Jane Salodof MacNeil

SCOTTSDALE, ARIZ. — Obesity and obstructive sleep apnea are independent risk factors for atrial fibrillation in patients younger than 65 years of age, but not in older patients, according to a retrospective cohort study of 3,542 people who had sleep studies at the Mayo Clinic in Rochester, Minn.

Heart failure was the only independent predictor of new-onset atrial fibrillation for people 65 years of age and older in the study, which followed patients a mean of 4.7 years after an initial polysomnography.

“The ability of sleep apnea to predict the development of atrial fibrillation was dependent on the age of the patient. If they were more than 65, and they were in sinus rhythm when you did the sleep study, they did not get atrial fibrillation,” Dr. Virend K. Somers, a coinvestigator, said at a meeting on sleep medicine sponsored by the American College of Chest Physicians.

None of the patients reviewed had atrial fibrillation before or at the time of the screenings, conducted from 1987 to 2003, for possible sleep disorders. All told, 133 people developed atrial fibrillation at some point after undergoing polysomnography (J. Am. Coll. Cardiol. 2007;49:565–71).

Obstructive sleep apnea was diagnosed in 2,626 people (74%), and the investigators reported it was a strong predictor (hazard ratio 2.18) of future atrial fibrillation. A total of 4.3% of patients with obstructive sleep apnea but only 2.1% without the disorder were subsequently diagnosed with atrial fibrillation.

An age-stratified analysis showed patients younger than 65 years were more vulnerable to atrial fibrillation, however, and had more risk factors. The most significant was lower oxygen levels at night (hazard ratio 3.29), but age (2.04), male gender (2.66), coronary artery disease (2.66), and body mass index (1.07) also were predictors. In older patients, heart failure had a hazard ratio of 7.68.

Why the older patients were less susceptible to atrial fibrillation is unclear, according to the authors. Dr. Somers, a professor of medicine at the Mayo Clinic, speculated that the older patients probably had undiagnosed apnea for many years.

“If you have sleep apnea and you last to 65–70 years without developing atrial fibrillation, you are going to be okay—you are going to live longer,” he said. “But if you are susceptible to the damage that sleep apnea does to your cardiovascular system, you will develop atrial fibrillation earlier on.”

Dr. Somers emphasized that this was a retrospective study in a referral population, and that these findings needed to be confirmed by more robust prospective investigation.

Dr. Somers is a consultant for Cardiac Concepts and is coinvestigator on a grant from the ResMed Foundation, which funded the study. The present study, for which the lead author is Dr. Apoor Gami, follows earlier research at the Mayo Clinic that showed an association between sleep apnea and atrial fibrillation.

In one study, Dr. Gamia, Dr. Somers, and coinvestigators found obstructive sleep apnea was “strikingly more prevalent” (odds ratio 2.19) in atrial fibrillation patients than in general cardiology patients. About half (49%) of 151 patients who underwent electrocardioversion for atrial fibrillation had obstructive sleep apnea vs. about a third (32%) of 312 patients treated for other heart conditions (Circulation 2004;110:364–7).

In a study of patients who underwent electrocardioversion, Dr. Somers' group found atrial fibrillation was more likely to recur if obstructive sleep apnea was not treated (Circulation 2003;107:2589–94). It compared 39 patients with obstructive sleep apnea with a control group of 79 patients who did not undergo a sleep study. Within 12 months, 82% of 27 untreated or inadequately treated apnea patients had their apnea recur, vs. 42% of 12 apnea patients treated with continuous positive airway pressure and 53% of the control group.

Dr. Somers noted that within the apnea population, risk doubled when the condition went untreated. Moreover, in the 25 untreated apnea patients, nocturnal oxygen saturation fell to lower levels in those who had a recurrence of atrial fibrillation.

Will Treating Apnea Prevent Heart Disease?

Despite presenting strong evidence of an association between obstructive sleep apnea and cardiovascular disease, Dr. Somers was careful not to say that treating the sleep disorder would prevent heart disease.

“Beyond lowering blood pressure and perhaps increasing EF [ejection fraction] in people with heart failure, treating sleep apnea has not been proven to prevent any cardiovascular end points,” he said.

“We have no evidence that treating sleep apnea will prevent a cardiac death, a heart attack, a stroke, or anything,” he said. “All we have now are soft end points—blood pressure [and] heart rate.”

Many markers of heart disease—notably hypertension, elevated levels of C-reactive protein, and systemic inflammation—occur with sleep apnea, according to Dr. Somers. Consequently, he maintained, it makes sense that an untreated apnea could lead to cardiovascular disease.

In addition to his work showing a link with atrial fibrillation, he cited studies associating sleep disorders with hypertension, sudden cardiac death, and heart failure. He noted the following:

▸ Apnea can cause hypertension, and hypertension becomes worse if apnea is not treated (N. Engl. J. Med. 2000;342:1378–84).

▸ Obstructive sleep apnea patients were two to three times more likely to have a first-degree relative who died of a heart attack or suddenly of an unexplained cause, according to a review of 500 people by Dr. Somers and his colleagues.

▸ Although 6 a.m.-11 a.m. is the peak time for sudden cardiac death in the general population, 46% of sudden cardiac deaths in people with obstructive sleep apnea occurred between midnight and 6 a.m. (N. Engl. J. Med. 2005;352:1206–14).

About 10% of heart failure patients have obstructive sleep apnea and 40% have central sleep apnea, Dr. Somers added, attributing the data to studies conducted during the 1990s. “Since then,” he said, “patients are substantially fatter, and we think there are more obstructive apneas in heart failure patients than there used to be.”

Although Dr. Somers believes in treating sleep disorders to prevent heart disease, he added that his colleagues in cardiology won't be convinced until cause and effect is proved.

As for randomized, controlled trials providing that proof, a major obstacle is that institutional review boards are not likely to approve a trial that allows a sleep disorder to go untreated because the patient is randomized to a control group.

“It's a double-edged sword,” Dr. Somers said. “They force you to treat everybody, so you can't do the study. But until you do the study, not everybody will be treated.”

SCOTTSDALE, ARIZ. — Obesity and obstructive sleep apnea are independent risk factors for atrial fibrillation in patients younger than 65 years of age, but not in older patients, according to a retrospective cohort study of 3,542 people who had sleep studies at the Mayo Clinic in Rochester, Minn.

Heart failure was the only independent predictor of new-onset atrial fibrillation for people 65 years of age and older in the study, which followed patients a mean of 4.7 years after an initial polysomnography.

“The ability of sleep apnea to predict the development of atrial fibrillation was dependent on the age of the patient. If they were more than 65, and they were in sinus rhythm when you did the sleep study, they did not get atrial fibrillation,” Dr. Virend K. Somers, a coinvestigator, said at a meeting on sleep medicine sponsored by the American College of Chest Physicians.

None of the patients reviewed had atrial fibrillation before or at the time of the screenings, conducted from 1987 to 2003, for possible sleep disorders. All told, 133 people developed atrial fibrillation at some point after undergoing polysomnography (J. Am. Coll. Cardiol. 2007;49:565–71).

Obstructive sleep apnea was diagnosed in 2,626 people (74%), and the investigators reported it was a strong predictor (hazard ratio 2.18) of future atrial fibrillation. A total of 4.3% of patients with obstructive sleep apnea but only 2.1% without the disorder were subsequently diagnosed with atrial fibrillation.

An age-stratified analysis showed patients younger than 65 years were more vulnerable to atrial fibrillation, however, and had more risk factors. The most significant was lower oxygen levels at night (hazard ratio 3.29), but age (2.04), male gender (2.66), coronary artery disease (2.66), and body mass index (1.07) also were predictors. In older patients, heart failure had a hazard ratio of 7.68.

Why the older patients were less susceptible to atrial fibrillation is unclear, according to the authors. Dr. Somers, a professor of medicine at the Mayo Clinic, speculated that the older patients probably had undiagnosed apnea for many years.

“If you have sleep apnea and you last to 65–70 years without developing atrial fibrillation, you are going to be okay—you are going to live longer,” he said. “But if you are susceptible to the damage that sleep apnea does to your cardiovascular system, you will develop atrial fibrillation earlier on.”

Dr. Somers emphasized that this was a retrospective study in a referral population, and that these findings needed to be confirmed by more robust prospective investigation.

Dr. Somers is a consultant for Cardiac Concepts and is coinvestigator on a grant from the ResMed Foundation, which funded the study. The present study, for which the lead author is Dr. Apoor Gami, follows earlier research at the Mayo Clinic that showed an association between sleep apnea and atrial fibrillation.

In one study, Dr. Gamia, Dr. Somers, and coinvestigators found obstructive sleep apnea was “strikingly more prevalent” (odds ratio 2.19) in atrial fibrillation patients than in general cardiology patients. About half (49%) of 151 patients who underwent electrocardioversion for atrial fibrillation had obstructive sleep apnea vs. about a third (32%) of 312 patients treated for other heart conditions (Circulation 2004;110:364–7).

In a study of patients who underwent electrocardioversion, Dr. Somers' group found atrial fibrillation was more likely to recur if obstructive sleep apnea was not treated (Circulation 2003;107:2589–94). It compared 39 patients with obstructive sleep apnea with a control group of 79 patients who did not undergo a sleep study. Within 12 months, 82% of 27 untreated or inadequately treated apnea patients had their apnea recur, vs. 42% of 12 apnea patients treated with continuous positive airway pressure and 53% of the control group.

Dr. Somers noted that within the apnea population, risk doubled when the condition went untreated. Moreover, in the 25 untreated apnea patients, nocturnal oxygen saturation fell to lower levels in those who had a recurrence of atrial fibrillation.

Will Treating Apnea Prevent Heart Disease?

Despite presenting strong evidence of an association between obstructive sleep apnea and cardiovascular disease, Dr. Somers was careful not to say that treating the sleep disorder would prevent heart disease.

“Beyond lowering blood pressure and perhaps increasing EF [ejection fraction] in people with heart failure, treating sleep apnea has not been proven to prevent any cardiovascular end points,” he said.

“We have no evidence that treating sleep apnea will prevent a cardiac death, a heart attack, a stroke, or anything,” he said. “All we have now are soft end points—blood pressure [and] heart rate.”

Many markers of heart disease—notably hypertension, elevated levels of C-reactive protein, and systemic inflammation—occur with sleep apnea, according to Dr. Somers. Consequently, he maintained, it makes sense that an untreated apnea could lead to cardiovascular disease.

In addition to his work showing a link with atrial fibrillation, he cited studies associating sleep disorders with hypertension, sudden cardiac death, and heart failure. He noted the following:

▸ Apnea can cause hypertension, and hypertension becomes worse if apnea is not treated (N. Engl. J. Med. 2000;342:1378–84).

▸ Obstructive sleep apnea patients were two to three times more likely to have a first-degree relative who died of a heart attack or suddenly of an unexplained cause, according to a review of 500 people by Dr. Somers and his colleagues.

▸ Although 6 a.m.-11 a.m. is the peak time for sudden cardiac death in the general population, 46% of sudden cardiac deaths in people with obstructive sleep apnea occurred between midnight and 6 a.m. (N. Engl. J. Med. 2005;352:1206–14).

About 10% of heart failure patients have obstructive sleep apnea and 40% have central sleep apnea, Dr. Somers added, attributing the data to studies conducted during the 1990s. “Since then,” he said, “patients are substantially fatter, and we think there are more obstructive apneas in heart failure patients than there used to be.”

Although Dr. Somers believes in treating sleep disorders to prevent heart disease, he added that his colleagues in cardiology won't be convinced until cause and effect is proved.

As for randomized, controlled trials providing that proof, a major obstacle is that institutional review boards are not likely to approve a trial that allows a sleep disorder to go untreated because the patient is randomized to a control group.

“It's a double-edged sword,” Dr. Somers said. “They force you to treat everybody, so you can't do the study. But until you do the study, not everybody will be treated.”

SCOTTSDALE, ARIZ. — Obesity and obstructive sleep apnea are independent risk factors for atrial fibrillation in patients younger than 65 years of age, but not in older patients, according to a retrospective cohort study of 3,542 people who had sleep studies at the Mayo Clinic in Rochester, Minn.

Heart failure was the only independent predictor of new-onset atrial fibrillation for people 65 years of age and older in the study, which followed patients a mean of 4.7 years after an initial polysomnography.

“The ability of sleep apnea to predict the development of atrial fibrillation was dependent on the age of the patient. If they were more than 65, and they were in sinus rhythm when you did the sleep study, they did not get atrial fibrillation,” Dr. Virend K. Somers, a coinvestigator, said at a meeting on sleep medicine sponsored by the American College of Chest Physicians.

None of the patients reviewed had atrial fibrillation before or at the time of the screenings, conducted from 1987 to 2003, for possible sleep disorders. All told, 133 people developed atrial fibrillation at some point after undergoing polysomnography (J. Am. Coll. Cardiol. 2007;49:565–71).

Obstructive sleep apnea was diagnosed in 2,626 people (74%), and the investigators reported it was a strong predictor (hazard ratio 2.18) of future atrial fibrillation. A total of 4.3% of patients with obstructive sleep apnea but only 2.1% without the disorder were subsequently diagnosed with atrial fibrillation.

An age-stratified analysis showed patients younger than 65 years were more vulnerable to atrial fibrillation, however, and had more risk factors. The most significant was lower oxygen levels at night (hazard ratio 3.29), but age (2.04), male gender (2.66), coronary artery disease (2.66), and body mass index (1.07) also were predictors. In older patients, heart failure had a hazard ratio of 7.68.

