older. Mean follow-up was 20 months, 71 months, and 81 months, respectively, in these age groups. There were equal numbers of men in each group with a baseline PSA above and below their age-specific median—0.7 ng/mL for men in their 40s, 0.9 ng/mL for men in their 50s, and 1.4 ng/mL for men in their 60s and older, said Ms. Mondo, a medical student at Northwestern University, Chicago.

Results of the study show that men who both are African American and have “a family history of prostate cancer and a baseline [PSA] below the median had a very low prevalence of prostate cancer,” Ms. Mondo said.

There were no cancers in patients with both risk factors and a lower PSA level in the 40- and 50-year-old age groups. However, three (14%) men aged 60 years or older developed prostate cancer during follow-up.

In contrast, in men with both risk factors and a PSA level above the median, cancer prevalence rates increased with age: 8% for men in their 40s, 16% for men in their 50s, and 30% for men aged 60 and older.

The findings could lead to highly individualized screening for prostate cancer based on a man's baseline PSA value and how it relates to established, age-specific medians, Ms. Mondo said.

Nine major professional organizations issue prostate cancer-screening guidelines, but only the National Comprehensive Cancer Network (NCCN) currently recommends a baseline PSA test beginning at age 40. “We believe all men starting at age 40 should have a baseline PSA measured,” Ms. Mondo said.

Other organizations should consider instituting baseline PSA readings, she said. The American Urological Association PSA Best Practice Guidelines from 2000 recommend PSA screening beginning at age 50, although a lower minimum age is under consideration for an update to be released this year, Dr. Kristen L. Greene said during a different presentation at the meeting. Dr. Greene is on the urology faculty at the University of California, San Francisco.

“If you can know one fact about the patient, the PSA is what you want to know,” said Dr. Freedland of the division of urologic surgery at Duke University, Durham, N.C. “I agree that the NCCN is on the forefront of where we need to go. And if you are low at age 40, you may not need to repeat it for 5 years.

ORLANDO — Among men who have a baseline prostate-specific antigen level above the median for their age, being African American and having a positive family history are predictive of future cancer. However, a baseline reading above the median was a more powerful overall predictor than were these two other factors, according to a study of 26,111 men.

“Our results demonstrated that the effect of [elevated] baseline PSA is so strong that it even holds true for men with two risk factors,” Dana M. Mondo said during a press briefing at the annual meeting of the American Urological Association. Compared with both race and family history, “baseline PSA reading is a more powerful clinical tool when it comes to predicting future risk of prostate cancer.”

It is widely accepted that African American men and those with a strong family history of prostate cancer are at increased risk (Prostate Cancer Prostatic Dis. 2008 Feb. 12 Epub ahead of print; J. Urol. 2007;177:444–9). “Having a baseline PSA level above the age-specific median has also been shown to increase risk, but has not been incorporated into most prostate cancer guidelines,” Ms. Mondo said.

The aim of the study was to determine if race, family history, or PSA was the most important predictor of risk. “This is a timely study,” said Dr. Stephen J. Freedland, moderator of the press briefing. “We know prostate cancer is a very common disease. Three standard risk factors are age, race, and family history. And we are learning more and more about PSA values and how to use that to predict who will develop prostate cancer.”

The participants volunteered in 1991–2001 for PSA testing and a digital rectal examination. Researchers assessed both African American men and white men with and without family histories of prostate cancer and then stratified them by age. In all, 329 men both were African American and reported a positive family history.

Researchers compared outcomes for three groups: men in their 40s, 50s, and 60 and older. Mean follow-up was 20 months, 71 months, and 81 months, respectively, in these age groups. There were equal numbers of men in each group with a baseline PSA above and below their age-specific median—0.7 ng/mL for men in their 40s, 0.9 ng/mL for men in their 50s, and 1.4 ng/mL for men in their 60s and older, said Ms. Mondo, a medical student at Northwestern University, Chicago.

Results of the study show that men who both are African American and have “a family history of prostate cancer and a baseline [PSA] below the median had a very low prevalence of prostate cancer,” Ms. Mondo said.

