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Virtual Reality Brings Relief to Hospitalized Patients With Cancer
suggests a new randomized controlled trial.
While both interventions brought some pain relief, VR therapy yielded greater, longer-lasting comfort, reported lead author Hunter Groninger, MD, of MedStar Health Research Institute, Hyattsville, Maryland, and colleagues.
“Investigators have explored immersive VR interventions in cancer populations for a variety of indications including anxiety, depression, fatigue, and procedure‐associated pain, particularly among patients with pediatric cancer and adult breast cancer,” the investigators wrote in Cancer. “Nevertheless, despite growing evidence supporting the efficacy of VR‐delivered interventions for analgesia, few data address its role to mitigate cancer‐related pain specifically.”
To address this knowledge gap, Dr. Groninger and colleagues enrolled 128 adult hospitalized patients with cancer of any kind, all of whom had moderate to severe pain (self-reported score at least 4 out of 10) within the past 24 hours.
Study Methods and Results
Patients were randomized to receive either 10 minutes of immersive VR distraction therapy or 10 minutes of two-dimensional guided imagery distraction therapy.
“[The VR therapy] provides noncompetitive experiences in which the user can move around and explore natural environments (e.g., beachscape, forest) from standing, seated, or fixed positions, including within a hospital bed or chair,” the investigators wrote. “We provided over‐the‐ear headphones to assure high sound quality for the experience in the virtual natural environment.”
The two-dimensional intervention, delivered via electronic tablet, featured a meditation with images of natural landscapes and instrumental background music.
“We chose this active control because it is readily available and reflects content similar to relaxation‐focused television channels that are increasingly common in hospital settings,” the investigators noted.
Compared with this more common approach, patients who received VR therapy had significantly greater immediate reduction in pain (mean change in pain score, –1.4 vs –0.7; P = .03). Twenty-four hours later, improvements in the VR group generally persisted, while pain level in the two-dimensional group returned almost to baseline (P = .004). In addition, patients in the VR group reported significantly greater improvements in general distress and pain bothersomeness.
“VR therapies may modulate the pain experience by reducing the level of attention paid to noxious stimuli, thereby suppressing transmission of painful sensations via pain processing pathways to the cerebral cortex, particularly with more active VR experiences compared to passive experiences,” the investigators wrote.
Downsides to Using VR
Although VR brought more benefit, participants in the VR group more often reported difficulty using the intervention compared with those who interacted with an electronic tablet.
Plus, one VR user described mild dizziness that resolved with pharmacologic intervention. Still, approximately 9 out of 10 participants in each group reported willingness to try the intervention again.
Future VR Research
“Virtual reality is a rapidly evolving technology with a wealth of potential patient‐facing applications,” the investigators wrote. “Future studies should explore repeated use, optimal dosing, and impact on VR therapy on opioid analgesic requirements as well as usability testing, VR content preferences and facilitators of analgesia, and barriers and facilitators to use in acute care settings.”
This study was supported by the American Cancer Society. The investigators disclosed no conflicts of interest.
suggests a new randomized controlled trial.
While both interventions brought some pain relief, VR therapy yielded greater, longer-lasting comfort, reported lead author Hunter Groninger, MD, of MedStar Health Research Institute, Hyattsville, Maryland, and colleagues.
“Investigators have explored immersive VR interventions in cancer populations for a variety of indications including anxiety, depression, fatigue, and procedure‐associated pain, particularly among patients with pediatric cancer and adult breast cancer,” the investigators wrote in Cancer. “Nevertheless, despite growing evidence supporting the efficacy of VR‐delivered interventions for analgesia, few data address its role to mitigate cancer‐related pain specifically.”
To address this knowledge gap, Dr. Groninger and colleagues enrolled 128 adult hospitalized patients with cancer of any kind, all of whom had moderate to severe pain (self-reported score at least 4 out of 10) within the past 24 hours.
Study Methods and Results
Patients were randomized to receive either 10 minutes of immersive VR distraction therapy or 10 minutes of two-dimensional guided imagery distraction therapy.
“[The VR therapy] provides noncompetitive experiences in which the user can move around and explore natural environments (e.g., beachscape, forest) from standing, seated, or fixed positions, including within a hospital bed or chair,” the investigators wrote. “We provided over‐the‐ear headphones to assure high sound quality for the experience in the virtual natural environment.”
The two-dimensional intervention, delivered via electronic tablet, featured a meditation with images of natural landscapes and instrumental background music.
“We chose this active control because it is readily available and reflects content similar to relaxation‐focused television channels that are increasingly common in hospital settings,” the investigators noted.
Compared with this more common approach, patients who received VR therapy had significantly greater immediate reduction in pain (mean change in pain score, –1.4 vs –0.7; P = .03). Twenty-four hours later, improvements in the VR group generally persisted, while pain level in the two-dimensional group returned almost to baseline (P = .004). In addition, patients in the VR group reported significantly greater improvements in general distress and pain bothersomeness.
“VR therapies may modulate the pain experience by reducing the level of attention paid to noxious stimuli, thereby suppressing transmission of painful sensations via pain processing pathways to the cerebral cortex, particularly with more active VR experiences compared to passive experiences,” the investigators wrote.
Downsides to Using VR
Although VR brought more benefit, participants in the VR group more often reported difficulty using the intervention compared with those who interacted with an electronic tablet.
Plus, one VR user described mild dizziness that resolved with pharmacologic intervention. Still, approximately 9 out of 10 participants in each group reported willingness to try the intervention again.
Future VR Research
“Virtual reality is a rapidly evolving technology with a wealth of potential patient‐facing applications,” the investigators wrote. “Future studies should explore repeated use, optimal dosing, and impact on VR therapy on opioid analgesic requirements as well as usability testing, VR content preferences and facilitators of analgesia, and barriers and facilitators to use in acute care settings.”
This study was supported by the American Cancer Society. The investigators disclosed no conflicts of interest.
suggests a new randomized controlled trial.
While both interventions brought some pain relief, VR therapy yielded greater, longer-lasting comfort, reported lead author Hunter Groninger, MD, of MedStar Health Research Institute, Hyattsville, Maryland, and colleagues.
“Investigators have explored immersive VR interventions in cancer populations for a variety of indications including anxiety, depression, fatigue, and procedure‐associated pain, particularly among patients with pediatric cancer and adult breast cancer,” the investigators wrote in Cancer. “Nevertheless, despite growing evidence supporting the efficacy of VR‐delivered interventions for analgesia, few data address its role to mitigate cancer‐related pain specifically.”
To address this knowledge gap, Dr. Groninger and colleagues enrolled 128 adult hospitalized patients with cancer of any kind, all of whom had moderate to severe pain (self-reported score at least 4 out of 10) within the past 24 hours.
Study Methods and Results
Patients were randomized to receive either 10 minutes of immersive VR distraction therapy or 10 minutes of two-dimensional guided imagery distraction therapy.
“[The VR therapy] provides noncompetitive experiences in which the user can move around and explore natural environments (e.g., beachscape, forest) from standing, seated, or fixed positions, including within a hospital bed or chair,” the investigators wrote. “We provided over‐the‐ear headphones to assure high sound quality for the experience in the virtual natural environment.”
The two-dimensional intervention, delivered via electronic tablet, featured a meditation with images of natural landscapes and instrumental background music.
“We chose this active control because it is readily available and reflects content similar to relaxation‐focused television channels that are increasingly common in hospital settings,” the investigators noted.
Compared with this more common approach, patients who received VR therapy had significantly greater immediate reduction in pain (mean change in pain score, –1.4 vs –0.7; P = .03). Twenty-four hours later, improvements in the VR group generally persisted, while pain level in the two-dimensional group returned almost to baseline (P = .004). In addition, patients in the VR group reported significantly greater improvements in general distress and pain bothersomeness.
“VR therapies may modulate the pain experience by reducing the level of attention paid to noxious stimuli, thereby suppressing transmission of painful sensations via pain processing pathways to the cerebral cortex, particularly with more active VR experiences compared to passive experiences,” the investigators wrote.
Downsides to Using VR
Although VR brought more benefit, participants in the VR group more often reported difficulty using the intervention compared with those who interacted with an electronic tablet.
Plus, one VR user described mild dizziness that resolved with pharmacologic intervention. Still, approximately 9 out of 10 participants in each group reported willingness to try the intervention again.
Future VR Research
“Virtual reality is a rapidly evolving technology with a wealth of potential patient‐facing applications,” the investigators wrote. “Future studies should explore repeated use, optimal dosing, and impact on VR therapy on opioid analgesic requirements as well as usability testing, VR content preferences and facilitators of analgesia, and barriers and facilitators to use in acute care settings.”
This study was supported by the American Cancer Society. The investigators disclosed no conflicts of interest.
FROM CANCER
Should Opioids Be Used for Chronic Cancer Pain?
from legal concerns to threats of violence, say the authors of new research.
These findings suggest that evidence-based, systematic guidance is needed to steer opioid usage in cancer survivorship, wrote lead author Hailey W. Bulls, PhD, of the University of Pittsburgh, and colleagues.
“Prescription opioids are considered the standard of care to treat moderate to severe cancer pain during active treatment, yet guidance in the posttreatment survivorship phase is much less clear,” the investigators wrote. “Existing clinical resources recognize that opioid prescribing in survivorship is complex and nuanced and that the relative benefits and risks in this population are not fully understood.”
Who Should Manage Chronic Cancer Pain?
Despite the knowledge gap, survivors are typically excluded from long-term opioid use studies, leaving providers in a largely data-free zone. Simultaneously, patients who had been receiving focused care during their cancer treatment find themselves with an ill-defined health care team.
“Without a clear transition of care, survivors may seek pain management services from a variety of specialties, including oncologists, palliative care clinicians, primary care clinicians, and pain management specialists,” the investigators wrote. “However, many clinicians may view pain management to be outside of their skill set and may not be well equipped to handle opioid continuation or deprescribing [or] to manage the potential consequences of long‐term opioid use like side effects, misuse, and/or opioid use disorder.”
What Factors Guide Opioid Prescribing Practices for Chronic Cancer Pain?
To learn more about prescribing practices in this setting, Dr. Bulls and colleagues conducted qualitative interviews with 20 providers representing four specialties: oncology (n = 5), palliative care (n = 8), primary care (n = 5), and pain management (n = 2). Eighteen of these participants were physicians and two were advanced practice providers. Average time in clinical practice was about 16 years.
These interviews yielded three themes.
First, no “medical home” exists for chronic pain management in cancer survivors.
“Although clinicians generally agreed that minimizing the role of opioids in chronic pain management in cancer survivors was desirable, they described a lack of common treatment protocols to guide pain management in survivorship,” the investigators wrote.
Second, the interviews revealed that prescribing strategies are partly driven by peer pressure, sometimes leading to tension between providers and feelings of self-doubt.
“I feel like there’s been this weird judgment thing that’s happened [to] the prescribers,” one primary care provider said during the interview. “Because, when I trained … pain was a vital sign, and we were supposed to treat pain, and now I feel like we’re all being judged for that.”
The third theme revolved around fear of consequences resulting from prescribing practices, including fears of violent repercussions.
“You may not know, but pain specialists have been shot in this country for [refusing to prescribe opioids],” one pain management specialist said during the interview. “There’s been a number of shootings of pain specialists who would not prescribe opioids. So, I mean, there’s real issues of violence.”
Meanwhile, a palliative care provider described legal pressure from the opposite direction:
“I think there’s a lot of fear of litigiousness … and loss of licenses. That sort of makes them pressure us into not prescribing opioids or sticking with a certain number per day that might not be therapeutic for a patient.”
Reflecting on these themes, the investigators identified “a fundamental uncertainty in survivorship pain management.”
What Strategies Might Improve Opioid Prescribing Practices for Chronic Cancer Pain?
After sharing their attitudes about prescribing opioids for chronic cancer pain, the clinicians were asked for suggestions to improve the situation.
They offered four main suggestions: create relevant guidelines, increase education and access to pain management options for clinicians, increase interdisciplinary communication across medical subspecialties, and promote multidisciplinary care in the survivorship setting.
Dr. Bulls and colleagues supported these strategies in their concluding remarks and called for more research.
This study was supported by the National Institute of Drug Abuse, the National Institutes of Health, the National Center for Advancing Translational Sciences, and the National Cancer Institute. The investigators disclosed relationships with Arcadia Health Solutions and Biomotivate.
from legal concerns to threats of violence, say the authors of new research.
These findings suggest that evidence-based, systematic guidance is needed to steer opioid usage in cancer survivorship, wrote lead author Hailey W. Bulls, PhD, of the University of Pittsburgh, and colleagues.
“Prescription opioids are considered the standard of care to treat moderate to severe cancer pain during active treatment, yet guidance in the posttreatment survivorship phase is much less clear,” the investigators wrote. “Existing clinical resources recognize that opioid prescribing in survivorship is complex and nuanced and that the relative benefits and risks in this population are not fully understood.”
Who Should Manage Chronic Cancer Pain?
Despite the knowledge gap, survivors are typically excluded from long-term opioid use studies, leaving providers in a largely data-free zone. Simultaneously, patients who had been receiving focused care during their cancer treatment find themselves with an ill-defined health care team.
“Without a clear transition of care, survivors may seek pain management services from a variety of specialties, including oncologists, palliative care clinicians, primary care clinicians, and pain management specialists,” the investigators wrote. “However, many clinicians may view pain management to be outside of their skill set and may not be well equipped to handle opioid continuation or deprescribing [or] to manage the potential consequences of long‐term opioid use like side effects, misuse, and/or opioid use disorder.”
What Factors Guide Opioid Prescribing Practices for Chronic Cancer Pain?
To learn more about prescribing practices in this setting, Dr. Bulls and colleagues conducted qualitative interviews with 20 providers representing four specialties: oncology (n = 5), palliative care (n = 8), primary care (n = 5), and pain management (n = 2). Eighteen of these participants were physicians and two were advanced practice providers. Average time in clinical practice was about 16 years.
