BOSTON – In women with in-breast failures following breast-conserving surgery and whole-breast irradiation, partial-breast irradiation with 3D conformal radiation appears to be an effective and safe alternative to mastectomy, results of a phase II trial indicate.

At a median follow-up of 3.6 years, there were only two ipsilateral breast recurrences, and four mastectomies required among 58 women treated with partial-breast irradiation after a second lumpectomy, reported Douglas W. Arthur, MD, chair of radiation oncology at Virginia Commonwealth University in Richmond.

Neil Osterweil/Frontline Medical News

[email protected]

BOSTON – In women with in-breast failures following breast-conserving surgery and whole-breast irradiation, partial-breast irradiation with 3D conformal radiation appears to be an effective and safe alternative to mastectomy, results of a phase II trial indicate.

At a median follow-up of 3.6 years, there were only two ipsilateral breast recurrences, and four mastectomies required among 58 women treated with partial-breast irradiation after a second lumpectomy, reported Douglas W. Arthur, MD, chair of radiation oncology at Virginia Commonwealth University in Richmond.

Neil Osterweil/Frontline Medical News

[email protected]

BOSTON – In women with in-breast failures following breast-conserving surgery and whole-breast irradiation, partial-breast irradiation with 3D conformal radiation appears to be an effective and safe alternative to mastectomy, results of a phase II trial indicate.

At a median follow-up of 3.6 years, there were only two ipsilateral breast recurrences, and four mastectomies required among 58 women treated with partial-breast irradiation after a second lumpectomy, reported Douglas W. Arthur, MD, chair of radiation oncology at Virginia Commonwealth University in Richmond.

Neil Osterweil/Frontline Medical News

[email protected]

WASHINGTON – Fear over how Medicare officials will operationalize the Medicare Access and CHIP Reauthorization Act – known as MACRA – should not be driving physicians in small and solo practices to become employees of large systems, a top federal health official said.

“If people want to sell their practices and they want to [be a] part of integrated care models for other reasons, that’s fine,” Andy Slavitt, acting administrator of the Centers for Medicare & Medicaid Services said during an Oct. 6 event hosted by the Association of Health Care Journalists. “I think we have to make a really big effort though to make sure that they are not being driven there because the world’s getting too complicated ... and they throw up their hands.”

[email protected]

WASHINGTON – Fear over how Medicare officials will operationalize the Medicare Access and CHIP Reauthorization Act – known as MACRA – should not be driving physicians in small and solo practices to become employees of large systems, a top federal health official said.

“If people want to sell their practices and they want to [be a] part of integrated care models for other reasons, that’s fine,” Andy Slavitt, acting administrator of the Centers for Medicare & Medicaid Services said during an Oct. 6 event hosted by the Association of Health Care Journalists. “I think we have to make a really big effort though to make sure that they are not being driven there because the world’s getting too complicated ... and they throw up their hands.”

[email protected]

WASHINGTON – Fear over how Medicare officials will operationalize the Medicare Access and CHIP Reauthorization Act – known as MACRA – should not be driving physicians in small and solo practices to become employees of large systems, a top federal health official said.

“If people want to sell their practices and they want to [be a] part of integrated care models for other reasons, that’s fine,” Andy Slavitt, acting administrator of the Centers for Medicare & Medicaid Services said during an Oct. 6 event hosted by the Association of Health Care Journalists. “I think we have to make a really big effort though to make sure that they are not being driven there because the world’s getting too complicated ... and they throw up their hands.”

[email protected]

Levosimendan does not reduce the likelihood of severe organ dysfunction in adults with sepsis, nor does it lower the mortality rate, according to research presented at the annual congress of the European Society of Intensive Care Medicine and published in the New England Journal of Medicine.

Levosimendan is a calcium-sensitizing drug with inotropic and vasodilatory properties, which is commonly used to treat decompensated heart failure. “Small studies that have investigated the use of levosimendan in patients with septic shock have shown improvements in hemodynamic variables, microcirculatory flow, and renal and hepatic function, as compared with dobutamine,” wrote Anthony C. Gordon, MD, of Imperial College London and Imperial College Healthcare NHS Trust and his coauthors.

©invisioner/thinkstockphotos.com

Levosimendan does not reduce the likelihood of severe organ dysfunction in adults with sepsis, nor does it lower the mortality rate, according to research presented at the annual congress of the European Society of Intensive Care Medicine and published in the New England Journal of Medicine.

Levosimendan is a calcium-sensitizing drug with inotropic and vasodilatory properties, which is commonly used to treat decompensated heart failure. “Small studies that have investigated the use of levosimendan in patients with septic shock have shown improvements in hemodynamic variables, microcirculatory flow, and renal and hepatic function, as compared with dobutamine,” wrote Anthony C. Gordon, MD, of Imperial College London and Imperial College Healthcare NHS Trust and his coauthors.

©invisioner/thinkstockphotos.com

Levosimendan does not reduce the likelihood of severe organ dysfunction in adults with sepsis, nor does it lower the mortality rate, according to research presented at the annual congress of the European Society of Intensive Care Medicine and published in the New England Journal of Medicine.

Levosimendan is a calcium-sensitizing drug with inotropic and vasodilatory properties, which is commonly used to treat decompensated heart failure. “Small studies that have investigated the use of levosimendan in patients with septic shock have shown improvements in hemodynamic variables, microcirculatory flow, and renal and hepatic function, as compared with dobutamine,” wrote Anthony C. Gordon, MD, of Imperial College London and Imperial College Healthcare NHS Trust and his coauthors.

©invisioner/thinkstockphotos.com

DENVER – Patients often do not cough hard enough during the cough stress test for it to identify urinary incontinence, Sudhi Trye, MD, reported at Pelvic Floor Disorders Week, sponsored by the American Urogynecologic Society.

“Based on our findings, 95% of patients with stress urinary incontinence will be missed on testing if abdominal pressure does not exceed 70 cm of water on the cough stress test,” said Dr. Trye, who is at Northwell Health, New Hyde Park, N.Y. In order to minimize false negatives, urodynamic operators should encourage patients to cough hard enough to exceed about 120-127 cm H₂O in abdominal pressure, she said.

Amy Karon/Frontline Medical News

DENVER – Patients often do not cough hard enough during the cough stress test for it to identify urinary incontinence, Sudhi Trye, MD, reported at Pelvic Floor Disorders Week, sponsored by the American Urogynecologic Society.

“Based on our findings, 95% of patients with stress urinary incontinence will be missed on testing if abdominal pressure does not exceed 70 cm of water on the cough stress test,” said Dr. Trye, who is at Northwell Health, New Hyde Park, N.Y. In order to minimize false negatives, urodynamic operators should encourage patients to cough hard enough to exceed about 120-127 cm H₂O in abdominal pressure, she said.

Amy Karon/Frontline Medical News

DENVER – Patients often do not cough hard enough during the cough stress test for it to identify urinary incontinence, Sudhi Trye, MD, reported at Pelvic Floor Disorders Week, sponsored by the American Urogynecologic Society.

“Based on our findings, 95% of patients with stress urinary incontinence will be missed on testing if abdominal pressure does not exceed 70 cm of water on the cough stress test,” said Dr. Trye, who is at Northwell Health, New Hyde Park, N.Y. In order to minimize false negatives, urodynamic operators should encourage patients to cough hard enough to exceed about 120-127 cm H₂O in abdominal pressure, she said.

Amy Karon/Frontline Medical News

This month, The Hospitalist spotlights G. Randy Smith Jr., MD, MS, SFHM, assistant professor in the Division of Hospital Medicine at the Northwestern University Feinberg School of Medicine and medical director of Unit 16 West at Northwestern Memorial Hospital in Chicago. Dr. Smith is an active member of SHM’s Practice Analysis Committee and a Leadership Academy veteran who has translated his learnings into more efficient rounding and patient-flow methodology.

Question: What inspired you to begin working in hospital medicine and later join SHM?

Answer: Interest in taking care of acutely ill patients inspired me to start working in hospital medicine. Evolution of this interest into care-delivery design inspired me to remain in hospital medicine. Joining SHM enabled me to make contacts nationally with people who share similar interests and engage in collaboration, which has been helpful for my growth as a physician.

Q: How has SHM provided you with resources to improve patient care during your time as a member?

A: The SHM annual meetings have provided a consistent framework for dissemination of clinically relevant innovations and discoveries. Each year I’ve attended, I’ve always learned something new from both the posters on display and from a quality improvement presentation. Last year at Hospital Medicine 2016, the HEADS-UP plenary abstract presentation was one very good example of a different approach to interdisciplinary rounding that I would not have been aware of without attending the SHM annual meeting.

Q: How did attending Leadership Academy help you grow to reach your medical director position at Northwestern Memorial?

A: Leadership Academy helped to open my mind to principles of negotiation and expectation management as well as self-awareness, which are not usually presented in medical school or residency. Many of the skills taught can be learned the hard way through the trials of life, but the Leadership Academy accelerated my real-world learning.

My hospital’s leadership recognized the skills I developed with the assistance of Leadership Academy, which helped me to maintain my effectiveness in my medical director role.

Skills obtained in the Leadership Academy helped me to incorporate ward-based afternoon throughput meetings into a hospital-wide patient-flow management network. I also learned to successfully negotiate procurement of chairs for our physicians to sit at the patient’s bedside in the hopes of improving patient satisfaction.

Q: How has your work on the Practice Analysis Committee impacted how you manage your hospital medicine teams?

A: My involvement in the Practice Analysis Committee is yet another example of an opportunity provided by SHM to develop a skills set I would not otherwise have the opportunity to develop. Working on the State of Hospital Medicine survey involves prioritizing information with the burden of the respondents’ time and effort in mind. Sensitivities to stakeholder interest play a major role as well.

Achieving balance between aspiring definitions of concepts to help drive the field and working definitions used heterogeneously throughout the country represents the hardest task of the committee members to sort; I’m very privileged to take the lessons learned through member dialogue and help colleagues apply the lessons locally.

Q: Hospital medicine is celebrating its 20th anniversary this year. How do you see the role of hospitalists evolving over the next 20 years?

A: Change has been a constant in hospital medicine since I began in 2004 and will continue to remain so. Because of the financial and documentary pressures placed on hospitals and physicians, hospital medicine finds itself in a state of flux at the moment. I believe these pressures will drive the 7-on/7-off hospitalist direct-care model as it exists today to evolve into something else. In particular, hospitalist groups, which engage solely in documentation and “decision in name” only and devolve all clinical decision making to another set of physicians in the hospital, are especially nonviable over the long term. I think many hospital administrators believe this as well. Hospital medicine must show value, including in the realm of direct clinical care.

One possibility is that we evolve into a “supervisor” model, where a program is composed of a few experienced hospitalists supervising numerous physician extenders, who in turn rely on multidisciplinary teams in the hospital for clinical decision-making input. Hospitalist physicians will slightly move away from direct clinical decision making in such a model.

Another possibility involves evolution of information support systems to a point where teams of providers organized around a single medical problem, e.g., congestive heart failure, can be replaced, leaving the hospitalist to make patient-centered clinical decisions with updated multidisciplinary input available electronically.

With information systems that provide equal access to evidence-driven guidance for optimal clinical practice, hospitalists will outperform subspecialists at the bedside on patient-centeredness, cost, and availability.

