General Thoracic

Women represent a minority of cardiothoracic surgeons in the United States, with roughly equal numbers being found in academic and private practice, according to a recent survey presented at the annual meeting of the Society for Thoracic Surgeons.

Overall, these women reported a high level of job satisfaction and the vast majority of them were still in practice.

Although there were comparatively few women in senior staff and faculty positions, in part because over 50% of women currently in practice entered the profession since the year 2000, "this exponential increase in the number of women in the field over the past ten years provides optimism for a continued recruitment," according to the report by Dr. Jessica S. Donington, assistant professor of cardiothoracic surgery at New York University, New York, N.Y.,and her colleagues on behalf of The Women in Thoracic Surgery (WTS).

The WTS was established as a professional organization in 1986, with the designated mission of providing mutual support and facilitating the professional advancement of women in cardiothoracic surgery.

With 2011 being the 50th anniversary of the first certification of a woman by the American Board of Thoracic Surgery (ABTS) and the year in which the 200th female was certified by the ABTS, the WTS deemed it important to survey the status of female cardiothoracic surgeons in the United States.

The WTS survey was designed to measure career progression and to provide insights in order to improve recruitment. All ABTS-certified women were surveyed anonymously in December 2010 using tools from surveymonkey.com, according to Dr. Donington.

Contact information was obtained from CTSNet, Google, and institutions of known employment.

Of the 204 living women with ABTS certification, 190 were contacted. Of these, 64% responded to the survey. The questions comprised five areas: demographics, training, practice activities, activities of non-practicing CT surgeons, and career satisfaction.

The researchers grouped the respondents by year of certification: Group 1 (1961-1999) and Group 2 (2000-2010). They used the STS/AATS 2009 practice survey of the entire thoracic surgery workforce in order to make broad-based comparisons.

The mean age of the women respondents was 48 years, with the majority being white (nearly 78%) and urban dwellers (61%).

Half of the women were certified within the past 10 years. Overall, the respondents had been practicing for a mean of 8 years, worked in groups of 2-10 surgeons, and were the only female surgeon in their group. The respondents had a mean of 9.1 years of training with 56% reporting non-Accreditation Council for Graduate Medical Education (ACGME) training time.

There was a significant increase in the duration of training and in the resultant debt over time. Group 1 respondents reported training for 8.5 years vs. 9.5 years in Group 2, with a doubling of graduates with educational debt greater than $100,000 in the later era.

Overall, the distribution of 118 respondents who answered the subspecialty question was 28% adult cardiac; 8.5% congenital cardiac; slightly less than 1% cardiopulmonary transplant; and 13.2% mixed subspecialties.

The 35.6% percent of women who identified themselves as general thoracic surgeons is higher than the 18% reported by the entire thoracic surgery workforce, with the percentage of women who identified themselves as general thoracic surgeons more than doubling in the second cohort of diplomates as compared with the first.

Slightly over 10% of respondents were no longer in CT surgery practice. All of these were certified prior to 2000, and the majority left practice due to retirement, health issues, or career advancement, according to their responses.

There was a large shift from the mixed category, which was cited by nearly 28% of the 51 women certified prior to 2000, compared with 3% of the 67 women certified after 2000.

This could be accounted for primarily by large increases in the adult cardiac (from nearly 20% prior to 2000 compared with 34% after 2000) and the general thoracic (from around 22% to 46%) subspecialty categories, reflecting the increase in subspecialization of our field.

Half of the women who responded had academic appointments, with 52% of these at the assistant professor level and 20% at the professor level. A minority of the women (20%) had protected research time, and 30% had secured research funding.

Overall, 64% of respondents reported that they were always or almost always satisfied with their profession.

The greatest source of dissatisfaction reported by both groups was demands on time, with workplace politics being a key concern expressed by Group 1 respondents, and lack of support a key concern expressed by Group 2.

Eighty percent of those polled stated that, if given the opportunity to choose a profession based on what they knew now, they would pursue cardiothoracic surgery again.

"Women still represent a minority of cardiothoracic surgeons in the United States, and over half are still very junior, having entered the profession since the year 2000.

Although the majority report being satisfied with their careers, and important academic milestones have been reached by some, there remains a scarcity of women in senior leadership positions.

"Since mentors and positive role models are consistently reported as significant factors in specialty decisions by surgical residents, this may still be the largest hurdle to recruiting women into cardiothoracic surgery," concluded Dr. Donington, in her presentation of the report.

Dr. Donington reported that she had no relevant financial disclosures.☐

Women represent a minority of cardiothoracic surgeons in the United States, with roughly equal numbers being found in academic and private practice, according to a recent survey presented at the annual meeting of the Society for Thoracic Surgeons.

Overall, these women reported a high level of job satisfaction and the vast majority of them were still in practice.

Although there were comparatively few women in senior staff and faculty positions, in part because over 50% of women currently in practice entered the profession since the year 2000, "this exponential increase in the number of women in the field over the past ten years provides optimism for a continued recruitment," according to the report by Dr. Jessica S. Donington, assistant professor of cardiothoracic surgery at New York University, New York, N.Y.,and her colleagues on behalf of The Women in Thoracic Surgery (WTS).

The WTS was established as a professional organization in 1986, with the designated mission of providing mutual support and facilitating the professional advancement of women in cardiothoracic surgery.

With 2011 being the 50th anniversary of the first certification of a woman by the American Board of Thoracic Surgery (ABTS) and the year in which the 200th female was certified by the ABTS, the WTS deemed it important to survey the status of female cardiothoracic surgeons in the United States.

The WTS survey was designed to measure career progression and to provide insights in order to improve recruitment. All ABTS-certified women were surveyed anonymously in December 2010 using tools from surveymonkey.com, according to Dr. Donington.

Contact information was obtained from CTSNet, Google, and institutions of known employment.

Of the 204 living women with ABTS certification, 190 were contacted. Of these, 64% responded to the survey. The questions comprised five areas: demographics, training, practice activities, activities of non-practicing CT surgeons, and career satisfaction.

The researchers grouped the respondents by year of certification: Group 1 (1961-1999) and Group 2 (2000-2010). They used the STS/AATS 2009 practice survey of the entire thoracic surgery workforce in order to make broad-based comparisons.

The mean age of the women respondents was 48 years, with the majority being white (nearly 78%) and urban dwellers (61%).

Half of the women were certified within the past 10 years. Overall, the respondents had been practicing for a mean of 8 years, worked in groups of 2-10 surgeons, and were the only female surgeon in their group. The respondents had a mean of 9.1 years of training with 56% reporting non-Accreditation Council for Graduate Medical Education (ACGME) training time.

There was a significant increase in the duration of training and in the resultant debt over time. Group 1 respondents reported training for 8.5 years vs. 9.5 years in Group 2, with a doubling of graduates with educational debt greater than $100,000 in the later era.

Overall, the distribution of 118 respondents who answered the subspecialty question was 28% adult cardiac; 8.5% congenital cardiac; slightly less than 1% cardiopulmonary transplant; and 13.2% mixed subspecialties.

The 35.6% percent of women who identified themselves as general thoracic surgeons is higher than the 18% reported by the entire thoracic surgery workforce, with the percentage of women who identified themselves as general thoracic surgeons more than doubling in the second cohort of diplomates as compared with the first.

Slightly over 10% of respondents were no longer in CT surgery practice. All of these were certified prior to 2000, and the majority left practice due to retirement, health issues, or career advancement, according to their responses.

There was a large shift from the mixed category, which was cited by nearly 28% of the 51 women certified prior to 2000, compared with 3% of the 67 women certified after 2000.

This could be accounted for primarily by large increases in the adult cardiac (from nearly 20% prior to 2000 compared with 34% after 2000) and the general thoracic (from around 22% to 46%) subspecialty categories, reflecting the increase in subspecialization of our field.

Half of the women who responded had academic appointments, with 52% of these at the assistant professor level and 20% at the professor level. A minority of the women (20%) had protected research time, and 30% had secured research funding.

Overall, 64% of respondents reported that they were always or almost always satisfied with their profession.

The greatest source of dissatisfaction reported by both groups was demands on time, with workplace politics being a key concern expressed by Group 1 respondents, and lack of support a key concern expressed by Group 2.

Eighty percent of those polled stated that, if given the opportunity to choose a profession based on what they knew now, they would pursue cardiothoracic surgery again.

"Women still represent a minority of cardiothoracic surgeons in the United States, and over half are still very junior, having entered the profession since the year 2000.

Although the majority report being satisfied with their careers, and important academic milestones have been reached by some, there remains a scarcity of women in senior leadership positions.

"Since mentors and positive role models are consistently reported as significant factors in specialty decisions by surgical residents, this may still be the largest hurdle to recruiting women into cardiothoracic surgery," concluded Dr. Donington, in her presentation of the report.

Dr. Donington reported that she had no relevant financial disclosures.☐

Women represent a minority of cardiothoracic surgeons in the United States, with roughly equal numbers being found in academic and private practice, according to a recent survey presented at the annual meeting of the Society for Thoracic Surgeons.

Overall, these women reported a high level of job satisfaction and the vast majority of them were still in practice.

Although there were comparatively few women in senior staff and faculty positions, in part because over 50% of women currently in practice entered the profession since the year 2000, "this exponential increase in the number of women in the field over the past ten years provides optimism for a continued recruitment," according to the report by Dr. Jessica S. Donington, assistant professor of cardiothoracic surgery at New York University, New York, N.Y.,and her colleagues on behalf of The Women in Thoracic Surgery (WTS).

The WTS was established as a professional organization in 1986, with the designated mission of providing mutual support and facilitating the professional advancement of women in cardiothoracic surgery.

With 2011 being the 50th anniversary of the first certification of a woman by the American Board of Thoracic Surgery (ABTS) and the year in which the 200th female was certified by the ABTS, the WTS deemed it important to survey the status of female cardiothoracic surgeons in the United States.

The WTS survey was designed to measure career progression and to provide insights in order to improve recruitment. All ABTS-certified women were surveyed anonymously in December 2010 using tools from surveymonkey.com, according to Dr. Donington.

Contact information was obtained from CTSNet, Google, and institutions of known employment.

Of the 204 living women with ABTS certification, 190 were contacted. Of these, 64% responded to the survey. The questions comprised five areas: demographics, training, practice activities, activities of non-practicing CT surgeons, and career satisfaction.

The researchers grouped the respondents by year of certification: Group 1 (1961-1999) and Group 2 (2000-2010). They used the STS/AATS 2009 practice survey of the entire thoracic surgery workforce in order to make broad-based comparisons.

The mean age of the women respondents was 48 years, with the majority being white (nearly 78%) and urban dwellers (61%).

Half of the women were certified within the past 10 years. Overall, the respondents had been practicing for a mean of 8 years, worked in groups of 2-10 surgeons, and were the only female surgeon in their group. The respondents had a mean of 9.1 years of training with 56% reporting non-Accreditation Council for Graduate Medical Education (ACGME) training time.

There was a significant increase in the duration of training and in the resultant debt over time. Group 1 respondents reported training for 8.5 years vs. 9.5 years in Group 2, with a doubling of graduates with educational debt greater than $100,000 in the later era.

Overall, the distribution of 118 respondents who answered the subspecialty question was 28% adult cardiac; 8.5% congenital cardiac; slightly less than 1% cardiopulmonary transplant; and 13.2% mixed subspecialties.

The 35.6% percent of women who identified themselves as general thoracic surgeons is higher than the 18% reported by the entire thoracic surgery workforce, with the percentage of women who identified themselves as general thoracic surgeons more than doubling in the second cohort of diplomates as compared with the first.

Slightly over 10% of respondents were no longer in CT surgery practice. All of these were certified prior to 2000, and the majority left practice due to retirement, health issues, or career advancement, according to their responses.

There was a large shift from the mixed category, which was cited by nearly 28% of the 51 women certified prior to 2000, compared with 3% of the 67 women certified after 2000.

This could be accounted for primarily by large increases in the adult cardiac (from nearly 20% prior to 2000 compared with 34% after 2000) and the general thoracic (from around 22% to 46%) subspecialty categories, reflecting the increase in subspecialization of our field.

Half of the women who responded had academic appointments, with 52% of these at the assistant professor level and 20% at the professor level. A minority of the women (20%) had protected research time, and 30% had secured research funding.

Overall, 64% of respondents reported that they were always or almost always satisfied with their profession.

The greatest source of dissatisfaction reported by both groups was demands on time, with workplace politics being a key concern expressed by Group 1 respondents, and lack of support a key concern expressed by Group 2.

Eighty percent of those polled stated that, if given the opportunity to choose a profession based on what they knew now, they would pursue cardiothoracic surgery again.

"Women still represent a minority of cardiothoracic surgeons in the United States, and over half are still very junior, having entered the profession since the year 2000.

Although the majority report being satisfied with their careers, and important academic milestones have been reached by some, there remains a scarcity of women in senior leadership positions.

"Since mentors and positive role models are consistently reported as significant factors in specialty decisions by surgical residents, this may still be the largest hurdle to recruiting women into cardiothoracic surgery," concluded Dr. Donington, in her presentation of the report.

Dr. Donington reported that she had no relevant financial disclosures.☐

SAN FRANCISCO – Recent surveys of patients and attending surgeons show differing views on disclosures, Dr. Susan Lee Char said at the clinical congress of the American College of Surgeons.

She and her associates surveyed 353 adult patients at their first postoperative clinic visit and 85 attending surgeons at hospitals affiliated with the University of California, San Francisco. The survey presented a hypothetical case of a patient’s undergoing elective partial hepatectomy and asked respondents to rate the importance of receiving or conveying various items of information on a 6-point Likert scale.

In all, 79% of patients said it’s essential to know if their surgeon would be doing a procedure for the first time on them, but only 55% of attending surgeons felt this was important information to disclose. A total of 63% of patients considered it essential to know the number of times a surgeon had performed a particular procedure and the outcomes in those cases, compared with just 25% and 20% of surgeons, respectively.

"The data suggest that surgeons do have an ethical obligation to disclose volumes and outcomes and if it’s the first time [they’re] doing a procedure," said Dr. Char, a surgical resident at the university who is also a lawyer. "This has possible legal implications."

The main barrier to surgeons’ disclosure may be a practical one, she added. Surgeons often don’t have data on the volumes and outcomes of their procedures.

Patients’ and attending surgeons’ perceptions of the importance of other types of information also differed significantly. A general description of the procedure was rated as important by 65% of patients vs. 58% of surgeons, and technical details of the procedure were important to 48% of patients and 13% of surgeons. Disclosure of risks and benefits of the procedure were deemed essential by 77% and 71% of patients, respectively, compared with 72% and 65% of surgeons, respectively. A total of 41% of patients and 5% of surgeons said the patient should be told the number of times the procedure has been done by other surgeons, and 44% of patients and 20% of surgeons said other surgeons’ outcomes should be disclosed.

A total of 64% of patients and 31% of surgeons believed it was important to discuss any special training by the surgeon doing the procedure. Some 64% of patients said they would want to be informed about the surgeon’s special training for a standard procedure, compared with 68% for a laparoscopic procedure and 71% for a robotic procedure.

Technological innovation made a difference in whether patients deemed certain information essential. Patients scheduled for a laparoscopic or robotic procedure were significantly more likely to want information than those undergoing a standard operation.

In all, 63% of patients said they would want to know the number of times that a standard procedure had been done by their surgeon. That percentage rose to 66% for a laparoscopic procedure and to 68% for a robotic procedure. Outcomes information was considered important by 63% of patients for a standard procedure, 66% for a laparoscopic procedure, and 67% for a robotic procedure. And 24% of patients, compared with 6% of surgeons, said the patient should be told if the surgeon planned to publish an article including the case. Disclosing whether a surgeon is a paid consultant was less important to patients (5%) than to surgeons (40%).

Dr. Char had no conflicts of interest.

SAN FRANCISCO – Recent surveys of patients and attending surgeons show differing views on disclosures, Dr. Susan Lee Char said at the clinical congress of the American College of Surgeons.

She and her associates surveyed 353 adult patients at their first postoperative clinic visit and 85 attending surgeons at hospitals affiliated with the University of California, San Francisco. The survey presented a hypothetical case of a patient’s undergoing elective partial hepatectomy and asked respondents to rate the importance of receiving or conveying various items of information on a 6-point Likert scale.

In all, 79% of patients said it’s essential to know if their surgeon would be doing a procedure for the first time on them, but only 55% of attending surgeons felt this was important information to disclose. A total of 63% of patients considered it essential to know the number of times a surgeon had performed a particular procedure and the outcomes in those cases, compared with just 25% and 20% of surgeons, respectively.

"The data suggest that surgeons do have an ethical obligation to disclose volumes and outcomes and if it’s the first time [they’re] doing a procedure," said Dr. Char, a surgical resident at the university who is also a lawyer. "This has possible legal implications."

The main barrier to surgeons’ disclosure may be a practical one, she added. Surgeons often don’t have data on the volumes and outcomes of their procedures.

Patients’ and attending surgeons’ perceptions of the importance of other types of information also differed significantly. A general description of the procedure was rated as important by 65% of patients vs. 58% of surgeons, and technical details of the procedure were important to 48% of patients and 13% of surgeons. Disclosure of risks and benefits of the procedure were deemed essential by 77% and 71% of patients, respectively, compared with 72% and 65% of surgeons, respectively. A total of 41% of patients and 5% of surgeons said the patient should be told the number of times the procedure has been done by other surgeons, and 44% of patients and 20% of surgeons said other surgeons’ outcomes should be disclosed.

A total of 64% of patients and 31% of surgeons believed it was important to discuss any special training by the surgeon doing the procedure. Some 64% of patients said they would want to be informed about the surgeon’s special training for a standard procedure, compared with 68% for a laparoscopic procedure and 71% for a robotic procedure.

Technological innovation made a difference in whether patients deemed certain information essential. Patients scheduled for a laparoscopic or robotic procedure were significantly more likely to want information than those undergoing a standard operation.

In all, 63% of patients said they would want to know the number of times that a standard procedure had been done by their surgeon. That percentage rose to 66% for a laparoscopic procedure and to 68% for a robotic procedure. Outcomes information was considered important by 63% of patients for a standard procedure, 66% for a laparoscopic procedure, and 67% for a robotic procedure. And 24% of patients, compared with 6% of surgeons, said the patient should be told if the surgeon planned to publish an article including the case. Disclosing whether a surgeon is a paid consultant was less important to patients (5%) than to surgeons (40%).

Dr. Char had no conflicts of interest.

SAN FRANCISCO – Recent surveys of patients and attending surgeons show differing views on disclosures, Dr. Susan Lee Char said at the clinical congress of the American College of Surgeons.

She and her associates surveyed 353 adult patients at their first postoperative clinic visit and 85 attending surgeons at hospitals affiliated with the University of California, San Francisco. The survey presented a hypothetical case of a patient’s undergoing elective partial hepatectomy and asked respondents to rate the importance of receiving or conveying various items of information on a 6-point Likert scale.

In all, 79% of patients said it’s essential to know if their surgeon would be doing a procedure for the first time on them, but only 55% of attending surgeons felt this was important information to disclose. A total of 63% of patients considered it essential to know the number of times a surgeon had performed a particular procedure and the outcomes in those cases, compared with just 25% and 20% of surgeons, respectively.

"The data suggest that surgeons do have an ethical obligation to disclose volumes and outcomes and if it’s the first time [they’re] doing a procedure," said Dr. Char, a surgical resident at the university who is also a lawyer. "This has possible legal implications."

The main barrier to surgeons’ disclosure may be a practical one, she added. Surgeons often don’t have data on the volumes and outcomes of their procedures.

Patients’ and attending surgeons’ perceptions of the importance of other types of information also differed significantly. A general description of the procedure was rated as important by 65% of patients vs. 58% of surgeons, and technical details of the procedure were important to 48% of patients and 13% of surgeons. Disclosure of risks and benefits of the procedure were deemed essential by 77% and 71% of patients, respectively, compared with 72% and 65% of surgeons, respectively. A total of 41% of patients and 5% of surgeons said the patient should be told the number of times the procedure has been done by other surgeons, and 44% of patients and 20% of surgeons said other surgeons’ outcomes should be disclosed.

A total of 64% of patients and 31% of surgeons believed it was important to discuss any special training by the surgeon doing the procedure. Some 64% of patients said they would want to be informed about the surgeon’s special training for a standard procedure, compared with 68% for a laparoscopic procedure and 71% for a robotic procedure.

Technological innovation made a difference in whether patients deemed certain information essential. Patients scheduled for a laparoscopic or robotic procedure were significantly more likely to want information than those undergoing a standard operation.

In all, 63% of patients said they would want to know the number of times that a standard procedure had been done by their surgeon. That percentage rose to 66% for a laparoscopic procedure and to 68% for a robotic procedure. Outcomes information was considered important by 63% of patients for a standard procedure, 66% for a laparoscopic procedure, and 67% for a robotic procedure. And 24% of patients, compared with 6% of surgeons, said the patient should be told if the surgeon planned to publish an article including the case. Disclosing whether a surgeon is a paid consultant was less important to patients (5%) than to surgeons (40%).

Dr. Char had no conflicts of interest.

SAN FRANCISCO – Recent surveys of patients and attending surgeons show differing views on disclosures, Dr. Susan Lee Char said at the clinical congress of the American College of Surgeons.

She and her associates surveyed 353 adult patients at their first postoperative clinic visit and 85 attending surgeons at hospitals affiliated with the University of California, San Francisco. The survey presented a hypothetical case of a patient’s undergoing elective partial hepatectomy and asked respondents to rate the importance of receiving or conveying various items of information on a 6-point Likert scale.

In all, 79% of patients said it’s essential to know if their surgeon would be doing a procedure for the first time on them, but only 55% of attending surgeons felt this was important information to disclose. A total of 63% of patients considered it essential to know the number of times a surgeon had performed a particular procedure and the outcomes in those cases, compared with just 25% and 20% of surgeons, respectively.

"The data suggest that surgeons do have an ethical obligation to disclose volumes and outcomes and if it’s the first time [they’re] doing a procedure," said Dr. Char, a surgical resident at the university who is also a lawyer. "This has possible legal implications."

The main barrier to surgeons’ disclosure may be a practical one, she added. Surgeons often don’t have data on the volumes and outcomes of their procedures.

Patients’ and attending surgeons’ perceptions of the importance of other types of information also differed significantly. A general description of the procedure was rated as important by 65% of patients vs. 58% of surgeons, and technical details of the procedure were important to 48% of patients and 13% of surgeons. Disclosure of risks and benefits of the procedure were deemed essential by 77% and 71% of patients, respectively, compared with 72% and 65% of surgeons, respectively. A total of 41% of patients and 5% of surgeons said the patient should be told the number of times the procedure has been done by other surgeons, and 44% of patients and 20% of surgeons said other surgeons’ outcomes should be disclosed.

A total of 64% of patients and 31% of surgeons believed it was important to discuss any special training by the surgeon doing the procedure. Some 64% of patients said they would want to be informed about the surgeon’s special training for a standard procedure, compared with 68% for a laparoscopic procedure and 71% for a robotic procedure.

Technological innovation made a difference in whether patients deemed certain information essential. Patients scheduled for a laparoscopic or robotic procedure were significantly more likely to want information than those undergoing a standard operation.

In all, 63% of patients said they would want to know the number of times that a standard procedure had been done by their surgeon. That percentage rose to 66% for a laparoscopic procedure and to 68% for a robotic procedure. Outcomes information was considered important by 63% of patients for a standard procedure, 66% for a laparoscopic procedure, and 67% for a robotic procedure. And 24% of patients, compared with 6% of surgeons, said the patient should be told if the surgeon planned to publish an article including the case. Disclosing whether a surgeon is a paid consultant was less important to patients (5%) than to surgeons (40%).