Why the older patients were less susceptible to atrial fibrillation is unclear, according to the authors. Dr. Somers, a professor of medicine at the Mayo Clinic, speculated that the older patients probably had undiagnosed apnea for many years.

“If you have sleep apnea and you last to 65–70 years without developing atrial fibrillation, you are going to be okay—you are going to live longer,” he said. “But if you are susceptible to the damage that sleep apnea does to your cardiovascular system, you will develop atrial fibrillation earlier on.”

Dr. Somers emphasized that this was a retrospective study in a referral population, and that these findings needed to be confirmed by more robust prospective investigation.

Dr. Somers is a consultant for Cardiac Concepts and is coinvestigator on a grant from the ResMed Foundation, which funded the study. The present study, for which the lead author is Dr. Apoor Gami, follows earlier research at the Mayo Clinic that showed an association between sleep apnea and atrial fibrillation.

In one study, Dr. Gamia, Dr. Somers, and coinvestigators found obstructive sleep apnea was “strikingly more prevalent” (odds ratio 2.19) in atrial fibrillation patients than in general cardiology patients. About half (49%) of 151 patients who underwent electrocardioversion for atrial fibrillation had obstructive sleep apnea vs. about a third (32%) of 312 patients treated for other heart conditions (Circulation 2004;110:364–7).

In a study of patients who underwent electrocardioversion, Dr. Somers' group found atrial fibrillation was more likely to recur if obstructive sleep apnea was not treated (Circulation 2003;107:2589–94). It compared 39 patients with obstructive sleep apnea with a control group of 79 patients who did not undergo a sleep study. Within 12 months, 82% of 27 untreated or inadequately treated apnea patients had their apnea recur, vs. 42% of 12 apnea patients treated with continuous positive airway pressure and 53% of the control group.

Dr. Somers noted that within the apnea population, risk doubled when the condition went untreated. Moreover, in the 25 untreated apnea patients, nocturnal oxygen saturation fell to lower levels in those who had a recurrence of atrial fibrillation.

Will Treating Apnea Prevent Heart Disease?

Despite presenting strong evidence of an association between obstructive sleep apnea and cardiovascular disease, Dr. Somers was careful not to say that treating the sleep disorder would prevent heart disease.

“Beyond lowering blood pressure and perhaps increasing EF [ejection fraction] in people with heart failure, treating sleep apnea has not been proven to prevent any cardiovascular end points,” he said.

“We have no evidence that treating sleep apnea will prevent a cardiac death, a heart attack, a stroke, or anything,” he said. “All we have now are soft end points—blood pressure [and] heart rate.”

Many markers of heart disease—notably hypertension, elevated levels of C-reactive protein, and systemic inflammation—occur with sleep apnea, according to Dr. Somers. Consequently, he maintained, it makes sense that an untreated apnea could lead to cardiovascular disease.

In addition to his work showing a link with atrial fibrillation, he cited studies associating sleep disorders with hypertension, sudden cardiac death, and heart failure. He noted the following:

▸ Apnea can cause hypertension, and hypertension becomes worse if apnea is not treated (N. Engl. J. Med. 2000;342:1378–84).

▸ Obstructive sleep apnea patients were two to three times more likely to have a first-degree relative who died of a heart attack or suddenly of an unexplained cause, according to a review of 500 people by Dr. Somers and his colleagues.

▸ Although 6 a.m.-11 a.m. is the peak time for sudden cardiac death in the general population, 46% of sudden cardiac deaths in people with obstructive sleep apnea occurred between midnight and 6 a.m. (N. Engl. J. Med. 2005;352:1206–14).

About 10% of heart failure patients have obstructive sleep apnea and 40% have central sleep apnea, Dr. Somers added, attributing the data to studies conducted during the 1990s. “Since then,” he said, “patients are substantially fatter, and we think there are more obstructive apneas in heart failure patients than there used to be.”

Although Dr. Somers believes in treating sleep disorders to prevent heart disease, he added that his colleagues in cardiology won't be convinced until cause and effect is proved.

As for randomized, controlled trials providing that proof, a major obstacle is that institutional review boards are not likely to approve a trial that allows a sleep disorder to go untreated because the patient is randomized to a control group.

“It's a double-edged sword,” Dr. Somers said. “They force you to treat everybody, so you can't do the study. But until you do the study, not everybody will be treated.”

PHOENIX — Consider keeping hyaluronidase for injection on hand for repairing problems caused by hyaluronic acid fillers and not relying on compounded forms of hyaluronidase, Dr. Alastair Carruthers advised at a clinical dermatology conference sponsored by Medicis.

"Vitrase [hyaluro-nidase for injection] is a pure form of hyaluronidase, and it is of consistent efficacy," said Dr. Carruthers, clinical professor of dermatology at the University of British Columbia in Vancouver.

Compounded products might contain ingredients that cause reactions, he warned. They also are inconsistent in their activity.

"You can have up to a 10-fold difference in the activity, and clearly that is important," he said. "If you are using 10 units to get rid of a lump or 100 units—that is a big difference."

A naturally occurring protein enzyme, hyaluronidase makes connective tissue more permeable through hydrolysis of hyaluronic acid. "It eats hyaluronic acid," Dr. Carruthers said. Ista Pharmaceuticals in Irvine, Calif., manufactures Vitrase from the purified testicular hyaluronidase of sheep.

The Food and Drug Administration approved Vitrase for use in increasing the absorption and dispersion of other injectable drugs in 2004. The FDA reported the rate of adverse events, including allergic reactions, to be less than 1%. Because the drug could spread infection or inflammation, the FDA advised that it not be used in areas that are swollen by bites, stings, infection, or inflammation.

Using too much hyaluronidase for injection to correct a bump or other problem is not a concern, Dr. Carruthers said.

Hyaluronidase comprises only about 3% of human skin and it turns over in about 24 hours. "You can put in as much as you feel like, but typically maybe 20 units is enough to get rid of almost everything," he said.

Having hyaluronidase for injection on hand in the dermatology office "prevents problems," said Dr. Carruthers. He noted that vascular occlusion has been reported in rare cases with hyaluronic acid fillers.

Though cause and effect was not proven, he said occlusions have cleared after injection of large doses of hyaluronidase. "That is one of the reasons I have hyaluronidase in my office."

'You can putin as much [hyaluronidase] as you feel like, but typically maybe 20 units is enough.' DR. CARRUTHERS

PHOENIX — Consider keeping hyaluronidase for injection on hand for repairing problems caused by hyaluronic acid fillers and not relying on compounded forms of hyaluronidase, Dr. Alastair Carruthers advised at a clinical dermatology conference sponsored by Medicis.

"Vitrase [hyaluro-nidase for injection] is a pure form of hyaluronidase, and it is of consistent efficacy," said Dr. Carruthers, clinical professor of dermatology at the University of British Columbia in Vancouver.

Compounded products might contain ingredients that cause reactions, he warned. They also are inconsistent in their activity.

"You can have up to a 10-fold difference in the activity, and clearly that is important," he said. "If you are using 10 units to get rid of a lump or 100 units—that is a big difference."

A naturally occurring protein enzyme, hyaluronidase makes connective tissue more permeable through hydrolysis of hyaluronic acid. "It eats hyaluronic acid," Dr. Carruthers said. Ista Pharmaceuticals in Irvine, Calif., manufactures Vitrase from the purified testicular hyaluronidase of sheep.

The Food and Drug Administration approved Vitrase for use in increasing the absorption and dispersion of other injectable drugs in 2004. The FDA reported the rate of adverse events, including allergic reactions, to be less than 1%. Because the drug could spread infection or inflammation, the FDA advised that it not be used in areas that are swollen by bites, stings, infection, or inflammation.

Using too much hyaluronidase for injection to correct a bump or other problem is not a concern, Dr. Carruthers said.

Hyaluronidase comprises only about 3% of human skin and it turns over in about 24 hours. "You can put in as much as you feel like, but typically maybe 20 units is enough to get rid of almost everything," he said.

Having hyaluronidase for injection on hand in the dermatology office "prevents problems," said Dr. Carruthers. He noted that vascular occlusion has been reported in rare cases with hyaluronic acid fillers.

Though cause and effect was not proven, he said occlusions have cleared after injection of large doses of hyaluronidase. "That is one of the reasons I have hyaluronidase in my office."

'You can putin as much [hyaluronidase] as you feel like, but typically maybe 20 units is enough.' DR. CARRUTHERS

PHOENIX — Consider keeping hyaluronidase for injection on hand for repairing problems caused by hyaluronic acid fillers and not relying on compounded forms of hyaluronidase, Dr. Alastair Carruthers advised at a clinical dermatology conference sponsored by Medicis.

"Vitrase [hyaluro-nidase for injection] is a pure form of hyaluronidase, and it is of consistent efficacy," said Dr. Carruthers, clinical professor of dermatology at the University of British Columbia in Vancouver.

Compounded products might contain ingredients that cause reactions, he warned. They also are inconsistent in their activity.

"You can have up to a 10-fold difference in the activity, and clearly that is important," he said. "If you are using 10 units to get rid of a lump or 100 units—that is a big difference."

A naturally occurring protein enzyme, hyaluronidase makes connective tissue more permeable through hydrolysis of hyaluronic acid. "It eats hyaluronic acid," Dr. Carruthers said. Ista Pharmaceuticals in Irvine, Calif., manufactures Vitrase from the purified testicular hyaluronidase of sheep.

The Food and Drug Administration approved Vitrase for use in increasing the absorption and dispersion of other injectable drugs in 2004. The FDA reported the rate of adverse events, including allergic reactions, to be less than 1%. Because the drug could spread infection or inflammation, the FDA advised that it not be used in areas that are swollen by bites, stings, infection, or inflammation.

Using too much hyaluronidase for injection to correct a bump or other problem is not a concern, Dr. Carruthers said.

Hyaluronidase comprises only about 3% of human skin and it turns over in about 24 hours. "You can put in as much as you feel like, but typically maybe 20 units is enough to get rid of almost everything," he said.

Having hyaluronidase for injection on hand in the dermatology office "prevents problems," said Dr. Carruthers. He noted that vascular occlusion has been reported in rare cases with hyaluronic acid fillers.

Though cause and effect was not proven, he said occlusions have cleared after injection of large doses of hyaluronidase. "That is one of the reasons I have hyaluronidase in my office."

'You can putin as much [hyaluronidase] as you feel like, but typically maybe 20 units is enough.' DR. CARRUTHERS

PHOENIX — Although cutting through a melanoma during a shave biopsy may make reaching an accurate prognosis more difficult, it probably will not harm the patient, Dr. Darrell Rigel said at a clinical dermatology conference sponsored by Medicis.

Dr. Rigel, who is with New York University Medical Center, New York, said that two recently published studies addressed the concern that cutting through certain cancers during a biopsy can disperse tumor cells and worsen prognosis. It probably is not harmful in melanoma patients, he said.

The studies he cited compared excisional with incisional biopsies.

In the first study, investigators from Carolinas Medical Center in Charlotte, N.C., reported that 22% of shave biopsies had positive deep margins (Ann. Surg. Oncol. 2007;14:893–98). In the second study, investigators from the Free University Hospital, Amsterdam, found that use of incisional biopsies did not have a negative impact on survival (Ann. Surg. Oncol. 2007;14:1424–30).

"So at least if you accidentally shave through a melanoma, you [probably] haven't harmed the patient," Dr. Rigel said. "However, you may have harmed your ability to get the right prognosis for the patient." Thinner melanomas have a better prognosis, he noted, but tumor thickness is harder to determine in patients with deep positive margins.

In the first study, Dr. Richard L. White Jr. and his colleagues analyzed pathology reports from Jan. 1, 2004, through June 30, 2005, for 223 cases of primary melanoma.

Although the National Comprehensive Cancer Network and the American Academy of Dermatology have each designated excisional biopsies with narrow margins as the preferred method for diagnosing primary cutaneous melanoma, more than half the biopsies were done with the easier, faster shave technique. The sample comprised 51 excisional biopsies, 44 punch biopsies, and 128 shave biopsies. Three-fourths (167) of the specimens analyzed were from thin melanomas (1 mm or less).

Only 16% of excisional biopsies had positive margins. Just 2% were positive deep margins, and none were found in specimens from the thin melanomas.

Punch biopsy specimens also had no positive deep margins in the thinner melanomas. Positive margins were more common overall (68%), but were mostly wide margins attributable to the punch technique. Only 7% of all punch biopsies had positive deep margins.

Half of all shave biopsies produced positive margins, including the 22% that had positive deep margins. The analysis revealed positive deep margins for 17% of the thinner melanomas sampled by the shave technique.

Shave biopsy was most commonly done for thinner melanomas. It also produced samples that were significantly thinner. A review of 56 specimens showed the average biopsy thickness to be 1.41 mm with the shave technique, 3.58 mm with the punch method, and 3.19 mm for excisional biopsies.

"Based on these data," the authors concluded, "we encourage the use of an excisional biopsy technique for all skin lesions where melanoma is in the differential diagnosis when excision is feasible."

In the second study, Dr. Paul A.M. van Leeuwen and his colleagues in the Netherlands prospectively studied 471 patients who were diagnosed with stage I or II melanoma after partial removal of a skin lesion. Most of the patients had a superficial spreading melanoma (65%) or a nodular melanoma (26.7%). Average follow-up was 5 years or more.