Regardless of how inpatient care evolves, hospital medicine will undoubtedly be at the epicenter of change for years to come. TH

This month, The Hospitalist spotlights G. Randy Smith Jr., MD, MS, SFHM, assistant professor in the Division of Hospital Medicine at the Northwestern University Feinberg School of Medicine and medical director of Unit 16 West at Northwestern Memorial Hospital in Chicago. Dr. Smith is an active member of SHM’s Practice Analysis Committee and a Leadership Academy veteran who has translated his learnings into more efficient rounding and patient-flow methodology.

Question: What inspired you to begin working in hospital medicine and later join SHM?

Answer: Interest in taking care of acutely ill patients inspired me to start working in hospital medicine. Evolution of this interest into care-delivery design inspired me to remain in hospital medicine. Joining SHM enabled me to make contacts nationally with people who share similar interests and engage in collaboration, which has been helpful for my growth as a physician.

Q: How has SHM provided you with resources to improve patient care during your time as a member?

A: The SHM annual meetings have provided a consistent framework for dissemination of clinically relevant innovations and discoveries. Each year I’ve attended, I’ve always learned something new from both the posters on display and from a quality improvement presentation. Last year at Hospital Medicine 2016, the HEADS-UP plenary abstract presentation was one very good example of a different approach to interdisciplinary rounding that I would not have been aware of without attending the SHM annual meeting.

Q: How did attending Leadership Academy help you grow to reach your medical director position at Northwestern Memorial?

A: Leadership Academy helped to open my mind to principles of negotiation and expectation management as well as self-awareness, which are not usually presented in medical school or residency. Many of the skills taught can be learned the hard way through the trials of life, but the Leadership Academy accelerated my real-world learning.

My hospital’s leadership recognized the skills I developed with the assistance of Leadership Academy, which helped me to maintain my effectiveness in my medical director role.

Skills obtained in the Leadership Academy helped me to incorporate ward-based afternoon throughput meetings into a hospital-wide patient-flow management network. I also learned to successfully negotiate procurement of chairs for our physicians to sit at the patient’s bedside in the hopes of improving patient satisfaction.

Q: How has your work on the Practice Analysis Committee impacted how you manage your hospital medicine teams?

A: My involvement in the Practice Analysis Committee is yet another example of an opportunity provided by SHM to develop a skills set I would not otherwise have the opportunity to develop. Working on the State of Hospital Medicine survey involves prioritizing information with the burden of the respondents’ time and effort in mind. Sensitivities to stakeholder interest play a major role as well.

Achieving balance between aspiring definitions of concepts to help drive the field and working definitions used heterogeneously throughout the country represents the hardest task of the committee members to sort; I’m very privileged to take the lessons learned through member dialogue and help colleagues apply the lessons locally.

Q: Hospital medicine is celebrating its 20th anniversary this year. How do you see the role of hospitalists evolving over the next 20 years?

A: Change has been a constant in hospital medicine since I began in 2004 and will continue to remain so. Because of the financial and documentary pressures placed on hospitals and physicians, hospital medicine finds itself in a state of flux at the moment. I believe these pressures will drive the 7-on/7-off hospitalist direct-care model as it exists today to evolve into something else. In particular, hospitalist groups, which engage solely in documentation and “decision in name” only and devolve all clinical decision making to another set of physicians in the hospital, are especially nonviable over the long term. I think many hospital administrators believe this as well. Hospital medicine must show value, including in the realm of direct clinical care.

One possibility is that we evolve into a “supervisor” model, where a program is composed of a few experienced hospitalists supervising numerous physician extenders, who in turn rely on multidisciplinary teams in the hospital for clinical decision-making input. Hospitalist physicians will slightly move away from direct clinical decision making in such a model.

Another possibility involves evolution of information support systems to a point where teams of providers organized around a single medical problem, e.g., congestive heart failure, can be replaced, leaving the hospitalist to make patient-centered clinical decisions with updated multidisciplinary input available electronically.

With information systems that provide equal access to evidence-driven guidance for optimal clinical practice, hospitalists will outperform subspecialists at the bedside on patient-centeredness, cost, and availability.

Regardless of how inpatient care evolves, hospital medicine will undoubtedly be at the epicenter of change for years to come. TH

This month, The Hospitalist spotlights G. Randy Smith Jr., MD, MS, SFHM, assistant professor in the Division of Hospital Medicine at the Northwestern University Feinberg School of Medicine and medical director of Unit 16 West at Northwestern Memorial Hospital in Chicago. Dr. Smith is an active member of SHM’s Practice Analysis Committee and a Leadership Academy veteran who has translated his learnings into more efficient rounding and patient-flow methodology.

Question: What inspired you to begin working in hospital medicine and later join SHM?

Answer: Interest in taking care of acutely ill patients inspired me to start working in hospital medicine. Evolution of this interest into care-delivery design inspired me to remain in hospital medicine. Joining SHM enabled me to make contacts nationally with people who share similar interests and engage in collaboration, which has been helpful for my growth as a physician.

Q: How has SHM provided you with resources to improve patient care during your time as a member?

A: The SHM annual meetings have provided a consistent framework for dissemination of clinically relevant innovations and discoveries. Each year I’ve attended, I’ve always learned something new from both the posters on display and from a quality improvement presentation. Last year at Hospital Medicine 2016, the HEADS-UP plenary abstract presentation was one very good example of a different approach to interdisciplinary rounding that I would not have been aware of without attending the SHM annual meeting.

Q: How did attending Leadership Academy help you grow to reach your medical director position at Northwestern Memorial?

A: Leadership Academy helped to open my mind to principles of negotiation and expectation management as well as self-awareness, which are not usually presented in medical school or residency. Many of the skills taught can be learned the hard way through the trials of life, but the Leadership Academy accelerated my real-world learning.

My hospital’s leadership recognized the skills I developed with the assistance of Leadership Academy, which helped me to maintain my effectiveness in my medical director role.

Skills obtained in the Leadership Academy helped me to incorporate ward-based afternoon throughput meetings into a hospital-wide patient-flow management network. I also learned to successfully negotiate procurement of chairs for our physicians to sit at the patient’s bedside in the hopes of improving patient satisfaction.

Q: How has your work on the Practice Analysis Committee impacted how you manage your hospital medicine teams?

A: My involvement in the Practice Analysis Committee is yet another example of an opportunity provided by SHM to develop a skills set I would not otherwise have the opportunity to develop. Working on the State of Hospital Medicine survey involves prioritizing information with the burden of the respondents’ time and effort in mind. Sensitivities to stakeholder interest play a major role as well.

Achieving balance between aspiring definitions of concepts to help drive the field and working definitions used heterogeneously throughout the country represents the hardest task of the committee members to sort; I’m very privileged to take the lessons learned through member dialogue and help colleagues apply the lessons locally.

Q: Hospital medicine is celebrating its 20th anniversary this year. How do you see the role of hospitalists evolving over the next 20 years?

A: Change has been a constant in hospital medicine since I began in 2004 and will continue to remain so. Because of the financial and documentary pressures placed on hospitals and physicians, hospital medicine finds itself in a state of flux at the moment. I believe these pressures will drive the 7-on/7-off hospitalist direct-care model as it exists today to evolve into something else. In particular, hospitalist groups, which engage solely in documentation and “decision in name” only and devolve all clinical decision making to another set of physicians in the hospital, are especially nonviable over the long term. I think many hospital administrators believe this as well. Hospital medicine must show value, including in the realm of direct clinical care.

One possibility is that we evolve into a “supervisor” model, where a program is composed of a few experienced hospitalists supervising numerous physician extenders, who in turn rely on multidisciplinary teams in the hospital for clinical decision-making input. Hospitalist physicians will slightly move away from direct clinical decision making in such a model.

Another possibility involves evolution of information support systems to a point where teams of providers organized around a single medical problem, e.g., congestive heart failure, can be replaced, leaving the hospitalist to make patient-centered clinical decisions with updated multidisciplinary input available electronically.

With information systems that provide equal access to evidence-driven guidance for optimal clinical practice, hospitalists will outperform subspecialists at the bedside on patient-centeredness, cost, and availability.

Regardless of how inpatient care evolves, hospital medicine will undoubtedly be at the epicenter of change for years to come. TH

Ruben Mesa, MD
© ASCO/Zach Boyden-Holmes

NEW YORK—The 11th NCCN Congress: Hematologic Malignancies coincided with the release of the inaugural edition of the NCCN treatment guideline on myeloproliferative neoplasms (MPNs), and Ruben A. Mesa, MD, took the opportunity to discuss the framework of the document and the evolving management of MPNs.

Dr Mesa, of the Mayo Clinic Cancer Center in Arizona, is the chair of the MPN guideline committee.

This initial version of the guideline focuses on the workup and diagnosis of primary myelofibrosis (MF), post-polycythemia vera MF, and post-essential thrombocythemia MF, and treatment guidelines for MF. 

The committee decided to first tackle the treatment guidelines in MF because, as Dr Mesa explained, MF is “the most severe of the MPNs with the most unmet needs in terms of guidance.”

Treatment guidelines for polycythemia vera (PV) and essential thrombocythemia (ET) will be forthcoming in 2017, he said, as well as diagnosis and treatment of atypical MPNs, such as hypereosinophilic syndrome and systemic mast cell disease.

Workup of an MPN

The guideline committee focused on information regarding diagnosis—the time and place to consider bone marrow biopsies, when to use cytogenetics, and when to perform next-generation sequencing. 

They stressed the importance of quantifying disease burden and utilizing the now-validated symptom assessment tools, particularly in MF.

“Finally, we leveraged the many prognostic scoring systems that have been developed for these diseases, particularly IPSS for myelofibrosis at diagnosis or the DIPSS and DIPSS-plus at subsequent time points,” Dr Mesa said. 

In addition to clinical-based prognostic scoring systems, information regarding molecular features and their impact is evolving, he said. 

The guideline provides a table of mutations with prognostic significance.  JAK2, MPL, or CALR mutations are “brighter mutations,” he said, while adverse prognostic markers include ASXL1, EZH2, IDH1/2, SRSF2, and TP53. 

“All of these have some significant prognostic implications in primary myelofibrosis, specifically,” he said.

Assessing MPN burden

“When treating these patients, it’s important to be mindful of the overall burden of the disease,” Dr Mesa said.

He called this emphasis on disease burden “an evolution from the past, where therapy was either supportive or primarily focused on prevention of thrombosis with ET or PV.” 

Practitioners need to be additionally mindful of the risk of vascular events, progression, the impact of cytopenias, splenomegaly, the burden of symptoms, and the baseline degree of comorbidities.

“[W]e encourage the use of validated symptom tools that have been used now in the majority of clinical trials in this setting,” Dr Mesa added.  

The MPN-10 assessment tool, included in the guideline, evaluates 10 symptoms—early satiety, abdominal discomfort, inactivity, problems concentrating, numbness/tingling, night sweats, itching, bone pain, fever, and unintentional weight loss—on a scale of 0 to 10. 

Patients with MF are the most symptomatic, Dr Mesa commented, although “it is notable how frequent symptoms are present in patients with PV and ET.”

