AVAHO

It is the best possible news after an advanced melanoma diagnosis: A clean 10-year scan. This, in all likelihood, means the patient is cured and can leave the office free from their annual ‘scanxiety.’ 

But even in the best-case scenarios, oncologists may dodge the word cure, searching for others such as “remission,” “no evidence of disease,” and “most likely cured” to communicate the good news. Using these more open-ended terms can give patients reassurance without providing false hope that the cancer won’t ever return.

The “risk of future recurrence — even when very small — makes oncologists reluctant to use the word cure, fearing it will be interpreted as a promise, and particularly one that might be broken,” Belinda E. Kiely, MD, and Martin R. Stockler, MD, medical oncologists from the University of Sydney in Australia, wrote in a recent editorial.

Is it ever safe for oncologists to use the word cure? Might doing so backfire? Or does a patient’s underlying fear of recurrence transcend the word?

 

A Word’s Heavy Impact

Part of clinicians’ hesitance to use the word cure may stem from a lack of accepted definition for the term in oncology.

For some experts, a cure means patients will have a normal life expectancy not affected by cancer. Being able to confidently tell a patient that “requires very long-term follow-up,” said James Larkin, PhD, a medical oncologist at The Royal Marsden Hospital, London, England.

The National Cancer Institute (NCI) has a similar definition: “Cure means that there are no traces of your cancer after treatment and the cancer will never come back,” the NCI website says.

The American Society of Clinical Oncology, however, defines cure much more narrowly, as “when a person’s cancer has not returned for at least 5 years after treatment.” 

Not having a standard definition of cure in oncology makes it even more challenging for an oncologist to know how to communicate that a cancer very likely won’t return, without overpromising.

Some of the hesitance in framing good news comes from nuances in prognoses that depend on the type and stage of cancer, explained Marleen Kok, MD, PhD, a breast cancer specialist from the Netherlands Cancer Institute in Amsterdam.

Patients with localized early-stage breast cancer, for instance, have a 5-year survival rate of nearly 100%, and most live 2 decades or longer but, for some, the cancer will return.

“If you talk about early disease, indeed, we cure 80% of breast cancer patients,” Kok said during a press conference at the annual 2024 European Society of Medical Oncology meeting. But sub-dividing breast cancer into tumor type adds complexity. “With triple negative breast cancer, if they relapse, they relapse during the first 2 or 3 years so, at 5 years, the majority are disease free. But that’s different for estrogen receptor positive breast cancer,” in which recurrences can come much later.

In advanced cancers, oncologists may, understandably, be more hesitant to use the word cure. However, ongoing progress in cancer treatments is making the prospect of a cure more likely for some patients.

Take recent findings in melanoma. The landmark CheckMate 067 study in advanced disease revealed that patients receiving the immunotherapy combination of nivolumab plus ipilimumab had a median melanoma-specific survival > 10 years and a median overall survival of about 6 years.

The findings from the trial suggest that “many patients may die from causes unrelated to melanoma — or, in essence, they are cured,” outside expert Elisa Funck-Brentano, MD, PhD, from Ambroise-Paré Hospital in Paris, France, explained to Medscape Medical News.

With CheckMate 067, “what we’re talking about here is potential cure of metastatic solid tumors, which in general is something that’s new,” said senior author Larkin. In fact, late relapses after the 2- to 3-year mark in immunotherapy-treated melanoma are extremely rare.

CheckMate 067 “really made people tempted to use the word cure, and I will say some people in our field do,” said Pauline Funchain, MD, a medical oncologist at Stanford Cancer Institute, and associate professor at Stanford University, Palo Alto, California. “The rest of us really, really want to, but are hesitant because of what we know about melanoma.”

Because the reality is late relapse is still possible.

The cancer can show up decades later and I think, as oncologists, that experience has sort of shaken us,” Funchain told this news organization.

“Oncologists are scarred by those examples,” agreed Evan Hall, MD, a medical oncologist at Fred Hutch Cancer Center and assistant professor at the University of Washington School of Medicine, both in Seattle.

Clinical trials also don’t typically frame patient outcomes in terms of being cured. A recent analysis, which examined the use of “cure” and “hope” in 13,363 oncology articles published between 2000 and 2019 in JAMA Oncology and the Journal of Clinical Oncology, found that both words were used infrequently, especially in primary research articles, and their use decreased significantly over time, even as survival rates in oncology improved. The word cure, for instance, appeared in about 0.1% of sentences in primary research papers published in either journal, though the context of its use was not identified.

Outcomes in cancer clinical trials, which may assess hundreds even thousands of patients, are largely framed in terms of risks and rates of survival — 85% of patients who received treatment X are alive at 5 years or patients receiving treatment Y have a 20% risk for recurrence, for instance.

These risks and rates can’t tell an oncologist whether the patient sitting in front of them can close the cancer chapter of their lives for good.

“I just saw a patient the other day who was 30 years out from their melanoma diagnosis, and they had a recurrence,” Hall recalled. That’s why, “ultimately, it’s a hard thing to tell somebody they’re cured,” he said. “I personally don’t really like using that term.”

While the literature on using the word cure in oncology is limited, one older survey of oncology clinicians supports this view that many feel reluctant to use the term. Of 117 oncology clinicians who responded, 81% said they were “hesitant to tell a patient that they are cured,” and 63% said that they “would never tell a patient that they are cured,” while just 36% said they were comfortable saying the word, with most respondents waiting at least 6-10 years before doing so.

A more recent Italian survey, however, revealed a more favorable view of the word cure in oncology. The survey, which included 224 clinicians and 249 patients, reported that > 90% of cancer physicians, which included surgeons, radiotherapists, and medical oncologists, agreed that it’s possible for a patient to be cured, while about 84% of patients believed this. And > 80% of respondents said using the word cure would be “beneficial” to patients.

Still, even for those hearing the word cure and feeling comforted by an oncologist’s reassurance, it may only provide short-term relief. Fear that the cancer will come slinking, even roaring, back eventually may loom. And this lingering worry can haunt cancer survivors for years.

In a recent cross-sectional study of 229 adults who survived childhood cancer and had lived cancer-free for decades, researchers found that one third reported experiencing clinically significant elevated fear that their primary cancer would recur or a subsequent malignant neoplasm would develop. Similar anxiety has been documented in long-term survivors of adult-onset cancers.

To some degree, every survivor will experience fear and anxiety that their cancer will come back and, at a certain level, that is normal, the study’s senior author Nicole Alberts, PhD, a psychologist, associate professor, and Canada research chair in Behavioural Health Intervention at Concordia University, Montréal, Quebec, Canada, told this news organization.

Although an oncologist’s words do matter and clinicians may wrestle with the right words for patients in the moment, it can take more than words to quell patients’ fear, she said.

“What we know about that kind of anxiety is that there’s this cycle where reassurance doesn’t really help in the long-term,” Alberts said. In other words, hearing the word cure from their oncologist initially makes people feel better, but the anxiety may eventually come back.

Alberts tries to help patients acknowledge and accept uncertainty while also calming residual or lingering anxiety about a cancer recurrence. Ultimately, Alberts’ goal is to help cancer survivors “find the sweet spot to live again.”

A version of this article first appeared on Medscape.com. 

It is the best possible news after an advanced melanoma diagnosis: A clean 10-year scan. This, in all likelihood, means the patient is cured and can leave the office free from their annual ‘scanxiety.’ 

But even in the best-case scenarios, oncologists may dodge the word cure, searching for others such as “remission,” “no evidence of disease,” and “most likely cured” to communicate the good news. Using these more open-ended terms can give patients reassurance without providing false hope that the cancer won’t ever return.

The “risk of future recurrence — even when very small — makes oncologists reluctant to use the word cure, fearing it will be interpreted as a promise, and particularly one that might be broken,” Belinda E. Kiely, MD, and Martin R. Stockler, MD, medical oncologists from the University of Sydney in Australia, wrote in a recent editorial.

Is it ever safe for oncologists to use the word cure? Might doing so backfire? Or does a patient’s underlying fear of recurrence transcend the word?

 

A Word’s Heavy Impact

Part of clinicians’ hesitance to use the word cure may stem from a lack of accepted definition for the term in oncology.

For some experts, a cure means patients will have a normal life expectancy not affected by cancer. Being able to confidently tell a patient that “requires very long-term follow-up,” said James Larkin, PhD, a medical oncologist at The Royal Marsden Hospital, London, England.

The National Cancer Institute (NCI) has a similar definition: “Cure means that there are no traces of your cancer after treatment and the cancer will never come back,” the NCI website says.

The American Society of Clinical Oncology, however, defines cure much more narrowly, as “when a person’s cancer has not returned for at least 5 years after treatment.” 

Not having a standard definition of cure in oncology makes it even more challenging for an oncologist to know how to communicate that a cancer very likely won’t return, without overpromising.

Some of the hesitance in framing good news comes from nuances in prognoses that depend on the type and stage of cancer, explained Marleen Kok, MD, PhD, a breast cancer specialist from the Netherlands Cancer Institute in Amsterdam.

Patients with localized early-stage breast cancer, for instance, have a 5-year survival rate of nearly 100%, and most live 2 decades or longer but, for some, the cancer will return.

“If you talk about early disease, indeed, we cure 80% of breast cancer patients,” Kok said during a press conference at the annual 2024 European Society of Medical Oncology meeting. But sub-dividing breast cancer into tumor type adds complexity. “With triple negative breast cancer, if they relapse, they relapse during the first 2 or 3 years so, at 5 years, the majority are disease free. But that’s different for estrogen receptor positive breast cancer,” in which recurrences can come much later.

In advanced cancers, oncologists may, understandably, be more hesitant to use the word cure. However, ongoing progress in cancer treatments is making the prospect of a cure more likely for some patients.

Take recent findings in melanoma. The landmark CheckMate 067 study in advanced disease revealed that patients receiving the immunotherapy combination of nivolumab plus ipilimumab had a median melanoma-specific survival > 10 years and a median overall survival of about 6 years.

The findings from the trial suggest that “many patients may die from causes unrelated to melanoma — or, in essence, they are cured,” outside expert Elisa Funck-Brentano, MD, PhD, from Ambroise-Paré Hospital in Paris, France, explained to Medscape Medical News.

With CheckMate 067, “what we’re talking about here is potential cure of metastatic solid tumors, which in general is something that’s new,” said senior author Larkin. In fact, late relapses after the 2- to 3-year mark in immunotherapy-treated melanoma are extremely rare.

CheckMate 067 “really made people tempted to use the word cure, and I will say some people in our field do,” said Pauline Funchain, MD, a medical oncologist at Stanford Cancer Institute, and associate professor at Stanford University, Palo Alto, California. “The rest of us really, really want to, but are hesitant because of what we know about melanoma.”

Because the reality is late relapse is still possible.

The cancer can show up decades later and I think, as oncologists, that experience has sort of shaken us,” Funchain told this news organization.

“Oncologists are scarred by those examples,” agreed Evan Hall, MD, a medical oncologist at Fred Hutch Cancer Center and assistant professor at the University of Washington School of Medicine, both in Seattle.

Clinical trials also don’t typically frame patient outcomes in terms of being cured. A recent analysis, which examined the use of “cure” and “hope” in 13,363 oncology articles published between 2000 and 2019 in JAMA Oncology and the Journal of Clinical Oncology, found that both words were used infrequently, especially in primary research articles, and their use decreased significantly over time, even as survival rates in oncology improved. The word cure, for instance, appeared in about 0.1% of sentences in primary research papers published in either journal, though the context of its use was not identified.

Outcomes in cancer clinical trials, which may assess hundreds even thousands of patients, are largely framed in terms of risks and rates of survival — 85% of patients who received treatment X are alive at 5 years or patients receiving treatment Y have a 20% risk for recurrence, for instance.

These risks and rates can’t tell an oncologist whether the patient sitting in front of them can close the cancer chapter of their lives for good.

“I just saw a patient the other day who was 30 years out from their melanoma diagnosis, and they had a recurrence,” Hall recalled. That’s why, “ultimately, it’s a hard thing to tell somebody they’re cured,” he said. “I personally don’t really like using that term.”

While the literature on using the word cure in oncology is limited, one older survey of oncology clinicians supports this view that many feel reluctant to use the term. Of 117 oncology clinicians who responded, 81% said they were “hesitant to tell a patient that they are cured,” and 63% said that they “would never tell a patient that they are cured,” while just 36% said they were comfortable saying the word, with most respondents waiting at least 6-10 years before doing so.

A more recent Italian survey, however, revealed a more favorable view of the word cure in oncology. The survey, which included 224 clinicians and 249 patients, reported that > 90% of cancer physicians, which included surgeons, radiotherapists, and medical oncologists, agreed that it’s possible for a patient to be cured, while about 84% of patients believed this. And > 80% of respondents said using the word cure would be “beneficial” to patients.

Still, even for those hearing the word cure and feeling comforted by an oncologist’s reassurance, it may only provide short-term relief. Fear that the cancer will come slinking, even roaring, back eventually may loom. And this lingering worry can haunt cancer survivors for years.

In a recent cross-sectional study of 229 adults who survived childhood cancer and had lived cancer-free for decades, researchers found that one third reported experiencing clinically significant elevated fear that their primary cancer would recur or a subsequent malignant neoplasm would develop. Similar anxiety has been documented in long-term survivors of adult-onset cancers.

To some degree, every survivor will experience fear and anxiety that their cancer will come back and, at a certain level, that is normal, the study’s senior author Nicole Alberts, PhD, a psychologist, associate professor, and Canada research chair in Behavioural Health Intervention at Concordia University, Montréal, Quebec, Canada, told this news organization.

Although an oncologist’s words do matter and clinicians may wrestle with the right words for patients in the moment, it can take more than words to quell patients’ fear, she said.

“What we know about that kind of anxiety is that there’s this cycle where reassurance doesn’t really help in the long-term,” Alberts said. In other words, hearing the word cure from their oncologist initially makes people feel better, but the anxiety may eventually come back.

Alberts tries to help patients acknowledge and accept uncertainty while also calming residual or lingering anxiety about a cancer recurrence. Ultimately, Alberts’ goal is to help cancer survivors “find the sweet spot to live again.”

A version of this article first appeared on Medscape.com. 

It is the best possible news after an advanced melanoma diagnosis: A clean 10-year scan. This, in all likelihood, means the patient is cured and can leave the office free from their annual ‘scanxiety.’ 

But even in the best-case scenarios, oncologists may dodge the word cure, searching for others such as “remission,” “no evidence of disease,” and “most likely cured” to communicate the good news. Using these more open-ended terms can give patients reassurance without providing false hope that the cancer won’t ever return.

The “risk of future recurrence — even when very small — makes oncologists reluctant to use the word cure, fearing it will be interpreted as a promise, and particularly one that might be broken,” Belinda E. Kiely, MD, and Martin R. Stockler, MD, medical oncologists from the University of Sydney in Australia, wrote in a recent editorial.

Is it ever safe for oncologists to use the word cure? Might doing so backfire? Or does a patient’s underlying fear of recurrence transcend the word?

