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MDedge conference coverage features onsite reporting of the latest study results and expert perspectives from leading researchers.
Could Aspirin Avert Bad Outcomes in Leukemia?
A new analysis hints that there may be a benefit from aspirin for hospitalized patients with leukemia. In a preliminary study, researchers found that aspirin users had much lower odds of intracranial bleeding, deep vein thrombosis, in-hospital mortality, and septic stroke.
Aspirin users also spent less time in the hospital and had less costly care.
No one is suggesting that clinicians give aspirin to hospitalized patients with leukemia when the drug is not otherwise indicated. However, the findings, released at the Society of Hematologic Oncology (SOHO 2024) meeting in Houston, do indicate that more research is warranted, study lead author Jayalekshmi Jayakumar, MD, of the Brooklyn Hospital Center in New York City, said in a presentation.
“We hope our study can act as background for further prospective and experimental studies to explore this association,” she said. “If we can establish causation, then aspirin has a potential to be a thromboprophylactic agent to enhance outcomes and reduce resource utilization among leukemia hospitalizations.”
Dr. Jayakumar noted that previous research has suggested aspirin may help prevent deep vein thrombosis in patients with breast and pancreatic cancer. And in blood cancer, animal research has suggested that aspirin may “promote apoptosis in leukemia cells and decrease the spread of leukemia cells through platelet inhibition,” she said.
However, “we do not have any prospective or retrospective studies to establish causation or to see if this actually has some value within the clinical practice,” she noted.
Dr. Jayakumar stated that new study aims to detect whether aspirin may be beneficial in leukemia. She and her colleagues retrospectively tracked 1,663,149 US hospitalizations of patients with leukemia from 2016 to 2020 via the National Inpatient Sample. Of those patients, 11.2% used aspirin, although the data didn’t say whether they started it during hospitalization, and dosages were not reported. Aspirin users were older (mean age, 74.53 years vs 64.83 years in nonusers).
After adjustment for confounders, aspirin users had lower odds of several conditions than nonusers:
- Epistaxis (odds ratio [OR], 0.63; 95% CI, 0.55-0.72; P < .001)
- Hemoptysis (OR, 0.71; 95% CI, 0.61-0.82; P < .001)
- Intracranial bleed (OR, 0.74; 95% CI, 0.64-0.85; P < .001)
- Deep vein thrombosis (OR, 0.72; 95% CI, 0.66-0.78; P < .001)
- In-hospital mortality (OR, 0.54; 95% CI, 0.50-0.58; P < .001)
- Sepsis (OR, 0.71; 95% CI, 0.68-0.75; P < .001)
- Septic shock (OR, 0.55; 95% CI, 0.50-0.60; P < .001)
There was no association reported for gastrointestinal bleeding, a possible side effect of aspirin use, or tumor lysis syndrome. Aspirin users also had a shorter typical stay (−2.8 days) and lower typical hospital charges ($40,719).
“We also found that aspirin users had a slightly reduced risk of minor bleeding and infection compared to non–aspirin users,” Dr. Jayakumar said.
In an interview, Dr. Jayakumar noted that the study is retrospective and declined to speculate on why aspirin may have benefits or why it may have the seemingly contradictory effect of reducing both blood clots and bleeding.
Aspirin is one of the least expensive drugs in existence.
In an interview, Richard M. Stone, MD, oncologist at Dana-Farber Cancer Institute in Boston, who’s familiar with the study findings but didn’t take part in the research, said the findings are “totally counterintuitive.”
“It doesn’t mean they should be rejected, but they should be highly scrutinized,” he said.
Dr. Stone added that bleeding is a major risk in leukemia due to low platelet counts, although platelet transplants can be helpful, and patients rarely die of bleeding. Thrombosis is also a problem in leukemia, he said, and it’s being increasingly recognized as a risk in acute myeloid leukemia.
No funding was reported. Dr. Jayakumar and Dr. Stone had no disclosures.
A version of this article appeared on Medscape.com.
A new analysis hints that there may be a benefit from aspirin for hospitalized patients with leukemia. In a preliminary study, researchers found that aspirin users had much lower odds of intracranial bleeding, deep vein thrombosis, in-hospital mortality, and septic stroke.
Aspirin users also spent less time in the hospital and had less costly care.
No one is suggesting that clinicians give aspirin to hospitalized patients with leukemia when the drug is not otherwise indicated. However, the findings, released at the Society of Hematologic Oncology (SOHO 2024) meeting in Houston, do indicate that more research is warranted, study lead author Jayalekshmi Jayakumar, MD, of the Brooklyn Hospital Center in New York City, said in a presentation.
“We hope our study can act as background for further prospective and experimental studies to explore this association,” she said. “If we can establish causation, then aspirin has a potential to be a thromboprophylactic agent to enhance outcomes and reduce resource utilization among leukemia hospitalizations.”
Dr. Jayakumar noted that previous research has suggested aspirin may help prevent deep vein thrombosis in patients with breast and pancreatic cancer. And in blood cancer, animal research has suggested that aspirin may “promote apoptosis in leukemia cells and decrease the spread of leukemia cells through platelet inhibition,” she said.
However, “we do not have any prospective or retrospective studies to establish causation or to see if this actually has some value within the clinical practice,” she noted.
Dr. Jayakumar stated that new study aims to detect whether aspirin may be beneficial in leukemia. She and her colleagues retrospectively tracked 1,663,149 US hospitalizations of patients with leukemia from 2016 to 2020 via the National Inpatient Sample. Of those patients, 11.2% used aspirin, although the data didn’t say whether they started it during hospitalization, and dosages were not reported. Aspirin users were older (mean age, 74.53 years vs 64.83 years in nonusers).
After adjustment for confounders, aspirin users had lower odds of several conditions than nonusers:
- Epistaxis (odds ratio [OR], 0.63; 95% CI, 0.55-0.72; P < .001)
- Hemoptysis (OR, 0.71; 95% CI, 0.61-0.82; P < .001)
- Intracranial bleed (OR, 0.74; 95% CI, 0.64-0.85; P < .001)
- Deep vein thrombosis (OR, 0.72; 95% CI, 0.66-0.78; P < .001)
- In-hospital mortality (OR, 0.54; 95% CI, 0.50-0.58; P < .001)
- Sepsis (OR, 0.71; 95% CI, 0.68-0.75; P < .001)
- Septic shock (OR, 0.55; 95% CI, 0.50-0.60; P < .001)
There was no association reported for gastrointestinal bleeding, a possible side effect of aspirin use, or tumor lysis syndrome. Aspirin users also had a shorter typical stay (−2.8 days) and lower typical hospital charges ($40,719).
“We also found that aspirin users had a slightly reduced risk of minor bleeding and infection compared to non–aspirin users,” Dr. Jayakumar said.
In an interview, Dr. Jayakumar noted that the study is retrospective and declined to speculate on why aspirin may have benefits or why it may have the seemingly contradictory effect of reducing both blood clots and bleeding.
Aspirin is one of the least expensive drugs in existence.
In an interview, Richard M. Stone, MD, oncologist at Dana-Farber Cancer Institute in Boston, who’s familiar with the study findings but didn’t take part in the research, said the findings are “totally counterintuitive.”
“It doesn’t mean they should be rejected, but they should be highly scrutinized,” he said.
Dr. Stone added that bleeding is a major risk in leukemia due to low platelet counts, although platelet transplants can be helpful, and patients rarely die of bleeding. Thrombosis is also a problem in leukemia, he said, and it’s being increasingly recognized as a risk in acute myeloid leukemia.
No funding was reported. Dr. Jayakumar and Dr. Stone had no disclosures.
A version of this article appeared on Medscape.com.
A new analysis hints that there may be a benefit from aspirin for hospitalized patients with leukemia. In a preliminary study, researchers found that aspirin users had much lower odds of intracranial bleeding, deep vein thrombosis, in-hospital mortality, and septic stroke.
Aspirin users also spent less time in the hospital and had less costly care.
No one is suggesting that clinicians give aspirin to hospitalized patients with leukemia when the drug is not otherwise indicated. However, the findings, released at the Society of Hematologic Oncology (SOHO 2024) meeting in Houston, do indicate that more research is warranted, study lead author Jayalekshmi Jayakumar, MD, of the Brooklyn Hospital Center in New York City, said in a presentation.
“We hope our study can act as background for further prospective and experimental studies to explore this association,” she said. “If we can establish causation, then aspirin has a potential to be a thromboprophylactic agent to enhance outcomes and reduce resource utilization among leukemia hospitalizations.”
Dr. Jayakumar noted that previous research has suggested aspirin may help prevent deep vein thrombosis in patients with breast and pancreatic cancer. And in blood cancer, animal research has suggested that aspirin may “promote apoptosis in leukemia cells and decrease the spread of leukemia cells through platelet inhibition,” she said.
However, “we do not have any prospective or retrospective studies to establish causation or to see if this actually has some value within the clinical practice,” she noted.
Dr. Jayakumar stated that new study aims to detect whether aspirin may be beneficial in leukemia. She and her colleagues retrospectively tracked 1,663,149 US hospitalizations of patients with leukemia from 2016 to 2020 via the National Inpatient Sample. Of those patients, 11.2% used aspirin, although the data didn’t say whether they started it during hospitalization, and dosages were not reported. Aspirin users were older (mean age, 74.53 years vs 64.83 years in nonusers).