Response criteria

For a complete response, individuals must have marked improvement to near normalization in both bone marrow and peripheral blood in addition to resolution of their disease symptoms. 

Partial response is basically “just shy” of the complete response level, Dr Mesa said, with bone marrow resolution not being required. 

The guideline also outlines response criteria for progressive, stable, and relapsed disease, clinical improvement, and anemia, spleen, and symptom response. 

“But I’ll highlight that the majority of the responses that are received currently with medical therapy are in the area of clinical improvement,” Dr Mesa said.

Treatment guidance

Specific treatment guidelines for low-risk, intermediate-1 risk, intermediate-2- or high-risk MF from the new guideline have been described in an earlier article and will not be discussed here. 

Of note, however, Dr Mesa explained that ruxolitinib is a very important part of the treatment guideline because it is the only therapy approved by the US Food and Drug Administration (FDA) to treat MF.

“Over time, it’s been shown that there is an improvement in survival [with ruxolitinib],” Dr Mesa said, perhaps because of a decrease with treatment in the morbidity and the debilitation of patients. 

Investigators presented the 5-year update of this information at ASCO 2016 and reported that patients maintained reduction in splenomegaly up through 5 years, both in those randomized to ruxolitinib and those crossing over from placebo. 

“Long-term, we clearly looked to see whether there was a signal of new onset or late onset toxicities,” Dr Mesa said, which largely was not the case. "Toxicities have been well described in earlier studies, primarily around anemia, thrombocytopenia, and mild constitutional symptoms.” 

However, long-term therapy increases the rate of development of shingles and non-melanoma skin cancer. Rates of transformation to acute myeloid leukemia were consistent with those published for similar patient populations with MF.

“If I see a patient stable on ruxolitinib who has a marked drop in their counts later on in the course of their disease,” Dr Mesa added, “I’m certainly suspicious of progression.”

He also works them up for other causes of anemia if it evolves out of the blue. 

Support in MF-related anemia

“With anemia, we’re mindful of iron stores, EPO level, and being certain there’s not the presence of hemolysis or other contributors,” Dr Mesa said. 

The guideline recommends stratifying patients based on serum EPO levels—those with less than 500 mU/mL and those with 500 mU/mL and higher. 

“If we lower the EPO level, the greater the likelihood of response,” Dr Mesa said. “In my experience, the lower the transfusion burden, the greater the likelihood of response.”

Other than erythropoiesis-stimulating agents for individuals with lower serum levels, androgens and immunomodulatory drugs for those with higher levels have some benefit.

But “they all have their limitations,” Dr Mesa said, and “they tend to range in benefit from 20% to 30%.”

The future 

Dr Mesa discussed a few agents in the pipeline that “might impact these guidelines,” such as the JAK2/FLT3 inhibitor pacritinib and the JAK1/JAK2 inhibitor momelotinib.

Pacritinib had a positive phase 3 study, but the mortality rate was higher than expected, and it was put on an FDA hold. 

Data from a second phase 3 study (PERSIST-1) will be reviewed in the aggregate to evaluate the benefit of pacritinib and whether the mortality rate was associated with drug-related side effects or adverse patient selection, “which we suspect might be the case,” Dr Mesa said. 

“This agent may come off hold, depending upon the data of that second phase 3 study,” he added.

Momelotinib is also in an advanced phase 3 program with 2 trials underway. Both trials have completed accrual. 

One is an upfront study of momelotinib versus ruxolitinib (NCT01969838). The goal is to reduce anemia without inferiority of splenomegaly and MPN symptoms.

The other phase 3 momelotinib trial is a second-line study versus best alternative therapy, including ruxoltinib (NCT02101268).

Combination studies are ongoing with a ruxolitinib base and a variety of secondary agents, including danazol, pomalidomide, PEG IFN α2a, 5-AZA, panobinostat, BKM-120, and LDE-225. All agents appear to achieve improvement in splenomegaly and symptoms. 

But  “incremental benefit over ruxolitinib alone is not yet clear,” Dr Mesa said. “I would say there’s not yet a recommended off-label combination which is widely being used.”

Dr Mesa also highlighted PRM-151, an antifibrosing drug that had a favorable early stage study with several doses, and the telomerase inhibitor imetelstat, which had a deep set of molecular responses in about a third of patients with MF. Imetelstat is currently being evaluated in the second-line setting (NCT02426086). 

Regarding the possible positioning of new therapies, Dr Mesa believes “momelotinib and pacritinib may play a role in front-line, depending on the final data from those studies.” 

“In second-line for MF—this is where most of the activity is in the trials,” he said. “Momelotinib, pacritinib, PRM-151, and imetelstat have possibilities.”

Ruben Mesa, MD
© ASCO/Zach Boyden-Holmes

NEW YORK—The 11th NCCN Congress: Hematologic Malignancies coincided with the release of the inaugural edition of the NCCN treatment guideline on myeloproliferative neoplasms (MPNs), and Ruben A. Mesa, MD, took the opportunity to discuss the framework of the document and the evolving management of MPNs.

Dr Mesa, of the Mayo Clinic Cancer Center in Arizona, is the chair of the MPN guideline committee.

This initial version of the guideline focuses on the workup and diagnosis of primary myelofibrosis (MF), post-polycythemia vera MF, and post-essential thrombocythemia MF, and treatment guidelines for MF. 

The committee decided to first tackle the treatment guidelines in MF because, as Dr Mesa explained, MF is “the most severe of the MPNs with the most unmet needs in terms of guidance.”

Treatment guidelines for polycythemia vera (PV) and essential thrombocythemia (ET) will be forthcoming in 2017, he said, as well as diagnosis and treatment of atypical MPNs, such as hypereosinophilic syndrome and systemic mast cell disease.

Workup of an MPN

The guideline committee focused on information regarding diagnosis—the time and place to consider bone marrow biopsies, when to use cytogenetics, and when to perform next-generation sequencing. 

They stressed the importance of quantifying disease burden and utilizing the now-validated symptom assessment tools, particularly in MF.

“Finally, we leveraged the many prognostic scoring systems that have been developed for these diseases, particularly IPSS for myelofibrosis at diagnosis or the DIPSS and DIPSS-plus at subsequent time points,” Dr Mesa said. 

In addition to clinical-based prognostic scoring systems, information regarding molecular features and their impact is evolving, he said. 

The guideline provides a table of mutations with prognostic significance.  JAK2, MPL, or CALR mutations are “brighter mutations,” he said, while adverse prognostic markers include ASXL1, EZH2, IDH1/2, SRSF2, and TP53. 

“All of these have some significant prognostic implications in primary myelofibrosis, specifically,” he said.

Assessing MPN burden

“When treating these patients, it’s important to be mindful of the overall burden of the disease,” Dr Mesa said.

He called this emphasis on disease burden “an evolution from the past, where therapy was either supportive or primarily focused on prevention of thrombosis with ET or PV.” 

Practitioners need to be additionally mindful of the risk of vascular events, progression, the impact of cytopenias, splenomegaly, the burden of symptoms, and the baseline degree of comorbidities.

“[W]e encourage the use of validated symptom tools that have been used now in the majority of clinical trials in this setting,” Dr Mesa added.  

The MPN-10 assessment tool, included in the guideline, evaluates 10 symptoms—early satiety, abdominal discomfort, inactivity, problems concentrating, numbness/tingling, night sweats, itching, bone pain, fever, and unintentional weight loss—on a scale of 0 to 10. 

Patients with MF are the most symptomatic, Dr Mesa commented, although “it is notable how frequent symptoms are present in patients with PV and ET.”

Response criteria

For a complete response, individuals must have marked improvement to near normalization in both bone marrow and peripheral blood in addition to resolution of their disease symptoms. 

Partial response is basically “just shy” of the complete response level, Dr Mesa said, with bone marrow resolution not being required. 

The guideline also outlines response criteria for progressive, stable, and relapsed disease, clinical improvement, and anemia, spleen, and symptom response. 

“But I’ll highlight that the majority of the responses that are received currently with medical therapy are in the area of clinical improvement,” Dr Mesa said.

Treatment guidance

Specific treatment guidelines for low-risk, intermediate-1 risk, intermediate-2- or high-risk MF from the new guideline have been described in an earlier article and will not be discussed here. 

Of note, however, Dr Mesa explained that ruxolitinib is a very important part of the treatment guideline because it is the only therapy approved by the US Food and Drug Administration (FDA) to treat MF.

“Over time, it’s been shown that there is an improvement in survival [with ruxolitinib],” Dr Mesa said, perhaps because of a decrease with treatment in the morbidity and the debilitation of patients. 

Investigators presented the 5-year update of this information at ASCO 2016 and reported that patients maintained reduction in splenomegaly up through 5 years, both in those randomized to ruxolitinib and those crossing over from placebo. 

“Long-term, we clearly looked to see whether there was a signal of new onset or late onset toxicities,” Dr Mesa said, which largely was not the case. "Toxicities have been well described in earlier studies, primarily around anemia, thrombocytopenia, and mild constitutional symptoms.” 

However, long-term therapy increases the rate of development of shingles and non-melanoma skin cancer. Rates of transformation to acute myeloid leukemia were consistent with those published for similar patient populations with MF.

“If I see a patient stable on ruxolitinib who has a marked drop in their counts later on in the course of their disease,” Dr Mesa added, “I’m certainly suspicious of progression.”

He also works them up for other causes of anemia if it evolves out of the blue. 

Support in MF-related anemia

“With anemia, we’re mindful of iron stores, EPO level, and being certain there’s not the presence of hemolysis or other contributors,” Dr Mesa said. 

The guideline recommends stratifying patients based on serum EPO levels—those with less than 500 mU/mL and those with 500 mU/mL and higher. 

“If we lower the EPO level, the greater the likelihood of response,” Dr Mesa said. “In my experience, the lower the transfusion burden, the greater the likelihood of response.”

Other than erythropoiesis-stimulating agents for individuals with lower serum levels, androgens and immunomodulatory drugs for those with higher levels have some benefit.

But “they all have their limitations,” Dr Mesa said, and “they tend to range in benefit from 20% to 30%.”

The future 

Dr Mesa discussed a few agents in the pipeline that “might impact these guidelines,” such as the JAK2/FLT3 inhibitor pacritinib and the JAK1/JAK2 inhibitor momelotinib.

Pacritinib had a positive phase 3 study, but the mortality rate was higher than expected, and it was put on an FDA hold. 

Data from a second phase 3 study (PERSIST-1) will be reviewed in the aggregate to evaluate the benefit of pacritinib and whether the mortality rate was associated with drug-related side effects or adverse patient selection, “which we suspect might be the case,” Dr Mesa said. 

“This agent may come off hold, depending upon the data of that second phase 3 study,” he added.

Momelotinib is also in an advanced phase 3 program with 2 trials underway. Both trials have completed accrual. 

One is an upfront study of momelotinib versus ruxolitinib (NCT01969838). The goal is to reduce anemia without inferiority of splenomegaly and MPN symptoms.

The other phase 3 momelotinib trial is a second-line study versus best alternative therapy, including ruxoltinib (NCT02101268).

Combination studies are ongoing with a ruxolitinib base and a variety of secondary agents, including danazol, pomalidomide, PEG IFN α2a, 5-AZA, panobinostat, BKM-120, and LDE-225. All agents appear to achieve improvement in splenomegaly and symptoms. 