 

A Word’s Heavy Impact

Part of clinicians’ hesitance to use the word cure may stem from a lack of accepted definition for the term in oncology.

For some experts, a cure means patients will have a normal life expectancy not affected by cancer. Being able to confidently tell a patient that “requires very long-term follow-up,” said James Larkin, PhD, a medical oncologist at The Royal Marsden Hospital, London, England.

The National Cancer Institute (NCI) has a similar definition: “Cure means that there are no traces of your cancer after treatment and the cancer will never come back,” the NCI website says.

The American Society of Clinical Oncology, however, defines cure much more narrowly, as “when a person’s cancer has not returned for at least 5 years after treatment.” 

Not having a standard definition of cure in oncology makes it even more challenging for an oncologist to know how to communicate that a cancer very likely won’t return, without overpromising.

Some of the hesitance in framing good news comes from nuances in prognoses that depend on the type and stage of cancer, explained Marleen Kok, MD, PhD, a breast cancer specialist from the Netherlands Cancer Institute in Amsterdam.

Patients with localized early-stage breast cancer, for instance, have a 5-year survival rate of nearly 100%, and most live 2 decades or longer but, for some, the cancer will return.

“If you talk about early disease, indeed, we cure 80% of breast cancer patients,” Kok said during a press conference at the annual 2024 European Society of Medical Oncology meeting. But sub-dividing breast cancer into tumor type adds complexity. “With triple negative breast cancer, if they relapse, they relapse during the first 2 or 3 years so, at 5 years, the majority are disease free. But that’s different for estrogen receptor positive breast cancer,” in which recurrences can come much later.

In advanced cancers, oncologists may, understandably, be more hesitant to use the word cure. However, ongoing progress in cancer treatments is making the prospect of a cure more likely for some patients.

Take recent findings in melanoma. The landmark CheckMate 067 study in advanced disease revealed that patients receiving the immunotherapy combination of nivolumab plus ipilimumab had a median melanoma-specific survival > 10 years and a median overall survival of about 6 years.

The findings from the trial suggest that “many patients may die from causes unrelated to melanoma — or, in essence, they are cured,” outside expert Elisa Funck-Brentano, MD, PhD, from Ambroise-Paré Hospital in Paris, France, explained to Medscape Medical News.

With CheckMate 067, “what we’re talking about here is potential cure of metastatic solid tumors, which in general is something that’s new,” said senior author Larkin. In fact, late relapses after the 2- to 3-year mark in immunotherapy-treated melanoma are extremely rare.

CheckMate 067 “really made people tempted to use the word cure, and I will say some people in our field do,” said Pauline Funchain, MD, a medical oncologist at Stanford Cancer Institute, and associate professor at Stanford University, Palo Alto, California. “The rest of us really, really want to, but are hesitant because of what we know about melanoma.”

Because the reality is late relapse is still possible.

The cancer can show up decades later and I think, as oncologists, that experience has sort of shaken us,” Funchain told this news organization.

“Oncologists are scarred by those examples,” agreed Evan Hall, MD, a medical oncologist at Fred Hutch Cancer Center and assistant professor at the University of Washington School of Medicine, both in Seattle.

Clinical trials also don’t typically frame patient outcomes in terms of being cured. A recent analysis, which examined the use of “cure” and “hope” in 13,363 oncology articles published between 2000 and 2019 in JAMA Oncology and the Journal of Clinical Oncology, found that both words were used infrequently, especially in primary research articles, and their use decreased significantly over time, even as survival rates in oncology improved. The word cure, for instance, appeared in about 0.1% of sentences in primary research papers published in either journal, though the context of its use was not identified.

Outcomes in cancer clinical trials, which may assess hundreds even thousands of patients, are largely framed in terms of risks and rates of survival — 85% of patients who received treatment X are alive at 5 years or patients receiving treatment Y have a 20% risk for recurrence, for instance.

These risks and rates can’t tell an oncologist whether the patient sitting in front of them can close the cancer chapter of their lives for good.

“I just saw a patient the other day who was 30 years out from their melanoma diagnosis, and they had a recurrence,” Hall recalled. That’s why, “ultimately, it’s a hard thing to tell somebody they’re cured,” he said. “I personally don’t really like using that term.”

While the literature on using the word cure in oncology is limited, one older survey of oncology clinicians supports this view that many feel reluctant to use the term. Of 117 oncology clinicians who responded, 81% said they were “hesitant to tell a patient that they are cured,” and 63% said that they “would never tell a patient that they are cured,” while just 36% said they were comfortable saying the word, with most respondents waiting at least 6-10 years before doing so.

A more recent Italian survey, however, revealed a more favorable view of the word cure in oncology. The survey, which included 224 clinicians and 249 patients, reported that > 90% of cancer physicians, which included surgeons, radiotherapists, and medical oncologists, agreed that it’s possible for a patient to be cured, while about 84% of patients believed this. And > 80% of respondents said using the word cure would be “beneficial” to patients.

Still, even for those hearing the word cure and feeling comforted by an oncologist’s reassurance, it may only provide short-term relief. Fear that the cancer will come slinking, even roaring, back eventually may loom. And this lingering worry can haunt cancer survivors for years.

In a recent cross-sectional study of 229 adults who survived childhood cancer and had lived cancer-free for decades, researchers found that one third reported experiencing clinically significant elevated fear that their primary cancer would recur or a subsequent malignant neoplasm would develop. Similar anxiety has been documented in long-term survivors of adult-onset cancers.

To some degree, every survivor will experience fear and anxiety that their cancer will come back and, at a certain level, that is normal, the study’s senior author Nicole Alberts, PhD, a psychologist, associate professor, and Canada research chair in Behavioural Health Intervention at Concordia University, Montréal, Quebec, Canada, told this news organization.

Although an oncologist’s words do matter and clinicians may wrestle with the right words for patients in the moment, it can take more than words to quell patients’ fear, she said.

“What we know about that kind of anxiety is that there’s this cycle where reassurance doesn’t really help in the long-term,” Alberts said. In other words, hearing the word cure from their oncologist initially makes people feel better, but the anxiety may eventually come back.

Alberts tries to help patients acknowledge and accept uncertainty while also calming residual or lingering anxiety about a cancer recurrence. Ultimately, Alberts’ goal is to help cancer survivors “find the sweet spot to live again.”

A version of this article first appeared on Medscape.com. 

The risk of detecting colorectal cancer (CRC) increases by up to 13-fold in the presence of prior fecal hemoglobin (f-Hb) concentrations in fecal immunochemical tests (FIT), especially negative ones, according to a large international dose-response meta-analysis.

Although the association with neoplasia decreased as f-Hb levels rose, the findings support the development of risk-stratified screening strategies based on these concentrations, according to researchers led by Danica M.N. van den Berg, MSc, a PhD candidate and econometrics researcher in the department of public health at Erasmus University Medical Center in Rotterdam, the Netherlands.

Higher f-Hb concentrations in prior negative screening tests are strongly associated with an increased risk of detecting colorectal neoplasia in subsequent screenings, van den Berg said in an interview. “Gastroenterologists and other clinicians should consider the value of f-Hb concentrations in refining screening protocols and personalizing patient care to detect colorectal neoplasia earlier and more accurately.”

Published in Gastroenterology, the study was prompted by prior research showing individuals with f-Hb concentrations just below the positivity cutoff had an elevated CRC risk vs those with low or no f-Hb. “However, global variations in FIT positivity cutoffs and f-Hb category definitions complicated cross-study comparisons,” van den Berg said. 

Given the lack of an established dose-response relationship, the study aimed to clarify how f-Hb levels in previous screenings correlate with colorectal neoplasia detection. “Understanding this relationship is crucial for developing risk-stratified colorectal cancer screening strategies based on prior FIT results, which could improve the harm-benefit balance of screening,” she said.

According to van den Berg, f-Hb concentrations could help determine optimal CRC screening intervals by identifying higher-risk individuals who could benefit from more frequent testing, while those with lower concentrations could be screened less frequently.

 

Study Details

The systematic review and meta-analysis are the first to focus on the dose-response relationship between f-Hb levels in prior FIT screenings and colorectal neoplasia detection, van den Berg said. It included 13 ethnically diverse studies published during 2011-2023 with 4,493,223 individuals from Spain, France, the Netherlands, Taiwan, Denmark, Scotland, Ireland, Korea, Italy, and Norway. Most studies were cohort-based, and one was a randomized controlled trial.

All studies demonstrated a positive association between f-Hb in previous screenings and colorectal neoplasia detection. Almost all reported the f-Hb concentration measured in the prior screening round, while one study combined the f-Hb concentration of two previous screening rounds by using the cumulative f-Hb value. There was, however, wide variability in the stool positivity cut-offs in the included studies, ranging from 10 μg f-Hb/g to 80 μg f-Hb/g.

With an overall effect size of 0.69 (95% CI, 0.59-0.79), pooled analysis revealed that in the next screening round, individuals with f-Hb concentrations in stool of 5, 10, 20, and 40 μg/g had a threefold, fivefold, eightfold, and 13-fold higher risk for colorectal neoplasia, respectively, vs individuals showing 0 μg/g. Although there was significant study heterogeneity (I² = 97.5%, P < .001), sensitivity analyses confirmed the consistency of findings. Interestingly, subgroup analyses indicated that f-Hb concentrations from a previous negative test were especially predictive of advanced neoplasia in subsequent screenings.

“This is a strategy worth pursuing and evaluating in the United States,” said gastroenterologist Theodore R. Levin, MD, a research scientist at Kaiser Permanente Division of Research in Northern California, commenting on the study but not involved in it. “However, there is no currently available FIT brand in the US that reports f-Hb concentration. All FITs in the United States report as a qualitative positive-negative result.”

The Dutch investigation aligns with prior studies demonstrating a positive association between f-Hb concentrations in previous screenings and the detection of colorectal neoplasia. “Our working hypothesis was that risk increases in a decreasing manner as f-Hb concentrations rise, and the findings supported this hypothesis,” van den Berg said.

Other research has projected f-Hb level risk stratification to be effective and perhaps cost-effective in reducing delayed diagnosis of CRC.

 

Feasibility of Implementation

In large national screening programs in Europe, Asia, and Australia, as well as those of Kaiser Permanente and the Veterans Health Administration in the United States, information on f-Hb concentrations is already available.

“Therefore, incorporating an Hb-based approach should be relatively easy and affordable,” van den Berg said, and may help to optimize resource use while maintaining high detection rates. “However, the more critical question is whether such an approach would be acceptable to the target population.” To that end, randomized controlled trials in Italy and the Netherlands are offering tailored invitation intervals based on prior f-Hb concentrations and may provide insight into the real-world application of risk-stratified screening.

Among the many variables to be considered in the context of population-wide screening are cost-effectiveness, acceptability, and practicality, as well as invitation intervals, positivity cut-off levels, and start and stop ages for screening. “A key focus will be understanding the acceptability of risk-stratified colorectal cancer screening based on f-Hb among the target population and addressing any information needs they may have, as these are critical factors for successful implementation,” said van den Berg. Her group is currently studying the most effective and cost-effective risk-based strategy for CRC screening based on f-Hb levels.

The authors cautioned that since individuals with undetectable f-Hb levels make up the majority of those with negative FIT results, care must be taken that reducing screening frequency for this low-risk group does not lead to unfavorable outcomes at the population level.

This study was funded by the Dutch Organization for Scientific Research, which had no role in study design, data collection, analysis, interpretation, or writing. The authors declared no competing interests. Levin disclosed no competing interests relevant to his comments.

A version of this article first appeared on Medscape.com. 

The risk of detecting colorectal cancer (CRC) increases by up to 13-fold in the presence of prior fecal hemoglobin (f-Hb) concentrations in fecal immunochemical tests (FIT), especially negative ones, according to a large international dose-response meta-analysis.

Although the association with neoplasia decreased as f-Hb levels rose, the findings support the development of risk-stratified screening strategies based on these concentrations, according to researchers led by Danica M.N. van den Berg, MSc, a PhD candidate and econometrics researcher in the department of public health at Erasmus University Medical Center in Rotterdam, the Netherlands.

Higher f-Hb concentrations in prior negative screening tests are strongly associated with an increased risk of detecting colorectal neoplasia in subsequent screenings, van den Berg said in an interview. “Gastroenterologists and other clinicians should consider the value of f-Hb concentrations in refining screening protocols and personalizing patient care to detect colorectal neoplasia earlier and more accurately.”

Published in Gastroenterology, the study was prompted by prior research showing individuals with f-Hb concentrations just below the positivity cutoff had an elevated CRC risk vs those with low or no f-Hb. “However, global variations in FIT positivity cutoffs and f-Hb category definitions complicated cross-study comparisons,” van den Berg said. 

Given the lack of an established dose-response relationship, the study aimed to clarify how f-Hb levels in previous screenings correlate with colorectal neoplasia detection. “Understanding this relationship is crucial for developing risk-stratified colorectal cancer screening strategies based on prior FIT results, which could improve the harm-benefit balance of screening,” she said.

According to van den Berg, f-Hb concentrations could help determine optimal CRC screening intervals by identifying higher-risk individuals who could benefit from more frequent testing, while those with lower concentrations could be screened less frequently.

 

Study Details

The systematic review and meta-analysis are the first to focus on the dose-response relationship between f-Hb levels in prior FIT screenings and colorectal neoplasia detection, van den Berg said. It included 13 ethnically diverse studies published during 2011-2023 with 4,493,223 individuals from Spain, France, the Netherlands, Taiwan, Denmark, Scotland, Ireland, Korea, Italy, and Norway. Most studies were cohort-based, and one was a randomized controlled trial.

All studies demonstrated a positive association between f-Hb in previous screenings and colorectal neoplasia detection. Almost all reported the f-Hb concentration measured in the prior screening round, while one study combined the f-Hb concentration of two previous screening rounds by using the cumulative f-Hb value. There was, however, wide variability in the stool positivity cut-offs in the included studies, ranging from 10 μg f-Hb/g to 80 μg f-Hb/g.

With an overall effect size of 0.69 (95% CI, 0.59-0.79), pooled analysis revealed that in the next screening round, individuals with f-Hb concentrations in stool of 5, 10, 20, and 40 μg/g had a threefold, fivefold, eightfold, and 13-fold higher risk for colorectal neoplasia, respectively, vs individuals showing 0 μg/g. Although there was significant study heterogeneity (I² = 97.5%, P < .001), sensitivity analyses confirmed the consistency of findings. Interestingly, subgroup analyses indicated that f-Hb concentrations from a previous negative test were especially predictive of advanced neoplasia in subsequent screenings.

“This is a strategy worth pursuing and evaluating in the United States,” said gastroenterologist Theodore R. Levin, MD, a research scientist at Kaiser Permanente Division of Research in Northern California, commenting on the study but not involved in it. “However, there is no currently available FIT brand in the US that reports f-Hb concentration. All FITs in the United States report as a qualitative positive-negative result.”