The investigators divided the population by biopsy type: wide excision biopsy (279 patients), narrow excision biopsy (109), excision biopsy with positive margins (52), and incision biopsy (31). Biopsy type did not prove to be significant in univariate or multivariate analyses of disease-free survival or overall survival. The presence of residual tumor cells in reexcision specimens for 41 patients also was not significant.

"Incisional biopsies are not recommended, but there is no cause for concern when an excision biopsy turns out to have positive margins," the authors concluded.

In a telephone interview, Dr. Randall K. Roenigk agreed that both studies make good points, but he said that they are not likely to dissuade physicians from doing shave biopsies.

"If you do a shave and miss the depth of the specimen, you miss a key bit of information—the thickness of the melanoma. Your decision-making tree could be compromised," said Dr. Roenigk, professor of dermatology and chair of the department of dermatology at Mayo Medical School, Rochester, Minn.

"On the flip side, it is easier to do a shave biopsy," he continued, citing the time required for an excisional biopsy, the delay in diagnosis until an excisional biopsy can be scheduled, and the reality that some patients won't come back for the procedure.

He suggested that, as a result, doing more shave biopsies can mean more melanoma diagnoses, even though excisional biopsies are more comprehensive. From Dr. Roenigk's perspective, the studies demonstrate the importance of doing deep biopsies even when the suspected melanoma appears to be thin.

"You shouldn't be shy about taking extra tissue when you are thinking about a melanoma. It should be a thick, deep shave," he said. "If you are thinking about melanoma, you shouldn't worry about the scar."

PHOENIX — Although cutting through a melanoma during a shave biopsy may make reaching an accurate prognosis more difficult, it probably will not harm the patient, Dr. Darrell Rigel said at a clinical dermatology conference sponsored by Medicis.

Dr. Rigel, who is with New York University Medical Center, New York, said that two recently published studies addressed the concern that cutting through certain cancers during a biopsy can disperse tumor cells and worsen prognosis. It probably is not harmful in melanoma patients, he said.

The studies he cited compared excisional with incisional biopsies.

In the first study, investigators from Carolinas Medical Center in Charlotte, N.C., reported that 22% of shave biopsies had positive deep margins (Ann. Surg. Oncol. 2007;14:893–98). In the second study, investigators from the Free University Hospital, Amsterdam, found that use of incisional biopsies did not have a negative impact on survival (Ann. Surg. Oncol. 2007;14:1424–30).

"So at least if you accidentally shave through a melanoma, you [probably] haven't harmed the patient," Dr. Rigel said. "However, you may have harmed your ability to get the right prognosis for the patient." Thinner melanomas have a better prognosis, he noted, but tumor thickness is harder to determine in patients with deep positive margins.

In the first study, Dr. Richard L. White Jr. and his colleagues analyzed pathology reports from Jan. 1, 2004, through June 30, 2005, for 223 cases of primary melanoma.

Although the National Comprehensive Cancer Network and the American Academy of Dermatology have each designated excisional biopsies with narrow margins as the preferred method for diagnosing primary cutaneous melanoma, more than half the biopsies were done with the easier, faster shave technique. The sample comprised 51 excisional biopsies, 44 punch biopsies, and 128 shave biopsies. Three-fourths (167) of the specimens analyzed were from thin melanomas (1 mm or less).

Only 16% of excisional biopsies had positive margins. Just 2% were positive deep margins, and none were found in specimens from the thin melanomas.

Punch biopsy specimens also had no positive deep margins in the thinner melanomas. Positive margins were more common overall (68%), but were mostly wide margins attributable to the punch technique. Only 7% of all punch biopsies had positive deep margins.

Half of all shave biopsies produced positive margins, including the 22% that had positive deep margins. The analysis revealed positive deep margins for 17% of the thinner melanomas sampled by the shave technique.

Shave biopsy was most commonly done for thinner melanomas. It also produced samples that were significantly thinner. A review of 56 specimens showed the average biopsy thickness to be 1.41 mm with the shave technique, 3.58 mm with the punch method, and 3.19 mm for excisional biopsies.

"Based on these data," the authors concluded, "we encourage the use of an excisional biopsy technique for all skin lesions where melanoma is in the differential diagnosis when excision is feasible."

In the second study, Dr. Paul A.M. van Leeuwen and his colleagues in the Netherlands prospectively studied 471 patients who were diagnosed with stage I or II melanoma after partial removal of a skin lesion. Most of the patients had a superficial spreading melanoma (65%) or a nodular melanoma (26.7%). Average follow-up was 5 years or more.

The investigators divided the population by biopsy type: wide excision biopsy (279 patients), narrow excision biopsy (109), excision biopsy with positive margins (52), and incision biopsy (31). Biopsy type did not prove to be significant in univariate or multivariate analyses of disease-free survival or overall survival. The presence of residual tumor cells in reexcision specimens for 41 patients also was not significant.

"Incisional biopsies are not recommended, but there is no cause for concern when an excision biopsy turns out to have positive margins," the authors concluded.

In a telephone interview, Dr. Randall K. Roenigk agreed that both studies make good points, but he said that they are not likely to dissuade physicians from doing shave biopsies.

"If you do a shave and miss the depth of the specimen, you miss a key bit of information—the thickness of the melanoma. Your decision-making tree could be compromised," said Dr. Roenigk, professor of dermatology and chair of the department of dermatology at Mayo Medical School, Rochester, Minn.

"On the flip side, it is easier to do a shave biopsy," he continued, citing the time required for an excisional biopsy, the delay in diagnosis until an excisional biopsy can be scheduled, and the reality that some patients won't come back for the procedure.

He suggested that, as a result, doing more shave biopsies can mean more melanoma diagnoses, even though excisional biopsies are more comprehensive. From Dr. Roenigk's perspective, the studies demonstrate the importance of doing deep biopsies even when the suspected melanoma appears to be thin.

"You shouldn't be shy about taking extra tissue when you are thinking about a melanoma. It should be a thick, deep shave," he said. "If you are thinking about melanoma, you shouldn't worry about the scar."

PHOENIX — Although cutting through a melanoma during a shave biopsy may make reaching an accurate prognosis more difficult, it probably will not harm the patient, Dr. Darrell Rigel said at a clinical dermatology conference sponsored by Medicis.

Dr. Rigel, who is with New York University Medical Center, New York, said that two recently published studies addressed the concern that cutting through certain cancers during a biopsy can disperse tumor cells and worsen prognosis. It probably is not harmful in melanoma patients, he said.

The studies he cited compared excisional with incisional biopsies.

In the first study, investigators from Carolinas Medical Center in Charlotte, N.C., reported that 22% of shave biopsies had positive deep margins (Ann. Surg. Oncol. 2007;14:893–98). In the second study, investigators from the Free University Hospital, Amsterdam, found that use of incisional biopsies did not have a negative impact on survival (Ann. Surg. Oncol. 2007;14:1424–30).

"So at least if you accidentally shave through a melanoma, you [probably] haven't harmed the patient," Dr. Rigel said. "However, you may have harmed your ability to get the right prognosis for the patient." Thinner melanomas have a better prognosis, he noted, but tumor thickness is harder to determine in patients with deep positive margins.

In the first study, Dr. Richard L. White Jr. and his colleagues analyzed pathology reports from Jan. 1, 2004, through June 30, 2005, for 223 cases of primary melanoma.

Although the National Comprehensive Cancer Network and the American Academy of Dermatology have each designated excisional biopsies with narrow margins as the preferred method for diagnosing primary cutaneous melanoma, more than half the biopsies were done with the easier, faster shave technique. The sample comprised 51 excisional biopsies, 44 punch biopsies, and 128 shave biopsies. Three-fourths (167) of the specimens analyzed were from thin melanomas (1 mm or less).

Only 16% of excisional biopsies had positive margins. Just 2% were positive deep margins, and none were found in specimens from the thin melanomas.

Punch biopsy specimens also had no positive deep margins in the thinner melanomas. Positive margins were more common overall (68%), but were mostly wide margins attributable to the punch technique. Only 7% of all punch biopsies had positive deep margins.

Half of all shave biopsies produced positive margins, including the 22% that had positive deep margins. The analysis revealed positive deep margins for 17% of the thinner melanomas sampled by the shave technique.

Shave biopsy was most commonly done for thinner melanomas. It also produced samples that were significantly thinner. A review of 56 specimens showed the average biopsy thickness to be 1.41 mm with the shave technique, 3.58 mm with the punch method, and 3.19 mm for excisional biopsies.

"Based on these data," the authors concluded, "we encourage the use of an excisional biopsy technique for all skin lesions where melanoma is in the differential diagnosis when excision is feasible."

In the second study, Dr. Paul A.M. van Leeuwen and his colleagues in the Netherlands prospectively studied 471 patients who were diagnosed with stage I or II melanoma after partial removal of a skin lesion. Most of the patients had a superficial spreading melanoma (65%) or a nodular melanoma (26.7%). Average follow-up was 5 years or more.

The investigators divided the population by biopsy type: wide excision biopsy (279 patients), narrow excision biopsy (109), excision biopsy with positive margins (52), and incision biopsy (31). Biopsy type did not prove to be significant in univariate or multivariate analyses of disease-free survival or overall survival. The presence of residual tumor cells in reexcision specimens for 41 patients also was not significant.

"Incisional biopsies are not recommended, but there is no cause for concern when an excision biopsy turns out to have positive margins," the authors concluded.

In a telephone interview, Dr. Randall K. Roenigk agreed that both studies make good points, but he said that they are not likely to dissuade physicians from doing shave biopsies.

"If you do a shave and miss the depth of the specimen, you miss a key bit of information—the thickness of the melanoma. Your decision-making tree could be compromised," said Dr. Roenigk, professor of dermatology and chair of the department of dermatology at Mayo Medical School, Rochester, Minn.

"On the flip side, it is easier to do a shave biopsy," he continued, citing the time required for an excisional biopsy, the delay in diagnosis until an excisional biopsy can be scheduled, and the reality that some patients won't come back for the procedure.

He suggested that, as a result, doing more shave biopsies can mean more melanoma diagnoses, even though excisional biopsies are more comprehensive. From Dr. Roenigk's perspective, the studies demonstrate the importance of doing deep biopsies even when the suspected melanoma appears to be thin.

"You shouldn't be shy about taking extra tissue when you are thinking about a melanoma. It should be a thick, deep shave," he said. "If you are thinking about melanoma, you shouldn't worry about the scar."

SAN DIEGO — Increases in the number of patients with advanced disease, high-risk histologies, and nonwhite racial backgrounds may be promoting a rise in deaths from uterine corpus cancer, Dr. Stephanie M. Ueda reported at the annual meeting of the Society of Gynecologic Oncologists.

Despite a relatively stable number of new cases, American Cancer Society data show the number of deaths has risen from about 3,000 in 1988 to more than 7,000 anticipated this year, according to Dr. Ueda of Stanford (Calif.) University.

In search of factors behind the rising death rate, she and her colleagues analyzed demographic data for all 48,150 women diagnosed with the disease and entered into the Surveillance, Epidemiology, and End Results (SEER) database from 1988 to 2001.

For study purposes, the investigators divided the women into three chronological cohorts of 13,591 cases from 1988 to 1992, 18,580 cases from 1993 to 1997, and 15,979 cases from 1998 to 2001.

Age at diagnosis dropped from 66 to 63 years during the course of the study. While this difference was not significant, the researchers found the patients who died were significantly older with a median age of 72 years vs. 62 years among those who survived.

Over time, the patients diagnosed as well as those who died increased among minority groups, according to Dr. Ueda. The proportion of white patients declined from 85.5% in the first cohort to 77.1% of the most recent group.

Meanwhile, the proportions of Hispanic patients increased from 3.6% to 7.5%, of black patients from 5.6% to 6.6%, and of Asian patients from 3.7% to 5.6%. Death rates also rose for these minority groups: from 12% to 14.2% for blacks, from 3.5% to 8.1% for Hispanics, and from 3.5% to 5.1% for Asians.

Dr. Ueda reported that significantly more patients were diagnosed with advanced disease and with high-risk histologies such as serous and clear cell adenocarcinoma and sarcomas in the later years of the study.

The proportion of stages III and IV cancers at diagnosis rose from 14.2% to 18% and of grade 3 tumors from 19.7% to 23.3%. Deaths also increased from 52.1% to 68.8% of advanced-stage cases and from 47.5% to 60.6% of those with grade 3 disease.

High-risk histologies went from 14.7% to 17.3%. While 41.5% of patients with high-risk histology died of their disease, only 13.9% of those with less aggressive cell types succumbed.

Endometrioid histology was the most common form overall, accounting for 83.7% of all cases during the 14-year study.

Based on a multivariate analysis of the total population, the researchers concluded that independent prognostic factors for death from uterine corpus cancer were older age at diagnosis (hazard ratio 1.027), nonwhite race (HR 1.411), advanced stage (HR 2.119), grade 3 (HR 2.328), and nonendometrioid histology (1.523).

“We are finding more deaths,” Dr. Ueda said in an interview. “We are seeing more of these higher-risk types that don't respond to surgery as well. So far we haven't found the right treatments.”

The racial data may be indicative of societal changes, she added. While minority women accounted for only about 15% of the patients, she noted, they were disproportionately represented among those who died.

In a discussion of the study, Dr. Scott McMeekin of the University of Oklahoma, Oklahoma City, said the study did not account for changes in the population as a whole, in treatment of uterine corpus cancer, and in use of hormone replacement therapy over time.

“Why are there more bad tumors? Are more people diagnosed late, or are we doing a better job with other cancers?” he said. “I still don't believe we know why more people are dying.”