But  “incremental benefit over ruxolitinib alone is not yet clear,” Dr Mesa said. “I would say there’s not yet a recommended off-label combination which is widely being used.”

Dr Mesa also highlighted PRM-151, an antifibrosing drug that had a favorable early stage study with several doses, and the telomerase inhibitor imetelstat, which had a deep set of molecular responses in about a third of patients with MF. Imetelstat is currently being evaluated in the second-line setting (NCT02426086). 

Regarding the possible positioning of new therapies, Dr Mesa believes “momelotinib and pacritinib may play a role in front-line, depending on the final data from those studies.” 

“In second-line for MF—this is where most of the activity is in the trials,” he said. “Momelotinib, pacritinib, PRM-151, and imetelstat have possibilities.”

Ruben Mesa, MD
© ASCO/Zach Boyden-Holmes

NEW YORK—The 11th NCCN Congress: Hematologic Malignancies coincided with the release of the inaugural edition of the NCCN treatment guideline on myeloproliferative neoplasms (MPNs), and Ruben A. Mesa, MD, took the opportunity to discuss the framework of the document and the evolving management of MPNs.

Dr Mesa, of the Mayo Clinic Cancer Center in Arizona, is the chair of the MPN guideline committee.

This initial version of the guideline focuses on the workup and diagnosis of primary myelofibrosis (MF), post-polycythemia vera MF, and post-essential thrombocythemia MF, and treatment guidelines for MF. 

The committee decided to first tackle the treatment guidelines in MF because, as Dr Mesa explained, MF is “the most severe of the MPNs with the most unmet needs in terms of guidance.”

Treatment guidelines for polycythemia vera (PV) and essential thrombocythemia (ET) will be forthcoming in 2017, he said, as well as diagnosis and treatment of atypical MPNs, such as hypereosinophilic syndrome and systemic mast cell disease.

Workup of an MPN

The guideline committee focused on information regarding diagnosis—the time and place to consider bone marrow biopsies, when to use cytogenetics, and when to perform next-generation sequencing. 

They stressed the importance of quantifying disease burden and utilizing the now-validated symptom assessment tools, particularly in MF.

“Finally, we leveraged the many prognostic scoring systems that have been developed for these diseases, particularly IPSS for myelofibrosis at diagnosis or the DIPSS and DIPSS-plus at subsequent time points,” Dr Mesa said. 

In addition to clinical-based prognostic scoring systems, information regarding molecular features and their impact is evolving, he said. 

The guideline provides a table of mutations with prognostic significance.  JAK2, MPL, or CALR mutations are “brighter mutations,” he said, while adverse prognostic markers include ASXL1, EZH2, IDH1/2, SRSF2, and TP53. 

“All of these have some significant prognostic implications in primary myelofibrosis, specifically,” he said.

Assessing MPN burden

“When treating these patients, it’s important to be mindful of the overall burden of the disease,” Dr Mesa said.

He called this emphasis on disease burden “an evolution from the past, where therapy was either supportive or primarily focused on prevention of thrombosis with ET or PV.” 

Practitioners need to be additionally mindful of the risk of vascular events, progression, the impact of cytopenias, splenomegaly, the burden of symptoms, and the baseline degree of comorbidities.

“[W]e encourage the use of validated symptom tools that have been used now in the majority of clinical trials in this setting,” Dr Mesa added.  

The MPN-10 assessment tool, included in the guideline, evaluates 10 symptoms—early satiety, abdominal discomfort, inactivity, problems concentrating, numbness/tingling, night sweats, itching, bone pain, fever, and unintentional weight loss—on a scale of 0 to 10. 

Patients with MF are the most symptomatic, Dr Mesa commented, although “it is notable how frequent symptoms are present in patients with PV and ET.”

Response criteria

For a complete response, individuals must have marked improvement to near normalization in both bone marrow and peripheral blood in addition to resolution of their disease symptoms. 

Partial response is basically “just shy” of the complete response level, Dr Mesa said, with bone marrow resolution not being required. 

The guideline also outlines response criteria for progressive, stable, and relapsed disease, clinical improvement, and anemia, spleen, and symptom response. 

“But I’ll highlight that the majority of the responses that are received currently with medical therapy are in the area of clinical improvement,” Dr Mesa said.

Treatment guidance

Specific treatment guidelines for low-risk, intermediate-1 risk, intermediate-2- or high-risk MF from the new guideline have been described in an earlier article and will not be discussed here. 

Of note, however, Dr Mesa explained that ruxolitinib is a very important part of the treatment guideline because it is the only therapy approved by the US Food and Drug Administration (FDA) to treat MF.

“Over time, it’s been shown that there is an improvement in survival [with ruxolitinib],” Dr Mesa said, perhaps because of a decrease with treatment in the morbidity and the debilitation of patients. 

Investigators presented the 5-year update of this information at ASCO 2016 and reported that patients maintained reduction in splenomegaly up through 5 years, both in those randomized to ruxolitinib and those crossing over from placebo. 

“Long-term, we clearly looked to see whether there was a signal of new onset or late onset toxicities,” Dr Mesa said, which largely was not the case. "Toxicities have been well described in earlier studies, primarily around anemia, thrombocytopenia, and mild constitutional symptoms.” 

However, long-term therapy increases the rate of development of shingles and non-melanoma skin cancer. Rates of transformation to acute myeloid leukemia were consistent with those published for similar patient populations with MF.

“If I see a patient stable on ruxolitinib who has a marked drop in their counts later on in the course of their disease,” Dr Mesa added, “I’m certainly suspicious of progression.”

He also works them up for other causes of anemia if it evolves out of the blue. 

Support in MF-related anemia

“With anemia, we’re mindful of iron stores, EPO level, and being certain there’s not the presence of hemolysis or other contributors,” Dr Mesa said. 

The guideline recommends stratifying patients based on serum EPO levels—those with less than 500 mU/mL and those with 500 mU/mL and higher. 

“If we lower the EPO level, the greater the likelihood of response,” Dr Mesa said. “In my experience, the lower the transfusion burden, the greater the likelihood of response.”

Other than erythropoiesis-stimulating agents for individuals with lower serum levels, androgens and immunomodulatory drugs for those with higher levels have some benefit.

But “they all have their limitations,” Dr Mesa said, and “they tend to range in benefit from 20% to 30%.”

The future 

Dr Mesa discussed a few agents in the pipeline that “might impact these guidelines,” such as the JAK2/FLT3 inhibitor pacritinib and the JAK1/JAK2 inhibitor momelotinib.

Pacritinib had a positive phase 3 study, but the mortality rate was higher than expected, and it was put on an FDA hold. 

Data from a second phase 3 study (PERSIST-1) will be reviewed in the aggregate to evaluate the benefit of pacritinib and whether the mortality rate was associated with drug-related side effects or adverse patient selection, “which we suspect might be the case,” Dr Mesa said. 

“This agent may come off hold, depending upon the data of that second phase 3 study,” he added.

Momelotinib is also in an advanced phase 3 program with 2 trials underway. Both trials have completed accrual. 

One is an upfront study of momelotinib versus ruxolitinib (NCT01969838). The goal is to reduce anemia without inferiority of splenomegaly and MPN symptoms.

The other phase 3 momelotinib trial is a second-line study versus best alternative therapy, including ruxoltinib (NCT02101268).

Combination studies are ongoing with a ruxolitinib base and a variety of secondary agents, including danazol, pomalidomide, PEG IFN α2a, 5-AZA, panobinostat, BKM-120, and LDE-225. All agents appear to achieve improvement in splenomegaly and symptoms. 

But  “incremental benefit over ruxolitinib alone is not yet clear,” Dr Mesa said. “I would say there’s not yet a recommended off-label combination which is widely being used.”

Dr Mesa also highlighted PRM-151, an antifibrosing drug that had a favorable early stage study with several doses, and the telomerase inhibitor imetelstat, which had a deep set of molecular responses in about a third of patients with MF. Imetelstat is currently being evaluated in the second-line setting (NCT02426086). 

Regarding the possible positioning of new therapies, Dr Mesa believes “momelotinib and pacritinib may play a role in front-line, depending on the final data from those studies.” 

“In second-line for MF—this is where most of the activity is in the trials,” he said. “Momelotinib, pacritinib, PRM-151, and imetelstat have possibilities.”

More than 102,000 people in Colombia have been infected with Zika virus since October 2015—when their epidemic began—and more than 18,000 of those are pregnant women. In the U.S., 731 women have been diagnosed with laboratory evidence of possible Zika infection, as have 1,156 in U.S. territories.

To help keep those numbers from rising, the CDC and Colombia’s Instituto Nacional de Salud have signed a memorandum of understanding to collaborate on Zika virus response in Colombia. The collaboration—including surveillance and epidemiology—will provide “critical scientific information to help the United States, Colombia, and other countries prepare for the unprecedented challenges posed by Zika,” says CDC Director Thomas R. Frieden, MD.

Colombia has been a “superb partner” in efforts thus far, Frieden says: Since 2016, the CDC and the Instituto Nacional de Salud  have worked together on Proyecto VEZ (Vigilancia de Embarazadas con Zika) to enhance surveillance of women infected with Zika during pregnancy in 3 sites in Colombia. To date, the project has enrolled more than 900 women.

The 2 agencies are also beginning a prospective study, ZEN Colombia (Zika en Embarazadas y Niños en Colombia) to investigate the long-term effects of the virus infection in pregnant women, their male partners, and their children.

More than 102,000 people in Colombia have been infected with Zika virus since October 2015—when their epidemic began—and more than 18,000 of those are pregnant women. In the U.S., 731 women have been diagnosed with laboratory evidence of possible Zika infection, as have 1,156 in U.S. territories.

To help keep those numbers from rising, the CDC and Colombia’s Instituto Nacional de Salud have signed a memorandum of understanding to collaborate on Zika virus response in Colombia. The collaboration—including surveillance and epidemiology—will provide “critical scientific information to help the United States, Colombia, and other countries prepare for the unprecedented challenges posed by Zika,” says CDC Director Thomas R. Frieden, MD.

Colombia has been a “superb partner” in efforts thus far, Frieden says: Since 2016, the CDC and the Instituto Nacional de Salud  have worked together on Proyecto VEZ (Vigilancia de Embarazadas con Zika) to enhance surveillance of women infected with Zika during pregnancy in 3 sites in Colombia. To date, the project has enrolled more than 900 women.

The 2 agencies are also beginning a prospective study, ZEN Colombia (Zika en Embarazadas y Niños en Colombia) to investigate the long-term effects of the virus infection in pregnant women, their male partners, and their children.

More than 102,000 people in Colombia have been infected with Zika virus since October 2015—when their epidemic began—and more than 18,000 of those are pregnant women. In the U.S., 731 women have been diagnosed with laboratory evidence of possible Zika infection, as have 1,156 in U.S. territories.

To help keep those numbers from rising, the CDC and Colombia’s Instituto Nacional de Salud have signed a memorandum of understanding to collaborate on Zika virus response in Colombia. The collaboration—including surveillance and epidemiology—will provide “critical scientific information to help the United States, Colombia, and other countries prepare for the unprecedented challenges posed by Zika,” says CDC Director Thomas R. Frieden, MD.

Colombia has been a “superb partner” in efforts thus far, Frieden says: Since 2016, the CDC and the Instituto Nacional de Salud  have worked together on Proyecto VEZ (Vigilancia de Embarazadas con Zika) to enhance surveillance of women infected with Zika during pregnancy in 3 sites in Colombia. To date, the project has enrolled more than 900 women.

The 2 agencies are also beginning a prospective study, ZEN Colombia (Zika en Embarazadas y Niños en Colombia) to investigate the long-term effects of the virus infection in pregnant women, their male partners, and their children.

Many years ago during medical school, I took time out to pursue graduate studies in philosophy. At that time, I took a number of courses that explored various approaches to the philosophical questions of morality and ethics. My ultimate goal, even back then, was to focus on ethical issues in the practice of medicine.

I often found the philosophical discussions from the “giants” in philosophy were not always easy to apply to everyday problems. After completing my graduate studies in philosophy and nearing the end of medical school, I found that I was drawn to surgery. Not surprisingly, many surgical faculty that I interviewed with for my residency saw little application of my philosophy studies to the practice of surgery. Although I felt confident that ethics was central to the practice of surgery, I let pass the general suggestions from many senior surgeons that surgery and philosophical analysis have little in common.

In recent years, however, I have increasingly seen an area of overlap that I believe will be central to the future of surgery. The options for the treatment of critically ill surgical patients across all areas of surgery have increased dramatically. Just in the area of cardiovascular disease, patients with failing hearts have the option of mechanical assist devices. Patients with multiple comorbidities and vascular problems can have numerous endovascular procedures done that years ago would have been unthinkable. Consider a patient with a ventricular assist device on a ventilator who is being dialyzed. Such a patient may be supported for weeks or months beyond what was possible just a few decades ago.

Whereas our surgical forefathers were constantly asking the question, “What can be done for this patient?” those caring for critically ill patients today must repeatedly ask, “What should we do for this patient?” Years ago, the statement, “there is nothing more that we can offer” was much more commonly heard than it is today. The critical question for today – “What should be done?” – is often more challenging and nuanced than “what can be done?” Whenever we ask “what should be done?” we must take into account the values of the patient and weigh the possible outcomes and the inherent risks of the possible interventions with the patient’s goals.

The current necessity to answer “what should be done?” has several striking parallels with the classical philosophical problem of “is” and “ought.” Over the centuries, many philosophers have considered whether we can derive an “ought” from an “is.” In other words, just because one can show that something is the case in the world, it does not automatically follow that it ought to be that way. David Hume, the Scottish philosopher (1711-1776), famously argued that there is a tremendous difference between statements about what is and statements about what ought to be. In particular, Hume argued that we cannot logically derive an “ought” from an “is.”

Despite the centuries that have passed since Hume’s days, I believe that his analysis has much to teach modern surgery. Just because we can undertake many interventions for our patients, it does not follow that we should undertake all of those interventions. A central aspect of what many of us refer to commonly as “surgical judgment” is deciding among the many possible interventions for a patient, what specific ones ought we offer. Although this entire discussion may seem theoretical (and possibly even arcane) to some surgeons, I firmly believe that one of the greatest challenges to the future of surgery is whether surgeons are willing to address the question of what should be done for every patient.

Excellent surgeons have traditionally been seen as having both technical mastery and sound judgment. In the current era in which surgeons are increasingly pushed to do more cases and maximize RVUs, multiple forces are encouraging surgeons to increasingly become pure technicians. Technicians can answer the question “what can be done?” However, “what should be done for this specific patient?” is a question that only a physician can answer. In the decades to come, we must ensure that surgeons continue to engage in the harder questions of “what should be done?” so that we do not forget that “is” and “ought” are different. The mastery of surgery involves not only the technical expertise that can be applied on behalf of a patient, but also the appreciation and understanding of the patient’s values so that surgeons can make recommendations about what should be done for their patients.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

Many years ago during medical school, I took time out to pursue graduate studies in philosophy. At that time, I took a number of courses that explored various approaches to the philosophical questions of morality and ethics. My ultimate goal, even back then, was to focus on ethical issues in the practice of medicine.

I often found the philosophical discussions from the “giants” in philosophy were not always easy to apply to everyday problems. After completing my graduate studies in philosophy and nearing the end of medical school, I found that I was drawn to surgery. Not surprisingly, many surgical faculty that I interviewed with for my residency saw little application of my philosophy studies to the practice of surgery. Although I felt confident that ethics was central to the practice of surgery, I let pass the general suggestions from many senior surgeons that surgery and philosophical analysis have little in common.

In recent years, however, I have increasingly seen an area of overlap that I believe will be central to the future of surgery. The options for the treatment of critically ill surgical patients across all areas of surgery have increased dramatically. Just in the area of cardiovascular disease, patients with failing hearts have the option of mechanical assist devices. Patients with multiple comorbidities and vascular problems can have numerous endovascular procedures done that years ago would have been unthinkable. Consider a patient with a ventricular assist device on a ventilator who is being dialyzed. Such a patient may be supported for weeks or months beyond what was possible just a few decades ago.

Whereas our surgical forefathers were constantly asking the question, “What can be done for this patient?” those caring for critically ill patients today must repeatedly ask, “What should we do for this patient?” Years ago, the statement, “there is nothing more that we can offer” was much more commonly heard than it is today. The critical question for today – “What should be done?” – is often more challenging and nuanced than “what can be done?” Whenever we ask “what should be done?” we must take into account the values of the patient and weigh the possible outcomes and the inherent risks of the possible interventions with the patient’s goals.

The current necessity to answer “what should be done?” has several striking parallels with the classical philosophical problem of “is” and “ought.” Over the centuries, many philosophers have considered whether we can derive an “ought” from an “is.” In other words, just because one can show that something is the case in the world, it does not automatically follow that it ought to be that way. David Hume, the Scottish philosopher (1711-1776), famously argued that there is a tremendous difference between statements about what is and statements about what ought to be. In particular, Hume argued that we cannot logically derive an “ought” from an “is.”

Despite the centuries that have passed since Hume’s days, I believe that his analysis has much to teach modern surgery. Just because we can undertake many interventions for our patients, it does not follow that we should undertake all of those interventions. A central aspect of what many of us refer to commonly as “surgical judgment” is deciding among the many possible interventions for a patient, what specific ones ought we offer. Although this entire discussion may seem theoretical (and possibly even arcane) to some surgeons, I firmly believe that one of the greatest challenges to the future of surgery is whether surgeons are willing to address the question of what should be done for every patient.

Excellent surgeons have traditionally been seen as having both technical mastery and sound judgment. In the current era in which surgeons are increasingly pushed to do more cases and maximize RVUs, multiple forces are encouraging surgeons to increasingly become pure technicians. Technicians can answer the question “what can be done?” However, “what should be done for this specific patient?” is a question that only a physician can answer. In the decades to come, we must ensure that surgeons continue to engage in the harder questions of “what should be done?” so that we do not forget that “is” and “ought” are different. The mastery of surgery involves not only the technical expertise that can be applied on behalf of a patient, but also the appreciation and understanding of the patient’s values so that surgeons can make recommendations about what should be done for their patients.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

Many years ago during medical school, I took time out to pursue graduate studies in philosophy. At that time, I took a number of courses that explored various approaches to the philosophical questions of morality and ethics. My ultimate goal, even back then, was to focus on ethical issues in the practice of medicine.

I often found the philosophical discussions from the “giants” in philosophy were not always easy to apply to everyday problems. After completing my graduate studies in philosophy and nearing the end of medical school, I found that I was drawn to surgery. Not surprisingly, many surgical faculty that I interviewed with for my residency saw little application of my philosophy studies to the practice of surgery. Although I felt confident that ethics was central to the practice of surgery, I let pass the general suggestions from many senior surgeons that surgery and philosophical analysis have little in common.

In recent years, however, I have increasingly seen an area of overlap that I believe will be central to the future of surgery. The options for the treatment of critically ill surgical patients across all areas of surgery have increased dramatically. Just in the area of cardiovascular disease, patients with failing hearts have the option of mechanical assist devices. Patients with multiple comorbidities and vascular problems can have numerous endovascular procedures done that years ago would have been unthinkable. Consider a patient with a ventricular assist device on a ventilator who is being dialyzed. Such a patient may be supported for weeks or months beyond what was possible just a few decades ago.

Whereas our surgical forefathers were constantly asking the question, “What can be done for this patient?” those caring for critically ill patients today must repeatedly ask, “What should we do for this patient?” Years ago, the statement, “there is nothing more that we can offer” was much more commonly heard than it is today. The critical question for today – “What should be done?” – is often more challenging and nuanced than “what can be done?” Whenever we ask “what should be done?” we must take into account the values of the patient and weigh the possible outcomes and the inherent risks of the possible interventions with the patient’s goals.

The current necessity to answer “what should be done?” has several striking parallels with the classical philosophical problem of “is” and “ought.” Over the centuries, many philosophers have considered whether we can derive an “ought” from an “is.” In other words, just because one can show that something is the case in the world, it does not automatically follow that it ought to be that way. David Hume, the Scottish philosopher (1711-1776), famously argued that there is a tremendous difference between statements about what is and statements about what ought to be. In particular, Hume argued that we cannot logically derive an “ought” from an “is.”

Despite the centuries that have passed since Hume’s days, I believe that his analysis has much to teach modern surgery. Just because we can undertake many interventions for our patients, it does not follow that we should undertake all of those interventions. A central aspect of what many of us refer to commonly as “surgical judgment” is deciding among the many possible interventions for a patient, what specific ones ought we offer. Although this entire discussion may seem theoretical (and possibly even arcane) to some surgeons, I firmly believe that one of the greatest challenges to the future of surgery is whether surgeons are willing to address the question of what should be done for every patient.

Excellent surgeons have traditionally been seen as having both technical mastery and sound judgment. In the current era in which surgeons are increasingly pushed to do more cases and maximize RVUs, multiple forces are encouraging surgeons to increasingly become pure technicians. Technicians can answer the question “what can be done?” However, “what should be done for this specific patient?” is a question that only a physician can answer. In the decades to come, we must ensure that surgeons continue to engage in the harder questions of “what should be done?” so that we do not forget that “is” and “ought” are different. The mastery of surgery involves not only the technical expertise that can be applied on behalf of a patient, but also the appreciation and understanding of the patient’s values so that surgeons can make recommendations about what should be done for their patients.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

Detection of thyroid cancer is widespread, increasing by about 4.5% annually. In the past year, approximately 64,300 new cases were identified. An estimated one in 100 people will be diagnosed with thyroid cancer during their lifetime, making it the eighth most common cancer in the United States.¹

Incidental thyroid nodules found on carotid ultrasounds and other neck imaging may account for much of the increase; evaluation of these “incidentalomas” may account for the doubling incidence of thyroid cancer cases. (For more on thyroid nodules, see “To Cut or Not to Cut?” Clinician Reviews. 2016;26[8]:34-36.) If this pace continues, thyroid cancer may become the third most common cancer among women in the US by 2019.²

RISK FACTORS

Generally, women are diagnosed with thyroid cancer more frequently than men.³ Other risk factors include

• Age (40 to 60 in women; 60 to 80 in men; median age at diagnosis, 51)
• Inherited conditions, such as multiple endocrine neoplasia (MEN) or familial medullary and nonmedullary thyroid carcinoma
• Other cancers, including breast cancer and familial adenomatous polyposis
• Iodine deficiency
• Radiation exposure, particularly head and neck radiation in childhood. This can be through treatment of acne, tinea capitis, enlarged tonsils, or adenoids (usually prior to 1960); treatment of lymphoma, Wilms tumor, or neuroblastoma; or proximity to Chernobyl in 1986.^1,2

BIOPSY RECOMMENDATIONS

While thyroid nodules are fairly common, only 7% to 15% of nodules are found to be malignant.² However, all patients presenting with a palpable thyroid nodule should undergo thyroid ultrasound for further evaluation.

According to American Thyroid Association guidelines, all nodules 2 cm or larger should be evaluated with fine needle aspiration (FNA) due to a concern for metastatic thyroid cancer in larger nodules.² Some clinicians prefer to aspirate nodules 1 cm or larger. Nodules that are smaller than 2 cm with sonographic features suspicious for thyroid cancer (see Table 1) should be biopsied.

Nodules that are spongiform in appearance or are completely cystic with no solid components may be monitored without FNA.²

The FNA is typically performed by an endocrinologist under ultrasound guidance. No anesthetic is required, but a topical ethyl chloride spray can assist with patient comfort. Three to four passes are made into the nodule with a 27-gauge needle; most patients describe pressure or a pinching sensation, rather than pain, during the procedure. After the procedure, ice applied to the FNA area may help with patient comfort.

Four possible types of thyroid cancer are identified on pathology after FNA: papillary, follicular, medullary, and anaplastic. Differentiated thyroid cancers, which encompass papillary and follicular cancers, are the most commonly diagnosed. Approximately 90% of thyroid cancers fall into this category.²

In most cases of differentiated thyroid cancer, patients can be treated with thyroidectomy alone if the cancer remains confined to the thyroid.² Just over two-thirds of differentiated thyroid cancer cases are localized in the thyroid. The five-year survival rate for these patients is nearly 100%.¹

About 27% of differentiated thyroid cancer is also found in neck lymph nodes; these patients may be treated with thyroidectomy and radioactive iodine.² The five-year survival rate in these cases is nearly 98%.¹ Chemotherapy is generally not needed for differentiated thyroid cancers.

Medullary thyroid cancer (MTC) is diagnosed in up to 4% of thyroid cancer patients. Characterized by high levels of calcitonin, MTC can be genetically mediated or sporadic. MTC is associated with a variety of RET oncogene mutations; genetic testing of family members is recommended, as well as prophylactic thyroidectomy when high-risk RET oncogenes are detected.³

The 10-year survival prognosis for MTC patients varies according to stage at diagnosis (see Table 2). Up to 70% of patients with a palpable MTC nodule present with metastasis consistent with stage III or IV disease.³

Medullary thyroid cancer is treated with total thyroidectomy and cervical lymph node dissection. Radioactive iodine has not been proven effective for MTC patients, unless there is also papillary or follicular thyroid cancer present.³

Anaplastic thyroid cancer has the highest mortality rate of all types of thyroid cancer. Fortunately, it is relatively rare, occurring in only 1.7% of thyroid cancer patients. The one-year survival rate is 20%, with a median postdiagnosis survival prognosis of approximately five months. Anaplastic thyroid cancer is treated with total thyroidectomy and radical neck dissection when it is considered resectable. Metastatic lesions in the brain or spine are often indicators of unresectable disease. In some cases, external beam radiation therapy is used as palliative treatment.⁴

Thyroid cancer in children is rare, making up only 1.8% of all pediatric cancers diagnosed in the US annually. Patients are most often between ages 15 and 19, but it is possible for thyroid cancer to manifest in younger patients. Thyroid nodules are more likely to be malignant in children, with a greater incidence of metastatic disease at diagnosis. Prognosis is generally better in children than in adults, however, even with extensive disease.⁵

Children with prior history of other types of cancer treated with radiation, such as Hodgkin lymphoma or leukemia, are at increased risk for thyroid cancer and should be monitored.⁵ Children with a family history of MEN or MTC and evidence of RET oncogenes should be monitored starting as early as age 3 with thyroid exam, ultrasound, and measurement of calcitonin levels.³ Prophylactic thyroidectomy is an option in the first few months of life, depending on the presence of specific RET oncogenes.³

CHEMOTHERAPY

Chemotherapy may be helpful for metastatic medullary or anaplastic thyroid cancer, particularly in patients with unresectable disease. Though not usually curative, it may increase progression-free survival time. New chemotherapy agents approved for use in metastatic MTC include cabozantinib and vandetanib.³ Carboplatin, docetaxel, doxorubicin, and pac­litaxel are used in treatment of anaplastic thyroid cancer.⁴

After thyroidectomy and radioactive iodine treatment, follicular cell cancers (eg, papillary, follicular, anaplastic) are managed by following patients’ thyroid-stimulating hormone (TSH), thyroglobulin, and antithyroglobulin antibody levels. A cervical ultrasound is performed to detect possible disease in lymph nodes.²

Levothyroxine is dosed to suppress TSH below the recommended levels for hypothyroid patients in order to prevent disease recurrence. Low-risk patients may have TSH suppression below 1 to 2 mU/L, while high-risk patients may be managed with TSH levels below 0.1 mU/L.²

Lab levels should be checked annually and a cervical ultrasound performed at six to 12 months, then periodically thereafter depending on patient risk status.² Patients with long-term TSH suppression must be monitored for atrial fibrillation and osteoporosis.

Patients who have been treated for medullary thyroid cancer require a different long-term management strategy. Patients should have ultrasound and measurement of TSH as well as calcitonin and carcinoembryonic antigen levels every six to 12 months.³ TSH suppression is not required; TSH may be maintained at typical euthyroid levels.

A FINAL THOUGHT

For clinicians, it’s easy to attempt to minimize thyroid cancer, since the disease is curable for most patients without the burden of chemotherapy and external radiation. However, for a patient, this is still a cancer diagnosis, with the accompanying surgery and required lifelong monitoring. It can be very disruptive to the lives of both patients and their families.

Support groups are available to help patients navigate their new reality. The Thyroid Cancer Survivors’ Association (www.thyca.org) has resources that may be beneficial to patients (and caregivers) as they learn how to live as a thyroid cancer survivor.

Detection of thyroid cancer is widespread, increasing by about 4.5% annually. In the past year, approximately 64,300 new cases were identified. An estimated one in 100 people will be diagnosed with thyroid cancer during their lifetime, making it the eighth most common cancer in the United States.¹

Incidental thyroid nodules found on carotid ultrasounds and other neck imaging may account for much of the increase; evaluation of these “incidentalomas” may account for the doubling incidence of thyroid cancer cases. (For more on thyroid nodules, see “To Cut or Not to Cut?” Clinician Reviews. 2016;26[8]:34-36.) If this pace continues, thyroid cancer may become the third most common cancer among women in the US by 2019.²

RISK FACTORS

Generally, women are diagnosed with thyroid cancer more frequently than men.³ Other risk factors include

• Age (40 to 60 in women; 60 to 80 in men; median age at diagnosis, 51)
• Inherited conditions, such as multiple endocrine neoplasia (MEN) or familial medullary and nonmedullary thyroid carcinoma
• Other cancers, including breast cancer and familial adenomatous polyposis
• Iodine deficiency
• Radiation exposure, particularly head and neck radiation in childhood. This can be through treatment of acne, tinea capitis, enlarged tonsils, or adenoids (usually prior to 1960); treatment of lymphoma, Wilms tumor, or neuroblastoma; or proximity to Chernobyl in 1986.^1,2

BIOPSY RECOMMENDATIONS

While thyroid nodules are fairly common, only 7% to 15% of nodules are found to be malignant.² However, all patients presenting with a palpable thyroid nodule should undergo thyroid ultrasound for further evaluation.

According to American Thyroid Association guidelines, all nodules 2 cm or larger should be evaluated with fine needle aspiration (FNA) due to a concern for metastatic thyroid cancer in larger nodules.² Some clinicians prefer to aspirate nodules 1 cm or larger. Nodules that are smaller than 2 cm with sonographic features suspicious for thyroid cancer (see Table 1) should be biopsied.

Nodules that are spongiform in appearance or are completely cystic with no solid components may be monitored without FNA.²

The FNA is typically performed by an endocrinologist under ultrasound guidance. No anesthetic is required, but a topical ethyl chloride spray can assist with patient comfort. Three to four passes are made into the nodule with a 27-gauge needle; most patients describe pressure or a pinching sensation, rather than pain, during the procedure. After the procedure, ice applied to the FNA area may help with patient comfort.

Four possible types of thyroid cancer are identified on pathology after FNA: papillary, follicular, medullary, and anaplastic. Differentiated thyroid cancers, which encompass papillary and follicular cancers, are the most commonly diagnosed. Approximately 90% of thyroid cancers fall into this category.²

In most cases of differentiated thyroid cancer, patients can be treated with thyroidectomy alone if the cancer remains confined to the thyroid.² Just over two-thirds of differentiated thyroid cancer cases are localized in the thyroid. The five-year survival rate for these patients is nearly 100%.¹

About 27% of differentiated thyroid cancer is also found in neck lymph nodes; these patients may be treated with thyroidectomy and radioactive iodine.² The five-year survival rate in these cases is nearly 98%.¹ Chemotherapy is generally not needed for differentiated thyroid cancers.

Medullary thyroid cancer (MTC) is diagnosed in up to 4% of thyroid cancer patients. Characterized by high levels of calcitonin, MTC can be genetically mediated or sporadic. MTC is associated with a variety of RET oncogene mutations; genetic testing of family members is recommended, as well as prophylactic thyroidectomy when high-risk RET oncogenes are detected.³

The 10-year survival prognosis for MTC patients varies according to stage at diagnosis (see Table 2). Up to 70% of patients with a palpable MTC nodule present with metastasis consistent with stage III or IV disease.³

Medullary thyroid cancer is treated with total thyroidectomy and cervical lymph node dissection. Radioactive iodine has not been proven effective for MTC patients, unless there is also papillary or follicular thyroid cancer present.³

Anaplastic thyroid cancer has the highest mortality rate of all types of thyroid cancer. Fortunately, it is relatively rare, occurring in only 1.7% of thyroid cancer patients. The one-year survival rate is 20%, with a median postdiagnosis survival prognosis of approximately five months. Anaplastic thyroid cancer is treated with total thyroidectomy and radical neck dissection when it is considered resectable. Metastatic lesions in the brain or spine are often indicators of unresectable disease. In some cases, external beam radiation therapy is used as palliative treatment.⁴

Thyroid cancer in children is rare, making up only 1.8% of all pediatric cancers diagnosed in the US annually. Patients are most often between ages 15 and 19, but it is possible for thyroid cancer to manifest in younger patients. Thyroid nodules are more likely to be malignant in children, with a greater incidence of metastatic disease at diagnosis. Prognosis is generally better in children than in adults, however, even with extensive disease.⁵

Children with prior history of other types of cancer treated with radiation, such as Hodgkin lymphoma or leukemia, are at increased risk for thyroid cancer and should be monitored.⁵ Children with a family history of MEN or MTC and evidence of RET oncogenes should be monitored starting as early as age 3 with thyroid exam, ultrasound, and measurement of calcitonin levels.³ Prophylactic thyroidectomy is an option in the first few months of life, depending on the presence of specific RET oncogenes.³

CHEMOTHERAPY

Chemotherapy may be helpful for metastatic medullary or anaplastic thyroid cancer, particularly in patients with unresectable disease. Though not usually curative, it may increase progression-free survival time. New chemotherapy agents approved for use in metastatic MTC include cabozantinib and vandetanib.³ Carboplatin, docetaxel, doxorubicin, and pac­litaxel are used in treatment of anaplastic thyroid cancer.⁴

After thyroidectomy and radioactive iodine treatment, follicular cell cancers (eg, papillary, follicular, anaplastic) are managed by following patients’ thyroid-stimulating hormone (TSH), thyroglobulin, and antithyroglobulin antibody levels. A cervical ultrasound is performed to detect possible disease in lymph nodes.²

Levothyroxine is dosed to suppress TSH below the recommended levels for hypothyroid patients in order to prevent disease recurrence. Low-risk patients may have TSH suppression below 1 to 2 mU/L, while high-risk patients may be managed with TSH levels below 0.1 mU/L.²

Lab levels should be checked annually and a cervical ultrasound performed at six to 12 months, then periodically thereafter depending on patient risk status.² Patients with long-term TSH suppression must be monitored for atrial fibrillation and osteoporosis.

Patients who have been treated for medullary thyroid cancer require a different long-term management strategy. Patients should have ultrasound and measurement of TSH as well as calcitonin and carcinoembryonic antigen levels every six to 12 months.³ TSH suppression is not required; TSH may be maintained at typical euthyroid levels.

A FINAL THOUGHT

For clinicians, it’s easy to attempt to minimize thyroid cancer, since the disease is curable for most patients without the burden of chemotherapy and external radiation. However, for a patient, this is still a cancer diagnosis, with the accompanying surgery and required lifelong monitoring. It can be very disruptive to the lives of both patients and their families.

Support groups are available to help patients navigate their new reality. The Thyroid Cancer Survivors’ Association (www.thyca.org) has resources that may be beneficial to patients (and caregivers) as they learn how to live as a thyroid cancer survivor.

Detection of thyroid cancer is widespread, increasing by about 4.5% annually. In the past year, approximately 64,300 new cases were identified. An estimated one in 100 people will be diagnosed with thyroid cancer during their lifetime, making it the eighth most common cancer in the United States.¹

Incidental thyroid nodules found on carotid ultrasounds and other neck imaging may account for much of the increase; evaluation of these “incidentalomas” may account for the doubling incidence of thyroid cancer cases. (For more on thyroid nodules, see “To Cut or Not to Cut?” Clinician Reviews. 2016;26[8]:34-36.) If this pace continues, thyroid cancer may become the third most common cancer among women in the US by 2019.²

RISK FACTORS

Generally, women are diagnosed with thyroid cancer more frequently than men.³ Other risk factors include

• Age (40 to 60 in women; 60 to 80 in men; median age at diagnosis, 51)
• Inherited conditions, such as multiple endocrine neoplasia (MEN) or familial medullary and nonmedullary thyroid carcinoma
• Other cancers, including breast cancer and familial adenomatous polyposis
• Iodine deficiency
• Radiation exposure, particularly head and neck radiation in childhood. This can be through treatment of acne, tinea capitis, enlarged tonsils, or adenoids (usually prior to 1960); treatment of lymphoma, Wilms tumor, or neuroblastoma; or proximity to Chernobyl in 1986.^1,2

BIOPSY RECOMMENDATIONS

While thyroid nodules are fairly common, only 7% to 15% of nodules are found to be malignant.² However, all patients presenting with a palpable thyroid nodule should undergo thyroid ultrasound for further evaluation.

According to American Thyroid Association guidelines, all nodules 2 cm or larger should be evaluated with fine needle aspiration (FNA) due to a concern for metastatic thyroid cancer in larger nodules.² Some clinicians prefer to aspirate nodules 1 cm or larger. Nodules that are smaller than 2 cm with sonographic features suspicious for thyroid cancer (see Table 1) should be biopsied.

Nodules that are spongiform in appearance or are completely cystic with no solid components may be monitored without FNA.²

The FNA is typically performed by an endocrinologist under ultrasound guidance. No anesthetic is required, but a topical ethyl chloride spray can assist with patient comfort. Three to four passes are made into the nodule with a 27-gauge needle; most patients describe pressure or a pinching sensation, rather than pain, during the procedure. After the procedure, ice applied to the FNA area may help with patient comfort.

Four possible types of thyroid cancer are identified on pathology after FNA: papillary, follicular, medullary, and anaplastic. Differentiated thyroid cancers, which encompass papillary and follicular cancers, are the most commonly diagnosed. Approximately 90% of thyroid cancers fall into this category.²

In most cases of differentiated thyroid cancer, patients can be treated with thyroidectomy alone if the cancer remains confined to the thyroid.² Just over two-thirds of differentiated thyroid cancer cases are localized in the thyroid. The five-year survival rate for these patients is nearly 100%.¹

About 27% of differentiated thyroid cancer is also found in neck lymph nodes; these patients may be treated with thyroidectomy and radioactive iodine.² The five-year survival rate in these cases is nearly 98%.¹ Chemotherapy is generally not needed for differentiated thyroid cancers.

Medullary thyroid cancer (MTC) is diagnosed in up to 4% of thyroid cancer patients. Characterized by high levels of calcitonin, MTC can be genetically mediated or sporadic. MTC is associated with a variety of RET oncogene mutations; genetic testing of family members is recommended, as well as prophylactic thyroidectomy when high-risk RET oncogenes are detected.³

The 10-year survival prognosis for MTC patients varies according to stage at diagnosis (see Table 2). Up to 70% of patients with a palpable MTC nodule present with metastasis consistent with stage III or IV disease.³

Medullary thyroid cancer is treated with total thyroidectomy and cervical lymph node dissection. Radioactive iodine has not been proven effective for MTC patients, unless there is also papillary or follicular thyroid cancer present.³

Anaplastic thyroid cancer has the highest mortality rate of all types of thyroid cancer. Fortunately, it is relatively rare, occurring in only 1.7% of thyroid cancer patients. The one-year survival rate is 20%, with a median postdiagnosis survival prognosis of approximately five months. Anaplastic thyroid cancer is treated with total thyroidectomy and radical neck dissection when it is considered resectable. Metastatic lesions in the brain or spine are often indicators of unresectable disease. In some cases, external beam radiation therapy is used as palliative treatment.⁴

Thyroid cancer in children is rare, making up only 1.8% of all pediatric cancers diagnosed in the US annually. Patients are most often between ages 15 and 19, but it is possible for thyroid cancer to manifest in younger patients. Thyroid nodules are more likely to be malignant in children, with a greater incidence of metastatic disease at diagnosis. Prognosis is generally better in children than in adults, however, even with extensive disease.⁵

Children with prior history of other types of cancer treated with radiation, such as Hodgkin lymphoma or leukemia, are at increased risk for thyroid cancer and should be monitored.⁵ Children with a family history of MEN or MTC and evidence of RET oncogenes should be monitored starting as early as age 3 with thyroid exam, ultrasound, and measurement of calcitonin levels.³ Prophylactic thyroidectomy is an option in the first few months of life, depending on the presence of specific RET oncogenes.³

CHEMOTHERAPY

Chemotherapy may be helpful for metastatic medullary or anaplastic thyroid cancer, particularly in patients with unresectable disease. Though not usually curative, it may increase progression-free survival time. New chemotherapy agents approved for use in metastatic MTC include cabozantinib and vandetanib.³ Carboplatin, docetaxel, doxorubicin, and pac­litaxel are used in treatment of anaplastic thyroid cancer.⁴

After thyroidectomy and radioactive iodine treatment, follicular cell cancers (eg, papillary, follicular, anaplastic) are managed by following patients’ thyroid-stimulating hormone (TSH), thyroglobulin, and antithyroglobulin antibody levels. A cervical ultrasound is performed to detect possible disease in lymph nodes.²

Levothyroxine is dosed to suppress TSH below the recommended levels for hypothyroid patients in order to prevent disease recurrence. Low-risk patients may have TSH suppression below 1 to 2 mU/L, while high-risk patients may be managed with TSH levels below 0.1 mU/L.²

Lab levels should be checked annually and a cervical ultrasound performed at six to 12 months, then periodically thereafter depending on patient risk status.² Patients with long-term TSH suppression must be monitored for atrial fibrillation and osteoporosis.

Patients who have been treated for medullary thyroid cancer require a different long-term management strategy. Patients should have ultrasound and measurement of TSH as well as calcitonin and carcinoembryonic antigen levels every six to 12 months.³ TSH suppression is not required; TSH may be maintained at typical euthyroid levels.

A FINAL THOUGHT

For clinicians, it’s easy to attempt to minimize thyroid cancer, since the disease is curable for most patients without the burden of chemotherapy and external radiation. However, for a patient, this is still a cancer diagnosis, with the accompanying surgery and required lifelong monitoring. It can be very disruptive to the lives of both patients and their families.

Support groups are available to help patients navigate their new reality. The Thyroid Cancer Survivors’ Association (www.thyca.org) has resources that may be beneficial to patients (and caregivers) as they learn how to live as a thyroid cancer survivor.

The email came with the words, “It is with sadness we report that Frank Moody died. …” I was instantly transported to the last time I saw the man and a flood of emotions swept over me. The name Frank Moody will ring a distant bell or none at all to some in our profession. Like many of the greats of surgery, he belongs to the ages.

I remember the first time I asked a student, “Who is Michael DeBakey?” I was dumbfounded to be greeted with a blank stare. How could a student of medicine not know of Dr. DeBakey? A few years later, the same question prompted a smart aleck reply that he was the man who invented DeBakey forceps. Well, of course he did invent the forceps, but to know nothing further of the man who was the world’s expert on ulcer disease in the 1940s, the progenitor of the National Medical Library, and among the foremost pioneers of heart surgery seemed beyond belief.

Photo credit: Dwight Andrews/UTHealth

My mentor, Ernest Poulos, has long since left the active surgical scene. At times he would note the passing of one of his heroes like Carl Moyer (look it up!) and say, “Sic transit gloria mundi.” At 27 and anxious to get the right to cut into my fellow human beings, I would cock my head like a confounded puppy and wonder what that meant. I looked up the translation and meaning long ago, but now with age I understand the phrase in my bones.

I have long been a hanger-on at surgical meetings, hoping to meet those mighty figures that shaped surgical history. I saw W. Dean Warren once and had a very long hour with the great Mark Ravitch. Oliver Beahrs once performed magic tricks at a dinner I attended. At every surgical meeting there is an old guy (and now occasionally with the change in our profession, an elderly lady) getting on the bus to go to the reception or dinner dance. Often they are alone, their spouses having departed before them. As a young man, I wondered why the heck they came to the meetings. Just like every generation before, ours was eager to grab the reins, and in our ardor for future glory, we were polite but also restless for them to move aside. I hadn’t yet learned the importance of history and of listening.

What I missed while carousing with my young colleagues was an opportunity to hear history first hand and to learn that, what we thought was so cutting edge, these men and women had long ago considered. Many of our living legends imagined some of today’s innovations but they lacked the technology to bring their dreams to fruition, or time and age defeated them before they reached the final chapter of their research. It was when I was about 50 that I wised up and began seeking out living legends like Frank Moody and Frank Spencer.

In the case of Frank Moody, he was quite elderly when I first met him. For some reason, he knew who I was and shook my hand softly. I didn’t recognize him initially, but at the sound of his name, I knew I was in the presence of a major figure in 20th century gastrointestinal surgery. He had been at the University of California, San Francisco, during an historic time when George Sheldon, Donald Trunkey and other great surgeons trained there with J. Englebert Dunphy as their chief. Dr. Moody’s CV lists 141 articles in basic and clinical science that have had a profound impact on how we view the gastrointestinal tract. He was Chief at the University of Utah and the University of Alabama and finished his career as professor at the University of Texas-Houston. His awards and achievements were legion.

Parkinson’s had only recently really begun to affect him when I met him, and as the years went by his voice became so very faint that I had to lean in to hear him. We would sit together at the back of the dinner dance room so that we could hear each other. And while the other guests entertained themselves, Dr. Moody and I would discuss his life, scientific method and philosophy as well as his insights into his own case of Parkinsonism. I would see him at meetings, making his way slowly but steadily along a corridor while others briskly walked by, unaware that the man they just passed was among the most important surgical pioneers of our time. It was not sad that Dr. Moody was elderly and unrecognized, but that we younger surgeons missed knowing a great man in our tendency to rush past history.

History is not facts and dates, but rather, it is people and their lives. Yes, the history of our profession is embodied by pioneers like Frank Moody and the others I’ve mentioned.

We have many Fellows among us who are living history, still contributing – maybe not at the dais but at the dinner table, speaking softly and walking a bit slower than their juniors. Thanks to LaMar McGinnis who started it and Don Nakayama who continues it, the College has a History Community on the ACS Communities, an active Surgical History Group, and a will to acknowledge the history that lives and breathes among us. The Surgical History Group has organized a full program of events at the Clinical Congress and I hope many attendees take the opportunity to attend.

Take a moment at your next meeting or at the Clinical Congress and look for those historic surgeons still with us. Be smarter than I was at a young age and get to know them. You may learn something from them you can’t learn anyplace else.

Dr. Hughes is clinical professor in the department of surgery and director of medical education at the Kansas University School of Medicine, Salina Campus, and Co-Editor of ACS Surgery News.

The email came with the words, “It is with sadness we report that Frank Moody died. …” I was instantly transported to the last time I saw the man and a flood of emotions swept over me. The name Frank Moody will ring a distant bell or none at all to some in our profession. Like many of the greats of surgery, he belongs to the ages.

I remember the first time I asked a student, “Who is Michael DeBakey?” I was dumbfounded to be greeted with a blank stare. How could a student of medicine not know of Dr. DeBakey? A few years later, the same question prompted a smart aleck reply that he was the man who invented DeBakey forceps. Well, of course he did invent the forceps, but to know nothing further of the man who was the world’s expert on ulcer disease in the 1940s, the progenitor of the National Medical Library, and among the foremost pioneers of heart surgery seemed beyond belief.

Photo credit: Dwight Andrews/UTHealth

My mentor, Ernest Poulos, has long since left the active surgical scene. At times he would note the passing of one of his heroes like Carl Moyer (look it up!) and say, “Sic transit gloria mundi.” At 27 and anxious to get the right to cut into my fellow human beings, I would cock my head like a confounded puppy and wonder what that meant. I looked up the translation and meaning long ago, but now with age I understand the phrase in my bones.

I have long been a hanger-on at surgical meetings, hoping to meet those mighty figures that shaped surgical history. I saw W. Dean Warren once and had a very long hour with the great Mark Ravitch. Oliver Beahrs once performed magic tricks at a dinner I attended. At every surgical meeting there is an old guy (and now occasionally with the change in our profession, an elderly lady) getting on the bus to go to the reception or dinner dance. Often they are alone, their spouses having departed before them. As a young man, I wondered why the heck they came to the meetings. Just like every generation before, ours was eager to grab the reins, and in our ardor for future glory, we were polite but also restless for them to move aside. I hadn’t yet learned the importance of history and of listening.

What I missed while carousing with my young colleagues was an opportunity to hear history first hand and to learn that, what we thought was so cutting edge, these men and women had long ago considered. Many of our living legends imagined some of today’s innovations but they lacked the technology to bring their dreams to fruition, or time and age defeated them before they reached the final chapter of their research. It was when I was about 50 that I wised up and began seeking out living legends like Frank Moody and Frank Spencer.

In the case of Frank Moody, he was quite elderly when I first met him. For some reason, he knew who I was and shook my hand softly. I didn’t recognize him initially, but at the sound of his name, I knew I was in the presence of a major figure in 20th century gastrointestinal surgery. He had been at the University of California, San Francisco, during an historic time when George Sheldon, Donald Trunkey and other great surgeons trained there with J. Englebert Dunphy as their chief. Dr. Moody’s CV lists 141 articles in basic and clinical science that have had a profound impact on how we view the gastrointestinal tract. He was Chief at the University of Utah and the University of Alabama and finished his career as professor at the University of Texas-Houston. His awards and achievements were legion.

Parkinson’s had only recently really begun to affect him when I met him, and as the years went by his voice became so very faint that I had to lean in to hear him. We would sit together at the back of the dinner dance room so that we could hear each other. And while the other guests entertained themselves, Dr. Moody and I would discuss his life, scientific method and philosophy as well as his insights into his own case of Parkinsonism. I would see him at meetings, making his way slowly but steadily along a corridor while others briskly walked by, unaware that the man they just passed was among the most important surgical pioneers of our time. It was not sad that Dr. Moody was elderly and unrecognized, but that we younger surgeons missed knowing a great man in our tendency to rush past history.

History is not facts and dates, but rather, it is people and their lives. Yes, the history of our profession is embodied by pioneers like Frank Moody and the others I’ve mentioned.

We have many Fellows among us who are living history, still contributing – maybe not at the dais but at the dinner table, speaking softly and walking a bit slower than their juniors. Thanks to LaMar McGinnis who started it and Don Nakayama who continues it, the College has a History Community on the ACS Communities, an active Surgical History Group, and a will to acknowledge the history that lives and breathes among us. The Surgical History Group has organized a full program of events at the Clinical Congress and I hope many attendees take the opportunity to attend.

Take a moment at your next meeting or at the Clinical Congress and look for those historic surgeons still with us. Be smarter than I was at a young age and get to know them. You may learn something from them you can’t learn anyplace else.

Dr. Hughes is clinical professor in the department of surgery and director of medical education at the Kansas University School of Medicine, Salina Campus, and Co-Editor of ACS Surgery News.

The email came with the words, “It is with sadness we report that Frank Moody died. …” I was instantly transported to the last time I saw the man and a flood of emotions swept over me. The name Frank Moody will ring a distant bell or none at all to some in our profession. Like many of the greats of surgery, he belongs to the ages.

I remember the first time I asked a student, “Who is Michael DeBakey?” I was dumbfounded to be greeted with a blank stare. How could a student of medicine not know of Dr. DeBakey? A few years later, the same question prompted a smart aleck reply that he was the man who invented DeBakey forceps. Well, of course he did invent the forceps, but to know nothing further of the man who was the world’s expert on ulcer disease in the 1940s, the progenitor of the National Medical Library, and among the foremost pioneers of heart surgery seemed beyond belief.

Photo credit: Dwight Andrews/UTHealth

My mentor, Ernest Poulos, has long since left the active surgical scene. At times he would note the passing of one of his heroes like Carl Moyer (look it up!) and say, “Sic transit gloria mundi.” At 27 and anxious to get the right to cut into my fellow human beings, I would cock my head like a confounded puppy and wonder what that meant. I looked up the translation and meaning long ago, but now with age I understand the phrase in my bones.

I have long been a hanger-on at surgical meetings, hoping to meet those mighty figures that shaped surgical history. I saw W. Dean Warren once and had a very long hour with the great Mark Ravitch. Oliver Beahrs once performed magic tricks at a dinner I attended. At every surgical meeting there is an old guy (and now occasionally with the change in our profession, an elderly lady) getting on the bus to go to the reception or dinner dance. Often they are alone, their spouses having departed before them. As a young man, I wondered why the heck they came to the meetings. Just like every generation before, ours was eager to grab the reins, and in our ardor for future glory, we were polite but also restless for them to move aside. I hadn’t yet learned the importance of history and of listening.

What I missed while carousing with my young colleagues was an opportunity to hear history first hand and to learn that, what we thought was so cutting edge, these men and women had long ago considered. Many of our living legends imagined some of today’s innovations but they lacked the technology to bring their dreams to fruition, or time and age defeated them before they reached the final chapter of their research. It was when I was about 50 that I wised up and began seeking out living legends like Frank Moody and Frank Spencer.

In the case of Frank Moody, he was quite elderly when I first met him. For some reason, he knew who I was and shook my hand softly. I didn’t recognize him initially, but at the sound of his name, I knew I was in the presence of a major figure in 20th century gastrointestinal surgery. He had been at the University of California, San Francisco, during an historic time when George Sheldon, Donald Trunkey and other great surgeons trained there with J. Englebert Dunphy as their chief. Dr. Moody’s CV lists 141 articles in basic and clinical science that have had a profound impact on how we view the gastrointestinal tract. He was Chief at the University of Utah and the University of Alabama and finished his career as professor at the University of Texas-Houston. His awards and achievements were legion.

Parkinson’s had only recently really begun to affect him when I met him, and as the years went by his voice became so very faint that I had to lean in to hear him. We would sit together at the back of the dinner dance room so that we could hear each other. And while the other guests entertained themselves, Dr. Moody and I would discuss his life, scientific method and philosophy as well as his insights into his own case of Parkinsonism. I would see him at meetings, making his way slowly but steadily along a corridor while others briskly walked by, unaware that the man they just passed was among the most important surgical pioneers of our time. It was not sad that Dr. Moody was elderly and unrecognized, but that we younger surgeons missed knowing a great man in our tendency to rush past history.

History is not facts and dates, but rather, it is people and their lives. Yes, the history of our profession is embodied by pioneers like Frank Moody and the others I’ve mentioned.

We have many Fellows among us who are living history, still contributing – maybe not at the dais but at the dinner table, speaking softly and walking a bit slower than their juniors. Thanks to LaMar McGinnis who started it and Don Nakayama who continues it, the College has a History Community on the ACS Communities, an active Surgical History Group, and a will to acknowledge the history that lives and breathes among us. The Surgical History Group has organized a full program of events at the Clinical Congress and I hope many attendees take the opportunity to attend.

Take a moment at your next meeting or at the Clinical Congress and look for those historic surgeons still with us. Be smarter than I was at a young age and get to know them. You may learn something from them you can’t learn anyplace else.

Dr. Hughes is clinical professor in the department of surgery and director of medical education at the Kansas University School of Medicine, Salina Campus, and Co-Editor of ACS Surgery News.