The Dutch investigation aligns with prior studies demonstrating a positive association between f-Hb concentrations in previous screenings and the detection of colorectal neoplasia. “Our working hypothesis was that risk increases in a decreasing manner as f-Hb concentrations rise, and the findings supported this hypothesis,” van den Berg said.

Other research has projected f-Hb level risk stratification to be effective and perhaps cost-effective in reducing delayed diagnosis of CRC.

 

Feasibility of Implementation

In large national screening programs in Europe, Asia, and Australia, as well as those of Kaiser Permanente and the Veterans Health Administration in the United States, information on f-Hb concentrations is already available.

“Therefore, incorporating an Hb-based approach should be relatively easy and affordable,” van den Berg said, and may help to optimize resource use while maintaining high detection rates. “However, the more critical question is whether such an approach would be acceptable to the target population.” To that end, randomized controlled trials in Italy and the Netherlands are offering tailored invitation intervals based on prior f-Hb concentrations and may provide insight into the real-world application of risk-stratified screening.

Among the many variables to be considered in the context of population-wide screening are cost-effectiveness, acceptability, and practicality, as well as invitation intervals, positivity cut-off levels, and start and stop ages for screening. “A key focus will be understanding the acceptability of risk-stratified colorectal cancer screening based on f-Hb among the target population and addressing any information needs they may have, as these are critical factors for successful implementation,” said van den Berg. Her group is currently studying the most effective and cost-effective risk-based strategy for CRC screening based on f-Hb levels.

The authors cautioned that since individuals with undetectable f-Hb levels make up the majority of those with negative FIT results, care must be taken that reducing screening frequency for this low-risk group does not lead to unfavorable outcomes at the population level.

This study was funded by the Dutch Organization for Scientific Research, which had no role in study design, data collection, analysis, interpretation, or writing. The authors declared no competing interests. Levin disclosed no competing interests relevant to his comments.

A version of this article first appeared on Medscape.com. 

The risk of detecting colorectal cancer (CRC) increases by up to 13-fold in the presence of prior fecal hemoglobin (f-Hb) concentrations in fecal immunochemical tests (FIT), especially negative ones, according to a large international dose-response meta-analysis.

Although the association with neoplasia decreased as f-Hb levels rose, the findings support the development of risk-stratified screening strategies based on these concentrations, according to researchers led by Danica M.N. van den Berg, MSc, a PhD candidate and econometrics researcher in the department of public health at Erasmus University Medical Center in Rotterdam, the Netherlands.

Higher f-Hb concentrations in prior negative screening tests are strongly associated with an increased risk of detecting colorectal neoplasia in subsequent screenings, van den Berg said in an interview. “Gastroenterologists and other clinicians should consider the value of f-Hb concentrations in refining screening protocols and personalizing patient care to detect colorectal neoplasia earlier and more accurately.”

Published in Gastroenterology, the study was prompted by prior research showing individuals with f-Hb concentrations just below the positivity cutoff had an elevated CRC risk vs those with low or no f-Hb. “However, global variations in FIT positivity cutoffs and f-Hb category definitions complicated cross-study comparisons,” van den Berg said. 

Given the lack of an established dose-response relationship, the study aimed to clarify how f-Hb levels in previous screenings correlate with colorectal neoplasia detection. “Understanding this relationship is crucial for developing risk-stratified colorectal cancer screening strategies based on prior FIT results, which could improve the harm-benefit balance of screening,” she said.

According to van den Berg, f-Hb concentrations could help determine optimal CRC screening intervals by identifying higher-risk individuals who could benefit from more frequent testing, while those with lower concentrations could be screened less frequently.

 

Study Details

The systematic review and meta-analysis are the first to focus on the dose-response relationship between f-Hb levels in prior FIT screenings and colorectal neoplasia detection, van den Berg said. It included 13 ethnically diverse studies published during 2011-2023 with 4,493,223 individuals from Spain, France, the Netherlands, Taiwan, Denmark, Scotland, Ireland, Korea, Italy, and Norway. Most studies were cohort-based, and one was a randomized controlled trial.

All studies demonstrated a positive association between f-Hb in previous screenings and colorectal neoplasia detection. Almost all reported the f-Hb concentration measured in the prior screening round, while one study combined the f-Hb concentration of two previous screening rounds by using the cumulative f-Hb value. There was, however, wide variability in the stool positivity cut-offs in the included studies, ranging from 10 μg f-Hb/g to 80 μg f-Hb/g.

With an overall effect size of 0.69 (95% CI, 0.59-0.79), pooled analysis revealed that in the next screening round, individuals with f-Hb concentrations in stool of 5, 10, 20, and 40 μg/g had a threefold, fivefold, eightfold, and 13-fold higher risk for colorectal neoplasia, respectively, vs individuals showing 0 μg/g. Although there was significant study heterogeneity (I² = 97.5%, P < .001), sensitivity analyses confirmed the consistency of findings. Interestingly, subgroup analyses indicated that f-Hb concentrations from a previous negative test were especially predictive of advanced neoplasia in subsequent screenings.

“This is a strategy worth pursuing and evaluating in the United States,” said gastroenterologist Theodore R. Levin, MD, a research scientist at Kaiser Permanente Division of Research in Northern California, commenting on the study but not involved in it. “However, there is no currently available FIT brand in the US that reports f-Hb concentration. All FITs in the United States report as a qualitative positive-negative result.”

The Dutch investigation aligns with prior studies demonstrating a positive association between f-Hb concentrations in previous screenings and the detection of colorectal neoplasia. “Our working hypothesis was that risk increases in a decreasing manner as f-Hb concentrations rise, and the findings supported this hypothesis,” van den Berg said.

Other research has projected f-Hb level risk stratification to be effective and perhaps cost-effective in reducing delayed diagnosis of CRC.

 

Feasibility of Implementation

In large national screening programs in Europe, Asia, and Australia, as well as those of Kaiser Permanente and the Veterans Health Administration in the United States, information on f-Hb concentrations is already available.

“Therefore, incorporating an Hb-based approach should be relatively easy and affordable,” van den Berg said, and may help to optimize resource use while maintaining high detection rates. “However, the more critical question is whether such an approach would be acceptable to the target population.” To that end, randomized controlled trials in Italy and the Netherlands are offering tailored invitation intervals based on prior f-Hb concentrations and may provide insight into the real-world application of risk-stratified screening.

Among the many variables to be considered in the context of population-wide screening are cost-effectiveness, acceptability, and practicality, as well as invitation intervals, positivity cut-off levels, and start and stop ages for screening. “A key focus will be understanding the acceptability of risk-stratified colorectal cancer screening based on f-Hb among the target population and addressing any information needs they may have, as these are critical factors for successful implementation,” said van den Berg. Her group is currently studying the most effective and cost-effective risk-based strategy for CRC screening based on f-Hb levels.

The authors cautioned that since individuals with undetectable f-Hb levels make up the majority of those with negative FIT results, care must be taken that reducing screening frequency for this low-risk group does not lead to unfavorable outcomes at the population level.

This study was funded by the Dutch Organization for Scientific Research, which had no role in study design, data collection, analysis, interpretation, or writing. The authors declared no competing interests. Levin disclosed no competing interests relevant to his comments.

A version of this article first appeared on Medscape.com. 

Quitting smoking is challenging, particularly when resources are limited. A recent study in the United States confirmed that an intensive program combining behavioral therapy and medication, linked to a lung cancer screening program, offers the highest success rate. However, its long-term success was similar to that of telephone counseling and drug therapy.

Pulmonologist and experienced smoking cessation specialist from Stuttgart, Germany, Alexander Rupp, MD, emphasized the importance of leveraging routine healthcare interactions to encourage smoking cessation. “Although every doctor-patient contact offers the opportunity to discuss the risks of smoking and the opportunities for smoking cessation, the ‘window of opportunity’ is very wide, especially during lung cancer screening,” he said.

Germany is preparing to launch a lung cancer screening program for high-risk individuals, primarily current smokers and former smokers. Following the establishment of radiation protection regulations for such a program last year, the German Federal Joint Committee is currently working on its design. The initiative could be a game-changer for smoking cessation.

Lung cancer screening has been available for smokers in the United States for some time. Paul M. Cinciripini, PhD, and colleagues from the University of Texas MD Anderson Cancer Center, Houston, examined three smoking cessation strategies with decreasing treatment intensity among screening participants.

 

Unique Opportunity

Previous studies have shown that participation in a lung cancer screening program — typically offered only to high-risk individuals — significantly increases motivation to quit smoking.

“Repeated contact with doctors, repeated CT scans, and especially the findings that require monitoring all contribute to this effect,” explained Rupp, who regularly offers smoking cessation courses.

It has long been known how smoking cessation works best. “The gold standard is a combination of behavioral therapy support and drug treatment — if there is an addiction and withdrawal symptoms occur after quitting, which is the case for the majority of smokers,” Rupp explained.

The US study reinforced what is already well known: More intensive treatment approaches lead to higher quit rates.

“We know that the more intensively we look after smokers, the higher the quit rate. This applies in both areas: The more therapy sessions we do and the more often we prescribe medication, the more likely the patients are to succeed in remaining abstinent,” Rupp said.

However, resources for intensive smoking cessation programs are limited. A database maintained by the German Cancer Research Center and the German Federal Center for Health Education lists only 455 providers of smoking cessation courses in Germany, “not all of which even work on an evidence-based basis,” Rupp emphasized. Given that there are around 16 million smokers in Germany, there is an urgent need for smoking cessation programs that are less resource-intensive.

 

Intensity Variations

The US study compared three smoking cessation strategies of varying intensities, integrating behavioral counseling and medication.

Group 1: An integrated program with eight behavioral therapy sessions and 10-12 weeks of nicotine replacement therapy or medication (bupropion or varenicline).

Group 2: Lighter version of the integrated program. It consisted of four telephone consultations, written materials, online support, and 12 weeks of nicotine replacement therapy or medication prescribed by a radiologist.

Group 3: The least intensive approach, with 12 weeks of nicotine replacement therapy alone.

Each strategy was evaluated in 210 lung cancer screening participants aged 55-64 years who smoked an average of 15-20 cigarettes per day.

After 3 months, significantly more participants in the most intensive program (Group 1, 37.1%) had quit smoking than those in the other two groups (Group 2, 27.1%; Group 3, 25.2%).

But after 6 months, the difference between Groups 1 and 2 was not significant. The quit rates were as follows: Group 1, 32.4%; Group 2, 27.6%; and Group 3, 20.5%.

“It can be concluded from these results that the intensity of smoking cessation can be reduced to a certain extent as long as the combination of behavioral counseling and medication is given,” Rupp concluded.

 

Digital Solutions

Another new possibility, which was not examined in the US study, is digital health applications.

Smoke Free is a digital health application that provides behavioral therapy support for smoking cessation and is available in both German and English. Designed to replicate structured smoking cessation programs and offers an accessible alternative for individuals seeking to quit smoking.

Rupp emphasized the potential of digital tools like Smoke Free to expand access to effective smoking cessation strategies, particularly for those unable to attend in-person programs. While traditional cessation programs are limited in availability, digital apps can increase engagement in and adherence to smoking cessation efforts.

However, the biggest hurdle is smokers’ procrastination: “If you make smokers an offer, they usually do not take action afterward because they are caught in their ambivalence about whether they should quit or not.”

 

Policy Implications

This makes smoking cessation a mandatory component of lung cancer screening in the future. “It’s about cancer, and patients are really afraid of that,” Rupp advocated.

In a position paper, the German Respiratory Society, supported by multiple medical societies, has called for smoking cessation to be integrated into lung cancer screening protocols, with full coverage of counseling and medication by health insurance.

“Smoking cessation must be a mandatory component. If a participant in the lung cancer screening does not want this, then he or she must actively object,” stressed Rupp, lead author of the position paper. Also, the costs of smoking cessation, including those of withdrawal-inhibiting medication, must be fully covered by statutory health insurance, which has not been the case to date.

“That’s the only thing that makes sense. You can’t deny an addict access to proven treatments, especially when we know that a smoker who quits spontaneously without support has a relapse rate of 95%-97%, and the medication per se increases the quit rate by a factor of two or three,” Rupp concluded.

This story was translated and adapted from Medscape’s German edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

Quitting smoking is challenging, particularly when resources are limited. A recent study in the United States confirmed that an intensive program combining behavioral therapy and medication, linked to a lung cancer screening program, offers the highest success rate. However, its long-term success was similar to that of telephone counseling and drug therapy.

Pulmonologist and experienced smoking cessation specialist from Stuttgart, Germany, Alexander Rupp, MD, emphasized the importance of leveraging routine healthcare interactions to encourage smoking cessation. “Although every doctor-patient contact offers the opportunity to discuss the risks of smoking and the opportunities for smoking cessation, the ‘window of opportunity’ is very wide, especially during lung cancer screening,” he said.

Germany is preparing to launch a lung cancer screening program for high-risk individuals, primarily current smokers and former smokers. Following the establishment of radiation protection regulations for such a program last year, the German Federal Joint Committee is currently working on its design. The initiative could be a game-changer for smoking cessation.

Lung cancer screening has been available for smokers in the United States for some time. Paul M. Cinciripini, PhD, and colleagues from the University of Texas MD Anderson Cancer Center, Houston, examined three smoking cessation strategies with decreasing treatment intensity among screening participants.

 

Unique Opportunity

Previous studies have shown that participation in a lung cancer screening program — typically offered only to high-risk individuals — significantly increases motivation to quit smoking.

“Repeated contact with doctors, repeated CT scans, and especially the findings that require monitoring all contribute to this effect,” explained Rupp, who regularly offers smoking cessation courses.

It has long been known how smoking cessation works best. “The gold standard is a combination of behavioral therapy support and drug treatment — if there is an addiction and withdrawal symptoms occur after quitting, which is the case for the majority of smokers,” Rupp explained.

The US study reinforced what is already well known: More intensive treatment approaches lead to higher quit rates.

“We know that the more intensively we look after smokers, the higher the quit rate. This applies in both areas: The more therapy sessions we do and the more often we prescribe medication, the more likely the patients are to succeed in remaining abstinent,” Rupp said.

However, resources for intensive smoking cessation programs are limited. A database maintained by the German Cancer Research Center and the German Federal Center for Health Education lists only 455 providers of smoking cessation courses in Germany, “not all of which even work on an evidence-based basis,” Rupp emphasized. Given that there are around 16 million smokers in Germany, there is an urgent need for smoking cessation programs that are less resource-intensive.

 

Intensity Variations

The US study compared three smoking cessation strategies of varying intensities, integrating behavioral counseling and medication.

Group 1: An integrated program with eight behavioral therapy sessions and 10-12 weeks of nicotine replacement therapy or medication (bupropion or varenicline).

Group 2: Lighter version of the integrated program. It consisted of four telephone consultations, written materials, online support, and 12 weeks of nicotine replacement therapy or medication prescribed by a radiologist.

Group 3: The least intensive approach, with 12 weeks of nicotine replacement therapy alone.