'We are seeing more of these higher-risk types that don't respond to surgery as well.' DR. UEDA

SAN DIEGO — Increases in the number of patients with advanced disease, high-risk histologies, and nonwhite racial backgrounds may be promoting a rise in deaths from uterine corpus cancer, Dr. Stephanie M. Ueda reported at the annual meeting of the Society of Gynecologic Oncologists.

Despite a relatively stable number of new cases, American Cancer Society data show the number of deaths has risen from about 3,000 in 1988 to more than 7,000 anticipated this year, according to Dr. Ueda of Stanford (Calif.) University.

In search of factors behind the rising death rate, she and her colleagues analyzed demographic data for all 48,150 women diagnosed with the disease and entered into the Surveillance, Epidemiology, and End Results (SEER) database from 1988 to 2001.

For study purposes, the investigators divided the women into three chronological cohorts of 13,591 cases from 1988 to 1992, 18,580 cases from 1993 to 1997, and 15,979 cases from 1998 to 2001.

Age at diagnosis dropped from 66 to 63 years during the course of the study. While this difference was not significant, the researchers found the patients who died were significantly older with a median age of 72 years vs. 62 years among those who survived.

Over time, the patients diagnosed as well as those who died increased among minority groups, according to Dr. Ueda. The proportion of white patients declined from 85.5% in the first cohort to 77.1% of the most recent group.

Meanwhile, the proportions of Hispanic patients increased from 3.6% to 7.5%, of black patients from 5.6% to 6.6%, and of Asian patients from 3.7% to 5.6%. Death rates also rose for these minority groups: from 12% to 14.2% for blacks, from 3.5% to 8.1% for Hispanics, and from 3.5% to 5.1% for Asians.

Dr. Ueda reported that significantly more patients were diagnosed with advanced disease and with high-risk histologies such as serous and clear cell adenocarcinoma and sarcomas in the later years of the study.

The proportion of stages III and IV cancers at diagnosis rose from 14.2% to 18% and of grade 3 tumors from 19.7% to 23.3%. Deaths also increased from 52.1% to 68.8% of advanced-stage cases and from 47.5% to 60.6% of those with grade 3 disease.

High-risk histologies went from 14.7% to 17.3%. While 41.5% of patients with high-risk histology died of their disease, only 13.9% of those with less aggressive cell types succumbed.

Endometrioid histology was the most common form overall, accounting for 83.7% of all cases during the 14-year study.

Based on a multivariate analysis of the total population, the researchers concluded that independent prognostic factors for death from uterine corpus cancer were older age at diagnosis (hazard ratio 1.027), nonwhite race (HR 1.411), advanced stage (HR 2.119), grade 3 (HR 2.328), and nonendometrioid histology (1.523).

“We are finding more deaths,” Dr. Ueda said in an interview. “We are seeing more of these higher-risk types that don't respond to surgery as well. So far we haven't found the right treatments.”

The racial data may be indicative of societal changes, she added. While minority women accounted for only about 15% of the patients, she noted, they were disproportionately represented among those who died.

In a discussion of the study, Dr. Scott McMeekin of the University of Oklahoma, Oklahoma City, said the study did not account for changes in the population as a whole, in treatment of uterine corpus cancer, and in use of hormone replacement therapy over time.

“Why are there more bad tumors? Are more people diagnosed late, or are we doing a better job with other cancers?” he said. “I still don't believe we know why more people are dying.”

'We are seeing more of these higher-risk types that don't respond to surgery as well.' DR. UEDA

SAN DIEGO — Increases in the number of patients with advanced disease, high-risk histologies, and nonwhite racial backgrounds may be promoting a rise in deaths from uterine corpus cancer, Dr. Stephanie M. Ueda reported at the annual meeting of the Society of Gynecologic Oncologists.

Despite a relatively stable number of new cases, American Cancer Society data show the number of deaths has risen from about 3,000 in 1988 to more than 7,000 anticipated this year, according to Dr. Ueda of Stanford (Calif.) University.

In search of factors behind the rising death rate, she and her colleagues analyzed demographic data for all 48,150 women diagnosed with the disease and entered into the Surveillance, Epidemiology, and End Results (SEER) database from 1988 to 2001.

For study purposes, the investigators divided the women into three chronological cohorts of 13,591 cases from 1988 to 1992, 18,580 cases from 1993 to 1997, and 15,979 cases from 1998 to 2001.

Age at diagnosis dropped from 66 to 63 years during the course of the study. While this difference was not significant, the researchers found the patients who died were significantly older with a median age of 72 years vs. 62 years among those who survived.

Over time, the patients diagnosed as well as those who died increased among minority groups, according to Dr. Ueda. The proportion of white patients declined from 85.5% in the first cohort to 77.1% of the most recent group.

Meanwhile, the proportions of Hispanic patients increased from 3.6% to 7.5%, of black patients from 5.6% to 6.6%, and of Asian patients from 3.7% to 5.6%. Death rates also rose for these minority groups: from 12% to 14.2% for blacks, from 3.5% to 8.1% for Hispanics, and from 3.5% to 5.1% for Asians.

Dr. Ueda reported that significantly more patients were diagnosed with advanced disease and with high-risk histologies such as serous and clear cell adenocarcinoma and sarcomas in the later years of the study.

The proportion of stages III and IV cancers at diagnosis rose from 14.2% to 18% and of grade 3 tumors from 19.7% to 23.3%. Deaths also increased from 52.1% to 68.8% of advanced-stage cases and from 47.5% to 60.6% of those with grade 3 disease.

High-risk histologies went from 14.7% to 17.3%. While 41.5% of patients with high-risk histology died of their disease, only 13.9% of those with less aggressive cell types succumbed.

Endometrioid histology was the most common form overall, accounting for 83.7% of all cases during the 14-year study.

Based on a multivariate analysis of the total population, the researchers concluded that independent prognostic factors for death from uterine corpus cancer were older age at diagnosis (hazard ratio 1.027), nonwhite race (HR 1.411), advanced stage (HR 2.119), grade 3 (HR 2.328), and nonendometrioid histology (1.523).

“We are finding more deaths,” Dr. Ueda said in an interview. “We are seeing more of these higher-risk types that don't respond to surgery as well. So far we haven't found the right treatments.”

The racial data may be indicative of societal changes, she added. While minority women accounted for only about 15% of the patients, she noted, they were disproportionately represented among those who died.

In a discussion of the study, Dr. Scott McMeekin of the University of Oklahoma, Oklahoma City, said the study did not account for changes in the population as a whole, in treatment of uterine corpus cancer, and in use of hormone replacement therapy over time.

“Why are there more bad tumors? Are more people diagnosed late, or are we doing a better job with other cancers?” he said. “I still don't believe we know why more people are dying.”

'We are seeing more of these higher-risk types that don't respond to surgery as well.' DR. UEDA

SAN DIEGO — A retrospective study of 1,491 Northern Californians diagnosed with ovarian cancer from 1994 to 1996 determined that women with the disease were likely to live significantly longer if treated by a gynecologic oncologist.

Women in the care of these cancer subspecialists had a 5-year survival rate of 39%, Dr. John K. Chan reported at the annual meeting of the Society of Gynecologic Oncologists. Only 30% of women treated by other physicians survived 5 years in the study of patients in the California Cancer Registry.

“Treatment by a gynecologic oncologist is an independent prognostic factor for improved survival,” said Dr. Chan, director of gynecologic oncology at the University of California, San Francisco. He worked on the study while a faculty member at Stanford (Calif.) University.

Dr. Chan and his colleagues attributed the survival advantage to gynecologic oncologists doing more primary surgery with appropriate staging and giving more chemotherapy. Nearly all the patients in subspecialist care had primary surgery (92%) and chemotherapy (90%), compared with 69% and 70% of those treated by other physicians. Women who didn't go to a gynecologic oncologist were four times more likely to have unstaged cancers (8% vs. 2%).

“We're just doing the standard treatment—what the guidelines recommend, and what all the national organizations and all the studies prove is efficacious. It is nothing magical,” Dr. Chan said in an interview.

He noted that the findings are consistent with smaller studies that have shown better outcomes in patients treated by gynecologic oncologists. Drawing patients from multiple institutions, the new study provides more demographic detail, he said. Investigators augmented registry data with chemotherapy information from a medical record review and a physician survey.

Despite the extensive literature favoring treatment by gynecologic oncologists, two-thirds of the patients were treated by “others,” a group that was not broken down but is presumed to include general surgeons and ob.gyns. Though the proportion of patients receiving subspecialist care increased from 28% to 36% during the period studied, it was still only 34% overall.

Compared with the larger group of women treated by other physicians, the women in the care of gynecologic oncologists were more affluent, more educated, and more often from urban areas. Poorer patients, especially from rural areas, were less likely to see a gynecologic oncologist.

Looking for factors associated with suboptimal treatment of higher-risk, early-stage cancers, the researchers found 21% of younger patients (up to age 55) with stage IC-II cancers did not receive chemotherapy; and only 39% of poorer patients and 38% of patients with early-grade tumors received chemotherapy

“Younger patients who did not receive appropriate treatment were more likely to be classified as poor, less likely to be treated by a gynecologic oncologist, and had more early-grade cancers,” Dr. Chan said.

SAN DIEGO — A retrospective study of 1,491 Northern Californians diagnosed with ovarian cancer from 1994 to 1996 determined that women with the disease were likely to live significantly longer if treated by a gynecologic oncologist.

Women in the care of these cancer subspecialists had a 5-year survival rate of 39%, Dr. John K. Chan reported at the annual meeting of the Society of Gynecologic Oncologists. Only 30% of women treated by other physicians survived 5 years in the study of patients in the California Cancer Registry.

“Treatment by a gynecologic oncologist is an independent prognostic factor for improved survival,” said Dr. Chan, director of gynecologic oncology at the University of California, San Francisco. He worked on the study while a faculty member at Stanford (Calif.) University.

Dr. Chan and his colleagues attributed the survival advantage to gynecologic oncologists doing more primary surgery with appropriate staging and giving more chemotherapy. Nearly all the patients in subspecialist care had primary surgery (92%) and chemotherapy (90%), compared with 69% and 70% of those treated by other physicians. Women who didn't go to a gynecologic oncologist were four times more likely to have unstaged cancers (8% vs. 2%).

“We're just doing the standard treatment—what the guidelines recommend, and what all the national organizations and all the studies prove is efficacious. It is nothing magical,” Dr. Chan said in an interview.

He noted that the findings are consistent with smaller studies that have shown better outcomes in patients treated by gynecologic oncologists. Drawing patients from multiple institutions, the new study provides more demographic detail, he said. Investigators augmented registry data with chemotherapy information from a medical record review and a physician survey.

Despite the extensive literature favoring treatment by gynecologic oncologists, two-thirds of the patients were treated by “others,” a group that was not broken down but is presumed to include general surgeons and ob.gyns. Though the proportion of patients receiving subspecialist care increased from 28% to 36% during the period studied, it was still only 34% overall.

Compared with the larger group of women treated by other physicians, the women in the care of gynecologic oncologists were more affluent, more educated, and more often from urban areas. Poorer patients, especially from rural areas, were less likely to see a gynecologic oncologist.

Looking for factors associated with suboptimal treatment of higher-risk, early-stage cancers, the researchers found 21% of younger patients (up to age 55) with stage IC-II cancers did not receive chemotherapy; and only 39% of poorer patients and 38% of patients with early-grade tumors received chemotherapy

“Younger patients who did not receive appropriate treatment were more likely to be classified as poor, less likely to be treated by a gynecologic oncologist, and had more early-grade cancers,” Dr. Chan said.

SAN DIEGO — A retrospective study of 1,491 Northern Californians diagnosed with ovarian cancer from 1994 to 1996 determined that women with the disease were likely to live significantly longer if treated by a gynecologic oncologist.

Women in the care of these cancer subspecialists had a 5-year survival rate of 39%, Dr. John K. Chan reported at the annual meeting of the Society of Gynecologic Oncologists. Only 30% of women treated by other physicians survived 5 years in the study of patients in the California Cancer Registry.

“Treatment by a gynecologic oncologist is an independent prognostic factor for improved survival,” said Dr. Chan, director of gynecologic oncology at the University of California, San Francisco. He worked on the study while a faculty member at Stanford (Calif.) University.

Dr. Chan and his colleagues attributed the survival advantage to gynecologic oncologists doing more primary surgery with appropriate staging and giving more chemotherapy. Nearly all the patients in subspecialist care had primary surgery (92%) and chemotherapy (90%), compared with 69% and 70% of those treated by other physicians. Women who didn't go to a gynecologic oncologist were four times more likely to have unstaged cancers (8% vs. 2%).

“We're just doing the standard treatment—what the guidelines recommend, and what all the national organizations and all the studies prove is efficacious. It is nothing magical,” Dr. Chan said in an interview.

He noted that the findings are consistent with smaller studies that have shown better outcomes in patients treated by gynecologic oncologists. Drawing patients from multiple institutions, the new study provides more demographic detail, he said. Investigators augmented registry data with chemotherapy information from a medical record review and a physician survey.

Despite the extensive literature favoring treatment by gynecologic oncologists, two-thirds of the patients were treated by “others,” a group that was not broken down but is presumed to include general surgeons and ob.gyns. Though the proportion of patients receiving subspecialist care increased from 28% to 36% during the period studied, it was still only 34% overall.

Compared with the larger group of women treated by other physicians, the women in the care of gynecologic oncologists were more affluent, more educated, and more often from urban areas. Poorer patients, especially from rural areas, were less likely to see a gynecologic oncologist.