Dr. Char had no conflicts of interest.

SAN FRANCISCO – Recent surveys of patients and attending surgeons show differing views on disclosures, Dr. Susan Lee Char said at the clinical congress of the American College of Surgeons.

She and her associates surveyed 353 adult patients at their first postoperative clinic visit and 85 attending surgeons at hospitals affiliated with the University of California, San Francisco. The survey presented a hypothetical case of a patient’s undergoing elective partial hepatectomy and asked respondents to rate the importance of receiving or conveying various items of information on a 6-point Likert scale.

In all, 79% of patients said it’s essential to know if their surgeon would be doing a procedure for the first time on them, but only 55% of attending surgeons felt this was important information to disclose. A total of 63% of patients considered it essential to know the number of times a surgeon had performed a particular procedure and the outcomes in those cases, compared with just 25% and 20% of surgeons, respectively.

"The data suggest that surgeons do have an ethical obligation to disclose volumes and outcomes and if it’s the first time [they’re] doing a procedure," said Dr. Char, a surgical resident at the university who is also a lawyer. "This has possible legal implications."

The main barrier to surgeons’ disclosure may be a practical one, she added. Surgeons often don’t have data on the volumes and outcomes of their procedures.

Patients’ and attending surgeons’ perceptions of the importance of other types of information also differed significantly. A general description of the procedure was rated as important by 65% of patients vs. 58% of surgeons, and technical details of the procedure were important to 48% of patients and 13% of surgeons. Disclosure of risks and benefits of the procedure were deemed essential by 77% and 71% of patients, respectively, compared with 72% and 65% of surgeons, respectively. A total of 41% of patients and 5% of surgeons said the patient should be told the number of times the procedure has been done by other surgeons, and 44% of patients and 20% of surgeons said other surgeons’ outcomes should be disclosed.

A total of 64% of patients and 31% of surgeons believed it was important to discuss any special training by the surgeon doing the procedure. Some 64% of patients said they would want to be informed about the surgeon’s special training for a standard procedure, compared with 68% for a laparoscopic procedure and 71% for a robotic procedure.

Technological innovation made a difference in whether patients deemed certain information essential. Patients scheduled for a laparoscopic or robotic procedure were significantly more likely to want information than those undergoing a standard operation.

In all, 63% of patients said they would want to know the number of times that a standard procedure had been done by their surgeon. That percentage rose to 66% for a laparoscopic procedure and to 68% for a robotic procedure. Outcomes information was considered important by 63% of patients for a standard procedure, 66% for a laparoscopic procedure, and 67% for a robotic procedure. And 24% of patients, compared with 6% of surgeons, said the patient should be told if the surgeon planned to publish an article including the case. Disclosing whether a surgeon is a paid consultant was less important to patients (5%) than to surgeons (40%).

Dr. Char had no conflicts of interest.

SAN FRANCISCO – Recent surveys of patients and attending surgeons show differing views on disclosures, Dr. Susan Lee Char said at the clinical congress of the American College of Surgeons.

She and her associates surveyed 353 adult patients at their first postoperative clinic visit and 85 attending surgeons at hospitals affiliated with the University of California, San Francisco. The survey presented a hypothetical case of a patient’s undergoing elective partial hepatectomy and asked respondents to rate the importance of receiving or conveying various items of information on a 6-point Likert scale.

In all, 79% of patients said it’s essential to know if their surgeon would be doing a procedure for the first time on them, but only 55% of attending surgeons felt this was important information to disclose. A total of 63% of patients considered it essential to know the number of times a surgeon had performed a particular procedure and the outcomes in those cases, compared with just 25% and 20% of surgeons, respectively.

"The data suggest that surgeons do have an ethical obligation to disclose volumes and outcomes and if it’s the first time [they’re] doing a procedure," said Dr. Char, a surgical resident at the university who is also a lawyer. "This has possible legal implications."

The main barrier to surgeons’ disclosure may be a practical one, she added. Surgeons often don’t have data on the volumes and outcomes of their procedures.

Patients’ and attending surgeons’ perceptions of the importance of other types of information also differed significantly. A general description of the procedure was rated as important by 65% of patients vs. 58% of surgeons, and technical details of the procedure were important to 48% of patients and 13% of surgeons. Disclosure of risks and benefits of the procedure were deemed essential by 77% and 71% of patients, respectively, compared with 72% and 65% of surgeons, respectively. A total of 41% of patients and 5% of surgeons said the patient should be told the number of times the procedure has been done by other surgeons, and 44% of patients and 20% of surgeons said other surgeons’ outcomes should be disclosed.

A total of 64% of patients and 31% of surgeons believed it was important to discuss any special training by the surgeon doing the procedure. Some 64% of patients said they would want to be informed about the surgeon’s special training for a standard procedure, compared with 68% for a laparoscopic procedure and 71% for a robotic procedure.

Technological innovation made a difference in whether patients deemed certain information essential. Patients scheduled for a laparoscopic or robotic procedure were significantly more likely to want information than those undergoing a standard operation.

In all, 63% of patients said they would want to know the number of times that a standard procedure had been done by their surgeon. That percentage rose to 66% for a laparoscopic procedure and to 68% for a robotic procedure. Outcomes information was considered important by 63% of patients for a standard procedure, 66% for a laparoscopic procedure, and 67% for a robotic procedure. And 24% of patients, compared with 6% of surgeons, said the patient should be told if the surgeon planned to publish an article including the case. Disclosing whether a surgeon is a paid consultant was less important to patients (5%) than to surgeons (40%).

Dr. Char had no conflicts of interest.

SAN FRANCISCO – A new 86-gene signature may add to metabolic imaging in guiding early treatment decisions for esophagogastric junction cancer, researchers reported.

The leptin gene, among others, stood out as having the potential to become a clinically useful biomarker in analyses that were presented at the meeting.

Dr. Russell Petty of the University of Aberdeen (Scotland) and colleagues studied 182 patients with locally advanced or metastatic disease. The investigators performed FDG-PET (¹⁸fluorodeoxyglucose–positron emission tomography) imaging and CT imaging, as well as gene expression profiling, and immunohistochemistry of pretreatment tumor tissue.

Results showed that among a subgroup of 14 patients who had a PET metabolic response to the first cycle of neoadjuvant chemotherapy, a set of 86 genes in pretreatment tumor tissue distinguished those who had a radiologic response on CT after completing all cycles of that chemotherapy, compared with those who did not respond. In a variety of predictive models, this gene signature correctly predicted radiologic response in all cases.

"We have shown that gene expression profiling can subclassify FDG-PET metabolic responders into those patients that will and will not subsequently go on to have a [radiologic] response. We have also shown that combining molecular biomarkers and FDG-PET allows an optimization of response prediction," Dr. Petty said at a meeting on gastrointestinal cancer sponosored by the American Society of Clinical Oncology.

This is key, as PET alone has a poor positive predictive value in this setting, with only half of PET responders to neoadjuvant chemotherapy eventually showing a histopathologic response.

"While I suppose there is little doubt that if we used PET in this way to make treatment decisions, we would have a system that would be better than unstratified empirical treatment, what it still means is that quite significant proportions of our patients will go on to receive ineffective and intensely toxic therapy," he commented.

A subsequent gene enrichment and pathway analysis identified a half-dozen pathways that provided potential mechanistic explanations for the different tumor behavior.

"Within the pathways identified, the adipocytokine-signaling pathway immediately caught our attention because of the strong known [epidemiologic] link between obesity and body weight, and esophagogastric adenocarcinoma," Dr. Petty noted.

Additional analyses specifically fingered the leptin gene (among others) and showed that among PET responders, leptin expression was higher in radiologic nonresponders than in responders (P = .026).

Yet, immunohistochemistry in an independent group of 154 patients showed that strong leptin staining was also associated with better survival (P = .021), an association that held up in multivariate analysis (hazard ratio, 0.85; P = .04).

In stratified analyses, patients with leptin-positive tumors derived little survival benefit from neoadjuvant chemotherapy, whereas those with leptin-negative tumors fared considerably better if they received this therapy (indeed, about as well as the positive group).

"Leptin in particular may be a molecular biomarker that is useful to combine with PET," Dr. Petty commented.

"Leptin expression is associated with chemoresistance, but at the same time is also a favorable therapy-independent biomarker, so this combination of predictive and therapy-independent prognostic impacts mean that leptin has the potential to be a clinically useful biomarker."

"I really think that this is groundbreaking. ... The real future is here" when it comes to predicting treatment response in this cancer, as suggested by this study and others," session cochair Dr. Mark Krasna of the St. Joseph Medical Center in Towson, Md., commented in an interview.

"The question now is, are we ready for prime time to adopt that throughout?"

At present, more research is needed, according to Dr. Krasna, such as the ongoing validation of the 86-gene signature and from trials like CALGB (Cancer and Leukemia Group B) 80803 exploring response-adaptive treatment in this cancer.

"I think those are the important things we can do today. We are ready for that," he concluded.

Dr. Petty and Dr. Krasna reported that they had no relevant financial conflicts of interest.

SAN FRANCISCO – A new 86-gene signature may add to metabolic imaging in guiding early treatment decisions for esophagogastric junction cancer, researchers reported.

The leptin gene, among others, stood out as having the potential to become a clinically useful biomarker in analyses that were presented at the meeting.

Dr. Russell Petty of the University of Aberdeen (Scotland) and colleagues studied 182 patients with locally advanced or metastatic disease. The investigators performed FDG-PET (¹⁸fluorodeoxyglucose–positron emission tomography) imaging and CT imaging, as well as gene expression profiling, and immunohistochemistry of pretreatment tumor tissue.

Results showed that among a subgroup of 14 patients who had a PET metabolic response to the first cycle of neoadjuvant chemotherapy, a set of 86 genes in pretreatment tumor tissue distinguished those who had a radiologic response on CT after completing all cycles of that chemotherapy, compared with those who did not respond. In a variety of predictive models, this gene signature correctly predicted radiologic response in all cases.

"We have shown that gene expression profiling can subclassify FDG-PET metabolic responders into those patients that will and will not subsequently go on to have a [radiologic] response. We have also shown that combining molecular biomarkers and FDG-PET allows an optimization of response prediction," Dr. Petty said at a meeting on gastrointestinal cancer sponosored by the American Society of Clinical Oncology.

This is key, as PET alone has a poor positive predictive value in this setting, with only half of PET responders to neoadjuvant chemotherapy eventually showing a histopathologic response.

"While I suppose there is little doubt that if we used PET in this way to make treatment decisions, we would have a system that would be better than unstratified empirical treatment, what it still means is that quite significant proportions of our patients will go on to receive ineffective and intensely toxic therapy," he commented.

A subsequent gene enrichment and pathway analysis identified a half-dozen pathways that provided potential mechanistic explanations for the different tumor behavior.

"Within the pathways identified, the adipocytokine-signaling pathway immediately caught our attention because of the strong known [epidemiologic] link between obesity and body weight, and esophagogastric adenocarcinoma," Dr. Petty noted.

Additional analyses specifically fingered the leptin gene (among others) and showed that among PET responders, leptin expression was higher in radiologic nonresponders than in responders (P = .026).

Yet, immunohistochemistry in an independent group of 154 patients showed that strong leptin staining was also associated with better survival (P = .021), an association that held up in multivariate analysis (hazard ratio, 0.85; P = .04).

In stratified analyses, patients with leptin-positive tumors derived little survival benefit from neoadjuvant chemotherapy, whereas those with leptin-negative tumors fared considerably better if they received this therapy (indeed, about as well as the positive group).

"Leptin in particular may be a molecular biomarker that is useful to combine with PET," Dr. Petty commented.

"Leptin expression is associated with chemoresistance, but at the same time is also a favorable therapy-independent biomarker, so this combination of predictive and therapy-independent prognostic impacts mean that leptin has the potential to be a clinically useful biomarker."

"I really think that this is groundbreaking. ... The real future is here" when it comes to predicting treatment response in this cancer, as suggested by this study and others," session cochair Dr. Mark Krasna of the St. Joseph Medical Center in Towson, Md., commented in an interview.

"The question now is, are we ready for prime time to adopt that throughout?"

At present, more research is needed, according to Dr. Krasna, such as the ongoing validation of the 86-gene signature and from trials like CALGB (Cancer and Leukemia Group B) 80803 exploring response-adaptive treatment in this cancer.

"I think those are the important things we can do today. We are ready for that," he concluded.

Dr. Petty and Dr. Krasna reported that they had no relevant financial conflicts of interest.

SAN FRANCISCO – A new 86-gene signature may add to metabolic imaging in guiding early treatment decisions for esophagogastric junction cancer, researchers reported.

The leptin gene, among others, stood out as having the potential to become a clinically useful biomarker in analyses that were presented at the meeting.

Dr. Russell Petty of the University of Aberdeen (Scotland) and colleagues studied 182 patients with locally advanced or metastatic disease. The investigators performed FDG-PET (¹⁸fluorodeoxyglucose–positron emission tomography) imaging and CT imaging, as well as gene expression profiling, and immunohistochemistry of pretreatment tumor tissue.

Results showed that among a subgroup of 14 patients who had a PET metabolic response to the first cycle of neoadjuvant chemotherapy, a set of 86 genes in pretreatment tumor tissue distinguished those who had a radiologic response on CT after completing all cycles of that chemotherapy, compared with those who did not respond. In a variety of predictive models, this gene signature correctly predicted radiologic response in all cases.

"We have shown that gene expression profiling can subclassify FDG-PET metabolic responders into those patients that will and will not subsequently go on to have a [radiologic] response. We have also shown that combining molecular biomarkers and FDG-PET allows an optimization of response prediction," Dr. Petty said at a meeting on gastrointestinal cancer sponosored by the American Society of Clinical Oncology.

This is key, as PET alone has a poor positive predictive value in this setting, with only half of PET responders to neoadjuvant chemotherapy eventually showing a histopathologic response.

"While I suppose there is little doubt that if we used PET in this way to make treatment decisions, we would have a system that would be better than unstratified empirical treatment, what it still means is that quite significant proportions of our patients will go on to receive ineffective and intensely toxic therapy," he commented.

A subsequent gene enrichment and pathway analysis identified a half-dozen pathways that provided potential mechanistic explanations for the different tumor behavior.

"Within the pathways identified, the adipocytokine-signaling pathway immediately caught our attention because of the strong known [epidemiologic] link between obesity and body weight, and esophagogastric adenocarcinoma," Dr. Petty noted.

Additional analyses specifically fingered the leptin gene (among others) and showed that among PET responders, leptin expression was higher in radiologic nonresponders than in responders (P = .026).

Yet, immunohistochemistry in an independent group of 154 patients showed that strong leptin staining was also associated with better survival (P = .021), an association that held up in multivariate analysis (hazard ratio, 0.85; P = .04).

In stratified analyses, patients with leptin-positive tumors derived little survival benefit from neoadjuvant chemotherapy, whereas those with leptin-negative tumors fared considerably better if they received this therapy (indeed, about as well as the positive group).

"Leptin in particular may be a molecular biomarker that is useful to combine with PET," Dr. Petty commented.

"Leptin expression is associated with chemoresistance, but at the same time is also a favorable therapy-independent biomarker, so this combination of predictive and therapy-independent prognostic impacts mean that leptin has the potential to be a clinically useful biomarker."

"I really think that this is groundbreaking. ... The real future is here" when it comes to predicting treatment response in this cancer, as suggested by this study and others," session cochair Dr. Mark Krasna of the St. Joseph Medical Center in Towson, Md., commented in an interview.

"The question now is, are we ready for prime time to adopt that throughout?"

At present, more research is needed, according to Dr. Krasna, such as the ongoing validation of the 86-gene signature and from trials like CALGB (Cancer and Leukemia Group B) 80803 exploring response-adaptive treatment in this cancer.

"I think those are the important things we can do today. We are ready for that," he concluded.

Dr. Petty and Dr. Krasna reported that they had no relevant financial conflicts of interest.

New noninvasive screening technologies are poised to improve the diagnostic yield of advanced imaging in lung cancer and, by so doing, improve patient outcomes. A blood test for detecting genetic mutations in circulating tumor cells of lung cancer specimens and a colorimetric sensor array that identifies cancerous compounds in exhaled human breath are among the technologies that could lead to earlier diagnosis and treatment, said Dr. Paul A. Bunn, executive director of the International Association for the Study of Lung Cancer (IASLC).

Lung cancer treatment has been hampered in the past by late diagnoses, typically achieved using invasive procedures only after symptoms have presented, said Dr. Bunn, the James Dudley Professor of Lung Cancer Research at the University of Colorado at Denver.

"Major breakthroughs are leading to interventions that make a huge difference and make it an exciting time for lung cancer," he said.

In particular, a test identifying lung cancer biomarkers through exhaled breath may also help clinicians and researchers identify which patients with abnormal CT scans need more aggressive follow-up. Dr. Nir Peled of Tel Hashomer, Israel, presented data from a comparative survey using breath analyses, in which investigators captured the "metabolic biosignatures" – the pattern of volatile organic compounds (VOCs) – of 74 patients with solitary pulmonary nodules to determine the VOC profiles for malignant and benign lung nodules.

"On analysis, two [VOCs] in patients’ exhaled breath showed statistically significant differences in concentration for benign and malignant lung nodules, and the sensor array distinguished between the corresponding collective VOC patterns with nearly 90% accuracy," Dr. Peled said in an interview.

Further, looking specifically at the malignant nodules, "the sensor array distinguished between small and non–small cell lung cancer with an accuracy approaching 94% and between early and advanced disease with nearly 90% accuracy."

Dr. Peled reported no disclosures.

New noninvasive screening technologies are poised to improve the diagnostic yield of advanced imaging in lung cancer and, by so doing, improve patient outcomes. A blood test for detecting genetic mutations in circulating tumor cells of lung cancer specimens and a colorimetric sensor array that identifies cancerous compounds in exhaled human breath are among the technologies that could lead to earlier diagnosis and treatment, said Dr. Paul A. Bunn, executive director of the International Association for the Study of Lung Cancer (IASLC).

Lung cancer treatment has been hampered in the past by late diagnoses, typically achieved using invasive procedures only after symptoms have presented, said Dr. Bunn, the James Dudley Professor of Lung Cancer Research at the University of Colorado at Denver.

"Major breakthroughs are leading to interventions that make a huge difference and make it an exciting time for lung cancer," he said.

In particular, a test identifying lung cancer biomarkers through exhaled breath may also help clinicians and researchers identify which patients with abnormal CT scans need more aggressive follow-up. Dr. Nir Peled of Tel Hashomer, Israel, presented data from a comparative survey using breath analyses, in which investigators captured the "metabolic biosignatures" – the pattern of volatile organic compounds (VOCs) – of 74 patients with solitary pulmonary nodules to determine the VOC profiles for malignant and benign lung nodules.

"On analysis, two [VOCs] in patients’ exhaled breath showed statistically significant differences in concentration for benign and malignant lung nodules, and the sensor array distinguished between the corresponding collective VOC patterns with nearly 90% accuracy," Dr. Peled said in an interview.

Further, looking specifically at the malignant nodules, "the sensor array distinguished between small and non–small cell lung cancer with an accuracy approaching 94% and between early and advanced disease with nearly 90% accuracy."

Dr. Peled reported no disclosures.

New noninvasive screening technologies are poised to improve the diagnostic yield of advanced imaging in lung cancer and, by so doing, improve patient outcomes. A blood test for detecting genetic mutations in circulating tumor cells of lung cancer specimens and a colorimetric sensor array that identifies cancerous compounds in exhaled human breath are among the technologies that could lead to earlier diagnosis and treatment, said Dr. Paul A. Bunn, executive director of the International Association for the Study of Lung Cancer (IASLC).

Lung cancer treatment has been hampered in the past by late diagnoses, typically achieved using invasive procedures only after symptoms have presented, said Dr. Bunn, the James Dudley Professor of Lung Cancer Research at the University of Colorado at Denver.

"Major breakthroughs are leading to interventions that make a huge difference and make it an exciting time for lung cancer," he said.

In particular, a test identifying lung cancer biomarkers through exhaled breath may also help clinicians and researchers identify which patients with abnormal CT scans need more aggressive follow-up. Dr. Nir Peled of Tel Hashomer, Israel, presented data from a comparative survey using breath analyses, in which investigators captured the "metabolic biosignatures" – the pattern of volatile organic compounds (VOCs) – of 74 patients with solitary pulmonary nodules to determine the VOC profiles for malignant and benign lung nodules.

"On analysis, two [VOCs] in patients’ exhaled breath showed statistically significant differences in concentration for benign and malignant lung nodules, and the sensor array distinguished between the corresponding collective VOC patterns with nearly 90% accuracy," Dr. Peled said in an interview.

Further, looking specifically at the malignant nodules, "the sensor array distinguished between small and non–small cell lung cancer with an accuracy approaching 94% and between early and advanced disease with nearly 90% accuracy."

Dr. Peled reported no disclosures.

SAN FRANCISCO – A new 86-gene signature may add to metabolic imaging in guiding early treatment decisions for esophagogastric junction cancer, researchers reported.

The leptin gene, among others, stood out as having the potential to become a clinically useful biomarker in analyses that were presented at the meeting.

Dr. Russell Petty of the University of Aberdeen (Scotland) and colleagues studied 182 patients with locally advanced or metastatic disease. The investigators performed FDG-PET (¹⁸fluorodeoxyglucose–positron emission tomography) imaging and CT imaging, as well as gene expression profiling, and immunohistochemistry of pretreatment tumor tissue.

Results showed that among a subgroup of 14 patients who had a PET metabolic response to the first cycle of neoadjuvant chemotherapy, a set of 86 genes in pretreatment tumor tissue distinguished those who had a radiologic response on CT after completing all cycles of that chemotherapy, compared with those who did not respond. In a variety of predictive models, this gene signature correctly predicted radiologic response in all cases.

"We have shown that gene expression profiling can subclassify FDG-PET metabolic responders into those patients that will and will not subsequently go on to have a [radiologic] response. We have also shown that combining molecular biomarkers and FDG-PET allows an optimization of response prediction," Dr. Petty said at a meeting on gastrointestinal cancer sponosored by the American Society of Clinical Oncology.

This is key, as PET alone has a poor positive predictive value in this setting, with only half of PET responders to neoadjuvant chemotherapy eventually showing a histopathologic response.

"While I suppose there is little doubt that if we used PET in this way to make treatment decisions, we would have a system that would be better than unstratified empirical treatment, what it still means is that quite significant proportions of our patients will go on to receive ineffective and intensely toxic therapy," he commented.

A subsequent gene enrichment and pathway analysis identified a half-dozen pathways that provided potential mechanistic explanations for the different tumor behavior.

"Within the pathways identified, the adipocytokine-signaling pathway immediately caught our attention because of the strong known [epidemiologic] link between obesity and body weight, and esophagogastric adenocarcinoma," Dr. Petty noted.

Additional analyses specifically fingered the leptin gene (among others) and showed that among PET responders, leptin expression was higher in radiologic nonresponders than in responders (P = .026).

Yet, immunohistochemistry in an independent group of 154 patients showed that strong leptin staining was also associated with better survival (P = .021), an association that held up in multivariate analysis (hazard ratio, 0.85; P = .04).

In stratified analyses, patients with leptin-positive tumors derived little survival benefit from neoadjuvant chemotherapy, whereas those with leptin-negative tumors fared considerably better if they received this therapy (indeed, about as well as the positive group).

"Leptin in particular may be a molecular biomarker that is useful to combine with PET," Dr. Petty commented.

"Leptin expression is associated with chemoresistance, but at the same time is also a favorable therapy-independent biomarker, so this combination of predictive and therapy-independent prognostic impacts mean that leptin has the potential to be a clinically useful biomarker."

"I really think that this is groundbreaking. ... The real future is here" when it comes to predicting treatment response in this cancer, as suggested by this study and others," session cochair Dr. Mark Krasna of the St. Joseph Medical Center in Towson, Md., commented in an interview.

"The question now is, are we ready for prime time to adopt that throughout?"

At present, more research is needed, according to Dr. Krasna, such as the ongoing validation of the 86-gene signature and from trials like CALGB (Cancer and Leukemia Group B) 80803 exploring response-adaptive treatment in this cancer.

"I think those are the important things we can do today. We are ready for that," he concluded.

Dr. Petty and Dr. Krasna reported that they had no relevant financial conflicts of interest.

SAN FRANCISCO – A new 86-gene signature may add to metabolic imaging in guiding early treatment decisions for esophagogastric junction cancer, researchers reported.

The leptin gene, among others, stood out as having the potential to become a clinically useful biomarker in analyses that were presented at the meeting.

Dr. Russell Petty of the University of Aberdeen (Scotland) and colleagues studied 182 patients with locally advanced or metastatic disease. The investigators performed FDG-PET (¹⁸fluorodeoxyglucose–positron emission tomography) imaging and CT imaging, as well as gene expression profiling, and immunohistochemistry of pretreatment tumor tissue.

Results showed that among a subgroup of 14 patients who had a PET metabolic response to the first cycle of neoadjuvant chemotherapy, a set of 86 genes in pretreatment tumor tissue distinguished those who had a radiologic response on CT after completing all cycles of that chemotherapy, compared with those who did not respond. In a variety of predictive models, this gene signature correctly predicted radiologic response in all cases.

"We have shown that gene expression profiling can subclassify FDG-PET metabolic responders into those patients that will and will not subsequently go on to have a [radiologic] response. We have also shown that combining molecular biomarkers and FDG-PET allows an optimization of response prediction," Dr. Petty said at a meeting on gastrointestinal cancer sponosored by the American Society of Clinical Oncology.

This is key, as PET alone has a poor positive predictive value in this setting, with only half of PET responders to neoadjuvant chemotherapy eventually showing a histopathologic response.

"While I suppose there is little doubt that if we used PET in this way to make treatment decisions, we would have a system that would be better than unstratified empirical treatment, what it still means is that quite significant proportions of our patients will go on to receive ineffective and intensely toxic therapy," he commented.

A subsequent gene enrichment and pathway analysis identified a half-dozen pathways that provided potential mechanistic explanations for the different tumor behavior.

"Within the pathways identified, the adipocytokine-signaling pathway immediately caught our attention because of the strong known [epidemiologic] link between obesity and body weight, and esophagogastric adenocarcinoma," Dr. Petty noted.

Additional analyses specifically fingered the leptin gene (among others) and showed that among PET responders, leptin expression was higher in radiologic nonresponders than in responders (P = .026).

Yet, immunohistochemistry in an independent group of 154 patients showed that strong leptin staining was also associated with better survival (P = .021), an association that held up in multivariate analysis (hazard ratio, 0.85; P = .04).

In stratified analyses, patients with leptin-positive tumors derived little survival benefit from neoadjuvant chemotherapy, whereas those with leptin-negative tumors fared considerably better if they received this therapy (indeed, about as well as the positive group).

"Leptin in particular may be a molecular biomarker that is useful to combine with PET," Dr. Petty commented.

"Leptin expression is associated with chemoresistance, but at the same time is also a favorable therapy-independent biomarker, so this combination of predictive and therapy-independent prognostic impacts mean that leptin has the potential to be a clinically useful biomarker."

"I really think that this is groundbreaking. ... The real future is here" when it comes to predicting treatment response in this cancer, as suggested by this study and others," session cochair Dr. Mark Krasna of the St. Joseph Medical Center in Towson, Md., commented in an interview.

"The question now is, are we ready for prime time to adopt that throughout?"

At present, more research is needed, according to Dr. Krasna, such as the ongoing validation of the 86-gene signature and from trials like CALGB (Cancer and Leukemia Group B) 80803 exploring response-adaptive treatment in this cancer.

"I think those are the important things we can do today. We are ready for that," he concluded.

Dr. Petty and Dr. Krasna reported that they had no relevant financial conflicts of interest.

SAN FRANCISCO – A new 86-gene signature may add to metabolic imaging in guiding early treatment decisions for esophagogastric junction cancer, researchers reported.

The leptin gene, among others, stood out as having the potential to become a clinically useful biomarker in analyses that were presented at the meeting.

Dr. Russell Petty of the University of Aberdeen (Scotland) and colleagues studied 182 patients with locally advanced or metastatic disease. The investigators performed FDG-PET (¹⁸fluorodeoxyglucose–positron emission tomography) imaging and CT imaging, as well as gene expression profiling, and immunohistochemistry of pretreatment tumor tissue.

Results showed that among a subgroup of 14 patients who had a PET metabolic response to the first cycle of neoadjuvant chemotherapy, a set of 86 genes in pretreatment tumor tissue distinguished those who had a radiologic response on CT after completing all cycles of that chemotherapy, compared with those who did not respond. In a variety of predictive models, this gene signature correctly predicted radiologic response in all cases.

"We have shown that gene expression profiling can subclassify FDG-PET metabolic responders into those patients that will and will not subsequently go on to have a [radiologic] response. We have also shown that combining molecular biomarkers and FDG-PET allows an optimization of response prediction," Dr. Petty said at a meeting on gastrointestinal cancer sponosored by the American Society of Clinical Oncology.

This is key, as PET alone has a poor positive predictive value in this setting, with only half of PET responders to neoadjuvant chemotherapy eventually showing a histopathologic response.

"While I suppose there is little doubt that if we used PET in this way to make treatment decisions, we would have a system that would be better than unstratified empirical treatment, what it still means is that quite significant proportions of our patients will go on to receive ineffective and intensely toxic therapy," he commented.

A subsequent gene enrichment and pathway analysis identified a half-dozen pathways that provided potential mechanistic explanations for the different tumor behavior.

"Within the pathways identified, the adipocytokine-signaling pathway immediately caught our attention because of the strong known [epidemiologic] link between obesity and body weight, and esophagogastric adenocarcinoma," Dr. Petty noted.

Additional analyses specifically fingered the leptin gene (among others) and showed that among PET responders, leptin expression was higher in radiologic nonresponders than in responders (P = .026).

Yet, immunohistochemistry in an independent group of 154 patients showed that strong leptin staining was also associated with better survival (P = .021), an association that held up in multivariate analysis (hazard ratio, 0.85; P = .04).

In stratified analyses, patients with leptin-positive tumors derived little survival benefit from neoadjuvant chemotherapy, whereas those with leptin-negative tumors fared considerably better if they received this therapy (indeed, about as well as the positive group).

"Leptin in particular may be a molecular biomarker that is useful to combine with PET," Dr. Petty commented.

"Leptin expression is associated with chemoresistance, but at the same time is also a favorable therapy-independent biomarker, so this combination of predictive and therapy-independent prognostic impacts mean that leptin has the potential to be a clinically useful biomarker."

"I really think that this is groundbreaking. ... The real future is here" when it comes to predicting treatment response in this cancer, as suggested by this study and others," session cochair Dr. Mark Krasna of the St. Joseph Medical Center in Towson, Md., commented in an interview.

"The question now is, are we ready for prime time to adopt that throughout?"

At present, more research is needed, according to Dr. Krasna, such as the ongoing validation of the 86-gene signature and from trials like CALGB (Cancer and Leukemia Group B) 80803 exploring response-adaptive treatment in this cancer.

"I think those are the important things we can do today. We are ready for that," he concluded.

Dr. Petty and Dr. Krasna reported that they had no relevant financial conflicts of interest.

New noninvasive screening technologies are poised to improve the diagnostic yield of advanced imaging in lung cancer and, by so doing, improve patient outcomes. A blood test for detecting genetic mutations in circulating tumor cells of lung cancer specimens and a colorimetric sensor array that identifies cancerous compounds in exhaled human breath are among the technologies that could lead to earlier diagnosis and treatment, said Dr. Paul A. Bunn, executive director of the International Association for the Study of Lung Cancer (IASLC).

Lung cancer treatment has been hampered in the past by late diagnoses, typically achieved using invasive procedures only after symptoms have presented, said Dr. Bunn, the James Dudley Professor of Lung Cancer Research at the University of Colorado at Denver.

"Major breakthroughs are leading to interventions that make a huge difference and make it an exciting time for lung cancer," he said.

In particular, a test identifying lung cancer biomarkers through exhaled breath may also help clinicians and researchers identify which patients with abnormal CT scans need more aggressive follow-up. Dr. Nir Peled of Tel Hashomer, Israel, presented data from a comparative survey using breath analyses, in which investigators captured the "metabolic biosignatures" – the pattern of volatile organic compounds (VOCs) – of 74 patients with solitary pulmonary nodules to determine the VOC profiles for malignant and benign lung nodules.

"On analysis, two [VOCs] in patients’ exhaled breath showed statistically significant differences in concentration for benign and malignant lung nodules, and the sensor array distinguished between the corresponding collective VOC patterns with nearly 90% accuracy," Dr. Peled said in an interview.

Further, looking specifically at the malignant nodules, "the sensor array distinguished between small and non–small cell lung cancer with an accuracy approaching 94% and between early and advanced disease with nearly 90% accuracy."

Dr. Peled reported no disclosures.

New noninvasive screening technologies are poised to improve the diagnostic yield of advanced imaging in lung cancer and, by so doing, improve patient outcomes. A blood test for detecting genetic mutations in circulating tumor cells of lung cancer specimens and a colorimetric sensor array that identifies cancerous compounds in exhaled human breath are among the technologies that could lead to earlier diagnosis and treatment, said Dr. Paul A. Bunn, executive director of the International Association for the Study of Lung Cancer (IASLC).

Lung cancer treatment has been hampered in the past by late diagnoses, typically achieved using invasive procedures only after symptoms have presented, said Dr. Bunn, the James Dudley Professor of Lung Cancer Research at the University of Colorado at Denver.

"Major breakthroughs are leading to interventions that make a huge difference and make it an exciting time for lung cancer," he said.

In particular, a test identifying lung cancer biomarkers through exhaled breath may also help clinicians and researchers identify which patients with abnormal CT scans need more aggressive follow-up. Dr. Nir Peled of Tel Hashomer, Israel, presented data from a comparative survey using breath analyses, in which investigators captured the "metabolic biosignatures" – the pattern of volatile organic compounds (VOCs) – of 74 patients with solitary pulmonary nodules to determine the VOC profiles for malignant and benign lung nodules.

"On analysis, two [VOCs] in patients’ exhaled breath showed statistically significant differences in concentration for benign and malignant lung nodules, and the sensor array distinguished between the corresponding collective VOC patterns with nearly 90% accuracy," Dr. Peled said in an interview.

Further, looking specifically at the malignant nodules, "the sensor array distinguished between small and non–small cell lung cancer with an accuracy approaching 94% and between early and advanced disease with nearly 90% accuracy."

Dr. Peled reported no disclosures.

New noninvasive screening technologies are poised to improve the diagnostic yield of advanced imaging in lung cancer and, by so doing, improve patient outcomes. A blood test for detecting genetic mutations in circulating tumor cells of lung cancer specimens and a colorimetric sensor array that identifies cancerous compounds in exhaled human breath are among the technologies that could lead to earlier diagnosis and treatment, said Dr. Paul A. Bunn, executive director of the International Association for the Study of Lung Cancer (IASLC).

Lung cancer treatment has been hampered in the past by late diagnoses, typically achieved using invasive procedures only after symptoms have presented, said Dr. Bunn, the James Dudley Professor of Lung Cancer Research at the University of Colorado at Denver.

"Major breakthroughs are leading to interventions that make a huge difference and make it an exciting time for lung cancer," he said.

In particular, a test identifying lung cancer biomarkers through exhaled breath may also help clinicians and researchers identify which patients with abnormal CT scans need more aggressive follow-up. Dr. Nir Peled of Tel Hashomer, Israel, presented data from a comparative survey using breath analyses, in which investigators captured the "metabolic biosignatures" – the pattern of volatile organic compounds (VOCs) – of 74 patients with solitary pulmonary nodules to determine the VOC profiles for malignant and benign lung nodules.

"On analysis, two [VOCs] in patients’ exhaled breath showed statistically significant differences in concentration for benign and malignant lung nodules, and the sensor array distinguished between the corresponding collective VOC patterns with nearly 90% accuracy," Dr. Peled said in an interview.

Further, looking specifically at the malignant nodules, "the sensor array distinguished between small and non–small cell lung cancer with an accuracy approaching 94% and between early and advanced disease with nearly 90% accuracy."

Dr. Peled reported no disclosures.

HOUSTON – Restricting the amount of initial enteral intake in mechanically ventilated patients who have acute lung injury neither reduces the duration of mechanical ventilation nor improves mortality relative to full enteral feeding, but the nutritional strategy may be slightly easier on the stomach, according to a study reported at the annual congress of the Society of Critical Care Medicine.

The importance of nutrition support in critically ill patients with acute lung injury (ALI) is well accepted as a means of maintaining gut integrity, modulating both stress and the systemic immune response, and attenuating disease severity, but conflicting data regarding the timing, formulation, and amount of enteral nutrition have contributed to uncertainty about the optimal feeding protocol, according to Dr. Todd W. Rice of Vanderbilt University Medical Center in Nashville, Tenn.

"How much nutrition we need to promote the protective benefits, we don’t know. Providing a little bit of nutrition (called trophic feeding) has been shown to decrease intestinal intolerances, compared with full-calorie feeds, but it may do so at the risk of malnutrition, worse immune function, and loss of muscle strength," he said. Full-calorie feeding, on the other hand, may lead to more intolerances, may cause hyperglycemia and other imbalances, may increase septic complications, and may fuel the inflammatory fire, he added.

In the current study, which was published simultaneously in JAMA, Dr. Rice and colleagues in the EDEN (Early vs. Delayed Enteral Nutrition in ALI) trial sought to examine the relative advantages of restricting the amount of initial enteral intake in mechanically ventilated ALI patients. Specifically, the prospective, randomized, open-label trial compared the effect on clinical outcomes and survival of initial trophic enteral feeding – approximately 25% of the full target feeding – with initial full-calorie feeding for the first 6 days of mechanical ventilation in ALI patients. "We hypothesized that reduced trophic feeding during the first [6 days] would increase ventilator-free days and reduce instances of gastrointestinal intolerances compared with the conventional full enteral nutrition strategy," he said.

The study’s primary end point was ventilator-free days through day 28; secondary end points were daily percentage of goal enteral feeding, frequency of gastrointestinal intolerances, 60-day mortality before hospital discharge with unassisted breathing, ICU- and organ failure–free days, and new infections (JAMA 2012 Feb. 5[doi:10.1001/jama2012.137]).

The multicenter study population comprised 1,000 patients, from January 2008 through mid-April 2011, who were initiated on mechanical ventilation within 48 hours of developing ALI. Within 6 hours of randomization, enteric nutrition was initiated in 508 patients assigned to trophic nutrition and 492 assigned to full feeding, and was continued until death, extubation, or day 6, Dr. Rice explained. Per standard protocol, enteral nutrition in the full-feeding group began at 25 mL/hr and advanced to goal weights (25-30 kcal/day of nonprotein calories and 1.2-1.6 g/kg per day of protein) as quickly as possible; gastric residual volumes were checked every 6 hours while enteral feeding was increased. In the trophic group, enteral feeding was initiated at 10-20 kcal/hr and gastric residual volumes were checked every 12 hours. After 6 days, patients in the trophic group who still required mechanical ventilation were advanced to the full-energy feeding rates, he said.

Baseline characteristics of the two groups were similar, Dr. Rice noted. "The primary etiologies of lung injury in both groups of patients were pneumonia and sepsis, and the average APACHE III [Acute Physiology and Chronic Health Evaluation III] score was approximately 92. These were sick patients," he said. For the first 6 days, the full- and trophic feeding groups received 1,300 kcal/day and 400 kcal/day, respectively.

With respect to the primary end point (28 days), the average number of ventilator-free days in both groups was similar, at 14.9 in the trophic group and 15.0 in the full-feeding group. "There were also no differences in 60-day mortality, organ failure–free days, ICU-free days, or the incidence of infection between groups," he said. Similarly, with respect to body mass index category or lung injury severity, "there were no between-group differences in ventilator free days or survival."

The full-feeding group did have a higher number of gastrointestinal intolerances on any one day, and statistically significant increase on days 2 and 3, but the overall percentages of intolerances were low, Dr. Rice said. There were no differences in albumin and protein levels between the groups over the first 7 days, he said.

Regarding the immediate clinical relevance of the findings, Dr. Rice stressed that the study wasn’t designed as an equivalence trial, "so I can’t tell you both feeding strategies are similar, but you can look at the results." In fact, he said, although the study did not show a benefit other than improved gastrointestinal tolerance, his group has moved toward trophic feeds because of the ease of administration

Dr. Rice had no financial conflicts.

HOUSTON – Restricting the amount of initial enteral intake in mechanically ventilated patients who have acute lung injury neither reduces the duration of mechanical ventilation nor improves mortality relative to full enteral feeding, but the nutritional strategy may be slightly easier on the stomach, according to a study reported at the annual congress of the Society of Critical Care Medicine.

The importance of nutrition support in critically ill patients with acute lung injury (ALI) is well accepted as a means of maintaining gut integrity, modulating both stress and the systemic immune response, and attenuating disease severity, but conflicting data regarding the timing, formulation, and amount of enteral nutrition have contributed to uncertainty about the optimal feeding protocol, according to Dr. Todd W. Rice of Vanderbilt University Medical Center in Nashville, Tenn.

"How much nutrition we need to promote the protective benefits, we don’t know. Providing a little bit of nutrition (called trophic feeding) has been shown to decrease intestinal intolerances, compared with full-calorie feeds, but it may do so at the risk of malnutrition, worse immune function, and loss of muscle strength," he said. Full-calorie feeding, on the other hand, may lead to more intolerances, may cause hyperglycemia and other imbalances, may increase septic complications, and may fuel the inflammatory fire, he added.

In the current study, which was published simultaneously in JAMA, Dr. Rice and colleagues in the EDEN (Early vs. Delayed Enteral Nutrition in ALI) trial sought to examine the relative advantages of restricting the amount of initial enteral intake in mechanically ventilated ALI patients. Specifically, the prospective, randomized, open-label trial compared the effect on clinical outcomes and survival of initial trophic enteral feeding – approximately 25% of the full target feeding – with initial full-calorie feeding for the first 6 days of mechanical ventilation in ALI patients. "We hypothesized that reduced trophic feeding during the first [6 days] would increase ventilator-free days and reduce instances of gastrointestinal intolerances compared with the conventional full enteral nutrition strategy," he said.

The study’s primary end point was ventilator-free days through day 28; secondary end points were daily percentage of goal enteral feeding, frequency of gastrointestinal intolerances, 60-day mortality before hospital discharge with unassisted breathing, ICU- and organ failure–free days, and new infections (JAMA 2012 Feb. 5[doi:10.1001/jama2012.137]).

The multicenter study population comprised 1,000 patients, from January 2008 through mid-April 2011, who were initiated on mechanical ventilation within 48 hours of developing ALI. Within 6 hours of randomization, enteric nutrition was initiated in 508 patients assigned to trophic nutrition and 492 assigned to full feeding, and was continued until death, extubation, or day 6, Dr. Rice explained. Per standard protocol, enteral nutrition in the full-feeding group began at 25 mL/hr and advanced to goal weights (25-30 kcal/day of nonprotein calories and 1.2-1.6 g/kg per day of protein) as quickly as possible; gastric residual volumes were checked every 6 hours while enteral feeding was increased. In the trophic group, enteral feeding was initiated at 10-20 kcal/hr and gastric residual volumes were checked every 12 hours. After 6 days, patients in the trophic group who still required mechanical ventilation were advanced to the full-energy feeding rates, he said.

Baseline characteristics of the two groups were similar, Dr. Rice noted. "The primary etiologies of lung injury in both groups of patients were pneumonia and sepsis, and the average APACHE III [Acute Physiology and Chronic Health Evaluation III] score was approximately 92. These were sick patients," he said. For the first 6 days, the full- and trophic feeding groups received 1,300 kcal/day and 400 kcal/day, respectively.

With respect to the primary end point (28 days), the average number of ventilator-free days in both groups was similar, at 14.9 in the trophic group and 15.0 in the full-feeding group. "There were also no differences in 60-day mortality, organ failure–free days, ICU-free days, or the incidence of infection between groups," he said. Similarly, with respect to body mass index category or lung injury severity, "there were no between-group differences in ventilator free days or survival."

The full-feeding group did have a higher number of gastrointestinal intolerances on any one day, and statistically significant increase on days 2 and 3, but the overall percentages of intolerances were low, Dr. Rice said. There were no differences in albumin and protein levels between the groups over the first 7 days, he said.

Regarding the immediate clinical relevance of the findings, Dr. Rice stressed that the study wasn’t designed as an equivalence trial, "so I can’t tell you both feeding strategies are similar, but you can look at the results." In fact, he said, although the study did not show a benefit other than improved gastrointestinal tolerance, his group has moved toward trophic feeds because of the ease of administration

Dr. Rice had no financial conflicts.

HOUSTON – Restricting the amount of initial enteral intake in mechanically ventilated patients who have acute lung injury neither reduces the duration of mechanical ventilation nor improves mortality relative to full enteral feeding, but the nutritional strategy may be slightly easier on the stomach, according to a study reported at the annual congress of the Society of Critical Care Medicine.

The importance of nutrition support in critically ill patients with acute lung injury (ALI) is well accepted as a means of maintaining gut integrity, modulating both stress and the systemic immune response, and attenuating disease severity, but conflicting data regarding the timing, formulation, and amount of enteral nutrition have contributed to uncertainty about the optimal feeding protocol, according to Dr. Todd W. Rice of Vanderbilt University Medical Center in Nashville, Tenn.

"How much nutrition we need to promote the protective benefits, we don’t know. Providing a little bit of nutrition (called trophic feeding) has been shown to decrease intestinal intolerances, compared with full-calorie feeds, but it may do so at the risk of malnutrition, worse immune function, and loss of muscle strength," he said. Full-calorie feeding, on the other hand, may lead to more intolerances, may cause hyperglycemia and other imbalances, may increase septic complications, and may fuel the inflammatory fire, he added.

In the current study, which was published simultaneously in JAMA, Dr. Rice and colleagues in the EDEN (Early vs. Delayed Enteral Nutrition in ALI) trial sought to examine the relative advantages of restricting the amount of initial enteral intake in mechanically ventilated ALI patients. Specifically, the prospective, randomized, open-label trial compared the effect on clinical outcomes and survival of initial trophic enteral feeding – approximately 25% of the full target feeding – with initial full-calorie feeding for the first 6 days of mechanical ventilation in ALI patients. "We hypothesized that reduced trophic feeding during the first [6 days] would increase ventilator-free days and reduce instances of gastrointestinal intolerances compared with the conventional full enteral nutrition strategy," he said.

The study’s primary end point was ventilator-free days through day 28; secondary end points were daily percentage of goal enteral feeding, frequency of gastrointestinal intolerances, 60-day mortality before hospital discharge with unassisted breathing, ICU- and organ failure–free days, and new infections (JAMA 2012 Feb. 5[doi:10.1001/jama2012.137]).

The multicenter study population comprised 1,000 patients, from January 2008 through mid-April 2011, who were initiated on mechanical ventilation within 48 hours of developing ALI. Within 6 hours of randomization, enteric nutrition was initiated in 508 patients assigned to trophic nutrition and 492 assigned to full feeding, and was continued until death, extubation, or day 6, Dr. Rice explained. Per standard protocol, enteral nutrition in the full-feeding group began at 25 mL/hr and advanced to goal weights (25-30 kcal/day of nonprotein calories and 1.2-1.6 g/kg per day of protein) as quickly as possible; gastric residual volumes were checked every 6 hours while enteral feeding was increased. In the trophic group, enteral feeding was initiated at 10-20 kcal/hr and gastric residual volumes were checked every 12 hours. After 6 days, patients in the trophic group who still required mechanical ventilation were advanced to the full-energy feeding rates, he said.

Baseline characteristics of the two groups were similar, Dr. Rice noted. "The primary etiologies of lung injury in both groups of patients were pneumonia and sepsis, and the average APACHE III [Acute Physiology and Chronic Health Evaluation III] score was approximately 92. These were sick patients," he said. For the first 6 days, the full- and trophic feeding groups received 1,300 kcal/day and 400 kcal/day, respectively.

With respect to the primary end point (28 days), the average number of ventilator-free days in both groups was similar, at 14.9 in the trophic group and 15.0 in the full-feeding group. "There were also no differences in 60-day mortality, organ failure–free days, ICU-free days, or the incidence of infection between groups," he said. Similarly, with respect to body mass index category or lung injury severity, "there were no between-group differences in ventilator free days or survival."

The full-feeding group did have a higher number of gastrointestinal intolerances on any one day, and statistically significant increase on days 2 and 3, but the overall percentages of intolerances were low, Dr. Rice said. There were no differences in albumin and protein levels between the groups over the first 7 days, he said.

Regarding the immediate clinical relevance of the findings, Dr. Rice stressed that the study wasn’t designed as an equivalence trial, "so I can’t tell you both feeding strategies are similar, but you can look at the results." In fact, he said, although the study did not show a benefit other than improved gastrointestinal tolerance, his group has moved toward trophic feeds because of the ease of administration

Dr. Rice had no financial conflicts.

HOUSTON – Restricting the amount of initial enteral intake in mechanically ventilated patients who have acute lung injury neither reduces the duration of mechanical ventilation nor improves mortality relative to full enteral feeding, but the nutritional strategy may be slightly easier on the stomach, according to a study reported at the annual congress of the Society of Critical Care Medicine.

The importance of nutrition support in critically ill patients with acute lung injury (ALI) is well accepted as a means of maintaining gut integrity, modulating both stress and the systemic immune response, and attenuating disease severity, but conflicting data regarding the timing, formulation, and amount of enteral nutrition have contributed to uncertainty about the optimal feeding protocol, according to Dr. Todd W. Rice of Vanderbilt University Medical Center in Nashville, Tenn.

"How much nutrition we need to promote the protective benefits, we don’t know. Providing a little bit of nutrition (called trophic feeding) has been shown to decrease intestinal intolerances, compared with full-calorie feeds, but it may do so at the risk of malnutrition, worse immune function, and loss of muscle strength," he said. Full-calorie feeding, on the other hand, may lead to more intolerances, may cause hyperglycemia and other imbalances, may increase septic complications, and may fuel the inflammatory fire, he added.

In the current study, which was published simultaneously in JAMA, Dr. Rice and colleagues in the EDEN (Early vs. Delayed Enteral Nutrition in ALI) trial sought to examine the relative advantages of restricting the amount of initial enteral intake in mechanically ventilated ALI patients. Specifically, the prospective, randomized, open-label trial compared the effect on clinical outcomes and survival of initial trophic enteral feeding – approximately 25% of the full target feeding – with initial full-calorie feeding for the first 6 days of mechanical ventilation in ALI patients. "We hypothesized that reduced trophic feeding during the first [6 days] would increase ventilator-free days and reduce instances of gastrointestinal intolerances compared with the conventional full enteral nutrition strategy," he said.

The study’s primary end point was ventilator-free days through day 28; secondary end points were daily percentage of goal enteral feeding, frequency of gastrointestinal intolerances, 60-day mortality before hospital discharge with unassisted breathing, ICU- and organ failure–free days, and new infections (JAMA 2012 Feb. 5[doi:10.1001/jama2012.137]).

The multicenter study population comprised 1,000 patients, from January 2008 through mid-April 2011, who were initiated on mechanical ventilation within 48 hours of developing ALI. Within 6 hours of randomization, enteric nutrition was initiated in 508 patients assigned to trophic nutrition and 492 assigned to full feeding, and was continued until death, extubation, or day 6, Dr. Rice explained. Per standard protocol, enteral nutrition in the full-feeding group began at 25 mL/hr and advanced to goal weights (25-30 kcal/day of nonprotein calories and 1.2-1.6 g/kg per day of protein) as quickly as possible; gastric residual volumes were checked every 6 hours while enteral feeding was increased. In the trophic group, enteral feeding was initiated at 10-20 kcal/hr and gastric residual volumes were checked every 12 hours. After 6 days, patients in the trophic group who still required mechanical ventilation were advanced to the full-energy feeding rates, he said.

Baseline characteristics of the two groups were similar, Dr. Rice noted. "The primary etiologies of lung injury in both groups of patients were pneumonia and sepsis, and the average APACHE III [Acute Physiology and Chronic Health Evaluation III] score was approximately 92. These were sick patients," he said. For the first 6 days, the full- and trophic feeding groups received 1,300 kcal/day and 400 kcal/day, respectively.

With respect to the primary end point (28 days), the average number of ventilator-free days in both groups was similar, at 14.9 in the trophic group and 15.0 in the full-feeding group. "There were also no differences in 60-day mortality, organ failure–free days, ICU-free days, or the incidence of infection between groups," he said. Similarly, with respect to body mass index category or lung injury severity, "there were no between-group differences in ventilator free days or survival."

The full-feeding group did have a higher number of gastrointestinal intolerances on any one day, and statistically significant increase on days 2 and 3, but the overall percentages of intolerances were low, Dr. Rice said. There were no differences in albumin and protein levels between the groups over the first 7 days, he said.

Regarding the immediate clinical relevance of the findings, Dr. Rice stressed that the study wasn’t designed as an equivalence trial, "so I can’t tell you both feeding strategies are similar, but you can look at the results." In fact, he said, although the study did not show a benefit other than improved gastrointestinal tolerance, his group has moved toward trophic feeds because of the ease of administration

Dr. Rice had no financial conflicts.

HOUSTON – Restricting the amount of initial enteral intake in mechanically ventilated patients who have acute lung injury neither reduces the duration of mechanical ventilation nor improves mortality relative to full enteral feeding, but the nutritional strategy may be slightly easier on the stomach, according to a study reported at the annual congress of the Society of Critical Care Medicine.

The importance of nutrition support in critically ill patients with acute lung injury (ALI) is well accepted as a means of maintaining gut integrity, modulating both stress and the systemic immune response, and attenuating disease severity, but conflicting data regarding the timing, formulation, and amount of enteral nutrition have contributed to uncertainty about the optimal feeding protocol, according to Dr. Todd W. Rice of Vanderbilt University Medical Center in Nashville, Tenn.

"How much nutrition we need to promote the protective benefits, we don’t know. Providing a little bit of nutrition (called trophic feeding) has been shown to decrease intestinal intolerances, compared with full-calorie feeds, but it may do so at the risk of malnutrition, worse immune function, and loss of muscle strength," he said. Full-calorie feeding, on the other hand, may lead to more intolerances, may cause hyperglycemia and other imbalances, may increase septic complications, and may fuel the inflammatory fire, he added.

In the current study, which was published simultaneously in JAMA, Dr. Rice and colleagues in the EDEN (Early vs. Delayed Enteral Nutrition in ALI) trial sought to examine the relative advantages of restricting the amount of initial enteral intake in mechanically ventilated ALI patients. Specifically, the prospective, randomized, open-label trial compared the effect on clinical outcomes and survival of initial trophic enteral feeding – approximately 25% of the full target feeding – with initial full-calorie feeding for the first 6 days of mechanical ventilation in ALI patients. "We hypothesized that reduced trophic feeding during the first [6 days] would increase ventilator-free days and reduce instances of gastrointestinal intolerances compared with the conventional full enteral nutrition strategy," he said.

The study’s primary end point was ventilator-free days through day 28; secondary end points were daily percentage of goal enteral feeding, frequency of gastrointestinal intolerances, 60-day mortality before hospital discharge with unassisted breathing, ICU- and organ failure–free days, and new infections (JAMA 2012 Feb. 5[doi:10.1001/jama2012.137]).

The multicenter study population comprised 1,000 patients, from January 2008 through mid-April 2011, who were initiated on mechanical ventilation within 48 hours of developing ALI. Within 6 hours of randomization, enteric nutrition was initiated in 508 patients assigned to trophic nutrition and 492 assigned to full feeding, and was continued until death, extubation, or day 6, Dr. Rice explained. Per standard protocol, enteral nutrition in the full-feeding group began at 25 mL/hr and advanced to goal weights (25-30 kcal/day of nonprotein calories and 1.2-1.6 g/kg per day of protein) as quickly as possible; gastric residual volumes were checked every 6 hours while enteral feeding was increased. In the trophic group, enteral feeding was initiated at 10-20 kcal/hr and gastric residual volumes were checked every 12 hours. After 6 days, patients in the trophic group who still required mechanical ventilation were advanced to the full-energy feeding rates, he said.

Baseline characteristics of the two groups were similar, Dr. Rice noted. "The primary etiologies of lung injury in both groups of patients were pneumonia and sepsis, and the average APACHE III [Acute Physiology and Chronic Health Evaluation III] score was approximately 92. These were sick patients," he said. For the first 6 days, the full- and trophic feeding groups received 1,300 kcal/day and 400 kcal/day, respectively.

With respect to the primary end point (28 days), the average number of ventilator-free days in both groups was similar, at 14.9 in the trophic group and 15.0 in the full-feeding group. "There were also no differences in 60-day mortality, organ failure–free days, ICU-free days, or the incidence of infection between groups," he said. Similarly, with respect to body mass index category or lung injury severity, "there were no between-group differences in ventilator free days or survival."

The full-feeding group did have a higher number of gastrointestinal intolerances on any one day, and statistically significant increase on days 2 and 3, but the overall percentages of intolerances were low, Dr. Rice said. There were no differences in albumin and protein levels between the groups over the first 7 days, he said.

Regarding the immediate clinical relevance of the findings, Dr. Rice stressed that the study wasn’t designed as an equivalence trial, "so I can’t tell you both feeding strategies are similar, but you can look at the results." In fact, he said, although the study did not show a benefit other than improved gastrointestinal tolerance, his group has moved toward trophic feeds because of the ease of administration

Dr. Rice had no financial conflicts.

HOUSTON – Restricting the amount of initial enteral intake in mechanically ventilated patients who have acute lung injury neither reduces the duration of mechanical ventilation nor improves mortality relative to full enteral feeding, but the nutritional strategy may be slightly easier on the stomach, according to a study reported at the annual congress of the Society of Critical Care Medicine.

The importance of nutrition support in critically ill patients with acute lung injury (ALI) is well accepted as a means of maintaining gut integrity, modulating both stress and the systemic immune response, and attenuating disease severity, but conflicting data regarding the timing, formulation, and amount of enteral nutrition have contributed to uncertainty about the optimal feeding protocol, according to Dr. Todd W. Rice of Vanderbilt University Medical Center in Nashville, Tenn.

"How much nutrition we need to promote the protective benefits, we don’t know. Providing a little bit of nutrition (called trophic feeding) has been shown to decrease intestinal intolerances, compared with full-calorie feeds, but it may do so at the risk of malnutrition, worse immune function, and loss of muscle strength," he said. Full-calorie feeding, on the other hand, may lead to more intolerances, may cause hyperglycemia and other imbalances, may increase septic complications, and may fuel the inflammatory fire, he added.

In the current study, which was published simultaneously in JAMA, Dr. Rice and colleagues in the EDEN (Early vs. Delayed Enteral Nutrition in ALI) trial sought to examine the relative advantages of restricting the amount of initial enteral intake in mechanically ventilated ALI patients. Specifically, the prospective, randomized, open-label trial compared the effect on clinical outcomes and survival of initial trophic enteral feeding – approximately 25% of the full target feeding – with initial full-calorie feeding for the first 6 days of mechanical ventilation in ALI patients. "We hypothesized that reduced trophic feeding during the first [6 days] would increase ventilator-free days and reduce instances of gastrointestinal intolerances compared with the conventional full enteral nutrition strategy," he said.

The study’s primary end point was ventilator-free days through day 28; secondary end points were daily percentage of goal enteral feeding, frequency of gastrointestinal intolerances, 60-day mortality before hospital discharge with unassisted breathing, ICU- and organ failure–free days, and new infections (JAMA 2012 Feb. 5[doi:10.1001/jama2012.137]).

The multicenter study population comprised 1,000 patients, from January 2008 through mid-April 2011, who were initiated on mechanical ventilation within 48 hours of developing ALI. Within 6 hours of randomization, enteric nutrition was initiated in 508 patients assigned to trophic nutrition and 492 assigned to full feeding, and was continued until death, extubation, or day 6, Dr. Rice explained. Per standard protocol, enteral nutrition in the full-feeding group began at 25 mL/hr and advanced to goal weights (25-30 kcal/day of nonprotein calories and 1.2-1.6 g/kg per day of protein) as quickly as possible; gastric residual volumes were checked every 6 hours while enteral feeding was increased. In the trophic group, enteral feeding was initiated at 10-20 kcal/hr and gastric residual volumes were checked every 12 hours. After 6 days, patients in the trophic group who still required mechanical ventilation were advanced to the full-energy feeding rates, he said.

Baseline characteristics of the two groups were similar, Dr. Rice noted. "The primary etiologies of lung injury in both groups of patients were pneumonia and sepsis, and the average APACHE III [Acute Physiology and Chronic Health Evaluation III] score was approximately 92. These were sick patients," he said. For the first 6 days, the full- and trophic feeding groups received 1,300 kcal/day and 400 kcal/day, respectively.

With respect to the primary end point (28 days), the average number of ventilator-free days in both groups was similar, at 14.9 in the trophic group and 15.0 in the full-feeding group. "There were also no differences in 60-day mortality, organ failure–free days, ICU-free days, or the incidence of infection between groups," he said. Similarly, with respect to body mass index category or lung injury severity, "there were no between-group differences in ventilator free days or survival."

The full-feeding group did have a higher number of gastrointestinal intolerances on any one day, and statistically significant increase on days 2 and 3, but the overall percentages of intolerances were low, Dr. Rice said. There were no differences in albumin and protein levels between the groups over the first 7 days, he said.

Regarding the immediate clinical relevance of the findings, Dr. Rice stressed that the study wasn’t designed as an equivalence trial, "so I can’t tell you both feeding strategies are similar, but you can look at the results." In fact, he said, although the study did not show a benefit other than improved gastrointestinal tolerance, his group has moved toward trophic feeds because of the ease of administration

Dr. Rice had no financial conflicts.

By PATRICE WENDLING

Elsevier Global Medical News

Would you allow patients to self-refer for a CT lung cancer screening? Would you screen a never-smoker? What size nodule would trigger a follow-up exam? What is your lower age limit and lower pack-year limit for screening? These are just a few of the questions that were tackled during an interactive lung cancer screening session at the recent Radiological Society of North America meeting, and that highlight the uncharted waters physicians face in the wake of the pivotal National Lung Screening Trial.

The NLST demonstrated a 20% reduction in lung cancer mortality when low-dose CT screening was used, compared with chest x-ray, among 53,000 asymptomatic current or former heavy smokers. However, CT produced more than three times the number of positive results and a higher false-positive rate than radiography.

Without a clear plan to manage abnormal findings or a firm handle on cost, policy makers and payers are hesitant to back reimbursement for widespread lung cancer screening. Results of the ongoing NLST cost-effectiveness analysis are expected early next year. Based on already published data, however, a crude back-of-the-envelope estimate puts the incremental cost-effectiveness ratio at $38,000 per life-year gained, NLST investigator Dr. William Black told attendees.

"That actually is a pretty good deal compared to a lot of things we do in medicine, and in fact most people would put the threshold for acceptability somewhere between $50,000 to $100,000 per life-year gained," he said. "So it certainly is feasible"

Dr. Black pointed out that low-dose CT saved 1 lung cancer death per 346 persons screened in NLST, which again is very favorable, compared with the rate of 1 per 2,000 patients for mammography.

Although the session provided just a small snapshot in time, audience responses suggested there is much work ahead. A full 77% of attendees were not using low-dose CT to screen for lung cancer, and 72% reported not being familiar with the recently published National Comprehensive Cancer Network guidelines for lung cancer screening. One-quarter of the audience had no lower age limit for screening, and 34% said they neither provide decision support nor obtained informed consent.

Radiologist and NLST collaborator Dr. Caroline Chiles said that informed consent in NLST helped prepare patients for the potential risks of a screen, for the likelihood of a positive result, and for the fact that a positive result didn’t mean they had lung cancer. "It made a huge difference once they got that letter saying they had a positive screen, because at that point you don’t want everyone rushing out to a surgeon to get that nodule resected," she added.

What attendees and panelists could agree on was the need for smoking cessation to be included in any future lung cancer CT screening program, with 60% of attendees saying they already do so.

Dr. Chiles pointed out that 16.6% of participants in the NELSON lung screening trial quit smoking, compared with 3%-7% in the general public, but that participants were less likely to stay nonsmokers. She also cited a recent MMWR article that said 70% of adult smokers want to quit smoking, but only about half had been advised by a health professional to quit.

"We really have to think of lung cancer screening as being a teachable moment," she said. She suggested that physicians visit www.smokefree.gov for help in guiding their patients. Dr. Black also noted the NLST team is working on a screening fact sheet for physicians and patients that will be made available on the Internet.☐

By PATRICE WENDLING

Elsevier Global Medical News

Would you allow patients to self-refer for a CT lung cancer screening? Would you screen a never-smoker? What size nodule would trigger a follow-up exam? What is your lower age limit and lower pack-year limit for screening? These are just a few of the questions that were tackled during an interactive lung cancer screening session at the recent Radiological Society of North America meeting, and that highlight the uncharted waters physicians face in the wake of the pivotal National Lung Screening Trial.

The NLST demonstrated a 20% reduction in lung cancer mortality when low-dose CT screening was used, compared with chest x-ray, among 53,000 asymptomatic current or former heavy smokers. However, CT produced more than three times the number of positive results and a higher false-positive rate than radiography.

Without a clear plan to manage abnormal findings or a firm handle on cost, policy makers and payers are hesitant to back reimbursement for widespread lung cancer screening. Results of the ongoing NLST cost-effectiveness analysis are expected early next year. Based on already published data, however, a crude back-of-the-envelope estimate puts the incremental cost-effectiveness ratio at $38,000 per life-year gained, NLST investigator Dr. William Black told attendees.

"That actually is a pretty good deal compared to a lot of things we do in medicine, and in fact most people would put the threshold for acceptability somewhere between $50,000 to $100,000 per life-year gained," he said. "So it certainly is feasible"

Dr. Black pointed out that low-dose CT saved 1 lung cancer death per 346 persons screened in NLST, which again is very favorable, compared with the rate of 1 per 2,000 patients for mammography.

Although the session provided just a small snapshot in time, audience responses suggested there is much work ahead. A full 77% of attendees were not using low-dose CT to screen for lung cancer, and 72% reported not being familiar with the recently published National Comprehensive Cancer Network guidelines for lung cancer screening. One-quarter of the audience had no lower age limit for screening, and 34% said they neither provide decision support nor obtained informed consent.

Radiologist and NLST collaborator Dr. Caroline Chiles said that informed consent in NLST helped prepare patients for the potential risks of a screen, for the likelihood of a positive result, and for the fact that a positive result didn’t mean they had lung cancer. "It made a huge difference once they got that letter saying they had a positive screen, because at that point you don’t want everyone rushing out to a surgeon to get that nodule resected," she added.

What attendees and panelists could agree on was the need for smoking cessation to be included in any future lung cancer CT screening program, with 60% of attendees saying they already do so.

Dr. Chiles pointed out that 16.6% of participants in the NELSON lung screening trial quit smoking, compared with 3%-7% in the general public, but that participants were less likely to stay nonsmokers. She also cited a recent MMWR article that said 70% of adult smokers want to quit smoking, but only about half had been advised by a health professional to quit.

"We really have to think of lung cancer screening as being a teachable moment," she said. She suggested that physicians visit www.smokefree.gov for help in guiding their patients. Dr. Black also noted the NLST team is working on a screening fact sheet for physicians and patients that will be made available on the Internet.☐

By PATRICE WENDLING

Elsevier Global Medical News

Would you allow patients to self-refer for a CT lung cancer screening? Would you screen a never-smoker? What size nodule would trigger a follow-up exam? What is your lower age limit and lower pack-year limit for screening? These are just a few of the questions that were tackled during an interactive lung cancer screening session at the recent Radiological Society of North America meeting, and that highlight the uncharted waters physicians face in the wake of the pivotal National Lung Screening Trial.

The NLST demonstrated a 20% reduction in lung cancer mortality when low-dose CT screening was used, compared with chest x-ray, among 53,000 asymptomatic current or former heavy smokers. However, CT produced more than three times the number of positive results and a higher false-positive rate than radiography.

Without a clear plan to manage abnormal findings or a firm handle on cost, policy makers and payers are hesitant to back reimbursement for widespread lung cancer screening. Results of the ongoing NLST cost-effectiveness analysis are expected early next year. Based on already published data, however, a crude back-of-the-envelope estimate puts the incremental cost-effectiveness ratio at $38,000 per life-year gained, NLST investigator Dr. William Black told attendees.

"That actually is a pretty good deal compared to a lot of things we do in medicine, and in fact most people would put the threshold for acceptability somewhere between $50,000 to $100,000 per life-year gained," he said. "So it certainly is feasible"

Dr. Black pointed out that low-dose CT saved 1 lung cancer death per 346 persons screened in NLST, which again is very favorable, compared with the rate of 1 per 2,000 patients for mammography.

Although the session provided just a small snapshot in time, audience responses suggested there is much work ahead. A full 77% of attendees were not using low-dose CT to screen for lung cancer, and 72% reported not being familiar with the recently published National Comprehensive Cancer Network guidelines for lung cancer screening. One-quarter of the audience had no lower age limit for screening, and 34% said they neither provide decision support nor obtained informed consent.

Radiologist and NLST collaborator Dr. Caroline Chiles said that informed consent in NLST helped prepare patients for the potential risks of a screen, for the likelihood of a positive result, and for the fact that a positive result didn’t mean they had lung cancer. "It made a huge difference once they got that letter saying they had a positive screen, because at that point you don’t want everyone rushing out to a surgeon to get that nodule resected," she added.

What attendees and panelists could agree on was the need for smoking cessation to be included in any future lung cancer CT screening program, with 60% of attendees saying they already do so.

Dr. Chiles pointed out that 16.6% of participants in the NELSON lung screening trial quit smoking, compared with 3%-7% in the general public, but that participants were less likely to stay nonsmokers. She also cited a recent MMWR article that said 70% of adult smokers want to quit smoking, but only about half had been advised by a health professional to quit.

"We really have to think of lung cancer screening as being a teachable moment," she said. She suggested that physicians visit www.smokefree.gov for help in guiding their patients. Dr. Black also noted the NLST team is working on a screening fact sheet for physicians and patients that will be made available on the Internet.☐