Each strategy was evaluated in 210 lung cancer screening participants aged 55-64 years who smoked an average of 15-20 cigarettes per day.

After 3 months, significantly more participants in the most intensive program (Group 1, 37.1%) had quit smoking than those in the other two groups (Group 2, 27.1%; Group 3, 25.2%).

But after 6 months, the difference between Groups 1 and 2 was not significant. The quit rates were as follows: Group 1, 32.4%; Group 2, 27.6%; and Group 3, 20.5%.

“It can be concluded from these results that the intensity of smoking cessation can be reduced to a certain extent as long as the combination of behavioral counseling and medication is given,” Rupp concluded.

 

Digital Solutions

Another new possibility, which was not examined in the US study, is digital health applications.

Smoke Free is a digital health application that provides behavioral therapy support for smoking cessation and is available in both German and English. Designed to replicate structured smoking cessation programs and offers an accessible alternative for individuals seeking to quit smoking.

Rupp emphasized the potential of digital tools like Smoke Free to expand access to effective smoking cessation strategies, particularly for those unable to attend in-person programs. While traditional cessation programs are limited in availability, digital apps can increase engagement in and adherence to smoking cessation efforts.

However, the biggest hurdle is smokers’ procrastination: “If you make smokers an offer, they usually do not take action afterward because they are caught in their ambivalence about whether they should quit or not.”

 

Policy Implications

This makes smoking cessation a mandatory component of lung cancer screening in the future. “It’s about cancer, and patients are really afraid of that,” Rupp advocated.

In a position paper, the German Respiratory Society, supported by multiple medical societies, has called for smoking cessation to be integrated into lung cancer screening protocols, with full coverage of counseling and medication by health insurance.

“Smoking cessation must be a mandatory component. If a participant in the lung cancer screening does not want this, then he or she must actively object,” stressed Rupp, lead author of the position paper. Also, the costs of smoking cessation, including those of withdrawal-inhibiting medication, must be fully covered by statutory health insurance, which has not been the case to date.

“That’s the only thing that makes sense. You can’t deny an addict access to proven treatments, especially when we know that a smoker who quits spontaneously without support has a relapse rate of 95%-97%, and the medication per se increases the quit rate by a factor of two or three,” Rupp concluded.

This story was translated and adapted from Medscape’s German edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

Quitting smoking is challenging, particularly when resources are limited. A recent study in the United States confirmed that an intensive program combining behavioral therapy and medication, linked to a lung cancer screening program, offers the highest success rate. However, its long-term success was similar to that of telephone counseling and drug therapy.

Pulmonologist and experienced smoking cessation specialist from Stuttgart, Germany, Alexander Rupp, MD, emphasized the importance of leveraging routine healthcare interactions to encourage smoking cessation. “Although every doctor-patient contact offers the opportunity to discuss the risks of smoking and the opportunities for smoking cessation, the ‘window of opportunity’ is very wide, especially during lung cancer screening,” he said.

Germany is preparing to launch a lung cancer screening program for high-risk individuals, primarily current smokers and former smokers. Following the establishment of radiation protection regulations for such a program last year, the German Federal Joint Committee is currently working on its design. The initiative could be a game-changer for smoking cessation.

Lung cancer screening has been available for smokers in the United States for some time. Paul M. Cinciripini, PhD, and colleagues from the University of Texas MD Anderson Cancer Center, Houston, examined three smoking cessation strategies with decreasing treatment intensity among screening participants.

 

Unique Opportunity

Previous studies have shown that participation in a lung cancer screening program — typically offered only to high-risk individuals — significantly increases motivation to quit smoking.

“Repeated contact with doctors, repeated CT scans, and especially the findings that require monitoring all contribute to this effect,” explained Rupp, who regularly offers smoking cessation courses.

It has long been known how smoking cessation works best. “The gold standard is a combination of behavioral therapy support and drug treatment — if there is an addiction and withdrawal symptoms occur after quitting, which is the case for the majority of smokers,” Rupp explained.

The US study reinforced what is already well known: More intensive treatment approaches lead to higher quit rates.

“We know that the more intensively we look after smokers, the higher the quit rate. This applies in both areas: The more therapy sessions we do and the more often we prescribe medication, the more likely the patients are to succeed in remaining abstinent,” Rupp said.

However, resources for intensive smoking cessation programs are limited. A database maintained by the German Cancer Research Center and the German Federal Center for Health Education lists only 455 providers of smoking cessation courses in Germany, “not all of which even work on an evidence-based basis,” Rupp emphasized. Given that there are around 16 million smokers in Germany, there is an urgent need for smoking cessation programs that are less resource-intensive.

 

Intensity Variations

The US study compared three smoking cessation strategies of varying intensities, integrating behavioral counseling and medication.

Group 1: An integrated program with eight behavioral therapy sessions and 10-12 weeks of nicotine replacement therapy or medication (bupropion or varenicline).

Group 2: Lighter version of the integrated program. It consisted of four telephone consultations, written materials, online support, and 12 weeks of nicotine replacement therapy or medication prescribed by a radiologist.

Group 3: The least intensive approach, with 12 weeks of nicotine replacement therapy alone.

Each strategy was evaluated in 210 lung cancer screening participants aged 55-64 years who smoked an average of 15-20 cigarettes per day.

After 3 months, significantly more participants in the most intensive program (Group 1, 37.1%) had quit smoking than those in the other two groups (Group 2, 27.1%; Group 3, 25.2%).

But after 6 months, the difference between Groups 1 and 2 was not significant. The quit rates were as follows: Group 1, 32.4%; Group 2, 27.6%; and Group 3, 20.5%.

“It can be concluded from these results that the intensity of smoking cessation can be reduced to a certain extent as long as the combination of behavioral counseling and medication is given,” Rupp concluded.

 

Digital Solutions

Another new possibility, which was not examined in the US study, is digital health applications.

Smoke Free is a digital health application that provides behavioral therapy support for smoking cessation and is available in both German and English. Designed to replicate structured smoking cessation programs and offers an accessible alternative for individuals seeking to quit smoking.

Rupp emphasized the potential of digital tools like Smoke Free to expand access to effective smoking cessation strategies, particularly for those unable to attend in-person programs. While traditional cessation programs are limited in availability, digital apps can increase engagement in and adherence to smoking cessation efforts.

However, the biggest hurdle is smokers’ procrastination: “If you make smokers an offer, they usually do not take action afterward because they are caught in their ambivalence about whether they should quit or not.”

 

Policy Implications

This makes smoking cessation a mandatory component of lung cancer screening in the future. “It’s about cancer, and patients are really afraid of that,” Rupp advocated.

In a position paper, the German Respiratory Society, supported by multiple medical societies, has called for smoking cessation to be integrated into lung cancer screening protocols, with full coverage of counseling and medication by health insurance.

“Smoking cessation must be a mandatory component. If a participant in the lung cancer screening does not want this, then he or she must actively object,” stressed Rupp, lead author of the position paper. Also, the costs of smoking cessation, including those of withdrawal-inhibiting medication, must be fully covered by statutory health insurance, which has not been the case to date.

“That’s the only thing that makes sense. You can’t deny an addict access to proven treatments, especially when we know that a smoker who quits spontaneously without support has a relapse rate of 95%-97%, and the medication per se increases the quit rate by a factor of two or three,” Rupp concluded.

This story was translated and adapted from Medscape’s German edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

Nearly 96,000 US Department of Veterans Affairs (VA) employees—about 20% of the workforce—will be required to return to in-office work by the end of February. The announcement follows a Jan. 20 presidential memorandum, which states agency heads must “take all necessary steps to terminate remote work arrangements and require employees to return to work in-person at their respective duty stations on a full-time basis.” According to a Jan. 28 email sent from the Office of Personnel Management but without a signature, federal employees who refuse will be offered “dignified, fair departure from the federal government utilizing a deferred resignation program.”

The revised VA work policy states “eligible employees must work full-time at their respective duty stations (agency worksites) unless excused due to a disability, qualifying medical condition or other compelling reason.” All nonbargaining unit employees and supervisors who are within 50 miles of their office have until Feb. 24 to return. The VA stated that further guidance is coming for those who live > 50 miles from a facility. 

“VA’s policy allows exceptions for arrangements approved for employees as a reasonable accommodation due to a disability or a qualifying medical condition. Exceptions may also be allowed for military spouses with permanent change of station orders,” according to a VA press release.

“This is a commonsense step toward treating all VA employees equally,” acting VA Secretary Todd Hunter said. “Most VA clinical staff don’t have the luxury of working remotely, and we believe the performance, collaboration and productivity of the department will improve if all VA employees are held to the same standard.” 

The impact on Veterans Health Administration operations remains difficult to determine. The order appears to include personnel providing telehealth care from remote locations, including those at the Clinical Resource Hub (CRH) program. CRH uses a hub and spoke model for limited time primary care and mental health care staffing to cover local clinician vacancies. CRH clinicians have provided > 500,000 veterans with care, averaging > 25,000 encounters in the program’s first year. Started during fiscal year 2020 amid the COVID-19 pandemic, CRH employed 636 clinicians, but more recent data are not available. The VA provided > 28 million telehealth sessions to veterans across all of its telehealth modalities in 2023. Details on how many CRH clinicians and other telehealth practitioners work remotely are also not available.

On Feb. 3, the Office of Personnel Management issued a memo to federal agency heads arguing that any collective bargaining agreements that include teleworking may “conflict with management rights” and therefore may be “unlawful and cannot be enforced.”

The American Federation of Government Employees (AFGE), which represents 800,000 federal employees, disputed the memo. “Federal employees should know that approved union contracts are enforceable by law, and the President does not have the authority to make unilateral changes to those agreements,” AFGE President Everett Kelley said. “AFGE members will not be intimidated. If our contracts are violated, we will aggressively defend them.”

The VA must decide where to put the more than 47,000 workers who may be coming back. According to the Government Accountability Office, “Federal agencies have long struggled to determine how much office space they needed to fulfill their missions efficiently.” The VA has reduced its office space by > 290,000 ft² over the last few years in the National Capital Region alone. 

In his confirmation hearing last month, VA Secretary nominee Doug Collins told lawmakers that, if confirmed, he would “encourage employees to come back to work,” but he also said he would ensure the department was following the White House’s remote work limits. “We’re going to make sure that we get people in there,” he said, “because at the end of the day, it’s about veterans.”

Nearly 96,000 US Department of Veterans Affairs (VA) employees—about 20% of the workforce—will be required to return to in-office work by the end of February. The announcement follows a Jan. 20 presidential memorandum, which states agency heads must “take all necessary steps to terminate remote work arrangements and require employees to return to work in-person at their respective duty stations on a full-time basis.” According to a Jan. 28 email sent from the Office of Personnel Management but without a signature, federal employees who refuse will be offered “dignified, fair departure from the federal government utilizing a deferred resignation program.”

The revised VA work policy states “eligible employees must work full-time at their respective duty stations (agency worksites) unless excused due to a disability, qualifying medical condition or other compelling reason.” All nonbargaining unit employees and supervisors who are within 50 miles of their office have until Feb. 24 to return. The VA stated that further guidance is coming for those who live > 50 miles from a facility. 

“VA’s policy allows exceptions for arrangements approved for employees as a reasonable accommodation due to a disability or a qualifying medical condition. Exceptions may also be allowed for military spouses with permanent change of station orders,” according to a VA press release.

“This is a commonsense step toward treating all VA employees equally,” acting VA Secretary Todd Hunter said. “Most VA clinical staff don’t have the luxury of working remotely, and we believe the performance, collaboration and productivity of the department will improve if all VA employees are held to the same standard.” 

The impact on Veterans Health Administration operations remains difficult to determine. The order appears to include personnel providing telehealth care from remote locations, including those at the Clinical Resource Hub (CRH) program. CRH uses a hub and spoke model for limited time primary care and mental health care staffing to cover local clinician vacancies. CRH clinicians have provided > 500,000 veterans with care, averaging > 25,000 encounters in the program’s first year. Started during fiscal year 2020 amid the COVID-19 pandemic, CRH employed 636 clinicians, but more recent data are not available. The VA provided > 28 million telehealth sessions to veterans across all of its telehealth modalities in 2023. Details on how many CRH clinicians and other telehealth practitioners work remotely are also not available.

On Feb. 3, the Office of Personnel Management issued a memo to federal agency heads arguing that any collective bargaining agreements that include teleworking may “conflict with management rights” and therefore may be “unlawful and cannot be enforced.”

The American Federation of Government Employees (AFGE), which represents 800,000 federal employees, disputed the memo. “Federal employees should know that approved union contracts are enforceable by law, and the President does not have the authority to make unilateral changes to those agreements,” AFGE President Everett Kelley said. “AFGE members will not be intimidated. If our contracts are violated, we will aggressively defend them.”

The VA must decide where to put the more than 47,000 workers who may be coming back. According to the Government Accountability Office, “Federal agencies have long struggled to determine how much office space they needed to fulfill their missions efficiently.” The VA has reduced its office space by > 290,000 ft² over the last few years in the National Capital Region alone. 

In his confirmation hearing last month, VA Secretary nominee Doug Collins told lawmakers that, if confirmed, he would “encourage employees to come back to work,” but he also said he would ensure the department was following the White House’s remote work limits. “We’re going to make sure that we get people in there,” he said, “because at the end of the day, it’s about veterans.”

Nearly 96,000 US Department of Veterans Affairs (VA) employees—about 20% of the workforce—will be required to return to in-office work by the end of February. The announcement follows a Jan. 20 presidential memorandum, which states agency heads must “take all necessary steps to terminate remote work arrangements and require employees to return to work in-person at their respective duty stations on a full-time basis.” According to a Jan. 28 email sent from the Office of Personnel Management but without a signature, federal employees who refuse will be offered “dignified, fair departure from the federal government utilizing a deferred resignation program.”

The revised VA work policy states “eligible employees must work full-time at their respective duty stations (agency worksites) unless excused due to a disability, qualifying medical condition or other compelling reason.” All nonbargaining unit employees and supervisors who are within 50 miles of their office have until Feb. 24 to return. The VA stated that further guidance is coming for those who live > 50 miles from a facility. 

“VA’s policy allows exceptions for arrangements approved for employees as a reasonable accommodation due to a disability or a qualifying medical condition. Exceptions may also be allowed for military spouses with permanent change of station orders,” according to a VA press release.

“This is a commonsense step toward treating all VA employees equally,” acting VA Secretary Todd Hunter said. “Most VA clinical staff don’t have the luxury of working remotely, and we believe the performance, collaboration and productivity of the department will improve if all VA employees are held to the same standard.” 

The impact on Veterans Health Administration operations remains difficult to determine. The order appears to include personnel providing telehealth care from remote locations, including those at the Clinical Resource Hub (CRH) program. CRH uses a hub and spoke model for limited time primary care and mental health care staffing to cover local clinician vacancies. CRH clinicians have provided > 500,000 veterans with care, averaging > 25,000 encounters in the program’s first year. Started during fiscal year 2020 amid the COVID-19 pandemic, CRH employed 636 clinicians, but more recent data are not available. The VA provided > 28 million telehealth sessions to veterans across all of its telehealth modalities in 2023. Details on how many CRH clinicians and other telehealth practitioners work remotely are also not available.