Looking for factors associated with suboptimal treatment of higher-risk, early-stage cancers, the researchers found 21% of younger patients (up to age 55) with stage IC-II cancers did not receive chemotherapy; and only 39% of poorer patients and 38% of patients with early-grade tumors received chemotherapy

“Younger patients who did not receive appropriate treatment were more likely to be classified as poor, less likely to be treated by a gynecologic oncologist, and had more early-grade cancers,” Dr. Chan said.

PHOENIX — Cutting through a melanoma during a shave biopsy may make reaching an accurate prognosis more difficult, but it probably won't harm the patient, Dr. Darrell Rigel said at a clinical dermatology conference sponsored by Medicis.

Dr. Rigel of New York University Medical Center, New York, said that two recently published studies addressed the concern that cutting through certain cancers during a biopsy can disperse tumor cells and worsen prognosis. Both of the studies compared excisional with incisional biopsies.

In the first study, researchers from Carolinas Medical Center in Charlotte, N.C., reported that 22% of shave biopsies had positive deep margins (Ann. Surg. Oncol. 2007; 14:893–8). In the second study, researchers from the Free University Hospital, Amsterdam, found that incisional biopsies did not have a negative impact on survival (Ann. Surg. Oncol. 2007;14:1424–30).

In the first study, Dr. Richard L. White Jr. and his colleagues analyzed pathology reports from Jan. 1, 2004, through June 30, 2005, for 223 cases of primary melanoma. The sample comprised 51 excisional biopsies, 44 punch biopsies, and 128 shave biopsies. Of the specimens analyzed, 167 were from thin melanomas (1 mm or less).

Only 16% of excisional biopsies had positive margins. Just 2% were positive deep margins, and none were found in specimens from the thin melanomas. Punch biopsy specimens also had no positive deep margins in the thinner melanomas. Positive margins were more common overall (68%), but were mostly wide margins attributable to the punch technique. Only 7% of punch biopsies had positive deep margins.

Half of all shave biopsies produced positive margins, including the 22% that had positive deep margins. The analysis revealed positive deep margins for 17% of the thinner melanomas sampled by the shave technique. Shave biopsy was most commonly done for thinner melanomas. It also produced samples that were significantly thinner. Of 56 specimens, the average biopsy thickness was 1.41 mm with the shave technique, 3.58 mm with the punch method, and 3.19 mm for excisional biopsies.

In the second study, Dr. Paul A.M. van Leeuwen and his colleagues in the Netherlands prospectively studied 471 patients diagnosed with stage I or II melanoma after partial removal of a skin lesion. Most of the patients had a superficial spreading melanoma (65%) or a nodular melanoma (26.7%). Average follow-up was 5 years or more. The investigators divided the population by biopsy type: wide excision biopsy (279 patients), narrow excision biopsy (109), excision biopsy with positive margins (52), and incision biopsy (31). Biopsy type did not prove to be significant in univariate or multivariate analyses of disease-free survival or overall survival. The presence of residual tumor cells in reexcision specimens for 41 patients also was not significant.

PHOENIX — Cutting through a melanoma during a shave biopsy may make reaching an accurate prognosis more difficult, but it probably won't harm the patient, Dr. Darrell Rigel said at a clinical dermatology conference sponsored by Medicis.

Dr. Rigel of New York University Medical Center, New York, said that two recently published studies addressed the concern that cutting through certain cancers during a biopsy can disperse tumor cells and worsen prognosis. Both of the studies compared excisional with incisional biopsies.

In the first study, researchers from Carolinas Medical Center in Charlotte, N.C., reported that 22% of shave biopsies had positive deep margins (Ann. Surg. Oncol. 2007; 14:893–8). In the second study, researchers from the Free University Hospital, Amsterdam, found that incisional biopsies did not have a negative impact on survival (Ann. Surg. Oncol. 2007;14:1424–30).

In the first study, Dr. Richard L. White Jr. and his colleagues analyzed pathology reports from Jan. 1, 2004, through June 30, 2005, for 223 cases of primary melanoma. The sample comprised 51 excisional biopsies, 44 punch biopsies, and 128 shave biopsies. Of the specimens analyzed, 167 were from thin melanomas (1 mm or less).

Only 16% of excisional biopsies had positive margins. Just 2% were positive deep margins, and none were found in specimens from the thin melanomas. Punch biopsy specimens also had no positive deep margins in the thinner melanomas. Positive margins were more common overall (68%), but were mostly wide margins attributable to the punch technique. Only 7% of punch biopsies had positive deep margins.

Half of all shave biopsies produced positive margins, including the 22% that had positive deep margins. The analysis revealed positive deep margins for 17% of the thinner melanomas sampled by the shave technique. Shave biopsy was most commonly done for thinner melanomas. It also produced samples that were significantly thinner. Of 56 specimens, the average biopsy thickness was 1.41 mm with the shave technique, 3.58 mm with the punch method, and 3.19 mm for excisional biopsies.

In the second study, Dr. Paul A.M. van Leeuwen and his colleagues in the Netherlands prospectively studied 471 patients diagnosed with stage I or II melanoma after partial removal of a skin lesion. Most of the patients had a superficial spreading melanoma (65%) or a nodular melanoma (26.7%). Average follow-up was 5 years or more. The investigators divided the population by biopsy type: wide excision biopsy (279 patients), narrow excision biopsy (109), excision biopsy with positive margins (52), and incision biopsy (31). Biopsy type did not prove to be significant in univariate or multivariate analyses of disease-free survival or overall survival. The presence of residual tumor cells in reexcision specimens for 41 patients also was not significant.

PHOENIX — Cutting through a melanoma during a shave biopsy may make reaching an accurate prognosis more difficult, but it probably won't harm the patient, Dr. Darrell Rigel said at a clinical dermatology conference sponsored by Medicis.

Dr. Rigel of New York University Medical Center, New York, said that two recently published studies addressed the concern that cutting through certain cancers during a biopsy can disperse tumor cells and worsen prognosis. Both of the studies compared excisional with incisional biopsies.

In the first study, researchers from Carolinas Medical Center in Charlotte, N.C., reported that 22% of shave biopsies had positive deep margins (Ann. Surg. Oncol. 2007; 14:893–8). In the second study, researchers from the Free University Hospital, Amsterdam, found that incisional biopsies did not have a negative impact on survival (Ann. Surg. Oncol. 2007;14:1424–30).

In the first study, Dr. Richard L. White Jr. and his colleagues analyzed pathology reports from Jan. 1, 2004, through June 30, 2005, for 223 cases of primary melanoma. The sample comprised 51 excisional biopsies, 44 punch biopsies, and 128 shave biopsies. Of the specimens analyzed, 167 were from thin melanomas (1 mm or less).

Only 16% of excisional biopsies had positive margins. Just 2% were positive deep margins, and none were found in specimens from the thin melanomas. Punch biopsy specimens also had no positive deep margins in the thinner melanomas. Positive margins were more common overall (68%), but were mostly wide margins attributable to the punch technique. Only 7% of punch biopsies had positive deep margins.

Half of all shave biopsies produced positive margins, including the 22% that had positive deep margins. The analysis revealed positive deep margins for 17% of the thinner melanomas sampled by the shave technique. Shave biopsy was most commonly done for thinner melanomas. It also produced samples that were significantly thinner. Of 56 specimens, the average biopsy thickness was 1.41 mm with the shave technique, 3.58 mm with the punch method, and 3.19 mm for excisional biopsies.

In the second study, Dr. Paul A.M. van Leeuwen and his colleagues in the Netherlands prospectively studied 471 patients diagnosed with stage I or II melanoma after partial removal of a skin lesion. Most of the patients had a superficial spreading melanoma (65%) or a nodular melanoma (26.7%). Average follow-up was 5 years or more. The investigators divided the population by biopsy type: wide excision biopsy (279 patients), narrow excision biopsy (109), excision biopsy with positive margins (52), and incision biopsy (31). Biopsy type did not prove to be significant in univariate or multivariate analyses of disease-free survival or overall survival. The presence of residual tumor cells in reexcision specimens for 41 patients also was not significant.

SAN DIEGO — Obese women may be shortchanged on chemotherapy but do not appear to have worse outcomes with cancer surgery, compared with patients of normal weight, and might do well with robotic-assisted surgery.

These findings, from three separate studies presented at the annual meeting of the Society of Gynecologic Oncologists, address a concern that is growing with the nation's waistline: Does obesity hamper the delivery of standard cancer treatments?

Reviewing a clinical trial conducted by the Gynecologic Oncology Group (GOG), Dr. Jason D. Wright reported that obese ovarian cancer patients had considerably less toxicity than did women of lesser weight and may have received a substandard dose of carboplatin.

His review focused on use of the Jelliffe formula to assess renal function when calculating the carboplatin dosage. The Jelliffe formula does not consider weight and, therefore, can lead to calculations that are significantly different from those reached with the Cockcroft-Gault formula, a similar common assessment method that does take weight into account.

Before reviewing clinical trial GOG 158, Dr. Wright, of the department of ob.gyn at Columbia University, New York, and his colleagues compared the formulas' effects on dosing a hypothetical 60-year-old woman, 5 feet 5 inches tall, with a serum creatinine level of 0.9 mg/dL, who was to receive carboplatin at a dosage that would result in a concentration over time of 7.5 mg/mL per minute. If she weighed 140 pounds, she received 0.7% less carboplatin with the Jelliffe formula. The difference increased with increases in weight, reaching 24% at 200 pounds and 37% at 250 pounds.

In the GOG 158 trial, 387 women received carboplatin and paclitaxel for optimally cytoreduced epithelial ovarian cancer. About half (194) had a body mass index (kg/m2) lower than 25. The rest were either overweight (122 patients, of whom 32% had a BMI of 25-29.9) or obese (71 patients, of whom 18% had a BMI of 30 or greater).

Whereas platelet count decreased 61% in normal-weight women, Dr. Wright's group found that it fell only 50% among the overweight women and only 25% in those who were obese. Relative changes in hemoglobin and hematocrit also differed significantly with weight.

When the investigators reviewed grade 3 and 4 toxicities, they found only 27% of obese women had thrombocytopenia, compared with 49.5% of women with normal weight and 32% of the overweight women. The obese women were significantly less likely to have leukopenia and granulocytopenia—and also significantly less likely to have dose reductions or dose delays. Only neurologic toxicity was more common in obese patients.

Although a trend toward decreased progression-free survival in obese patients did not reach statistical significance, Dr. Wright noted that the trial did not have sufficient power to find this difference. Overall survival was comparable for all three weight groups.

“You've opened Pandora's box here,” Dr. Linda Van Le, professor of ob.gyn. at the University of North Carolina at Chapel Hill, told him in a discussion of the study. “If the dose method is inaccurate, what is the best formula, and should we switch? The ramifications of this are huge.”

In an interview after the talk, Dr. Wright said the Jelliffe formula is used in all GOG trials as well as by many gynecologic oncologists in their practices, but other fields of oncology tend to use the Cockcroft-Gault formula.

Concern that a high BMI could increase the risk of death after radical abdominal hysterectomy for cervical cancer led Dr. Meredith P. Crisp to review records of 332 stage IB and IIA patients who underwent the procedure between 1990 and 2003 at the University of Miami. “With any surgery, you need optimal visualization, and radical hysterectomy is certainly no exception to this rule,” said Dr. Crisp, of the university. “We can use [devices for positioning patients]. Despite many of these devices, we still have problems with visualization in the obese population.”

Dr. Crisp and her colleagues found BMI data for 281 patients. Of these, 10 (4%) were underweight (BMI less than 18.5); 110 (39%) were normal weight; 105 (37%) were overweight; and 56 (20%) were obese. She reported that the only significant difference in outcomes was that obese women lost more blood: The amount reached 1,000 cc or more in 52% of obese women, compared with only 35% of overweight women and 38% of normal-weight women. Surgical-margin measures, surgical complications, and operating times were not significantly different. “Radical hysterectomy is an appropriate and safe therapy for overweight and obese patients with cervical cancer,” Dr. Crisp concluded.

Dr. Diane C. Bodurka praised the investigators for adding to the literature on an important issue that gynecologic oncologists face in their practices, but questioned whether the study had an inherent selection bias. “It is a logical assumption that the healthier obese women were offered radical hysterectomy, which could likely bias the results,” said Dr. Bodurka of the University of Texas M.D. Anderson Cancer Center, Houston. “It is difficult for me to accept the generalization that radical hysterectomy is an appropriate therapy for obese women.”

Dr. Crisp responded that she would not eliminate a patient for radical hysterectomy solely because of obesity. Because such patients are at greater risk of comorbidity, she said that diabetes, cardiac disease, and pulmonary disease should be assessed to make sure the patient is an appropriate candidate for surgery.

Robotic surgery may expand the surgical options for women with cervical cancer, Dr. Aaron Shafer reported in the third study. Dr. Shafer, of the University of North Carolina at Chapel Hill, compared outcomes for 31 women who had robotic type III radical hysterectomies to the experience of 48 case controls who underwent open procedures at that institution. The groups included 13 and 11 obese patients, respectively. Of the robotic group, 15% were morbidly obese.

Dr. Shafer reported that the robotic group had significantly less mean blood loss (119 mL vs. 562 mL), greater lymph node yield on average (38.4 vs. 22.3), and shorter median hospital stays (1 vs. 3.5 days).

SAN DIEGO — Obese women may be shortchanged on chemotherapy but do not appear to have worse outcomes with cancer surgery, compared with patients of normal weight, and might do well with robotic-assisted surgery.

