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Research and Reviews for the Practicing Oncologist
Docs to Congress: SGR fix can't wait
The American Medical Association, the American College of Family Physicians, the American College of Physicians, the American College of Surgeons, and the American Osteopathic Association together met with more than a dozen lawmakers.
The American Medical Association, the American College of Family Physicians, the American College of Physicians, the American College of Surgeons, and the American Osteopathic Association together met with more than a dozen lawmakers.
The American Medical Association, the American College of Family Physicians, the American College of Physicians, the American College of Surgeons, and the American Osteopathic Association together met with more than a dozen lawmakers.
Challenges in managing a patient with multiple primary malignancies
An 81-year-old African American man presented to the emergency department with right flank pain for 3 days. He had first noticed the pain after lifting a heavy box. He described the pain as sharp, nonradiating, and worsening with movement. He denied nausea, vomiting, diarrhea, fever, chills, cough, abdominal or back pain, dysuria, hematuria, or increased urinary frequency. The differential diagnosis for flank pain is broad. In this case, the pain started after lifting a heavy box, suggestive of musculoskeletal etiology such as muscle strain or rib fracture. Although less likely, both nephrolithiasis with passage of a stone and pyelonephritis must be ruled out. Other genitourinary pathologic processes to be considered would include renal infarct or hemorrhage, ureteral obstruction, and malignancy. The pain may also be of hepatic or biliary origin. Diverticulitis and colitis need to be considered. Finally, the pain may be referred from a pulmonary process such as right lower lobe pneumonia. Further history and a thorough physical exam are needed to narrow down these possibilities...
Click on the PDF icon at the top of this introduction to read the full article.
An 81-year-old African American man presented to the emergency department with right flank pain for 3 days. He had first noticed the pain after lifting a heavy box. He described the pain as sharp, nonradiating, and worsening with movement. He denied nausea, vomiting, diarrhea, fever, chills, cough, abdominal or back pain, dysuria, hematuria, or increased urinary frequency. The differential diagnosis for flank pain is broad. In this case, the pain started after lifting a heavy box, suggestive of musculoskeletal etiology such as muscle strain or rib fracture. Although less likely, both nephrolithiasis with passage of a stone and pyelonephritis must be ruled out. Other genitourinary pathologic processes to be considered would include renal infarct or hemorrhage, ureteral obstruction, and malignancy. The pain may also be of hepatic or biliary origin. Diverticulitis and colitis need to be considered. Finally, the pain may be referred from a pulmonary process such as right lower lobe pneumonia. Further history and a thorough physical exam are needed to narrow down these possibilities...
Click on the PDF icon at the top of this introduction to read the full article.
An 81-year-old African American man presented to the emergency department with right flank pain for 3 days. He had first noticed the pain after lifting a heavy box. He described the pain as sharp, nonradiating, and worsening with movement. He denied nausea, vomiting, diarrhea, fever, chills, cough, abdominal or back pain, dysuria, hematuria, or increased urinary frequency. The differential diagnosis for flank pain is broad. In this case, the pain started after lifting a heavy box, suggestive of musculoskeletal etiology such as muscle strain or rib fracture. Although less likely, both nephrolithiasis with passage of a stone and pyelonephritis must be ruled out. Other genitourinary pathologic processes to be considered would include renal infarct or hemorrhage, ureteral obstruction, and malignancy. The pain may also be of hepatic or biliary origin. Diverticulitis and colitis need to be considered. Finally, the pain may be referred from a pulmonary process such as right lower lobe pneumonia. Further history and a thorough physical exam are needed to narrow down these possibilities...
Click on the PDF icon at the top of this introduction to read the full article.