On Feb. 3, the Office of Personnel Management issued a memo to federal agency heads arguing that any collective bargaining agreements that include teleworking may “conflict with management rights” and therefore may be “unlawful and cannot be enforced.”

The American Federation of Government Employees (AFGE), which represents 800,000 federal employees, disputed the memo. “Federal employees should know that approved union contracts are enforceable by law, and the President does not have the authority to make unilateral changes to those agreements,” AFGE President Everett Kelley said. “AFGE members will not be intimidated. If our contracts are violated, we will aggressively defend them.”

The VA must decide where to put the more than 47,000 workers who may be coming back. According to the Government Accountability Office, “Federal agencies have long struggled to determine how much office space they needed to fulfill their missions efficiently.” The VA has reduced its office space by > 290,000 ft² over the last few years in the National Capital Region alone. 

In his confirmation hearing last month, VA Secretary nominee Doug Collins told lawmakers that, if confirmed, he would “encourage employees to come back to work,” but he also said he would ensure the department was following the White House’s remote work limits. “We’re going to make sure that we get people in there,” he said, “because at the end of the day, it’s about veterans.”

TOPLINE:

Adding cetuximab (C) to postoperative radiotherapy (RT) improves disease-free survival (DFS) but not overall survival (OS) in intermediate-risk squamous cell carcinoma of the head and neck. Benefits were specifically observed in human papillomavirus–negative patients, who represented 80.2% of the study participants.

METHODOLOGY:

• Previous research showed that adding high-dose cisplatin to postoperative RT in patients with squamous cell carcinoma of the head and neck (SCCHN) improved outcomes in those with positive margins and nodal extracapsular extension of the tumor.
• The new phase 3 randomized trial, which enrolled patients from November 2009 to March 2018 included 577 individuals with resected SCCHN of the oral cavity, oropharynx, or larynx, specifically.
• Participants were randomly assigned 1:1 to receive either intensity-modulated RT (60-66 Gy) with weekly C (400 mg/m² loading dose, followed by 250 mg/m² weekly) or RT alone.
• The primary endpoint was OS in randomly assigned eligible patients, with DFS and toxicity as secondary endpoints.
• Analysis included stratified log-rank test for OS and DFS, while toxicity was compared using Fisher’s exact test.

TAKEAWAY:

• OS was not significantly improved with RT plus C vs RT alone (hazard ratio [HR], 0.81; 95% CI, 0.60-1.08; P = .0747), though 5-year OS rates were 76.5% vs 68.7%.
• DFS showed significant improvement with combined therapy (HR, 0.75; 95% CI, 0.57-0.98; P = .0168), with 5-year rates of 71.7% vs 63.6%.
• Grade 3-4 acute toxicity rates were significantly higher with combination therapy (70.3% vs 39.7%; P < .0001), primarily affecting skin and mucosa, though late toxicity rates were similar (33.2% vs 29.0%; P = .3101).
• The benefit of RT plus C was only observed in those patients who were human papillomavirus–negative, which comprised 80.2% of trial participants.

IN PRACTICE:

RT plus C “significantly improved DFS, but not OS, with no increase in long-term toxicity, compared with RT alone for resected, intermediate-risk SCCHN. RT plus C is an appropriate option for carefully selected patients with HPV-negative disease,” the authors of the study wrote.

SOURCE:

This study was led by Mitchell Machtay, MD, Penn State Health Milton S. Hershey Medical Center in Hershey, Pennsylvania. It was published online  in Journal of Clinical Oncology.

LIMITATIONS:

According to the researchers, the OS in the control group was higher than predicted, resulting in the trial being underpowered to detect the initial targeted HR. The authors noted that the better-than-expected survival rates could be attributed to improvements in surgical and radiotherapeutic techniques, including mandatory intensity-modulated RT for all patients. Additionally, the researchers pointed out that patient selection may have influenced outcomes, as only 30% of study participants had more than two risk factors.

DISCLOSURES:

This study was supported by grants from the US National Cancer Institute and Eli Lilly Inc. Machtay received grants from Lilly/ImClone, AstraZeneca, and Merck Sharp & Dohme. Additional disclosures are noted in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Adding cetuximab (C) to postoperative radiotherapy (RT) improves disease-free survival (DFS) but not overall survival (OS) in intermediate-risk squamous cell carcinoma of the head and neck. Benefits were specifically observed in human papillomavirus–negative patients, who represented 80.2% of the study participants.

METHODOLOGY:

• Previous research showed that adding high-dose cisplatin to postoperative RT in patients with squamous cell carcinoma of the head and neck (SCCHN) improved outcomes in those with positive margins and nodal extracapsular extension of the tumor.
• The new phase 3 randomized trial, which enrolled patients from November 2009 to March 2018 included 577 individuals with resected SCCHN of the oral cavity, oropharynx, or larynx, specifically.
• Participants were randomly assigned 1:1 to receive either intensity-modulated RT (60-66 Gy) with weekly C (400 mg/m² loading dose, followed by 250 mg/m² weekly) or RT alone.
• The primary endpoint was OS in randomly assigned eligible patients, with DFS and toxicity as secondary endpoints.
• Analysis included stratified log-rank test for OS and DFS, while toxicity was compared using Fisher’s exact test.

TAKEAWAY:

• OS was not significantly improved with RT plus C vs RT alone (hazard ratio [HR], 0.81; 95% CI, 0.60-1.08; P = .0747), though 5-year OS rates were 76.5% vs 68.7%.
• DFS showed significant improvement with combined therapy (HR, 0.75; 95% CI, 0.57-0.98; P = .0168), with 5-year rates of 71.7% vs 63.6%.
• Grade 3-4 acute toxicity rates were significantly higher with combination therapy (70.3% vs 39.7%; P < .0001), primarily affecting skin and mucosa, though late toxicity rates were similar (33.2% vs 29.0%; P = .3101).
• The benefit of RT plus C was only observed in those patients who were human papillomavirus–negative, which comprised 80.2% of trial participants.

IN PRACTICE:

RT plus C “significantly improved DFS, but not OS, with no increase in long-term toxicity, compared with RT alone for resected, intermediate-risk SCCHN. RT plus C is an appropriate option for carefully selected patients with HPV-negative disease,” the authors of the study wrote.

SOURCE:

This study was led by Mitchell Machtay, MD, Penn State Health Milton S. Hershey Medical Center in Hershey, Pennsylvania. It was published online  in Journal of Clinical Oncology.

LIMITATIONS:

According to the researchers, the OS in the control group was higher than predicted, resulting in the trial being underpowered to detect the initial targeted HR. The authors noted that the better-than-expected survival rates could be attributed to improvements in surgical and radiotherapeutic techniques, including mandatory intensity-modulated RT for all patients. Additionally, the researchers pointed out that patient selection may have influenced outcomes, as only 30% of study participants had more than two risk factors.

DISCLOSURES:

This study was supported by grants from the US National Cancer Institute and Eli Lilly Inc. Machtay received grants from Lilly/ImClone, AstraZeneca, and Merck Sharp & Dohme. Additional disclosures are noted in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Adding cetuximab (C) to postoperative radiotherapy (RT) improves disease-free survival (DFS) but not overall survival (OS) in intermediate-risk squamous cell carcinoma of the head and neck. Benefits were specifically observed in human papillomavirus–negative patients, who represented 80.2% of the study participants.

METHODOLOGY:

• Previous research showed that adding high-dose cisplatin to postoperative RT in patients with squamous cell carcinoma of the head and neck (SCCHN) improved outcomes in those with positive margins and nodal extracapsular extension of the tumor.
• The new phase 3 randomized trial, which enrolled patients from November 2009 to March 2018 included 577 individuals with resected SCCHN of the oral cavity, oropharynx, or larynx, specifically.
• Participants were randomly assigned 1:1 to receive either intensity-modulated RT (60-66 Gy) with weekly C (400 mg/m² loading dose, followed by 250 mg/m² weekly) or RT alone.
• The primary endpoint was OS in randomly assigned eligible patients, with DFS and toxicity as secondary endpoints.
• Analysis included stratified log-rank test for OS and DFS, while toxicity was compared using Fisher’s exact test.

TAKEAWAY:

• OS was not significantly improved with RT plus C vs RT alone (hazard ratio [HR], 0.81; 95% CI, 0.60-1.08; P = .0747), though 5-year OS rates were 76.5% vs 68.7%.
• DFS showed significant improvement with combined therapy (HR, 0.75; 95% CI, 0.57-0.98; P = .0168), with 5-year rates of 71.7% vs 63.6%.
• Grade 3-4 acute toxicity rates were significantly higher with combination therapy (70.3% vs 39.7%; P < .0001), primarily affecting skin and mucosa, though late toxicity rates were similar (33.2% vs 29.0%; P = .3101).
• The benefit of RT plus C was only observed in those patients who were human papillomavirus–negative, which comprised 80.2% of trial participants.

IN PRACTICE:

RT plus C “significantly improved DFS, but not OS, with no increase in long-term toxicity, compared with RT alone for resected, intermediate-risk SCCHN. RT plus C is an appropriate option for carefully selected patients with HPV-negative disease,” the authors of the study wrote.

SOURCE:

This study was led by Mitchell Machtay, MD, Penn State Health Milton S. Hershey Medical Center in Hershey, Pennsylvania. It was published online  in Journal of Clinical Oncology.

LIMITATIONS:

According to the researchers, the OS in the control group was higher than predicted, resulting in the trial being underpowered to detect the initial targeted HR. The authors noted that the better-than-expected survival rates could be attributed to improvements in surgical and radiotherapeutic techniques, including mandatory intensity-modulated RT for all patients. Additionally, the researchers pointed out that patient selection may have influenced outcomes, as only 30% of study participants had more than two risk factors.

DISCLOSURES:

This study was supported by grants from the US National Cancer Institute and Eli Lilly Inc. Machtay received grants from Lilly/ImClone, AstraZeneca, and Merck Sharp & Dohme. Additional disclosures are noted in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

Heavy menstrual bleeding is more than an inconvenience in adolescents: It often leads to significant medical complications, in addition to disruptions in quality of life. While measuring the true level of bleeding can be a challenge, hematologists say treatments are helpful and can be as simple — and surprising — as doses of aspirin.

About 90% of adolescents with heavy menstrual bleeding will have low ferritin, and 70% will develop anemia, said benign hematologist Juliana Perez Botero, MD, of the Mayo Clinic in Rochester, Minnesota, in a presentation at the American Society of Hematology (ASH) 2024 Annual Meeting. “This is an issue of big magnitude that has public health implications, but it’s also an issue of gender equality and social justice.”

 

Measuring Menstruation: What Counts as Heavy Bleeding?

According to hematologist Allison Wheeler, MD, of the University of Washington in Seattle, normal menstrual bleeding is defined as lasting for about 5 days with 30-50 mL of blood loss.

“Historically, heavy menstrual bleeding was defined as bleeding as > 7 days or > 80 mL of blood loss,” Wheeler said. “It’s pretty hard to measure those mL. So a more modern definition is increased menstrual blood loss that interferes with a female’s physical, social, emotional, or material quality of life.”

Measuring blood loss during menstruation isn’t simple. The alkaline hematin method, which measures blood in feminine hygiene products, is the “gold standard, but that’s all I’m going to say about that,” Wheeler said.

An alternative is the Pictorial Blood Loss Assessment Chart, a visual tool that patients can use to estimate blood loss, she said, although there have been questions about its accuracy. In addition, it only covers pads and tampons even though other products are now available.

Another option is the Adolescent Menstrual Bleeding Questionnaire. “It captures both how much patients are bleeding and a lot of quality-of-life aspects,” she said.

 

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), Surprisingly, Can Be Effective Treatments

It seems counterintuitive that NSAIDs can be helpful in patients with heavy bleeding. “We don’t think about them because Cox inhibition ends up leading to decreases in thromboxane A2, which is going to increase bleeding,” Wheeler said. However, she said, the drugs also decrease prostaglandin within the endometrium, which can improve menstrual bleeding.

“In a meta-analysis, when NSAIDs were compared to placebo, there was decreased menstrual bleeding,” she said. “It was pretty similar to estrogen-progesterone formulations together. And when compared to antifibrinolytics, there was a little more menstrual bleeding with the NSAID use.”

Wheeler cautioned that “it’s important to optimize NSAID dosage. You really can’t use lower doses, and you can’t use sporadic doses.”

 

Other Options: Tranexamic Acid, Hormone Management

Tranexamic acid is the most common antifibrinolytic treatment for heavy bleeding, Wheeler said. “This is a lysine analog that’s going to inhibit the conversion from plasminogen to plasmin,” she said. “This is going to strengthen and stabilize blood clots that are already formed.”

Multiple clinical trials have studied the treatment in heavy menstrual bleeding, she said. “There’s no increased risk of venous or arterial thrombosis among participants in these clinical trials, but patients with a history of thrombosis were excluded from the majority of them. So we do need to keep that in mind.”

As for adverse effects, they’re mild and sporadic and include headaches and stomach upset, she said.

Another treatment option is estrogen and progesterone therapy using pill, patch, or vaginal ring, Wheeler said. The treatment leads to a “stable and thin very endometrium,” and typically takes 3-6 months to fully kick in. Studies have suggested the therapy can lead to 35%-80% reduction in menstrual blood loss, she said.

Keep in mind, Wheeler noted, “that there are many contraindications associated with estrogen use. Please take note of this, especially in consideration of discussions with patients shifting over to progesterone-only hormonal therapy” — another option to treat excess bleeding.

In most patients, she added, progesterone-only therapy “is going to result in irregular bleeding when you first start taking it. That irregular bleeding can last from up to 3-6 months. It’s something that’s really important to discuss with patients.”

She also noted that this therapy can be given to patients in forms that do not prevent pregnancy.

Botero had no disclosures. Wheeler reported relationships with Novo Nordisk, Bayer, BioMarin, Bioverativ, CSL Behring, Genentech, HEMA, Octapharma, Pfizer, Sanofi-Aventis, Shire North America, Spark, and Takeda.

A version of this article first appeared on Medscape.com.

Heavy menstrual bleeding is more than an inconvenience in adolescents: It often leads to significant medical complications, in addition to disruptions in quality of life. While measuring the true level of bleeding can be a challenge, hematologists say treatments are helpful and can be as simple — and surprising — as doses of aspirin.

About 90% of adolescents with heavy menstrual bleeding will have low ferritin, and 70% will develop anemia, said benign hematologist Juliana Perez Botero, MD, of the Mayo Clinic in Rochester, Minnesota, in a presentation at the American Society of Hematology (ASH) 2024 Annual Meeting. “This is an issue of big magnitude that has public health implications, but it’s also an issue of gender equality and social justice.”

 

Measuring Menstruation: What Counts as Heavy Bleeding?