There were no cancers in patients with both risk factors and a lower PSA level in the 40- and 50-year-old age groups. However, three (14%) men aged 60 years or older developed prostate cancer during follow-up.

In contrast, in men with both risk factors and a PSA level above the median, cancer prevalence rates increased with age: 8% for men in their 40s, 16% for men in their 50s, and 30% for men aged 60 and older.

The findings could lead to highly individualized screening for prostate cancer based on a man's baseline PSA value and how it relates to established, age-specific medians, Ms. Mondo said.

Nine major professional organizations issue prostate cancer-screening guidelines, but only the National Comprehensive Cancer Network (NCCN) currently recommends a baseline PSA test beginning at age 40. “We believe all men starting at age 40 should have a baseline PSA measured,” Ms. Mondo said.

Other organizations should consider instituting baseline PSA readings, she said. The American Urological Association PSA Best Practice Guidelines from 2000 recommend PSA screening beginning at age 50, although a lower minimum age is under consideration for an update to be released this year, Dr. Kristen L. Greene said during a different presentation at the meeting. Dr. Greene is on the urology faculty at the University of California, San Francisco.

“If you can know one fact about the patient, the PSA is what you want to know,” said Dr. Freedland of the division of urologic surgery at Duke University, Durham, N.C. “I agree that the NCCN is on the forefront of where we need to go. And if you are low at age 40, you may not need to repeat it for 5 years.

The Clinical Practice Guideline and related documents are available at www.surgeongeneral.gov/tobacco

Many new and effective treatment strategies are available to help patients quit tobacco use, according to an updated Clinical Practice Guideline released by the U.S. Public Health Service.

Expanding tobacco dependence literature and treatments available since 1999 led a consortium of eight federal agencies and nonprofit organizations to update the guideline for the first time since 2000. The new recognition of tobacco dependence as a chronic disease that generally requires ongoing assessment and repeated intervention is central to the update.

A 24-member panel screened more than 8,700 publications on tobacco dependence and treatment published since 1975 in preparation for the update. A total of 81 outside peer experts reviewed the findings.

The universal aim of the 276-page “Treating Tobacco Use and Dependence: 2008 Update” is to assist providers in strongly recommending effective tobacco dependence counseling and medications to patients who use tobacco. This includes consideration of seven first-line medications now approved by the Food and Drug Administration that “reliably increase long-term smoking abstinence rates.” Those medications are bupropion SR, nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, nicotine patch, and varenicline (Chantix).

It is important to encourage use of effective medications alone or in combination for all patients attempting to quit smoking, except when medically contraindicated, according to the guideline. Also, evidence is insufficient for effectiveness in specific populations, including pregnant women, smokeless tobacco users, light smokers, and adolescents.

Increased evidence that counseling, alone and especially with medication, greatly increases a person's chances of quitting tobacco is recognized. There is a new consensus that counseling efforts can be effective in adolescent tobacco users, for example. Also, quitlines such as 1–800-QUIT-NOW are an effective intervention that can reach a large number of the 70% of 45 million smokers in the United States who indicate a desire to quit.

Individual and group counseling also are deemed effective, particularly with increasing treatment intensity. Practical counseling (problem-solving/skills training) and social support delivered as part of treatment were found especially effective.

The authors recognized that counseling and medication are effective when used by themselves for treating tobacco dependence. However, they suggest that providers encourage all patients to consider both, because the combination is more effective than either strategy alone.

The guideline also identifies areas where additional progress is needed. For example, although adolescents appear to benefit from counseling, more consistent and effective interventions and options for use with children, adolescents, and young adults are clearly needed. Future strategies should focus on populations where smoking prevalence “remains discouragingly high,” including people with a low socioeconomic status/low educational attainment, some American Indian populations, and individuals with psychiatric disorders, including substance use disorders.

The authors also call for additional research in real-world clinical settings and new strategies to increase consumer demand for effective cessation treatments. There has been little increase in the percentage of smokers who make quit attempts, they noted, and too few smokers who do try to quit take advantage of evidence-based treatments that can double or triple their odds of success.

The guideline was sponsored by the Agency for Healthcare Research and Quality; the Centers for Disease Control and Prevention; the National Cancer Institute; the National Heart, Lung, and Blood Institute; the National Institute on Drug Abuse; the American Legacy Foundation; the Robert Wood Johnson Foundation; and the University of Wisconsin School of Medicine and Public Health's Center for Tobacco Research and Intervention.

Twenty-one of 24 panel members had no significant financial interests. The other panel members were recused from deliberations relating to their areas of conflict.

The Clinical Practice Guideline and related documents are available at www.surgeongeneral.gov/tobacco

Many new and effective treatment strategies are available to help patients quit tobacco use, according to an updated Clinical Practice Guideline released by the U.S. Public Health Service.

Expanding tobacco dependence literature and treatments available since 1999 led a consortium of eight federal agencies and nonprofit organizations to update the guideline for the first time since 2000. The new recognition of tobacco dependence as a chronic disease that generally requires ongoing assessment and repeated intervention is central to the update.

A 24-member panel screened more than 8,700 publications on tobacco dependence and treatment published since 1975 in preparation for the update. A total of 81 outside peer experts reviewed the findings.

The universal aim of the 276-page “Treating Tobacco Use and Dependence: 2008 Update” is to assist providers in strongly recommending effective tobacco dependence counseling and medications to patients who use tobacco. This includes consideration of seven first-line medications now approved by the Food and Drug Administration that “reliably increase long-term smoking abstinence rates.” Those medications are bupropion SR, nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, nicotine patch, and varenicline (Chantix).

It is important to encourage use of effective medications alone or in combination for all patients attempting to quit smoking, except when medically contraindicated, according to the guideline. Also, evidence is insufficient for effectiveness in specific populations, including pregnant women, smokeless tobacco users, light smokers, and adolescents.

Increased evidence that counseling, alone and especially with medication, greatly increases a person's chances of quitting tobacco is recognized. There is a new consensus that counseling efforts can be effective in adolescent tobacco users, for example. Also, quitlines such as 1–800-QUIT-NOW are an effective intervention that can reach a large number of the 70% of 45 million smokers in the United States who indicate a desire to quit.

Individual and group counseling also are deemed effective, particularly with increasing treatment intensity. Practical counseling (problem-solving/skills training) and social support delivered as part of treatment were found especially effective.

The authors recognized that counseling and medication are effective when used by themselves for treating tobacco dependence. However, they suggest that providers encourage all patients to consider both, because the combination is more effective than either strategy alone.

The guideline also identifies areas where additional progress is needed. For example, although adolescents appear to benefit from counseling, more consistent and effective interventions and options for use with children, adolescents, and young adults are clearly needed. Future strategies should focus on populations where smoking prevalence “remains discouragingly high,” including people with a low socioeconomic status/low educational attainment, some American Indian populations, and individuals with psychiatric disorders, including substance use disorders.

The authors also call for additional research in real-world clinical settings and new strategies to increase consumer demand for effective cessation treatments. There has been little increase in the percentage of smokers who make quit attempts, they noted, and too few smokers who do try to quit take advantage of evidence-based treatments that can double or triple their odds of success.

The guideline was sponsored by the Agency for Healthcare Research and Quality; the Centers for Disease Control and Prevention; the National Cancer Institute; the National Heart, Lung, and Blood Institute; the National Institute on Drug Abuse; the American Legacy Foundation; the Robert Wood Johnson Foundation; and the University of Wisconsin School of Medicine and Public Health's Center for Tobacco Research and Intervention.

Twenty-one of 24 panel members had no significant financial interests. The other panel members were recused from deliberations relating to their areas of conflict.

The Clinical Practice Guideline and related documents are available at www.surgeongeneral.gov/tobacco

Many new and effective treatment strategies are available to help patients quit tobacco use, according to an updated Clinical Practice Guideline released by the U.S. Public Health Service.

Expanding tobacco dependence literature and treatments available since 1999 led a consortium of eight federal agencies and nonprofit organizations to update the guideline for the first time since 2000. The new recognition of tobacco dependence as a chronic disease that generally requires ongoing assessment and repeated intervention is central to the update.

A 24-member panel screened more than 8,700 publications on tobacco dependence and treatment published since 1975 in preparation for the update. A total of 81 outside peer experts reviewed the findings.

The universal aim of the 276-page “Treating Tobacco Use and Dependence: 2008 Update” is to assist providers in strongly recommending effective tobacco dependence counseling and medications to patients who use tobacco. This includes consideration of seven first-line medications now approved by the Food and Drug Administration that “reliably increase long-term smoking abstinence rates.” Those medications are bupropion SR, nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, nicotine patch, and varenicline (Chantix).

It is important to encourage use of effective medications alone or in combination for all patients attempting to quit smoking, except when medically contraindicated, according to the guideline. Also, evidence is insufficient for effectiveness in specific populations, including pregnant women, smokeless tobacco users, light smokers, and adolescents.

Increased evidence that counseling, alone and especially with medication, greatly increases a person's chances of quitting tobacco is recognized. There is a new consensus that counseling efforts can be effective in adolescent tobacco users, for example. Also, quitlines such as 1–800-QUIT-NOW are an effective intervention that can reach a large number of the 70% of 45 million smokers in the United States who indicate a desire to quit.

Individual and group counseling also are deemed effective, particularly with increasing treatment intensity. Practical counseling (problem-solving/skills training) and social support delivered as part of treatment were found especially effective.

The authors recognized that counseling and medication are effective when used by themselves for treating tobacco dependence. However, they suggest that providers encourage all patients to consider both, because the combination is more effective than either strategy alone.

The guideline also identifies areas where additional progress is needed. For example, although adolescents appear to benefit from counseling, more consistent and effective interventions and options for use with children, adolescents, and young adults are clearly needed. Future strategies should focus on populations where smoking prevalence “remains discouragingly high,” including people with a low socioeconomic status/low educational attainment, some American Indian populations, and individuals with psychiatric disorders, including substance use disorders.

The authors also call for additional research in real-world clinical settings and new strategies to increase consumer demand for effective cessation treatments. There has been little increase in the percentage of smokers who make quit attempts, they noted, and too few smokers who do try to quit take advantage of evidence-based treatments that can double or triple their odds of success.

The guideline was sponsored by the Agency for Healthcare Research and Quality; the Centers for Disease Control and Prevention; the National Cancer Institute; the National Heart, Lung, and Blood Institute; the National Institute on Drug Abuse; the American Legacy Foundation; the Robert Wood Johnson Foundation; and the University of Wisconsin School of Medicine and Public Health's Center for Tobacco Research and Intervention.

Twenty-one of 24 panel members had no significant financial interests. The other panel members were recused from deliberations relating to their areas of conflict.

Many new and effective treatment strategies are available that clinicians can employ to help patients quit tobacco use, according to an updated Clinical Practice Guideline released recently by the U.S. Public Health Service.

Use of multiple interventions, individual and group counseling, integration of effective therapies into routine health care delivery, and insurance reimbursement increase the likelihood a patient with tobacco dependence can quit, according to the guideline.

Expanding tobacco dependence literature and new treatments available since 1999 led a consortium of eight federal agencies and nonprofit organizations to update the guideline for the first time since 2000. The new recognition of tobacco dependence as a chronic disease that generally requires ongoing assessment and repeated intervention is central to the update.

A 24-member panel screened more than 8,700 publications on tobacco dependence and treatment published since 1975 in preparation for the update. A total of 81 outside peer experts reviewed the panel's findings.

The universal aim of the 276-page “Treating Tobacco Use and Dependence: 2008 Update” is assist clinicians in strongly recommending effective tobacco dependence counseling and medications to patients who use tobacco. This includes consideration of seven first-line medications now approved by the Food and Drug Administration that “reliably increase long-term smoking abstinence rates.” Those medications are bupropion SR, nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, nicotine patch, and varenicline (Chantix).

It is important to encourage use of effective medications alone or in combination for all patients attempting to quit smoking, except when medically contraindicated, according to the guideline. Also, evidence is insufficient for effectiveness in specific populations, including pregnant women, smokeless tobacco users, light smokers, and adolescents.

However, it is not enough for clinicians to recommend these medications. Health systems, insurers, and purchasers need to increase availability and facilitate use of these therapies to help physicians help their patients. “Making tobacco dependence treatment a covered benefit of insurance plans increases the likelihood that a tobacco user will receive treatment and quit successfully,” the authors wrote.

Increased evidence that counseling, alone and especially with medication, greatly increases a person's chances of quitting tobacco is recognized. There is a new consensus that counseling efforts can be effective in adolescent tobacco users, for example. Also, quitlines such as 1–800-QUIT-NOW are an effective intervention that can reach a large number of the 70% of 45 million smokers in the United States who indicate a desire to quit, according to the guideline.

Individual and group counseling also are deemed effective, particularly with increasing treatment intensity. Practical counseling (problem-solving/skills training) and social support delivered as part of treatment were found especially effective. Use these interventions when counseling patients making a quit attempt, the authors suggested.

Clinical interventions both for patients who are willing or unwilling to make a quit attempt at the time are outlined. Interventions for individuals with psychiatric disorders, including substance use disorders, are also recommended.

The guideline was sponsored by the Agency for Healthcare Research and Quality; the Centers for Disease Control and Prevention; the National Cancer Institute; the National Heart, Lung, and Blood Institute; the National Institute on Drug Abuse; the American Legacy Foundation; the Robert Wood Johnson Foundation; and the University of Wisconsin School of Medicine and Public Health's Center for Tobacco Research and Intervention.

Of the 24 panel members, 21 had no significant financial interests. The three other panel members were recused from panel deliberations relating to their areas of conflict.

The Clinical Practice Guideline and related documents are available at www.surgeongeneral.gov/tobacco

Many new and effective treatment strategies are available that clinicians can employ to help patients quit tobacco use, according to an updated Clinical Practice Guideline released recently by the U.S. Public Health Service.

Use of multiple interventions, individual and group counseling, integration of effective therapies into routine health care delivery, and insurance reimbursement increase the likelihood a patient with tobacco dependence can quit, according to the guideline.

Expanding tobacco dependence literature and new treatments available since 1999 led a consortium of eight federal agencies and nonprofit organizations to update the guideline for the first time since 2000. The new recognition of tobacco dependence as a chronic disease that generally requires ongoing assessment and repeated intervention is central to the update.

A 24-member panel screened more than 8,700 publications on tobacco dependence and treatment published since 1975 in preparation for the update. A total of 81 outside peer experts reviewed the panel's findings.

The universal aim of the 276-page “Treating Tobacco Use and Dependence: 2008 Update” is assist clinicians in strongly recommending effective tobacco dependence counseling and medications to patients who use tobacco. This includes consideration of seven first-line medications now approved by the Food and Drug Administration that “reliably increase long-term smoking abstinence rates.” Those medications are bupropion SR, nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, nicotine patch, and varenicline (Chantix).

It is important to encourage use of effective medications alone or in combination for all patients attempting to quit smoking, except when medically contraindicated, according to the guideline. Also, evidence is insufficient for effectiveness in specific populations, including pregnant women, smokeless tobacco users, light smokers, and adolescents.

However, it is not enough for clinicians to recommend these medications. Health systems, insurers, and purchasers need to increase availability and facilitate use of these therapies to help physicians help their patients. “Making tobacco dependence treatment a covered benefit of insurance plans increases the likelihood that a tobacco user will receive treatment and quit successfully,” the authors wrote.

Increased evidence that counseling, alone and especially with medication, greatly increases a person's chances of quitting tobacco is recognized. There is a new consensus that counseling efforts can be effective in adolescent tobacco users, for example. Also, quitlines such as 1–800-QUIT-NOW are an effective intervention that can reach a large number of the 70% of 45 million smokers in the United States who indicate a desire to quit, according to the guideline.

Individual and group counseling also are deemed effective, particularly with increasing treatment intensity. Practical counseling (problem-solving/skills training) and social support delivered as part of treatment were found especially effective. Use these interventions when counseling patients making a quit attempt, the authors suggested.

Clinical interventions both for patients who are willing or unwilling to make a quit attempt at the time are outlined. Interventions for individuals with psychiatric disorders, including substance use disorders, are also recommended.

The guideline was sponsored by the Agency for Healthcare Research and Quality; the Centers for Disease Control and Prevention; the National Cancer Institute; the National Heart, Lung, and Blood Institute; the National Institute on Drug Abuse; the American Legacy Foundation; the Robert Wood Johnson Foundation; and the University of Wisconsin School of Medicine and Public Health's Center for Tobacco Research and Intervention.

Of the 24 panel members, 21 had no significant financial interests. The three other panel members were recused from panel deliberations relating to their areas of conflict.

The Clinical Practice Guideline and related documents are available at www.surgeongeneral.gov/tobacco

Many new and effective treatment strategies are available that clinicians can employ to help patients quit tobacco use, according to an updated Clinical Practice Guideline released recently by the U.S. Public Health Service.

Use of multiple interventions, individual and group counseling, integration of effective therapies into routine health care delivery, and insurance reimbursement increase the likelihood a patient with tobacco dependence can quit, according to the guideline.

Expanding tobacco dependence literature and new treatments available since 1999 led a consortium of eight federal agencies and nonprofit organizations to update the guideline for the first time since 2000. The new recognition of tobacco dependence as a chronic disease that generally requires ongoing assessment and repeated intervention is central to the update.

A 24-member panel screened more than 8,700 publications on tobacco dependence and treatment published since 1975 in preparation for the update. A total of 81 outside peer experts reviewed the panel's findings.

The universal aim of the 276-page “Treating Tobacco Use and Dependence: 2008 Update” is assist clinicians in strongly recommending effective tobacco dependence counseling and medications to patients who use tobacco. This includes consideration of seven first-line medications now approved by the Food and Drug Administration that “reliably increase long-term smoking abstinence rates.” Those medications are bupropion SR, nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, nicotine patch, and varenicline (Chantix).

It is important to encourage use of effective medications alone or in combination for all patients attempting to quit smoking, except when medically contraindicated, according to the guideline. Also, evidence is insufficient for effectiveness in specific populations, including pregnant women, smokeless tobacco users, light smokers, and adolescents.

However, it is not enough for clinicians to recommend these medications. Health systems, insurers, and purchasers need to increase availability and facilitate use of these therapies to help physicians help their patients. “Making tobacco dependence treatment a covered benefit of insurance plans increases the likelihood that a tobacco user will receive treatment and quit successfully,” the authors wrote.

Increased evidence that counseling, alone and especially with medication, greatly increases a person's chances of quitting tobacco is recognized. There is a new consensus that counseling efforts can be effective in adolescent tobacco users, for example. Also, quitlines such as 1–800-QUIT-NOW are an effective intervention that can reach a large number of the 70% of 45 million smokers in the United States who indicate a desire to quit, according to the guideline.

Individual and group counseling also are deemed effective, particularly with increasing treatment intensity. Practical counseling (problem-solving/skills training) and social support delivered as part of treatment were found especially effective. Use these interventions when counseling patients making a quit attempt, the authors suggested.

Clinical interventions both for patients who are willing or unwilling to make a quit attempt at the time are outlined. Interventions for individuals with psychiatric disorders, including substance use disorders, are also recommended.

The guideline was sponsored by the Agency for Healthcare Research and Quality; the Centers for Disease Control and Prevention; the National Cancer Institute; the National Heart, Lung, and Blood Institute; the National Institute on Drug Abuse; the American Legacy Foundation; the Robert Wood Johnson Foundation; and the University of Wisconsin School of Medicine and Public Health's Center for Tobacco Research and Intervention.

Of the 24 panel members, 21 had no significant financial interests. The three other panel members were recused from panel deliberations relating to their areas of conflict.

The Clinical Practice Guideline and related documents are available at www.surgeongeneral.gov/tobacco