Most women (72%) are not aware they are at risk for developing uterine fibroids, though up to 77% of women will develop them in their lifetime, results of a new survey indicate.

Data from The Harris Poll, conducted on behalf of the Society of Interventional Radiology, also found that 17% of women mistakenly think a hysterectomy is the only treatment option, including more than one in four women (27%) who are between the ages of 18 and 34. Results were shared in a press release. The survey included 1,122 US women, some who have been diagnosed with uterine fibroids.

Fibroids may not cause symptoms for some, but some women may have heavy, prolonged, debilitating bleeding. Some women experience pelvic pain, a diminished sex life, and declining energy. However, the growths do not spread to other body regions and typically are not dangerous.
 

Hysterectomy Is Only One Option

Among the women in the survey who had been diagnosed with fibroids, 53% were presented the option of hysterectomy and 20% were told about other, less-invasive options, including over-the-counter NSAIDs (19%); uterine fibroid embolization (UFE) (17%); oral contraceptives (17%); and endometrial ablation (17%).

“Women need to be informed about the complete range of options available for treating their uterine fibroids, not just the surgical options as is most commonly done by gynecologists,” John C. Lipman, MD, founder and medical director of the Atlanta Fibroid Center in Smyrna, Georgia, said in the press release.

The survey also found that:

• More than half of women ages 18-34 (56%) and women ages 35-44 (51%) were either not familiar with uterine fibroids or never heard of them.
• Awareness was particularly low among Hispanic women, as 50% of Hispanic women say they’ve never heard of or aren’t familiar with the condition, compared with 37% of Black women who answered that way.
• More than one third (36%) of Black women and 22% of Hispanic women mistakenly think they are not at risk for developing fibroids, yet research has shown that uterine fibroids are three times more common in Black women and two times more common in Hispanic women than in White women.

For this study, the full sample data is accurate to within +/– 3.2 percentage points using a 95% confidence level. The data are part of the report “The Fibroid Fix: What Women Need to Know,” published on July 9 by the Society of Interventional Radiology.

Linda Fan, MD, chief of gynecology at Yale University in New Haven, Connecticut, said she is not surprised by those numbers. She says many patients are referred to her department who have not been given the full array of medical options for their fibroids or have not had thorough discussions with their providers, such as whether they want to preserve their fertility, or how they feel about an incision, undergoing anesthesia, or having their uterus removed.

Sometimes the hysterectomy choice is clear, she said — for instance, if there are indications of the rare cancer leiomyosarcoma, or if a postmenopausal woman has rapid growth of fibroids or heavy bleeding. Fibroids should not start growing after menopause, she said.

Additional options include radiofrequency ablation, performed while a patient is under anesthesia, by laparoscopy or hysteroscopy. The procedure uses ultrasound to watch a probe as it shrinks the fibroids with heat.

Currently, if a woman wants large fibroids removed and wants to keep her fertility options open, Dr. Fan says, myomectomy or medication are best “because we have the most information or data on (those options).”

When treating patients who don’t prioritize fertility, she said, UFE is a good option that doesn’t need incisions or anesthesia. But patients sometimes require a lot of pain medication afterward, Dr. Fan said. With radiofrequency ablation, specifically the Acessa and Sonata procedures, she said, “patients don’t experience a lot of pain after the procedure because the shrinking happens when they’re asleep under anesthesia.”
 

Uterine Fibroid Embolization a Nonsurgical Option

The report describes how UFE works but the Harris Poll showed that 60% of women who have heard of UFE did not hear about it first from a healthcare provider.

“UFE is a nonsurgical treatment, performed by interventional radiologists, that has been proven to significantly reduce heavy menstrual bleeding, relieve uterine pain, and improve energy levels,” the authors write. “Through a tiny incision in the wrist or thigh, a catheter is guided via imaging to the vessels leading to the fibroids. Through this catheter, small clear particles are injected to block the blood flow leading to the fibroids causing them to shrink and disappear.”

After UFE, most women leave the hospital the day of or the day after treatment, according to the report authors, who add that many patients also report they can resume normal activity in about 2 weeks, more quickly than with surgical treatments.

In some cases, watchful waiting will be the best option, the report notes, and that may require repeated checkups and scans.

Dr. Lipman is an adviser on The Fibroid Fix report.

Most women (72%) are not aware they are at risk for developing uterine fibroids, though up to 77% of women will develop them in their lifetime, results of a new survey indicate.

Data from The Harris Poll, conducted on behalf of the Society of Interventional Radiology, also found that 17% of women mistakenly think a hysterectomy is the only treatment option, including more than one in four women (27%) who are between the ages of 18 and 34. Results were shared in a press release. The survey included 1,122 US women, some who have been diagnosed with uterine fibroids.

Fibroids may not cause symptoms for some, but some women may have heavy, prolonged, debilitating bleeding. Some women experience pelvic pain, a diminished sex life, and declining energy. However, the growths do not spread to other body regions and typically are not dangerous.
 

Hysterectomy Is Only One Option

Among the women in the survey who had been diagnosed with fibroids, 53% were presented the option of hysterectomy and 20% were told about other, less-invasive options, including over-the-counter NSAIDs (19%); uterine fibroid embolization (UFE) (17%); oral contraceptives (17%); and endometrial ablation (17%).

“Women need to be informed about the complete range of options available for treating their uterine fibroids, not just the surgical options as is most commonly done by gynecologists,” John C. Lipman, MD, founder and medical director of the Atlanta Fibroid Center in Smyrna, Georgia, said in the press release.

The survey also found that:

• More than half of women ages 18-34 (56%) and women ages 35-44 (51%) were either not familiar with uterine fibroids or never heard of them.
• Awareness was particularly low among Hispanic women, as 50% of Hispanic women say they’ve never heard of or aren’t familiar with the condition, compared with 37% of Black women who answered that way.
• More than one third (36%) of Black women and 22% of Hispanic women mistakenly think they are not at risk for developing fibroids, yet research has shown that uterine fibroids are three times more common in Black women and two times more common in Hispanic women than in White women.

For this study, the full sample data is accurate to within +/– 3.2 percentage points using a 95% confidence level. The data are part of the report “The Fibroid Fix: What Women Need to Know,” published on July 9 by the Society of Interventional Radiology.

Linda Fan, MD, chief of gynecology at Yale University in New Haven, Connecticut, said she is not surprised by those numbers. She says many patients are referred to her department who have not been given the full array of medical options for their fibroids or have not had thorough discussions with their providers, such as whether they want to preserve their fertility, or how they feel about an incision, undergoing anesthesia, or having their uterus removed.

Sometimes the hysterectomy choice is clear, she said — for instance, if there are indications of the rare cancer leiomyosarcoma, or if a postmenopausal woman has rapid growth of fibroids or heavy bleeding. Fibroids should not start growing after menopause, she said.

Additional options include radiofrequency ablation, performed while a patient is under anesthesia, by laparoscopy or hysteroscopy. The procedure uses ultrasound to watch a probe as it shrinks the fibroids with heat.

Currently, if a woman wants large fibroids removed and wants to keep her fertility options open, Dr. Fan says, myomectomy or medication are best “because we have the most information or data on (those options).”

When treating patients who don’t prioritize fertility, she said, UFE is a good option that doesn’t need incisions or anesthesia. But patients sometimes require a lot of pain medication afterward, Dr. Fan said. With radiofrequency ablation, specifically the Acessa and Sonata procedures, she said, “patients don’t experience a lot of pain after the procedure because the shrinking happens when they’re asleep under anesthesia.”
 

Uterine Fibroid Embolization a Nonsurgical Option

The report describes how UFE works but the Harris Poll showed that 60% of women who have heard of UFE did not hear about it first from a healthcare provider.

“UFE is a nonsurgical treatment, performed by interventional radiologists, that has been proven to significantly reduce heavy menstrual bleeding, relieve uterine pain, and improve energy levels,” the authors write. “Through a tiny incision in the wrist or thigh, a catheter is guided via imaging to the vessels leading to the fibroids. Through this catheter, small clear particles are injected to block the blood flow leading to the fibroids causing them to shrink and disappear.”

After UFE, most women leave the hospital the day of or the day after treatment, according to the report authors, who add that many patients also report they can resume normal activity in about 2 weeks, more quickly than with surgical treatments.

In some cases, watchful waiting will be the best option, the report notes, and that may require repeated checkups and scans.

Dr. Lipman is an adviser on The Fibroid Fix report.

Most women (72%) are not aware they are at risk for developing uterine fibroids, though up to 77% of women will develop them in their lifetime, results of a new survey indicate.

Data from The Harris Poll, conducted on behalf of the Society of Interventional Radiology, also found that 17% of women mistakenly think a hysterectomy is the only treatment option, including more than one in four women (27%) who are between the ages of 18 and 34. Results were shared in a press release. The survey included 1,122 US women, some who have been diagnosed with uterine fibroids.

Fibroids may not cause symptoms for some, but some women may have heavy, prolonged, debilitating bleeding. Some women experience pelvic pain, a diminished sex life, and declining energy. However, the growths do not spread to other body regions and typically are not dangerous.
 

Hysterectomy Is Only One Option

Among the women in the survey who had been diagnosed with fibroids, 53% were presented the option of hysterectomy and 20% were told about other, less-invasive options, including over-the-counter NSAIDs (19%); uterine fibroid embolization (UFE) (17%); oral contraceptives (17%); and endometrial ablation (17%).

“Women need to be informed about the complete range of options available for treating their uterine fibroids, not just the surgical options as is most commonly done by gynecologists,” John C. Lipman, MD, founder and medical director of the Atlanta Fibroid Center in Smyrna, Georgia, said in the press release.

The survey also found that:

• More than half of women ages 18-34 (56%) and women ages 35-44 (51%) were either not familiar with uterine fibroids or never heard of them.
• Awareness was particularly low among Hispanic women, as 50% of Hispanic women say they’ve never heard of or aren’t familiar with the condition, compared with 37% of Black women who answered that way.
• More than one third (36%) of Black women and 22% of Hispanic women mistakenly think they are not at risk for developing fibroids, yet research has shown that uterine fibroids are three times more common in Black women and two times more common in Hispanic women than in White women.

For this study, the full sample data is accurate to within +/– 3.2 percentage points using a 95% confidence level. The data are part of the report “The Fibroid Fix: What Women Need to Know,” published on July 9 by the Society of Interventional Radiology.

Linda Fan, MD, chief of gynecology at Yale University in New Haven, Connecticut, said she is not surprised by those numbers. She says many patients are referred to her department who have not been given the full array of medical options for their fibroids or have not had thorough discussions with their providers, such as whether they want to preserve their fertility, or how they feel about an incision, undergoing anesthesia, or having their uterus removed.

Sometimes the hysterectomy choice is clear, she said — for instance, if there are indications of the rare cancer leiomyosarcoma, or if a postmenopausal woman has rapid growth of fibroids or heavy bleeding. Fibroids should not start growing after menopause, she said.

Additional options include radiofrequency ablation, performed while a patient is under anesthesia, by laparoscopy or hysteroscopy. The procedure uses ultrasound to watch a probe as it shrinks the fibroids with heat.

Currently, if a woman wants large fibroids removed and wants to keep her fertility options open, Dr. Fan says, myomectomy or medication are best “because we have the most information or data on (those options).”

When treating patients who don’t prioritize fertility, she said, UFE is a good option that doesn’t need incisions or anesthesia. But patients sometimes require a lot of pain medication afterward, Dr. Fan said. With radiofrequency ablation, specifically the Acessa and Sonata procedures, she said, “patients don’t experience a lot of pain after the procedure because the shrinking happens when they’re asleep under anesthesia.”
 

Uterine Fibroid Embolization a Nonsurgical Option

The report describes how UFE works but the Harris Poll showed that 60% of women who have heard of UFE did not hear about it first from a healthcare provider.

“UFE is a nonsurgical treatment, performed by interventional radiologists, that has been proven to significantly reduce heavy menstrual bleeding, relieve uterine pain, and improve energy levels,” the authors write. “Through a tiny incision in the wrist or thigh, a catheter is guided via imaging to the vessels leading to the fibroids. Through this catheter, small clear particles are injected to block the blood flow leading to the fibroids causing them to shrink and disappear.”

After UFE, most women leave the hospital the day of or the day after treatment, according to the report authors, who add that many patients also report they can resume normal activity in about 2 weeks, more quickly than with surgical treatments.

In some cases, watchful waiting will be the best option, the report notes, and that may require repeated checkups and scans.

Dr. Lipman is an adviser on The Fibroid Fix report.

To discuss issues related to counseling patients about weight loss with glucagon-like peptide 1 receptor agonists (GLP-1 RAs), I recently posted a case from my own practice. This was a 44-year-old woman with hyperlipidemia, hypertension, and obesity who wanted to try to lose weight with a GLP-1 RA, having been unsuccessful in maintaining a normal weight with lifestyle change alone.

I am very happy to see a high number of favorable responses to this article, and I also recognize that it was very focused on GLP-1 RA therapy while not addressing the multivariate treatment of obesity. 

A healthy lifestyle remains foundational for the management of obesity, and clinicians should guide patients to make constructive choices regarding their diet, physical activity, mental health, and sleep. However, like for our patient introduced in that article, lifestyle changes are rarely sufficient to obtain a goal of sustained weight loss that promotes better health outcomes. A meta-analysis of clinical trials testing lifestyle interventions to lose weight among adults with overweight and obesity found that the relative reduction in body weight in the intervention vs control cohorts was −3.63 kg at 1 year and −2.45 kg at 3 years. More intensive programs with at least 28 interventions per year were associated with slightly more weight loss than less intensive programs.

That is why clinicians and patients have been reaching for effective pharmacotherapy to create better outcomes among adults with obesity. In a national survey of 1479 US adults, 12% reported having used a GLP-1 RA. Diabetes was the most common indication (43%), followed by heart disease (26%) and overweight/obesity (22%).

The high cost of GLP-1 RA therapy was a major barrier to even wider use. Some 54% of participants said that it was difficult to afford GLP-1 RA therapy, and an additional 22% found it very difficult to pay for the drugs. Having health insurance did not alter these figures substantially.

While cost and access remain some of the greatest challenges with the use of GLP-1 RAs, there is hope for change there. In March 2024, the US Food and Drug Administration approved semaglutide to reduce the risk for cardiovascular events among patients with overweight and obesity and existing cardiovascular disease. It appears that Medicare will cover semaglutide for that indication, which bucks a trend of more than 20 years during which Medicare Part D would not cover pharmacotherapy for weight loss.

There is bipartisan support in the US Congress to further increase coverage of GLP-1 RAs for obesity, which makes sense. GLP-1 RAs are associated with greater average weight loss than either lifestyle interventions alone or that associated with previous anti-obesity medications. While there are no safety data for these drugs stretching back for 50 or 100 years, clinicians should bear in mind that exenatide was approved for the management of type 2 diabetes in 2005. So, we are approaching two decades of practical experience with these drugs, and it appears clear that the benefits of GLP-1 RAs outweigh any known harms. For the right patient, and with the right kind of guidance by clinicians, GLP-1 RA therapy can have a profound effect on individual and public health.
 

Dr. Vega, health sciences clinical professor, Family Medicine, University of California, Irvine, disclosed ties with McNeil Pharmaceuticals.

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

To discuss issues related to counseling patients about weight loss with glucagon-like peptide 1 receptor agonists (GLP-1 RAs), I recently posted a case from my own practice. This was a 44-year-old woman with hyperlipidemia, hypertension, and obesity who wanted to try to lose weight with a GLP-1 RA, having been unsuccessful in maintaining a normal weight with lifestyle change alone.

I am very happy to see a high number of favorable responses to this article, and I also recognize that it was very focused on GLP-1 RA therapy while not addressing the multivariate treatment of obesity. 

A healthy lifestyle remains foundational for the management of obesity, and clinicians should guide patients to make constructive choices regarding their diet, physical activity, mental health, and sleep. However, like for our patient introduced in that article, lifestyle changes are rarely sufficient to obtain a goal of sustained weight loss that promotes better health outcomes. A meta-analysis of clinical trials testing lifestyle interventions to lose weight among adults with overweight and obesity found that the relative reduction in body weight in the intervention vs control cohorts was −3.63 kg at 1 year and −2.45 kg at 3 years. More intensive programs with at least 28 interventions per year were associated with slightly more weight loss than less intensive programs.

That is why clinicians and patients have been reaching for effective pharmacotherapy to create better outcomes among adults with obesity. In a national survey of 1479 US adults, 12% reported having used a GLP-1 RA. Diabetes was the most common indication (43%), followed by heart disease (26%) and overweight/obesity (22%).

The high cost of GLP-1 RA therapy was a major barrier to even wider use. Some 54% of participants said that it was difficult to afford GLP-1 RA therapy, and an additional 22% found it very difficult to pay for the drugs. Having health insurance did not alter these figures substantially.

While cost and access remain some of the greatest challenges with the use of GLP-1 RAs, there is hope for change there. In March 2024, the US Food and Drug Administration approved semaglutide to reduce the risk for cardiovascular events among patients with overweight and obesity and existing cardiovascular disease. It appears that Medicare will cover semaglutide for that indication, which bucks a trend of more than 20 years during which Medicare Part D would not cover pharmacotherapy for weight loss.

There is bipartisan support in the US Congress to further increase coverage of GLP-1 RAs for obesity, which makes sense. GLP-1 RAs are associated with greater average weight loss than either lifestyle interventions alone or that associated with previous anti-obesity medications. While there are no safety data for these drugs stretching back for 50 or 100 years, clinicians should bear in mind that exenatide was approved for the management of type 2 diabetes in 2005. So, we are approaching two decades of practical experience with these drugs, and it appears clear that the benefits of GLP-1 RAs outweigh any known harms. For the right patient, and with the right kind of guidance by clinicians, GLP-1 RA therapy can have a profound effect on individual and public health.
 