According to hematologist Allison Wheeler, MD, of the University of Washington in Seattle, normal menstrual bleeding is defined as lasting for about 5 days with 30-50 mL of blood loss.

“Historically, heavy menstrual bleeding was defined as bleeding as > 7 days or > 80 mL of blood loss,” Wheeler said. “It’s pretty hard to measure those mL. So a more modern definition is increased menstrual blood loss that interferes with a female’s physical, social, emotional, or material quality of life.”

Measuring blood loss during menstruation isn’t simple. The alkaline hematin method, which measures blood in feminine hygiene products, is the “gold standard, but that’s all I’m going to say about that,” Wheeler said.

An alternative is the Pictorial Blood Loss Assessment Chart, a visual tool that patients can use to estimate blood loss, she said, although there have been questions about its accuracy. In addition, it only covers pads and tampons even though other products are now available.

Another option is the Adolescent Menstrual Bleeding Questionnaire. “It captures both how much patients are bleeding and a lot of quality-of-life aspects,” she said.

 

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), Surprisingly, Can Be Effective Treatments

It seems counterintuitive that NSAIDs can be helpful in patients with heavy bleeding. “We don’t think about them because Cox inhibition ends up leading to decreases in thromboxane A2, which is going to increase bleeding,” Wheeler said. However, she said, the drugs also decrease prostaglandin within the endometrium, which can improve menstrual bleeding.

“In a meta-analysis, when NSAIDs were compared to placebo, there was decreased menstrual bleeding,” she said. “It was pretty similar to estrogen-progesterone formulations together. And when compared to antifibrinolytics, there was a little more menstrual bleeding with the NSAID use.”

Wheeler cautioned that “it’s important to optimize NSAID dosage. You really can’t use lower doses, and you can’t use sporadic doses.”

 

Other Options: Tranexamic Acid, Hormone Management

Tranexamic acid is the most common antifibrinolytic treatment for heavy bleeding, Wheeler said. “This is a lysine analog that’s going to inhibit the conversion from plasminogen to plasmin,” she said. “This is going to strengthen and stabilize blood clots that are already formed.”

Multiple clinical trials have studied the treatment in heavy menstrual bleeding, she said. “There’s no increased risk of venous or arterial thrombosis among participants in these clinical trials, but patients with a history of thrombosis were excluded from the majority of them. So we do need to keep that in mind.”

As for adverse effects, they’re mild and sporadic and include headaches and stomach upset, she said.

Another treatment option is estrogen and progesterone therapy using pill, patch, or vaginal ring, Wheeler said. The treatment leads to a “stable and thin very endometrium,” and typically takes 3-6 months to fully kick in. Studies have suggested the therapy can lead to 35%-80% reduction in menstrual blood loss, she said.

Keep in mind, Wheeler noted, “that there are many contraindications associated with estrogen use. Please take note of this, especially in consideration of discussions with patients shifting over to progesterone-only hormonal therapy” — another option to treat excess bleeding.

In most patients, she added, progesterone-only therapy “is going to result in irregular bleeding when you first start taking it. That irregular bleeding can last from up to 3-6 months. It’s something that’s really important to discuss with patients.”

She also noted that this therapy can be given to patients in forms that do not prevent pregnancy.

Botero had no disclosures. Wheeler reported relationships with Novo Nordisk, Bayer, BioMarin, Bioverativ, CSL Behring, Genentech, HEMA, Octapharma, Pfizer, Sanofi-Aventis, Shire North America, Spark, and Takeda.

A version of this article first appeared on Medscape.com.

Heavy menstrual bleeding is more than an inconvenience in adolescents: It often leads to significant medical complications, in addition to disruptions in quality of life. While measuring the true level of bleeding can be a challenge, hematologists say treatments are helpful and can be as simple — and surprising — as doses of aspirin.

About 90% of adolescents with heavy menstrual bleeding will have low ferritin, and 70% will develop anemia, said benign hematologist Juliana Perez Botero, MD, of the Mayo Clinic in Rochester, Minnesota, in a presentation at the American Society of Hematology (ASH) 2024 Annual Meeting. “This is an issue of big magnitude that has public health implications, but it’s also an issue of gender equality and social justice.”

 

Measuring Menstruation: What Counts as Heavy Bleeding?

According to hematologist Allison Wheeler, MD, of the University of Washington in Seattle, normal menstrual bleeding is defined as lasting for about 5 days with 30-50 mL of blood loss.

“Historically, heavy menstrual bleeding was defined as bleeding as > 7 days or > 80 mL of blood loss,” Wheeler said. “It’s pretty hard to measure those mL. So a more modern definition is increased menstrual blood loss that interferes with a female’s physical, social, emotional, or material quality of life.”

Measuring blood loss during menstruation isn’t simple. The alkaline hematin method, which measures blood in feminine hygiene products, is the “gold standard, but that’s all I’m going to say about that,” Wheeler said.

An alternative is the Pictorial Blood Loss Assessment Chart, a visual tool that patients can use to estimate blood loss, she said, although there have been questions about its accuracy. In addition, it only covers pads and tampons even though other products are now available.

Another option is the Adolescent Menstrual Bleeding Questionnaire. “It captures both how much patients are bleeding and a lot of quality-of-life aspects,” she said.

 

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), Surprisingly, Can Be Effective Treatments

It seems counterintuitive that NSAIDs can be helpful in patients with heavy bleeding. “We don’t think about them because Cox inhibition ends up leading to decreases in thromboxane A2, which is going to increase bleeding,” Wheeler said. However, she said, the drugs also decrease prostaglandin within the endometrium, which can improve menstrual bleeding.

“In a meta-analysis, when NSAIDs were compared to placebo, there was decreased menstrual bleeding,” she said. “It was pretty similar to estrogen-progesterone formulations together. And when compared to antifibrinolytics, there was a little more menstrual bleeding with the NSAID use.”

Wheeler cautioned that “it’s important to optimize NSAID dosage. You really can’t use lower doses, and you can’t use sporadic doses.”

 

Other Options: Tranexamic Acid, Hormone Management

Tranexamic acid is the most common antifibrinolytic treatment for heavy bleeding, Wheeler said. “This is a lysine analog that’s going to inhibit the conversion from plasminogen to plasmin,” she said. “This is going to strengthen and stabilize blood clots that are already formed.”

Multiple clinical trials have studied the treatment in heavy menstrual bleeding, she said. “There’s no increased risk of venous or arterial thrombosis among participants in these clinical trials, but patients with a history of thrombosis were excluded from the majority of them. So we do need to keep that in mind.”

As for adverse effects, they’re mild and sporadic and include headaches and stomach upset, she said.

Another treatment option is estrogen and progesterone therapy using pill, patch, or vaginal ring, Wheeler said. The treatment leads to a “stable and thin very endometrium,” and typically takes 3-6 months to fully kick in. Studies have suggested the therapy can lead to 35%-80% reduction in menstrual blood loss, she said.

Keep in mind, Wheeler noted, “that there are many contraindications associated with estrogen use. Please take note of this, especially in consideration of discussions with patients shifting over to progesterone-only hormonal therapy” — another option to treat excess bleeding.

In most patients, she added, progesterone-only therapy “is going to result in irregular bleeding when you first start taking it. That irregular bleeding can last from up to 3-6 months. It’s something that’s really important to discuss with patients.”

She also noted that this therapy can be given to patients in forms that do not prevent pregnancy.

Botero had no disclosures. Wheeler reported relationships with Novo Nordisk, Bayer, BioMarin, Bioverativ, CSL Behring, Genentech, HEMA, Octapharma, Pfizer, Sanofi-Aventis, Shire North America, Spark, and Takeda.

A version of this article first appeared on Medscape.com.

TOPLINE:

A cross-sectional survey of patients preparing for their first radiation therapy consultation found that many patients worried about the physical effects of radiation therapy, including pain, memory loss, and nausea, and more than 60% said they were concerned about their ability to perform daily activities. Respondents reported a range of other worries, including the financial cost of treatment, transportation to treatment sessions, and the ability to continue working, as well as misconceptions about radiation therapy, such as concerns about emitting radiation to others.

METHODOLOGY:

• Toxicities from cancer therapies can significantly affect patients’ quality of life and may contribute to their apprehensions before starting a new treatment. Some studies have indicated that patients may have misconceptions about chemotherapy, but less is known about patients’ perceptions of radiation therapy.
• Researchers conducted a cross-sectional survey of patients presenting for initial radiation therapy consultation at a single academic institution and analyzed responses from 214 patients (52% men; 51% White individuals) with no prior radiation therapy experience.
• The patients completed a 30-question electronic survey about radiation therapy perceptions and fears or concerns prior to their initial radiation consultation.
• Cancer diagnoses spanned 18 disease sites, with hematologic malignancies (21%), breast cancer (18%), and lung cancer (15%) being the most common.

TAKEAWAY:

• Physical adverse effects were the top concern for patients. These included radiation-induced pain (67%), memory loss (62%), nausea/vomiting (60%), and skin reactions (58%).
• Patients expressed concerns about the impact radiation therapy would have on daily activities, with 62% reporting being moderately or very concerned about their ability to perform daily activities and 37% worried about their ability to continue working. Other concerns included the ability to exercise (over half of respondents), financial cost (36%), and transportation to treatment sessions (26%).
• Misconceptions among patients were also common, with 48% expressing concerns about emitting radiation to others and 45% worrying about excreting radioactive urine or stool.
• Patients had varied levels of prior understanding of radiation therapy. Half of patients reported a complete lack of knowledge about radiation therapy, and 35% said they had read or heard stories about bad adverse effects.

IN PRACTICE:

“Our study suggests that a survey administered prior to radiation oncology consultation can reveal patients’ primary concerns which could promote a more patient-centered discussion that addresses specific concerns and involves appropriate services to help the patient,” the authors wrote.

SOURCE:

This study, led by Jennifer Novak, MD, MS, Department of Radiation Oncology, City of Hope National Medical Center, Duarte, California, was published online in Advances in Radiation Oncology.

LIMITATIONS:

Limitations included response bias and time constraints, which prevented many eligible patients from completing the survey. The single-institution design limits the generalizability of the findings. The survey results also showed a disproportionate focus on physical effects over the social impacts of radiation therapy, which could have limited the comprehensiveness of the findings.

DISCLOSURES:

The authors reported no specific funding for this work and no relevant competing financial interests or personal relationships that could have influenced the work.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

A cross-sectional survey of patients preparing for their first radiation therapy consultation found that many patients worried about the physical effects of radiation therapy, including pain, memory loss, and nausea, and more than 60% said they were concerned about their ability to perform daily activities. Respondents reported a range of other worries, including the financial cost of treatment, transportation to treatment sessions, and the ability to continue working, as well as misconceptions about radiation therapy, such as concerns about emitting radiation to others.

METHODOLOGY:

• Toxicities from cancer therapies can significantly affect patients’ quality of life and may contribute to their apprehensions before starting a new treatment. Some studies have indicated that patients may have misconceptions about chemotherapy, but less is known about patients’ perceptions of radiation therapy.
• Researchers conducted a cross-sectional survey of patients presenting for initial radiation therapy consultation at a single academic institution and analyzed responses from 214 patients (52% men; 51% White individuals) with no prior radiation therapy experience.
• The patients completed a 30-question electronic survey about radiation therapy perceptions and fears or concerns prior to their initial radiation consultation.
• Cancer diagnoses spanned 18 disease sites, with hematologic malignancies (21%), breast cancer (18%), and lung cancer (15%) being the most common.

TAKEAWAY:

• Physical adverse effects were the top concern for patients. These included radiation-induced pain (67%), memory loss (62%), nausea/vomiting (60%), and skin reactions (58%).
• Patients expressed concerns about the impact radiation therapy would have on daily activities, with 62% reporting being moderately or very concerned about their ability to perform daily activities and 37% worried about their ability to continue working. Other concerns included the ability to exercise (over half of respondents), financial cost (36%), and transportation to treatment sessions (26%).
• Misconceptions among patients were also common, with 48% expressing concerns about emitting radiation to others and 45% worrying about excreting radioactive urine or stool.
• Patients had varied levels of prior understanding of radiation therapy. Half of patients reported a complete lack of knowledge about radiation therapy, and 35% said they had read or heard stories about bad adverse effects.

IN PRACTICE:

“Our study suggests that a survey administered prior to radiation oncology consultation can reveal patients’ primary concerns which could promote a more patient-centered discussion that addresses specific concerns and involves appropriate services to help the patient,” the authors wrote.

SOURCE:

This study, led by Jennifer Novak, MD, MS, Department of Radiation Oncology, City of Hope National Medical Center, Duarte, California, was published online in Advances in Radiation Oncology.

LIMITATIONS:

Limitations included response bias and time constraints, which prevented many eligible patients from completing the survey. The single-institution design limits the generalizability of the findings. The survey results also showed a disproportionate focus on physical effects over the social impacts of radiation therapy, which could have limited the comprehensiveness of the findings.

DISCLOSURES:

The authors reported no specific funding for this work and no relevant competing financial interests or personal relationships that could have influenced the work.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

A cross-sectional survey of patients preparing for their first radiation therapy consultation found that many patients worried about the physical effects of radiation therapy, including pain, memory loss, and nausea, and more than 60% said they were concerned about their ability to perform daily activities. Respondents reported a range of other worries, including the financial cost of treatment, transportation to treatment sessions, and the ability to continue working, as well as misconceptions about radiation therapy, such as concerns about emitting radiation to others.

METHODOLOGY:

• Toxicities from cancer therapies can significantly affect patients’ quality of life and may contribute to their apprehensions before starting a new treatment. Some studies have indicated that patients may have misconceptions about chemotherapy, but less is known about patients’ perceptions of radiation therapy.
• Researchers conducted a cross-sectional survey of patients presenting for initial radiation therapy consultation at a single academic institution and analyzed responses from 214 patients (52% men; 51% White individuals) with no prior radiation therapy experience.
• The patients completed a 30-question electronic survey about radiation therapy perceptions and fears or concerns prior to their initial radiation consultation.
• Cancer diagnoses spanned 18 disease sites, with hematologic malignancies (21%), breast cancer (18%), and lung cancer (15%) being the most common.

TAKEAWAY:

• Physical adverse effects were the top concern for patients. These included radiation-induced pain (67%), memory loss (62%), nausea/vomiting (60%), and skin reactions (58%).
• Patients expressed concerns about the impact radiation therapy would have on daily activities, with 62% reporting being moderately or very concerned about their ability to perform daily activities and 37% worried about their ability to continue working. Other concerns included the ability to exercise (over half of respondents), financial cost (36%), and transportation to treatment sessions (26%).
• Misconceptions among patients were also common, with 48% expressing concerns about emitting radiation to others and 45% worrying about excreting radioactive urine or stool.
• Patients had varied levels of prior understanding of radiation therapy. Half of patients reported a complete lack of knowledge about radiation therapy, and 35% said they had read or heard stories about bad adverse effects.