These findings, from three separate studies presented at the annual meeting of the Society of Gynecologic Oncologists, address a concern that is growing with the nation's waistline: Does obesity hamper the delivery of standard cancer treatments?

Reviewing a clinical trial conducted by the Gynecologic Oncology Group (GOG), Dr. Jason D. Wright reported that obese ovarian cancer patients had considerably less toxicity than did women of lesser weight and may have received a substandard dose of carboplatin.

His review focused on use of the Jelliffe formula to assess renal function when calculating the carboplatin dosage. The Jelliffe formula does not consider weight and, therefore, can lead to calculations that are significantly different from those reached with the Cockcroft-Gault formula, a similar common assessment method that does take weight into account.

Before reviewing clinical trial GOG 158, Dr. Wright, of the department of ob.gyn at Columbia University, New York, and his colleagues compared the formulas' effects on dosing a hypothetical 60-year-old woman, 5 feet 5 inches tall, with a serum creatinine level of 0.9 mg/dL, who was to receive carboplatin at a dosage that would result in a concentration over time of 7.5 mg/mL per minute. If she weighed 140 pounds, she received 0.7% less carboplatin with the Jelliffe formula. The difference increased with increases in weight, reaching 24% at 200 pounds and 37% at 250 pounds.

In the GOG 158 trial, 387 women received carboplatin and paclitaxel for optimally cytoreduced epithelial ovarian cancer. About half (194) had a body mass index (kg/m2) lower than 25. The rest were either overweight (122 patients, of whom 32% had a BMI of 25-29.9) or obese (71 patients, of whom 18% had a BMI of 30 or greater).

Whereas platelet count decreased 61% in normal-weight women, Dr. Wright's group found that it fell only 50% among the overweight women and only 25% in those who were obese. Relative changes in hemoglobin and hematocrit also differed significantly with weight.

When the investigators reviewed grade 3 and 4 toxicities, they found only 27% of obese women had thrombocytopenia, compared with 49.5% of women with normal weight and 32% of the overweight women. The obese women were significantly less likely to have leukopenia and granulocytopenia—and also significantly less likely to have dose reductions or dose delays. Only neurologic toxicity was more common in obese patients.

Although a trend toward decreased progression-free survival in obese patients did not reach statistical significance, Dr. Wright noted that the trial did not have sufficient power to find this difference. Overall survival was comparable for all three weight groups.

“You've opened Pandora's box here,” Dr. Linda Van Le, professor of ob.gyn. at the University of North Carolina at Chapel Hill, told him in a discussion of the study. “If the dose method is inaccurate, what is the best formula, and should we switch? The ramifications of this are huge.”

In an interview after the talk, Dr. Wright said the Jelliffe formula is used in all GOG trials as well as by many gynecologic oncologists in their practices, but other fields of oncology tend to use the Cockcroft-Gault formula.

Concern that a high BMI could increase the risk of death after radical abdominal hysterectomy for cervical cancer led Dr. Meredith P. Crisp to review records of 332 stage IB and IIA patients who underwent the procedure between 1990 and 2003 at the University of Miami. “With any surgery, you need optimal visualization, and radical hysterectomy is certainly no exception to this rule,” said Dr. Crisp, of the university. “We can use [devices for positioning patients]. Despite many of these devices, we still have problems with visualization in the obese population.”

Dr. Crisp and her colleagues found BMI data for 281 patients. Of these, 10 (4%) were underweight (BMI less than 18.5); 110 (39%) were normal weight; 105 (37%) were overweight; and 56 (20%) were obese. She reported that the only significant difference in outcomes was that obese women lost more blood: The amount reached 1,000 cc or more in 52% of obese women, compared with only 35% of overweight women and 38% of normal-weight women. Surgical-margin measures, surgical complications, and operating times were not significantly different. “Radical hysterectomy is an appropriate and safe therapy for overweight and obese patients with cervical cancer,” Dr. Crisp concluded.

Dr. Diane C. Bodurka praised the investigators for adding to the literature on an important issue that gynecologic oncologists face in their practices, but questioned whether the study had an inherent selection bias. “It is a logical assumption that the healthier obese women were offered radical hysterectomy, which could likely bias the results,” said Dr. Bodurka of the University of Texas M.D. Anderson Cancer Center, Houston. “It is difficult for me to accept the generalization that radical hysterectomy is an appropriate therapy for obese women.”

Dr. Crisp responded that she would not eliminate a patient for radical hysterectomy solely because of obesity. Because such patients are at greater risk of comorbidity, she said that diabetes, cardiac disease, and pulmonary disease should be assessed to make sure the patient is an appropriate candidate for surgery.

Robotic surgery may expand the surgical options for women with cervical cancer, Dr. Aaron Shafer reported in the third study. Dr. Shafer, of the University of North Carolina at Chapel Hill, compared outcomes for 31 women who had robotic type III radical hysterectomies to the experience of 48 case controls who underwent open procedures at that institution. The groups included 13 and 11 obese patients, respectively. Of the robotic group, 15% were morbidly obese.

Dr. Shafer reported that the robotic group had significantly less mean blood loss (119 mL vs. 562 mL), greater lymph node yield on average (38.4 vs. 22.3), and shorter median hospital stays (1 vs. 3.5 days).

SAN DIEGO — Obese women may be shortchanged on chemotherapy but do not appear to have worse outcomes with cancer surgery, compared with patients of normal weight, and might do well with robotic-assisted surgery.

These findings, from three separate studies presented at the annual meeting of the Society of Gynecologic Oncologists, address a concern that is growing with the nation's waistline: Does obesity hamper the delivery of standard cancer treatments?

Reviewing a clinical trial conducted by the Gynecologic Oncology Group (GOG), Dr. Jason D. Wright reported that obese ovarian cancer patients had considerably less toxicity than did women of lesser weight and may have received a substandard dose of carboplatin.

His review focused on use of the Jelliffe formula to assess renal function when calculating the carboplatin dosage. The Jelliffe formula does not consider weight and, therefore, can lead to calculations that are significantly different from those reached with the Cockcroft-Gault formula, a similar common assessment method that does take weight into account.

Before reviewing clinical trial GOG 158, Dr. Wright, of the department of ob.gyn at Columbia University, New York, and his colleagues compared the formulas' effects on dosing a hypothetical 60-year-old woman, 5 feet 5 inches tall, with a serum creatinine level of 0.9 mg/dL, who was to receive carboplatin at a dosage that would result in a concentration over time of 7.5 mg/mL per minute. If she weighed 140 pounds, she received 0.7% less carboplatin with the Jelliffe formula. The difference increased with increases in weight, reaching 24% at 200 pounds and 37% at 250 pounds.

In the GOG 158 trial, 387 women received carboplatin and paclitaxel for optimally cytoreduced epithelial ovarian cancer. About half (194) had a body mass index (kg/m2) lower than 25. The rest were either overweight (122 patients, of whom 32% had a BMI of 25-29.9) or obese (71 patients, of whom 18% had a BMI of 30 or greater).

Whereas platelet count decreased 61% in normal-weight women, Dr. Wright's group found that it fell only 50% among the overweight women and only 25% in those who were obese. Relative changes in hemoglobin and hematocrit also differed significantly with weight.

When the investigators reviewed grade 3 and 4 toxicities, they found only 27% of obese women had thrombocytopenia, compared with 49.5% of women with normal weight and 32% of the overweight women. The obese women were significantly less likely to have leukopenia and granulocytopenia—and also significantly less likely to have dose reductions or dose delays. Only neurologic toxicity was more common in obese patients.

Although a trend toward decreased progression-free survival in obese patients did not reach statistical significance, Dr. Wright noted that the trial did not have sufficient power to find this difference. Overall survival was comparable for all three weight groups.

“You've opened Pandora's box here,” Dr. Linda Van Le, professor of ob.gyn. at the University of North Carolina at Chapel Hill, told him in a discussion of the study. “If the dose method is inaccurate, what is the best formula, and should we switch? The ramifications of this are huge.”

In an interview after the talk, Dr. Wright said the Jelliffe formula is used in all GOG trials as well as by many gynecologic oncologists in their practices, but other fields of oncology tend to use the Cockcroft-Gault formula.

Concern that a high BMI could increase the risk of death after radical abdominal hysterectomy for cervical cancer led Dr. Meredith P. Crisp to review records of 332 stage IB and IIA patients who underwent the procedure between 1990 and 2003 at the University of Miami. “With any surgery, you need optimal visualization, and radical hysterectomy is certainly no exception to this rule,” said Dr. Crisp, of the university. “We can use [devices for positioning patients]. Despite many of these devices, we still have problems with visualization in the obese population.”

Dr. Crisp and her colleagues found BMI data for 281 patients. Of these, 10 (4%) were underweight (BMI less than 18.5); 110 (39%) were normal weight; 105 (37%) were overweight; and 56 (20%) were obese. She reported that the only significant difference in outcomes was that obese women lost more blood: The amount reached 1,000 cc or more in 52% of obese women, compared with only 35% of overweight women and 38% of normal-weight women. Surgical-margin measures, surgical complications, and operating times were not significantly different. “Radical hysterectomy is an appropriate and safe therapy for overweight and obese patients with cervical cancer,” Dr. Crisp concluded.

Dr. Diane C. Bodurka praised the investigators for adding to the literature on an important issue that gynecologic oncologists face in their practices, but questioned whether the study had an inherent selection bias. “It is a logical assumption that the healthier obese women were offered radical hysterectomy, which could likely bias the results,” said Dr. Bodurka of the University of Texas M.D. Anderson Cancer Center, Houston. “It is difficult for me to accept the generalization that radical hysterectomy is an appropriate therapy for obese women.”

Dr. Crisp responded that she would not eliminate a patient for radical hysterectomy solely because of obesity. Because such patients are at greater risk of comorbidity, she said that diabetes, cardiac disease, and pulmonary disease should be assessed to make sure the patient is an appropriate candidate for surgery.

Robotic surgery may expand the surgical options for women with cervical cancer, Dr. Aaron Shafer reported in the third study. Dr. Shafer, of the University of North Carolina at Chapel Hill, compared outcomes for 31 women who had robotic type III radical hysterectomies to the experience of 48 case controls who underwent open procedures at that institution. The groups included 13 and 11 obese patients, respectively. Of the robotic group, 15% were morbidly obese.

Dr. Shafer reported that the robotic group had significantly less mean blood loss (119 mL vs. 562 mL), greater lymph node yield on average (38.4 vs. 22.3), and shorter median hospital stays (1 vs. 3.5 days).

SCOTTSDALE, ARIZ. – Sustained opioid therapy should be prescribed only for chronic headache patients under stringent new guidelines that would exclude most headache patients, Dr. Joel R. Saper proposed at a symposium sponsored by the American Headache Society.

Dr. Saper, founder and director of the Michigan Head, Pain, and Neurological Institute in Ann Arbor, said his group revisited the outcomes of a 5-year observational study of 160 patients on daily opioid therapy for intractable headaches and found even fewer people benefited over time than had been reported in the original published manuscript (Neurology 2004;62:1687–94).

Instead of 26% cutting their pain by one-half or more as a result of opioid therapy, Dr. Saper said that “no more than 15% of those patients did well.” He attributed the overestimate to “a significant disconnect between objective markers and patient perception.”

Patients were less than honest about their analgesia use, he said. Even though the program was tightly controlled, he added, the investigators determined that about half of the patients had continuing increases in their opioid doses.

Further, a more recent study, he continued, revealed that most patients on opioid therapy have behavioral disturbances.

Dr. Saper and his colleagues reviewed 267 consecutively admitted patients, of whom 76% were discharged with moderate to significant pain control. Opioid use was highest in patients with borderline, narcissistic, and antisocial personality disorders as defined under Axis II, Cluster B of the Diagnostic and Statistical Manual of Mental Disorders IV.

“Headache patients who obtain opioids are different,” he said, describing them as being more likely to have Axis II disorders and, in many cases, unwilling or unable to stop taking opioids even if their headaches do not lessen with therapy. Some patients, he added, use the prescribed opioid as a medication for something other than pain, such as relief of anxiety.

“Opioids make borderline patients angrier and more combative,” Dr. Saper warned.

In many cases, he acknowledged, physicians prescribe opioids against their better judgment. “I believe that the behavior of the patient more than the pain itself often drives the doctor to give them opioids–if nothing else, to simply quiet them down,” he said.

To help physicians say “no” to such patients, Dr. Saper offered conservative guidelines that he developed in collaboration with Alvin E. Lake, Ph.D. (Headache Curr. 2006;3:67–70).

Headache patients would have to meet all four of the following criteria to be eligible for opioid therapy:

1. Older than age 50 years.

2. Convincing moderate to severe pain occurring daily or almost daily with recognizable impairment.

3. Visited the physician at least four times over 3 months to ensure familiarity before the first opioid prescription is written.

4. A history of being compliant and trustworthy in use of medication.

In addition, Dr. Saper said, patients must meet one or more of the following criteria: (1) a history of failing to respond to multiple appropriate treatments, (2) pregnancy threatened by headache, or (3) significant confounding disease or treatment that aggravates headache or limits treatment.

Moreover, he said, chronic headache patients should be disqualified from receiving opioid therapy if they have a moderate to severe Axis I diagnosis; past or current addictive disease (with the exception of a “nondrinking rehabilitated alcoholic”); any Axis II, Cluster B personality disorder; or moderate to severe somatoform or histrionic features.

Finally, opioid-treated patients must be seen frequently to ensure they are not abusing their medication. “If you start them, you had better be willing and able to monitor and stop them,” he said.

Some headache patients use opioids as a medication for something other than pain. DR. SAPER

SCOTTSDALE, ARIZ. – Sustained opioid therapy should be prescribed only for chronic headache patients under stringent new guidelines that would exclude most headache patients, Dr. Joel R. Saper proposed at a symposium sponsored by the American Headache Society.

Dr. Saper, founder and director of the Michigan Head, Pain, and Neurological Institute in Ann Arbor, said his group revisited the outcomes of a 5-year observational study of 160 patients on daily opioid therapy for intractable headaches and found even fewer people benefited over time than had been reported in the original published manuscript (Neurology 2004;62:1687–94).

Instead of 26% cutting their pain by one-half or more as a result of opioid therapy, Dr. Saper said that “no more than 15% of those patients did well.” He attributed the overestimate to “a significant disconnect between objective markers and patient perception.”

Patients were less than honest about their analgesia use, he said. Even though the program was tightly controlled, he added, the investigators determined that about half of the patients had continuing increases in their opioid doses.

Further, a more recent study, he continued, revealed that most patients on opioid therapy have behavioral disturbances.

Dr. Saper and his colleagues reviewed 267 consecutively admitted patients, of whom 76% were discharged with moderate to significant pain control. Opioid use was highest in patients with borderline, narcissistic, and antisocial personality disorders as defined under Axis II, Cluster B of the Diagnostic and Statistical Manual of Mental Disorders IV.

“Headache patients who obtain opioids are different,” he said, describing them as being more likely to have Axis II disorders and, in many cases, unwilling or unable to stop taking opioids even if their headaches do not lessen with therapy. Some patients, he added, use the prescribed opioid as a medication for something other than pain, such as relief of anxiety.

“Opioids make borderline patients angrier and more combative,” Dr. Saper warned.

In many cases, he acknowledged, physicians prescribe opioids against their better judgment. “I believe that the behavior of the patient more than the pain itself often drives the doctor to give them opioids–if nothing else, to simply quiet them down,” he said.

To help physicians say “no” to such patients, Dr. Saper offered conservative guidelines that he developed in collaboration with Alvin E. Lake, Ph.D. (Headache Curr. 2006;3:67–70).

Headache patients would have to meet all four of the following criteria to be eligible for opioid therapy:

1. Older than age 50 years.

2. Convincing moderate to severe pain occurring daily or almost daily with recognizable impairment.

3. Visited the physician at least four times over 3 months to ensure familiarity before the first opioid prescription is written.

4. A history of being compliant and trustworthy in use of medication.

In addition, Dr. Saper said, patients must meet one or more of the following criteria: (1) a history of failing to respond to multiple appropriate treatments, (2) pregnancy threatened by headache, or (3) significant confounding disease or treatment that aggravates headache or limits treatment.

Moreover, he said, chronic headache patients should be disqualified from receiving opioid therapy if they have a moderate to severe Axis I diagnosis; past or current addictive disease (with the exception of a “nondrinking rehabilitated alcoholic”); any Axis II, Cluster B personality disorder; or moderate to severe somatoform or histrionic features.

Finally, opioid-treated patients must be seen frequently to ensure they are not abusing their medication. “If you start them, you had better be willing and able to monitor and stop them,” he said.

Some headache patients use opioids as a medication for something other than pain. DR. SAPER

SCOTTSDALE, ARIZ. – Sustained opioid therapy should be prescribed only for chronic headache patients under stringent new guidelines that would exclude most headache patients, Dr. Joel R. Saper proposed at a symposium sponsored by the American Headache Society.

Dr. Saper, founder and director of the Michigan Head, Pain, and Neurological Institute in Ann Arbor, said his group revisited the outcomes of a 5-year observational study of 160 patients on daily opioid therapy for intractable headaches and found even fewer people benefited over time than had been reported in the original published manuscript (Neurology 2004;62:1687–94).

Instead of 26% cutting their pain by one-half or more as a result of opioid therapy, Dr. Saper said that “no more than 15% of those patients did well.” He attributed the overestimate to “a significant disconnect between objective markers and patient perception.”

Patients were less than honest about their analgesia use, he said. Even though the program was tightly controlled, he added, the investigators determined that about half of the patients had continuing increases in their opioid doses.

Further, a more recent study, he continued, revealed that most patients on opioid therapy have behavioral disturbances.

Dr. Saper and his colleagues reviewed 267 consecutively admitted patients, of whom 76% were discharged with moderate to significant pain control. Opioid use was highest in patients with borderline, narcissistic, and antisocial personality disorders as defined under Axis II, Cluster B of the Diagnostic and Statistical Manual of Mental Disorders IV.

“Headache patients who obtain opioids are different,” he said, describing them as being more likely to have Axis II disorders and, in many cases, unwilling or unable to stop taking opioids even if their headaches do not lessen with therapy. Some patients, he added, use the prescribed opioid as a medication for something other than pain, such as relief of anxiety.

“Opioids make borderline patients angrier and more combative,” Dr. Saper warned.

In many cases, he acknowledged, physicians prescribe opioids against their better judgment. “I believe that the behavior of the patient more than the pain itself often drives the doctor to give them opioids–if nothing else, to simply quiet them down,” he said.

To help physicians say “no” to such patients, Dr. Saper offered conservative guidelines that he developed in collaboration with Alvin E. Lake, Ph.D. (Headache Curr. 2006;3:67–70).

Headache patients would have to meet all four of the following criteria to be eligible for opioid therapy:

1. Older than age 50 years.

2. Convincing moderate to severe pain occurring daily or almost daily with recognizable impairment.

3. Visited the physician at least four times over 3 months to ensure familiarity before the first opioid prescription is written.

4. A history of being compliant and trustworthy in use of medication.

In addition, Dr. Saper said, patients must meet one or more of the following criteria: (1) a history of failing to respond to multiple appropriate treatments, (2) pregnancy threatened by headache, or (3) significant confounding disease or treatment that aggravates headache or limits treatment.

Moreover, he said, chronic headache patients should be disqualified from receiving opioid therapy if they have a moderate to severe Axis I diagnosis; past or current addictive disease (with the exception of a “nondrinking rehabilitated alcoholic”); any Axis II, Cluster B personality disorder; or moderate to severe somatoform or histrionic features.

Finally, opioid-treated patients must be seen frequently to ensure they are not abusing their medication. “If you start them, you had better be willing and able to monitor and stop them,” he said.

Some headache patients use opioids as a medication for something other than pain. DR. SAPER

SCOTTSDALE, ARIZ. — Patients with sleep disorders should be screened for gastrointestinal reflux, Dr. Susan M. Harding advised at a meeting on sleep medicine sponsored by the American College of Chest Physicians.

Heartburn is common in patients with sleep complaints and can make their sleep problems worse, according to Dr. Harding, a professor of medicine and medical director of the Sleep/Wake Disorders Center at the University of Alabama, Birmingham.

It has not been shown to cause sleep disorders, or vice versa, she said. Nonetheless, researchers have demonstrated that treating gastrointestinal reflux can improve sleep—and that treating sleep disorders can improve reflux.

In one study cited by Dr. Harding, 62% of obstructive sleep apnea patients had symptoms of nighttime reflux. The patients who were compliant with continuous positive airway pressure therapy reduced their symptoms by 48%. Noncompliant patients had no improvement (Arch. Intern. Med. 2003;163:41–5).

Conversely, Dr. Harding cited a trial that enrolled 650 reflux patients with sleep complaints. Four weeks of treatment with a proton pump inhibitor significantly reduced sleep disturbances and improved sleep quality (Am. J. Gastroenterol. 2005;100:1914–22).

“Nighttime reflux is common in heartburn patients,” she said. “It causes sleep difficulties, and it is inadequately treated.”

Stable sleep protects against reflux, according to Dr. Harding. Esophageal acid take much longer to clear during sleep, and people swallow less often. Acid clearance mostly occurs during arousals.

“Is there an association between sleep-related reflux and obstructive sleep apnea?” she asked rhetorically. “Maybe. Maybe not.”

Despite identifying reflux in many obstructive sleep apnea patients, Dr. Harding noted that studies have failed to find a causal relationship or correlations among reflux scores, apnea severity, and other variables by which the two conditions are measured.

The conditions coexist in many patients, she said, which suggests that the relationship may be complex. “Reflux is not caused by obstructive sleep apnea, but reflux may be facilitated by obstructive sleep apnea,” she said, and called for more studies examining transient lower esophageal sphincter relaxations in obstructive sleep apnea patients.

Reflux should be considered whenever a patient presents with insomnia or excessive daytime sleepiness, according to Dr. Harding. Patients with erosive esophagitis are prone to sleep disturbances, she said, and nocturnal reflux has been shown to trigger respiratory symptoms in asthma patients. Sleep-related laryngospasm also can be triggered by reflux.

Consider doing esophageal pH monitoring along with polysomnography, Dr. Harding advised. If sleep-related reflux is diagnosed, urge patients to make the following lifestyle modifications (Arch. Intern. Med. 2006;166:965–71):

▸ Not eating for 2 hours before bedtime.

▸ Raising the head of the bed by about 6 inches using stacked bricks or a wedge.

▸ Avoiding certain foods (fats, caffeine, tomato products, sodas, and so forth).

▸ Avoiding medications (such as calcium channel blockers) that can worsen reflux.

▸ Taking antacids or alginic acid.

▸ Not smoking.

▸ Losing weight if obese.

Dr. Harding also suggested that patients try acid blockers (H₂-receptor antagonists and proton pump inhibitors), prokinetic agents (metoclopramide), continuous positive airway pressure in obstructive sleep apnea patients, and surgical fundoplication.

Some sleep patients should be referred to a gastrointestinal specialist for endoscopic screening, she added. These would include patients with dysphagia; older patients with blood loss, anemia, or weight loss; men over 40 who have frequent reflux episodes; and patients not being treated with a proton pump inhibitor.

“There are a lot of esophageal diseases,” she said. “If your patients are not getting better, refer them.”

Dr. Harding disclosed that she receives grant support from and is a contributor to AstraZeneca LLP, maker of a proton pump inhibitor.

SCOTTSDALE, ARIZ. — Patients with sleep disorders should be screened for gastrointestinal reflux, Dr. Susan M. Harding advised at a meeting on sleep medicine sponsored by the American College of Chest Physicians.

Heartburn is common in patients with sleep complaints and can make their sleep problems worse, according to Dr. Harding, a professor of medicine and medical director of the Sleep/Wake Disorders Center at the University of Alabama, Birmingham.

It has not been shown to cause sleep disorders, or vice versa, she said. Nonetheless, researchers have demonstrated that treating gastrointestinal reflux can improve sleep—and that treating sleep disorders can improve reflux.

In one study cited by Dr. Harding, 62% of obstructive sleep apnea patients had symptoms of nighttime reflux. The patients who were compliant with continuous positive airway pressure therapy reduced their symptoms by 48%. Noncompliant patients had no improvement (Arch. Intern. Med. 2003;163:41–5).

Conversely, Dr. Harding cited a trial that enrolled 650 reflux patients with sleep complaints. Four weeks of treatment with a proton pump inhibitor significantly reduced sleep disturbances and improved sleep quality (Am. J. Gastroenterol. 2005;100:1914–22).

“Nighttime reflux is common in heartburn patients,” she said. “It causes sleep difficulties, and it is inadequately treated.”

Stable sleep protects against reflux, according to Dr. Harding. Esophageal acid take much longer to clear during sleep, and people swallow less often. Acid clearance mostly occurs during arousals.

“Is there an association between sleep-related reflux and obstructive sleep apnea?” she asked rhetorically. “Maybe. Maybe not.”

Despite identifying reflux in many obstructive sleep apnea patients, Dr. Harding noted that studies have failed to find a causal relationship or correlations among reflux scores, apnea severity, and other variables by which the two conditions are measured.

The conditions coexist in many patients, she said, which suggests that the relationship may be complex. “Reflux is not caused by obstructive sleep apnea, but reflux may be facilitated by obstructive sleep apnea,” she said, and called for more studies examining transient lower esophageal sphincter relaxations in obstructive sleep apnea patients.

Reflux should be considered whenever a patient presents with insomnia or excessive daytime sleepiness, according to Dr. Harding. Patients with erosive esophagitis are prone to sleep disturbances, she said, and nocturnal reflux has been shown to trigger respiratory symptoms in asthma patients. Sleep-related laryngospasm also can be triggered by reflux.

Consider doing esophageal pH monitoring along with polysomnography, Dr. Harding advised. If sleep-related reflux is diagnosed, urge patients to make the following lifestyle modifications (Arch. Intern. Med. 2006;166:965–71):

▸ Not eating for 2 hours before bedtime.

▸ Raising the head of the bed by about 6 inches using stacked bricks or a wedge.

▸ Avoiding certain foods (fats, caffeine, tomato products, sodas, and so forth).

▸ Avoiding medications (such as calcium channel blockers) that can worsen reflux.

▸ Taking antacids or alginic acid.

▸ Not smoking.

▸ Losing weight if obese.

Dr. Harding also suggested that patients try acid blockers (H₂-receptor antagonists and proton pump inhibitors), prokinetic agents (metoclopramide), continuous positive airway pressure in obstructive sleep apnea patients, and surgical fundoplication.

Some sleep patients should be referred to a gastrointestinal specialist for endoscopic screening, she added. These would include patients with dysphagia; older patients with blood loss, anemia, or weight loss; men over 40 who have frequent reflux episodes; and patients not being treated with a proton pump inhibitor.