These interviews yielded three themes.
First, no “medical home” exists for chronic pain management in cancer survivors.
“Although clinicians generally agreed that minimizing the role of opioids in chronic pain management in cancer survivors was desirable, they described a lack of common treatment protocols to guide pain management in survivorship,” the investigators wrote.
Second, the interviews revealed that prescribing strategies are partly driven by peer pressure, sometimes leading to tension between providers and feelings of self-doubt.
“I feel like there’s been this weird judgment thing that’s happened [to] the prescribers,” one primary care provider said during the interview. “Because, when I trained … pain was a vital sign, and we were supposed to treat pain, and now I feel like we’re all being judged for that.”
The third theme revolved around fear of consequences resulting from prescribing practices, including fears of violent repercussions.
“You may not know, but pain specialists have been shot in this country for [refusing to prescribe opioids],” one pain management specialist said during the interview. “There’s been a number of shootings of pain specialists who would not prescribe opioids. So, I mean, there’s real issues of violence.”
Meanwhile, a palliative care provider described legal pressure from the opposite direction:
“I think there’s a lot of fear of litigiousness … and loss of licenses. That sort of makes them pressure us into not prescribing opioids or sticking with a certain number per day that might not be therapeutic for a patient.”
Reflecting on these themes, the investigators identified “a fundamental uncertainty in survivorship pain management.”
What Strategies Might Improve Opioid Prescribing Practices for Chronic Cancer Pain?
After sharing their attitudes about prescribing opioids for chronic cancer pain, the clinicians were asked for suggestions to improve the situation.
They offered four main suggestions: create relevant guidelines, increase education and access to pain management options for clinicians, increase interdisciplinary communication across medical subspecialties, and promote multidisciplinary care in the survivorship setting.
Dr. Bulls and colleagues supported these strategies in their concluding remarks and called for more research.
This study was supported by the National Institute of Drug Abuse, the National Institutes of Health, the National Center for Advancing Translational Sciences, and the National Cancer Institute. The investigators disclosed relationships with Arcadia Health Solutions and Biomotivate.
from legal concerns to threats of violence, say the authors of new research.
These findings suggest that evidence-based, systematic guidance is needed to steer opioid usage in cancer survivorship, wrote lead author Hailey W. Bulls, PhD, of the University of Pittsburgh, and colleagues.
“Prescription opioids are considered the standard of care to treat moderate to severe cancer pain during active treatment, yet guidance in the posttreatment survivorship phase is much less clear,” the investigators wrote. “Existing clinical resources recognize that opioid prescribing in survivorship is complex and nuanced and that the relative benefits and risks in this population are not fully understood.”
Who Should Manage Chronic Cancer Pain?
Despite the knowledge gap, survivors are typically excluded from long-term opioid use studies, leaving providers in a largely data-free zone. Simultaneously, patients who had been receiving focused care during their cancer treatment find themselves with an ill-defined health care team.
“Without a clear transition of care, survivors may seek pain management services from a variety of specialties, including oncologists, palliative care clinicians, primary care clinicians, and pain management specialists,” the investigators wrote. “However, many clinicians may view pain management to be outside of their skill set and may not be well equipped to handle opioid continuation or deprescribing [or] to manage the potential consequences of long‐term opioid use like side effects, misuse, and/or opioid use disorder.”
What Factors Guide Opioid Prescribing Practices for Chronic Cancer Pain?
To learn more about prescribing practices in this setting, Dr. Bulls and colleagues conducted qualitative interviews with 20 providers representing four specialties: oncology (n = 5), palliative care (n = 8), primary care (n = 5), and pain management (n = 2). Eighteen of these participants were physicians and two were advanced practice providers. Average time in clinical practice was about 16 years.
These interviews yielded three themes.
First, no “medical home” exists for chronic pain management in cancer survivors.
“Although clinicians generally agreed that minimizing the role of opioids in chronic pain management in cancer survivors was desirable, they described a lack of common treatment protocols to guide pain management in survivorship,” the investigators wrote.
Second, the interviews revealed that prescribing strategies are partly driven by peer pressure, sometimes leading to tension between providers and feelings of self-doubt.
“I feel like there’s been this weird judgment thing that’s happened [to] the prescribers,” one primary care provider said during the interview. “Because, when I trained … pain was a vital sign, and we were supposed to treat pain, and now I feel like we’re all being judged for that.”
The third theme revolved around fear of consequences resulting from prescribing practices, including fears of violent repercussions.
“You may not know, but pain specialists have been shot in this country for [refusing to prescribe opioids],” one pain management specialist said during the interview. “There’s been a number of shootings of pain specialists who would not prescribe opioids. So, I mean, there’s real issues of violence.”
Meanwhile, a palliative care provider described legal pressure from the opposite direction:
“I think there’s a lot of fear of litigiousness … and loss of licenses. That sort of makes them pressure us into not prescribing opioids or sticking with a certain number per day that might not be therapeutic for a patient.”
Reflecting on these themes, the investigators identified “a fundamental uncertainty in survivorship pain management.”
What Strategies Might Improve Opioid Prescribing Practices for Chronic Cancer Pain?
After sharing their attitudes about prescribing opioids for chronic cancer pain, the clinicians were asked for suggestions to improve the situation.
They offered four main suggestions: create relevant guidelines, increase education and access to pain management options for clinicians, increase interdisciplinary communication across medical subspecialties, and promote multidisciplinary care in the survivorship setting.
Dr. Bulls and colleagues supported these strategies in their concluding remarks and called for more research.
This study was supported by the National Institute of Drug Abuse, the National Institutes of Health, the National Center for Advancing Translational Sciences, and the National Cancer Institute. The investigators disclosed relationships with Arcadia Health Solutions and Biomotivate.
FROM CANCER
Immunohistochemistry May Improve Melanoma Diagnosis
. Rising utilization — and substantial geographic variation in practice patterns — argue for further research to optimize IHC use in the diagnoses of melanoma, according to the authors.
But with sparse guidance regarding best practices for IHC in melanoma diagnosis, concerns for appropriate use are rising, they wrote in their report, recently published in JAMA Dermatology.
Kenechukwu Ojukwu, MD, MPP, of the department of pathology and laboratory medicine, University of California, Los Angeles, and coinvestigators, searched the Surveillance, Epidemiology, and End Results (SEER)–Medicare database for incident in situ or invasive cutaneous melanoma in patients 65 years and older and accompanying IHC claims made during the month of diagnosis through 14 days afterward.
Among 132,547 melanomas in 116,117 patients, 43,396 (33%) had accompanying IHC claims. Such claims were less common with increasing age, declining from 44% in patients aged 65-74 years to 18% in patients 85 aged years and older. Although melanoma incidence increased throughout the period studied, melanoma mortality rates remained relatively stable.
By summary stage at diagnosis, IHC utilization ranged from 29% of in situ cases to 75% of distant cases. After the researchers controlled for year of diagnosis, IHC use was statistically significantly associated with all demographic, tumor, and geographic characteristics examined, except race and ethnicity. Across all the years of the study, regional usage ranged from a low of 22% in Detroit to a high of 44% in both Louisiana and San Jose-Monterey, California. Figures for 2017 ranged from 39% of cases in Kentucky and Atlanta to 68% in New Mexico.
“Given the extensive use of IHC in clinical practice,” the authors concluded, “studies examining the resulting outcomes of IHC on different domains, such as symptom burden, quality of life, and mortality, are crucial.”
The “notable” regional variation in IHC utilization suggests uncertainty about its optimal employment in clinical practice, and, they wrote, “these findings highlight the need for research to identify where IHC provides the most value and to develop guidelines regarding the appropriate use of IHC.”
In an accompanying JAMA Dermatology editorial, Alexandra Flamm, MD, wrote, “now is an exciting time to practice dermatopathology, with an increased number of ancillary tests, such as IHC, that can be used to diagnose malignant neoplasms more precisely and to more accurately determine prognosis and therapeutic options in this age of precision medicine”.
However, added Dr. Flamm, a dermatologist and dermatopathologist at New York University, New York City, the increasing number of ancillary tests is fueling awareness of appropriate use and the importance of ensuring high-quality, value-based healthcare. “With this increased scrutiny on the appropriateness of ancillary histopathologic testing within dermatopathology,” she wrote, “the need is growing for parameters that can be used to guide when to use IHC testing and other ancillary testing.” And using dermatopathologist-developed tools such as American Society of Dermatopathology guidelines for 11 IHC tests can help ensure that appropriate medical decision-making is taken into account when creating these tools, she added.
IHC Usage Growing
“The paper confirms what I already knew,” said Whitney High, MD, JD, who was not involved with the study and was asked to comment on the results. “Use of IHC in dermatopathology has increased substantially, and probably will continue to increase over time.” The societal burden of IHC costs represents a legitimate concern, said Dr. High, professor of dermatology and pathology and director of dermatopathology at the University of Colorado, Aurora.
“However,” he told this news organization, “the histologic diagnosis of melanoma is sometimes substantially subjective — and all physicians, including pathologists, even though they are not providing care in the physical presence of the patient, are fiduciaries.” If an IHC stain would meaningfully improve a patient’s care, he said, physicians should attempt to provide it, unless strictly disallowed by a payer. Controlling medical-care costs might be better left to professional societies to guide care standards over time, he noted.
IHC has the potential to improve the accuracy and reliability of melanoma assessments by providing additional data, said Dr. High.“To this end, disallowing the use of immunostains simply due to cost, without substantial evidence, has the potential to alter diagnoses and impact care negatively.” This is particularly true for melanoma, he said, where “finding even one additional melanoma with IHC has life-altering consequences for that patient.”
How IHC might impact melanoma overdiagnosis remains unclear without additional study. IHC might allow dermatologists to avoid diagnosing melanoma in borderline cases unsupported by IHC, explained Dr. High, or false-positive results could further fuel melanoma overdiagnosis.
Limitations of the IHC paper included an inability to determine whether IHC improved outcomes. Additional shortcomings included use of a SEER-specific older population. And because CPT codes are not site-specific, some samples may have come from surgical margins or non-skin locations.
Study authors reported receiving grants from the National Cancer Institute (NCI) during the conduct of the study. The study was funded by the University of California, Los Angeles (UCLA) National Clinician Scholars Program, the UCLA Department of Pathology, the California Department of Public Health, and the NCI. Dr. High reports no relevant financial interests.
. Rising utilization — and substantial geographic variation in practice patterns — argue for further research to optimize IHC use in the diagnoses of melanoma, according to the authors.
But with sparse guidance regarding best practices for IHC in melanoma diagnosis, concerns for appropriate use are rising, they wrote in their report, recently published in JAMA Dermatology.
Kenechukwu Ojukwu, MD, MPP, of the department of pathology and laboratory medicine, University of California, Los Angeles, and coinvestigators, searched the Surveillance, Epidemiology, and End Results (SEER)–Medicare database for incident in situ or invasive cutaneous melanoma in patients 65 years and older and accompanying IHC claims made during the month of diagnosis through 14 days afterward.
Among 132,547 melanomas in 116,117 patients, 43,396 (33%) had accompanying IHC claims. Such claims were less common with increasing age, declining from 44% in patients aged 65-74 years to 18% in patients 85 aged years and older. Although melanoma incidence increased throughout the period studied, melanoma mortality rates remained relatively stable.
By summary stage at diagnosis, IHC utilization ranged from 29% of in situ cases to 75% of distant cases. After the researchers controlled for year of diagnosis, IHC use was statistically significantly associated with all demographic, tumor, and geographic characteristics examined, except race and ethnicity. Across all the years of the study, regional usage ranged from a low of 22% in Detroit to a high of 44% in both Louisiana and San Jose-Monterey, California. Figures for 2017 ranged from 39% of cases in Kentucky and Atlanta to 68% in New Mexico.
“Given the extensive use of IHC in clinical practice,” the authors concluded, “studies examining the resulting outcomes of IHC on different domains, such as symptom burden, quality of life, and mortality, are crucial.”
The “notable” regional variation in IHC utilization suggests uncertainty about its optimal employment in clinical practice, and, they wrote, “these findings highlight the need for research to identify where IHC provides the most value and to develop guidelines regarding the appropriate use of IHC.”
In an accompanying JAMA Dermatology editorial, Alexandra Flamm, MD, wrote, “now is an exciting time to practice dermatopathology, with an increased number of ancillary tests, such as IHC, that can be used to diagnose malignant neoplasms more precisely and to more accurately determine prognosis and therapeutic options in this age of precision medicine”.
However, added Dr. Flamm, a dermatologist and dermatopathologist at New York University, New York City, the increasing number of ancillary tests is fueling awareness of appropriate use and the importance of ensuring high-quality, value-based healthcare. “With this increased scrutiny on the appropriateness of ancillary histopathologic testing within dermatopathology,” she wrote, “the need is growing for parameters that can be used to guide when to use IHC testing and other ancillary testing.” And using dermatopathologist-developed tools such as American Society of Dermatopathology guidelines for 11 IHC tests can help ensure that appropriate medical decision-making is taken into account when creating these tools, she added.
IHC Usage Growing
“The paper confirms what I already knew,” said Whitney High, MD, JD, who was not involved with the study and was asked to comment on the results. “Use of IHC in dermatopathology has increased substantially, and probably will continue to increase over time.” The societal burden of IHC costs represents a legitimate concern, said Dr. High, professor of dermatology and pathology and director of dermatopathology at the University of Colorado, Aurora.
“However,” he told this news organization, “the histologic diagnosis of melanoma is sometimes substantially subjective — and all physicians, including pathologists, even though they are not providing care in the physical presence of the patient, are fiduciaries.” If an IHC stain would meaningfully improve a patient’s care, he said, physicians should attempt to provide it, unless strictly disallowed by a payer. Controlling medical-care costs might be better left to professional societies to guide care standards over time, he noted.
IHC has the potential to improve the accuracy and reliability of melanoma assessments by providing additional data, said Dr. High.“To this end, disallowing the use of immunostains simply due to cost, without substantial evidence, has the potential to alter diagnoses and impact care negatively.” This is particularly true for melanoma, he said, where “finding even one additional melanoma with IHC has life-altering consequences for that patient.”
How IHC might impact melanoma overdiagnosis remains unclear without additional study. IHC might allow dermatologists to avoid diagnosing melanoma in borderline cases unsupported by IHC, explained Dr. High, or false-positive results could further fuel melanoma overdiagnosis.
Limitations of the IHC paper included an inability to determine whether IHC improved outcomes. Additional shortcomings included use of a SEER-specific older population. And because CPT codes are not site-specific, some samples may have come from surgical margins or non-skin locations.
Study authors reported receiving grants from the National Cancer Institute (NCI) during the conduct of the study. The study was funded by the University of California, Los Angeles (UCLA) National Clinician Scholars Program, the UCLA Department of Pathology, the California Department of Public Health, and the NCI. Dr. High reports no relevant financial interests.
. Rising utilization — and substantial geographic variation in practice patterns — argue for further research to optimize IHC use in the diagnoses of melanoma, according to the authors.
But with sparse guidance regarding best practices for IHC in melanoma diagnosis, concerns for appropriate use are rising, they wrote in their report, recently published in JAMA Dermatology.
Kenechukwu Ojukwu, MD, MPP, of the department of pathology and laboratory medicine, University of California, Los Angeles, and coinvestigators, searched the Surveillance, Epidemiology, and End Results (SEER)–Medicare database for incident in situ or invasive cutaneous melanoma in patients 65 years and older and accompanying IHC claims made during the month of diagnosis through 14 days afterward.
Among 132,547 melanomas in 116,117 patients, 43,396 (33%) had accompanying IHC claims. Such claims were less common with increasing age, declining from 44% in patients aged 65-74 years to 18% in patients 85 aged years and older. Although melanoma incidence increased throughout the period studied, melanoma mortality rates remained relatively stable.
By summary stage at diagnosis, IHC utilization ranged from 29% of in situ cases to 75% of distant cases. After the researchers controlled for year of diagnosis, IHC use was statistically significantly associated with all demographic, tumor, and geographic characteristics examined, except race and ethnicity. Across all the years of the study, regional usage ranged from a low of 22% in Detroit to a high of 44% in both Louisiana and San Jose-Monterey, California. Figures for 2017 ranged from 39% of cases in Kentucky and Atlanta to 68% in New Mexico.
“Given the extensive use of IHC in clinical practice,” the authors concluded, “studies examining the resulting outcomes of IHC on different domains, such as symptom burden, quality of life, and mortality, are crucial.”
The “notable” regional variation in IHC utilization suggests uncertainty about its optimal employment in clinical practice, and, they wrote, “these findings highlight the need for research to identify where IHC provides the most value and to develop guidelines regarding the appropriate use of IHC.”
In an accompanying JAMA Dermatology editorial, Alexandra Flamm, MD, wrote, “now is an exciting time to practice dermatopathology, with an increased number of ancillary tests, such as IHC, that can be used to diagnose malignant neoplasms more precisely and to more accurately determine prognosis and therapeutic options in this age of precision medicine”.
However, added Dr. Flamm, a dermatologist and dermatopathologist at New York University, New York City, the increasing number of ancillary tests is fueling awareness of appropriate use and the importance of ensuring high-quality, value-based healthcare. “With this increased scrutiny on the appropriateness of ancillary histopathologic testing within dermatopathology,” she wrote, “the need is growing for parameters that can be used to guide when to use IHC testing and other ancillary testing.” And using dermatopathologist-developed tools such as American Society of Dermatopathology guidelines for 11 IHC tests can help ensure that appropriate medical decision-making is taken into account when creating these tools, she added.
IHC Usage Growing
“The paper confirms what I already knew,” said Whitney High, MD, JD, who was not involved with the study and was asked to comment on the results. “Use of IHC in dermatopathology has increased substantially, and probably will continue to increase over time.” The societal burden of IHC costs represents a legitimate concern, said Dr. High, professor of dermatology and pathology and director of dermatopathology at the University of Colorado, Aurora.
“However,” he told this news organization, “the histologic diagnosis of melanoma is sometimes substantially subjective — and all physicians, including pathologists, even though they are not providing care in the physical presence of the patient, are fiduciaries.” If an IHC stain would meaningfully improve a patient’s care, he said, physicians should attempt to provide it, unless strictly disallowed by a payer. Controlling medical-care costs might be better left to professional societies to guide care standards over time, he noted.
IHC has the potential to improve the accuracy and reliability of melanoma assessments by providing additional data, said Dr. High.“To this end, disallowing the use of immunostains simply due to cost, without substantial evidence, has the potential to alter diagnoses and impact care negatively.” This is particularly true for melanoma, he said, where “finding even one additional melanoma with IHC has life-altering consequences for that patient.”
How IHC might impact melanoma overdiagnosis remains unclear without additional study. IHC might allow dermatologists to avoid diagnosing melanoma in borderline cases unsupported by IHC, explained Dr. High, or false-positive results could further fuel melanoma overdiagnosis.
Limitations of the IHC paper included an inability to determine whether IHC improved outcomes. Additional shortcomings included use of a SEER-specific older population. And because CPT codes are not site-specific, some samples may have come from surgical margins or non-skin locations.
Study authors reported receiving grants from the National Cancer Institute (NCI) during the conduct of the study. The study was funded by the University of California, Los Angeles (UCLA) National Clinician Scholars Program, the UCLA Department of Pathology, the California Department of Public Health, and the NCI. Dr. High reports no relevant financial interests.
FROM JAMA DERMATOLOGY
A Banned Chemical That Is Still Causing Cancer
This transcript has been edited for clarity.
These types of stories usually end with a call for regulation — to ban said chemical or substance, or to regulate it — but in this case, that has already happened. This new carcinogen I’m telling you about is actually an old chemical. And it has not been manufactured or legally imported in the US since 2013.
So, why bother? Because in this case, the chemical — or, really, a group of chemicals called polybrominated diphenyl ethers (PBDEs) — are still around: in our soil, in our food, and in our blood.
PBDEs are a group of compounds that confer flame-retardant properties to plastics, and they were used extensively in the latter part of the 20th century in electronic enclosures, business equipment, and foam cushioning in upholstery.
But there was a problem. They don’t chemically bond to plastics; they are just sort of mixed in, which means they can leach out. They are hydrophobic, meaning they don’t get washed out of soil, and, when ingested or inhaled by humans, they dissolve in our fat stores, making it difficult for our normal excretory systems to excrete them.
PBDEs biomagnify. Small animals can take them up from contaminated soil or water, and those animals are eaten by larger animals, which accumulate higher concentrations of the chemicals. This bioaccumulation increases as you move up the food web until you get to an apex predator — like you and me.
This is true of lots of chemicals, of course. The concern arises when these chemicals are toxic. To date, the toxicity data for PBDEs were pretty limited. There were some animal studies where rats were exposed to extremely high doses and they developed liver lesions — but I am always very wary of extrapolating high-dose rat toxicity studies to humans. There was also some suggestion that the chemicals could be endocrine disruptors, affecting breast and thyroid tissue.
What about cancer? In 2016, the International Agency for Research on Cancer concluded there was “inadequate evidence in humans for the carcinogencity of” PBDEs.
In the same report, though, they suggested PBDEs are “probably carcinogenic to humans” based on mechanistic studies.
In other words, we can’t prove they’re cancerous — but come on, they probably are.
Finally, we have some evidence that really pushes us toward the carcinogenic conclusion, in the form of this study, appearing in JAMA Network Open. It’s a nice bit of epidemiology leveraging the population-based National Health and Nutrition Examination Survey (NHANES).
Researchers measured PBDE levels in blood samples from 1100 people enrolled in NHANES in 2003 and 2004 and linked them to death records collected over the next 20 years or so.
The first thing to note is that the researchers were able to measure PBDEs in the blood samples. They were in there. They were detectable. And they were variable. Dividing the 1100 participants into low, medium, and high PBDE tertiles, you can see a nearly 10-fold difference across the population.
Importantly, not many baseline variables correlated with PBDE levels. People in the highest group were a bit younger but had a fairly similar sex distribution, race, ethnicity, education, income, physical activity, smoking status, and body mass index.
This is not a randomized trial, of course — but at least based on these data, exposure levels do seem fairly random, which is what you would expect from an environmental toxin that percolates up through the food chain. They are often somewhat indiscriminate.
This similarity in baseline characteristics between people with low or high blood levels of PBDE also allows us to make some stronger inferences about the observed outcomes. Let’s take a look at them.
After adjustment for baseline factors, individuals in the highest PBDE group had a 43% higher rate of death from any cause over the follow-up period. This was not enough to achieve statistical significance, but it was close.
But the key finding is deaths due to cancer. After adjustment, cancer deaths occurred four times as frequently among those in the high PBDE group, and that is a statistically significant difference.
To be fair, cancer deaths were rare in this cohort. The vast majority of people did not die of anything during the follow-up period regardless of PBDE level. But the data are strongly suggestive of the carcinogenicity of these chemicals.
I should also point out that the researchers are linking the PBDE level at a single time point to all these future events. If PBDE levels remain relatively stable within an individual over time, that’s fine, but if they tend to vary with intake of different foods for example, this would not be captured and would actually lead to an underestimation of the cancer risk.
The researchers also didn’t have granular enough data to determine the type of cancer, but they do show that rates are similar between men and women, which might point away from the more sex-specific cancer etiologies. Clearly, some more work is needed.
Of course, I started this piece by telling you that these chemicals are already pretty much banned in the United States. What are we supposed to do about these findings? Studies have examined the primary ongoing sources of PBDE in our environment and it seems like most of our exposure will be coming from the food we eat due to that biomagnification thing: high-fat fish, meat and dairy products, and fish oil supplements. It may be worth some investigation into the relative adulteration of these products with this new old carcinogen.
Dr. F. Perry Wilson is associate professor of medicine and public health and director of the Clinical and Translational Research Accelerator at Yale University, New Haven, Conn. He has disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
This transcript has been edited for clarity.
These types of stories usually end with a call for regulation — to ban said chemical or substance, or to regulate it — but in this case, that has already happened. This new carcinogen I’m telling you about is actually an old chemical. And it has not been manufactured or legally imported in the US since 2013.
So, why bother? Because in this case, the chemical — or, really, a group of chemicals called polybrominated diphenyl ethers (PBDEs) — are still around: in our soil, in our food, and in our blood.
PBDEs are a group of compounds that confer flame-retardant properties to plastics, and they were used extensively in the latter part of the 20th century in electronic enclosures, business equipment, and foam cushioning in upholstery.
But there was a problem. They don’t chemically bond to plastics; they are just sort of mixed in, which means they can leach out. They are hydrophobic, meaning they don’t get washed out of soil, and, when ingested or inhaled by humans, they dissolve in our fat stores, making it difficult for our normal excretory systems to excrete them.
PBDEs biomagnify. Small animals can take them up from contaminated soil or water, and those animals are eaten by larger animals, which accumulate higher concentrations of the chemicals. This bioaccumulation increases as you move up the food web until you get to an apex predator — like you and me.
This is true of lots of chemicals, of course. The concern arises when these chemicals are toxic. To date, the toxicity data for PBDEs were pretty limited. There were some animal studies where rats were exposed to extremely high doses and they developed liver lesions — but I am always very wary of extrapolating high-dose rat toxicity studies to humans. There was also some suggestion that the chemicals could be endocrine disruptors, affecting breast and thyroid tissue.
What about cancer? In 2016, the International Agency for Research on Cancer concluded there was “inadequate evidence in humans for the carcinogencity of” PBDEs.
In the same report, though, they suggested PBDEs are “probably carcinogenic to humans” based on mechanistic studies.
In other words, we can’t prove they’re cancerous — but come on, they probably are.
Finally, we have some evidence that really pushes us toward the carcinogenic conclusion, in the form of this study, appearing in JAMA Network Open. It’s a nice bit of epidemiology leveraging the population-based National Health and Nutrition Examination Survey (NHANES).
Researchers measured PBDE levels in blood samples from 1100 people enrolled in NHANES in 2003 and 2004 and linked them to death records collected over the next 20 years or so.
The first thing to note is that the researchers were able to measure PBDEs in the blood samples. They were in there. They were detectable. And they were variable. Dividing the 1100 participants into low, medium, and high PBDE tertiles, you can see a nearly 10-fold difference across the population.
Importantly, not many baseline variables correlated with PBDE levels. People in the highest group were a bit younger but had a fairly similar sex distribution, race, ethnicity, education, income, physical activity, smoking status, and body mass index.
This is not a randomized trial, of course — but at least based on these data, exposure levels do seem fairly random, which is what you would expect from an environmental toxin that percolates up through the food chain. They are often somewhat indiscriminate.
This similarity in baseline characteristics between people with low or high blood levels of PBDE also allows us to make some stronger inferences about the observed outcomes. Let’s take a look at them.
After adjustment for baseline factors, individuals in the highest PBDE group had a 43% higher rate of death from any cause over the follow-up period. This was not enough to achieve statistical significance, but it was close.
But the key finding is deaths due to cancer. After adjustment, cancer deaths occurred four times as frequently among those in the high PBDE group, and that is a statistically significant difference.
To be fair, cancer deaths were rare in this cohort. The vast majority of people did not die of anything during the follow-up period regardless of PBDE level. But the data are strongly suggestive of the carcinogenicity of these chemicals.
I should also point out that the researchers are linking the PBDE level at a single time point to all these future events. If PBDE levels remain relatively stable within an individual over time, that’s fine, but if they tend to vary with intake of different foods for example, this would not be captured and would actually lead to an underestimation of the cancer risk.
The researchers also didn’t have granular enough data to determine the type of cancer, but they do show that rates are similar between men and women, which might point away from the more sex-specific cancer etiologies. Clearly, some more work is needed.
Of course, I started this piece by telling you that these chemicals are already pretty much banned in the United States. What are we supposed to do about these findings? Studies have examined the primary ongoing sources of PBDE in our environment and it seems like most of our exposure will be coming from the food we eat due to that biomagnification thing: high-fat fish, meat and dairy products, and fish oil supplements. It may be worth some investigation into the relative adulteration of these products with this new old carcinogen.
Dr. F. Perry Wilson is associate professor of medicine and public health and director of the Clinical and Translational Research Accelerator at Yale University, New Haven, Conn. He has disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
This transcript has been edited for clarity.
These types of stories usually end with a call for regulation — to ban said chemical or substance, or to regulate it — but in this case, that has already happened. This new carcinogen I’m telling you about is actually an old chemical. And it has not been manufactured or legally imported in the US since 2013.
So, why bother? Because in this case, the chemical — or, really, a group of chemicals called polybrominated diphenyl ethers (PBDEs) — are still around: in our soil, in our food, and in our blood.
PBDEs are a group of compounds that confer flame-retardant properties to plastics, and they were used extensively in the latter part of the 20th century in electronic enclosures, business equipment, and foam cushioning in upholstery.
But there was a problem. They don’t chemically bond to plastics; they are just sort of mixed in, which means they can leach out. They are hydrophobic, meaning they don’t get washed out of soil, and, when ingested or inhaled by humans, they dissolve in our fat stores, making it difficult for our normal excretory systems to excrete them.
PBDEs biomagnify. Small animals can take them up from contaminated soil or water, and those animals are eaten by larger animals, which accumulate higher concentrations of the chemicals. This bioaccumulation increases as you move up the food web until you get to an apex predator — like you and me.
This is true of lots of chemicals, of course. The concern arises when these chemicals are toxic. To date, the toxicity data for PBDEs were pretty limited. There were some animal studies where rats were exposed to extremely high doses and they developed liver lesions — but I am always very wary of extrapolating high-dose rat toxicity studies to humans. There was also some suggestion that the chemicals could be endocrine disruptors, affecting breast and thyroid tissue.
What about cancer? In 2016, the International Agency for Research on Cancer concluded there was “inadequate evidence in humans for the carcinogencity of” PBDEs.
In the same report, though, they suggested PBDEs are “probably carcinogenic to humans” based on mechanistic studies.
In other words, we can’t prove they’re cancerous — but come on, they probably are.
Finally, we have some evidence that really pushes us toward the carcinogenic conclusion, in the form of this study, appearing in JAMA Network Open. It’s a nice bit of epidemiology leveraging the population-based National Health and Nutrition Examination Survey (NHANES).
Researchers measured PBDE levels in blood samples from 1100 people enrolled in NHANES in 2003 and 2004 and linked them to death records collected over the next 20 years or so.
The first thing to note is that the researchers were able to measure PBDEs in the blood samples. They were in there. They were detectable. And they were variable. Dividing the 1100 participants into low, medium, and high PBDE tertiles, you can see a nearly 10-fold difference across the population.
Importantly, not many baseline variables correlated with PBDE levels. People in the highest group were a bit younger but had a fairly similar sex distribution, race, ethnicity, education, income, physical activity, smoking status, and body mass index.
This is not a randomized trial, of course — but at least based on these data, exposure levels do seem fairly random, which is what you would expect from an environmental toxin that percolates up through the food chain. They are often somewhat indiscriminate.
This similarity in baseline characteristics between people with low or high blood levels of PBDE also allows us to make some stronger inferences about the observed outcomes. Let’s take a look at them.
After adjustment for baseline factors, individuals in the highest PBDE group had a 43% higher rate of death from any cause over the follow-up period. This was not enough to achieve statistical significance, but it was close.
But the key finding is deaths due to cancer. After adjustment, cancer deaths occurred four times as frequently among those in the high PBDE group, and that is a statistically significant difference.
To be fair, cancer deaths were rare in this cohort. The vast majority of people did not die of anything during the follow-up period regardless of PBDE level. But the data are strongly suggestive of the carcinogenicity of these chemicals.
I should also point out that the researchers are linking the PBDE level at a single time point to all these future events. If PBDE levels remain relatively stable within an individual over time, that’s fine, but if they tend to vary with intake of different foods for example, this would not be captured and would actually lead to an underestimation of the cancer risk.
The researchers also didn’t have granular enough data to determine the type of cancer, but they do show that rates are similar between men and women, which might point away from the more sex-specific cancer etiologies. Clearly, some more work is needed.
Of course, I started this piece by telling you that these chemicals are already pretty much banned in the United States. What are we supposed to do about these findings? Studies have examined the primary ongoing sources of PBDE in our environment and it seems like most of our exposure will be coming from the food we eat due to that biomagnification thing: high-fat fish, meat and dairy products, and fish oil supplements. It may be worth some investigation into the relative adulteration of these products with this new old carcinogen.
Dr. F. Perry Wilson is associate professor of medicine and public health and director of the Clinical and Translational Research Accelerator at Yale University, New Haven, Conn. He has disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
Active Surveillance for Cancer Doesn’t Increase Malpractice Risk
TOPLINE:
METHODOLOGY:
- Although practice guidelines from the National Comprehensive Cancer Network consider active surveillance an effective strategy for managing low-risk cancers, some physicians have been hesitant to incorporate it into their practice because of concerns about potential litigation.
- Researchers used Westlaw Edge and LexisNexis Advance databases to identify malpractice trends involving active surveillance related to thyroid, prostate, kidney, and or from 1990 to 2022.
- Data included unpublished cases, trial orders, jury verdicts, and administrative decisions.
- Researchers identified 201 malpractice cases across all low-risk cancers in the initial screening. Out of these, only five cases, all , involved active surveillance as the point of allegation.
TAKEAWAY:
- Out of the five prostate cancer cases, two involved incarcerated patients with Gleason 6 very-low-risk prostate adenocarcinoma that was managed with active surveillance by their urologists.
- In these two cases, the patients claimed that active surveillance violated their 8th Amendment right to be free from cruel or unusual punishment. In both cases, there was no metastasis or spread detected and the court determined active surveillance management was performed under national standards.
- The other three cases involved litigation claiming that active surveillance was not explicitly recommended as a treatment option for patients who all had very-low-risk prostate adenocarcinoma and had reported negligence from an intervention ( or cryoablation). However, all cases had documented informed consent for active surveillance.
- No relevant cases were found relating to active surveillance in any other type of cancer, whether in an initial diagnosis or recurrence.
IN PRACTICE:
“This data should bolster physicians’ confidence in recommending active surveillance for their patients when it is an appropriate option,” study coauthor Timothy Daskivich, MD, assistant professor of surgery at Cedars-Sinai Medical Center, Los Angeles, said in a statement . “Active surveillance maximizes quality of life and avoids unnecessary overtreatment, and it does not increase medicolegal liability to physicians, as detailed in the case dismissals identified in this study.”
SOURCE:
This study, led by Samuel Chang, JD, with Athene Law LLP, San Francisco, was recently published in Annals of Surgery.
LIMITATIONS:
The Westlaw and Lexis databases may not contain all cases or decisions issued by a state regulatory agency, like a medical board. Federal and state decisions from lower courts may not be published and available. Also, settlements outside of court or suits filed and not pursued were not included in the data.
DISCLOSURES:
The researchers did not provide any disclosures.
A version of this article appeared on Medscape.com.
TOPLINE:
METHODOLOGY:
- Although practice guidelines from the National Comprehensive Cancer Network consider active surveillance an effective strategy for managing low-risk cancers, some physicians have been hesitant to incorporate it into their practice because of concerns about potential litigation.
- Researchers used Westlaw Edge and LexisNexis Advance databases to identify malpractice trends involving active surveillance related to thyroid, prostate, kidney, and or from 1990 to 2022.
- Data included unpublished cases, trial orders, jury verdicts, and administrative decisions.
- Researchers identified 201 malpractice cases across all low-risk cancers in the initial screening. Out of these, only five cases, all , involved active surveillance as the point of allegation.
TAKEAWAY:
- Out of the five prostate cancer cases, two involved incarcerated patients with Gleason 6 very-low-risk prostate adenocarcinoma that was managed with active surveillance by their urologists.
- In these two cases, the patients claimed that active surveillance violated their 8th Amendment right to be free from cruel or unusual punishment. In both cases, there was no metastasis or spread detected and the court determined active surveillance management was performed under national standards.
- The other three cases involved litigation claiming that active surveillance was not explicitly recommended as a treatment option for patients who all had very-low-risk prostate adenocarcinoma and had reported negligence from an intervention ( or cryoablation). However, all cases had documented informed consent for active surveillance.
- No relevant cases were found relating to active surveillance in any other type of cancer, whether in an initial diagnosis or recurrence.
IN PRACTICE:
“This data should bolster physicians’ confidence in recommending active surveillance for their patients when it is an appropriate option,” study coauthor Timothy Daskivich, MD, assistant professor of surgery at Cedars-Sinai Medical Center, Los Angeles, said in a statement . “Active surveillance maximizes quality of life and avoids unnecessary overtreatment, and it does not increase medicolegal liability to physicians, as detailed in the case dismissals identified in this study.”
SOURCE:
This study, led by Samuel Chang, JD, with Athene Law LLP, San Francisco, was recently published in Annals of Surgery.
LIMITATIONS:
The Westlaw and Lexis databases may not contain all cases or decisions issued by a state regulatory agency, like a medical board. Federal and state decisions from lower courts may not be published and available. Also, settlements outside of court or suits filed and not pursued were not included in the data.
DISCLOSURES:
The researchers did not provide any disclosures.
A version of this article appeared on Medscape.com.
TOPLINE:
METHODOLOGY:
- Although practice guidelines from the National Comprehensive Cancer Network consider active surveillance an effective strategy for managing low-risk cancers, some physicians have been hesitant to incorporate it into their practice because of concerns about potential litigation.
- Researchers used Westlaw Edge and LexisNexis Advance databases to identify malpractice trends involving active surveillance related to thyroid, prostate, kidney, and or from 1990 to 2022.
- Data included unpublished cases, trial orders, jury verdicts, and administrative decisions.
- Researchers identified 201 malpractice cases across all low-risk cancers in the initial screening. Out of these, only five cases, all , involved active surveillance as the point of allegation.
TAKEAWAY:
- Out of the five prostate cancer cases, two involved incarcerated patients with Gleason 6 very-low-risk prostate adenocarcinoma that was managed with active surveillance by their urologists.
- In these two cases, the patients claimed that active surveillance violated their 8th Amendment right to be free from cruel or unusual punishment. In both cases, there was no metastasis or spread detected and the court determined active surveillance management was performed under national standards.
- The other three cases involved litigation claiming that active surveillance was not explicitly recommended as a treatment option for patients who all had very-low-risk prostate adenocarcinoma and had reported negligence from an intervention ( or cryoablation). However, all cases had documented informed consent for active surveillance.
- No relevant cases were found relating to active surveillance in any other type of cancer, whether in an initial diagnosis or recurrence.
IN PRACTICE:
“This data should bolster physicians’ confidence in recommending active surveillance for their patients when it is an appropriate option,” study coauthor Timothy Daskivich, MD, assistant professor of surgery at Cedars-Sinai Medical Center, Los Angeles, said in a statement . “Active surveillance maximizes quality of life and avoids unnecessary overtreatment, and it does not increase medicolegal liability to physicians, as detailed in the case dismissals identified in this study.”
SOURCE:
This study, led by Samuel Chang, JD, with Athene Law LLP, San Francisco, was recently published in Annals of Surgery.
LIMITATIONS:
The Westlaw and Lexis databases may not contain all cases or decisions issued by a state regulatory agency, like a medical board. Federal and state decisions from lower courts may not be published and available. Also, settlements outside of court or suits filed and not pursued were not included in the data.
DISCLOSURES:
The researchers did not provide any disclosures.
A version of this article appeared on Medscape.com.
ASCO Releases Vaccination Guidelines for Adults With Cancer
TOPLINE:
“Optimizing vaccination status should be considered a key element in the care of patients with cancer,” according to the authors of newly released American of Clinical Oncology (ASCO) guidelines.
METHODOLOGY:
- “Infections are the second most common cause of noncancer-related mortality within the first year after a cancer diagnosis,” highlighting the need for oncologists to help ensure patients are up to date on key vaccines, an ASCO panel of experts wrote.
- The expert panel reviewed the existing evidence and made recommendations to guide vaccination of adults with solid tumors or hematologic malignancies, including those who received hematopoietic stem-cell transplantation (HSCT), chimeric antigen T-cell (CAR T-cell) therapy and B-cell-depleting therapy, as well as guide vaccination of their household contacts.
- The panel reviewed 102 publications, including 24 systematic reviews, 14 randomized controlled trials, and 64 nonrandomized studies.
- Vaccines evaluated included those for COVID-19, influenza, hepatitis A and B, respiratory syncytial virus, Tdap, human papillomavirus, inactivated polio, and rabies.
- The authors noted that patients’ underlying immune status and their cancer therapy could affect vaccination and revaccination strategies compared with recommendations for a general adult population without cancer.
TAKEAWAY:
- The first step is to determine patients’ vaccination status and ensure adults newly diagnosed with cancer (as well as their household contacts) are up to date on seasonal and age or risk-based vaccines before starting their cancer treatment. If there are gaps, patients would ideally receive their vaccinations 2-4 weeks before their cancer treatment begins; however, non-live vaccines can be given during or after treatment.
- The authors recommended complete revaccination of patients 6-12 months following HSCT to restore vaccine-induced immunity. The caveats: COVID-19, influenza, and pneumococcal vaccines can be given as early as 3 months after transplant, and patients should receive live and live attenuated vaccines only in the absence of active GVHD or immunosuppression and only ≥ 2 years following HSCT.
- After CAR T-cell therapy directed against B-cell antigens (CD19/BCMA), patients should not receive influenza and COVID-19 vaccines sooner than 3 months after completing therapy and nonlive vaccines should not be given before 6 months.
- After B-cell depleting therapy, revaccinate patients for COVID-19 only and no sooner than 6 months after completing treatment. Long-term survivors of hematologic cancer with or without active disease or those with long-standing B-cell dysfunction or hypogammaglobulinemia from therapy or B-cell lineage malignancies should receive the recommended nonlive vaccines.
- Adults with solid and hematologic cancers traveling to an area of risk should follow the CDC standard recommendations for the destination. Hepatitis A, intramuscular typhoid vaccine, inactivated polio, hepatitis B, rabies, meningococcal, and nonlive Japanese encephalitis vaccines are safe.
IN PRACTICE:
“Enhancing vaccine uptake against preventable illnesses will help the community and improve the quality of care for patients with cancer,” the authors said. “Clinicians play a critical role in helping the patient and caregiver to understand the potential benefits and risks of recommended vaccination[s]. In addition, clinicians should provide authoritative resources, such as fact-based vaccine informational handouts and Internet sites, to help patients and caregivers learn more about the topic.”
SOURCE:
Mini Kamboj, MD, with Memorial Sloan Kettering Cancer Center, New York City, and Elise Kohn, MD, with the National Cancer Institute, Rockville, Maryland, served as cochairs for the expert panel. The guideline was published March 18 in the Journal of Clinical Oncology.
LIMITATIONS:
The evidence for some vaccines in cancer patients continues to evolve, particularly for new vaccines like COVID-19 vaccines.
DISCLOSURES:
This research had no commercial funding. Disclosures for the guideline panel are available with the original article.
A version of this article appeared on Medscape.com.
TOPLINE:
“Optimizing vaccination status should be considered a key element in the care of patients with cancer,” according to the authors of newly released American of Clinical Oncology (ASCO) guidelines.
METHODOLOGY:
- “Infections are the second most common cause of noncancer-related mortality within the first year after a cancer diagnosis,” highlighting the need for oncologists to help ensure patients are up to date on key vaccines, an ASCO panel of experts wrote.
- The expert panel reviewed the existing evidence and made recommendations to guide vaccination of adults with solid tumors or hematologic malignancies, including those who received hematopoietic stem-cell transplantation (HSCT), chimeric antigen T-cell (CAR T-cell) therapy and B-cell-depleting therapy, as well as guide vaccination of their household contacts.
- The panel reviewed 102 publications, including 24 systematic reviews, 14 randomized controlled trials, and 64 nonrandomized studies.
- Vaccines evaluated included those for COVID-19, influenza, hepatitis A and B, respiratory syncytial virus, Tdap, human papillomavirus, inactivated polio, and rabies.
- The authors noted that patients’ underlying immune status and their cancer therapy could affect vaccination and revaccination strategies compared with recommendations for a general adult population without cancer.
TAKEAWAY:
- The first step is to determine patients’ vaccination status and ensure adults newly diagnosed with cancer (as well as their household contacts) are up to date on seasonal and age or risk-based vaccines before starting their cancer treatment. If there are gaps, patients would ideally receive their vaccinations 2-4 weeks before their cancer treatment begins; however, non-live vaccines can be given during or after treatment.
- The authors recommended complete revaccination of patients 6-12 months following HSCT to restore vaccine-induced immunity. The caveats: COVID-19, influenza, and pneumococcal vaccines can be given as early as 3 months after transplant, and patients should receive live and live attenuated vaccines only in the absence of active GVHD or immunosuppression and only ≥ 2 years following HSCT.
- After CAR T-cell therapy directed against B-cell antigens (CD19/BCMA), patients should not receive influenza and COVID-19 vaccines sooner than 3 months after completing therapy and nonlive vaccines should not be given before 6 months.
- After B-cell depleting therapy, revaccinate patients for COVID-19 only and no sooner than 6 months after completing treatment. Long-term survivors of hematologic cancer with or without active disease or those with long-standing B-cell dysfunction or hypogammaglobulinemia from therapy or B-cell lineage malignancies should receive the recommended nonlive vaccines.
- Adults with solid and hematologic cancers traveling to an area of risk should follow the CDC standard recommendations for the destination. Hepatitis A, intramuscular typhoid vaccine, inactivated polio, hepatitis B, rabies, meningococcal, and nonlive Japanese encephalitis vaccines are safe.
IN PRACTICE:
“Enhancing vaccine uptake against preventable illnesses will help the community and improve the quality of care for patients with cancer,” the authors said. “Clinicians play a critical role in helping the patient and caregiver to understand the potential benefits and risks of recommended vaccination[s]. In addition, clinicians should provide authoritative resources, such as fact-based vaccine informational handouts and Internet sites, to help patients and caregivers learn more about the topic.”
SOURCE:
Mini Kamboj, MD, with Memorial Sloan Kettering Cancer Center, New York City, and Elise Kohn, MD, with the National Cancer Institute, Rockville, Maryland, served as cochairs for the expert panel. The guideline was published March 18 in the Journal of Clinical Oncology.
LIMITATIONS:
The evidence for some vaccines in cancer patients continues to evolve, particularly for new vaccines like COVID-19 vaccines.
DISCLOSURES:
This research had no commercial funding. Disclosures for the guideline panel are available with the original article.
A version of this article appeared on Medscape.com.
TOPLINE:
“Optimizing vaccination status should be considered a key element in the care of patients with cancer,” according to the authors of newly released American of Clinical Oncology (ASCO) guidelines.
METHODOLOGY:
- “Infections are the second most common cause of noncancer-related mortality within the first year after a cancer diagnosis,” highlighting the need for oncologists to help ensure patients are up to date on key vaccines, an ASCO panel of experts wrote.
- The expert panel reviewed the existing evidence and made recommendations to guide vaccination of adults with solid tumors or hematologic malignancies, including those who received hematopoietic stem-cell transplantation (HSCT), chimeric antigen T-cell (CAR T-cell) therapy and B-cell-depleting therapy, as well as guide vaccination of their household contacts.
- The panel reviewed 102 publications, including 24 systematic reviews, 14 randomized controlled trials, and 64 nonrandomized studies.
- Vaccines evaluated included those for COVID-19, influenza, hepatitis A and B, respiratory syncytial virus, Tdap, human papillomavirus, inactivated polio, and rabies.
- The authors noted that patients’ underlying immune status and their cancer therapy could affect vaccination and revaccination strategies compared with recommendations for a general adult population without cancer.
TAKEAWAY:
- The first step is to determine patients’ vaccination status and ensure adults newly diagnosed with cancer (as well as their household contacts) are up to date on seasonal and age or risk-based vaccines before starting their cancer treatment. If there are gaps, patients would ideally receive their vaccinations 2-4 weeks before their cancer treatment begins; however, non-live vaccines can be given during or after treatment.
- The authors recommended complete revaccination of patients 6-12 months following HSCT to restore vaccine-induced immunity. The caveats: COVID-19, influenza, and pneumococcal vaccines can be given as early as 3 months after transplant, and patients should receive live and live attenuated vaccines only in the absence of active GVHD or immunosuppression and only ≥ 2 years following HSCT.
- After CAR T-cell therapy directed against B-cell antigens (CD19/BCMA), patients should not receive influenza and COVID-19 vaccines sooner than 3 months after completing therapy and nonlive vaccines should not be given before 6 months.
- After B-cell depleting therapy, revaccinate patients for COVID-19 only and no sooner than 6 months after completing treatment. Long-term survivors of hematologic cancer with or without active disease or those with long-standing B-cell dysfunction or hypogammaglobulinemia from therapy or B-cell lineage malignancies should receive the recommended nonlive vaccines.
- Adults with solid and hematologic cancers traveling to an area of risk should follow the CDC standard recommendations for the destination. Hepatitis A, intramuscular typhoid vaccine, inactivated polio, hepatitis B, rabies, meningococcal, and nonlive Japanese encephalitis vaccines are safe.
IN PRACTICE:
“Enhancing vaccine uptake against preventable illnesses will help the community and improve the quality of care for patients with cancer,” the authors said. “Clinicians play a critical role in helping the patient and caregiver to understand the potential benefits and risks of recommended vaccination[s]. In addition, clinicians should provide authoritative resources, such as fact-based vaccine informational handouts and Internet sites, to help patients and caregivers learn more about the topic.”
SOURCE:
Mini Kamboj, MD, with Memorial Sloan Kettering Cancer Center, New York City, and Elise Kohn, MD, with the National Cancer Institute, Rockville, Maryland, served as cochairs for the expert panel. The guideline was published March 18 in the Journal of Clinical Oncology.
LIMITATIONS:
The evidence for some vaccines in cancer patients continues to evolve, particularly for new vaccines like COVID-19 vaccines.
DISCLOSURES:
This research had no commercial funding. Disclosures for the guideline panel are available with the original article.
A version of this article appeared on Medscape.com.
Florida Legislature Passes Free Skin Cancer Screening Requirement
By this summer, state employees in Florida covered by state group health insurance plans should have access to free annual skin cancer screenings.
On March 1, 2024, legislation was unanimously passed by both chambers of the state legislature that will provide for the free screenings for this group as of July 1. Some 321,000 state employees would be eligible, at a cost of about $357,000 per year, according to a legislative analysis. Gov. Ron DeSantis (R) has received and is expected to sign the bill.
The analysis concluded that the bill would have a “significant negative fiscal impact on the state employee group health plan,” as screenings will ultimately reduce cancer incidence and related morbidity and mortality.
The screenings aim to provide access to patients who may think they might not be able to afford a visit or who may have other perceived or real barriers to going for a skin check, said Sima Jain, MD, president of the Florida Academy of Dermatology. “It’s really meant to give patients access who need it,” said Dr. Jain, a dermatologist in private practice in Orlando.
The goal is early detection. “If I do a simple excision on a melanoma and we catch it early, it’s done, it’s cured,” Dr. Jain told this news organization. “It’s a win-win. We catch it early and insurance companies pay less money,” she said.
An effort to have all insurers in the state provide free screenings failed in 2023.
From 2016 to 2020, Florida had a higher overall incidence of melanoma at 25.4 per 100,000 than the national average of 22.5, according to the National Cancer Institute. The state had some 7500 cases of melanoma each year during that period. The incidence rate in some Florida counties is as high as 32.7-45.6 per 100,000.
The Florida legislation will allow physician assistants and advanced practice nurses who operate under the supervision of a dermatologist to conduct the screenings.
It’s not clear how many state employees will access the free skin checks. “I don’t expect to see a flood of skin cancer screenings,” said Dr. Jain, noting that she hopes that it attracts primarily those at highest risk.
Once the bill is signed by the governor, Florida will be the second state to cover skin cancer screenings in some way. Illinois has required free skin cancer screening for all insured residents since 2020.
A version of this article appeared on Medscape.com .
By this summer, state employees in Florida covered by state group health insurance plans should have access to free annual skin cancer screenings.
On March 1, 2024, legislation was unanimously passed by both chambers of the state legislature that will provide for the free screenings for this group as of July 1. Some 321,000 state employees would be eligible, at a cost of about $357,000 per year, according to a legislative analysis. Gov. Ron DeSantis (R) has received and is expected to sign the bill.
The analysis concluded that the bill would have a “significant negative fiscal impact on the state employee group health plan,” as screenings will ultimately reduce cancer incidence and related morbidity and mortality.
The screenings aim to provide access to patients who may think they might not be able to afford a visit or who may have other perceived or real barriers to going for a skin check, said Sima Jain, MD, president of the Florida Academy of Dermatology. “It’s really meant to give patients access who need it,” said Dr. Jain, a dermatologist in private practice in Orlando.
The goal is early detection. “If I do a simple excision on a melanoma and we catch it early, it’s done, it’s cured,” Dr. Jain told this news organization. “It’s a win-win. We catch it early and insurance companies pay less money,” she said.
An effort to have all insurers in the state provide free screenings failed in 2023.
From 2016 to 2020, Florida had a higher overall incidence of melanoma at 25.4 per 100,000 than the national average of 22.5, according to the National Cancer Institute. The state had some 7500 cases of melanoma each year during that period. The incidence rate in some Florida counties is as high as 32.7-45.6 per 100,000.
The Florida legislation will allow physician assistants and advanced practice nurses who operate under the supervision of a dermatologist to conduct the screenings.
It’s not clear how many state employees will access the free skin checks. “I don’t expect to see a flood of skin cancer screenings,” said Dr. Jain, noting that she hopes that it attracts primarily those at highest risk.
Once the bill is signed by the governor, Florida will be the second state to cover skin cancer screenings in some way. Illinois has required free skin cancer screening for all insured residents since 2020.
A version of this article appeared on Medscape.com .
By this summer, state employees in Florida covered by state group health insurance plans should have access to free annual skin cancer screenings.
On March 1, 2024, legislation was unanimously passed by both chambers of the state legislature that will provide for the free screenings for this group as of July 1. Some 321,000 state employees would be eligible, at a cost of about $357,000 per year, according to a legislative analysis. Gov. Ron DeSantis (R) has received and is expected to sign the bill.
The analysis concluded that the bill would have a “significant negative fiscal impact on the state employee group health plan,” as screenings will ultimately reduce cancer incidence and related morbidity and mortality.
The screenings aim to provide access to patients who may think they might not be able to afford a visit or who may have other perceived or real barriers to going for a skin check, said Sima Jain, MD, president of the Florida Academy of Dermatology. “It’s really meant to give patients access who need it,” said Dr. Jain, a dermatologist in private practice in Orlando.
The goal is early detection. “If I do a simple excision on a melanoma and we catch it early, it’s done, it’s cured,” Dr. Jain told this news organization. “It’s a win-win. We catch it early and insurance companies pay less money,” she said.
An effort to have all insurers in the state provide free screenings failed in 2023.
From 2016 to 2020, Florida had a higher overall incidence of melanoma at 25.4 per 100,000 than the national average of 22.5, according to the National Cancer Institute. The state had some 7500 cases of melanoma each year during that period. The incidence rate in some Florida counties is as high as 32.7-45.6 per 100,000.
The Florida legislation will allow physician assistants and advanced practice nurses who operate under the supervision of a dermatologist to conduct the screenings.
It’s not clear how many state employees will access the free skin checks. “I don’t expect to see a flood of skin cancer screenings,” said Dr. Jain, noting that she hopes that it attracts primarily those at highest risk.
Once the bill is signed by the governor, Florida will be the second state to cover skin cancer screenings in some way. Illinois has required free skin cancer screening for all insured residents since 2020.
A version of this article appeared on Medscape.com .
Few Childhood Cancer Survivors Get Recommended Screenings
Among childhood cancer survivors in Ontario, Canada, who faced an elevated risk due to chemotherapy or radiation treatments, 53% followed screening recommendations for cardiomyopathy, 13% met colorectal cancer screening guidelines, and 6% adhered to breast cancer screening guidelines.
“Although over 80% of children newly diagnosed with cancer will become long-term survivors, as many as four out of five of these survivors will develop a serious or life-threatening late effect of their cancer therapy by age 45,” lead author Jennifer Shuldiner, PhD, MPH, a scientist at Women’s College Hospital Institute for Health Systems Solutions and Virtual Care in Toronto, told this news organization.
For instance, the risk for colorectal cancer in childhood cancer survivors is two to three times higher than it is among the general population, and the risk for breast cancer is similar between those who underwent chest radiation and those with a BRCA mutation. As many as 50% of those who received anthracycline chemotherapy or radiation involving the heart later develop cardiotoxicity.
The North American Children’s Oncology Group has published long-term follow-up guidelines for survivors of childhood cancer, yet many survivors don’t follow them because of lack of awareness or other barriers, said Dr. Shuldiner.
“Prior research has shown that many survivors do not complete these recommended tests,” she said. “With better knowledge of this at-risk population, we can design, test, and implement appropriate interventions and supports to tackle the issues.”
The study was published online on March 11 in CMAJ.
Changes in Adherence
The researchers conducted a retrospective population-based cohort study analyzing Ontario healthcare administrative data for adult survivors of childhood cancer diagnosed between 1986 and 2014 who faced an elevated risk for therapy-related colorectal cancer, breast cancer, or cardiomyopathy. The research team then assessed long-term adherence to the North American Children’s Oncology Group guidelines and predictors of adherence.
Among 3241 survivors, 3205 (99%) were at elevated risk for cardiomyopathy, 327 (10%) were at elevated risk for colorectal cancer, and 234 (7%) were at elevated risk for breast cancer. In addition, 2806 (87%) were at risk for one late effect, 345 (11%) were at risk for two late effects, and 90 (3%) were at risk for three late effects.
Overall, 53%, 13%, and 6% were adherent to their recommended surveillance for cardiomyopathy, colorectal cancer, and breast cancer, respectively. Over time, adherence increased for colorectal cancer and cardiomyopathy but decreased for breast cancer.
In addition, patients who were older at diagnosis were more likely to follow screening guidelines for colorectal and breast cancers, whereas those who were younger at diagnosis were more likely to follow screening guidelines for cardiomyopathy.
During a median follow-up of 7.8 years, the proportion of time spent adherent was 43% for cardiomyopathy, 14% for colorectal cancer, and 10% for breast cancer.
Survivors who attended a long-term follow-up clinic in the previous year had low adherence rates as well, though they were higher than in the rest of the cohort. In this group, the proportion of time that was spent adherent was 71% for cardiomyopathy, 27% for colorectal cancer, and 15% for breast cancer.
Shuldiner and colleagues are launching a research trial to determine whether a provincial support system can help childhood cancer survivors receive the recommended surveillance. The support system provides information about screening recommendations to survivors as well as reminders and sends key information to their family doctors.
“We now understand that childhood cancer survivors need help to complete the recommended tests,” said Dr. Shuldiner. “If the trial is successful, we hope it will be implemented in Ontario.”
Survivorship Care Plans
Low screening rates may result from a lack of awareness about screening recommendations and the negative long-term effects of cancer treatments, the study authors wrote. Cancer survivors, caregivers, family physicians, specialists, and survivor support groups can share the responsibility of spreading awareness and adhering to guidelines, they noted. In some cases, a survivorship care plan (SCP) may help.
“SCPs are intended to improve adherence by providing follow-up information and facilitating the transition from cancer treatment to survivorship and from pediatric to adult care,” Adam Yan, MD, a staff oncologist and oncology informatics lead at the Hospital for Sick Children in Toronto, told this news organization.
Dr. Yan, who wasn’t involved with this study, has researched surveillance adherence for secondary cancers and cardiac dysfunction among childhood cancer survivors. He and his colleagues found that screening rates were typically low among survivors who faced high risks for cardiac dysfunction and breast, colorectal, or skin cancers.
However, having a survivorship care plan seemed to help, and survivors treated after 1990 were more likely to have an SCP.
“SCP possession by high-risk survivors was associated with increased breast, skin, and cardiac surveillance,” he said. “It is uncertain whether SCP possession leads to adherence or whether SCP possession is a marker of survivors who are focused on their health and thus likely to adhere to preventive health practices, including surveillance.”
The study was funded by the Canadian Institutes of Health Research and ICES, which receives support from the Ontario Ministry of Health and the Ministry of Long-Term Care. Dr. Shuldiner received a Canadian Institutes of Health Research Health System Impact Postdoctoral Fellowship in support of the work. Dr. Yan disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
Among childhood cancer survivors in Ontario, Canada, who faced an elevated risk due to chemotherapy or radiation treatments, 53% followed screening recommendations for cardiomyopathy, 13% met colorectal cancer screening guidelines, and 6% adhered to breast cancer screening guidelines.
“Although over 80% of children newly diagnosed with cancer will become long-term survivors, as many as four out of five of these survivors will develop a serious or life-threatening late effect of their cancer therapy by age 45,” lead author Jennifer Shuldiner, PhD, MPH, a scientist at Women’s College Hospital Institute for Health Systems Solutions and Virtual Care in Toronto, told this news organization.
For instance, the risk for colorectal cancer in childhood cancer survivors is two to three times higher than it is among the general population, and the risk for breast cancer is similar between those who underwent chest radiation and those with a BRCA mutation. As many as 50% of those who received anthracycline chemotherapy or radiation involving the heart later develop cardiotoxicity.
The North American Children’s Oncology Group has published long-term follow-up guidelines for survivors of childhood cancer, yet many survivors don’t follow them because of lack of awareness or other barriers, said Dr. Shuldiner.
“Prior research has shown that many survivors do not complete these recommended tests,” she said. “With better knowledge of this at-risk population, we can design, test, and implement appropriate interventions and supports to tackle the issues.”
The study was published online on March 11 in CMAJ.
Changes in Adherence
The researchers conducted a retrospective population-based cohort study analyzing Ontario healthcare administrative data for adult survivors of childhood cancer diagnosed between 1986 and 2014 who faced an elevated risk for therapy-related colorectal cancer, breast cancer, or cardiomyopathy. The research team then assessed long-term adherence to the North American Children’s Oncology Group guidelines and predictors of adherence.
Among 3241 survivors, 3205 (99%) were at elevated risk for cardiomyopathy, 327 (10%) were at elevated risk for colorectal cancer, and 234 (7%) were at elevated risk for breast cancer. In addition, 2806 (87%) were at risk for one late effect, 345 (11%) were at risk for two late effects, and 90 (3%) were at risk for three late effects.
Overall, 53%, 13%, and 6% were adherent to their recommended surveillance for cardiomyopathy, colorectal cancer, and breast cancer, respectively. Over time, adherence increased for colorectal cancer and cardiomyopathy but decreased for breast cancer.
In addition, patients who were older at diagnosis were more likely to follow screening guidelines for colorectal and breast cancers, whereas those who were younger at diagnosis were more likely to follow screening guidelines for cardiomyopathy.
During a median follow-up of 7.8 years, the proportion of time spent adherent was 43% for cardiomyopathy, 14% for colorectal cancer, and 10% for breast cancer.
Survivors who attended a long-term follow-up clinic in the previous year had low adherence rates as well, though they were higher than in the rest of the cohort. In this group, the proportion of time that was spent adherent was 71% for cardiomyopathy, 27% for colorectal cancer, and 15% for breast cancer.
Shuldiner and colleagues are launching a research trial to determine whether a provincial support system can help childhood cancer survivors receive the recommended surveillance. The support system provides information about screening recommendations to survivors as well as reminders and sends key information to their family doctors.
“We now understand that childhood cancer survivors need help to complete the recommended tests,” said Dr. Shuldiner. “If the trial is successful, we hope it will be implemented in Ontario.”
Survivorship Care Plans
Low screening rates may result from a lack of awareness about screening recommendations and the negative long-term effects of cancer treatments, the study authors wrote. Cancer survivors, caregivers, family physicians, specialists, and survivor support groups can share the responsibility of spreading awareness and adhering to guidelines, they noted. In some cases, a survivorship care plan (SCP) may help.
“SCPs are intended to improve adherence by providing follow-up information and facilitating the transition from cancer treatment to survivorship and from pediatric to adult care,” Adam Yan, MD, a staff oncologist and oncology informatics lead at the Hospital for Sick Children in Toronto, told this news organization.
Dr. Yan, who wasn’t involved with this study, has researched surveillance adherence for secondary cancers and cardiac dysfunction among childhood cancer survivors. He and his colleagues found that screening rates were typically low among survivors who faced high risks for cardiac dysfunction and breast, colorectal, or skin cancers.
However, having a survivorship care plan seemed to help, and survivors treated after 1990 were more likely to have an SCP.
“SCP possession by high-risk survivors was associated with increased breast, skin, and cardiac surveillance,” he said. “It is uncertain whether SCP possession leads to adherence or whether SCP possession is a marker of survivors who are focused on their health and thus likely to adhere to preventive health practices, including surveillance.”
The study was funded by the Canadian Institutes of Health Research and ICES, which receives support from the Ontario Ministry of Health and the Ministry of Long-Term Care. Dr. Shuldiner received a Canadian Institutes of Health Research Health System Impact Postdoctoral Fellowship in support of the work. Dr. Yan disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
Among childhood cancer survivors in Ontario, Canada, who faced an elevated risk due to chemotherapy or radiation treatments, 53% followed screening recommendations for cardiomyopathy, 13% met colorectal cancer screening guidelines, and 6% adhered to breast cancer screening guidelines.
“Although over 80% of children newly diagnosed with cancer will become long-term survivors, as many as four out of five of these survivors will develop a serious or life-threatening late effect of their cancer therapy by age 45,” lead author Jennifer Shuldiner, PhD, MPH, a scientist at Women’s College Hospital Institute for Health Systems Solutions and Virtual Care in Toronto, told this news organization.
For instance, the risk for colorectal cancer in childhood cancer survivors is two to three times higher than it is among the general population, and the risk for breast cancer is similar between those who underwent chest radiation and those with a BRCA mutation. As many as 50% of those who received anthracycline chemotherapy or radiation involving the heart later develop cardiotoxicity.
The North American Children’s Oncology Group has published long-term follow-up guidelines for survivors of childhood cancer, yet many survivors don’t follow them because of lack of awareness or other barriers, said Dr. Shuldiner.
“Prior research has shown that many survivors do not complete these recommended tests,” she said. “With better knowledge of this at-risk population, we can design, test, and implement appropriate interventions and supports to tackle the issues.”
The study was published online on March 11 in CMAJ.
Changes in Adherence
The researchers conducted a retrospective population-based cohort study analyzing Ontario healthcare administrative data for adult survivors of childhood cancer diagnosed between 1986 and 2014 who faced an elevated risk for therapy-related colorectal cancer, breast cancer, or cardiomyopathy. The research team then assessed long-term adherence to the North American Children’s Oncology Group guidelines and predictors of adherence.
Among 3241 survivors, 3205 (99%) were at elevated risk for cardiomyopathy, 327 (10%) were at elevated risk for colorectal cancer, and 234 (7%) were at elevated risk for breast cancer. In addition, 2806 (87%) were at risk for one late effect, 345 (11%) were at risk for two late effects, and 90 (3%) were at risk for three late effects.
Overall, 53%, 13%, and 6% were adherent to their recommended surveillance for cardiomyopathy, colorectal cancer, and breast cancer, respectively. Over time, adherence increased for colorectal cancer and cardiomyopathy but decreased for breast cancer.
In addition, patients who were older at diagnosis were more likely to follow screening guidelines for colorectal and breast cancers, whereas those who were younger at diagnosis were more likely to follow screening guidelines for cardiomyopathy.
During a median follow-up of 7.8 years, the proportion of time spent adherent was 43% for cardiomyopathy, 14% for colorectal cancer, and 10% for breast cancer.
Survivors who attended a long-term follow-up clinic in the previous year had low adherence rates as well, though they were higher than in the rest of the cohort. In this group, the proportion of time that was spent adherent was 71% for cardiomyopathy, 27% for colorectal cancer, and 15% for breast cancer.
Shuldiner and colleagues are launching a research trial to determine whether a provincial support system can help childhood cancer survivors receive the recommended surveillance. The support system provides information about screening recommendations to survivors as well as reminders and sends key information to their family doctors.
“We now understand that childhood cancer survivors need help to complete the recommended tests,” said Dr. Shuldiner. “If the trial is successful, we hope it will be implemented in Ontario.”
Survivorship Care Plans
Low screening rates may result from a lack of awareness about screening recommendations and the negative long-term effects of cancer treatments, the study authors wrote. Cancer survivors, caregivers, family physicians, specialists, and survivor support groups can share the responsibility of spreading awareness and adhering to guidelines, they noted. In some cases, a survivorship care plan (SCP) may help.
“SCPs are intended to improve adherence by providing follow-up information and facilitating the transition from cancer treatment to survivorship and from pediatric to adult care,” Adam Yan, MD, a staff oncologist and oncology informatics lead at the Hospital for Sick Children in Toronto, told this news organization.
Dr. Yan, who wasn’t involved with this study, has researched surveillance adherence for secondary cancers and cardiac dysfunction among childhood cancer survivors. He and his colleagues found that screening rates were typically low among survivors who faced high risks for cardiac dysfunction and breast, colorectal, or skin cancers.
However, having a survivorship care plan seemed to help, and survivors treated after 1990 were more likely to have an SCP.
“SCP possession by high-risk survivors was associated with increased breast, skin, and cardiac surveillance,” he said. “It is uncertain whether SCP possession leads to adherence or whether SCP possession is a marker of survivors who are focused on their health and thus likely to adhere to preventive health practices, including surveillance.”
The study was funded by the Canadian Institutes of Health Research and ICES, which receives support from the Ontario Ministry of Health and the Ministry of Long-Term Care. Dr. Shuldiner received a Canadian Institutes of Health Research Health System Impact Postdoctoral Fellowship in support of the work. Dr. Yan disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
AI in Clinical Dermatology: Consider Limitations, Current Issues
SAN DIEGO — Just a day before the annual meeting of the American Academy of Dermatology (AAD) began, .
Not least of the problems among the 41 apps evaluated, the majority offered no supporting evidence, no information about whether the app performance had been validated, and no information about how user privacy would be managed, reported Shannon Wongvibulsin, MD, PhD, a resident in the dermatology program at the University of California, Los Angeles, and her coauthors.
The findings from this report were also summarized in a poster at the AAD meeting, and the major themes were reiterated in several AAD symposia devoted to AI at the meeting. Veronica Rotemberg, MD, PhD, a dermatologist at Memorial Sloan Kettering Cancer Center, New York City, was one of those who weighed in on the future of AI. Although she was the senior author of the report, she did not address the report or poster directly, but her presentation on the practical aspects of incorporating AI into dermatology practice revisited several of its themes.
Of the different themes, perhaps the most important were the concept that the source of AI data matters and the point that practicing clinicians should be familiar with the data source.
To date, “there is not much transparency in what data AI models are using,” Dr. Rotemberg said at the meeting. Based on the expectation that dermatologists will be purchasing rather than developing their own AI-based systems, she reiterated more than once that “transparency of data is critical,” even if vendors are often reluctant to reveal how their proprietary systems have been developed.
Few Dermatology Apps Are Vetted for Accuracy
In the poster and in the more detailed JAMA Dermatology paper, Dr. Wongvibulsin and her coinvestigators evaluated direct-to-consumer downloadable apps that claim to help with the assessment and management of skin conditions. Very few provided any supporting evidence of accuracy or even information about how they functioned.
The 41 apps were drawn from more than 300 apps; the others were excluded for failing to meet such criteria as failing to employ AI, not being available in English, or not addressing clinical management of dermatologic diseases. Dr. Wongvibulsin pointed out that none of the apps had been granted regulatory approval even though only two provided a disclaimer to that effect.
In all, just 5 of the 41 provided supporting evidence from a peer-reviewed journal, and less than 40% were created with any input from a dermatologist, Dr. Wongvibulsin reported. The result is that the utility and accuracy of these apps were, for the most part, difficult to judge.
“At a minimum, app developers should provide details on what AI algorithms are used, what data sets were used for training, testing, and validation, whether there was any clinician input, whether there are any supporting publications, how user-submitted images are used, and if there are any measures used to ensure data privacy,” Dr. Wongvibulsin wrote in the poster.
For AI-based apps or systems designed for use by dermatologists, Dr. Rotemberg made similar assertions in her overview of what clinicians should be considering for proprietary AI systems, whether to help with diagnosis or improve office efficiency.
Only One Dermatology App Cleared By the FDA
Currently, the only FDA-cleared app for dermatologic use is the DermaSensor, an AI-driven device. It was cleared for use in January 2024 for the evaluation of skin lesions “suggestive” of melanoma, basal cell carcinoma, and/or squamous cell carcinoma in patients aged ≥ 40 years “to assist health care providers in determining whether to refer a patient to a dermatologist,” according to an FDA announcement.
Using elastic scattering spectroscopy to analyze light reflecting off the skin to detect malignancy, the manufacturer’s promotional material claims a 96% sensitivity and a 97% specificity.
While Dr. Rotemberg did not comment on these claims, she cautioned that AI models differ with regards to how they were trained and the relative heterogeneity of the training dataset defined by types of patients, types of skin, and types of AI learning processes. All of these variables are relevant in whether the AI will perform in a given clinical setting at the level it performed during development.
“The most accurate models employ narrow datasets, but these do not necessarily mimic what we see in practice,” she said.
In addition, even when an AI-based system is working for a given task, it must be monitored over time. Dr. Rotemberg warned about the potential for “data drift,” which describes the slow evolution in how diseases present, their prevalence by age, or other factors that might affect AI performance. She explained that repeated validation is needed to ensure that the AI-based models remain as accurate over time as they were when first used.
Many of these concepts were explored in a consensus statement from the International Skin Imaging Collaboration AI Working Group, published in JAMA Dermatology in December 2021. The statement, of which Dr. Rotemberg was a coauthor, provided recommendations for the principles of AI algorithm development specific to dermatologic considerations.
At the AAD symposium, Dr. Rotemberg asked the audience for suggestions about the needs they hoped AI might address for in office care or efficiency. Their responses included generating prior authorizations for prescriptions, triaging email for importance, and helping to improve efficiency for common front desk tasks. She liked all of these suggestions, but she warned that as powerful as it can be, AI is not likely to provide technology that will fit seamlessly into workflows without adjustment.
“Our current systems do not allow human integration of AI models,” Dr. Rotemberg said. Rather than counting on AI to adapt to current practices, she cautioned that “we may have to redesign our entire structure to actually be able to accommodate AI-based” systems. The risk for users is tasks that become more challenging before they become easier.
AI Should Not Be a Black Box
AI is promising, but it is not magic, according to other investigators, including Tofunmi A. Omiye, PhD, a postdoctoral scholar in dermatology at Stanford University, California. First author of a recent review of AI in dermatology published in Frontiers in Medicine, Dr. Omiye agreed that clinicians who want to employ AI should be able to understand basic principles if they want the technology to perform as expected.
“I totally agree that physicians should at least have a basic understanding of the data sources for training AI models as we have found that to be important to the performance of these models in the clinical setting,” he told this news organization.
“Beyond understanding the data sources, I believe physicians can also try to have a comprehensive understanding of what AI means, its training process, and evaluation as this will help them to evaluate its utility in their practice,” he added. He also reinforced the relevance of data drift.
“Concepts like distribution shift — where models perform less well over time due to changes in the patient population — are also important to keep in mind,” Dr. Omiye said.
Dr. Wongvibulsin, Dr. Rotemberg, and Dr. Omiye reported no potential financial conflicts of interest relevant to this topic.
A version of this article appeared on Medscape.com .
SAN DIEGO — Just a day before the annual meeting of the American Academy of Dermatology (AAD) began, .
Not least of the problems among the 41 apps evaluated, the majority offered no supporting evidence, no information about whether the app performance had been validated, and no information about how user privacy would be managed, reported Shannon Wongvibulsin, MD, PhD, a resident in the dermatology program at the University of California, Los Angeles, and her coauthors.
The findings from this report were also summarized in a poster at the AAD meeting, and the major themes were reiterated in several AAD symposia devoted to AI at the meeting. Veronica Rotemberg, MD, PhD, a dermatologist at Memorial Sloan Kettering Cancer Center, New York City, was one of those who weighed in on the future of AI. Although she was the senior author of the report, she did not address the report or poster directly, but her presentation on the practical aspects of incorporating AI into dermatology practice revisited several of its themes.
Of the different themes, perhaps the most important were the concept that the source of AI data matters and the point that practicing clinicians should be familiar with the data source.
To date, “there is not much transparency in what data AI models are using,” Dr. Rotemberg said at the meeting. Based on the expectation that dermatologists will be purchasing rather than developing their own AI-based systems, she reiterated more than once that “transparency of data is critical,” even if vendors are often reluctant to reveal how their proprietary systems have been developed.
Few Dermatology Apps Are Vetted for Accuracy
In the poster and in the more detailed JAMA Dermatology paper, Dr. Wongvibulsin and her coinvestigators evaluated direct-to-consumer downloadable apps that claim to help with the assessment and management of skin conditions. Very few provided any supporting evidence of accuracy or even information about how they functioned.
The 41 apps were drawn from more than 300 apps; the others were excluded for failing to meet such criteria as failing to employ AI, not being available in English, or not addressing clinical management of dermatologic diseases. Dr. Wongvibulsin pointed out that none of the apps had been granted regulatory approval even though only two provided a disclaimer to that effect.
In all, just 5 of the 41 provided supporting evidence from a peer-reviewed journal, and less than 40% were created with any input from a dermatologist, Dr. Wongvibulsin reported. The result is that the utility and accuracy of these apps were, for the most part, difficult to judge.
“At a minimum, app developers should provide details on what AI algorithms are used, what data sets were used for training, testing, and validation, whether there was any clinician input, whether there are any supporting publications, how user-submitted images are used, and if there are any measures used to ensure data privacy,” Dr. Wongvibulsin wrote in the poster.
For AI-based apps or systems designed for use by dermatologists, Dr. Rotemberg made similar assertions in her overview of what clinicians should be considering for proprietary AI systems, whether to help with diagnosis or improve office efficiency.
Only One Dermatology App Cleared By the FDA
Currently, the only FDA-cleared app for dermatologic use is the DermaSensor, an AI-driven device. It was cleared for use in January 2024 for the evaluation of skin lesions “suggestive” of melanoma, basal cell carcinoma, and/or squamous cell carcinoma in patients aged ≥ 40 years “to assist health care providers in determining whether to refer a patient to a dermatologist,” according to an FDA announcement.
Using elastic scattering spectroscopy to analyze light reflecting off the skin to detect malignancy, the manufacturer’s promotional material claims a 96% sensitivity and a 97% specificity.
While Dr. Rotemberg did not comment on these claims, she cautioned that AI models differ with regards to how they were trained and the relative heterogeneity of the training dataset defined by types of patients, types of skin, and types of AI learning processes. All of these variables are relevant in whether the AI will perform in a given clinical setting at the level it performed during development.
“The most accurate models employ narrow datasets, but these do not necessarily mimic what we see in practice,” she said.
In addition, even when an AI-based system is working for a given task, it must be monitored over time. Dr. Rotemberg warned about the potential for “data drift,” which describes the slow evolution in how diseases present, their prevalence by age, or other factors that might affect AI performance. She explained that repeated validation is needed to ensure that the AI-based models remain as accurate over time as they were when first used.
Many of these concepts were explored in a consensus statement from the International Skin Imaging Collaboration AI Working Group, published in JAMA Dermatology in December 2021. The statement, of which Dr. Rotemberg was a coauthor, provided recommendations for the principles of AI algorithm development specific to dermatologic considerations.
At the AAD symposium, Dr. Rotemberg asked the audience for suggestions about the needs they hoped AI might address for in office care or efficiency. Their responses included generating prior authorizations for prescriptions, triaging email for importance, and helping to improve efficiency for common front desk tasks. She liked all of these suggestions, but she warned that as powerful as it can be, AI is not likely to provide technology that will fit seamlessly into workflows without adjustment.
“Our current systems do not allow human integration of AI models,” Dr. Rotemberg said. Rather than counting on AI to adapt to current practices, she cautioned that “we may have to redesign our entire structure to actually be able to accommodate AI-based” systems. The risk for users is tasks that become more challenging before they become easier.
AI Should Not Be a Black Box
AI is promising, but it is not magic, according to other investigators, including Tofunmi A. Omiye, PhD, a postdoctoral scholar in dermatology at Stanford University, California. First author of a recent review of AI in dermatology published in Frontiers in Medicine, Dr. Omiye agreed that clinicians who want to employ AI should be able to understand basic principles if they want the technology to perform as expected.
“I totally agree that physicians should at least have a basic understanding of the data sources for training AI models as we have found that to be important to the performance of these models in the clinical setting,” he told this news organization.
“Beyond understanding the data sources, I believe physicians can also try to have a comprehensive understanding of what AI means, its training process, and evaluation as this will help them to evaluate its utility in their practice,” he added. He also reinforced the relevance of data drift.
“Concepts like distribution shift — where models perform less well over time due to changes in the patient population — are also important to keep in mind,” Dr. Omiye said.
Dr. Wongvibulsin, Dr. Rotemberg, and Dr. Omiye reported no potential financial conflicts of interest relevant to this topic.
A version of this article appeared on Medscape.com .
SAN DIEGO — Just a day before the annual meeting of the American Academy of Dermatology (AAD) began, .
Not least of the problems among the 41 apps evaluated, the majority offered no supporting evidence, no information about whether the app performance had been validated, and no information about how user privacy would be managed, reported Shannon Wongvibulsin, MD, PhD, a resident in the dermatology program at the University of California, Los Angeles, and her coauthors.
The findings from this report were also summarized in a poster at the AAD meeting, and the major themes were reiterated in several AAD symposia devoted to AI at the meeting. Veronica Rotemberg, MD, PhD, a dermatologist at Memorial Sloan Kettering Cancer Center, New York City, was one of those who weighed in on the future of AI. Although she was the senior author of the report, she did not address the report or poster directly, but her presentation on the practical aspects of incorporating AI into dermatology practice revisited several of its themes.
Of the different themes, perhaps the most important were the concept that the source of AI data matters and the point that practicing clinicians should be familiar with the data source.
To date, “there is not much transparency in what data AI models are using,” Dr. Rotemberg said at the meeting. Based on the expectation that dermatologists will be purchasing rather than developing their own AI-based systems, she reiterated more than once that “transparency of data is critical,” even if vendors are often reluctant to reveal how their proprietary systems have been developed.
Few Dermatology Apps Are Vetted for Accuracy
In the poster and in the more detailed JAMA Dermatology paper, Dr. Wongvibulsin and her coinvestigators evaluated direct-to-consumer downloadable apps that claim to help with the assessment and management of skin conditions. Very few provided any supporting evidence of accuracy or even information about how they functioned.
The 41 apps were drawn from more than 300 apps; the others were excluded for failing to meet such criteria as failing to employ AI, not being available in English, or not addressing clinical management of dermatologic diseases. Dr. Wongvibulsin pointed out that none of the apps had been granted regulatory approval even though only two provided a disclaimer to that effect.
In all, just 5 of the 41 provided supporting evidence from a peer-reviewed journal, and less than 40% were created with any input from a dermatologist, Dr. Wongvibulsin reported. The result is that the utility and accuracy of these apps were, for the most part, difficult to judge.
“At a minimum, app developers should provide details on what AI algorithms are used, what data sets were used for training, testing, and validation, whether there was any clinician input, whether there are any supporting publications, how user-submitted images are used, and if there are any measures used to ensure data privacy,” Dr. Wongvibulsin wrote in the poster.
For AI-based apps or systems designed for use by dermatologists, Dr. Rotemberg made similar assertions in her overview of what clinicians should be considering for proprietary AI systems, whether to help with diagnosis or improve office efficiency.
Only One Dermatology App Cleared By the FDA
Currently, the only FDA-cleared app for dermatologic use is the DermaSensor, an AI-driven device. It was cleared for use in January 2024 for the evaluation of skin lesions “suggestive” of melanoma, basal cell carcinoma, and/or squamous cell carcinoma in patients aged ≥ 40 years “to assist health care providers in determining whether to refer a patient to a dermatologist,” according to an FDA announcement.
Using elastic scattering spectroscopy to analyze light reflecting off the skin to detect malignancy, the manufacturer’s promotional material claims a 96% sensitivity and a 97% specificity.
While Dr. Rotemberg did not comment on these claims, she cautioned that AI models differ with regards to how they were trained and the relative heterogeneity of the training dataset defined by types of patients, types of skin, and types of AI learning processes. All of these variables are relevant in whether the AI will perform in a given clinical setting at the level it performed during development.
“The most accurate models employ narrow datasets, but these do not necessarily mimic what we see in practice,” she said.
In addition, even when an AI-based system is working for a given task, it must be monitored over time. Dr. Rotemberg warned about the potential for “data drift,” which describes the slow evolution in how diseases present, their prevalence by age, or other factors that might affect AI performance. She explained that repeated validation is needed to ensure that the AI-based models remain as accurate over time as they were when first used.
Many of these concepts were explored in a consensus statement from the International Skin Imaging Collaboration AI Working Group, published in JAMA Dermatology in December 2021. The statement, of which Dr. Rotemberg was a coauthor, provided recommendations for the principles of AI algorithm development specific to dermatologic considerations.
At the AAD symposium, Dr. Rotemberg asked the audience for suggestions about the needs they hoped AI might address for in office care or efficiency. Their responses included generating prior authorizations for prescriptions, triaging email for importance, and helping to improve efficiency for common front desk tasks. She liked all of these suggestions, but she warned that as powerful as it can be, AI is not likely to provide technology that will fit seamlessly into workflows without adjustment.
“Our current systems do not allow human integration of AI models,” Dr. Rotemberg said. Rather than counting on AI to adapt to current practices, she cautioned that “we may have to redesign our entire structure to actually be able to accommodate AI-based” systems. The risk for users is tasks that become more challenging before they become easier.
AI Should Not Be a Black Box
AI is promising, but it is not magic, according to other investigators, including Tofunmi A. Omiye, PhD, a postdoctoral scholar in dermatology at Stanford University, California. First author of a recent review of AI in dermatology published in Frontiers in Medicine, Dr. Omiye agreed that clinicians who want to employ AI should be able to understand basic principles if they want the technology to perform as expected.
“I totally agree that physicians should at least have a basic understanding of the data sources for training AI models as we have found that to be important to the performance of these models in the clinical setting,” he told this news organization.
“Beyond understanding the data sources, I believe physicians can also try to have a comprehensive understanding of what AI means, its training process, and evaluation as this will help them to evaluate its utility in their practice,” he added. He also reinforced the relevance of data drift.
“Concepts like distribution shift — where models perform less well over time due to changes in the patient population — are also important to keep in mind,” Dr. Omiye said.
Dr. Wongvibulsin, Dr. Rotemberg, and Dr. Omiye reported no potential financial conflicts of interest relevant to this topic.
A version of this article appeared on Medscape.com .
FROM AAD 2024
Most Cancer Trial Centers Located Closer to White, Affluent Populations
This inequity may be potentiating the underrepresentation of racially minoritized and socioeconomically disadvantaged populations in clinical trials, suggesting that employment of satellite hospitals is needed to expand access to investigational therapies, reported lead author Hassal Lee, MD, PhD, of Cold Spring Harbor Laboratory, Cold Spring Harbor, New York, and colleagues.
“Minoritized and socioeconomically disadvantaged populations are underrepresented in clinical trials,” the investigators wrote in JAMA Oncology. “This may reduce the generalizability of trial results and propagate health disparities. Contributors to inequitable trial participation include individual-level factors and structural factors.”
Specifically, travel time to trial centers, as well as socioeconomic deprivation, can reduce likelihood of trial participation.
“Data on these parameters and population data on self-identified race exist, but their interrelation with clinical research facilities has not been systematically analyzed,” they wrote.
To try to draw comparisons between the distribution of patients of different races and socioeconomic statuses and the locations of clinical research facilities, Dr. Lee and colleagues aggregated data from the US Census, National Trial registry, Nature Index of Cancer Research Health Institutions, OpenStreetMap, National Cancer Institute–designated Cancer Centers list, and National Homeland Infrastructure Foundation. They then characterized catchment population demographics within 30-, 60-, and 120-minute driving commute times of all US hospitals, along with a more focused look at centers capable of conducting phase 1, phase 2, and phase 3 trials.
These efforts revealed broad geographic inequity.The 78 major centers that conduct 94% of all US cancer trials are located within 30 minutes of populations that have a 10.1% higher proportion of self-identified White individuals than the average US county, and a median income $18,900 higher than average (unpaired mean differences).
The publication also includes several maps characterizing racial and socioeconomic demographics within various catchment areas. For example, centers in New York City, Houston, and Chicago have the most diverse catchment populations within a 30-minute commute. Maps of all cities in the United States with populations greater than 500,000 are available in a supplementary index.
“This study indicates that geographical population distributions may present barriers to equitable clinical trial access and that data are available to proactively strategize about reduction of such barriers,” Dr. Lee and colleagues wrote.
The findings call attention to modifiable socioeconomic factors associated with trial participation, they added, like financial toxicity and affordable transportation, noting that ethnic and racial groups consent to trials at similar rates after controlling for income.
In addition, Dr. Lee and colleagues advised clinical trial designers to enlist satellite hospitals to increase participant diversity, since long commutes exacerbate “socioeconomic burdens associated with clinical trial participation,” with trial participation decreasing as commute time increases.
“Existing clinical trial centers may build collaborative efforts with nearby hospitals closer to underrepresented populations or set up community centers to support new collaborative networks to improve geographical access equity,” they wrote. “Methodologically, our approach is transferable to any country, region, or global effort with sufficient source data and can inform decision-making along the continuum of cancer care, from screening to implementing specialist care.”
A coauthor disclosed relationships with Flagship Therapeutics, Leidos Holding Ltd, Pershing Square Foundation, and others.
This inequity may be potentiating the underrepresentation of racially minoritized and socioeconomically disadvantaged populations in clinical trials, suggesting that employment of satellite hospitals is needed to expand access to investigational therapies, reported lead author Hassal Lee, MD, PhD, of Cold Spring Harbor Laboratory, Cold Spring Harbor, New York, and colleagues.
“Minoritized and socioeconomically disadvantaged populations are underrepresented in clinical trials,” the investigators wrote in JAMA Oncology. “This may reduce the generalizability of trial results and propagate health disparities. Contributors to inequitable trial participation include individual-level factors and structural factors.”
Specifically, travel time to trial centers, as well as socioeconomic deprivation, can reduce likelihood of trial participation.
“Data on these parameters and population data on self-identified race exist, but their interrelation with clinical research facilities has not been systematically analyzed,” they wrote.
To try to draw comparisons between the distribution of patients of different races and socioeconomic statuses and the locations of clinical research facilities, Dr. Lee and colleagues aggregated data from the US Census, National Trial registry, Nature Index of Cancer Research Health Institutions, OpenStreetMap, National Cancer Institute–designated Cancer Centers list, and National Homeland Infrastructure Foundation. They then characterized catchment population demographics within 30-, 60-, and 120-minute driving commute times of all US hospitals, along with a more focused look at centers capable of conducting phase 1, phase 2, and phase 3 trials.
These efforts revealed broad geographic inequity.The 78 major centers that conduct 94% of all US cancer trials are located within 30 minutes of populations that have a 10.1% higher proportion of self-identified White individuals than the average US county, and a median income $18,900 higher than average (unpaired mean differences).
The publication also includes several maps characterizing racial and socioeconomic demographics within various catchment areas. For example, centers in New York City, Houston, and Chicago have the most diverse catchment populations within a 30-minute commute. Maps of all cities in the United States with populations greater than 500,000 are available in a supplementary index.
“This study indicates that geographical population distributions may present barriers to equitable clinical trial access and that data are available to proactively strategize about reduction of such barriers,” Dr. Lee and colleagues wrote.
The findings call attention to modifiable socioeconomic factors associated with trial participation, they added, like financial toxicity and affordable transportation, noting that ethnic and racial groups consent to trials at similar rates after controlling for income.
In addition, Dr. Lee and colleagues advised clinical trial designers to enlist satellite hospitals to increase participant diversity, since long commutes exacerbate “socioeconomic burdens associated with clinical trial participation,” with trial participation decreasing as commute time increases.
“Existing clinical trial centers may build collaborative efforts with nearby hospitals closer to underrepresented populations or set up community centers to support new collaborative networks to improve geographical access equity,” they wrote. “Methodologically, our approach is transferable to any country, region, or global effort with sufficient source data and can inform decision-making along the continuum of cancer care, from screening to implementing specialist care.”
A coauthor disclosed relationships with Flagship Therapeutics, Leidos Holding Ltd, Pershing Square Foundation, and others.
This inequity may be potentiating the underrepresentation of racially minoritized and socioeconomically disadvantaged populations in clinical trials, suggesting that employment of satellite hospitals is needed to expand access to investigational therapies, reported lead author Hassal Lee, MD, PhD, of Cold Spring Harbor Laboratory, Cold Spring Harbor, New York, and colleagues.
“Minoritized and socioeconomically disadvantaged populations are underrepresented in clinical trials,” the investigators wrote in JAMA Oncology. “This may reduce the generalizability of trial results and propagate health disparities. Contributors to inequitable trial participation include individual-level factors and structural factors.”
Specifically, travel time to trial centers, as well as socioeconomic deprivation, can reduce likelihood of trial participation.
“Data on these parameters and population data on self-identified race exist, but their interrelation with clinical research facilities has not been systematically analyzed,” they wrote.
To try to draw comparisons between the distribution of patients of different races and socioeconomic statuses and the locations of clinical research facilities, Dr. Lee and colleagues aggregated data from the US Census, National Trial registry, Nature Index of Cancer Research Health Institutions, OpenStreetMap, National Cancer Institute–designated Cancer Centers list, and National Homeland Infrastructure Foundation. They then characterized catchment population demographics within 30-, 60-, and 120-minute driving commute times of all US hospitals, along with a more focused look at centers capable of conducting phase 1, phase 2, and phase 3 trials.
These efforts revealed broad geographic inequity.The 78 major centers that conduct 94% of all US cancer trials are located within 30 minutes of populations that have a 10.1% higher proportion of self-identified White individuals than the average US county, and a median income $18,900 higher than average (unpaired mean differences).
The publication also includes several maps characterizing racial and socioeconomic demographics within various catchment areas. For example, centers in New York City, Houston, and Chicago have the most diverse catchment populations within a 30-minute commute. Maps of all cities in the United States with populations greater than 500,000 are available in a supplementary index.
“This study indicates that geographical population distributions may present barriers to equitable clinical trial access and that data are available to proactively strategize about reduction of such barriers,” Dr. Lee and colleagues wrote.
The findings call attention to modifiable socioeconomic factors associated with trial participation, they added, like financial toxicity and affordable transportation, noting that ethnic and racial groups consent to trials at similar rates after controlling for income.
In addition, Dr. Lee and colleagues advised clinical trial designers to enlist satellite hospitals to increase participant diversity, since long commutes exacerbate “socioeconomic burdens associated with clinical trial participation,” with trial participation decreasing as commute time increases.
“Existing clinical trial centers may build collaborative efforts with nearby hospitals closer to underrepresented populations or set up community centers to support new collaborative networks to improve geographical access equity,” they wrote. “Methodologically, our approach is transferable to any country, region, or global effort with sufficient source data and can inform decision-making along the continuum of cancer care, from screening to implementing specialist care.”
A coauthor disclosed relationships with Flagship Therapeutics, Leidos Holding Ltd, Pershing Square Foundation, and others.
FROM JAMA ONCOLOGY