IN PRACTICE:

“Our study suggests that a survey administered prior to radiation oncology consultation can reveal patients’ primary concerns which could promote a more patient-centered discussion that addresses specific concerns and involves appropriate services to help the patient,” the authors wrote.

SOURCE:

This study, led by Jennifer Novak, MD, MS, Department of Radiation Oncology, City of Hope National Medical Center, Duarte, California, was published online in Advances in Radiation Oncology.

LIMITATIONS:

Limitations included response bias and time constraints, which prevented many eligible patients from completing the survey. The single-institution design limits the generalizability of the findings. The survey results also showed a disproportionate focus on physical effects over the social impacts of radiation therapy, which could have limited the comprehensiveness of the findings.

DISCLOSURES:

The authors reported no specific funding for this work and no relevant competing financial interests or personal relationships that could have influenced the work.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

Last year, Eric Singhi, MD, a thoracic medical oncologist at MD Anderson Cancer Center in Houston, noticed a shift in his team. The small band of four clinicians, once motivated and enthusiastic, were now withdrawn and distant.

“We had to take a break from clinic one day. We went out, got food and…acknowledged something was off,” Singhi recalled.

That something: Intense emotional exhaustion.

No thoracic oncology team has it easy. Lung cancer remains the leading cause of cancer deaths. But over the last 12 months Singhi’s team had taken on more and more cases in younger patients. Watching patients so close to their own age struggle and ultimately be consumed by this disease took its toll, Singhi said. And the toll was showing up in the lives of his colleagues.

Singhi’s team was suffering from compassion fatigue — the mental, physical, or emotional exhaustion brought on by prolonged exposure to the trauma of people in one’s care. Also referred to secondary trauma, compassion fatigue “leaves someone feeling numb, detached, or like they don’t have emotional resources to keep on giving,” Singhi said.

This fatigue is common among people who work in high-stress caretaking professions. Those involved in cancer care, who frequently find themselves navigating life and death conversations and experiences with patients, are particularly at risk, experts told this news organization.

“I think anyone in medical oncology or hematology who has practiced long enough will feel this,” said Alfred Lee, MD, PhD, burnout researcher and director of the hematology/oncology fellowship at Yale School of Medicine in New Haven, Connecticut. “It’s par for the course, even in training.”

Still, compassion fatigue can be hard to detect without help. Left unaddressed, compassion fatigue can undermine good patient care, even lead to burnout.

“I’ve absolutely treated people leaving the field who think they shouldn’t be a doctor anymore,” said Jennifer Bickel, MD, recently named MD Anderson’s inaugural vice president and chief wellness officer. Those are preventable losses the field can’t afford in a provider shortage, she said.

 

Recognizing the Signs

Compassion is an essential part of patient care as is empathy. Expressing compassion or feeling empathy toward patients can foster the doctor-patient bond and help both navigate challenging conversations and decisions.

“Compassion and being able to empathize are so important — it’s how you gain trust,” Singhi said. This is especially true for patients who may be underrepresented. “That’s how they become a partner in their care, how they agree to listen about a clinical trial or agree to adhere to their treatment plan,” Singhi noted.

But there’s a risk when clinicians start to give too much.

Overtime, repeated exposure to patients’ trauma can create a sense of heaviness and fatigue, and ultimately cause caregivers to detach, Lee said.

A case study of compassion fatigue, based on the experience of one oncologist, highlighted that the condition parallels posttraumatic stress disorder, aligning on three main symptoms: Feeling hyperarousal, notably hypervigilance or irritability, avoiding stressful situations, and reliving traumatic events.

The initial phases of compassion fatigue, however, can be subtle and easily dismissed. An oncologist may begin to feel a creeping sense of detachment — a divide slowly growing with their patients, a buzz of dissatisfaction on the job, unusual mood changes.

While it’s normal for healthcare workers to experience moments of irritability, dissatisfaction, exhaustion or avoidance, when these experiences become pervasive, compassion fatigue could be the culprit, according to Marra Ackerman, MD, a psychiatrist at NYU Langone Health in New York City.

Compassion fatigue is “a form of coping more than anything,” Ackerman explained. Most of the time, it’s not a conscious choice, she said. When a brain experiences repeated distressing inputs it can shift into self-protection mode. The tipping point is different for everyone, but eventually the brain tries to detach and distance itself from the stressor, Ackerman said. And, in oncology, that stressor is often very sick patients.

If not addressed, the emotional exhaustion can limit a doctor’s efficacy at work. Clinicians suffering from compassion fatigue may find themselves calling in sick more often, making more mistakes, avoiding very sick patients, or having panic attacks at work, said Ackerman.

Clinicians also might use food, drugs, or alcohol to feel better, or detach from their patients, Lee added. “We find if you detach, you can’t provide the care patients need,” he said.

When trying to identify the issue, it’s important to understand that compassion fatigue is not burnout. The two issues can look similar, sharing symptoms like emotional detachment or disillusionment, and may co-exist, but the phenomena stem from different root causes.

While compassion fatigue is rooted in emotions and isn’t necessarily tied to work, burnout is a product of work-related stress. It’s often caused by system-level problems that leave clinicians feeling their work has lost its meaning. Inefficient technology or excessive data entry, for instance, could be drivers of burnout for oncologists because these tasks can pull the doctor away from the meaningful work of treating patients.

 

What Can Be Done

Oncology comes with its own set of risks and traumas, but for a long time, doctors weren’t equipped or encouraged to see the constant life-or-death tension of the job as a risk factor to their well-being, said Bickel.

“It’s not something we are inherently taught to identify and it’s not something we can identify without time for self-reflection,” Bickel told this news organization. In fact, many people don’t see their own compassion fatigue until a colleague points it out or they’re already past it and have some distance.

Although common among oncology clinicians, compassion fatigue is not inevitable. Oncologists can learn strategies to help manage their exposures to suffering and stave off reverting to coping mechanisms that only perpetuate the problem.

The key, Bickel said, is creating environments where people can feel safe and share their vulnerabilities. Formal peer support check-ins are a good example because they normalize regular communication about day-to-day difficulties as they happen and create space to experience grief. In these groups, no one has to worry that they’re complaining, she said.

Formalized groups also serve as a training ground where staff can learn to be better listeners. Healthcare providers are more likely to reach out to peers because so few people outside their field can relate to the challenges, Bickel explained. That’s why Moffitt Cancer Center, where Bickel recently worked before moving to MD Anderson, offers trainings to help staff learn to listen more effectively. Thirty doctors, nurses and health professionals have received the training so far and serve as a point of contact for colleagues who might be struggling, Bickel said. They can offer their peers an empathic ear, without providing unsolicited advice or commentary.

NYU Langone has a similar offering, Ackerman said. Providers can reach out to fellow nurses or doctors who have more mental health training. The conversation isn’t recorded like an appointment with a therapist may be. It’s more like mentorship where doctors can be open about what they are facing and find some comradery from someone who understands, without fear of stigma.

Talking to colleagues or having debriefs with your care team is critical because it eliminates the isolation that allows compassion fatigue to fester, Lee said. “Reflecting on positive encounters can help inspire us to keep going. Reflecting on the negative can be therapeutic and help find that sense of balance that everyone needs to find.”

As for Singhi’s team, “lots has changed since we’ve become more open,” he said. The team talks about hard patients early and often. These discussions have helped team members keep the challenges at work from seeping into their home life.

Experts agree that the threshold for seeking out help and guidance should be low. Waiting for depression or more severe symptoms to set in is not the best point of intervention, Bickel said. As soon as an oncologist begins to acknowledge a shift in how they connect with patients and the job, that’s enough to reach out.

“It’s not about what you can handle, it’s about how can you thrive and find joy,” she said.

A version of this article first appeared on Medscape.com.

Last year, Eric Singhi, MD, a thoracic medical oncologist at MD Anderson Cancer Center in Houston, noticed a shift in his team. The small band of four clinicians, once motivated and enthusiastic, were now withdrawn and distant.

“We had to take a break from clinic one day. We went out, got food and…acknowledged something was off,” Singhi recalled.

That something: Intense emotional exhaustion.

No thoracic oncology team has it easy. Lung cancer remains the leading cause of cancer deaths. But over the last 12 months Singhi’s team had taken on more and more cases in younger patients. Watching patients so close to their own age struggle and ultimately be consumed by this disease took its toll, Singhi said. And the toll was showing up in the lives of his colleagues.

Singhi’s team was suffering from compassion fatigue — the mental, physical, or emotional exhaustion brought on by prolonged exposure to the trauma of people in one’s care. Also referred to secondary trauma, compassion fatigue “leaves someone feeling numb, detached, or like they don’t have emotional resources to keep on giving,” Singhi said.

This fatigue is common among people who work in high-stress caretaking professions. Those involved in cancer care, who frequently find themselves navigating life and death conversations and experiences with patients, are particularly at risk, experts told this news organization.

“I think anyone in medical oncology or hematology who has practiced long enough will feel this,” said Alfred Lee, MD, PhD, burnout researcher and director of the hematology/oncology fellowship at Yale School of Medicine in New Haven, Connecticut. “It’s par for the course, even in training.”

Still, compassion fatigue can be hard to detect without help. Left unaddressed, compassion fatigue can undermine good patient care, even lead to burnout.

“I’ve absolutely treated people leaving the field who think they shouldn’t be a doctor anymore,” said Jennifer Bickel, MD, recently named MD Anderson’s inaugural vice president and chief wellness officer. Those are preventable losses the field can’t afford in a provider shortage, she said.

 

Recognizing the Signs

Compassion is an essential part of patient care as is empathy. Expressing compassion or feeling empathy toward patients can foster the doctor-patient bond and help both navigate challenging conversations and decisions.

“Compassion and being able to empathize are so important — it’s how you gain trust,” Singhi said. This is especially true for patients who may be underrepresented. “That’s how they become a partner in their care, how they agree to listen about a clinical trial or agree to adhere to their treatment plan,” Singhi noted.

But there’s a risk when clinicians start to give too much.

Overtime, repeated exposure to patients’ trauma can create a sense of heaviness and fatigue, and ultimately cause caregivers to detach, Lee said.

A case study of compassion fatigue, based on the experience of one oncologist, highlighted that the condition parallels posttraumatic stress disorder, aligning on three main symptoms: Feeling hyperarousal, notably hypervigilance or irritability, avoiding stressful situations, and reliving traumatic events.

The initial phases of compassion fatigue, however, can be subtle and easily dismissed. An oncologist may begin to feel a creeping sense of detachment — a divide slowly growing with their patients, a buzz of dissatisfaction on the job, unusual mood changes.

While it’s normal for healthcare workers to experience moments of irritability, dissatisfaction, exhaustion or avoidance, when these experiences become pervasive, compassion fatigue could be the culprit, according to Marra Ackerman, MD, a psychiatrist at NYU Langone Health in New York City.

Compassion fatigue is “a form of coping more than anything,” Ackerman explained. Most of the time, it’s not a conscious choice, she said. When a brain experiences repeated distressing inputs it can shift into self-protection mode. The tipping point is different for everyone, but eventually the brain tries to detach and distance itself from the stressor, Ackerman said. And, in oncology, that stressor is often very sick patients.

If not addressed, the emotional exhaustion can limit a doctor’s efficacy at work. Clinicians suffering from compassion fatigue may find themselves calling in sick more often, making more mistakes, avoiding very sick patients, or having panic attacks at work, said Ackerman.

Clinicians also might use food, drugs, or alcohol to feel better, or detach from their patients, Lee added. “We find if you detach, you can’t provide the care patients need,” he said.

When trying to identify the issue, it’s important to understand that compassion fatigue is not burnout. The two issues can look similar, sharing symptoms like emotional detachment or disillusionment, and may co-exist, but the phenomena stem from different root causes.

While compassion fatigue is rooted in emotions and isn’t necessarily tied to work, burnout is a product of work-related stress. It’s often caused by system-level problems that leave clinicians feeling their work has lost its meaning. Inefficient technology or excessive data entry, for instance, could be drivers of burnout for oncologists because these tasks can pull the doctor away from the meaningful work of treating patients.

 

What Can Be Done

Oncology comes with its own set of risks and traumas, but for a long time, doctors weren’t equipped or encouraged to see the constant life-or-death tension of the job as a risk factor to their well-being, said Bickel.

“It’s not something we are inherently taught to identify and it’s not something we can identify without time for self-reflection,” Bickel told this news organization. In fact, many people don’t see their own compassion fatigue until a colleague points it out or they’re already past it and have some distance.

Although common among oncology clinicians, compassion fatigue is not inevitable. Oncologists can learn strategies to help manage their exposures to suffering and stave off reverting to coping mechanisms that only perpetuate the problem.

The key, Bickel said, is creating environments where people can feel safe and share their vulnerabilities. Formal peer support check-ins are a good example because they normalize regular communication about day-to-day difficulties as they happen and create space to experience grief. In these groups, no one has to worry that they’re complaining, she said.

Formalized groups also serve as a training ground where staff can learn to be better listeners. Healthcare providers are more likely to reach out to peers because so few people outside their field can relate to the challenges, Bickel explained. That’s why Moffitt Cancer Center, where Bickel recently worked before moving to MD Anderson, offers trainings to help staff learn to listen more effectively. Thirty doctors, nurses and health professionals have received the training so far and serve as a point of contact for colleagues who might be struggling, Bickel said. They can offer their peers an empathic ear, without providing unsolicited advice or commentary.

NYU Langone has a similar offering, Ackerman said. Providers can reach out to fellow nurses or doctors who have more mental health training. The conversation isn’t recorded like an appointment with a therapist may be. It’s more like mentorship where doctors can be open about what they are facing and find some comradery from someone who understands, without fear of stigma.

Talking to colleagues or having debriefs with your care team is critical because it eliminates the isolation that allows compassion fatigue to fester, Lee said. “Reflecting on positive encounters can help inspire us to keep going. Reflecting on the negative can be therapeutic and help find that sense of balance that everyone needs to find.”

As for Singhi’s team, “lots has changed since we’ve become more open,” he said. The team talks about hard patients early and often. These discussions have helped team members keep the challenges at work from seeping into their home life.

Experts agree that the threshold for seeking out help and guidance should be low. Waiting for depression or more severe symptoms to set in is not the best point of intervention, Bickel said. As soon as an oncologist begins to acknowledge a shift in how they connect with patients and the job, that’s enough to reach out.

“It’s not about what you can handle, it’s about how can you thrive and find joy,” she said.

A version of this article first appeared on Medscape.com.

Last year, Eric Singhi, MD, a thoracic medical oncologist at MD Anderson Cancer Center in Houston, noticed a shift in his team. The small band of four clinicians, once motivated and enthusiastic, were now withdrawn and distant.

“We had to take a break from clinic one day. We went out, got food and…acknowledged something was off,” Singhi recalled.

That something: Intense emotional exhaustion.

No thoracic oncology team has it easy. Lung cancer remains the leading cause of cancer deaths. But over the last 12 months Singhi’s team had taken on more and more cases in younger patients. Watching patients so close to their own age struggle and ultimately be consumed by this disease took its toll, Singhi said. And the toll was showing up in the lives of his colleagues.