After adjustment for confounders, aspirin users had lower odds of several conditions than nonusers:
- Epistaxis (odds ratio [OR], 0.63; 95% CI, 0.55-0.72; P < .001)
- Hemoptysis (OR, 0.71; 95% CI, 0.61-0.82; P < .001)
- Intracranial bleed (OR, 0.74; 95% CI, 0.64-0.85; P < .001)
- Deep vein thrombosis (OR, 0.72; 95% CI, 0.66-0.78; P < .001)
- In-hospital mortality (OR, 0.54; 95% CI, 0.50-0.58; P < .001)
- Sepsis (OR, 0.71; 95% CI, 0.68-0.75; P < .001)
- Septic shock (OR, 0.55; 95% CI, 0.50-0.60; P < .001)
There was no association reported for gastrointestinal bleeding, a possible side effect of aspirin use, or tumor lysis syndrome. Aspirin users also had a shorter typical stay (−2.8 days) and lower typical hospital charges ($40,719).
“We also found that aspirin users had a slightly reduced risk of minor bleeding and infection compared to non–aspirin users,” Dr. Jayakumar said.
In an interview, Dr. Jayakumar noted that the study is retrospective and declined to speculate on why aspirin may have benefits or why it may have the seemingly contradictory effect of reducing both blood clots and bleeding.
Aspirin is one of the least expensive drugs in existence.
In an interview, Richard M. Stone, MD, oncologist at Dana-Farber Cancer Institute in Boston, who’s familiar with the study findings but didn’t take part in the research, said the findings are “totally counterintuitive.”
“It doesn’t mean they should be rejected, but they should be highly scrutinized,” he said.
Dr. Stone added that bleeding is a major risk in leukemia due to low platelet counts, although platelet transplants can be helpful, and patients rarely die of bleeding. Thrombosis is also a problem in leukemia, he said, and it’s being increasingly recognized as a risk in acute myeloid leukemia.
No funding was reported. Dr. Jayakumar and Dr. Stone had no disclosures.
A version of this article appeared on Medscape.com.
FROM SOHO 2024
Focusing on Value in Social Media Posts
CARLSBAD, CALIFORNIA — Posting on social media may not be your cup of tea, but in the opinion of Jessica G. Labadie, MD,
“Over the past 2 decades, there has been a surge in social media use,” Dr. Labadie, a dermatologist who practices in Chestnut Hill, Massachusetts, said at the Controversies & Conversations in Laser & Cosmetic Surgery symposium. “Most of our patients use social media to find their doctors, and it plays a role in how our patients form their decision about whether to have a cosmetic procedure or not. Doctors, especially dermatologists, continue to actively participate in this ‘skinfluencer’ trend.”
According to a review of social media’s impact on aesthetic medicine, use of social media by American adults increased from 5% in 2005 to 72% in 2020, and 77% of patients search for a physician online. The review’s authors cited YouTube as the most popular platform among adults and noted that social media ranks as the sixth top factor for a patient deciding whether to have a laser procedure.
Dr. Labadie, who is also an assistant professor of dermatology at the Icahn School of Medicine at Mount Sinai in New York City, said several factors should be considered when establishing and maintaining a social media presence, starting with personal ones. “Your followers are not your patients yet, and just because you may have thousands of followers does not necessarily mean that you’re busier in the clinic,” she said. “Be careful if you combine professional and personal accounts; be careful of those parasocial relationships that can form. Your followers tend to learn a lot about you. Posting can take a lot of time; it can take away from your clinical duties. Do you want to make your account private or public? There are pros and cons to both.”
Ethics also play a role. “Be transparent in your disclosure forms, especially if you’re posting ‘before’ and ‘after’ images of patients,” advised Dr. Labadie, who described herself as a social media minimalist. “Stay true to yourself in your posts, and always prioritize safety over posting.”
Don’t forget legal obligations. “Social media can facilitate a passive income, but make sure this isn’t impacting any conflicts of interest, and make sure that you meticulously follow any Health Insurance Portability and Accountability Act regulations,” she said. She also cautioned against violating intellectual property rights and making false claims about a product or procedure.
Deciding which platforms to use and what voice or tone to adopt requires some soul-searching. “What is your brand?” Dr. Labadie asked. “How do you want to portray yourself? Does your social media brand match your office brand? Does it match who you are as a provider and the type of patient you wish to attract? Would you prefer to have one collective social media presence as an office or multiple provider accounts?”
Being mindful of how your patients perceive and use social media in relation to their dermatologic concerns is also important. “What are your patients viewing on social media, and how is it affecting their decisions?” Dr. Labadie asked. “Are they coming in asking for something that is not right for what they need? At the end of the day, you are their doctor, and it’s your duty to treat the patients and not the trend.”
She encouraged dermatologists to “aim for high value and accurate posts coupled with high popularity and reach.” She added that “this is really the future of getting our research out there to the public. Academic notoriety is not enough. Our professional societies and skinfluencer colleagues need to get involved to help promote our expert research.”
Dr. Labadie reported having no financial disclosures.
A version of this article appeared on Medscape.com.
CARLSBAD, CALIFORNIA — Posting on social media may not be your cup of tea, but in the opinion of Jessica G. Labadie, MD,
“Over the past 2 decades, there has been a surge in social media use,” Dr. Labadie, a dermatologist who practices in Chestnut Hill, Massachusetts, said at the Controversies & Conversations in Laser & Cosmetic Surgery symposium. “Most of our patients use social media to find their doctors, and it plays a role in how our patients form their decision about whether to have a cosmetic procedure or not. Doctors, especially dermatologists, continue to actively participate in this ‘skinfluencer’ trend.”
According to a review of social media’s impact on aesthetic medicine, use of social media by American adults increased from 5% in 2005 to 72% in 2020, and 77% of patients search for a physician online. The review’s authors cited YouTube as the most popular platform among adults and noted that social media ranks as the sixth top factor for a patient deciding whether to have a laser procedure.
Dr. Labadie, who is also an assistant professor of dermatology at the Icahn School of Medicine at Mount Sinai in New York City, said several factors should be considered when establishing and maintaining a social media presence, starting with personal ones. “Your followers are not your patients yet, and just because you may have thousands of followers does not necessarily mean that you’re busier in the clinic,” she said. “Be careful if you combine professional and personal accounts; be careful of those parasocial relationships that can form. Your followers tend to learn a lot about you. Posting can take a lot of time; it can take away from your clinical duties. Do you want to make your account private or public? There are pros and cons to both.”
Ethics also play a role. “Be transparent in your disclosure forms, especially if you’re posting ‘before’ and ‘after’ images of patients,” advised Dr. Labadie, who described herself as a social media minimalist. “Stay true to yourself in your posts, and always prioritize safety over posting.”
Don’t forget legal obligations. “Social media can facilitate a passive income, but make sure this isn’t impacting any conflicts of interest, and make sure that you meticulously follow any Health Insurance Portability and Accountability Act regulations,” she said. She also cautioned against violating intellectual property rights and making false claims about a product or procedure.
Deciding which platforms to use and what voice or tone to adopt requires some soul-searching. “What is your brand?” Dr. Labadie asked. “How do you want to portray yourself? Does your social media brand match your office brand? Does it match who you are as a provider and the type of patient you wish to attract? Would you prefer to have one collective social media presence as an office or multiple provider accounts?”
Being mindful of how your patients perceive and use social media in relation to their dermatologic concerns is also important. “What are your patients viewing on social media, and how is it affecting their decisions?” Dr. Labadie asked. “Are they coming in asking for something that is not right for what they need? At the end of the day, you are their doctor, and it’s your duty to treat the patients and not the trend.”
She encouraged dermatologists to “aim for high value and accurate posts coupled with high popularity and reach.” She added that “this is really the future of getting our research out there to the public. Academic notoriety is not enough. Our professional societies and skinfluencer colleagues need to get involved to help promote our expert research.”
Dr. Labadie reported having no financial disclosures.
A version of this article appeared on Medscape.com.
CARLSBAD, CALIFORNIA — Posting on social media may not be your cup of tea, but in the opinion of Jessica G. Labadie, MD,
“Over the past 2 decades, there has been a surge in social media use,” Dr. Labadie, a dermatologist who practices in Chestnut Hill, Massachusetts, said at the Controversies & Conversations in Laser & Cosmetic Surgery symposium. “Most of our patients use social media to find their doctors, and it plays a role in how our patients form their decision about whether to have a cosmetic procedure or not. Doctors, especially dermatologists, continue to actively participate in this ‘skinfluencer’ trend.”
According to a review of social media’s impact on aesthetic medicine, use of social media by American adults increased from 5% in 2005 to 72% in 2020, and 77% of patients search for a physician online. The review’s authors cited YouTube as the most popular platform among adults and noted that social media ranks as the sixth top factor for a patient deciding whether to have a laser procedure.
Dr. Labadie, who is also an assistant professor of dermatology at the Icahn School of Medicine at Mount Sinai in New York City, said several factors should be considered when establishing and maintaining a social media presence, starting with personal ones. “Your followers are not your patients yet, and just because you may have thousands of followers does not necessarily mean that you’re busier in the clinic,” she said. “Be careful if you combine professional and personal accounts; be careful of those parasocial relationships that can form. Your followers tend to learn a lot about you. Posting can take a lot of time; it can take away from your clinical duties. Do you want to make your account private or public? There are pros and cons to both.”
Ethics also play a role. “Be transparent in your disclosure forms, especially if you’re posting ‘before’ and ‘after’ images of patients,” advised Dr. Labadie, who described herself as a social media minimalist. “Stay true to yourself in your posts, and always prioritize safety over posting.”
Don’t forget legal obligations. “Social media can facilitate a passive income, but make sure this isn’t impacting any conflicts of interest, and make sure that you meticulously follow any Health Insurance Portability and Accountability Act regulations,” she said. She also cautioned against violating intellectual property rights and making false claims about a product or procedure.
Deciding which platforms to use and what voice or tone to adopt requires some soul-searching. “What is your brand?” Dr. Labadie asked. “How do you want to portray yourself? Does your social media brand match your office brand? Does it match who you are as a provider and the type of patient you wish to attract? Would you prefer to have one collective social media presence as an office or multiple provider accounts?”
Being mindful of how your patients perceive and use social media in relation to their dermatologic concerns is also important. “What are your patients viewing on social media, and how is it affecting their decisions?” Dr. Labadie asked. “Are they coming in asking for something that is not right for what they need? At the end of the day, you are their doctor, and it’s your duty to treat the patients and not the trend.”
She encouraged dermatologists to “aim for high value and accurate posts coupled with high popularity and reach.” She added that “this is really the future of getting our research out there to the public. Academic notoriety is not enough. Our professional societies and skinfluencer colleagues need to get involved to help promote our expert research.”
Dr. Labadie reported having no financial disclosures.
A version of this article appeared on Medscape.com.
Skip Potassium After Cardiac Surgery
LONDON —
“The widespread practice of giving patients potassium after bypass heart surgery even though their blood levels are within the normal range can be abandoned,” said Benjamin O’Brien, MD, PhD, director of the Clinic for Cardioanesthesiology and Intensive Care Medicine at Charité Hospital in Berlin, Germany.
Results from the randomized TIGHT-K trial that assessed two levels of potassium supplementation were presented at the annual congress of the European Society of Cardiology.
In the tight-control group, supplementation was provided to maintain high-normal levels of potassium (> 4.5 mEq/L). In the relaxed-control group, supplementation was provided only when potassium levels fell below the low-normal threshold (< 3.6 mEq/L).
Trial Upending Popular Practice
The multinational trial involved 23 centers in Germany and the United Kingdom. All 1690 participants enrolled were scheduled to undergo a coronary artery bypass graft procedure, but Dr. O’Brien said he considers the results of TIGHT-K to be broadly applicable.
“There is no physiological basis to expect a different result in patients undergoing different types of cardiac surgery,” he said.
The primary endpoint was clinically and electrocardiography confirmed new-onset atrial fibrillation that occurred in the 5 days after the bypass procedure.
For the primary atrial fibrillation endpoint, event rates were similar in the tight-control and the relaxed-control groups (26.2% vs 27.8%); the 1.7% difference did not approach statistical significance (P = .44). The difference in dysrhythmias other than atrial fibrillation, although numerically lower in the tight-control group, was also not significant (19.1% vs 21.1%; P = .26).
There were no significant differences in several secondary endpoints, including length of hospital stay and in-patient mortality, but cost, a prespecified secondary endpoint, was approximately $120 lower per patient in the relaxed-control group than in the tight-control group (P < .001).
Lowering Cost Across Cardiac Surgeries
During the 5-day follow-up, median potassium levels were higher in the tight-control group. Levels in both groups fell gradually, but essentially in parallel, over the study period, so median potassium levels were always higher in the tight-control group than in the relaxed-control group. At the end of the observation period, mean potassium levels were 4.34 mEq/L in the tight-control group and 4.08 mEq/L in the relaxed-control group.
Prior to the development of atrial fibrillation, participants in the tight-control group received a medium of seven potassium administrations (range, 4-12), whereas those in the relaxed-control group received a medium of zero.
There were no significant differences in episodes in any subgroup evaluated, including those divided by age, sex, baseline left ventricular ejection fraction, and the absence or presence of beta blockers or loop diuretics. A per-protocol analysis also failed to show any advantage for tight potassium control.
Atrial fibrillation occurs in about one third of patients after bypass surgery, as it does after many types of cardiac surgery. Institutions often have strategies in place to reduce the risk after cardiac surgery, and potassium supplementation is one of the most common, despite the lack of supportive evidence, Dr. O’Brien said.
Narrow Window for Optimal Potassium Levels
The difference in potassium levels between the tight-control group and the relaxed-control group were modest in this study, said Subodh Verma, MD, a cardiac surgeon at St Michael’s Hospital and professor at the University of Toronto, Ontario, Canada.
However, this is unavoidable and central to the question being posed, Dr. O’Brien pointed out. Because of the risks for both hypokalemia and hyperkalemia, the window for safe supplementation is short. Current practice is to achieve high-normal levels to reduce atrial fibrillation, but TIGHT-K demonstrates this has no benefit.
The conclusion of TIGHT-K is appropriate, said Faiez Zannad, MD, PhD, professor of therapeutics in the Division of Cardiology at the University of Lorraine in Nancy, France, who praised the design and conduct of the study.
He acknowledged an unmet need for effective methods to reduce the risk for atrial fibrillation after cardiac surgery, but the ESC invited discussant said it is now necessary to look at other strategies. Several are under current evaluation, such as supplementary magnesium and the use of sodium-glucose transporter-2 inhibitors.
Although Dr. Zannad encouraged more studies of methods to reduce atrial fibrillation risk after cardiac surgery, he said that TIGHT-K has answered the question of whether potassium supplementation is beneficial.
Potassium supplementation should no longer be offered, he said, which will “reduce healthcare costs and decrease patient risk from an unnecessary intervention.”
A version of this article first appeared on Medscape.com.
LONDON —
“The widespread practice of giving patients potassium after bypass heart surgery even though their blood levels are within the normal range can be abandoned,” said Benjamin O’Brien, MD, PhD, director of the Clinic for Cardioanesthesiology and Intensive Care Medicine at Charité Hospital in Berlin, Germany.
Results from the randomized TIGHT-K trial that assessed two levels of potassium supplementation were presented at the annual congress of the European Society of Cardiology.
In the tight-control group, supplementation was provided to maintain high-normal levels of potassium (> 4.5 mEq/L). In the relaxed-control group, supplementation was provided only when potassium levels fell below the low-normal threshold (< 3.6 mEq/L).
Trial Upending Popular Practice
The multinational trial involved 23 centers in Germany and the United Kingdom. All 1690 participants enrolled were scheduled to undergo a coronary artery bypass graft procedure, but Dr. O’Brien said he considers the results of TIGHT-K to be broadly applicable.
“There is no physiological basis to expect a different result in patients undergoing different types of cardiac surgery,” he said.
The primary endpoint was clinically and electrocardiography confirmed new-onset atrial fibrillation that occurred in the 5 days after the bypass procedure.
For the primary atrial fibrillation endpoint, event rates were similar in the tight-control and the relaxed-control groups (26.2% vs 27.8%); the 1.7% difference did not approach statistical significance (P = .44). The difference in dysrhythmias other than atrial fibrillation, although numerically lower in the tight-control group, was also not significant (19.1% vs 21.1%; P = .26).
There were no significant differences in several secondary endpoints, including length of hospital stay and in-patient mortality, but cost, a prespecified secondary endpoint, was approximately $120 lower per patient in the relaxed-control group than in the tight-control group (P < .001).
Lowering Cost Across Cardiac Surgeries
During the 5-day follow-up, median potassium levels were higher in the tight-control group. Levels in both groups fell gradually, but essentially in parallel, over the study period, so median potassium levels were always higher in the tight-control group than in the relaxed-control group. At the end of the observation period, mean potassium levels were 4.34 mEq/L in the tight-control group and 4.08 mEq/L in the relaxed-control group.
Prior to the development of atrial fibrillation, participants in the tight-control group received a medium of seven potassium administrations (range, 4-12), whereas those in the relaxed-control group received a medium of zero.
There were no significant differences in episodes in any subgroup evaluated, including those divided by age, sex, baseline left ventricular ejection fraction, and the absence or presence of beta blockers or loop diuretics. A per-protocol analysis also failed to show any advantage for tight potassium control.
Atrial fibrillation occurs in about one third of patients after bypass surgery, as it does after many types of cardiac surgery. Institutions often have strategies in place to reduce the risk after cardiac surgery, and potassium supplementation is one of the most common, despite the lack of supportive evidence, Dr. O’Brien said.
Narrow Window for Optimal Potassium Levels
The difference in potassium levels between the tight-control group and the relaxed-control group were modest in this study, said Subodh Verma, MD, a cardiac surgeon at St Michael’s Hospital and professor at the University of Toronto, Ontario, Canada.
However, this is unavoidable and central to the question being posed, Dr. O’Brien pointed out. Because of the risks for both hypokalemia and hyperkalemia, the window for safe supplementation is short. Current practice is to achieve high-normal levels to reduce atrial fibrillation, but TIGHT-K demonstrates this has no benefit.
The conclusion of TIGHT-K is appropriate, said Faiez Zannad, MD, PhD, professor of therapeutics in the Division of Cardiology at the University of Lorraine in Nancy, France, who praised the design and conduct of the study.
He acknowledged an unmet need for effective methods to reduce the risk for atrial fibrillation after cardiac surgery, but the ESC invited discussant said it is now necessary to look at other strategies. Several are under current evaluation, such as supplementary magnesium and the use of sodium-glucose transporter-2 inhibitors.
Although Dr. Zannad encouraged more studies of methods to reduce atrial fibrillation risk after cardiac surgery, he said that TIGHT-K has answered the question of whether potassium supplementation is beneficial.
Potassium supplementation should no longer be offered, he said, which will “reduce healthcare costs and decrease patient risk from an unnecessary intervention.”
A version of this article first appeared on Medscape.com.
LONDON —
“The widespread practice of giving patients potassium after bypass heart surgery even though their blood levels are within the normal range can be abandoned,” said Benjamin O’Brien, MD, PhD, director of the Clinic for Cardioanesthesiology and Intensive Care Medicine at Charité Hospital in Berlin, Germany.
Results from the randomized TIGHT-K trial that assessed two levels of potassium supplementation were presented at the annual congress of the European Society of Cardiology.
In the tight-control group, supplementation was provided to maintain high-normal levels of potassium (> 4.5 mEq/L). In the relaxed-control group, supplementation was provided only when potassium levels fell below the low-normal threshold (< 3.6 mEq/L).
Trial Upending Popular Practice
The multinational trial involved 23 centers in Germany and the United Kingdom. All 1690 participants enrolled were scheduled to undergo a coronary artery bypass graft procedure, but Dr. O’Brien said he considers the results of TIGHT-K to be broadly applicable.
“There is no physiological basis to expect a different result in patients undergoing different types of cardiac surgery,” he said.
The primary endpoint was clinically and electrocardiography confirmed new-onset atrial fibrillation that occurred in the 5 days after the bypass procedure.
For the primary atrial fibrillation endpoint, event rates were similar in the tight-control and the relaxed-control groups (26.2% vs 27.8%); the 1.7% difference did not approach statistical significance (P = .44). The difference in dysrhythmias other than atrial fibrillation, although numerically lower in the tight-control group, was also not significant (19.1% vs 21.1%; P = .26).
There were no significant differences in several secondary endpoints, including length of hospital stay and in-patient mortality, but cost, a prespecified secondary endpoint, was approximately $120 lower per patient in the relaxed-control group than in the tight-control group (P < .001).
Lowering Cost Across Cardiac Surgeries
During the 5-day follow-up, median potassium levels were higher in the tight-control group. Levels in both groups fell gradually, but essentially in parallel, over the study period, so median potassium levels were always higher in the tight-control group than in the relaxed-control group. At the end of the observation period, mean potassium levels were 4.34 mEq/L in the tight-control group and 4.08 mEq/L in the relaxed-control group.
Prior to the development of atrial fibrillation, participants in the tight-control group received a medium of seven potassium administrations (range, 4-12), whereas those in the relaxed-control group received a medium of zero.
There were no significant differences in episodes in any subgroup evaluated, including those divided by age, sex, baseline left ventricular ejection fraction, and the absence or presence of beta blockers or loop diuretics. A per-protocol analysis also failed to show any advantage for tight potassium control.
Atrial fibrillation occurs in about one third of patients after bypass surgery, as it does after many types of cardiac surgery. Institutions often have strategies in place to reduce the risk after cardiac surgery, and potassium supplementation is one of the most common, despite the lack of supportive evidence, Dr. O’Brien said.
Narrow Window for Optimal Potassium Levels
The difference in potassium levels between the tight-control group and the relaxed-control group were modest in this study, said Subodh Verma, MD, a cardiac surgeon at St Michael’s Hospital and professor at the University of Toronto, Ontario, Canada.
However, this is unavoidable and central to the question being posed, Dr. O’Brien pointed out. Because of the risks for both hypokalemia and hyperkalemia, the window for safe supplementation is short. Current practice is to achieve high-normal levels to reduce atrial fibrillation, but TIGHT-K demonstrates this has no benefit.
The conclusion of TIGHT-K is appropriate, said Faiez Zannad, MD, PhD, professor of therapeutics in the Division of Cardiology at the University of Lorraine in Nancy, France, who praised the design and conduct of the study.
He acknowledged an unmet need for effective methods to reduce the risk for atrial fibrillation after cardiac surgery, but the ESC invited discussant said it is now necessary to look at other strategies. Several are under current evaluation, such as supplementary magnesium and the use of sodium-glucose transporter-2 inhibitors.
Although Dr. Zannad encouraged more studies of methods to reduce atrial fibrillation risk after cardiac surgery, he said that TIGHT-K has answered the question of whether potassium supplementation is beneficial.
Potassium supplementation should no longer be offered, he said, which will “reduce healthcare costs and decrease patient risk from an unnecessary intervention.”
A version of this article first appeared on Medscape.com.
FROM ESC CONGRESS 2024
Changes in Age-Related Mortality in Malignant Melanoma From 1999- 2022: A CDC Wonder Study
Background
Melanoma is one of the leading causes of solid tumor cancers. This study’s objective is to analyze temporal trends in melanoma-related mortality among age groups in the US before and during COVID-19. To date, no previous studies have analyzed year-to-year trends in melanoma mortality by age group using the CDC Wonder database. A 2011 analysis previously showed increasing death rates only among those over age 65 between 1992-2006.
Methods
The CDC Wonder database was used to collect data on melanoma-related mortality rates in the US from 1999-2022. Crude mortality rates per 100,000 and annual percentage change using Joinpoint regression were used to analyze yearly trends among age groups.
Results
From 1999 to 2022, overall mortality rate fell from 2.91 to 2.07, and mortality rates among all age groups decreased with the exception of those over age 85. Age 35-44 crude mortality rate decreased from 1.42 to .7. Age 45-54 crude mortality rate decreased from 3.2 to 1.51. Age 55-64 decreased from 5.6 to 3.61. Age 65-74 decreased from 9.91 to 7.79. Age 75-84 decreased from 15.44 to 15.43. Ages 85+ increased from 21.5 to 33.1. Notably, mortality among those age 75-85 decreased by only .01, and were increased across the timespan of 2000-2020.
Conclusions
These results show that there may be differences between age groups in how mortality due to melanoma of age groups has changed from 1992-2022. While overall mortality attributed to melanoma fell during this period, mortality in those over age 85 increased. Future studies should confirm these results with different data sets and further investigate the reasons for these disparities.
Background
Melanoma is one of the leading causes of solid tumor cancers. This study’s objective is to analyze temporal trends in melanoma-related mortality among age groups in the US before and during COVID-19. To date, no previous studies have analyzed year-to-year trends in melanoma mortality by age group using the CDC Wonder database. A 2011 analysis previously showed increasing death rates only among those over age 65 between 1992-2006.
Methods
The CDC Wonder database was used to collect data on melanoma-related mortality rates in the US from 1999-2022. Crude mortality rates per 100,000 and annual percentage change using Joinpoint regression were used to analyze yearly trends among age groups.
Results
From 1999 to 2022, overall mortality rate fell from 2.91 to 2.07, and mortality rates among all age groups decreased with the exception of those over age 85. Age 35-44 crude mortality rate decreased from 1.42 to .7. Age 45-54 crude mortality rate decreased from 3.2 to 1.51. Age 55-64 decreased from 5.6 to 3.61. Age 65-74 decreased from 9.91 to 7.79. Age 75-84 decreased from 15.44 to 15.43. Ages 85+ increased from 21.5 to 33.1. Notably, mortality among those age 75-85 decreased by only .01, and were increased across the timespan of 2000-2020.
Conclusions
These results show that there may be differences between age groups in how mortality due to melanoma of age groups has changed from 1992-2022. While overall mortality attributed to melanoma fell during this period, mortality in those over age 85 increased. Future studies should confirm these results with different data sets and further investigate the reasons for these disparities.
Background
Melanoma is one of the leading causes of solid tumor cancers. This study’s objective is to analyze temporal trends in melanoma-related mortality among age groups in the US before and during COVID-19. To date, no previous studies have analyzed year-to-year trends in melanoma mortality by age group using the CDC Wonder database. A 2011 analysis previously showed increasing death rates only among those over age 65 between 1992-2006.
Methods
The CDC Wonder database was used to collect data on melanoma-related mortality rates in the US from 1999-2022. Crude mortality rates per 100,000 and annual percentage change using Joinpoint regression were used to analyze yearly trends among age groups.
Results
From 1999 to 2022, overall mortality rate fell from 2.91 to 2.07, and mortality rates among all age groups decreased with the exception of those over age 85. Age 35-44 crude mortality rate decreased from 1.42 to .7. Age 45-54 crude mortality rate decreased from 3.2 to 1.51. Age 55-64 decreased from 5.6 to 3.61. Age 65-74 decreased from 9.91 to 7.79. Age 75-84 decreased from 15.44 to 15.43. Ages 85+ increased from 21.5 to 33.1. Notably, mortality among those age 75-85 decreased by only .01, and were increased across the timespan of 2000-2020.
Conclusions
These results show that there may be differences between age groups in how mortality due to melanoma of age groups has changed from 1992-2022. While overall mortality attributed to melanoma fell during this period, mortality in those over age 85 increased. Future studies should confirm these results with different data sets and further investigate the reasons for these disparities.
Geographical Trends in Malignant Melanoma from 1999-2022: A CDC Wonder Study
Background
Melanoma is the fifth leading cause of cancer in the United States. This study’s objective is to analyze geographical trends in melanoma-related mortality in the US before and during COVID-19. To date, no previous studies have analyzed geographical trends in melanoma mortality using the CDC Wonder data base. Previous literature reports Utah, Vermont, Delaware, Minnesota and New Hampshire as having the highest UV-attributable incidence rates of melanoma.
Methods
The CDC Wonder database was used to collect data on melanoma-related mortality rates in the US from 1999-2022. Age-adjusted mortality rates (AAMR) per 100,000 and annual percentage change (APC) using Joinpoint regression were used to analyze state and regional trends.
Results
From 1999 to 2019, the states with the largest increase in AAMR were Idaho (0.91) and Colorado (0.63) while Oklahoma (-1.07), Nevada (-0.94), and Texas (-0.92) saw the largest decreases. During COVID-19 (2019 to 2021), the states with the largest increase in AAMR were South Dakota (1.42), Oregon (1.09), and Montana (1.08) while Vermont (-1.02), Minnesota (-0.45), and Connecticut (-0.38) had the largest declines. From 2006-2022, except 2020, the Northeast consistently had the lowest AAMR. From 2008-2012 the West consistently had the highest AAMR. From 2013-2022, except 2015, the Midwest had the highest AAMR. From 2009 onwards, all 4 regions have seen an overall decline in AAMR with their lowest values being in 2022.
Conclusions
Idaho had the highest AAMR before COVID-19 while Oklahoma had the lowest. During COVID-19, South Dakota saw the highest AAMR while Vermont had the lowest. AAMRs have been trending downwards across all 4 regions since 2009 and the Northeast has fared the best over that period. These results should be used to increase implementation and enforcement of preventative measures to reduce UV exposure, especially in states with higher AAMRs. Further research should examine statewide sun protection programs to search for any relationship with their AAMRs.
Background
Melanoma is the fifth leading cause of cancer in the United States. This study’s objective is to analyze geographical trends in melanoma-related mortality in the US before and during COVID-19. To date, no previous studies have analyzed geographical trends in melanoma mortality using the CDC Wonder data base. Previous literature reports Utah, Vermont, Delaware, Minnesota and New Hampshire as having the highest UV-attributable incidence rates of melanoma.
Methods
The CDC Wonder database was used to collect data on melanoma-related mortality rates in the US from 1999-2022. Age-adjusted mortality rates (AAMR) per 100,000 and annual percentage change (APC) using Joinpoint regression were used to analyze state and regional trends.
Results
From 1999 to 2019, the states with the largest increase in AAMR were Idaho (0.91) and Colorado (0.63) while Oklahoma (-1.07), Nevada (-0.94), and Texas (-0.92) saw the largest decreases. During COVID-19 (2019 to 2021), the states with the largest increase in AAMR were South Dakota (1.42), Oregon (1.09), and Montana (1.08) while Vermont (-1.02), Minnesota (-0.45), and Connecticut (-0.38) had the largest declines. From 2006-2022, except 2020, the Northeast consistently had the lowest AAMR. From 2008-2012 the West consistently had the highest AAMR. From 2013-2022, except 2015, the Midwest had the highest AAMR. From 2009 onwards, all 4 regions have seen an overall decline in AAMR with their lowest values being in 2022.
Conclusions
Idaho had the highest AAMR before COVID-19 while Oklahoma had the lowest. During COVID-19, South Dakota saw the highest AAMR while Vermont had the lowest. AAMRs have been trending downwards across all 4 regions since 2009 and the Northeast has fared the best over that period. These results should be used to increase implementation and enforcement of preventative measures to reduce UV exposure, especially in states with higher AAMRs. Further research should examine statewide sun protection programs to search for any relationship with their AAMRs.
Background
Melanoma is the fifth leading cause of cancer in the United States. This study’s objective is to analyze geographical trends in melanoma-related mortality in the US before and during COVID-19. To date, no previous studies have analyzed geographical trends in melanoma mortality using the CDC Wonder data base. Previous literature reports Utah, Vermont, Delaware, Minnesota and New Hampshire as having the highest UV-attributable incidence rates of melanoma.
Methods
The CDC Wonder database was used to collect data on melanoma-related mortality rates in the US from 1999-2022. Age-adjusted mortality rates (AAMR) per 100,000 and annual percentage change (APC) using Joinpoint regression were used to analyze state and regional trends.
Results
From 1999 to 2019, the states with the largest increase in AAMR were Idaho (0.91) and Colorado (0.63) while Oklahoma (-1.07), Nevada (-0.94), and Texas (-0.92) saw the largest decreases. During COVID-19 (2019 to 2021), the states with the largest increase in AAMR were South Dakota (1.42), Oregon (1.09), and Montana (1.08) while Vermont (-1.02), Minnesota (-0.45), and Connecticut (-0.38) had the largest declines. From 2006-2022, except 2020, the Northeast consistently had the lowest AAMR. From 2008-2012 the West consistently had the highest AAMR. From 2013-2022, except 2015, the Midwest had the highest AAMR. From 2009 onwards, all 4 regions have seen an overall decline in AAMR with their lowest values being in 2022.
Conclusions
Idaho had the highest AAMR before COVID-19 while Oklahoma had the lowest. During COVID-19, South Dakota saw the highest AAMR while Vermont had the lowest. AAMRs have been trending downwards across all 4 regions since 2009 and the Northeast has fared the best over that period. These results should be used to increase implementation and enforcement of preventative measures to reduce UV exposure, especially in states with higher AAMRs. Further research should examine statewide sun protection programs to search for any relationship with their AAMRs.
To Choose the Best First-line Drug for CML, Consider Efficacy and Cost
When it comes to selecting a cost-effective, first-line tyrosine kinase inhibitor (TKI) for the treatment of chronic myeloid leukemia (CML), consider the treatment goal.
For survival, generic imatinib remains the gold standard, Elias Jabbour, MD, said during a session at the annual meeting of the Society of Hematologic Oncology in Houston.
For treatment-free remission, generic dasatinib or another generic second-generation TKI is needed, but not yet available in the United States, so generic imatinib is the best current choice, said Dr. Jabbour, a professor of medicine in the Department of Leukemia at the University of Texas MD Anderson Cancer Center, Houston.
Prior to the availability of generic imatinib, that wasn’t the case, he noted, explaining that second-generation TKIs met the cost-efficacy criteria, but now — at about $35 per month or about $400 per year — imatinib is far less expensive than the approximately $250,000 per year that brand-name second- and third-generation TKIs can currently cost.
To have treatment value, any new TKI should cost $40,000-$50,000 per quality-adjusted life-year, which is defined as the quality and duration of life after a novel TKI vs with the existing standard of care, Dr. Jabbour said.
And to qualify as a frontline therapy for CML, any new TKI should show efficacy superior to second-generation TKIs, in addition to meeting the cost-effectiveness criteria.
“It is hard to show survival benefit anymore, but we need to improve on the rate of durable deep molecular remission,” he said.
An equivalent or better long-term safety profile over at least 7-8 years is also needed.
Based on the current literature, none of the TKIs currently being evaluated has met that standard, although some trials are ongoing.
In a recent editorial, Dr. Jabbour and colleagues outlined treatment recommendations based on the currently available data. They suggested using lower-than-approved doses of TKIs in both frontline and later therapies to reduce toxicity, improve treatment compliance, and reduce costs.
They also suggested that the absence of an early molecular response might not warrant changing the TKI, especially when a second-generation TKI was used first line.
When treatment-free remission is not a therapeutic goal or is unlikely, changing the TKI to improve the depth of molecular response, which has been shown to improve the likelihood of treatment-free remission, could do more harm than good, they argued.
Instead, consider reducing the dose to manage reversible side effects, they suggested, noting that generic imatinib, and eventually generic dasatinib and possibly other generic second-generation TKIs, will likely offer 90% of patients with CML an effective, safe, and affordable treatment that normalizes life expectancy and leads to treatment-free remission in 30%-50% of patients over time.
Dr. Jabbour disclosed ties with AbbVie, Almoosa Specialist Hospital, Amgen, Ascentage Pharma, Biologix FZ, Hikma Pharmaceuticals, Kite, Takeda, and Terns.
A version of this article first appeared on Medscape.com.
When it comes to selecting a cost-effective, first-line tyrosine kinase inhibitor (TKI) for the treatment of chronic myeloid leukemia (CML), consider the treatment goal.
For survival, generic imatinib remains the gold standard, Elias Jabbour, MD, said during a session at the annual meeting of the Society of Hematologic Oncology in Houston.
For treatment-free remission, generic dasatinib or another generic second-generation TKI is needed, but not yet available in the United States, so generic imatinib is the best current choice, said Dr. Jabbour, a professor of medicine in the Department of Leukemia at the University of Texas MD Anderson Cancer Center, Houston.
Prior to the availability of generic imatinib, that wasn’t the case, he noted, explaining that second-generation TKIs met the cost-efficacy criteria, but now — at about $35 per month or about $400 per year — imatinib is far less expensive than the approximately $250,000 per year that brand-name second- and third-generation TKIs can currently cost.
To have treatment value, any new TKI should cost $40,000-$50,000 per quality-adjusted life-year, which is defined as the quality and duration of life after a novel TKI vs with the existing standard of care, Dr. Jabbour said.
And to qualify as a frontline therapy for CML, any new TKI should show efficacy superior to second-generation TKIs, in addition to meeting the cost-effectiveness criteria.
“It is hard to show survival benefit anymore, but we need to improve on the rate of durable deep molecular remission,” he said.
An equivalent or better long-term safety profile over at least 7-8 years is also needed.
Based on the current literature, none of the TKIs currently being evaluated has met that standard, although some trials are ongoing.
In a recent editorial, Dr. Jabbour and colleagues outlined treatment recommendations based on the currently available data. They suggested using lower-than-approved doses of TKIs in both frontline and later therapies to reduce toxicity, improve treatment compliance, and reduce costs.
They also suggested that the absence of an early molecular response might not warrant changing the TKI, especially when a second-generation TKI was used first line.
When treatment-free remission is not a therapeutic goal or is unlikely, changing the TKI to improve the depth of molecular response, which has been shown to improve the likelihood of treatment-free remission, could do more harm than good, they argued.
Instead, consider reducing the dose to manage reversible side effects, they suggested, noting that generic imatinib, and eventually generic dasatinib and possibly other generic second-generation TKIs, will likely offer 90% of patients with CML an effective, safe, and affordable treatment that normalizes life expectancy and leads to treatment-free remission in 30%-50% of patients over time.
Dr. Jabbour disclosed ties with AbbVie, Almoosa Specialist Hospital, Amgen, Ascentage Pharma, Biologix FZ, Hikma Pharmaceuticals, Kite, Takeda, and Terns.
A version of this article first appeared on Medscape.com.
When it comes to selecting a cost-effective, first-line tyrosine kinase inhibitor (TKI) for the treatment of chronic myeloid leukemia (CML), consider the treatment goal.
For survival, generic imatinib remains the gold standard, Elias Jabbour, MD, said during a session at the annual meeting of the Society of Hematologic Oncology in Houston.
For treatment-free remission, generic dasatinib or another generic second-generation TKI is needed, but not yet available in the United States, so generic imatinib is the best current choice, said Dr. Jabbour, a professor of medicine in the Department of Leukemia at the University of Texas MD Anderson Cancer Center, Houston.
Prior to the availability of generic imatinib, that wasn’t the case, he noted, explaining that second-generation TKIs met the cost-efficacy criteria, but now — at about $35 per month or about $400 per year — imatinib is far less expensive than the approximately $250,000 per year that brand-name second- and third-generation TKIs can currently cost.
To have treatment value, any new TKI should cost $40,000-$50,000 per quality-adjusted life-year, which is defined as the quality and duration of life after a novel TKI vs with the existing standard of care, Dr. Jabbour said.
And to qualify as a frontline therapy for CML, any new TKI should show efficacy superior to second-generation TKIs, in addition to meeting the cost-effectiveness criteria.
“It is hard to show survival benefit anymore, but we need to improve on the rate of durable deep molecular remission,” he said.
An equivalent or better long-term safety profile over at least 7-8 years is also needed.
Based on the current literature, none of the TKIs currently being evaluated has met that standard, although some trials are ongoing.
In a recent editorial, Dr. Jabbour and colleagues outlined treatment recommendations based on the currently available data. They suggested using lower-than-approved doses of TKIs in both frontline and later therapies to reduce toxicity, improve treatment compliance, and reduce costs.
They also suggested that the absence of an early molecular response might not warrant changing the TKI, especially when a second-generation TKI was used first line.
When treatment-free remission is not a therapeutic goal or is unlikely, changing the TKI to improve the depth of molecular response, which has been shown to improve the likelihood of treatment-free remission, could do more harm than good, they argued.
Instead, consider reducing the dose to manage reversible side effects, they suggested, noting that generic imatinib, and eventually generic dasatinib and possibly other generic second-generation TKIs, will likely offer 90% of patients with CML an effective, safe, and affordable treatment that normalizes life expectancy and leads to treatment-free remission in 30%-50% of patients over time.
Dr. Jabbour disclosed ties with AbbVie, Almoosa Specialist Hospital, Amgen, Ascentage Pharma, Biologix FZ, Hikma Pharmaceuticals, Kite, Takeda, and Terns.
A version of this article first appeared on Medscape.com.
FROM SOHO 2024
Implementation of an Intervention to Improve Efficiency and Accuracy of Data Entry into the Veterans Affairs Central Cancer Registry at the Lexington VA Healthcare System
Background
The Veterans Affairs Central Cancer Registry (VACCR) is an information system, which collects and organizes data on Veterans with cancer for use in cancer surveillance activities, such as epidemiologic based efforts to reduce the overall cancer burden. Unfortunately, there was no structured standardized data acquisition method in place to ensure accurate or timely data entry of Lexington VA Healthcare System (LVAHCS) statistics. This quality improvement study evaluated the implementation of a Structured Query Language (SQL) code to identify specific documents in the Computerized Patient Records System (CPRS) electronic medical record with associated ICD-10 codes matching the reportable cancer cases in the Surveillance, Epidemiology, and End Results (SEER) program.
Methods
Outcomes Studied: Accuracy of the SQL code, rates of data entry into the VACCR pre- and postintervention. Cancer Program leadership collaborated with the VISN 9 Program Analyst to write a SQL code identifying the Veteran’s name; social security number; location by city, state, and county; and visit associated data such as visit location, ICD-10 code documented by the provider, and visit year. This code can be run manually or at a pre-determined cadence.
Results
A total of 3,099 incidences of cancer were entered into the VACCR by local Oncology Data Specialists (ODSs) for calendar years 2015 to 2022. This is approximately 238 cases yearly. After the intervention, 1692 patients were entered into the VACCR in 2023. This is an increased rate of data entry of 611%.
Conclusions
This study demonstrated the feasibility of implementing a SQL code to accurately identify Veterans with diagnoses matching the SEER list. Increasing accuracy of identification has led to increased data entry efficiency into the VACCR by local ODS staff. After proving the feasibility of this intervention, we are partnering with the VISN 9 Program Analyst to create a static, daily recurring report provided to the ODS staff. Future application of this intervention could also include expansion into other VHA sites, increasing their accuracy and timeliness of data entry. Overall, improving the timeliness and accuracy of the VACCR would subsequently improve the ability of the VHA to target interventions aimed at reducing the overall cancer burden.
Background
The Veterans Affairs Central Cancer Registry (VACCR) is an information system, which collects and organizes data on Veterans with cancer for use in cancer surveillance activities, such as epidemiologic based efforts to reduce the overall cancer burden. Unfortunately, there was no structured standardized data acquisition method in place to ensure accurate or timely data entry of Lexington VA Healthcare System (LVAHCS) statistics. This quality improvement study evaluated the implementation of a Structured Query Language (SQL) code to identify specific documents in the Computerized Patient Records System (CPRS) electronic medical record with associated ICD-10 codes matching the reportable cancer cases in the Surveillance, Epidemiology, and End Results (SEER) program.
Methods
Outcomes Studied: Accuracy of the SQL code, rates of data entry into the VACCR pre- and postintervention. Cancer Program leadership collaborated with the VISN 9 Program Analyst to write a SQL code identifying the Veteran’s name; social security number; location by city, state, and county; and visit associated data such as visit location, ICD-10 code documented by the provider, and visit year. This code can be run manually or at a pre-determined cadence.
Results
A total of 3,099 incidences of cancer were entered into the VACCR by local Oncology Data Specialists (ODSs) for calendar years 2015 to 2022. This is approximately 238 cases yearly. After the intervention, 1692 patients were entered into the VACCR in 2023. This is an increased rate of data entry of 611%.
Conclusions
This study demonstrated the feasibility of implementing a SQL code to accurately identify Veterans with diagnoses matching the SEER list. Increasing accuracy of identification has led to increased data entry efficiency into the VACCR by local ODS staff. After proving the feasibility of this intervention, we are partnering with the VISN 9 Program Analyst to create a static, daily recurring report provided to the ODS staff. Future application of this intervention could also include expansion into other VHA sites, increasing their accuracy and timeliness of data entry. Overall, improving the timeliness and accuracy of the VACCR would subsequently improve the ability of the VHA to target interventions aimed at reducing the overall cancer burden.
Background
The Veterans Affairs Central Cancer Registry (VACCR) is an information system, which collects and organizes data on Veterans with cancer for use in cancer surveillance activities, such as epidemiologic based efforts to reduce the overall cancer burden. Unfortunately, there was no structured standardized data acquisition method in place to ensure accurate or timely data entry of Lexington VA Healthcare System (LVAHCS) statistics. This quality improvement study evaluated the implementation of a Structured Query Language (SQL) code to identify specific documents in the Computerized Patient Records System (CPRS) electronic medical record with associated ICD-10 codes matching the reportable cancer cases in the Surveillance, Epidemiology, and End Results (SEER) program.
Methods
Outcomes Studied: Accuracy of the SQL code, rates of data entry into the VACCR pre- and postintervention. Cancer Program leadership collaborated with the VISN 9 Program Analyst to write a SQL code identifying the Veteran’s name; social security number; location by city, state, and county; and visit associated data such as visit location, ICD-10 code documented by the provider, and visit year. This code can be run manually or at a pre-determined cadence.
Results
A total of 3,099 incidences of cancer were entered into the VACCR by local Oncology Data Specialists (ODSs) for calendar years 2015 to 2022. This is approximately 238 cases yearly. After the intervention, 1692 patients were entered into the VACCR in 2023. This is an increased rate of data entry of 611%.
Conclusions
This study demonstrated the feasibility of implementing a SQL code to accurately identify Veterans with diagnoses matching the SEER list. Increasing accuracy of identification has led to increased data entry efficiency into the VACCR by local ODS staff. After proving the feasibility of this intervention, we are partnering with the VISN 9 Program Analyst to create a static, daily recurring report provided to the ODS staff. Future application of this intervention could also include expansion into other VHA sites, increasing their accuracy and timeliness of data entry. Overall, improving the timeliness and accuracy of the VACCR would subsequently improve the ability of the VHA to target interventions aimed at reducing the overall cancer burden.
A Phase II Study With Androgen Deprivation Therapy and Up-Front Radiotherapy in High-Intermediate and High-Risk Prostate Cancer With Stereotactic Body Radiation Therapy to Pelvic Nodes and Concomitant Prostate Boost by Simultaneous Integrated Boost
Background
The adoption of Stereotactic Body Radiation Therapy (SBRT) for prostate cancer has allowed treatment to be completed in less than 2 weeks, but has predominantly been given to the prostate only. Currently, very few prospective studies have compared delivery of SBRT versus hypofractionated radiotherapy (HFX) when giving concurrent pelvic radiation. The aim of the study is to evaluate the tolerance and efficacy of pelvic node radiotherapy and SIB to the prostate in prostate patients requiring nodal irradiation.
Methods
A total of 58 patients were irradiated with SBRT and initiated ADT therapy between 2014 and 2023. 57 patients were treated with 7.5 Gy to the prostate and 1 to 7.25 Gy. All patients were treated with 5 Gy x 5 fraction to the pelvis. This group was compared to a preselected historical cohort of 65 HFX patients with 57 of these patients treated with 67.5/50 Gy in 25 fractions, 1 with patient 67.5/45 Gy in 25 fractions, and 6 patients with 60/44-46 Gy in 20 fractions. Patients were evaluated for GU and GI toxicities according to Radiation Therapy Oncology Group Toxicity criteria at one year post radiation therapy.
Results
There were 31 grade 0 (53.4%), 1 grade 1 (1.7%), 25 grade 2 (43.1%), 1 grade 3 (1.7%) events in the SBRT group and 29 GU grade 0 (44.6%), 3 grade 1 (4.6%), and 33 grade 2 (50.8%) GU toxicities in the HFX group with no significant difference between the groups (p=0.464). There were 55 grade 0 (94.8%), 1 grade 1 (1.7%), and 2 grade 2 (3.4%) GI toxicities in the SBRT group and 59 grade 0 (90.8%), 1 grade 1 (1.5%), and 5 grade 2 (7.7%) events in the HFX group with no significant difference between the groups (p=0.381).
Conclusions
This prospective study provides data to support the use of concurrent pelvic radiation with SBRT to the prostate. Our findings suggest there is no difference in toxicity between HFX and 25 Gy pelvic radiation (5 Gy/5 fractions) concurrent with SBRT to the prostate, therefore it appears to be a safe and convenient option for veterans with prostate cancer.
Background
The adoption of Stereotactic Body Radiation Therapy (SBRT) for prostate cancer has allowed treatment to be completed in less than 2 weeks, but has predominantly been given to the prostate only. Currently, very few prospective studies have compared delivery of SBRT versus hypofractionated radiotherapy (HFX) when giving concurrent pelvic radiation. The aim of the study is to evaluate the tolerance and efficacy of pelvic node radiotherapy and SIB to the prostate in prostate patients requiring nodal irradiation.
Methods
A total of 58 patients were irradiated with SBRT and initiated ADT therapy between 2014 and 2023. 57 patients were treated with 7.5 Gy to the prostate and 1 to 7.25 Gy. All patients were treated with 5 Gy x 5 fraction to the pelvis. This group was compared to a preselected historical cohort of 65 HFX patients with 57 of these patients treated with 67.5/50 Gy in 25 fractions, 1 with patient 67.5/45 Gy in 25 fractions, and 6 patients with 60/44-46 Gy in 20 fractions. Patients were evaluated for GU and GI toxicities according to Radiation Therapy Oncology Group Toxicity criteria at one year post radiation therapy.
Results
There were 31 grade 0 (53.4%), 1 grade 1 (1.7%), 25 grade 2 (43.1%), 1 grade 3 (1.7%) events in the SBRT group and 29 GU grade 0 (44.6%), 3 grade 1 (4.6%), and 33 grade 2 (50.8%) GU toxicities in the HFX group with no significant difference between the groups (p=0.464). There were 55 grade 0 (94.8%), 1 grade 1 (1.7%), and 2 grade 2 (3.4%) GI toxicities in the SBRT group and 59 grade 0 (90.8%), 1 grade 1 (1.5%), and 5 grade 2 (7.7%) events in the HFX group with no significant difference between the groups (p=0.381).
Conclusions
This prospective study provides data to support the use of concurrent pelvic radiation with SBRT to the prostate. Our findings suggest there is no difference in toxicity between HFX and 25 Gy pelvic radiation (5 Gy/5 fractions) concurrent with SBRT to the prostate, therefore it appears to be a safe and convenient option for veterans with prostate cancer.
Background
The adoption of Stereotactic Body Radiation Therapy (SBRT) for prostate cancer has allowed treatment to be completed in less than 2 weeks, but has predominantly been given to the prostate only. Currently, very few prospective studies have compared delivery of SBRT versus hypofractionated radiotherapy (HFX) when giving concurrent pelvic radiation. The aim of the study is to evaluate the tolerance and efficacy of pelvic node radiotherapy and SIB to the prostate in prostate patients requiring nodal irradiation.
Methods
A total of 58 patients were irradiated with SBRT and initiated ADT therapy between 2014 and 2023. 57 patients were treated with 7.5 Gy to the prostate and 1 to 7.25 Gy. All patients were treated with 5 Gy x 5 fraction to the pelvis. This group was compared to a preselected historical cohort of 65 HFX patients with 57 of these patients treated with 67.5/50 Gy in 25 fractions, 1 with patient 67.5/45 Gy in 25 fractions, and 6 patients with 60/44-46 Gy in 20 fractions. Patients were evaluated for GU and GI toxicities according to Radiation Therapy Oncology Group Toxicity criteria at one year post radiation therapy.
Results
There were 31 grade 0 (53.4%), 1 grade 1 (1.7%), 25 grade 2 (43.1%), 1 grade 3 (1.7%) events in the SBRT group and 29 GU grade 0 (44.6%), 3 grade 1 (4.6%), and 33 grade 2 (50.8%) GU toxicities in the HFX group with no significant difference between the groups (p=0.464). There were 55 grade 0 (94.8%), 1 grade 1 (1.7%), and 2 grade 2 (3.4%) GI toxicities in the SBRT group and 59 grade 0 (90.8%), 1 grade 1 (1.5%), and 5 grade 2 (7.7%) events in the HFX group with no significant difference between the groups (p=0.381).
Conclusions
This prospective study provides data to support the use of concurrent pelvic radiation with SBRT to the prostate. Our findings suggest there is no difference in toxicity between HFX and 25 Gy pelvic radiation (5 Gy/5 fractions) concurrent with SBRT to the prostate, therefore it appears to be a safe and convenient option for veterans with prostate cancer.
Identifying Barriers in Germline Genetic Testing Referrals for Breast Cancer: A Single-Center Experience
Background
Purpose: to review the number of genetic testing referrals for breast cancer at the Stratton VA Medical Center and identify barriers that hinder testing, aiming to improve risk reduction strategies and therapeutic options for patients. National guidelines recommend genetic testing for breast cancer susceptibility genes in specific patient populations, such as those under 50, those with a high-risk family history, high-risk pathology, male breast cancer, or Ashkenazi Jewish ancestry. Despite efforts to adhere to these guidelines, several barriers persist that limit testing rates among eligible patients.
Methods
The medical oncology team selected breast cancer as the focus for reviewing adherence to germline genetic testing referrals in the Stratton VA Medical Center. With assistance from cancer registrars, a list of genetics referrals for breast cancer from January to December 2023 was compiled. Descriptive analysis was conducted to assess referral rates, evaluation visit completion rates, genetic testing outcomes, and reasons for non-completion of genetic testing.
Results
During the study period, 32 patients were referred for germline genetic testing for breast cancer. Of these, 26 (81%) completed the evaluation visit, and 11 (34%) underwent genetic testing. Of these, 7 patients had noteworthy results, and 2 patients (6%) were found to carry pathogenic variants: BRCA2 and CDH1. Reasons for non-completion included perceived irrelevance without biological children, need for additional time to consider testing, fear of exacerbating self-harm thoughts, and fear of losing service connection. Additionally, 2 patients did not meet the guidelines for testing per genetic counselor.
Conclusions
This project marks the initial step in identifying barriers to germline genetic testing for breast cancer based on an extensive review of patients diagnosed and treated at a single VA site. Despite the removal of the service connection clause from the consent form, some veterans still declined testing due to fear of losing their service connection. The findings emphasize the importance of educating providers on counseling techniques and education of veterans to enhance risk reduction strategies and patient care. Further research is essential to quantify the real-world outcomes and longterm impacts of improving genetic counseling rates on patient management and outcomes.
Background
Purpose: to review the number of genetic testing referrals for breast cancer at the Stratton VA Medical Center and identify barriers that hinder testing, aiming to improve risk reduction strategies and therapeutic options for patients. National guidelines recommend genetic testing for breast cancer susceptibility genes in specific patient populations, such as those under 50, those with a high-risk family history, high-risk pathology, male breast cancer, or Ashkenazi Jewish ancestry. Despite efforts to adhere to these guidelines, several barriers persist that limit testing rates among eligible patients.
Methods
The medical oncology team selected breast cancer as the focus for reviewing adherence to germline genetic testing referrals in the Stratton VA Medical Center. With assistance from cancer registrars, a list of genetics referrals for breast cancer from January to December 2023 was compiled. Descriptive analysis was conducted to assess referral rates, evaluation visit completion rates, genetic testing outcomes, and reasons for non-completion of genetic testing.
Results
During the study period, 32 patients were referred for germline genetic testing for breast cancer. Of these, 26 (81%) completed the evaluation visit, and 11 (34%) underwent genetic testing. Of these, 7 patients had noteworthy results, and 2 patients (6%) were found to carry pathogenic variants: BRCA2 and CDH1. Reasons for non-completion included perceived irrelevance without biological children, need for additional time to consider testing, fear of exacerbating self-harm thoughts, and fear of losing service connection. Additionally, 2 patients did not meet the guidelines for testing per genetic counselor.
Conclusions
This project marks the initial step in identifying barriers to germline genetic testing for breast cancer based on an extensive review of patients diagnosed and treated at a single VA site. Despite the removal of the service connection clause from the consent form, some veterans still declined testing due to fear of losing their service connection. The findings emphasize the importance of educating providers on counseling techniques and education of veterans to enhance risk reduction strategies and patient care. Further research is essential to quantify the real-world outcomes and longterm impacts of improving genetic counseling rates on patient management and outcomes.
Background
Purpose: to review the number of genetic testing referrals for breast cancer at the Stratton VA Medical Center and identify barriers that hinder testing, aiming to improve risk reduction strategies and therapeutic options for patients. National guidelines recommend genetic testing for breast cancer susceptibility genes in specific patient populations, such as those under 50, those with a high-risk family history, high-risk pathology, male breast cancer, or Ashkenazi Jewish ancestry. Despite efforts to adhere to these guidelines, several barriers persist that limit testing rates among eligible patients.
Methods
The medical oncology team selected breast cancer as the focus for reviewing adherence to germline genetic testing referrals in the Stratton VA Medical Center. With assistance from cancer registrars, a list of genetics referrals for breast cancer from January to December 2023 was compiled. Descriptive analysis was conducted to assess referral rates, evaluation visit completion rates, genetic testing outcomes, and reasons for non-completion of genetic testing.
Results
During the study period, 32 patients were referred for germline genetic testing for breast cancer. Of these, 26 (81%) completed the evaluation visit, and 11 (34%) underwent genetic testing. Of these, 7 patients had noteworthy results, and 2 patients (6%) were found to carry pathogenic variants: BRCA2 and CDH1. Reasons for non-completion included perceived irrelevance without biological children, need for additional time to consider testing, fear of exacerbating self-harm thoughts, and fear of losing service connection. Additionally, 2 patients did not meet the guidelines for testing per genetic counselor.
Conclusions
This project marks the initial step in identifying barriers to germline genetic testing for breast cancer based on an extensive review of patients diagnosed and treated at a single VA site. Despite the removal of the service connection clause from the consent form, some veterans still declined testing due to fear of losing their service connection. The findings emphasize the importance of educating providers on counseling techniques and education of veterans to enhance risk reduction strategies and patient care. Further research is essential to quantify the real-world outcomes and longterm impacts of improving genetic counseling rates on patient management and outcomes.
Do We Need More Screen Time? Patterns of Telehealth Utilization for Patients With Prostate Cancer in the Veterans Health Administration (VHA)
Background
Prostate cancer is the most common cancer in the VHA. Telehealth use has increased and has the potential to improve access for patients. We examined patterns of care for VHA patients with prostate cancer, including whether visits were in person, by telephone or by video.
Methods
Using the VHA Corporate Data Warehouse, we extracted data on all incident cases of prostate cancer from 1/1/2016-1/31/2023 with sufficient information (Gleason score, prostate-specific antigen [PSA], and tumor stage) to categorize into National Comprehensive Cancer Network (NCCN) risk strata. We excluded patients who died within 1 year of diagnosis and those with no evidence of PSA testing, prostate biopsy or treatment within 2 years. We categorized all outpatient visits related to a person’s Urology- and Medical Oncology based care – including the visit modality – based on administrative visit stop codes. We defined ‘during COVID’ as visits after 3/11/2020. We calculated the percent of visits performed by modality in each year after diagnosis.
Results
Among the 60,381 men with prostate cancer, 61% were White, 33% Black; 5% Hispanic; 32% rural. For NCCN category, 30% had high risk prostate cancer, which increased with age, 50% had intermediate risk and 20% had low risk. Prior to COVID, for visits to Urology within the first year after diagnosis, 79% were in person, 20% were by telephone and 0.1% were by video. Visits to Oncology within the first year after diagnosis were similar—82% in person, 16% by phone and 0.3% by video.
Discussion
During the COVID period, video visits increased significantly but remained a small proportion, accounting for only 2% of visits for both Urology and Oncology. Video visits increased during the COVID-19 pandemic but remained rare. Across many diseases and conditions, the quality of care for video visits has been at least as good as for in-person care.
Conclusions
There is a missed opportunity to provide care by video within VHA for patients with prostate cancer, particularly given that about 1/3 of patients are from rural areas. Future analyses will examine barriers to video telehealth and the impact of video visits on quality and equity of prostate cancer care.
Background
Prostate cancer is the most common cancer in the VHA. Telehealth use has increased and has the potential to improve access for patients. We examined patterns of care for VHA patients with prostate cancer, including whether visits were in person, by telephone or by video.
Methods
Using the VHA Corporate Data Warehouse, we extracted data on all incident cases of prostate cancer from 1/1/2016-1/31/2023 with sufficient information (Gleason score, prostate-specific antigen [PSA], and tumor stage) to categorize into National Comprehensive Cancer Network (NCCN) risk strata. We excluded patients who died within 1 year of diagnosis and those with no evidence of PSA testing, prostate biopsy or treatment within 2 years. We categorized all outpatient visits related to a person’s Urology- and Medical Oncology based care – including the visit modality – based on administrative visit stop codes. We defined ‘during COVID’ as visits after 3/11/2020. We calculated the percent of visits performed by modality in each year after diagnosis.
Results
Among the 60,381 men with prostate cancer, 61% were White, 33% Black; 5% Hispanic; 32% rural. For NCCN category, 30% had high risk prostate cancer, which increased with age, 50% had intermediate risk and 20% had low risk. Prior to COVID, for visits to Urology within the first year after diagnosis, 79% were in person, 20% were by telephone and 0.1% were by video. Visits to Oncology within the first year after diagnosis were similar—82% in person, 16% by phone and 0.3% by video.
Discussion
During the COVID period, video visits increased significantly but remained a small proportion, accounting for only 2% of visits for both Urology and Oncology. Video visits increased during the COVID-19 pandemic but remained rare. Across many diseases and conditions, the quality of care for video visits has been at least as good as for in-person care.
Conclusions
There is a missed opportunity to provide care by video within VHA for patients with prostate cancer, particularly given that about 1/3 of patients are from rural areas. Future analyses will examine barriers to video telehealth and the impact of video visits on quality and equity of prostate cancer care.
Background
Prostate cancer is the most common cancer in the VHA. Telehealth use has increased and has the potential to improve access for patients. We examined patterns of care for VHA patients with prostate cancer, including whether visits were in person, by telephone or by video.
Methods
Using the VHA Corporate Data Warehouse, we extracted data on all incident cases of prostate cancer from 1/1/2016-1/31/2023 with sufficient information (Gleason score, prostate-specific antigen [PSA], and tumor stage) to categorize into National Comprehensive Cancer Network (NCCN) risk strata. We excluded patients who died within 1 year of diagnosis and those with no evidence of PSA testing, prostate biopsy or treatment within 2 years. We categorized all outpatient visits related to a person’s Urology- and Medical Oncology based care – including the visit modality – based on administrative visit stop codes. We defined ‘during COVID’ as visits after 3/11/2020. We calculated the percent of visits performed by modality in each year after diagnosis.
Results
Among the 60,381 men with prostate cancer, 61% were White, 33% Black; 5% Hispanic; 32% rural. For NCCN category, 30% had high risk prostate cancer, which increased with age, 50% had intermediate risk and 20% had low risk. Prior to COVID, for visits to Urology within the first year after diagnosis, 79% were in person, 20% were by telephone and 0.1% were by video. Visits to Oncology within the first year after diagnosis were similar—82% in person, 16% by phone and 0.3% by video.
Discussion
During the COVID period, video visits increased significantly but remained a small proportion, accounting for only 2% of visits for both Urology and Oncology. Video visits increased during the COVID-19 pandemic but remained rare. Across many diseases and conditions, the quality of care for video visits has been at least as good as for in-person care.
Conclusions
There is a missed opportunity to provide care by video within VHA for patients with prostate cancer, particularly given that about 1/3 of patients are from rural areas. Future analyses will examine barriers to video telehealth and the impact of video visits on quality and equity of prostate cancer care.