Thoughts and recommendations on cancer care site of service
Within community practice, we are faced with the dual challenge of providing health care and operating a viable business entity. This problem is not unique to oncology; however, the specialty has been unfairly burdened with preferential payment incentives that favor treatment in hospital outpatient departments (HOPDs) over independent community-based clinics. This trend toward HOPD care has caused a shift in the model of delivery of care and remains a problem for those who practice in community clinics. Furthermore, the shift is driving spending for oncology care higher at a time when payers and patients are contending with rising, unsustainable costs. Providers in individual practices who are focused on the daily responsibilities of caring for cancer patients understandably may find it difficult to keep abreast of national policy changes and understand how those changes might affect their ability to take care of patients. The US Oncology Network and the Community Oncology Alliance (COA) are collaborating to interpret this proposed policy change and to make recommendations for improvement to empower community oncologists to comprehend the impact of this policy and to work toward a better outcome. We will present this proposed policy change in 2 parts: first, an analysis of the impact of current policies on community oncology practice, and second, recommendations for proposed changes to ensure balanced payment amounts for delivery of equivalent services and strategic initiatives for value-based cost reduction.
*For PDFs of the full article and related review of 2012, click on the links to the left of this introduction.
Within community practice, we are faced with the dual challenge of providing health care and operating a viable business entity. This problem is not unique to oncology; however, the specialty has been unfairly burdened with preferential payment incentives that favor treatment in hospital outpatient departments (HOPDs) over independent community-based clinics. This trend toward HOPD care has caused a shift in the model of delivery of care and remains a problem for those who practice in community clinics. Furthermore, the shift is driving spending for oncology care higher at a time when payers and patients are contending with rising, unsustainable costs. Providers in individual practices who are focused on the daily responsibilities of caring for cancer patients understandably may find it difficult to keep abreast of national policy changes and understand how those changes might affect their ability to take care of patients. The US Oncology Network and the Community Oncology Alliance (COA) are collaborating to interpret this proposed policy change and to make recommendations for improvement to empower community oncologists to comprehend the impact of this policy and to work toward a better outcome. We will present this proposed policy change in 2 parts: first, an analysis of the impact of current policies on community oncology practice, and second, recommendations for proposed changes to ensure balanced payment amounts for delivery of equivalent services and strategic initiatives for value-based cost reduction.
*For PDFs of the full article and related review of 2012, click on the links to the left of this introduction.
Within community practice, we are faced with the dual challenge of providing health care and operating a viable business entity. This problem is not unique to oncology; however, the specialty has been unfairly burdened with preferential payment incentives that favor treatment in hospital outpatient departments (HOPDs) over independent community-based clinics. This trend toward HOPD care has caused a shift in the model of delivery of care and remains a problem for those who practice in community clinics. Furthermore, the shift is driving spending for oncology care higher at a time when payers and patients are contending with rising, unsustainable costs. Providers in individual practices who are focused on the daily responsibilities of caring for cancer patients understandably may find it difficult to keep abreast of national policy changes and understand how those changes might affect their ability to take care of patients. The US Oncology Network and the Community Oncology Alliance (COA) are collaborating to interpret this proposed policy change and to make recommendations for improvement to empower community oncologists to comprehend the impact of this policy and to work toward a better outcome. We will present this proposed policy change in 2 parts: first, an analysis of the impact of current policies on community oncology practice, and second, recommendations for proposed changes to ensure balanced payment amounts for delivery of equivalent services and strategic initiatives for value-based cost reduction.
*For PDFs of the full article and related review of 2012, click on the links to the left of this introduction.
BRCA1/2 testing and cancer risk management in underserved women at a public hospital
Background and objective Genetic test uptake and cancer risk management have been understudied in medically underserved populations. Study aims were to quantify rates of BRCA1/2 genetic testing and evidence-based cancer risk management (ie, prophylactic surgeries and surveillance practices) in women who were seen for breast and ovarian cancer genetic counseling in a public, safety net health system.
Methods We conducted a retrospective medical record abstraction of 195 women who presented for breast or ovarian genetic counseling within a 2-year period (2008-2009) at Parkland Health & Hospital System in Dallas, Texas.
Results The identified women represented a racially and ethnically diverse population: 48% Hispanic, 37% non-Hispanic black, 12% non-Hispanic white, and 3% Asian. Among the 158 women who were medically eligible for genetic testing, 134 (84.8%) received BRCA1/2 results, with most tests funded through a financial assistance program. In all, 29 women (22%) tested positive for BRCA1/2 mutations. Financial and funding barriers were identified for 20 of the untested women. Among the identified high-risk women (mutation carriers, selected variants, and noncarriers with pretest BRCAPRO scores 30 or more), 26% had prophylactic breast surgeries and 33% had prophylactic ovarian surgeries within the follow-up period averaging 35 months. Of those who opted for surveillance, 71% had at least 1 mammogram or MRI and 38% had CA-125 tests. Trends indicated lower rates of all risk management behaviors, except for mammogram or MRI, among non-Hispanic black women.
Conclusions Within this racially and ethnically diverse sample, BRCA1/2 test uptake was high, but financial barriers were identified for nontested women. The rates of breast cancer risk management were generally comparable with other studies, but risk management for ovarian cancer was limited, especially among non-Hispanic black women. The reasons for these apparen disparities should be further explored.
Click on the PDF icon at the top of this introduction to read the full article.
Background and objective Genetic test uptake and cancer risk management have been understudied in medically underserved populations. Study aims were to quantify rates of BRCA1/2 genetic testing and evidence-based cancer risk management (ie, prophylactic surgeries and surveillance practices) in women who were seen for breast and ovarian cancer genetic counseling in a public, safety net health system.
Methods We conducted a retrospective medical record abstraction of 195 women who presented for breast or ovarian genetic counseling within a 2-year period (2008-2009) at Parkland Health & Hospital System in Dallas, Texas.
Results The identified women represented a racially and ethnically diverse population: 48% Hispanic, 37% non-Hispanic black, 12% non-Hispanic white, and 3% Asian. Among the 158 women who were medically eligible for genetic testing, 134 (84.8%) received BRCA1/2 results, with most tests funded through a financial assistance program. In all, 29 women (22%) tested positive for BRCA1/2 mutations. Financial and funding barriers were identified for 20 of the untested women. Among the identified high-risk women (mutation carriers, selected variants, and noncarriers with pretest BRCAPRO scores 30 or more), 26% had prophylactic breast surgeries and 33% had prophylactic ovarian surgeries within the follow-up period averaging 35 months. Of those who opted for surveillance, 71% had at least 1 mammogram or MRI and 38% had CA-125 tests. Trends indicated lower rates of all risk management behaviors, except for mammogram or MRI, among non-Hispanic black women.
Conclusions Within this racially and ethnically diverse sample, BRCA1/2 test uptake was high, but financial barriers were identified for nontested women. The rates of breast cancer risk management were generally comparable with other studies, but risk management for ovarian cancer was limited, especially among non-Hispanic black women. The reasons for these apparen disparities should be further explored.
Click on the PDF icon at the top of this introduction to read the full article.
Background and objective Genetic test uptake and cancer risk management have been understudied in medically underserved populations. Study aims were to quantify rates of BRCA1/2 genetic testing and evidence-based cancer risk management (ie, prophylactic surgeries and surveillance practices) in women who were seen for breast and ovarian cancer genetic counseling in a public, safety net health system.
Methods We conducted a retrospective medical record abstraction of 195 women who presented for breast or ovarian genetic counseling within a 2-year period (2008-2009) at Parkland Health & Hospital System in Dallas, Texas.
Results The identified women represented a racially and ethnically diverse population: 48% Hispanic, 37% non-Hispanic black, 12% non-Hispanic white, and 3% Asian. Among the 158 women who were medically eligible for genetic testing, 134 (84.8%) received BRCA1/2 results, with most tests funded through a financial assistance program. In all, 29 women (22%) tested positive for BRCA1/2 mutations. Financial and funding barriers were identified for 20 of the untested women. Among the identified high-risk women (mutation carriers, selected variants, and noncarriers with pretest BRCAPRO scores 30 or more), 26% had prophylactic breast surgeries and 33% had prophylactic ovarian surgeries within the follow-up period averaging 35 months. Of those who opted for surveillance, 71% had at least 1 mammogram or MRI and 38% had CA-125 tests. Trends indicated lower rates of all risk management behaviors, except for mammogram or MRI, among non-Hispanic black women.
Conclusions Within this racially and ethnically diverse sample, BRCA1/2 test uptake was high, but financial barriers were identified for nontested women. The rates of breast cancer risk management were generally comparable with other studies, but risk management for ovarian cancer was limited, especially among non-Hispanic black women. The reasons for these apparen disparities should be further explored.
Click on the PDF icon at the top of this introduction to read the full article.
Community Oncology Podcast - Pazopanib in soft tissue sarcoma
Dr. David Henry's podcast covers highlights of the November issue including pazopanib in soft tissue sarcoma and dasatinib in first-line treatment of chronic myeloid leukemia.
Dr. David Henry's podcast covers highlights of the November issue including pazopanib in soft tissue sarcoma and dasatinib in first-line treatment of chronic myeloid leukemia.
Dr. David Henry's podcast covers highlights of the November issue including pazopanib in soft tissue sarcoma and dasatinib in first-line treatment of chronic myeloid leukemia.
Highlights from ASCO
We caught up with Debra L Barton, PhD, RN at the eighth annual Chicago Supportive Oncology Conference. and asked her what she believed were the highlights from the 2012 American Society of Clinical Oncology annual meeting in the area of patient and survivor care research. Dr Barton is involved in research at the Mayo Clinic centering on symptom management in cancer survivors. See the November/December 2012 issue of The Journal of Supportive Oncology for additional ASCO highlights.
We caught up with Debra L Barton, PhD, RN at the eighth annual Chicago Supportive Oncology Conference. and asked her what she believed were the highlights from the 2012 American Society of Clinical Oncology annual meeting in the area of patient and survivor care research. Dr Barton is involved in research at the Mayo Clinic centering on symptom management in cancer survivors. See the November/December 2012 issue of The Journal of Supportive Oncology for additional ASCO highlights.
We caught up with Debra L Barton, PhD, RN at the eighth annual Chicago Supportive Oncology Conference. and asked her what she believed were the highlights from the 2012 American Society of Clinical Oncology annual meeting in the area of patient and survivor care research. Dr Barton is involved in research at the Mayo Clinic centering on symptom management in cancer survivors. See the November/December 2012 issue of The Journal of Supportive Oncology for additional ASCO highlights.
Tips to Facing Difficult Patient Conversations
At the eighth annual Chicago Supportive Oncology Conference, we spoke with Dr. Anthony Back about talking to patients about the cost of care and whether the costs are worth it. Dr. Back stressed that it is crucial for cost to be a part of the decision making process, and not a separate stand-alone issue. He added that it is the physician who should take the lead in initiating this discussion.
Dr. Back is a professor in the Department of Medicine, Division of Oncology at the University of Washington's School of Medicine and a medical oncologist with the Seattle Cancer Care Alliance in Seattle, Washington.
At the eighth annual Chicago Supportive Oncology Conference, we spoke with Dr. Anthony Back about talking to patients about the cost of care and whether the costs are worth it. Dr. Back stressed that it is crucial for cost to be a part of the decision making process, and not a separate stand-alone issue. He added that it is the physician who should take the lead in initiating this discussion.
Dr. Back is a professor in the Department of Medicine, Division of Oncology at the University of Washington's School of Medicine and a medical oncologist with the Seattle Cancer Care Alliance in Seattle, Washington.
At the eighth annual Chicago Supportive Oncology Conference, we spoke with Dr. Anthony Back about talking to patients about the cost of care and whether the costs are worth it. Dr. Back stressed that it is crucial for cost to be a part of the decision making process, and not a separate stand-alone issue. He added that it is the physician who should take the lead in initiating this discussion.
Dr. Back is a professor in the Department of Medicine, Division of Oncology at the University of Washington's School of Medicine and a medical oncologist with the Seattle Cancer Care Alliance in Seattle, Washington.
Experts: Palliative Care Lowers Costs
It is very common for health care professionals to want to shy away from those difficult conversations with patients when caring for them throughout their cancer treatment.
At the eighth annual Chicago Supportive Oncology Conference, Thomas J. Smith, M.D., Director of Palliative Care for Johns Hopkins Medicine and the Hopkins’ Sidney Kimmel Comprehensive Cancer Center, offered practical insight on the economics of integrating palliative care.
When it comes to discussing patient preferences for end-of-life and treatment decisions, Dr. Smith said: "People do want this information; it won't make [them] depressed; it won’t take away their hope; it won’t make them die sooner. We can give realistic forecasts for survival. It is always culturally appropriate to ask, 'How much do you know about your illness?' "
Is it possible to provide the best in care while "bending the cost curve" by having open and honest discussions with your patients? Absolutely, said Dr. Smith, because "we are asking [them] what is important to them." (See the commentary, "Talking with Patients about Dying,” by Dr. Smith and Dan L. Longo, M.D.; N Engl J Med 2012;367:1651-2.)
It is very common for health care professionals to want to shy away from those difficult conversations with patients when caring for them throughout their cancer treatment.
At the eighth annual Chicago Supportive Oncology Conference, Thomas J. Smith, M.D., Director of Palliative Care for Johns Hopkins Medicine and the Hopkins’ Sidney Kimmel Comprehensive Cancer Center, offered practical insight on the economics of integrating palliative care.
When it comes to discussing patient preferences for end-of-life and treatment decisions, Dr. Smith said: "People do want this information; it won't make [them] depressed; it won’t take away their hope; it won’t make them die sooner. We can give realistic forecasts for survival. It is always culturally appropriate to ask, 'How much do you know about your illness?' "
Is it possible to provide the best in care while "bending the cost curve" by having open and honest discussions with your patients? Absolutely, said Dr. Smith, because "we are asking [them] what is important to them." (See the commentary, "Talking with Patients about Dying,” by Dr. Smith and Dan L. Longo, M.D.; N Engl J Med 2012;367:1651-2.)
It is very common for health care professionals to want to shy away from those difficult conversations with patients when caring for them throughout their cancer treatment.
At the eighth annual Chicago Supportive Oncology Conference, Thomas J. Smith, M.D., Director of Palliative Care for Johns Hopkins Medicine and the Hopkins’ Sidney Kimmel Comprehensive Cancer Center, offered practical insight on the economics of integrating palliative care.
When it comes to discussing patient preferences for end-of-life and treatment decisions, Dr. Smith said: "People do want this information; it won't make [them] depressed; it won’t take away their hope; it won’t make them die sooner. We can give realistic forecasts for survival. It is always culturally appropriate to ask, 'How much do you know about your illness?' "
Is it possible to provide the best in care while "bending the cost curve" by having open and honest discussions with your patients? Absolutely, said Dr. Smith, because "we are asking [them] what is important to them." (See the commentary, "Talking with Patients about Dying,” by Dr. Smith and Dan L. Longo, M.D.; N Engl J Med 2012;367:1651-2.)
Twelve Reasons for Considering Buprenorphine as a Frontline Analgesic in the Management of Pain
Mellar P. Davis, MD, FCCP, FAAHPM
ABSTRACT: Buprenorphine is an opioid that has a complex and unique pharmacology which provides some advantages over other potent mu agonists. We review 12 reasons for considering buprenorphine as a frontline analgesic for moderate to severe pain: (1) Buprenorphine is effective in cancer pain; (2) buprenorphine is effective in treating neuropathic pain; (3) buprenorphine treats a broader array of pain phenotypes than do certain potent mu agonists, is associated with less analgesic tolerance, and can be combined with other mu agonists; (4) buprenorphine produces less constipation than do certain other potent mu agonists, and does not adversely affect the sphincter of Oddi; (5) buprenorphine has a ceiling effect on respiratory depression but not analgesia; (6) buprenorphine causes less cognitive impairment than do certain other opioids; (7) buprenorphine is not immunosuppressive like morphine and fentanyl; (8) buprenorphine does not adversely affect the hypothalamic-pituitary-adrenal axis or cause hypogonadism; (9) buprenorphine does not significantly prolong the QTc interval, and is associated with less sudden death than is methadone; (10) buprenorphine is a safe and effective analgesic for the elderly; (11) buprenorphine is one of the safest opioids to use in patients in renal failure and those on dialysis; and (12) withdrawal symptoms are milder and drug dependence is less with buprenorphine. In light of evidence for efficacy, safety, versatility, and cost, buprenorphine should be considered as a first-line analgesic.
*For a PDF of the full article and a Commentary by Paul Sloan, MD, click on the links to the left of this introduction.
Mellar P. Davis, MD, FCCP, FAAHPM
ABSTRACT: Buprenorphine is an opioid that has a complex and unique pharmacology which provides some advantages over other potent mu agonists. We review 12 reasons for considering buprenorphine as a frontline analgesic for moderate to severe pain: (1) Buprenorphine is effective in cancer pain; (2) buprenorphine is effective in treating neuropathic pain; (3) buprenorphine treats a broader array of pain phenotypes than do certain potent mu agonists, is associated with less analgesic tolerance, and can be combined with other mu agonists; (4) buprenorphine produces less constipation than do certain other potent mu agonists, and does not adversely affect the sphincter of Oddi; (5) buprenorphine has a ceiling effect on respiratory depression but not analgesia; (6) buprenorphine causes less cognitive impairment than do certain other opioids; (7) buprenorphine is not immunosuppressive like morphine and fentanyl; (8) buprenorphine does not adversely affect the hypothalamic-pituitary-adrenal axis or cause hypogonadism; (9) buprenorphine does not significantly prolong the QTc interval, and is associated with less sudden death than is methadone; (10) buprenorphine is a safe and effective analgesic for the elderly; (11) buprenorphine is one of the safest opioids to use in patients in renal failure and those on dialysis; and (12) withdrawal symptoms are milder and drug dependence is less with buprenorphine. In light of evidence for efficacy, safety, versatility, and cost, buprenorphine should be considered as a first-line analgesic.
*For a PDF of the full article and a Commentary by Paul Sloan, MD, click on the links to the left of this introduction.
Mellar P. Davis, MD, FCCP, FAAHPM
ABSTRACT: Buprenorphine is an opioid that has a complex and unique pharmacology which provides some advantages over other potent mu agonists. We review 12 reasons for considering buprenorphine as a frontline analgesic for moderate to severe pain: (1) Buprenorphine is effective in cancer pain; (2) buprenorphine is effective in treating neuropathic pain; (3) buprenorphine treats a broader array of pain phenotypes than do certain potent mu agonists, is associated with less analgesic tolerance, and can be combined with other mu agonists; (4) buprenorphine produces less constipation than do certain other potent mu agonists, and does not adversely affect the sphincter of Oddi; (5) buprenorphine has a ceiling effect on respiratory depression but not analgesia; (6) buprenorphine causes less cognitive impairment than do certain other opioids; (7) buprenorphine is not immunosuppressive like morphine and fentanyl; (8) buprenorphine does not adversely affect the hypothalamic-pituitary-adrenal axis or cause hypogonadism; (9) buprenorphine does not significantly prolong the QTc interval, and is associated with less sudden death than is methadone; (10) buprenorphine is a safe and effective analgesic for the elderly; (11) buprenorphine is one of the safest opioids to use in patients in renal failure and those on dialysis; and (12) withdrawal symptoms are milder and drug dependence is less with buprenorphine. In light of evidence for efficacy, safety, versatility, and cost, buprenorphine should be considered as a first-line analgesic.
*For a PDF of the full article and a Commentary by Paul Sloan, MD, click on the links to the left of this introduction.
Highlights from the 2012 Annual Meeting of the American Society of Clinical Oncology
Highlights from the 2012 Annual Meeting of the American Society of Clinical Oncology 48th Annual Meeting
*For a PDF of the full article, click on the link to the left of this introduction.
Highlights from the 2012 Annual Meeting of the American Society of Clinical Oncology 48th Annual Meeting
*For a PDF of the full article, click on the link to the left of this introduction.
Highlights from the 2012 Annual Meeting of the American Society of Clinical Oncology 48th Annual Meeting
*For a PDF of the full article, click on the link to the left of this introduction.