Singhi’s team was suffering from compassion fatigue — the mental, physical, or emotional exhaustion brought on by prolonged exposure to the trauma of people in one’s care. Also referred to secondary trauma, compassion fatigue “leaves someone feeling numb, detached, or like they don’t have emotional resources to keep on giving,” Singhi said.

This fatigue is common among people who work in high-stress caretaking professions. Those involved in cancer care, who frequently find themselves navigating life and death conversations and experiences with patients, are particularly at risk, experts told this news organization.

“I think anyone in medical oncology or hematology who has practiced long enough will feel this,” said Alfred Lee, MD, PhD, burnout researcher and director of the hematology/oncology fellowship at Yale School of Medicine in New Haven, Connecticut. “It’s par for the course, even in training.”

Still, compassion fatigue can be hard to detect without help. Left unaddressed, compassion fatigue can undermine good patient care, even lead to burnout.

“I’ve absolutely treated people leaving the field who think they shouldn’t be a doctor anymore,” said Jennifer Bickel, MD, recently named MD Anderson’s inaugural vice president and chief wellness officer. Those are preventable losses the field can’t afford in a provider shortage, she said.

 

Recognizing the Signs

Compassion is an essential part of patient care as is empathy. Expressing compassion or feeling empathy toward patients can foster the doctor-patient bond and help both navigate challenging conversations and decisions.

“Compassion and being able to empathize are so important — it’s how you gain trust,” Singhi said. This is especially true for patients who may be underrepresented. “That’s how they become a partner in their care, how they agree to listen about a clinical trial or agree to adhere to their treatment plan,” Singhi noted.

But there’s a risk when clinicians start to give too much.

Overtime, repeated exposure to patients’ trauma can create a sense of heaviness and fatigue, and ultimately cause caregivers to detach, Lee said.

A case study of compassion fatigue, based on the experience of one oncologist, highlighted that the condition parallels posttraumatic stress disorder, aligning on three main symptoms: Feeling hyperarousal, notably hypervigilance or irritability, avoiding stressful situations, and reliving traumatic events.

The initial phases of compassion fatigue, however, can be subtle and easily dismissed. An oncologist may begin to feel a creeping sense of detachment — a divide slowly growing with their patients, a buzz of dissatisfaction on the job, unusual mood changes.

While it’s normal for healthcare workers to experience moments of irritability, dissatisfaction, exhaustion or avoidance, when these experiences become pervasive, compassion fatigue could be the culprit, according to Marra Ackerman, MD, a psychiatrist at NYU Langone Health in New York City.

Compassion fatigue is “a form of coping more than anything,” Ackerman explained. Most of the time, it’s not a conscious choice, she said. When a brain experiences repeated distressing inputs it can shift into self-protection mode. The tipping point is different for everyone, but eventually the brain tries to detach and distance itself from the stressor, Ackerman said. And, in oncology, that stressor is often very sick patients.

If not addressed, the emotional exhaustion can limit a doctor’s efficacy at work. Clinicians suffering from compassion fatigue may find themselves calling in sick more often, making more mistakes, avoiding very sick patients, or having panic attacks at work, said Ackerman.

Clinicians also might use food, drugs, or alcohol to feel better, or detach from their patients, Lee added. “We find if you detach, you can’t provide the care patients need,” he said.

When trying to identify the issue, it’s important to understand that compassion fatigue is not burnout. The two issues can look similar, sharing symptoms like emotional detachment or disillusionment, and may co-exist, but the phenomena stem from different root causes.

While compassion fatigue is rooted in emotions and isn’t necessarily tied to work, burnout is a product of work-related stress. It’s often caused by system-level problems that leave clinicians feeling their work has lost its meaning. Inefficient technology or excessive data entry, for instance, could be drivers of burnout for oncologists because these tasks can pull the doctor away from the meaningful work of treating patients.

 

What Can Be Done

Oncology comes with its own set of risks and traumas, but for a long time, doctors weren’t equipped or encouraged to see the constant life-or-death tension of the job as a risk factor to their well-being, said Bickel.

“It’s not something we are inherently taught to identify and it’s not something we can identify without time for self-reflection,” Bickel told this news organization. In fact, many people don’t see their own compassion fatigue until a colleague points it out or they’re already past it and have some distance.

Although common among oncology clinicians, compassion fatigue is not inevitable. Oncologists can learn strategies to help manage their exposures to suffering and stave off reverting to coping mechanisms that only perpetuate the problem.

The key, Bickel said, is creating environments where people can feel safe and share their vulnerabilities. Formal peer support check-ins are a good example because they normalize regular communication about day-to-day difficulties as they happen and create space to experience grief. In these groups, no one has to worry that they’re complaining, she said.

Formalized groups also serve as a training ground where staff can learn to be better listeners. Healthcare providers are more likely to reach out to peers because so few people outside their field can relate to the challenges, Bickel explained. That’s why Moffitt Cancer Center, where Bickel recently worked before moving to MD Anderson, offers trainings to help staff learn to listen more effectively. Thirty doctors, nurses and health professionals have received the training so far and serve as a point of contact for colleagues who might be struggling, Bickel said. They can offer their peers an empathic ear, without providing unsolicited advice or commentary.

NYU Langone has a similar offering, Ackerman said. Providers can reach out to fellow nurses or doctors who have more mental health training. The conversation isn’t recorded like an appointment with a therapist may be. It’s more like mentorship where doctors can be open about what they are facing and find some comradery from someone who understands, without fear of stigma.

Talking to colleagues or having debriefs with your care team is critical because it eliminates the isolation that allows compassion fatigue to fester, Lee said. “Reflecting on positive encounters can help inspire us to keep going. Reflecting on the negative can be therapeutic and help find that sense of balance that everyone needs to find.”

As for Singhi’s team, “lots has changed since we’ve become more open,” he said. The team talks about hard patients early and often. These discussions have helped team members keep the challenges at work from seeping into their home life.

Experts agree that the threshold for seeking out help and guidance should be low. Waiting for depression or more severe symptoms to set in is not the best point of intervention, Bickel said. As soon as an oncologist begins to acknowledge a shift in how they connect with patients and the job, that’s enough to reach out.

“It’s not about what you can handle, it’s about how can you thrive and find joy,” she said.

A version of this article first appeared on Medscape.com.

TOPLINE: A small study of veterans found that high-intensity focused ultrasound (HIFU) demonstrated similar oncologic outcomes when compared to standard treatments for localized prostate cancer, while maintaining erectile and urinary function. 

METHODOLOGY: 

•      A retrospective analysis at the Michael E. DeBakey Veterans Affairs Medical Center in Houston between 2018 and 2022, with data acquired from electronic health record.
•      A total of 43 veterans were included in the analysis; 31 patients (72%) receiving primary treatment and 12 patients (28%) receiving salvage therapy.
•      Patient risk stratification was performed using prostate specific antigen (PSA), Gleason Score, and clinical stage based on National Comprehensive Cancer Network and D'Amico criteria.
•      Follow-up assessments included serial PSA measurements at 3, 6, 12, 18, and 24 months, with functional outcomes evaluated through Sexual Health Inventory for Men and American Urological Association Symptom Score questionnaires.

TAKEAWAY:

•       The 31 patients in the primary treatment group had a median PSA nadir of 0.16, while the 12 patients in the salvage therapy group had a median PSA nadir of 0.12, with median follow-up periods of 23 and 25 months, respectively.
•       Local recurrence rates were comparable between groups, occurring in 5 patients (16%) in the primary group and 2 (17%) in the salvage group.
•       Sexual Health Inventory for Men scores and American Urological Association Symptom Score showed no statistically significant differences before and after HIFU therapy in both groups (P = .35). > .05).
•       Short- and intermediate-term results demonstrated HIFU's effectiveness in maintaining potency and urinary function while providing adequate oncological control for both primary and salvage therapies.
•      Two patients (7%) from the primary treatment group experienced 30-day complications, including one case of epididymo-orchitis and 1 case of urethral stricture.
•      Three patients (25%) from the salvage treatment group experienced 30-day complications, including one bladder neck contracture.

IN PRACTICE: "The application of HIFU in a veteran population is of particular interest due to the unique medical challenges this group faces. Veterans often present with complex medical conditions and a higher comorbidity burden compared to the general population, as indicated by a median Charleson Comorbidity Index of 7 in our primary HIFU group," wrote the authors of the study. 

SOURCE: The study was led by Sagar Patel and Ali Antar, Operative Care Line, Urology Section, Michael E. DeBakey Veteran Affairs Medical Center in Houston. It was published online in Life.

 LIMITATIONS: The study's relatively short median follow-up period of 23-25 months limits the assessment of long-term oncological outcomes in prostate cancer. The sample size, while substantial for an initial series, remains modest, particularly for the salvage therapy group. According to the authors, larger multi-center studies with longer follow-up periods will be necessary to confirm and extend these findings, especially for establishing the durability of oncological control and functional preservation. 

DISCLOSURES: The study received no external funding. The research was conducted in accordance with the Declaration of Helsinki and received approval from the Institutional Review Board in February 2024. Support was obtained from the Prostate Cancer Foundation-VALOR Challenge Program. The authors declared no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication

TOPLINE: A small study of veterans found that high-intensity focused ultrasound (HIFU) demonstrated similar oncologic outcomes when compared to standard treatments for localized prostate cancer, while maintaining erectile and urinary function. 

METHODOLOGY: 

•      A retrospective analysis at the Michael E. DeBakey Veterans Affairs Medical Center in Houston between 2018 and 2022, with data acquired from electronic health record.
•      A total of 43 veterans were included in the analysis; 31 patients (72%) receiving primary treatment and 12 patients (28%) receiving salvage therapy.
•      Patient risk stratification was performed using prostate specific antigen (PSA), Gleason Score, and clinical stage based on National Comprehensive Cancer Network and D'Amico criteria.
•      Follow-up assessments included serial PSA measurements at 3, 6, 12, 18, and 24 months, with functional outcomes evaluated through Sexual Health Inventory for Men and American Urological Association Symptom Score questionnaires.

TAKEAWAY:

•       The 31 patients in the primary treatment group had a median PSA nadir of 0.16, while the 12 patients in the salvage therapy group had a median PSA nadir of 0.12, with median follow-up periods of 23 and 25 months, respectively.
•       Local recurrence rates were comparable between groups, occurring in 5 patients (16%) in the primary group and 2 (17%) in the salvage group.
•       Sexual Health Inventory for Men scores and American Urological Association Symptom Score showed no statistically significant differences before and after HIFU therapy in both groups (P = .35). > .05).
•       Short- and intermediate-term results demonstrated HIFU's effectiveness in maintaining potency and urinary function while providing adequate oncological control for both primary and salvage therapies.
•      Two patients (7%) from the primary treatment group experienced 30-day complications, including one case of epididymo-orchitis and 1 case of urethral stricture.
•      Three patients (25%) from the salvage treatment group experienced 30-day complications, including one bladder neck contracture.

IN PRACTICE: "The application of HIFU in a veteran population is of particular interest due to the unique medical challenges this group faces. Veterans often present with complex medical conditions and a higher comorbidity burden compared to the general population, as indicated by a median Charleson Comorbidity Index of 7 in our primary HIFU group," wrote the authors of the study. 

SOURCE: The study was led by Sagar Patel and Ali Antar, Operative Care Line, Urology Section, Michael E. DeBakey Veteran Affairs Medical Center in Houston. It was published online in Life.

 LIMITATIONS: The study's relatively short median follow-up period of 23-25 months limits the assessment of long-term oncological outcomes in prostate cancer. The sample size, while substantial for an initial series, remains modest, particularly for the salvage therapy group. According to the authors, larger multi-center studies with longer follow-up periods will be necessary to confirm and extend these findings, especially for establishing the durability of oncological control and functional preservation. 

DISCLOSURES: The study received no external funding. The research was conducted in accordance with the Declaration of Helsinki and received approval from the Institutional Review Board in February 2024. Support was obtained from the Prostate Cancer Foundation-VALOR Challenge Program. The authors declared no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication

TOPLINE: A small study of veterans found that high-intensity focused ultrasound (HIFU) demonstrated similar oncologic outcomes when compared to standard treatments for localized prostate cancer, while maintaining erectile and urinary function. 

METHODOLOGY: 

•      A retrospective analysis at the Michael E. DeBakey Veterans Affairs Medical Center in Houston between 2018 and 2022, with data acquired from electronic health record.
•      A total of 43 veterans were included in the analysis; 31 patients (72%) receiving primary treatment and 12 patients (28%) receiving salvage therapy.
•      Patient risk stratification was performed using prostate specific antigen (PSA), Gleason Score, and clinical stage based on National Comprehensive Cancer Network and D'Amico criteria.
•      Follow-up assessments included serial PSA measurements at 3, 6, 12, 18, and 24 months, with functional outcomes evaluated through Sexual Health Inventory for Men and American Urological Association Symptom Score questionnaires.

TAKEAWAY:

•       The 31 patients in the primary treatment group had a median PSA nadir of 0.16, while the 12 patients in the salvage therapy group had a median PSA nadir of 0.12, with median follow-up periods of 23 and 25 months, respectively.
•       Local recurrence rates were comparable between groups, occurring in 5 patients (16%) in the primary group and 2 (17%) in the salvage group.
•       Sexual Health Inventory for Men scores and American Urological Association Symptom Score showed no statistically significant differences before and after HIFU therapy in both groups (P = .35). > .05).
•       Short- and intermediate-term results demonstrated HIFU's effectiveness in maintaining potency and urinary function while providing adequate oncological control for both primary and salvage therapies.
•      Two patients (7%) from the primary treatment group experienced 30-day complications, including one case of epididymo-orchitis and 1 case of urethral stricture.
•      Three patients (25%) from the salvage treatment group experienced 30-day complications, including one bladder neck contracture.

IN PRACTICE: "The application of HIFU in a veteran population is of particular interest due to the unique medical challenges this group faces. Veterans often present with complex medical conditions and a higher comorbidity burden compared to the general population, as indicated by a median Charleson Comorbidity Index of 7 in our primary HIFU group," wrote the authors of the study. 

SOURCE: The study was led by Sagar Patel and Ali Antar, Operative Care Line, Urology Section, Michael E. DeBakey Veteran Affairs Medical Center in Houston. It was published online in Life.

 LIMITATIONS: The study's relatively short median follow-up period of 23-25 months limits the assessment of long-term oncological outcomes in prostate cancer. The sample size, while substantial for an initial series, remains modest, particularly for the salvage therapy group. According to the authors, larger multi-center studies with longer follow-up periods will be necessary to confirm and extend these findings, especially for establishing the durability of oncological control and functional preservation. 

DISCLOSURES: The study received no external funding. The research was conducted in accordance with the Declaration of Helsinki and received approval from the Institutional Review Board in February 2024. Support was obtained from the Prostate Cancer Foundation-VALOR Challenge Program. The authors declared no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication