Jane Salodof MacNeil

LOS ANGELES — Use of intensity-modulated radiation therapy rather than conventional radiation significantly reduced the severity and duration of acute dermatitis in a review of consecutive cancer patients who underwent whole breast radiation after breast-conserving surgery.

All but 3% of 804 women experienced some acute dermatitis during the treatments, which typically lasted 7-8 weeks, Dr. Gary M. Freedman of Fox Chase Cancer Center in Philadelphia reported at the annual meeting of the American Society for Therapeutic Radiation and Oncology.

Of all patients who were treated from 2001 to 2006 in the multivariate analysis that considered week of treatment and breast size, 61% experienced grade 2 toxicity (with 0 being no toxicity and 5 being death), according to the National Cancer Institute Common Toxicity Criteria scale for acute dermatitis. For these women, skin reactions included moderate to brisk erythema, patchy moist desquamation (mostly confined to skinfolds and creases), and moderate edema.

Of all the women who underwent radiation therapy, 34% had grade 1 skin toxicity, a category comprising faint erythema or dry desquamation. For 2%, radiation treatments resulted in grade 3 toxicity, by which minor trauma or abrasion could cause the breast to bleed and moist desquamation went beyond the skinfolds and creases.

The investigators then stratified the women and found acute dermatitis tended to be milder with the newer intensity-modulated radiation therapy (IMRT). The advantage was seen every week that treatment was given in women with all breast sizes.

Nearly half, 48%, of the 399 women undergoing IMRT had nothing worse than grade 1 dermatitis, compared with 25% of 405 women given radiation with conventional wedged photon tangents. Conversely, three-fourths of the women treated with conventional radiation, but only 52% of the IMRT cohort, experienced grade 2 and 3 dermatitis, a statistically significant difference.

The duration of grade 2 and 3 dermatitis also was shorter with IMRT. Women treated with this technique spent only 18% of their treatment weeks in this combined category, as opposed to 71% of the time for women given conventional radiation.

IMRT conveys "less toxicity to the skin during treatment and less risk of peeling of the skin," Dr. Freedman said in an interview. Longer follow-up is needed before investigators can show better cosmetic results 5 years after treatment. However, "we feel that is going to translate long term into better cosmetic results," he said.

At Fox Chase, radiation oncologists transitioned to IMRT around 2004, and use it in most cases, "insurance permitting," according to Dr. Freedman. Some major carriers have balked at the higher cost of IMRT, which employs more radiation beams and requires more planning. Where they don't disallow it outright, they may pay for IMRT only in cases of left-sided breast cancer where there is a risk of radiation damaging the heart.

"The majority of women in this country are still being treated with conventional radiation," he said, questioning the fairness of insurance industry practices limiting access to IMRT for women with breast cancer.

IMRT is favored as a way of reducing radiation doses to the bladder and rectum in men with prostate cancer, Dr. Freedman maintained. "The first thing to come through was prostate cancer, and insurance companies welcomed that with open arms," he said. "I feel breast cancer is being held to a higher standard. The same is true for head and neck cancer."

LOS ANGELES — Use of intensity-modulated radiation therapy rather than conventional radiation significantly reduced the severity and duration of acute dermatitis in a review of consecutive cancer patients who underwent whole breast radiation after breast-conserving surgery.

All but 3% of 804 women experienced some acute dermatitis during the treatments, which typically lasted 7-8 weeks, Dr. Gary M. Freedman of Fox Chase Cancer Center in Philadelphia reported at the annual meeting of the American Society for Therapeutic Radiation and Oncology.

Of all patients who were treated from 2001 to 2006 in the multivariate analysis that considered week of treatment and breast size, 61% experienced grade 2 toxicity (with 0 being no toxicity and 5 being death), according to the National Cancer Institute Common Toxicity Criteria scale for acute dermatitis. For these women, skin reactions included moderate to brisk erythema, patchy moist desquamation (mostly confined to skinfolds and creases), and moderate edema.

Of all the women who underwent radiation therapy, 34% had grade 1 skin toxicity, a category comprising faint erythema or dry desquamation. For 2%, radiation treatments resulted in grade 3 toxicity, by which minor trauma or abrasion could cause the breast to bleed and moist desquamation went beyond the skinfolds and creases.

The investigators then stratified the women and found acute dermatitis tended to be milder with the newer intensity-modulated radiation therapy (IMRT). The advantage was seen every week that treatment was given in women with all breast sizes.

Nearly half, 48%, of the 399 women undergoing IMRT had nothing worse than grade 1 dermatitis, compared with 25% of 405 women given radiation with conventional wedged photon tangents. Conversely, three-fourths of the women treated with conventional radiation, but only 52% of the IMRT cohort, experienced grade 2 and 3 dermatitis, a statistically significant difference.

The duration of grade 2 and 3 dermatitis also was shorter with IMRT. Women treated with this technique spent only 18% of their treatment weeks in this combined category, as opposed to 71% of the time for women given conventional radiation.

IMRT conveys "less toxicity to the skin during treatment and less risk of peeling of the skin," Dr. Freedman said in an interview. Longer follow-up is needed before investigators can show better cosmetic results 5 years after treatment. However, "we feel that is going to translate long term into better cosmetic results," he said.

At Fox Chase, radiation oncologists transitioned to IMRT around 2004, and use it in most cases, "insurance permitting," according to Dr. Freedman. Some major carriers have balked at the higher cost of IMRT, which employs more radiation beams and requires more planning. Where they don't disallow it outright, they may pay for IMRT only in cases of left-sided breast cancer where there is a risk of radiation damaging the heart.

"The majority of women in this country are still being treated with conventional radiation," he said, questioning the fairness of insurance industry practices limiting access to IMRT for women with breast cancer.

IMRT is favored as a way of reducing radiation doses to the bladder and rectum in men with prostate cancer, Dr. Freedman maintained. "The first thing to come through was prostate cancer, and insurance companies welcomed that with open arms," he said. "I feel breast cancer is being held to a higher standard. The same is true for head and neck cancer."

LOS ANGELES — Use of intensity-modulated radiation therapy rather than conventional radiation significantly reduced the severity and duration of acute dermatitis in a review of consecutive cancer patients who underwent whole breast radiation after breast-conserving surgery.

All but 3% of 804 women experienced some acute dermatitis during the treatments, which typically lasted 7-8 weeks, Dr. Gary M. Freedman of Fox Chase Cancer Center in Philadelphia reported at the annual meeting of the American Society for Therapeutic Radiation and Oncology.

Of all patients who were treated from 2001 to 2006 in the multivariate analysis that considered week of treatment and breast size, 61% experienced grade 2 toxicity (with 0 being no toxicity and 5 being death), according to the National Cancer Institute Common Toxicity Criteria scale for acute dermatitis. For these women, skin reactions included moderate to brisk erythema, patchy moist desquamation (mostly confined to skinfolds and creases), and moderate edema.

Of all the women who underwent radiation therapy, 34% had grade 1 skin toxicity, a category comprising faint erythema or dry desquamation. For 2%, radiation treatments resulted in grade 3 toxicity, by which minor trauma or abrasion could cause the breast to bleed and moist desquamation went beyond the skinfolds and creases.

The investigators then stratified the women and found acute dermatitis tended to be milder with the newer intensity-modulated radiation therapy (IMRT). The advantage was seen every week that treatment was given in women with all breast sizes.

Nearly half, 48%, of the 399 women undergoing IMRT had nothing worse than grade 1 dermatitis, compared with 25% of 405 women given radiation with conventional wedged photon tangents. Conversely, three-fourths of the women treated with conventional radiation, but only 52% of the IMRT cohort, experienced grade 2 and 3 dermatitis, a statistically significant difference.

The duration of grade 2 and 3 dermatitis also was shorter with IMRT. Women treated with this technique spent only 18% of their treatment weeks in this combined category, as opposed to 71% of the time for women given conventional radiation.

IMRT conveys "less toxicity to the skin during treatment and less risk of peeling of the skin," Dr. Freedman said in an interview. Longer follow-up is needed before investigators can show better cosmetic results 5 years after treatment. However, "we feel that is going to translate long term into better cosmetic results," he said.

At Fox Chase, radiation oncologists transitioned to IMRT around 2004, and use it in most cases, "insurance permitting," according to Dr. Freedman. Some major carriers have balked at the higher cost of IMRT, which employs more radiation beams and requires more planning. Where they don't disallow it outright, they may pay for IMRT only in cases of left-sided breast cancer where there is a risk of radiation damaging the heart.

"The majority of women in this country are still being treated with conventional radiation," he said, questioning the fairness of insurance industry practices limiting access to IMRT for women with breast cancer.

IMRT is favored as a way of reducing radiation doses to the bladder and rectum in men with prostate cancer, Dr. Freedman maintained. "The first thing to come through was prostate cancer, and insurance companies welcomed that with open arms," he said. "I feel breast cancer is being held to a higher standard. The same is true for head and neck cancer."

LOS ANGELES — A “boost” dose of radiation to the tumor bed after breast-conserving surgery and whole breast radiation cut the 10-year rate of local breast cancer recurrence by nearly half in a large European trial designed to test this common practice.

The boost so reduced the effect of close and positive margins after treatment that the only significant risk factors for local relapse were younger age and a high grade of invasive tumor or ductal carcinoma in situ (DCIS), researchers reported at the annual meeting of the American Society for Therapeutic Radiation and Oncology (ASTRO).

“You don't need the re-excision. You don't need the mastectomy,” principal investigator Dr. Harry Bartelink of the Netherlands Cancer Institute in Amsterdam told reporters. If margins are found to be close or even positive after treatment, radiating the tumor bed should eliminate stray tumor cells without further surgery.

The European Organisation for Research and Treatment of Cancer sponsored the Boost-No Boost trial, which randomized 5,318 women with stage I or II breast cancer. All participants underwent lumpectomies and 50 Gy of whole breast radiation. Half received the additional 16 Gy boost to the tumor bed, while the remainder had no further radiation.

Trial investigators reported that the boost reduced cumulative local recurrence from 12% to 7% overall at a medium follow-up of 10.8 years, with the greatest reduction in absolute risk observed in women 40 years of age or less: 23.9% to 13.5%. Severe fibrosis did increase from 1.6% to 4.4% with the boost. Ten-year survival was the same, 82%, in both groups (J. Clin. Oncol. 2007;25:3259–65).

To assess the impact of margins and other risk factors, investigators conducted a subgroup analysis of 1,724 patients.

A central pathology review reported by Dr. Heather A. Jones at the ASTRO plenary session showed that 78% (1,345 women) had negative margins, 12% (207) had close margins, and 7% (120) had positive margins (remaining 3% were not classified).

The boost did not make a significant impact in patients without margin involvement, according to Dr. Jones, who did the analysis while a visiting clinician in the Netherlands and is now at the University of Pittsburgh. Radiating the tumor bed reduced the local recurrence rate from 6% to 5% if these patients had invasive disease and from 7% to 6% if they had DCIS.

Recurrence rates were greatly reduced, however, for patients with margin involvement. They fell from 13% to 4% in women with invasive tumors, and from 15% to 6% in those with DCIS.

Women with high-grade tumors that continue to put them at higher risk than the other patients also derived substantial benefit from the boost. Dr. Jones reported local recurrence rates dropped from 19% to 7% in women with high-grade invasive disease and from 17% to 5% in women with high-grade DCIS.

Margin involvement did predict greater risk of recurrence in a univariate analysis of the data, but dropped out when the investigators did a multivariate Cox regression analysis. Dr. Jones identified two positive prognostic factors favoring freedom from recurrence: age greater than 50 years (hazard ratio 0.41) and receiving the boost (HR 0.56). Only two factors predicted increased risk of recurrence: high-grade DCIS (HR 1.51) and high-grade invasive tumor (HR 1.86).

“Age was the most striking risk factor for local recurrence,” Dr. Jones said. “Having a high grade of invasive tumor seems to be a more important prognostic factor than margin involvement. The boost dose reduces the effects of margin involvement, and it substantially reduces the risk of local recurrence in our high-risk patients.”

Dr. Bartelink said a new randomized trial will attempt to integrate the boost into standard treatment instead of making women come back for the additional radiation.

LOS ANGELES — A “boost” dose of radiation to the tumor bed after breast-conserving surgery and whole breast radiation cut the 10-year rate of local breast cancer recurrence by nearly half in a large European trial designed to test this common practice.

The boost so reduced the effect of close and positive margins after treatment that the only significant risk factors for local relapse were younger age and a high grade of invasive tumor or ductal carcinoma in situ (DCIS), researchers reported at the annual meeting of the American Society for Therapeutic Radiation and Oncology (ASTRO).

“You don't need the re-excision. You don't need the mastectomy,” principal investigator Dr. Harry Bartelink of the Netherlands Cancer Institute in Amsterdam told reporters. If margins are found to be close or even positive after treatment, radiating the tumor bed should eliminate stray tumor cells without further surgery.

The European Organisation for Research and Treatment of Cancer sponsored the Boost-No Boost trial, which randomized 5,318 women with stage I or II breast cancer. All participants underwent lumpectomies and 50 Gy of whole breast radiation. Half received the additional 16 Gy boost to the tumor bed, while the remainder had no further radiation.

Trial investigators reported that the boost reduced cumulative local recurrence from 12% to 7% overall at a medium follow-up of 10.8 years, with the greatest reduction in absolute risk observed in women 40 years of age or less: 23.9% to 13.5%. Severe fibrosis did increase from 1.6% to 4.4% with the boost. Ten-year survival was the same, 82%, in both groups (J. Clin. Oncol. 2007;25:3259–65).

To assess the impact of margins and other risk factors, investigators conducted a subgroup analysis of 1,724 patients.

A central pathology review reported by Dr. Heather A. Jones at the ASTRO plenary session showed that 78% (1,345 women) had negative margins, 12% (207) had close margins, and 7% (120) had positive margins (remaining 3% were not classified).

The boost did not make a significant impact in patients without margin involvement, according to Dr. Jones, who did the analysis while a visiting clinician in the Netherlands and is now at the University of Pittsburgh. Radiating the tumor bed reduced the local recurrence rate from 6% to 5% if these patients had invasive disease and from 7% to 6% if they had DCIS.

Recurrence rates were greatly reduced, however, for patients with margin involvement. They fell from 13% to 4% in women with invasive tumors, and from 15% to 6% in those with DCIS.

Women with high-grade tumors that continue to put them at higher risk than the other patients also derived substantial benefit from the boost. Dr. Jones reported local recurrence rates dropped from 19% to 7% in women with high-grade invasive disease and from 17% to 5% in women with high-grade DCIS.

Margin involvement did predict greater risk of recurrence in a univariate analysis of the data, but dropped out when the investigators did a multivariate Cox regression analysis. Dr. Jones identified two positive prognostic factors favoring freedom from recurrence: age greater than 50 years (hazard ratio 0.41) and receiving the boost (HR 0.56). Only two factors predicted increased risk of recurrence: high-grade DCIS (HR 1.51) and high-grade invasive tumor (HR 1.86).

“Age was the most striking risk factor for local recurrence,” Dr. Jones said. “Having a high grade of invasive tumor seems to be a more important prognostic factor than margin involvement. The boost dose reduces the effects of margin involvement, and it substantially reduces the risk of local recurrence in our high-risk patients.”

Dr. Bartelink said a new randomized trial will attempt to integrate the boost into standard treatment instead of making women come back for the additional radiation.

LOS ANGELES — A “boost” dose of radiation to the tumor bed after breast-conserving surgery and whole breast radiation cut the 10-year rate of local breast cancer recurrence by nearly half in a large European trial designed to test this common practice.

The boost so reduced the effect of close and positive margins after treatment that the only significant risk factors for local relapse were younger age and a high grade of invasive tumor or ductal carcinoma in situ (DCIS), researchers reported at the annual meeting of the American Society for Therapeutic Radiation and Oncology (ASTRO).

“You don't need the re-excision. You don't need the mastectomy,” principal investigator Dr. Harry Bartelink of the Netherlands Cancer Institute in Amsterdam told reporters. If margins are found to be close or even positive after treatment, radiating the tumor bed should eliminate stray tumor cells without further surgery.

The European Organisation for Research and Treatment of Cancer sponsored the Boost-No Boost trial, which randomized 5,318 women with stage I or II breast cancer. All participants underwent lumpectomies and 50 Gy of whole breast radiation. Half received the additional 16 Gy boost to the tumor bed, while the remainder had no further radiation.

Trial investigators reported that the boost reduced cumulative local recurrence from 12% to 7% overall at a medium follow-up of 10.8 years, with the greatest reduction in absolute risk observed in women 40 years of age or less: 23.9% to 13.5%. Severe fibrosis did increase from 1.6% to 4.4% with the boost. Ten-year survival was the same, 82%, in both groups (J. Clin. Oncol. 2007;25:3259–65).

To assess the impact of margins and other risk factors, investigators conducted a subgroup analysis of 1,724 patients.

A central pathology review reported by Dr. Heather A. Jones at the ASTRO plenary session showed that 78% (1,345 women) had negative margins, 12% (207) had close margins, and 7% (120) had positive margins (remaining 3% were not classified).

The boost did not make a significant impact in patients without margin involvement, according to Dr. Jones, who did the analysis while a visiting clinician in the Netherlands and is now at the University of Pittsburgh. Radiating the tumor bed reduced the local recurrence rate from 6% to 5% if these patients had invasive disease and from 7% to 6% if they had DCIS.

Recurrence rates were greatly reduced, however, for patients with margin involvement. They fell from 13% to 4% in women with invasive tumors, and from 15% to 6% in those with DCIS.

Women with high-grade tumors that continue to put them at higher risk than the other patients also derived substantial benefit from the boost. Dr. Jones reported local recurrence rates dropped from 19% to 7% in women with high-grade invasive disease and from 17% to 5% in women with high-grade DCIS.

Margin involvement did predict greater risk of recurrence in a univariate analysis of the data, but dropped out when the investigators did a multivariate Cox regression analysis. Dr. Jones identified two positive prognostic factors favoring freedom from recurrence: age greater than 50 years (hazard ratio 0.41) and receiving the boost (HR 0.56). Only two factors predicted increased risk of recurrence: high-grade DCIS (HR 1.51) and high-grade invasive tumor (HR 1.86).

“Age was the most striking risk factor for local recurrence,” Dr. Jones said. “Having a high grade of invasive tumor seems to be a more important prognostic factor than margin involvement. The boost dose reduces the effects of margin involvement, and it substantially reduces the risk of local recurrence in our high-risk patients.”

Dr. Bartelink said a new randomized trial will attempt to integrate the boost into standard treatment instead of making women come back for the additional radiation.

Building clinical alerts and recommendations into electronic health records significantly improved immunization rates for inner-city children in a primary care network affiliated with the Children's Hospital of Philadelphia.

During the first year the system was in place, adjusted immunization rates rose from 82% to 90% at 2 years of age, according to a study of the intervention. When children arrived due for a vaccination at a well visit, the proportion vaccinated rose from 78% to 90%. At sick visits, the impact tripled from 11% to 32%, said Dr. Alexander G. Fiks, of the University of Pennsylvania and the Children's Hospital of Philadelphia (CHOP) and his colleagues (Pediatrics 2007;120:707–14).

“No one has published or developed a system that we are aware of that works quite [the same],” Dr. Fiks, a codeveloper of the system, said in an interview.

The system, used at four urban practices in the CHOP network, alerts physicians when they open a patient chart with an incomplete immunization record. It makes recommendations based on a process that:

▸ Excludes invalid vaccine doses and vaccinations given at too young an age or too close together.

▸ Considers the child's age, timing of past doses, and interval since the last dose to determine which vaccinations are due.

▸ Checks for combination vaccine products to minimize the number of shots required.

The study began Sept. 1, 2004, and covered 1,669 children who reached age 24 months in the next year. They were compared with 1,548 ccontrols who reached 24 months in the previous year. There were 15,928 immunization alerts recorded during the intervention year. More than 80% of the children in both groups were black.

One of the authors received a grant from the Ambulatory Podiatric Association.

Building clinical alerts and recommendations into electronic health records significantly improved immunization rates for inner-city children in a primary care network affiliated with the Children's Hospital of Philadelphia.

During the first year the system was in place, adjusted immunization rates rose from 82% to 90% at 2 years of age, according to a study of the intervention. When children arrived due for a vaccination at a well visit, the proportion vaccinated rose from 78% to 90%. At sick visits, the impact tripled from 11% to 32%, said Dr. Alexander G. Fiks, of the University of Pennsylvania and the Children's Hospital of Philadelphia (CHOP) and his colleagues (Pediatrics 2007;120:707–14).

“No one has published or developed a system that we are aware of that works quite [the same],” Dr. Fiks, a codeveloper of the system, said in an interview.

The system, used at four urban practices in the CHOP network, alerts physicians when they open a patient chart with an incomplete immunization record. It makes recommendations based on a process that:

▸ Excludes invalid vaccine doses and vaccinations given at too young an age or too close together.

▸ Considers the child's age, timing of past doses, and interval since the last dose to determine which vaccinations are due.

▸ Checks for combination vaccine products to minimize the number of shots required.

The study began Sept. 1, 2004, and covered 1,669 children who reached age 24 months in the next year. They were compared with 1,548 ccontrols who reached 24 months in the previous year. There were 15,928 immunization alerts recorded during the intervention year. More than 80% of the children in both groups were black.

One of the authors received a grant from the Ambulatory Podiatric Association.

Building clinical alerts and recommendations into electronic health records significantly improved immunization rates for inner-city children in a primary care network affiliated with the Children's Hospital of Philadelphia.

During the first year the system was in place, adjusted immunization rates rose from 82% to 90% at 2 years of age, according to a study of the intervention. When children arrived due for a vaccination at a well visit, the proportion vaccinated rose from 78% to 90%. At sick visits, the impact tripled from 11% to 32%, said Dr. Alexander G. Fiks, of the University of Pennsylvania and the Children's Hospital of Philadelphia (CHOP) and his colleagues (Pediatrics 2007;120:707–14).

“No one has published or developed a system that we are aware of that works quite [the same],” Dr. Fiks, a codeveloper of the system, said in an interview.

The system, used at four urban practices in the CHOP network, alerts physicians when they open a patient chart with an incomplete immunization record. It makes recommendations based on a process that:

▸ Excludes invalid vaccine doses and vaccinations given at too young an age or too close together.

▸ Considers the child's age, timing of past doses, and interval since the last dose to determine which vaccinations are due.

▸ Checks for combination vaccine products to minimize the number of shots required.

The study began Sept. 1, 2004, and covered 1,669 children who reached age 24 months in the next year. They were compared with 1,548 ccontrols who reached 24 months in the previous year. There were 15,928 immunization alerts recorded during the intervention year. More than 80% of the children in both groups were black.

One of the authors received a grant from the Ambulatory Podiatric Association.

LOS ANGELES — Increased risk of breast cancer after successful treatment for Hodgkin's lymphoma “definitely exists,” and is very much a matter of time, according to a researcher who reviewed records for 248 women cured of Hodgkin's lymphoma from 1964 through 2001.

Women who were younger than 30 years of age at the time of radiotherapy and those who survive 15 years or more after their treatments face the greatest risk of breast cancer, Dr. Mohamed Alm El-Din of Massachusetts General Hospital, Boston, reported at the annual meeting of the American Society for Therapeutic Radiation and Oncology.

Radiation dose and technique were not significant predictors when Dr. Alm El-Din and his coinvestigators compared the records of 36 women diagnosed with breast cancer with the rest of the survivors. Neither was a history of splenectomy, mediastinal disease, or chemotherapy with alkylating agents.

Perhaps the most striking finding, Dr. Alm El-Din noted, was that 11 (31%) of the 36 had bilateral breast cancer. Whether these women had other risk factors, such as a BRCA 1 or 2 gene or family history of breast cancer, is not known. Although slightly more than half (56%) of the breast cancers were detected by mammography, 11% were found incidentally during elective mastectomies.

“The younger the patient at the time of treatment for Hodgkin's lymphoma, the higher the risk, and the longer the time since radiation, the higher the risk,” Dr. Alm El-Din said in an interview. Patients who were irradiated for the disease at a young age “should be counseled about the higher risk, and we should design long-term surveillance, so we can detect any breast cancer very early and enhance their chances for a cure again.”

The presentation expanded upon an earlier Massachusetts General Hospital study of 111 Hodgkin's lymphoma patients, 14 of whom developed breast cancer (Cancer 1997;79:1203–10).

In the larger updated group, the median age at the time of supradiaphragmatic irradiation (SDI) was 26 years and median follow-up 15.2 years. Among the 36 women who developed breast cancer, the median age at first breast cancer diagnosis was 43.8 years, and the median time since radiation for Hodgkin's lymphoma was 18.4 years. Of these patients, 19 had their breast cancer treated at Massachusetts General. They developed 28 cancers: 9 ductal carcinomas in situ and 17 invasive ductal carcinomas. One had a mixed ductal and lobular tumor, and another had unknown histology.

Overall, the researchers reported a standardized morbidity ratio (SMR) of 9.78 for a woman developing a first breast cancer after SDI for Hodgkin's lymphoma. The ratio represents the number of observed breast cancers in a cohort divided by the number of breast cancers expected based on age-specific and calendar-year specific incidence rates from the Surveillance, Epidemiology, and End Results (SEER) database.

The highest SMR, 279.23, was for those irradiated before the age of 14 years. For all women treated before the age of 30, the SMR was significantly higher compared with those who were 30 years of age or older when originally treated: 19.05 vs. 4.64.

Looking at the interval between radiation and the diagnosis of a first breast cancer, the researchers found a peak SMR of 18.90 for the period 15–20 years afterward during which 14 women were diagnosed with breast cancer. Dr. Alm El-Din said survivors had an SMR of 14.34 when they were 15 or more years past radiotherapy as opposed to 5.01 when they were within 15 years of treatment.

In his conclusion, he recommended that all female survivors of Hodgkin's lymphoma, but especially those treated before the age of 30, be counseled about their increased risk. He said breast MRI, chemoprevention, and intensive screening should be considered for high-risk Hodgkin's survivors, many of whom are likely to be in primary care. Prophylactic mastectomy might be considered, he added, “in view of the high incidence of bilaterality and cases discovered incidentally.”

Physicians at Massachusetts General have already started to contact these patients to put them on long-term screening protocols. “Prophylactic mastectomy could be an option, but it is a very personal decision that should be discussed between doctor and patient.”

LOS ANGELES — Increased risk of breast cancer after successful treatment for Hodgkin's lymphoma “definitely exists,” and is very much a matter of time, according to a researcher who reviewed records for 248 women cured of Hodgkin's lymphoma from 1964 through 2001.

Women who were younger than 30 years of age at the time of radiotherapy and those who survive 15 years or more after their treatments face the greatest risk of breast cancer, Dr. Mohamed Alm El-Din of Massachusetts General Hospital, Boston, reported at the annual meeting of the American Society for Therapeutic Radiation and Oncology.

Radiation dose and technique were not significant predictors when Dr. Alm El-Din and his coinvestigators compared the records of 36 women diagnosed with breast cancer with the rest of the survivors. Neither was a history of splenectomy, mediastinal disease, or chemotherapy with alkylating agents.

Perhaps the most striking finding, Dr. Alm El-Din noted, was that 11 (31%) of the 36 had bilateral breast cancer. Whether these women had other risk factors, such as a BRCA 1 or 2 gene or family history of breast cancer, is not known. Although slightly more than half (56%) of the breast cancers were detected by mammography, 11% were found incidentally during elective mastectomies.

“The younger the patient at the time of treatment for Hodgkin's lymphoma, the higher the risk, and the longer the time since radiation, the higher the risk,” Dr. Alm El-Din said in an interview. Patients who were irradiated for the disease at a young age “should be counseled about the higher risk, and we should design long-term surveillance, so we can detect any breast cancer very early and enhance their chances for a cure again.”

The presentation expanded upon an earlier Massachusetts General Hospital study of 111 Hodgkin's lymphoma patients, 14 of whom developed breast cancer (Cancer 1997;79:1203–10).

In the larger updated group, the median age at the time of supradiaphragmatic irradiation (SDI) was 26 years and median follow-up 15.2 years. Among the 36 women who developed breast cancer, the median age at first breast cancer diagnosis was 43.8 years, and the median time since radiation for Hodgkin's lymphoma was 18.4 years. Of these patients, 19 had their breast cancer treated at Massachusetts General. They developed 28 cancers: 9 ductal carcinomas in situ and 17 invasive ductal carcinomas. One had a mixed ductal and lobular tumor, and another had unknown histology.

Overall, the researchers reported a standardized morbidity ratio (SMR) of 9.78 for a woman developing a first breast cancer after SDI for Hodgkin's lymphoma. The ratio represents the number of observed breast cancers in a cohort divided by the number of breast cancers expected based on age-specific and calendar-year specific incidence rates from the Surveillance, Epidemiology, and End Results (SEER) database.

The highest SMR, 279.23, was for those irradiated before the age of 14 years. For all women treated before the age of 30, the SMR was significantly higher compared with those who were 30 years of age or older when originally treated: 19.05 vs. 4.64.

Looking at the interval between radiation and the diagnosis of a first breast cancer, the researchers found a peak SMR of 18.90 for the period 15–20 years afterward during which 14 women were diagnosed with breast cancer. Dr. Alm El-Din said survivors had an SMR of 14.34 when they were 15 or more years past radiotherapy as opposed to 5.01 when they were within 15 years of treatment.

In his conclusion, he recommended that all female survivors of Hodgkin's lymphoma, but especially those treated before the age of 30, be counseled about their increased risk. He said breast MRI, chemoprevention, and intensive screening should be considered for high-risk Hodgkin's survivors, many of whom are likely to be in primary care. Prophylactic mastectomy might be considered, he added, “in view of the high incidence of bilaterality and cases discovered incidentally.”

Physicians at Massachusetts General have already started to contact these patients to put them on long-term screening protocols. “Prophylactic mastectomy could be an option, but it is a very personal decision that should be discussed between doctor and patient.”

LOS ANGELES — Increased risk of breast cancer after successful treatment for Hodgkin's lymphoma “definitely exists,” and is very much a matter of time, according to a researcher who reviewed records for 248 women cured of Hodgkin's lymphoma from 1964 through 2001.

Women who were younger than 30 years of age at the time of radiotherapy and those who survive 15 years or more after their treatments face the greatest risk of breast cancer, Dr. Mohamed Alm El-Din of Massachusetts General Hospital, Boston, reported at the annual meeting of the American Society for Therapeutic Radiation and Oncology.

Radiation dose and technique were not significant predictors when Dr. Alm El-Din and his coinvestigators compared the records of 36 women diagnosed with breast cancer with the rest of the survivors. Neither was a history of splenectomy, mediastinal disease, or chemotherapy with alkylating agents.

Perhaps the most striking finding, Dr. Alm El-Din noted, was that 11 (31%) of the 36 had bilateral breast cancer. Whether these women had other risk factors, such as a BRCA 1 or 2 gene or family history of breast cancer, is not known. Although slightly more than half (56%) of the breast cancers were detected by mammography, 11% were found incidentally during elective mastectomies.

“The younger the patient at the time of treatment for Hodgkin's lymphoma, the higher the risk, and the longer the time since radiation, the higher the risk,” Dr. Alm El-Din said in an interview. Patients who were irradiated for the disease at a young age “should be counseled about the higher risk, and we should design long-term surveillance, so we can detect any breast cancer very early and enhance their chances for a cure again.”

The presentation expanded upon an earlier Massachusetts General Hospital study of 111 Hodgkin's lymphoma patients, 14 of whom developed breast cancer (Cancer 1997;79:1203–10).

In the larger updated group, the median age at the time of supradiaphragmatic irradiation (SDI) was 26 years and median follow-up 15.2 years. Among the 36 women who developed breast cancer, the median age at first breast cancer diagnosis was 43.8 years, and the median time since radiation for Hodgkin's lymphoma was 18.4 years. Of these patients, 19 had their breast cancer treated at Massachusetts General. They developed 28 cancers: 9 ductal carcinomas in situ and 17 invasive ductal carcinomas. One had a mixed ductal and lobular tumor, and another had unknown histology.

Overall, the researchers reported a standardized morbidity ratio (SMR) of 9.78 for a woman developing a first breast cancer after SDI for Hodgkin's lymphoma. The ratio represents the number of observed breast cancers in a cohort divided by the number of breast cancers expected based on age-specific and calendar-year specific incidence rates from the Surveillance, Epidemiology, and End Results (SEER) database.

The highest SMR, 279.23, was for those irradiated before the age of 14 years. For all women treated before the age of 30, the SMR was significantly higher compared with those who were 30 years of age or older when originally treated: 19.05 vs. 4.64.

Looking at the interval between radiation and the diagnosis of a first breast cancer, the researchers found a peak SMR of 18.90 for the period 15–20 years afterward during which 14 women were diagnosed with breast cancer. Dr. Alm El-Din said survivors had an SMR of 14.34 when they were 15 or more years past radiotherapy as opposed to 5.01 when they were within 15 years of treatment.

In his conclusion, he recommended that all female survivors of Hodgkin's lymphoma, but especially those treated before the age of 30, be counseled about their increased risk. He said breast MRI, chemoprevention, and intensive screening should be considered for high-risk Hodgkin's survivors, many of whom are likely to be in primary care. Prophylactic mastectomy might be considered, he added, “in view of the high incidence of bilaterality and cases discovered incidentally.”

Physicians at Massachusetts General have already started to contact these patients to put them on long-term screening protocols. “Prophylactic mastectomy could be an option, but it is a very personal decision that should be discussed between doctor and patient.”

LOS ANGELES — Primary care physicians cannot assume cancer patients are receiving influenza or pneumonia vaccinations while in the care of oncology specialists.

When surveyed at the University of Pennsylvania in Philadelphia, a third of radiotherapy patients aged 50 years and older reported they never had an annual flu shot. Among those who were aged 65 years and older, 30% said that they never were vaccinated against pneumococcal pneumonia.

National guidelines call for vaccination of persons in these age groups. Moreover, by dint of their cancers and the treatments they were receiving, the patients surveyed were susceptible to life-threatening infections. Yet many of them said that they did not know about the vaccines, did not need them, or that the vaccinations were not recommended by a physician.

Such patients are falling into a gray zone, according to Dr. Neha Vapiwala, who presented results of the 214-person survey in a poster at the annual meeting of the American Society for Therapeutic Radiation and Oncology. Cancer patients see multiple physicians, none of whom are taking responsibility for routine prevention and maintenance measures, she said.

Although primary care physicians were more likely to recommend vaccinations than oncologists were, they did not do so routinely, according to the subgroup of patients who were vaccinated. Only 7% said a cancer specialist discussed vaccinations with them; 44% cited conversations with their primary care physicians.

“If there is ever a question about that cancer patient sitting in your office—a question about which routine health maintenance and prevention measures should or shouldn't be recommended—pick up the phone, send that e-mail, communicate with the oncologist,” Dr. Vapiwala urged primary care physicians during a press briefing at the meeting.

Clearer mandates are needed on vaccinations for cancer patients and “which physician is responsible for what,” she said. “Until that happens, we have patients now every single day in our clinic where assumptions are being made that specialist X is taking care of this item and primary care physician Y is taking care of that.”

Though the study relied on patient responses, Dr. Vapiwala, a radiation oncologist at the university, said anecdotal experience supports the finding that vaccinations are being overlooked by oncologists.

“We only have to survey the 12 physicians in our department to find the overwhelming majority are guilty. I include myself in that group,” she said.

Patients with a wide range of cancers were surveyed in outpatient clinics at the University of Pennsylvania. An unusually high proportion, 98%, completed usable questionnaires. Overall, 28% of patients reported having received one or two doses of the pneumococcal vaccine. More than half, 58%, said they had yearly flu shots. The median age was 56 years.

The investigators reported no difference among cancer types or treatment regimens with respect to inadequate vaccinations. “There is no reason to believe any of these patients—being in an outpatient setting—had any condition that would prevent them from receiving their vaccines,” Dr. Vapiwala noted.

Asked whether using electronic health records to prompt oncologists might be a solution, she said that would be of limited help in tracking which patients need the flu shots.

“Everyone in the room can go get it [a flu shot] at the supermarket, but the people who are actually really sick are not getting it anywhere because they either think they don't need it or they think they are too sick or their doctor didn't bring it up,” she said with the admonition: “Somebody has to bring it up.”

Cancer patients see multiple physicians, none of whom oversee routine prevention and maintenance measures. DR. VAPIWALA

LOS ANGELES — Primary care physicians cannot assume cancer patients are receiving influenza or pneumonia vaccinations while in the care of oncology specialists.

When surveyed at the University of Pennsylvania in Philadelphia, a third of radiotherapy patients aged 50 years and older reported they never had an annual flu shot. Among those who were aged 65 years and older, 30% said that they never were vaccinated against pneumococcal pneumonia.

National guidelines call for vaccination of persons in these age groups. Moreover, by dint of their cancers and the treatments they were receiving, the patients surveyed were susceptible to life-threatening infections. Yet many of them said that they did not know about the vaccines, did not need them, or that the vaccinations were not recommended by a physician.

Such patients are falling into a gray zone, according to Dr. Neha Vapiwala, who presented results of the 214-person survey in a poster at the annual meeting of the American Society for Therapeutic Radiation and Oncology. Cancer patients see multiple physicians, none of whom are taking responsibility for routine prevention and maintenance measures, she said.

Although primary care physicians were more likely to recommend vaccinations than oncologists were, they did not do so routinely, according to the subgroup of patients who were vaccinated. Only 7% said a cancer specialist discussed vaccinations with them; 44% cited conversations with their primary care physicians.

“If there is ever a question about that cancer patient sitting in your office—a question about which routine health maintenance and prevention measures should or shouldn't be recommended—pick up the phone, send that e-mail, communicate with the oncologist,” Dr. Vapiwala urged primary care physicians during a press briefing at the meeting.

Clearer mandates are needed on vaccinations for cancer patients and “which physician is responsible for what,” she said. “Until that happens, we have patients now every single day in our clinic where assumptions are being made that specialist X is taking care of this item and primary care physician Y is taking care of that.”

Though the study relied on patient responses, Dr. Vapiwala, a radiation oncologist at the university, said anecdotal experience supports the finding that vaccinations are being overlooked by oncologists.

“We only have to survey the 12 physicians in our department to find the overwhelming majority are guilty. I include myself in that group,” she said.

Patients with a wide range of cancers were surveyed in outpatient clinics at the University of Pennsylvania. An unusually high proportion, 98%, completed usable questionnaires. Overall, 28% of patients reported having received one or two doses of the pneumococcal vaccine. More than half, 58%, said they had yearly flu shots. The median age was 56 years.

The investigators reported no difference among cancer types or treatment regimens with respect to inadequate vaccinations. “There is no reason to believe any of these patients—being in an outpatient setting—had any condition that would prevent them from receiving their vaccines,” Dr. Vapiwala noted.

Asked whether using electronic health records to prompt oncologists might be a solution, she said that would be of limited help in tracking which patients need the flu shots.

“Everyone in the room can go get it [a flu shot] at the supermarket, but the people who are actually really sick are not getting it anywhere because they either think they don't need it or they think they are too sick or their doctor didn't bring it up,” she said with the admonition: “Somebody has to bring it up.”

Cancer patients see multiple physicians, none of whom oversee routine prevention and maintenance measures. DR. VAPIWALA

LOS ANGELES — Primary care physicians cannot assume cancer patients are receiving influenza or pneumonia vaccinations while in the care of oncology specialists.

When surveyed at the University of Pennsylvania in Philadelphia, a third of radiotherapy patients aged 50 years and older reported they never had an annual flu shot. Among those who were aged 65 years and older, 30% said that they never were vaccinated against pneumococcal pneumonia.

National guidelines call for vaccination of persons in these age groups. Moreover, by dint of their cancers and the treatments they were receiving, the patients surveyed were susceptible to life-threatening infections. Yet many of them said that they did not know about the vaccines, did not need them, or that the vaccinations were not recommended by a physician.

Such patients are falling into a gray zone, according to Dr. Neha Vapiwala, who presented results of the 214-person survey in a poster at the annual meeting of the American Society for Therapeutic Radiation and Oncology. Cancer patients see multiple physicians, none of whom are taking responsibility for routine prevention and maintenance measures, she said.

Although primary care physicians were more likely to recommend vaccinations than oncologists were, they did not do so routinely, according to the subgroup of patients who were vaccinated. Only 7% said a cancer specialist discussed vaccinations with them; 44% cited conversations with their primary care physicians.

“If there is ever a question about that cancer patient sitting in your office—a question about which routine health maintenance and prevention measures should or shouldn't be recommended—pick up the phone, send that e-mail, communicate with the oncologist,” Dr. Vapiwala urged primary care physicians during a press briefing at the meeting.

Clearer mandates are needed on vaccinations for cancer patients and “which physician is responsible for what,” she said. “Until that happens, we have patients now every single day in our clinic where assumptions are being made that specialist X is taking care of this item and primary care physician Y is taking care of that.”

Though the study relied on patient responses, Dr. Vapiwala, a radiation oncologist at the university, said anecdotal experience supports the finding that vaccinations are being overlooked by oncologists.

“We only have to survey the 12 physicians in our department to find the overwhelming majority are guilty. I include myself in that group,” she said.

Patients with a wide range of cancers were surveyed in outpatient clinics at the University of Pennsylvania. An unusually high proportion, 98%, completed usable questionnaires. Overall, 28% of patients reported having received one or two doses of the pneumococcal vaccine. More than half, 58%, said they had yearly flu shots. The median age was 56 years.

The investigators reported no difference among cancer types or treatment regimens with respect to inadequate vaccinations. “There is no reason to believe any of these patients—being in an outpatient setting—had any condition that would prevent them from receiving their vaccines,” Dr. Vapiwala noted.

Asked whether using electronic health records to prompt oncologists might be a solution, she said that would be of limited help in tracking which patients need the flu shots.

“Everyone in the room can go get it [a flu shot] at the supermarket, but the people who are actually really sick are not getting it anywhere because they either think they don't need it or they think they are too sick or their doctor didn't bring it up,” she said with the admonition: “Somebody has to bring it up.”

Cancer patients see multiple physicians, none of whom oversee routine prevention and maintenance measures. DR. VAPIWALA

CHICAGO — A decision aid designed to explain choices about chemotherapy and palliative care can help patients with metastatic cancer understand that the goal of therapy is not a cure, without increasing their anxiety, Dr. Natasha B. Leighl reported at the annual meeting of the American Society of Clinical Oncology.

A randomized, controlled trial conducted in Australia and Canada focused on communication of information to adult patients considering first-line therapy for metastatic colorectal cancer. The decision aid was used during a physician consultation, and patients received a booklet to read at home, said Dr. Leighl of Princess Margaret Hospital, Toronto.

Compared with 100 patients who had only a standard consultation, a larger proportion of 107 patients given the decision aid claimed English as their first language (78% vs. 64%). All patients had a median age in their early 60s, about half were men, and only about a third had prior chemotherapy.

Although the decision aid clarified the patients' poor prognosis, the investigators saw no difference between the groups in satisfaction with the treatment decision, conflict over the treatment decision, or anxiety levels immediately or in the weeks after the consultations.

Initially, both sets of patients understood the definition of metastatic cancer (89%), the general effects of chemotherapy (76%), and chemotherapy side effects (75%). Most overestimated the likelihood of experiencing chemotherapy side effects, and only 17% knew the correct percentage of patients who suffer severe chemotherapy toxicity. Other difficult concepts were survival with supportive care (17%), 1-year survival with chemotherapy (23%), and palliative intent of chemotherapy (57%).

Compared with the control group, patients given the decision aid had a significantly better grasp of information 2 weeks after the initial consult. Both groups knew a median of 8 out of 16 important facts about their disease before the decision aid was introduced. Two weeks later, patients given the decision aid knew a median of 11 facts correctly vs. 9 for the control group (P = .0008).

Similarly, less than 60% understood that the goal of therapy was not a cure after the initial consult. Two weeks later, more than 90% of the decision aid group but barely 70% of the control group understood this important but disheartening concept. Although the decision aid led to improved comprehension of the goal of therapy, it did not have much impact on treatment decisions. That's because two-thirds of decisions were made at the initial consultations, before the patients could read the material.

“Delayed decision making needs to be evaluated as an optimal strategy,” Dr. Leighl said. More than 70% of both groups opted for chemotherapy.

In discussing the study and another investigation that found parents of pediatric cancer patients felt more hopeful when given more information—even if a child's prognosis was poor—Dr. Paul R. Helft of Indiana University, Indianapolis, observed that curable and incurable cancer patients see hope differently. “Patients treated with curable intent have a kind of built-in hope. … Patients treated with noncurable intent have a different problem with hope,” he said. “What should they hope for? Is it longer life? Is it cure? Is it a good death? I've heard that said many times.”

Dr. Leighl's study shows that a decision aid can benefit patients in the latter group when making difficult “gray area” decisions, according to Dr. Helft.

Nonetheless, Dr. Helft called for a moratorium on trials of new and existing decision aids. The problem is that they are not used, he said, calling for greater efforts at bringing them into practice, possibly through the use of “information prescriptions” and lobbying for reimbursement for their use.

Patients given the decision aid had a significantly better grasp of information 2 weeks after the initial consult. DR. LEIGHL

CHICAGO — A decision aid designed to explain choices about chemotherapy and palliative care can help patients with metastatic cancer understand that the goal of therapy is not a cure, without increasing their anxiety, Dr. Natasha B. Leighl reported at the annual meeting of the American Society of Clinical Oncology.

A randomized, controlled trial conducted in Australia and Canada focused on communication of information to adult patients considering first-line therapy for metastatic colorectal cancer. The decision aid was used during a physician consultation, and patients received a booklet to read at home, said Dr. Leighl of Princess Margaret Hospital, Toronto.

Compared with 100 patients who had only a standard consultation, a larger proportion of 107 patients given the decision aid claimed English as their first language (78% vs. 64%). All patients had a median age in their early 60s, about half were men, and only about a third had prior chemotherapy.

Although the decision aid clarified the patients' poor prognosis, the investigators saw no difference between the groups in satisfaction with the treatment decision, conflict over the treatment decision, or anxiety levels immediately or in the weeks after the consultations.

Initially, both sets of patients understood the definition of metastatic cancer (89%), the general effects of chemotherapy (76%), and chemotherapy side effects (75%). Most overestimated the likelihood of experiencing chemotherapy side effects, and only 17% knew the correct percentage of patients who suffer severe chemotherapy toxicity. Other difficult concepts were survival with supportive care (17%), 1-year survival with chemotherapy (23%), and palliative intent of chemotherapy (57%).

Compared with the control group, patients given the decision aid had a significantly better grasp of information 2 weeks after the initial consult. Both groups knew a median of 8 out of 16 important facts about their disease before the decision aid was introduced. Two weeks later, patients given the decision aid knew a median of 11 facts correctly vs. 9 for the control group (P = .0008).

Similarly, less than 60% understood that the goal of therapy was not a cure after the initial consult. Two weeks later, more than 90% of the decision aid group but barely 70% of the control group understood this important but disheartening concept. Although the decision aid led to improved comprehension of the goal of therapy, it did not have much impact on treatment decisions. That's because two-thirds of decisions were made at the initial consultations, before the patients could read the material.

“Delayed decision making needs to be evaluated as an optimal strategy,” Dr. Leighl said. More than 70% of both groups opted for chemotherapy.

In discussing the study and another investigation that found parents of pediatric cancer patients felt more hopeful when given more information—even if a child's prognosis was poor—Dr. Paul R. Helft of Indiana University, Indianapolis, observed that curable and incurable cancer patients see hope differently. “Patients treated with curable intent have a kind of built-in hope. … Patients treated with noncurable intent have a different problem with hope,” he said. “What should they hope for? Is it longer life? Is it cure? Is it a good death? I've heard that said many times.”

Dr. Leighl's study shows that a decision aid can benefit patients in the latter group when making difficult “gray area” decisions, according to Dr. Helft.

Nonetheless, Dr. Helft called for a moratorium on trials of new and existing decision aids. The problem is that they are not used, he said, calling for greater efforts at bringing them into practice, possibly through the use of “information prescriptions” and lobbying for reimbursement for their use.

Patients given the decision aid had a significantly better grasp of information 2 weeks after the initial consult. DR. LEIGHL

CHICAGO — A decision aid designed to explain choices about chemotherapy and palliative care can help patients with metastatic cancer understand that the goal of therapy is not a cure, without increasing their anxiety, Dr. Natasha B. Leighl reported at the annual meeting of the American Society of Clinical Oncology.

A randomized, controlled trial conducted in Australia and Canada focused on communication of information to adult patients considering first-line therapy for metastatic colorectal cancer. The decision aid was used during a physician consultation, and patients received a booklet to read at home, said Dr. Leighl of Princess Margaret Hospital, Toronto.

Compared with 100 patients who had only a standard consultation, a larger proportion of 107 patients given the decision aid claimed English as their first language (78% vs. 64%). All patients had a median age in their early 60s, about half were men, and only about a third had prior chemotherapy.

Although the decision aid clarified the patients' poor prognosis, the investigators saw no difference between the groups in satisfaction with the treatment decision, conflict over the treatment decision, or anxiety levels immediately or in the weeks after the consultations.

Initially, both sets of patients understood the definition of metastatic cancer (89%), the general effects of chemotherapy (76%), and chemotherapy side effects (75%). Most overestimated the likelihood of experiencing chemotherapy side effects, and only 17% knew the correct percentage of patients who suffer severe chemotherapy toxicity. Other difficult concepts were survival with supportive care (17%), 1-year survival with chemotherapy (23%), and palliative intent of chemotherapy (57%).

Compared with the control group, patients given the decision aid had a significantly better grasp of information 2 weeks after the initial consult. Both groups knew a median of 8 out of 16 important facts about their disease before the decision aid was introduced. Two weeks later, patients given the decision aid knew a median of 11 facts correctly vs. 9 for the control group (P = .0008).

Similarly, less than 60% understood that the goal of therapy was not a cure after the initial consult. Two weeks later, more than 90% of the decision aid group but barely 70% of the control group understood this important but disheartening concept. Although the decision aid led to improved comprehension of the goal of therapy, it did not have much impact on treatment decisions. That's because two-thirds of decisions were made at the initial consultations, before the patients could read the material.

“Delayed decision making needs to be evaluated as an optimal strategy,” Dr. Leighl said. More than 70% of both groups opted for chemotherapy.

In discussing the study and another investigation that found parents of pediatric cancer patients felt more hopeful when given more information—even if a child's prognosis was poor—Dr. Paul R. Helft of Indiana University, Indianapolis, observed that curable and incurable cancer patients see hope differently. “Patients treated with curable intent have a kind of built-in hope. … Patients treated with noncurable intent have a different problem with hope,” he said. “What should they hope for? Is it longer life? Is it cure? Is it a good death? I've heard that said many times.”

Dr. Leighl's study shows that a decision aid can benefit patients in the latter group when making difficult “gray area” decisions, according to Dr. Helft.

Nonetheless, Dr. Helft called for a moratorium on trials of new and existing decision aids. The problem is that they are not used, he said, calling for greater efforts at bringing them into practice, possibly through the use of “information prescriptions” and lobbying for reimbursement for their use.

Patients given the decision aid had a significantly better grasp of information 2 weeks after the initial consult. DR. LEIGHL

CHICAGO — Provocative findings from two studies presented at the annual meeting of the American Society of Clinical Oncology suggest that some patients with HER2-negative breast cancer may benefit from trastuzumab.

A retrospective analysis of the phase III Cancer and Leukemia Group B (CALGB) 9840 trial revealed that human epidermal growth factor 2 (HER2)-negative metastatic breast cancer patients with multiple copies of the chromosome carrying HER2 had significantly better response rates (63% vs. 26%) when they were treated with trastuzumab (Herceptin) in addition to paclitaxel.

In the adjuvant setting, another retrospective analysis showed that a small group of HER2-negative patients in the phase III National Surgical Adjuvant Breast and Bowel Project (NSABP) B-31 trial had significantly better disease-free survival with a relative risk of 0.40 when given trastuzumab after completing treatment for early breast cancer.

Both studies drew considerable attention, with investigators and discussants discouraging attendees from using findings in the clinical setting before they can be verified.

“We emphasize that additional study is needed. At the moment we don't feel that these data should be used clinically,” Dr. Peter A. Kaufman concluded in his presentation of the CALGB data.

He stressed that only a small number of patients were analyzed and noted that trastuzumab did not improve progression-free survival or overall survival for the HER2-negative patients with polysomy of chromosome 17.

Dr. Soonmyung Paik of the NSABP called for a randomized clinical trial to test adjuvant trastuzumab in HER2-negative women.

A favorable outcome might lead to expansion of trastuzumab's indication from 20% to about 60% of breast cancer patients, he said.

“The major question raised by this paper is, what now?” Dr. James H. Doroshow said, advising that the NSABP study needs to be confirmed before new standards for HER2 positivity can be developed.

“It is critical that all appropriate adjuvant breast cancer sets be reevaluated, so that a new consensus can be established for HER2 testing,” said Dr. Doroshow, director of the National Cancer Institute's division of cancer treatment and diagnosis.

After a lengthy audience discussion in which one physician demanded a reason not to expand use of trastuzumab, Dr. Vered Stearns advocated further investigation of HER2 copy number in available data sets from large clinical trials in the metastatic and adjuvant settings.

“Until additional information is available, HER2 copy number and proteomics are not ready for prime time,” said Dr. Stearns of the cancer center at Johns Hopkins University, Baltimore.

Investigators were limited to available tissue blocks in the two retrospective studies of completed trials. They also grappled with disparities between local and central laboratories testing for HER2 positivity, and with standards for making the determination by immunohistochemistry (IHC) and/or fluorescent in situ hybridization (FISH).

The original report from the CALGB 9840 trial indicated that weekly paclitaxel was superior to paclitaxel taken every 3 weeks in metastatic breast cancer. Although more HER2-negative women responded when trastuzumab was added to paclitaxel, the difference was not significant.

For the new report (CALGB 150002), a laboratory correlative science study associated with CALGB 9840, Dr. Kaufman and his associates found that 303 tissue blocks were available from the original 585 patients.

These included samples from 129 patients whom local pathologists and/or central testing had classified as HER2-negative at the time that the data were collected.

Within this group, the new investigation determined that 25 patients (19%) had polysomy (defined as 2.2 copies or more per cell) of chromosome 17.

Because the HER2 gene is located on chromosome 17, polysomy is typically associated with increased copies of the HER2 gene as well, according to Dr. Kaufman of the cancer center at the Dartmouth-Hitchcock Medical Center, Lebanon, N.H.

Retesting all the available samples, the investigators classified 192 patients as FISH-negative and identified 38 patients with extra copies of the chromosome. This group included the original 25 HER2-negative patients plus 7 patients who had been classified previously as HER2-positive and 6 whose original HER2 status was unknown.

New central IHC testing of 37 of the 38 cases determined that only 3 (8%) were HER2-positive based on an IHC count of 3+. The remaining 34 (92%) were HER2-negative with IHC counts of 0–2+.

Although trastuzumab significantly increased response in the 38 women, Dr. Kaufman reported that it added no benefit for 103 women who were HER2-negative and did not have polysomy of chromosome 17. An identical proportion (36%) responded to paclitaxel with and without trastuzumab.

Reporting on the reevaluation of the NSABP trial, Dr. Paik noted that the protocol was changed during the trial to require that IHC testing for HER2 be done by qualified laboratories. He said the proportion of patients classified as HER2-negative by IHC and FISH fell from 16.4% before the amendment to 6.8% afterward. Of the trial population, 9.5% (171/1,795) was negative by both measures.

“This is the bottom line. We couldn't find any subset that didn't benefit from trastuzumab,” he said, acknowledging the subsets were small.

In patients deemed negative by both IHC and FISH, the relative risk of recurrence was 0.34.

Noting that the parameters of HER2 positivity originated in the metastatic setting, Dr. Paik and his associates concluded that the “current definition of HER2 overexpression/gene amplification based on data from advanced disease may need to be modified for the adjuvant setting.”

CHICAGO — Provocative findings from two studies presented at the annual meeting of the American Society of Clinical Oncology suggest that some patients with HER2-negative breast cancer may benefit from trastuzumab.

A retrospective analysis of the phase III Cancer and Leukemia Group B (CALGB) 9840 trial revealed that human epidermal growth factor 2 (HER2)-negative metastatic breast cancer patients with multiple copies of the chromosome carrying HER2 had significantly better response rates (63% vs. 26%) when they were treated with trastuzumab (Herceptin) in addition to paclitaxel.

In the adjuvant setting, another retrospective analysis showed that a small group of HER2-negative patients in the phase III National Surgical Adjuvant Breast and Bowel Project (NSABP) B-31 trial had significantly better disease-free survival with a relative risk of 0.40 when given trastuzumab after completing treatment for early breast cancer.

Both studies drew considerable attention, with investigators and discussants discouraging attendees from using findings in the clinical setting before they can be verified.

“We emphasize that additional study is needed. At the moment we don't feel that these data should be used clinically,” Dr. Peter A. Kaufman concluded in his presentation of the CALGB data.

He stressed that only a small number of patients were analyzed and noted that trastuzumab did not improve progression-free survival or overall survival for the HER2-negative patients with polysomy of chromosome 17.

Dr. Soonmyung Paik of the NSABP called for a randomized clinical trial to test adjuvant trastuzumab in HER2-negative women.

A favorable outcome might lead to expansion of trastuzumab's indication from 20% to about 60% of breast cancer patients, he said.

“The major question raised by this paper is, what now?” Dr. James H. Doroshow said, advising that the NSABP study needs to be confirmed before new standards for HER2 positivity can be developed.

“It is critical that all appropriate adjuvant breast cancer sets be reevaluated, so that a new consensus can be established for HER2 testing,” said Dr. Doroshow, director of the National Cancer Institute's division of cancer treatment and diagnosis.

After a lengthy audience discussion in which one physician demanded a reason not to expand use of trastuzumab, Dr. Vered Stearns advocated further investigation of HER2 copy number in available data sets from large clinical trials in the metastatic and adjuvant settings.

“Until additional information is available, HER2 copy number and proteomics are not ready for prime time,” said Dr. Stearns of the cancer center at Johns Hopkins University, Baltimore.

Investigators were limited to available tissue blocks in the two retrospective studies of completed trials. They also grappled with disparities between local and central laboratories testing for HER2 positivity, and with standards for making the determination by immunohistochemistry (IHC) and/or fluorescent in situ hybridization (FISH).

The original report from the CALGB 9840 trial indicated that weekly paclitaxel was superior to paclitaxel taken every 3 weeks in metastatic breast cancer. Although more HER2-negative women responded when trastuzumab was added to paclitaxel, the difference was not significant.

For the new report (CALGB 150002), a laboratory correlative science study associated with CALGB 9840, Dr. Kaufman and his associates found that 303 tissue blocks were available from the original 585 patients.

These included samples from 129 patients whom local pathologists and/or central testing had classified as HER2-negative at the time that the data were collected.

Within this group, the new investigation determined that 25 patients (19%) had polysomy (defined as 2.2 copies or more per cell) of chromosome 17.

Because the HER2 gene is located on chromosome 17, polysomy is typically associated with increased copies of the HER2 gene as well, according to Dr. Kaufman of the cancer center at the Dartmouth-Hitchcock Medical Center, Lebanon, N.H.

Retesting all the available samples, the investigators classified 192 patients as FISH-negative and identified 38 patients with extra copies of the chromosome. This group included the original 25 HER2-negative patients plus 7 patients who had been classified previously as HER2-positive and 6 whose original HER2 status was unknown.

New central IHC testing of 37 of the 38 cases determined that only 3 (8%) were HER2-positive based on an IHC count of 3+. The remaining 34 (92%) were HER2-negative with IHC counts of 0–2+.

Although trastuzumab significantly increased response in the 38 women, Dr. Kaufman reported that it added no benefit for 103 women who were HER2-negative and did not have polysomy of chromosome 17. An identical proportion (36%) responded to paclitaxel with and without trastuzumab.

Reporting on the reevaluation of the NSABP trial, Dr. Paik noted that the protocol was changed during the trial to require that IHC testing for HER2 be done by qualified laboratories. He said the proportion of patients classified as HER2-negative by IHC and FISH fell from 16.4% before the amendment to 6.8% afterward. Of the trial population, 9.5% (171/1,795) was negative by both measures.

“This is the bottom line. We couldn't find any subset that didn't benefit from trastuzumab,” he said, acknowledging the subsets were small.

In patients deemed negative by both IHC and FISH, the relative risk of recurrence was 0.34.

Noting that the parameters of HER2 positivity originated in the metastatic setting, Dr. Paik and his associates concluded that the “current definition of HER2 overexpression/gene amplification based on data from advanced disease may need to be modified for the adjuvant setting.”

CHICAGO — Provocative findings from two studies presented at the annual meeting of the American Society of Clinical Oncology suggest that some patients with HER2-negative breast cancer may benefit from trastuzumab.

A retrospective analysis of the phase III Cancer and Leukemia Group B (CALGB) 9840 trial revealed that human epidermal growth factor 2 (HER2)-negative metastatic breast cancer patients with multiple copies of the chromosome carrying HER2 had significantly better response rates (63% vs. 26%) when they were treated with trastuzumab (Herceptin) in addition to paclitaxel.

In the adjuvant setting, another retrospective analysis showed that a small group of HER2-negative patients in the phase III National Surgical Adjuvant Breast and Bowel Project (NSABP) B-31 trial had significantly better disease-free survival with a relative risk of 0.40 when given trastuzumab after completing treatment for early breast cancer.

Both studies drew considerable attention, with investigators and discussants discouraging attendees from using findings in the clinical setting before they can be verified.

“We emphasize that additional study is needed. At the moment we don't feel that these data should be used clinically,” Dr. Peter A. Kaufman concluded in his presentation of the CALGB data.

He stressed that only a small number of patients were analyzed and noted that trastuzumab did not improve progression-free survival or overall survival for the HER2-negative patients with polysomy of chromosome 17.

Dr. Soonmyung Paik of the NSABP called for a randomized clinical trial to test adjuvant trastuzumab in HER2-negative women.

A favorable outcome might lead to expansion of trastuzumab's indication from 20% to about 60% of breast cancer patients, he said.

“The major question raised by this paper is, what now?” Dr. James H. Doroshow said, advising that the NSABP study needs to be confirmed before new standards for HER2 positivity can be developed.

“It is critical that all appropriate adjuvant breast cancer sets be reevaluated, so that a new consensus can be established for HER2 testing,” said Dr. Doroshow, director of the National Cancer Institute's division of cancer treatment and diagnosis.

After a lengthy audience discussion in which one physician demanded a reason not to expand use of trastuzumab, Dr. Vered Stearns advocated further investigation of HER2 copy number in available data sets from large clinical trials in the metastatic and adjuvant settings.

“Until additional information is available, HER2 copy number and proteomics are not ready for prime time,” said Dr. Stearns of the cancer center at Johns Hopkins University, Baltimore.

Investigators were limited to available tissue blocks in the two retrospective studies of completed trials. They also grappled with disparities between local and central laboratories testing for HER2 positivity, and with standards for making the determination by immunohistochemistry (IHC) and/or fluorescent in situ hybridization (FISH).

The original report from the CALGB 9840 trial indicated that weekly paclitaxel was superior to paclitaxel taken every 3 weeks in metastatic breast cancer. Although more HER2-negative women responded when trastuzumab was added to paclitaxel, the difference was not significant.

For the new report (CALGB 150002), a laboratory correlative science study associated with CALGB 9840, Dr. Kaufman and his associates found that 303 tissue blocks were available from the original 585 patients.

These included samples from 129 patients whom local pathologists and/or central testing had classified as HER2-negative at the time that the data were collected.

Within this group, the new investigation determined that 25 patients (19%) had polysomy (defined as 2.2 copies or more per cell) of chromosome 17.

Because the HER2 gene is located on chromosome 17, polysomy is typically associated with increased copies of the HER2 gene as well, according to Dr. Kaufman of the cancer center at the Dartmouth-Hitchcock Medical Center, Lebanon, N.H.

Retesting all the available samples, the investigators classified 192 patients as FISH-negative and identified 38 patients with extra copies of the chromosome. This group included the original 25 HER2-negative patients plus 7 patients who had been classified previously as HER2-positive and 6 whose original HER2 status was unknown.

New central IHC testing of 37 of the 38 cases determined that only 3 (8%) were HER2-positive based on an IHC count of 3+. The remaining 34 (92%) were HER2-negative with IHC counts of 0–2+.

Although trastuzumab significantly increased response in the 38 women, Dr. Kaufman reported that it added no benefit for 103 women who were HER2-negative and did not have polysomy of chromosome 17. An identical proportion (36%) responded to paclitaxel with and without trastuzumab.

Reporting on the reevaluation of the NSABP trial, Dr. Paik noted that the protocol was changed during the trial to require that IHC testing for HER2 be done by qualified laboratories. He said the proportion of patients classified as HER2-negative by IHC and FISH fell from 16.4% before the amendment to 6.8% afterward. Of the trial population, 9.5% (171/1,795) was negative by both measures.

“This is the bottom line. We couldn't find any subset that didn't benefit from trastuzumab,” he said, acknowledging the subsets were small.

In patients deemed negative by both IHC and FISH, the relative risk of recurrence was 0.34.

Noting that the parameters of HER2 positivity originated in the metastatic setting, Dr. Paik and his associates concluded that the “current definition of HER2 overexpression/gene amplification based on data from advanced disease may need to be modified for the adjuvant setting.”

PHOENIX — A 10-patient experiment comparing Juvéderm with Restylane revealed little difference between the two hyaluronic acid fillers, Dr. Seth L. Matarasso reported at a clinical dermatology conference sponsored by Medicis.

Half of each patient's face was injected with Restylane, the other half with Juvéderm. The only difference observed was "perhaps" a little less edema in the lip area with Juvéderm. Cost, flow, redness, and bruising were otherwise comparable, said Dr. Matarasso, professor of dermatology at the University of California, San Francisco.

"As far as discomfort and appearance, I didn't find it that much different," he said.

Two patients returned for botulinum toxin treatments after 6–7 months, he added. The durability of the two fillers appeared comparable at that point, he said.

The U.S. Food and Drug Administration approved Juvéderm, a hyaluronic acid gel marketed by Allergan Inc. for "injection into the mid to deep dermis for correction of moderate to severe facial wrinkles and folds (such as nasolabial folds)."

The approval was based on a 6-month, double-blind, randomized controlled clinical trial in which Juvéderm compared favorably to Zyplast, a bovine-based collagen. Juvéderm provided longer wrinkle correction in that trial, but Dr. Mattarasso said that studies comparing it to other hyaluronic acids are needed. "My suspicion is the complication rate will be [the] same as other hyaluronic acids. I don't know what the advantages will be. … I think it is way too early to tell," he said.

He did not recommend switching from Restylane, which is marketed by Medicis, to Juvéderm, based on the results of his small study. Juvéderm may cause slightly less swelling, but Dr. Matarasso said that the limited evidence was not a reason to change products. "I think you should pick a product you feel comfortable with, and then branch out," he said.

The ideal filler does not exist, according to Dr. Matarasso, but new products are giving cosmetic dermatologists "an incredible buffet" from which to choose. The deciding factors ultimately will be how the product feels in the clinician's hands and how much the patient likes it, he predicted.

Theoretically, hyaluronic acid fillers are nonallergenic, but Dr. Matarasso said they can cause hypersensitivity reactions. Juvéderm is contraindicated in patients with severe allergies and/or a history of allergies to gram-positive bacterial proteins.

Hyaluronic acid fillers do not include anesthesia and can cause discomfort, so a topical anesthetic—he uses EMLA cream or Betacaine—should be applied before procedures. "Patients don't want a nerve block," he said, and added that patients should be told to expect some edema.

Another new hyaluronic acid filler, Perlane, was approved by the FDA in May ("New Hyaluronic Acid Gel Filler Receives Approval," SKIN & ALLERGY NEWS, June 2007, p. 9).

Clinicians should be aware of products available abroad because patients are returning from overseas trips with complications from injections of fillers not approved by the FDA. "I see a lot of people from the Pacific rim and Australia," he said. "What is astonishing to me is they have injectables, and they don't know what was injected into their face."

Dr. Matarasso has served as a consultant to Allergan and Medicis.

Juvéderm may cause slightlyless swelling, but there's not enough evidence to change products. DR. MATARASSO

PHOENIX — A 10-patient experiment comparing Juvéderm with Restylane revealed little difference between the two hyaluronic acid fillers, Dr. Seth L. Matarasso reported at a clinical dermatology conference sponsored by Medicis.

Half of each patient's face was injected with Restylane, the other half with Juvéderm. The only difference observed was "perhaps" a little less edema in the lip area with Juvéderm. Cost, flow, redness, and bruising were otherwise comparable, said Dr. Matarasso, professor of dermatology at the University of California, San Francisco.

"As far as discomfort and appearance, I didn't find it that much different," he said.

Two patients returned for botulinum toxin treatments after 6–7 months, he added. The durability of the two fillers appeared comparable at that point, he said.

The U.S. Food and Drug Administration approved Juvéderm, a hyaluronic acid gel marketed by Allergan Inc. for "injection into the mid to deep dermis for correction of moderate to severe facial wrinkles and folds (such as nasolabial folds)."

The approval was based on a 6-month, double-blind, randomized controlled clinical trial in which Juvéderm compared favorably to Zyplast, a bovine-based collagen. Juvéderm provided longer wrinkle correction in that trial, but Dr. Mattarasso said that studies comparing it to other hyaluronic acids are needed. "My suspicion is the complication rate will be [the] same as other hyaluronic acids. I don't know what the advantages will be. … I think it is way too early to tell," he said.

He did not recommend switching from Restylane, which is marketed by Medicis, to Juvéderm, based on the results of his small study. Juvéderm may cause slightly less swelling, but Dr. Matarasso said that the limited evidence was not a reason to change products. "I think you should pick a product you feel comfortable with, and then branch out," he said.

The ideal filler does not exist, according to Dr. Matarasso, but new products are giving cosmetic dermatologists "an incredible buffet" from which to choose. The deciding factors ultimately will be how the product feels in the clinician's hands and how much the patient likes it, he predicted.

Theoretically, hyaluronic acid fillers are nonallergenic, but Dr. Matarasso said they can cause hypersensitivity reactions. Juvéderm is contraindicated in patients with severe allergies and/or a history of allergies to gram-positive bacterial proteins.

Hyaluronic acid fillers do not include anesthesia and can cause discomfort, so a topical anesthetic—he uses EMLA cream or Betacaine—should be applied before procedures. "Patients don't want a nerve block," he said, and added that patients should be told to expect some edema.

Another new hyaluronic acid filler, Perlane, was approved by the FDA in May ("New Hyaluronic Acid Gel Filler Receives Approval," SKIN & ALLERGY NEWS, June 2007, p. 9).

Clinicians should be aware of products available abroad because patients are returning from overseas trips with complications from injections of fillers not approved by the FDA. "I see a lot of people from the Pacific rim and Australia," he said. "What is astonishing to me is they have injectables, and they don't know what was injected into their face."

Dr. Matarasso has served as a consultant to Allergan and Medicis.

Juvéderm may cause slightlyless swelling, but there's not enough evidence to change products. DR. MATARASSO

PHOENIX — A 10-patient experiment comparing Juvéderm with Restylane revealed little difference between the two hyaluronic acid fillers, Dr. Seth L. Matarasso reported at a clinical dermatology conference sponsored by Medicis.

Half of each patient's face was injected with Restylane, the other half with Juvéderm. The only difference observed was "perhaps" a little less edema in the lip area with Juvéderm. Cost, flow, redness, and bruising were otherwise comparable, said Dr. Matarasso, professor of dermatology at the University of California, San Francisco.

"As far as discomfort and appearance, I didn't find it that much different," he said.

Two patients returned for botulinum toxin treatments after 6–7 months, he added. The durability of the two fillers appeared comparable at that point, he said.

The U.S. Food and Drug Administration approved Juvéderm, a hyaluronic acid gel marketed by Allergan Inc. for "injection into the mid to deep dermis for correction of moderate to severe facial wrinkles and folds (such as nasolabial folds)."

The approval was based on a 6-month, double-blind, randomized controlled clinical trial in which Juvéderm compared favorably to Zyplast, a bovine-based collagen. Juvéderm provided longer wrinkle correction in that trial, but Dr. Mattarasso said that studies comparing it to other hyaluronic acids are needed. "My suspicion is the complication rate will be [the] same as other hyaluronic acids. I don't know what the advantages will be. … I think it is way too early to tell," he said.

He did not recommend switching from Restylane, which is marketed by Medicis, to Juvéderm, based on the results of his small study. Juvéderm may cause slightly less swelling, but Dr. Matarasso said that the limited evidence was not a reason to change products. "I think you should pick a product you feel comfortable with, and then branch out," he said.

The ideal filler does not exist, according to Dr. Matarasso, but new products are giving cosmetic dermatologists "an incredible buffet" from which to choose. The deciding factors ultimately will be how the product feels in the clinician's hands and how much the patient likes it, he predicted.

Theoretically, hyaluronic acid fillers are nonallergenic, but Dr. Matarasso said they can cause hypersensitivity reactions. Juvéderm is contraindicated in patients with severe allergies and/or a history of allergies to gram-positive bacterial proteins.

Hyaluronic acid fillers do not include anesthesia and can cause discomfort, so a topical anesthetic—he uses EMLA cream or Betacaine—should be applied before procedures. "Patients don't want a nerve block," he said, and added that patients should be told to expect some edema.

Another new hyaluronic acid filler, Perlane, was approved by the FDA in May ("New Hyaluronic Acid Gel Filler Receives Approval," SKIN & ALLERGY NEWS, June 2007, p. 9).

Clinicians should be aware of products available abroad because patients are returning from overseas trips with complications from injections of fillers not approved by the FDA. "I see a lot of people from the Pacific rim and Australia," he said. "What is astonishing to me is they have injectables, and they don't know what was injected into their face."

Dr. Matarasso has served as a consultant to Allergan and Medicis.

Juvéderm may cause slightlyless swelling, but there's not enough evidence to change products. DR. MATARASSO

CHICAGO — Six years after being diagnosed with colorectal cancer, nearly two-thirds of people tracked in a retrospective longitudinal study of 1,541 elderly survivors relied entirely on their primary care physicians for follow-up care.

Over the same time period, the role of oncology specialists was much smaller and declined significantly, as did the amount of cancer screening that they performed.

With the exception of mammography, primary care physicians provided more preventive services than did oncologists. They ordered more flu shots, Pap smears, cholesterol screening, and bone densitometry tests.

Visits to both types of physician resulted in more of all these measures than did visits to either type alone. “Survivors who see both an oncology specialist and a primary care provider are most likely to receive preventive care,” lead investigator Claire Snyder, Ph.D., reported at the annual meeting of the American Society of Clinical Oncology.

The study, supported in part by an unrestricted grant from Pfizer Inc., explored the growing issue of who takes responsibility for long-term care of cancer survivors in the United States. “The role of oncology specialists and primary care providers during the posttreatment phase is unclear,” said Dr. Snyder, of the division of general internal medicine at Johns Hopkins University, Baltimore.

She and her coauthors linked data from the Surveillance, Epidemiology, and End Results (SEER) registry with Medicare fee-for-services claims to follow patients from 1 year after diagnosis to the end of the sixth year. The study population had an average age of 76 years, included fewer men (42.7%) than women, comprised mostly whites (85.3%), survived stage I or II disease predominantly (82.8%), and had a mean comorbidity index of 1.76.

Initially, 37% of survivors went to both a primary care physician and an oncology specialist, but this fell to 21% by the end of the study. Meanwhile, the proportion seeing only a primary care physician increased from 44% to 62% over the 5-year period, while those seeing only an oncology specialist fell from 8% to 4%.

In any given year, slightly more than 10% of survivors saw neither type of physician, but some visited other specialists, often cardiologists, according to Dr. Snyder.

Additionally, the average number of visits to a primary care physician increased from 4.2 in the first year to 4.7 during the fifth year. Visits to an oncology specialist fell from 1.3 in the first year to 0.5 in the fifth year. Both changes were statistically significant (P = .0001).

“Most primary care provider visits were to internal medicine or family physicians, and most of the oncology specialist visits were to medical oncologists, hematologist/oncologists, or general surgeons,” Dr. Snyder said.

The primary care physician category also included general, ob.gyn., geriatric, and multispecialty practices. The oncology specialist category included colorectal surgery, surgical oncology, and radiation oncology practices.

Who provides care is important, Dr. Snyder said, because survivors have special medical needs. She cited surveillance for recurrence; monitoring for long-term and late treatment effects; general primary and preventive care; and care for comorbid conditions, which can be chronic in these patients.

To assess how the physician mix affected preventive services, her group looked at influenza vaccination and cholesterol screening for the entire population, along with mammography, cervical cancer screening, and bone densitometry in women, with the mammography standard being applied only to women younger than 76 years of age.

The investigators found that the mammography rate fell from 54% in the first year to 43% in the fifth year, and cervical cancer screening from 19% to 11%. “There were no clear trends in flu shots, cholesterol screening, or bone densitometry,” she said.

Cumulative 5-year data on these measures showed statistically significant differences (P less than or equal to .0001) for all based on the medical provider. For example, flu shots were documented for 61.7% of people seen by a primary care physician and an oncologist, for 52.4% of those who visited only a primary care physician, and for 49.2% of those who visited only an oncologist. The rate dropped to 31.4% when survivors saw neither.

Dr. Snyder cautioned that the investigators had no way to ask why some services were not provided. “Did the physician not offer the service? Did the patient refuse it?” she asked, noting that “some question the usefulness of certain screening procedures in the very old.”

The study's main implication, she concluded, is that there is a need for survivorship care plans that clearly delineate the roles and responsibilities of oncologists and primary care physicians in providing future care to cancer survivors.

Discussant Julia H. Rowland, Ph.D., director of the National Cancer Institute's office of cancer survivorship, seconded the call for such plans along with treatment summaries.

Today, the U.S. population includes more than 10.8 million cancer survivors, according to Dr. Rowland. Not only are more people surviving cancer, but survivors are living longer. Some 72% are aged 60 years and older, and 14% were diagnosed 20 or more years ago.

Dr. Patricia A. Ganz of the University of California, Los Angeles, also addressed the need for better communication between oncologists and primary care physicians in a press briefing at the meeting. The average cancer patient sees three specialists, according to Dr. Ganz, director of cancer prevention and control research at the university's Jonsson Comprehensive Cancer Center.

Because most referrals to medical oncologists come from surgeons, Dr. Ganz pointed out that the medical oncologist might not even know who the patient's primary care physician is. Oncologists need to provide a survivorship care plan directly to the patient, she said, so that survivors and their physicians can keep track of “what has been done and what needs to be done in the future.”

Oncologists need to provide a survivorship care plan directly to the patient. DR. GANZ

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO — Six years after being diagnosed with colorectal cancer, nearly two-thirds of people tracked in a retrospective longitudinal study of 1,541 elderly survivors relied entirely on their primary care physicians for follow-up care.

Over the same time period, the role of oncology specialists was much smaller and declined significantly, as did the amount of cancer screening that they performed.

With the exception of mammography, primary care physicians provided more preventive services than did oncologists. They ordered more flu shots, Pap smears, cholesterol screening, and bone densitometry tests.

Visits to both types of physician resulted in more of all these measures than did visits to either type alone. “Survivors who see both an oncology specialist and a primary care provider are most likely to receive preventive care,” lead investigator Claire Snyder, Ph.D., reported at the annual meeting of the American Society of Clinical Oncology.

The study, supported in part by an unrestricted grant from Pfizer Inc., explored the growing issue of who takes responsibility for long-term care of cancer survivors in the United States. “The role of oncology specialists and primary care providers during the posttreatment phase is unclear,” said Dr. Snyder, of the division of general internal medicine at Johns Hopkins University, Baltimore.

She and her coauthors linked data from the Surveillance, Epidemiology, and End Results (SEER) registry with Medicare fee-for-services claims to follow patients from 1 year after diagnosis to the end of the sixth year. The study population had an average age of 76 years, included fewer men (42.7%) than women, comprised mostly whites (85.3%), survived stage I or II disease predominantly (82.8%), and had a mean comorbidity index of 1.76.

Initially, 37% of survivors went to both a primary care physician and an oncology specialist, but this fell to 21% by the end of the study. Meanwhile, the proportion seeing only a primary care physician increased from 44% to 62% over the 5-year period, while those seeing only an oncology specialist fell from 8% to 4%.

In any given year, slightly more than 10% of survivors saw neither type of physician, but some visited other specialists, often cardiologists, according to Dr. Snyder.

Additionally, the average number of visits to a primary care physician increased from 4.2 in the first year to 4.7 during the fifth year. Visits to an oncology specialist fell from 1.3 in the first year to 0.5 in the fifth year. Both changes were statistically significant (P = .0001).

“Most primary care provider visits were to internal medicine or family physicians, and most of the oncology specialist visits were to medical oncologists, hematologist/oncologists, or general surgeons,” Dr. Snyder said.

The primary care physician category also included general, ob.gyn., geriatric, and multispecialty practices. The oncology specialist category included colorectal surgery, surgical oncology, and radiation oncology practices.

Who provides care is important, Dr. Snyder said, because survivors have special medical needs. She cited surveillance for recurrence; monitoring for long-term and late treatment effects; general primary and preventive care; and care for comorbid conditions, which can be chronic in these patients.

To assess how the physician mix affected preventive services, her group looked at influenza vaccination and cholesterol screening for the entire population, along with mammography, cervical cancer screening, and bone densitometry in women, with the mammography standard being applied only to women younger than 76 years of age.

The investigators found that the mammography rate fell from 54% in the first year to 43% in the fifth year, and cervical cancer screening from 19% to 11%. “There were no clear trends in flu shots, cholesterol screening, or bone densitometry,” she said.

Cumulative 5-year data on these measures showed statistically significant differences (P less than or equal to .0001) for all based on the medical provider. For example, flu shots were documented for 61.7% of people seen by a primary care physician and an oncologist, for 52.4% of those who visited only a primary care physician, and for 49.2% of those who visited only an oncologist. The rate dropped to 31.4% when survivors saw neither.

Dr. Snyder cautioned that the investigators had no way to ask why some services were not provided. “Did the physician not offer the service? Did the patient refuse it?” she asked, noting that “some question the usefulness of certain screening procedures in the very old.”

The study's main implication, she concluded, is that there is a need for survivorship care plans that clearly delineate the roles and responsibilities of oncologists and primary care physicians in providing future care to cancer survivors.

Discussant Julia H. Rowland, Ph.D., director of the National Cancer Institute's office of cancer survivorship, seconded the call for such plans along with treatment summaries.

Today, the U.S. population includes more than 10.8 million cancer survivors, according to Dr. Rowland. Not only are more people surviving cancer, but survivors are living longer. Some 72% are aged 60 years and older, and 14% were diagnosed 20 or more years ago.

Dr. Patricia A. Ganz of the University of California, Los Angeles, also addressed the need for better communication between oncologists and primary care physicians in a press briefing at the meeting. The average cancer patient sees three specialists, according to Dr. Ganz, director of cancer prevention and control research at the university's Jonsson Comprehensive Cancer Center.

Because most referrals to medical oncologists come from surgeons, Dr. Ganz pointed out that the medical oncologist might not even know who the patient's primary care physician is. Oncologists need to provide a survivorship care plan directly to the patient, she said, so that survivors and their physicians can keep track of “what has been done and what needs to be done in the future.”

Oncologists need to provide a survivorship care plan directly to the patient. DR. GANZ

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO — Six years after being diagnosed with colorectal cancer, nearly two-thirds of people tracked in a retrospective longitudinal study of 1,541 elderly survivors relied entirely on their primary care physicians for follow-up care.

Over the same time period, the role of oncology specialists was much smaller and declined significantly, as did the amount of cancer screening that they performed.

With the exception of mammography, primary care physicians provided more preventive services than did oncologists. They ordered more flu shots, Pap smears, cholesterol screening, and bone densitometry tests.

Visits to both types of physician resulted in more of all these measures than did visits to either type alone. “Survivors who see both an oncology specialist and a primary care provider are most likely to receive preventive care,” lead investigator Claire Snyder, Ph.D., reported at the annual meeting of the American Society of Clinical Oncology.

The study, supported in part by an unrestricted grant from Pfizer Inc., explored the growing issue of who takes responsibility for long-term care of cancer survivors in the United States. “The role of oncology specialists and primary care providers during the posttreatment phase is unclear,” said Dr. Snyder, of the division of general internal medicine at Johns Hopkins University, Baltimore.

She and her coauthors linked data from the Surveillance, Epidemiology, and End Results (SEER) registry with Medicare fee-for-services claims to follow patients from 1 year after diagnosis to the end of the sixth year. The study population had an average age of 76 years, included fewer men (42.7%) than women, comprised mostly whites (85.3%), survived stage I or II disease predominantly (82.8%), and had a mean comorbidity index of 1.76.

Initially, 37% of survivors went to both a primary care physician and an oncology specialist, but this fell to 21% by the end of the study. Meanwhile, the proportion seeing only a primary care physician increased from 44% to 62% over the 5-year period, while those seeing only an oncology specialist fell from 8% to 4%.

In any given year, slightly more than 10% of survivors saw neither type of physician, but some visited other specialists, often cardiologists, according to Dr. Snyder.

Additionally, the average number of visits to a primary care physician increased from 4.2 in the first year to 4.7 during the fifth year. Visits to an oncology specialist fell from 1.3 in the first year to 0.5 in the fifth year. Both changes were statistically significant (P = .0001).

“Most primary care provider visits were to internal medicine or family physicians, and most of the oncology specialist visits were to medical oncologists, hematologist/oncologists, or general surgeons,” Dr. Snyder said.

The primary care physician category also included general, ob.gyn., geriatric, and multispecialty practices. The oncology specialist category included colorectal surgery, surgical oncology, and radiation oncology practices.

Who provides care is important, Dr. Snyder said, because survivors have special medical needs. She cited surveillance for recurrence; monitoring for long-term and late treatment effects; general primary and preventive care; and care for comorbid conditions, which can be chronic in these patients.

To assess how the physician mix affected preventive services, her group looked at influenza vaccination and cholesterol screening for the entire population, along with mammography, cervical cancer screening, and bone densitometry in women, with the mammography standard being applied only to women younger than 76 years of age.

The investigators found that the mammography rate fell from 54% in the first year to 43% in the fifth year, and cervical cancer screening from 19% to 11%. “There were no clear trends in flu shots, cholesterol screening, or bone densitometry,” she said.

Cumulative 5-year data on these measures showed statistically significant differences (P less than or equal to .0001) for all based on the medical provider. For example, flu shots were documented for 61.7% of people seen by a primary care physician and an oncologist, for 52.4% of those who visited only a primary care physician, and for 49.2% of those who visited only an oncologist. The rate dropped to 31.4% when survivors saw neither.

Dr. Snyder cautioned that the investigators had no way to ask why some services were not provided. “Did the physician not offer the service? Did the patient refuse it?” she asked, noting that “some question the usefulness of certain screening procedures in the very old.”

The study's main implication, she concluded, is that there is a need for survivorship care plans that clearly delineate the roles and responsibilities of oncologists and primary care physicians in providing future care to cancer survivors.

Discussant Julia H. Rowland, Ph.D., director of the National Cancer Institute's office of cancer survivorship, seconded the call for such plans along with treatment summaries.

Today, the U.S. population includes more than 10.8 million cancer survivors, according to Dr. Rowland. Not only are more people surviving cancer, but survivors are living longer. Some 72% are aged 60 years and older, and 14% were diagnosed 20 or more years ago.

Dr. Patricia A. Ganz of the University of California, Los Angeles, also addressed the need for better communication between oncologists and primary care physicians in a press briefing at the meeting. The average cancer patient sees three specialists, according to Dr. Ganz, director of cancer prevention and control research at the university's Jonsson Comprehensive Cancer Center.

Because most referrals to medical oncologists come from surgeons, Dr. Ganz pointed out that the medical oncologist might not even know who the patient's primary care physician is. Oncologists need to provide a survivorship care plan directly to the patient, she said, so that survivors and their physicians can keep track of “what has been done and what needs to be done in the future.”

Oncologists need to provide a survivorship care plan directly to the patient. DR. GANZ

ELSEVIER GLOBAL MEDICAL NEWS

PHOENIX – When a child presents with what looks like a spider bite, but the family can't find a spider, Dr. Lawrence F. Eichenfield considers community-acquired methicillin-resistant Staphylococcus aureus.

“Most pediatric cases we see are not in wrestlers or football players. They are in families that have problems with MRSA, so the epidemiology has changed,” he told clinicians at a clinical dermatology conference sponsored by Medicis.

Spider bite-appearing lesions are a classic presentation of MRSA, according to Dr. Eichenfield, chief of pediatric and adolescent dermatology at Rady Children's Hospital-San Diego and professor of pediatrics and medicine at the University of California, San Diego. If the child's lesion looks like a spider bite, he recommended asking whether anyone in the family has a history of abscesses or recurrent folliculitis.

Draining abscesses is usually more effective than using antibiotics when patients have community-acquired MRSA, Dr. Eichenfield said. He cited a recent study that found 57% of emergency department patients received the wrong antibiotics for skin and soft-tissue infections caused by community-acquired MRSA (N. Engl. J. Med. 2006;355:666-74). Many busy physicians don't want to take the time to drain an abscess, he said, but “study after study shows it [drainage] is way more effective.”

Warm soaks and drainage often are sufficient, he said, but warned that lesions greater than 5 cm present a higher risk. “Many times we use antibiotics concurrently, but drainage is really the key,” he said.

The lesion always should be cultured, Dr. Eichenfield said. Community-acquired MRSA has different patterns of susceptibility to antibiotics than does hospital-acquired MRSA.

Community-acquired MRSA skin infections are being seen in neonates, though less frequently than in older children. He cited a study of 89 infants, mostly boys, who were less than 30 days old and had S. aureus infections. Among these, 77 infections involved skin and soft tissue, and 61 were methicillin resistant. Mothers of 13 infants with MRSA had a history of skin infections (Pediatrics 2006;118:874-81).

'Many times we use antibiotics concurrently, but drainage is really the key.' DR. EICHENFIELD

A MRSA abscess, like this one on a patient's hip, often can resemble a spider bite. CDC/Bruno Coignard M.D/Jeff Hageman, M.H.S.

PHOENIX – When a child presents with what looks like a spider bite, but the family can't find a spider, Dr. Lawrence F. Eichenfield considers community-acquired methicillin-resistant Staphylococcus aureus.

“Most pediatric cases we see are not in wrestlers or football players. They are in families that have problems with MRSA, so the epidemiology has changed,” he told clinicians at a clinical dermatology conference sponsored by Medicis.

Spider bite-appearing lesions are a classic presentation of MRSA, according to Dr. Eichenfield, chief of pediatric and adolescent dermatology at Rady Children's Hospital-San Diego and professor of pediatrics and medicine at the University of California, San Diego. If the child's lesion looks like a spider bite, he recommended asking whether anyone in the family has a history of abscesses or recurrent folliculitis.

Draining abscesses is usually more effective than using antibiotics when patients have community-acquired MRSA, Dr. Eichenfield said. He cited a recent study that found 57% of emergency department patients received the wrong antibiotics for skin and soft-tissue infections caused by community-acquired MRSA (N. Engl. J. Med. 2006;355:666-74). Many busy physicians don't want to take the time to drain an abscess, he said, but “study after study shows it [drainage] is way more effective.”

Warm soaks and drainage often are sufficient, he said, but warned that lesions greater than 5 cm present a higher risk. “Many times we use antibiotics concurrently, but drainage is really the key,” he said.

The lesion always should be cultured, Dr. Eichenfield said. Community-acquired MRSA has different patterns of susceptibility to antibiotics than does hospital-acquired MRSA.

Community-acquired MRSA skin infections are being seen in neonates, though less frequently than in older children. He cited a study of 89 infants, mostly boys, who were less than 30 days old and had S. aureus infections. Among these, 77 infections involved skin and soft tissue, and 61 were methicillin resistant. Mothers of 13 infants with MRSA had a history of skin infections (Pediatrics 2006;118:874-81).

'Many times we use antibiotics concurrently, but drainage is really the key.' DR. EICHENFIELD

A MRSA abscess, like this one on a patient's hip, often can resemble a spider bite. CDC/Bruno Coignard M.D/Jeff Hageman, M.H.S.

PHOENIX – When a child presents with what looks like a spider bite, but the family can't find a spider, Dr. Lawrence F. Eichenfield considers community-acquired methicillin-resistant Staphylococcus aureus.

“Most pediatric cases we see are not in wrestlers or football players. They are in families that have problems with MRSA, so the epidemiology has changed,” he told clinicians at a clinical dermatology conference sponsored by Medicis.

Spider bite-appearing lesions are a classic presentation of MRSA, according to Dr. Eichenfield, chief of pediatric and adolescent dermatology at Rady Children's Hospital-San Diego and professor of pediatrics and medicine at the University of California, San Diego. If the child's lesion looks like a spider bite, he recommended asking whether anyone in the family has a history of abscesses or recurrent folliculitis.

Draining abscesses is usually more effective than using antibiotics when patients have community-acquired MRSA, Dr. Eichenfield said. He cited a recent study that found 57% of emergency department patients received the wrong antibiotics for skin and soft-tissue infections caused by community-acquired MRSA (N. Engl. J. Med. 2006;355:666-74). Many busy physicians don't want to take the time to drain an abscess, he said, but “study after study shows it [drainage] is way more effective.”

Warm soaks and drainage often are sufficient, he said, but warned that lesions greater than 5 cm present a higher risk. “Many times we use antibiotics concurrently, but drainage is really the key,” he said.

The lesion always should be cultured, Dr. Eichenfield said. Community-acquired MRSA has different patterns of susceptibility to antibiotics than does hospital-acquired MRSA.

Community-acquired MRSA skin infections are being seen in neonates, though less frequently than in older children. He cited a study of 89 infants, mostly boys, who were less than 30 days old and had S. aureus infections. Among these, 77 infections involved skin and soft tissue, and 61 were methicillin resistant. Mothers of 13 infants with MRSA had a history of skin infections (Pediatrics 2006;118:874-81).

'Many times we use antibiotics concurrently, but drainage is really the key.' DR. EICHENFIELD

A MRSA abscess, like this one on a patient's hip, often can resemble a spider bite. CDC/Bruno Coignard M.D/Jeff Hageman, M.H.S.