“There are a lot of esophageal diseases,” she said. “If your patients are not getting better, refer them.”

Dr. Harding disclosed that she receives grant support from and is a contributor to AstraZeneca LLP, maker of a proton pump inhibitor.

SCOTTSDALE, ARIZ. — Patients with sleep disorders should be screened for gastrointestinal reflux, Dr. Susan M. Harding advised at a meeting on sleep medicine sponsored by the American College of Chest Physicians.

Heartburn is common in patients with sleep complaints and can make their sleep problems worse, according to Dr. Harding, a professor of medicine and medical director of the Sleep/Wake Disorders Center at the University of Alabama, Birmingham.

It has not been shown to cause sleep disorders, or vice versa, she said. Nonetheless, researchers have demonstrated that treating gastrointestinal reflux can improve sleep—and that treating sleep disorders can improve reflux.

In one study cited by Dr. Harding, 62% of obstructive sleep apnea patients had symptoms of nighttime reflux. The patients who were compliant with continuous positive airway pressure therapy reduced their symptoms by 48%. Noncompliant patients had no improvement (Arch. Intern. Med. 2003;163:41–5).

Conversely, Dr. Harding cited a trial that enrolled 650 reflux patients with sleep complaints. Four weeks of treatment with a proton pump inhibitor significantly reduced sleep disturbances and improved sleep quality (Am. J. Gastroenterol. 2005;100:1914–22).

“Nighttime reflux is common in heartburn patients,” she said. “It causes sleep difficulties, and it is inadequately treated.”

Stable sleep protects against reflux, according to Dr. Harding. Esophageal acid take much longer to clear during sleep, and people swallow less often. Acid clearance mostly occurs during arousals.

“Is there an association between sleep-related reflux and obstructive sleep apnea?” she asked rhetorically. “Maybe. Maybe not.”

Despite identifying reflux in many obstructive sleep apnea patients, Dr. Harding noted that studies have failed to find a causal relationship or correlations among reflux scores, apnea severity, and other variables by which the two conditions are measured.

The conditions coexist in many patients, she said, which suggests that the relationship may be complex. “Reflux is not caused by obstructive sleep apnea, but reflux may be facilitated by obstructive sleep apnea,” she said, and called for more studies examining transient lower esophageal sphincter relaxations in obstructive sleep apnea patients.

Reflux should be considered whenever a patient presents with insomnia or excessive daytime sleepiness, according to Dr. Harding. Patients with erosive esophagitis are prone to sleep disturbances, she said, and nocturnal reflux has been shown to trigger respiratory symptoms in asthma patients. Sleep-related laryngospasm also can be triggered by reflux.

Consider doing esophageal pH monitoring along with polysomnography, Dr. Harding advised. If sleep-related reflux is diagnosed, urge patients to make the following lifestyle modifications (Arch. Intern. Med. 2006;166:965–71):

▸ Not eating for 2 hours before bedtime.

▸ Raising the head of the bed by about 6 inches using stacked bricks or a wedge.

▸ Avoiding certain foods (fats, caffeine, tomato products, sodas, and so forth).

▸ Avoiding medications (such as calcium channel blockers) that can worsen reflux.

▸ Taking antacids or alginic acid.

▸ Not smoking.

▸ Losing weight if obese.

Dr. Harding also suggested that patients try acid blockers (H₂-receptor antagonists and proton pump inhibitors), prokinetic agents (metoclopramide), continuous positive airway pressure in obstructive sleep apnea patients, and surgical fundoplication.

Some sleep patients should be referred to a gastrointestinal specialist for endoscopic screening, she added. These would include patients with dysphagia; older patients with blood loss, anemia, or weight loss; men over 40 who have frequent reflux episodes; and patients not being treated with a proton pump inhibitor.

“There are a lot of esophageal diseases,” she said. “If your patients are not getting better, refer them.”

Dr. Harding disclosed that she receives grant support from and is a contributor to AstraZeneca LLP, maker of a proton pump inhibitor.

SCOTTSDALE, ARIZ. — Automatic devices that adjust continuous positive airway pressure in response to changes in airway resistance or flow are as effective as conventional machines for the treatment of uncomplicated obstructive sleep apnea, Dr. Neil S. Freedman said at a meeting on sleep medicine sponsored by the American College of Chest Physicians.

AutoCPAP (APAP) will never be superior to fixed continuous positive airway pressure (CPAP) as a treatment, but it offers two advantages: faster treatment of apnea, and the potential for lower costs, according to Dr. Freedman, who is with a group practice that specializes in sleep disorders in Bannockburn, Ill., and the sleep center at Lake Forest (Ill.) Hospital.

Citing long waits for sleep studies, he said that he will put a patient on APAP pending a sleep study if the person weighs 300 pounds, snores, has had observed apnea, and is drowsy during the day. In such cases, he said, the sleep study must still be done within 30 days to secure reimbursement and to determine pressures.

Although attended APAP in a sleep laboratory is currently accepted as useful for titrating fixed CPAP pressures in uncomplicated patients, Dr. Freedman said that unattended APAP has not been established as useful for that purpose. Unattended APAP also is not established as a treatment for patients who have never used CPAP, but Dr. Freedman said this may no longer be valid.

He cited a randomized controlled trial in which 360 patients were randomized to standard CPAP, APAP titrated at home, or titration at home by a predicted formula (Am. J. Respir. Crit. Care Med. 2004;170:1218–24). Successful home titration of APAP went from 83% on the first try to 96% on the second try. All groups had equivalent improvements in quality of life, and nearly all patients wanted to continue the treatments to which they had been assigned.

Dr. Freedman listed various monikers for the new technology—automated, auto-titrating, auto-adjusting, and self-titrating—but settled on APAP as a common term. The devices vary considerably in efficacy, he advised, and their role in treating obstructive sleep apnea is not well defined.

“All APAPs are not the same,” he said, warning against generalizing conclusions from clinical studies of any one APAP technology to APAP devices as a class.

He emphasized that the devices use different detection methods, employ different algorithms, and have different response times. Notably, whereas some monitor inspiratory flow, others measure resistance.

“They all respond in different ways,” he said. “Nobody knows what the best algorithm is.”

Among the studies he cited was a benchmark testing of five APAP machines (Eur. Respir. J. 2004;24:649–58). All five suppressed obstructive apnea, but none suppressed flow limitation. The investigators reported considerable variation in residual hypopnea, control of snoring, and response to mask leaks. Four of the machines inappropriately increased pressure in response to central apnea.

Dr. Freedman suggested APAP machines that use a forced oscillation technique (FOT) may be better suited than flow-based APAP for evaluation of central apnea.

“You don't want a machine to make central apnea worse,” he said.

APAP should not be used to treat patients who hyperventilate, have heart failure or COPD/chronic lung disease, or do not snore, according to Dr. Freedman. All these conditions have been excluded from the studies performed so far.

He said the lack of data also makes APAP's efficacy unclear for obstructive sleep apneas that are related to rapid eye movement, are position dependent, involve high pressures, or occur in patients who are intolerant of CPAP.

AutoCPAP will never be superior to fixed CPAP, but it's faster and less expensive. DR. FREEDMAN

SCOTTSDALE, ARIZ. — Automatic devices that adjust continuous positive airway pressure in response to changes in airway resistance or flow are as effective as conventional machines for the treatment of uncomplicated obstructive sleep apnea, Dr. Neil S. Freedman said at a meeting on sleep medicine sponsored by the American College of Chest Physicians.

AutoCPAP (APAP) will never be superior to fixed continuous positive airway pressure (CPAP) as a treatment, but it offers two advantages: faster treatment of apnea, and the potential for lower costs, according to Dr. Freedman, who is with a group practice that specializes in sleep disorders in Bannockburn, Ill., and the sleep center at Lake Forest (Ill.) Hospital.

Citing long waits for sleep studies, he said that he will put a patient on APAP pending a sleep study if the person weighs 300 pounds, snores, has had observed apnea, and is drowsy during the day. In such cases, he said, the sleep study must still be done within 30 days to secure reimbursement and to determine pressures.

Although attended APAP in a sleep laboratory is currently accepted as useful for titrating fixed CPAP pressures in uncomplicated patients, Dr. Freedman said that unattended APAP has not been established as useful for that purpose. Unattended APAP also is not established as a treatment for patients who have never used CPAP, but Dr. Freedman said this may no longer be valid.

He cited a randomized controlled trial in which 360 patients were randomized to standard CPAP, APAP titrated at home, or titration at home by a predicted formula (Am. J. Respir. Crit. Care Med. 2004;170:1218–24). Successful home titration of APAP went from 83% on the first try to 96% on the second try. All groups had equivalent improvements in quality of life, and nearly all patients wanted to continue the treatments to which they had been assigned.

Dr. Freedman listed various monikers for the new technology—automated, auto-titrating, auto-adjusting, and self-titrating—but settled on APAP as a common term. The devices vary considerably in efficacy, he advised, and their role in treating obstructive sleep apnea is not well defined.

“All APAPs are not the same,” he said, warning against generalizing conclusions from clinical studies of any one APAP technology to APAP devices as a class.

He emphasized that the devices use different detection methods, employ different algorithms, and have different response times. Notably, whereas some monitor inspiratory flow, others measure resistance.

“They all respond in different ways,” he said. “Nobody knows what the best algorithm is.”

Among the studies he cited was a benchmark testing of five APAP machines (Eur. Respir. J. 2004;24:649–58). All five suppressed obstructive apnea, but none suppressed flow limitation. The investigators reported considerable variation in residual hypopnea, control of snoring, and response to mask leaks. Four of the machines inappropriately increased pressure in response to central apnea.

Dr. Freedman suggested APAP machines that use a forced oscillation technique (FOT) may be better suited than flow-based APAP for evaluation of central apnea.

“You don't want a machine to make central apnea worse,” he said.

APAP should not be used to treat patients who hyperventilate, have heart failure or COPD/chronic lung disease, or do not snore, according to Dr. Freedman. All these conditions have been excluded from the studies performed so far.

He said the lack of data also makes APAP's efficacy unclear for obstructive sleep apneas that are related to rapid eye movement, are position dependent, involve high pressures, or occur in patients who are intolerant of CPAP.

AutoCPAP will never be superior to fixed CPAP, but it's faster and less expensive. DR. FREEDMAN

SCOTTSDALE, ARIZ. — Automatic devices that adjust continuous positive airway pressure in response to changes in airway resistance or flow are as effective as conventional machines for the treatment of uncomplicated obstructive sleep apnea, Dr. Neil S. Freedman said at a meeting on sleep medicine sponsored by the American College of Chest Physicians.

AutoCPAP (APAP) will never be superior to fixed continuous positive airway pressure (CPAP) as a treatment, but it offers two advantages: faster treatment of apnea, and the potential for lower costs, according to Dr. Freedman, who is with a group practice that specializes in sleep disorders in Bannockburn, Ill., and the sleep center at Lake Forest (Ill.) Hospital.

Citing long waits for sleep studies, he said that he will put a patient on APAP pending a sleep study if the person weighs 300 pounds, snores, has had observed apnea, and is drowsy during the day. In such cases, he said, the sleep study must still be done within 30 days to secure reimbursement and to determine pressures.

Although attended APAP in a sleep laboratory is currently accepted as useful for titrating fixed CPAP pressures in uncomplicated patients, Dr. Freedman said that unattended APAP has not been established as useful for that purpose. Unattended APAP also is not established as a treatment for patients who have never used CPAP, but Dr. Freedman said this may no longer be valid.

He cited a randomized controlled trial in which 360 patients were randomized to standard CPAP, APAP titrated at home, or titration at home by a predicted formula (Am. J. Respir. Crit. Care Med. 2004;170:1218–24). Successful home titration of APAP went from 83% on the first try to 96% on the second try. All groups had equivalent improvements in quality of life, and nearly all patients wanted to continue the treatments to which they had been assigned.

Dr. Freedman listed various monikers for the new technology—automated, auto-titrating, auto-adjusting, and self-titrating—but settled on APAP as a common term. The devices vary considerably in efficacy, he advised, and their role in treating obstructive sleep apnea is not well defined.

“All APAPs are not the same,” he said, warning against generalizing conclusions from clinical studies of any one APAP technology to APAP devices as a class.

He emphasized that the devices use different detection methods, employ different algorithms, and have different response times. Notably, whereas some monitor inspiratory flow, others measure resistance.

“They all respond in different ways,” he said. “Nobody knows what the best algorithm is.”

Among the studies he cited was a benchmark testing of five APAP machines (Eur. Respir. J. 2004;24:649–58). All five suppressed obstructive apnea, but none suppressed flow limitation. The investigators reported considerable variation in residual hypopnea, control of snoring, and response to mask leaks. Four of the machines inappropriately increased pressure in response to central apnea.

Dr. Freedman suggested APAP machines that use a forced oscillation technique (FOT) may be better suited than flow-based APAP for evaluation of central apnea.

“You don't want a machine to make central apnea worse,” he said.

APAP should not be used to treat patients who hyperventilate, have heart failure or COPD/chronic lung disease, or do not snore, according to Dr. Freedman. All these conditions have been excluded from the studies performed so far.

He said the lack of data also makes APAP's efficacy unclear for obstructive sleep apneas that are related to rapid eye movement, are position dependent, involve high pressures, or occur in patients who are intolerant of CPAP.

AutoCPAP will never be superior to fixed CPAP, but it's faster and less expensive. DR. FREEDMAN