Dr. Vega, health sciences clinical professor, Family Medicine, University of California, Irvine, disclosed ties with McNeil Pharmaceuticals.

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

To discuss issues related to counseling patients about weight loss with glucagon-like peptide 1 receptor agonists (GLP-1 RAs), I recently posted a case from my own practice. This was a 44-year-old woman with hyperlipidemia, hypertension, and obesity who wanted to try to lose weight with a GLP-1 RA, having been unsuccessful in maintaining a normal weight with lifestyle change alone.

I am very happy to see a high number of favorable responses to this article, and I also recognize that it was very focused on GLP-1 RA therapy while not addressing the multivariate treatment of obesity. 

A healthy lifestyle remains foundational for the management of obesity, and clinicians should guide patients to make constructive choices regarding their diet, physical activity, mental health, and sleep. However, like for our patient introduced in that article, lifestyle changes are rarely sufficient to obtain a goal of sustained weight loss that promotes better health outcomes. A meta-analysis of clinical trials testing lifestyle interventions to lose weight among adults with overweight and obesity found that the relative reduction in body weight in the intervention vs control cohorts was −3.63 kg at 1 year and −2.45 kg at 3 years. More intensive programs with at least 28 interventions per year were associated with slightly more weight loss than less intensive programs.

That is why clinicians and patients have been reaching for effective pharmacotherapy to create better outcomes among adults with obesity. In a national survey of 1479 US adults, 12% reported having used a GLP-1 RA. Diabetes was the most common indication (43%), followed by heart disease (26%) and overweight/obesity (22%).

The high cost of GLP-1 RA therapy was a major barrier to even wider use. Some 54% of participants said that it was difficult to afford GLP-1 RA therapy, and an additional 22% found it very difficult to pay for the drugs. Having health insurance did not alter these figures substantially.

While cost and access remain some of the greatest challenges with the use of GLP-1 RAs, there is hope for change there. In March 2024, the US Food and Drug Administration approved semaglutide to reduce the risk for cardiovascular events among patients with overweight and obesity and existing cardiovascular disease. It appears that Medicare will cover semaglutide for that indication, which bucks a trend of more than 20 years during which Medicare Part D would not cover pharmacotherapy for weight loss.

There is bipartisan support in the US Congress to further increase coverage of GLP-1 RAs for obesity, which makes sense. GLP-1 RAs are associated with greater average weight loss than either lifestyle interventions alone or that associated with previous anti-obesity medications. While there are no safety data for these drugs stretching back for 50 or 100 years, clinicians should bear in mind that exenatide was approved for the management of type 2 diabetes in 2005. So, we are approaching two decades of practical experience with these drugs, and it appears clear that the benefits of GLP-1 RAs outweigh any known harms. For the right patient, and with the right kind of guidance by clinicians, GLP-1 RA therapy can have a profound effect on individual and public health.
 

Dr. Vega, health sciences clinical professor, Family Medicine, University of California, Irvine, disclosed ties with McNeil Pharmaceuticals.

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

In this special supplement to Federal Practitioner, Dr. Jameel Muzaffar, MD shares insights into a second-line treatment option for previously treated radioiodine-refractory differentiated thyroid cancer (DTC), along with an exploratory analysis of BRAF mutation status. It discusses the challenges associated with metastatic DTC and the significance of understanding factors like BRAF mutation status in treatment decisions. Additionally, it highlights the efficacy and safety profiles of the treatment option.

Click here to Read More

CA-3326

In this special supplement to Federal Practitioner, Dr. Jameel Muzaffar, MD shares insights into a second-line treatment option for previously treated radioiodine-refractory differentiated thyroid cancer (DTC), along with an exploratory analysis of BRAF mutation status. It discusses the challenges associated with metastatic DTC and the significance of understanding factors like BRAF mutation status in treatment decisions. Additionally, it highlights the efficacy and safety profiles of the treatment option.

Click here to Read More

CA-3326

In this special supplement to Federal Practitioner, Dr. Jameel Muzaffar, MD shares insights into a second-line treatment option for previously treated radioiodine-refractory differentiated thyroid cancer (DTC), along with an exploratory analysis of BRAF mutation status. It discusses the challenges associated with metastatic DTC and the significance of understanding factors like BRAF mutation status in treatment decisions. Additionally, it highlights the efficacy and safety profiles of the treatment option.

Click here to Read More

CA-3326

TOPLINE:

Lowering the dose of edoxaban to 30 mg in patients 80 years of age and older with atrial fibrillation (AF) reduces major bleeding events without increasing ischemic events.

METHODOLOGY:

• Researchers conducted a parallel design, double-blind clinical trial of 21,105 patients with AF.
• Nearly 3000 patients aged 80 years and older were included in the secondary analysis, focusing on edoxaban, 60 mg vs 30 mg, and edoxaban 30 mg vs warfarin.
• The primary outcome was a composite of death, stroke or systemic embolism, and major bleeding, with secondary outcomes including ischemic stroke and all-cause death.
• People were excluded from the study if they had moderate or severe mitral stenosis, a mechanical heart valve, a high risk for bleeding, or were on antiplatelet drugs.

TAKEAWAY:

• Participants without dose-reduction criteria who received edoxaban 30 mg had lower rates of major bleeding than those who received 60 mg (hazard ratio [HR], 1.57; 95% CI, 1.04-2.38; P = .03).
• Rates of major gastrointestinal hemorrhage were higher with edoxaban 60 mg than with 30 mg (HR, 2.24; 95% CI, 1.29-3.90; P = .004).
• People who took edoxaban 30 mg had a 17% lower risk for all-cause death than those who received warfarin (HR, 0.83; 95% CI, 0.70-1.00; P = .046).
• In a little over 2400 participants with or without dose-reduction criteria, those receiving edoxaban 30 mg had the lower risk for major bleeding (HR, 0.59; 95% CI, 0.45-0.77; P < .001) and death (HR, 0.83; 95% CI, 0.70-1.00; P = .046); risk for stroke or systemic embolism was comparable between the two drugs.

IN PRACTICE:

“These data suggest that lower-dose anticoagulants, such as edoxaban, 30 mg once daily, may be considered in all patients 80 years and older with AF irrespective of dose-reduction criteria,” the study authors wrote.

SOURCE:

The study was led by André Zimerman, MD, PhD, of Brigham and Women’s Hospital and the Department of Medicine at Harvard Medical School in Boston. It was published online in JAMA Cardiology. The study was funded by Daiichi Sankyo for the TIMI Study Group.

LIMITATIONS:

The study did not adjust for multiple comparisons, increasing the risk for type I and type II errors. Additionally, the trial participants may represent a more compliant subset of the target population, which could influence the results.

DISCLOSURES:

Various authors reported receiving grants, consultant fees, and consulting fees from AstraZeneca, Merck, Novartis, Amgen, Boehringer Ingelheim/Lilly, and Cardurion Pharmaceuticals, among others.

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:

Lowering the dose of edoxaban to 30 mg in patients 80 years of age and older with atrial fibrillation (AF) reduces major bleeding events without increasing ischemic events.

METHODOLOGY:

• Researchers conducted a parallel design, double-blind clinical trial of 21,105 patients with AF.
• Nearly 3000 patients aged 80 years and older were included in the secondary analysis, focusing on edoxaban, 60 mg vs 30 mg, and edoxaban 30 mg vs warfarin.
• The primary outcome was a composite of death, stroke or systemic embolism, and major bleeding, with secondary outcomes including ischemic stroke and all-cause death.
• People were excluded from the study if they had moderate or severe mitral stenosis, a mechanical heart valve, a high risk for bleeding, or were on antiplatelet drugs.

TAKEAWAY:

• Participants without dose-reduction criteria who received edoxaban 30 mg had lower rates of major bleeding than those who received 60 mg (hazard ratio [HR], 1.57; 95% CI, 1.04-2.38; P = .03).
• Rates of major gastrointestinal hemorrhage were higher with edoxaban 60 mg than with 30 mg (HR, 2.24; 95% CI, 1.29-3.90; P = .004).
• People who took edoxaban 30 mg had a 17% lower risk for all-cause death than those who received warfarin (HR, 0.83; 95% CI, 0.70-1.00; P = .046).
• In a little over 2400 participants with or without dose-reduction criteria, those receiving edoxaban 30 mg had the lower risk for major bleeding (HR, 0.59; 95% CI, 0.45-0.77; P < .001) and death (HR, 0.83; 95% CI, 0.70-1.00; P = .046); risk for stroke or systemic embolism was comparable between the two drugs.

IN PRACTICE:

“These data suggest that lower-dose anticoagulants, such as edoxaban, 30 mg once daily, may be considered in all patients 80 years and older with AF irrespective of dose-reduction criteria,” the study authors wrote.

SOURCE:

The study was led by André Zimerman, MD, PhD, of Brigham and Women’s Hospital and the Department of Medicine at Harvard Medical School in Boston. It was published online in JAMA Cardiology. The study was funded by Daiichi Sankyo for the TIMI Study Group.

LIMITATIONS:

The study did not adjust for multiple comparisons, increasing the risk for type I and type II errors. Additionally, the trial participants may represent a more compliant subset of the target population, which could influence the results.

DISCLOSURES:

Various authors reported receiving grants, consultant fees, and consulting fees from AstraZeneca, Merck, Novartis, Amgen, Boehringer Ingelheim/Lilly, and Cardurion Pharmaceuticals, among others.

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:

Lowering the dose of edoxaban to 30 mg in patients 80 years of age and older with atrial fibrillation (AF) reduces major bleeding events without increasing ischemic events.

METHODOLOGY:

• Researchers conducted a parallel design, double-blind clinical trial of 21,105 patients with AF.
• Nearly 3000 patients aged 80 years and older were included in the secondary analysis, focusing on edoxaban, 60 mg vs 30 mg, and edoxaban 30 mg vs warfarin.
• The primary outcome was a composite of death, stroke or systemic embolism, and major bleeding, with secondary outcomes including ischemic stroke and all-cause death.
• People were excluded from the study if they had moderate or severe mitral stenosis, a mechanical heart valve, a high risk for bleeding, or were on antiplatelet drugs.

TAKEAWAY:

• Participants without dose-reduction criteria who received edoxaban 30 mg had lower rates of major bleeding than those who received 60 mg (hazard ratio [HR], 1.57; 95% CI, 1.04-2.38; P = .03).
• Rates of major gastrointestinal hemorrhage were higher with edoxaban 60 mg than with 30 mg (HR, 2.24; 95% CI, 1.29-3.90; P = .004).
• People who took edoxaban 30 mg had a 17% lower risk for all-cause death than those who received warfarin (HR, 0.83; 95% CI, 0.70-1.00; P = .046).
• In a little over 2400 participants with or without dose-reduction criteria, those receiving edoxaban 30 mg had the lower risk for major bleeding (HR, 0.59; 95% CI, 0.45-0.77; P < .001) and death (HR, 0.83; 95% CI, 0.70-1.00; P = .046); risk for stroke or systemic embolism was comparable between the two drugs.

IN PRACTICE:

“These data suggest that lower-dose anticoagulants, such as edoxaban, 30 mg once daily, may be considered in all patients 80 years and older with AF irrespective of dose-reduction criteria,” the study authors wrote.

SOURCE:

The study was led by André Zimerman, MD, PhD, of Brigham and Women’s Hospital and the Department of Medicine at Harvard Medical School in Boston. It was published online in JAMA Cardiology. The study was funded by Daiichi Sankyo for the TIMI Study Group.

LIMITATIONS:

The study did not adjust for multiple comparisons, increasing the risk for type I and type II errors. Additionally, the trial participants may represent a more compliant subset of the target population, which could influence the results.

DISCLOSURES:

Various authors reported receiving grants, consultant fees, and consulting fees from AstraZeneca, Merck, Novartis, Amgen, Boehringer Ingelheim/Lilly, and Cardurion Pharmaceuticals, among others.

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.

CHICAGO — Chinese investigators have reported a potentially new first-line treatment option for the up to 30% of diffuse large B-cell lymphoma (DLBCL) patients with increased expression of the oncogenes MYC and BCLC.

At the annual meeting of the American Society of Clinical Oncology (ASCO), they announced that combining the histone deacetylase inhibitor tucidinostat with standard R-CHOP chemotherapy in previously untreated “double-expresser” patients improved complete response and event-free survival (EFS) rates over R-CHOP alone.

The trial, dubbed DEB, is the first phase 3 investigation to confirm the benefit of combination treatment with an epigenetic agent for such patients, lead investigator and study presenter Weili Zhao, MD, PhD, a hematologist at the Shanghai Institute of Hematology, told her audience.

“Tucidinostat plus R-CHOP could be a new frontline treatment option in this patient population,” Dr. Zhao said.

However, the agent is not available in the United States, at least for now. It is approved in China for peripheral T-cell lymphoma (PTCL) and HER2-negative breast cancer and in Japan for PTCL and adult T-cell leukemia/lymphoma.

Dr. Zhao said that tucidinostat was also conditionally approved for DLBCL in China recently, based on the strength of the DEB results.

Study discussant Peter Riedell, MD, a hematologist at the University of Chicago, Illinois, was cautious on several points.

First, there’s been no overall survival benefit in the trial, but follow-up so far has been short, at a median of 13.9 months, and Dr. Zhao reported interim, not final, results.

Dr. Riedell also noted that there were more grade 3 or worse adverse events, particularly hematologic side effects, hypokalemia, and pneumonia, with tucidinostat add-on in DEB.

Other outstanding questions include the applicability of the findings to non-Chinese patients and the effect of adding tucidinostat to another common DLCBL chemotherapy regimen, pola-R-CHP, which is being increasingly used in the United States for higher-risk disease, which includes double-expressers of the MYC and BCLC oncogenes.

DEB equally randomized 423 patients at 40 centers in China to either six cycles of R-CHOP with tucidinostat 20 μg twice weekly or R-CHOP with placebo. Complete responders went on to either tucidinostat or placebo maintenance treatment for up to 24 weeks. Subjects had an International Prognostic Index score of at least 2.

Out of a total of 152 EFS events, 64 (30.3%) were in the tucidinostat group and 88 (41.5%) were in the placebo group; 24-month EFS was 58.9% with tucidinostat and 46.2% with R-CHOP alone (hazard ratio, 0.68; P = .018).

Meanwhile, the complete response rate with tucidinostat was 73.0% versus 61.8% (P = .014).

Although there were more higher-grade adverse events in the experimental arm, most patients were able to tolerate and complete the planned treatment cycles.

The study was funded by tucidinostat maker Chipscreen Biosciences. Dr. Zhao reported no disclosures. Dr. Riedell disclosed ties with numerous companies, including BeiGene (a partner of Chipscreen) and Novartis.

CHICAGO — Chinese investigators have reported a potentially new first-line treatment option for the up to 30% of diffuse large B-cell lymphoma (DLBCL) patients with increased expression of the oncogenes MYC and BCLC.

At the annual meeting of the American Society of Clinical Oncology (ASCO), they announced that combining the histone deacetylase inhibitor tucidinostat with standard R-CHOP chemotherapy in previously untreated “double-expresser” patients improved complete response and event-free survival (EFS) rates over R-CHOP alone.

The trial, dubbed DEB, is the first phase 3 investigation to confirm the benefit of combination treatment with an epigenetic agent for such patients, lead investigator and study presenter Weili Zhao, MD, PhD, a hematologist at the Shanghai Institute of Hematology, told her audience.

“Tucidinostat plus R-CHOP could be a new frontline treatment option in this patient population,” Dr. Zhao said.

However, the agent is not available in the United States, at least for now. It is approved in China for peripheral T-cell lymphoma (PTCL) and HER2-negative breast cancer and in Japan for PTCL and adult T-cell leukemia/lymphoma.

Dr. Zhao said that tucidinostat was also conditionally approved for DLBCL in China recently, based on the strength of the DEB results.

Study discussant Peter Riedell, MD, a hematologist at the University of Chicago, Illinois, was cautious on several points.

First, there’s been no overall survival benefit in the trial, but follow-up so far has been short, at a median of 13.9 months, and Dr. Zhao reported interim, not final, results.

Dr. Riedell also noted that there were more grade 3 or worse adverse events, particularly hematologic side effects, hypokalemia, and pneumonia, with tucidinostat add-on in DEB.

Other outstanding questions include the applicability of the findings to non-Chinese patients and the effect of adding tucidinostat to another common DLCBL chemotherapy regimen, pola-R-CHP, which is being increasingly used in the United States for higher-risk disease, which includes double-expressers of the MYC and BCLC oncogenes.

DEB equally randomized 423 patients at 40 centers in China to either six cycles of R-CHOP with tucidinostat 20 μg twice weekly or R-CHOP with placebo. Complete responders went on to either tucidinostat or placebo maintenance treatment for up to 24 weeks. Subjects had an International Prognostic Index score of at least 2.

Out of a total of 152 EFS events, 64 (30.3%) were in the tucidinostat group and 88 (41.5%) were in the placebo group; 24-month EFS was 58.9% with tucidinostat and 46.2% with R-CHOP alone (hazard ratio, 0.68; P = .018).

Meanwhile, the complete response rate with tucidinostat was 73.0% versus 61.8% (P = .014).

Although there were more higher-grade adverse events in the experimental arm, most patients were able to tolerate and complete the planned treatment cycles.

The study was funded by tucidinostat maker Chipscreen Biosciences. Dr. Zhao reported no disclosures. Dr. Riedell disclosed ties with numerous companies, including BeiGene (a partner of Chipscreen) and Novartis.

CHICAGO — Chinese investigators have reported a potentially new first-line treatment option for the up to 30% of diffuse large B-cell lymphoma (DLBCL) patients with increased expression of the oncogenes MYC and BCLC.

At the annual meeting of the American Society of Clinical Oncology (ASCO), they announced that combining the histone deacetylase inhibitor tucidinostat with standard R-CHOP chemotherapy in previously untreated “double-expresser” patients improved complete response and event-free survival (EFS) rates over R-CHOP alone.

The trial, dubbed DEB, is the first phase 3 investigation to confirm the benefit of combination treatment with an epigenetic agent for such patients, lead investigator and study presenter Weili Zhao, MD, PhD, a hematologist at the Shanghai Institute of Hematology, told her audience.

“Tucidinostat plus R-CHOP could be a new frontline treatment option in this patient population,” Dr. Zhao said.

However, the agent is not available in the United States, at least for now. It is approved in China for peripheral T-cell lymphoma (PTCL) and HER2-negative breast cancer and in Japan for PTCL and adult T-cell leukemia/lymphoma.

Dr. Zhao said that tucidinostat was also conditionally approved for DLBCL in China recently, based on the strength of the DEB results.

Study discussant Peter Riedell, MD, a hematologist at the University of Chicago, Illinois, was cautious on several points.

First, there’s been no overall survival benefit in the trial, but follow-up so far has been short, at a median of 13.9 months, and Dr. Zhao reported interim, not final, results.

Dr. Riedell also noted that there were more grade 3 or worse adverse events, particularly hematologic side effects, hypokalemia, and pneumonia, with tucidinostat add-on in DEB.

Other outstanding questions include the applicability of the findings to non-Chinese patients and the effect of adding tucidinostat to another common DLCBL chemotherapy regimen, pola-R-CHP, which is being increasingly used in the United States for higher-risk disease, which includes double-expressers of the MYC and BCLC oncogenes.

DEB equally randomized 423 patients at 40 centers in China to either six cycles of R-CHOP with tucidinostat 20 μg twice weekly or R-CHOP with placebo. Complete responders went on to either tucidinostat or placebo maintenance treatment for up to 24 weeks. Subjects had an International Prognostic Index score of at least 2.

Out of a total of 152 EFS events, 64 (30.3%) were in the tucidinostat group and 88 (41.5%) were in the placebo group; 24-month EFS was 58.9% with tucidinostat and 46.2% with R-CHOP alone (hazard ratio, 0.68; P = .018).

Meanwhile, the complete response rate with tucidinostat was 73.0% versus 61.8% (P = .014).

Although there were more higher-grade adverse events in the experimental arm, most patients were able to tolerate and complete the planned treatment cycles.

The study was funded by tucidinostat maker Chipscreen Biosciences. Dr. Zhao reported no disclosures. Dr. Riedell disclosed ties with numerous companies, including BeiGene (a partner of Chipscreen) and Novartis.

Decreased prevalence of Helicobacter pylori infection is not associated with an increased rate of esophageal cancer, based on a multinational cohort study.

This finding suggests that eradication of H pylori is safe with regard to esophageal cancer risk, and eradication campaigns are not contributing to the rising incidence of esophageal adenocarcinoma (EAC) over the past four decades, reported lead author Anna-Klara Wiklund, MD, of Karolinska Institutet, Stockholm, Sweden, and colleagues.“The decreased risk of esophageal adenocarcinoma seen in individuals with H pylori infection is probably explained by the H pylori–induced gastric atrophy, which reduces gastric acid production and thus acidic gastroesophageal reflux, the main risk factor for this tumor,” the investigators wrote in Gastroenterology. “It seems plausible that eradication of H pylori would increase the risk of EAC, although the answer to this question is unknown with the only study on the topic (from our group) having too few cases and too short follow-up.”

That study involved only 11 cases of EAC.

For the present study, Dr. Wiklund and colleagues aggregated data from all individuals who had undergone H pylori eradication in Finland, Denmark, Iceland, Norway, and Sweden from 1995 to 2019. The dataset comprised 661,987 such individuals with more than 5 million person-years after eradication therapy, including 550 cases of EAC. Median follow-up time was approximately 8 years, ranging from 1 to 24 years.

Analyzing these data revealed that standardized incidence ratio (SIR) of EAC was not increased after eradication therapy (0.89; 95% CI, 0.82-0.97). In fact, SIR decreased over time after eradication, reaching as low as 0.73 (95% CI, 0.61-0.86) during the follow-up period of 11-24 years. These findings were maintained regardless of age or sex, and within country-by-country analyses.

SIR for esophageal squamous cell carcinoma, which was calculated for comparison, showed no association with eradication therapy (0.99; 95% CI, 0.89-1.11).

“This study found no evidence supporting the hypothesis of a gradually increasing risk of esophageal adenocarcinoma over time after H pylori eradication treatment,” the investigators wrote.

Other risks were detected, including an overall increased SIR of EAC observed among participants with gastroesophageal reflux disease (GERD) and those using long-term proton pump inhibitors (PPIs). These were expected, however, “considering the strong and well-established association with EAC.”

Dr. Wiklund and colleagues suggested that more studies are needed to confirm their findings, although the present data provide confidence that H pylori eradication does not raise risk of EAC.

“This is valuable knowledge when considering eradication treatment for individual patients and eradication programs in high-risk populations of gastric cancer,” they wrote. “The results should be generalizable to other high-income countries with low prevalence of H pylori and high incidence of EAC, but studies from other regions with different patterns of these conditions are warranted.”

They also called for more basic research to understand why eradicating H pylori does not lead to an increased risk of EAC.The study was supported by Sjoberg Foundation, Nordic Cancer Union, Stockholm County Council, Stockholm Cancer Society. Investigators disclosed no conflicts of interest.

Decreased prevalence of Helicobacter pylori infection is not associated with an increased rate of esophageal cancer, based on a multinational cohort study.

This finding suggests that eradication of H pylori is safe with regard to esophageal cancer risk, and eradication campaigns are not contributing to the rising incidence of esophageal adenocarcinoma (EAC) over the past four decades, reported lead author Anna-Klara Wiklund, MD, of Karolinska Institutet, Stockholm, Sweden, and colleagues.“The decreased risk of esophageal adenocarcinoma seen in individuals with H pylori infection is probably explained by the H pylori–induced gastric atrophy, which reduces gastric acid production and thus acidic gastroesophageal reflux, the main risk factor for this tumor,” the investigators wrote in Gastroenterology. “It seems plausible that eradication of H pylori would increase the risk of EAC, although the answer to this question is unknown with the only study on the topic (from our group) having too few cases and too short follow-up.”

That study involved only 11 cases of EAC.

For the present study, Dr. Wiklund and colleagues aggregated data from all individuals who had undergone H pylori eradication in Finland, Denmark, Iceland, Norway, and Sweden from 1995 to 2019. The dataset comprised 661,987 such individuals with more than 5 million person-years after eradication therapy, including 550 cases of EAC. Median follow-up time was approximately 8 years, ranging from 1 to 24 years.

Analyzing these data revealed that standardized incidence ratio (SIR) of EAC was not increased after eradication therapy (0.89; 95% CI, 0.82-0.97). In fact, SIR decreased over time after eradication, reaching as low as 0.73 (95% CI, 0.61-0.86) during the follow-up period of 11-24 years. These findings were maintained regardless of age or sex, and within country-by-country analyses.

SIR for esophageal squamous cell carcinoma, which was calculated for comparison, showed no association with eradication therapy (0.99; 95% CI, 0.89-1.11).

“This study found no evidence supporting the hypothesis of a gradually increasing risk of esophageal adenocarcinoma over time after H pylori eradication treatment,” the investigators wrote.

Other risks were detected, including an overall increased SIR of EAC observed among participants with gastroesophageal reflux disease (GERD) and those using long-term proton pump inhibitors (PPIs). These were expected, however, “considering the strong and well-established association with EAC.”

Dr. Wiklund and colleagues suggested that more studies are needed to confirm their findings, although the present data provide confidence that H pylori eradication does not raise risk of EAC.

“This is valuable knowledge when considering eradication treatment for individual patients and eradication programs in high-risk populations of gastric cancer,” they wrote. “The results should be generalizable to other high-income countries with low prevalence of H pylori and high incidence of EAC, but studies from other regions with different patterns of these conditions are warranted.”

They also called for more basic research to understand why eradicating H pylori does not lead to an increased risk of EAC.The study was supported by Sjoberg Foundation, Nordic Cancer Union, Stockholm County Council, Stockholm Cancer Society. Investigators disclosed no conflicts of interest.

Decreased prevalence of Helicobacter pylori infection is not associated with an increased rate of esophageal cancer, based on a multinational cohort study.

This finding suggests that eradication of H pylori is safe with regard to esophageal cancer risk, and eradication campaigns are not contributing to the rising incidence of esophageal adenocarcinoma (EAC) over the past four decades, reported lead author Anna-Klara Wiklund, MD, of Karolinska Institutet, Stockholm, Sweden, and colleagues.“The decreased risk of esophageal adenocarcinoma seen in individuals with H pylori infection is probably explained by the H pylori–induced gastric atrophy, which reduces gastric acid production and thus acidic gastroesophageal reflux, the main risk factor for this tumor,” the investigators wrote in Gastroenterology. “It seems plausible that eradication of H pylori would increase the risk of EAC, although the answer to this question is unknown with the only study on the topic (from our group) having too few cases and too short follow-up.”

That study involved only 11 cases of EAC.

For the present study, Dr. Wiklund and colleagues aggregated data from all individuals who had undergone H pylori eradication in Finland, Denmark, Iceland, Norway, and Sweden from 1995 to 2019. The dataset comprised 661,987 such individuals with more than 5 million person-years after eradication therapy, including 550 cases of EAC. Median follow-up time was approximately 8 years, ranging from 1 to 24 years.

Analyzing these data revealed that standardized incidence ratio (SIR) of EAC was not increased after eradication therapy (0.89; 95% CI, 0.82-0.97). In fact, SIR decreased over time after eradication, reaching as low as 0.73 (95% CI, 0.61-0.86) during the follow-up period of 11-24 years. These findings were maintained regardless of age or sex, and within country-by-country analyses.

SIR for esophageal squamous cell carcinoma, which was calculated for comparison, showed no association with eradication therapy (0.99; 95% CI, 0.89-1.11).

“This study found no evidence supporting the hypothesis of a gradually increasing risk of esophageal adenocarcinoma over time after H pylori eradication treatment,” the investigators wrote.

Other risks were detected, including an overall increased SIR of EAC observed among participants with gastroesophageal reflux disease (GERD) and those using long-term proton pump inhibitors (PPIs). These were expected, however, “considering the strong and well-established association with EAC.”

Dr. Wiklund and colleagues suggested that more studies are needed to confirm their findings, although the present data provide confidence that H pylori eradication does not raise risk of EAC.

“This is valuable knowledge when considering eradication treatment for individual patients and eradication programs in high-risk populations of gastric cancer,” they wrote. “The results should be generalizable to other high-income countries with low prevalence of H pylori and high incidence of EAC, but studies from other regions with different patterns of these conditions are warranted.”

They also called for more basic research to understand why eradicating H pylori does not lead to an increased risk of EAC.The study was supported by Sjoberg Foundation, Nordic Cancer Union, Stockholm County Council, Stockholm Cancer Society. Investigators disclosed no conflicts of interest.

TOPLINE:

For patients with gastric cancer, extending regular follow-up beyond the typical 5 years after gastrectomy was associated with improved overall and post-recurrence survival rates, new data from a retrospective analysis showed.

METHODOLOGY:

• Currently, postgastrectomy cancer surveillance typically lasts 5 years, although some centers now monitor patients beyond this point.
• To investigate the potential benefit of extended surveillance, researchers used Korean National Health Insurance claims data to identify 40,468 patients with gastric cancer who were disease free 5 years after gastrectomy — 14,294 received extended regular follow-up visits and 26,174 did not.
• The extended regular follow-up group was defined as having endoscopy or abdominopelvic CT between 2 months and 2 years before diagnosis of late recurrence or gastric remnant cancer and having two or more examinations between 5.5 and 8.5 years after gastrectomy. Late recurrence was a recurrence diagnosed 5 years after gastrectomy.
• Researchers used Cox proportional hazards regression to evaluate the independent association between follow-up and overall and postrecurrence survival rates.

TAKEAWAY:

• Overall, 5 years postgastrectomy, the incidence of late recurrence or gastric remnant cancer was 7.8% — 4.0% between 5 and 10 years (1610 of 40,468 patients) and 9.4% after 10 years (1528 of 16,287 patients).
• Regular follow-up beyond 5 years was associated with a significant reduction in overall mortality — from 49.4% to 36.9% at 15 years (P < .001). Overall survival after late recurrence or gastric remnant cancer also improved significantly with extended regular follow-up, with the 5-year postrecurrence survival rate increasing from 32.7% to 71.1% (P < .001).
• The combination of endoscopy and abdominopelvic CT provided the highest 5-year postrecurrence survival rate (74.5%), compared with endoscopy alone (54.5%) or CT alone (47.1%).
• A time interval of more than 2 years between a previous endoscopy or abdominopelvic CT and diagnosis of late recurrence or gastric remnant cancer significantly decreased postrecurrence survival (hazard ratio [HR], 1.72 for endoscopy and HR, 1.48 for abdominopelvic CT).

IN PRACTICE:

“These findings suggest that extended regular follow-up after 5 years post gastrectomy should be implemented clinically and that current practice and value of follow-up protocols in postoperative care of patients with gastric cancer be reconsidered,” the authors concluded.

The authors of an accompanying commentary cautioned that, while the study “successfully establishes groundwork for extending surveillance of gastric cancer in high-risk populations, more work is needed to strategically identify those who would benefit most from extended surveillance.”
 

SOURCE:

The study, with first author Ju-Hee Lee, MD, PhD, Department of Surgery, Hanyang University College of Medicine, Seoul, South Korea, and accompanying commentary were published online on June 18 in JAMA Surgery.

LIMITATIONS:

Recurrent cancer and gastric remnant cancer could not be distinguished from each other because clinical records were not analyzed. The claims database lacked detailed clinical information on individual patients, including cancer stages, and a separate analysis of tumor markers could not be performed.

DISCLOSURES:

The study was funded by a grant from the Korean Gastric Cancer Association. The study authors and commentary authors reported no conflicts of interest.

A version of this article appeared on Medscape.com.

TOPLINE:

For patients with gastric cancer, extending regular follow-up beyond the typical 5 years after gastrectomy was associated with improved overall and post-recurrence survival rates, new data from a retrospective analysis showed.

METHODOLOGY:

• Currently, postgastrectomy cancer surveillance typically lasts 5 years, although some centers now monitor patients beyond this point.
• To investigate the potential benefit of extended surveillance, researchers used Korean National Health Insurance claims data to identify 40,468 patients with gastric cancer who were disease free 5 years after gastrectomy — 14,294 received extended regular follow-up visits and 26,174 did not.
• The extended regular follow-up group was defined as having endoscopy or abdominopelvic CT between 2 months and 2 years before diagnosis of late recurrence or gastric remnant cancer and having two or more examinations between 5.5 and 8.5 years after gastrectomy. Late recurrence was a recurrence diagnosed 5 years after gastrectomy.
• Researchers used Cox proportional hazards regression to evaluate the independent association between follow-up and overall and postrecurrence survival rates.

TAKEAWAY:

• Overall, 5 years postgastrectomy, the incidence of late recurrence or gastric remnant cancer was 7.8% — 4.0% between 5 and 10 years (1610 of 40,468 patients) and 9.4% after 10 years (1528 of 16,287 patients).
• Regular follow-up beyond 5 years was associated with a significant reduction in overall mortality — from 49.4% to 36.9% at 15 years (P < .001). Overall survival after late recurrence or gastric remnant cancer also improved significantly with extended regular follow-up, with the 5-year postrecurrence survival rate increasing from 32.7% to 71.1% (P < .001).
• The combination of endoscopy and abdominopelvic CT provided the highest 5-year postrecurrence survival rate (74.5%), compared with endoscopy alone (54.5%) or CT alone (47.1%).
• A time interval of more than 2 years between a previous endoscopy or abdominopelvic CT and diagnosis of late recurrence or gastric remnant cancer significantly decreased postrecurrence survival (hazard ratio [HR], 1.72 for endoscopy and HR, 1.48 for abdominopelvic CT).

IN PRACTICE:

“These findings suggest that extended regular follow-up after 5 years post gastrectomy should be implemented clinically and that current practice and value of follow-up protocols in postoperative care of patients with gastric cancer be reconsidered,” the authors concluded.

The authors of an accompanying commentary cautioned that, while the study “successfully establishes groundwork for extending surveillance of gastric cancer in high-risk populations, more work is needed to strategically identify those who would benefit most from extended surveillance.”
 

SOURCE:

The study, with first author Ju-Hee Lee, MD, PhD, Department of Surgery, Hanyang University College of Medicine, Seoul, South Korea, and accompanying commentary were published online on June 18 in JAMA Surgery.

LIMITATIONS:

Recurrent cancer and gastric remnant cancer could not be distinguished from each other because clinical records were not analyzed. The claims database lacked detailed clinical information on individual patients, including cancer stages, and a separate analysis of tumor markers could not be performed.

DISCLOSURES:

The study was funded by a grant from the Korean Gastric Cancer Association. The study authors and commentary authors reported no conflicts of interest.

A version of this article appeared on Medscape.com.

TOPLINE:

For patients with gastric cancer, extending regular follow-up beyond the typical 5 years after gastrectomy was associated with improved overall and post-recurrence survival rates, new data from a retrospective analysis showed.

METHODOLOGY:

• Currently, postgastrectomy cancer surveillance typically lasts 5 years, although some centers now monitor patients beyond this point.
• To investigate the potential benefit of extended surveillance, researchers used Korean National Health Insurance claims data to identify 40,468 patients with gastric cancer who were disease free 5 years after gastrectomy — 14,294 received extended regular follow-up visits and 26,174 did not.
• The extended regular follow-up group was defined as having endoscopy or abdominopelvic CT between 2 months and 2 years before diagnosis of late recurrence or gastric remnant cancer and having two or more examinations between 5.5 and 8.5 years after gastrectomy. Late recurrence was a recurrence diagnosed 5 years after gastrectomy.
• Researchers used Cox proportional hazards regression to evaluate the independent association between follow-up and overall and postrecurrence survival rates.

TAKEAWAY:

• Overall, 5 years postgastrectomy, the incidence of late recurrence or gastric remnant cancer was 7.8% — 4.0% between 5 and 10 years (1610 of 40,468 patients) and 9.4% after 10 years (1528 of 16,287 patients).
• Regular follow-up beyond 5 years was associated with a significant reduction in overall mortality — from 49.4% to 36.9% at 15 years (P < .001). Overall survival after late recurrence or gastric remnant cancer also improved significantly with extended regular follow-up, with the 5-year postrecurrence survival rate increasing from 32.7% to 71.1% (P < .001).
• The combination of endoscopy and abdominopelvic CT provided the highest 5-year postrecurrence survival rate (74.5%), compared with endoscopy alone (54.5%) or CT alone (47.1%).
• A time interval of more than 2 years between a previous endoscopy or abdominopelvic CT and diagnosis of late recurrence or gastric remnant cancer significantly decreased postrecurrence survival (hazard ratio [HR], 1.72 for endoscopy and HR, 1.48 for abdominopelvic CT).

IN PRACTICE:

“These findings suggest that extended regular follow-up after 5 years post gastrectomy should be implemented clinically and that current practice and value of follow-up protocols in postoperative care of patients with gastric cancer be reconsidered,” the authors concluded.

The authors of an accompanying commentary cautioned that, while the study “successfully establishes groundwork for extending surveillance of gastric cancer in high-risk populations, more work is needed to strategically identify those who would benefit most from extended surveillance.”
 

SOURCE:

The study, with first author Ju-Hee Lee, MD, PhD, Department of Surgery, Hanyang University College of Medicine, Seoul, South Korea, and accompanying commentary were published online on June 18 in JAMA Surgery.

LIMITATIONS:

Recurrent cancer and gastric remnant cancer could not be distinguished from each other because clinical records were not analyzed. The claims database lacked detailed clinical information on individual patients, including cancer stages, and a separate analysis of tumor markers could not be performed.

DISCLOSURES:

The study was funded by a grant from the Korean Gastric Cancer Association. The study authors and commentary authors reported no conflicts of interest.

A version of this article appeared on Medscape.com.

This transcript has been edited for clarity.

I’m Dr. Neil Skolnik, and today I’m going to talk about the Endocrine Society Guideline on Vitamin D. The question of who and when to test for vitamin D, and when to prescribe vitamin D, comes up frequently. There have been a lot of studies, and many people I know have opinions about this, but I haven’t seen a lot of clear, evidence-based guidance. This much-needed guideline provides guidance, though I’m not sure that everyone is going to be happy with the recommendations. That said, the society did conduct a comprehensive assessment and systematic review of the evidence that was impressive and well done. For our discussion, I will focus on the recommendations for nonpregnant adults.

The assumption for all of the recommendations is that these are for individuals who are already getting the Institute of Medicine’s recommended amount of vitamin D, which is 600 IU daily for those 50-70 years of age and 800 IU daily for those above 80 years.

For adults aged 18-74 years, who do not have prediabetes, the guidelines suggest against routinely testing for vitamin D deficiency and recommend against routine supplementation. For the older part of this cohort, adults aged 50-74 years, there is abundant randomized trial evidence showing little to no significant differences with vitamin D supplementation on outcomes of fracture, cancer, cardiovascular disease, kidney stones, or mortality. While supplementation is safe, there does not appear to be any benefit to routine supplementation or testing. It is important to note that the trials were done in populations that were meeting the daily recommended intake of vitamin D and who did not have low vitamin D levels at baseline, so individuals who may not be meeting the recommended daily intake though their diet or through sun exposure may consider vitamin D supplementation.

For adults with prediabetes, vitamin D supplementation is recommended to reduce the risk for progression from prediabetes to diabetes. This is about 1 in 3 adults in the United States. A number of trials have looked at vitamin D supplementation for adults with prediabetes in addition to lifestyle modification (diet and exercise). Vitamin D decreases the risk for progression from prediabetes to diabetes by approximately 10%-15%. The effect may be greater in those who are over age 60 and who have lower initial vitamin D levels.

Vitamin D in older adults (aged 75 or older) has a separate recommendation. In this age group, low vitamin D levels are common, with up to 20% of older adults having low levels. The guidelines suggest against testing vitamin D in adults aged 75 or over and recommend empiric vitamin D supplementation for all adults aged 75 or older. While observational studies have shown a relationship between low vitamin D levels in this age group and adverse outcomes, including falls, fractures, and respiratory infections, evidence from randomized placebo-controlled trials of vitamin D supplementation have been inconsistent in regard to benefit. That said, a meta-analysis has shown that vitamin D supplementation lowers mortality compared with placebo, with a relative risk of 0.96 (confidence interval, 0.93-1.00). There was no difference in effect according to setting (community vs nursing home), vitamin D dosage, or baseline vitamin D level.

There appeared to be a benefit of low-dose vitamin D supplementation on fall risk, with possibly greater fall risk when high-dose supplementation was used. No significant effect on fracture rate was seen with vitamin D supplementation alone, although there was a decrease in fractures when vitamin D was combined with calcium. In these studies, the median dose of calcium was 1000 mg per day.

Based on the probability of a “slight decrease in all-cause mortality” and its safety, as well as possible benefit to decrease falls, the recommendation is for supplementation for all adults aged 75 or older. Since there was not a consistent difference by vitamin D level, testing is not necessary.

Let’s now discuss dosage. The guidelines recommend daily lower-dose vitamin D over nondaily higher-dose vitamin D. Unfortunately, the guideline does not specify a specific dose of vitamin D. The supplementation dose used in trials of adults aged 75 or older ranged from 400 to 3333 IU daily, with an average dose of 900 IU daily, so it seems to me that a dose of 1000-2000 IU daily is a reasonable choice for older adults. In the prediabetes trials, a higher average dose was used, with a mean of 3500 IU daily, so a higher dose might make sense in this group.
 

Dr. Skolnik, is a professor in the Department of Family Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, and associate director, Department of Family Medicine, Abington Jefferson Health, Abington, Pennsylvania. He disclosed ties with AstraZeneca, Bayer, Teva, Eli Lilly, Boehringer Ingelheim, Sanofi, Sanofi Pasteur, GlaxoSmithKline, and Merck.

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

This transcript has been edited for clarity.

I’m Dr. Neil Skolnik, and today I’m going to talk about the Endocrine Society Guideline on Vitamin D. The question of who and when to test for vitamin D, and when to prescribe vitamin D, comes up frequently. There have been a lot of studies, and many people I know have opinions about this, but I haven’t seen a lot of clear, evidence-based guidance. This much-needed guideline provides guidance, though I’m not sure that everyone is going to be happy with the recommendations. That said, the society did conduct a comprehensive assessment and systematic review of the evidence that was impressive and well done. For our discussion, I will focus on the recommendations for nonpregnant adults.

The assumption for all of the recommendations is that these are for individuals who are already getting the Institute of Medicine’s recommended amount of vitamin D, which is 600 IU daily for those 50-70 years of age and 800 IU daily for those above 80 years.

For adults aged 18-74 years, who do not have prediabetes, the guidelines suggest against routinely testing for vitamin D deficiency and recommend against routine supplementation. For the older part of this cohort, adults aged 50-74 years, there is abundant randomized trial evidence showing little to no significant differences with vitamin D supplementation on outcomes of fracture, cancer, cardiovascular disease, kidney stones, or mortality. While supplementation is safe, there does not appear to be any benefit to routine supplementation or testing. It is important to note that the trials were done in populations that were meeting the daily recommended intake of vitamin D and who did not have low vitamin D levels at baseline, so individuals who may not be meeting the recommended daily intake though their diet or through sun exposure may consider vitamin D supplementation.

For adults with prediabetes, vitamin D supplementation is recommended to reduce the risk for progression from prediabetes to diabetes. This is about 1 in 3 adults in the United States. A number of trials have looked at vitamin D supplementation for adults with prediabetes in addition to lifestyle modification (diet and exercise). Vitamin D decreases the risk for progression from prediabetes to diabetes by approximately 10%-15%. The effect may be greater in those who are over age 60 and who have lower initial vitamin D levels.

Vitamin D in older adults (aged 75 or older) has a separate recommendation. In this age group, low vitamin D levels are common, with up to 20% of older adults having low levels. The guidelines suggest against testing vitamin D in adults aged 75 or over and recommend empiric vitamin D supplementation for all adults aged 75 or older. While observational studies have shown a relationship between low vitamin D levels in this age group and adverse outcomes, including falls, fractures, and respiratory infections, evidence from randomized placebo-controlled trials of vitamin D supplementation have been inconsistent in regard to benefit. That said, a meta-analysis has shown that vitamin D supplementation lowers mortality compared with placebo, with a relative risk of 0.96 (confidence interval, 0.93-1.00). There was no difference in effect according to setting (community vs nursing home), vitamin D dosage, or baseline vitamin D level.

There appeared to be a benefit of low-dose vitamin D supplementation on fall risk, with possibly greater fall risk when high-dose supplementation was used. No significant effect on fracture rate was seen with vitamin D supplementation alone, although there was a decrease in fractures when vitamin D was combined with calcium. In these studies, the median dose of calcium was 1000 mg per day.

Based on the probability of a “slight decrease in all-cause mortality” and its safety, as well as possible benefit to decrease falls, the recommendation is for supplementation for all adults aged 75 or older. Since there was not a consistent difference by vitamin D level, testing is not necessary.

Let’s now discuss dosage. The guidelines recommend daily lower-dose vitamin D over nondaily higher-dose vitamin D. Unfortunately, the guideline does not specify a specific dose of vitamin D. The supplementation dose used in trials of adults aged 75 or older ranged from 400 to 3333 IU daily, with an average dose of 900 IU daily, so it seems to me that a dose of 1000-2000 IU daily is a reasonable choice for older adults. In the prediabetes trials, a higher average dose was used, with a mean of 3500 IU daily, so a higher dose might make sense in this group.
 

Dr. Skolnik, is a professor in the Department of Family Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, and associate director, Department of Family Medicine, Abington Jefferson Health, Abington, Pennsylvania. He disclosed ties with AstraZeneca, Bayer, Teva, Eli Lilly, Boehringer Ingelheim, Sanofi, Sanofi Pasteur, GlaxoSmithKline, and Merck.

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

This transcript has been edited for clarity.

I’m Dr. Neil Skolnik, and today I’m going to talk about the Endocrine Society Guideline on Vitamin D. The question of who and when to test for vitamin D, and when to prescribe vitamin D, comes up frequently. There have been a lot of studies, and many people I know have opinions about this, but I haven’t seen a lot of clear, evidence-based guidance. This much-needed guideline provides guidance, though I’m not sure that everyone is going to be happy with the recommendations. That said, the society did conduct a comprehensive assessment and systematic review of the evidence that was impressive and well done. For our discussion, I will focus on the recommendations for nonpregnant adults.

The assumption for all of the recommendations is that these are for individuals who are already getting the Institute of Medicine’s recommended amount of vitamin D, which is 600 IU daily for those 50-70 years of age and 800 IU daily for those above 80 years.

For adults aged 18-74 years, who do not have prediabetes, the guidelines suggest against routinely testing for vitamin D deficiency and recommend against routine supplementation. For the older part of this cohort, adults aged 50-74 years, there is abundant randomized trial evidence showing little to no significant differences with vitamin D supplementation on outcomes of fracture, cancer, cardiovascular disease, kidney stones, or mortality. While supplementation is safe, there does not appear to be any benefit to routine supplementation or testing. It is important to note that the trials were done in populations that were meeting the daily recommended intake of vitamin D and who did not have low vitamin D levels at baseline, so individuals who may not be meeting the recommended daily intake though their diet or through sun exposure may consider vitamin D supplementation.

For adults with prediabetes, vitamin D supplementation is recommended to reduce the risk for progression from prediabetes to diabetes. This is about 1 in 3 adults in the United States. A number of trials have looked at vitamin D supplementation for adults with prediabetes in addition to lifestyle modification (diet and exercise). Vitamin D decreases the risk for progression from prediabetes to diabetes by approximately 10%-15%. The effect may be greater in those who are over age 60 and who have lower initial vitamin D levels.

Vitamin D in older adults (aged 75 or older) has a separate recommendation. In this age group, low vitamin D levels are common, with up to 20% of older adults having low levels. The guidelines suggest against testing vitamin D in adults aged 75 or over and recommend empiric vitamin D supplementation for all adults aged 75 or older. While observational studies have shown a relationship between low vitamin D levels in this age group and adverse outcomes, including falls, fractures, and respiratory infections, evidence from randomized placebo-controlled trials of vitamin D supplementation have been inconsistent in regard to benefit. That said, a meta-analysis has shown that vitamin D supplementation lowers mortality compared with placebo, with a relative risk of 0.96 (confidence interval, 0.93-1.00). There was no difference in effect according to setting (community vs nursing home), vitamin D dosage, or baseline vitamin D level.

There appeared to be a benefit of low-dose vitamin D supplementation on fall risk, with possibly greater fall risk when high-dose supplementation was used. No significant effect on fracture rate was seen with vitamin D supplementation alone, although there was a decrease in fractures when vitamin D was combined with calcium. In these studies, the median dose of calcium was 1000 mg per day.

Based on the probability of a “slight decrease in all-cause mortality” and its safety, as well as possible benefit to decrease falls, the recommendation is for supplementation for all adults aged 75 or older. Since there was not a consistent difference by vitamin D level, testing is not necessary.

Let’s now discuss dosage. The guidelines recommend daily lower-dose vitamin D over nondaily higher-dose vitamin D. Unfortunately, the guideline does not specify a specific dose of vitamin D. The supplementation dose used in trials of adults aged 75 or older ranged from 400 to 3333 IU daily, with an average dose of 900 IU daily, so it seems to me that a dose of 1000-2000 IU daily is a reasonable choice for older adults. In the prediabetes trials, a higher average dose was used, with a mean of 3500 IU daily, so a higher dose might make sense in this group.
 

Dr. Skolnik, is a professor in the Department of Family Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, and associate director, Department of Family Medicine, Abington Jefferson Health, Abington, Pennsylvania. He disclosed ties with AstraZeneca, Bayer, Teva, Eli Lilly, Boehringer Ingelheim, Sanofi, Sanofi Pasteur, GlaxoSmithKline, and Merck.

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

Over the last couple of decades, I have become increasingly more uncomfortable watching American-style football on television. Lax refereeing coupled with over-juiced players who can generate g-forces previously attainable only on a NASA rocket sled has resulted in a spate of injuries I find unacceptable. The revolving door of transfers from college to college has made the term scholar-athlete a relic that can be applied to only a handful of players at the smallest uncompetitive schools.

Many of you who are regular readers of Letters from Maine have probably tired of my boasting that when I played football in high school we wore leather helmets. I enjoyed playing football and continued playing in college for a couple of years until it became obvious that “bench” was going to be my usual position. But, I would not want my grandson to play college football. Certainly, not at the elite college level. Were he to do so, he would be putting himself at risk for significant injury by participating in what I no longer view as an appealing activity. Let me add that I am not including chronic traumatic encephalopathy among my concerns, because I think its association with football injuries is far from settled. My concern is more about spinal cord injuries, which, although infrequent, are almost always devastating.

I should also make it perfectly clear that my lack of enthusiasm for college and professional football does not place me among the increasingly vocal throng calling for the elimination of youth football. For the 5- to 12-year-olds, putting on pads and a helmet and scrambling around on a grassy field bumping shoulders and heads with their peers is a wonderful way to burn off energy and satisfies a need for roughhousing that comes naturally to most young boys (and many girls). The chance of anyone of those kids playing youth football reaching the elite college or professional level is extremely unlikely. Other activities and the realization that football is not in their future weeds the field during adolescence.

Although there have been some studies suggesting that starting football at an early age is associated with increased injury risk, a recent and well-controlled study published in the journal Sports Medicine has found no such association in professional football players. This finding makes some sense when you consider that most of the children in this age group are not mustering g-forces anywhere close to those a college or professional athlete can generate.

Another recent study published in the Journal of Pediatrics offers more evidence to consider before one passes judgment on youth football. When reviewing the records of nearly 1500 patients in a specialty-care concussion setting at the Children’s Hospital of Philadelphia, investigators found that recreation-related concussions and non–sport- or recreation-related concussions were more prevalent than sports-related concussions. The authors propose that “less supervision at the time of injury and less access to established concussion healthcare following injury” may explain their observations.

Of course as a card-carrying AARP old fogey, I long for the good old days when youth sports were organized by the kids in backyards and playgrounds. There we learned to pick teams and deal with the disappointment of not being a first-round pick and the embarrassment of being a last rounder. We settled out-of-bounds calls and arguments about ball possession without adults’ assistance — or video replays for that matter. But those days are gone and likely never to return, with parental anxiety running at record highs. We must accept youth sports organized for kids by adults is the way it’s going to be for the foreseeable future.

The football that we see on TV, with all its hoopla, ugliness, and mind-numbing advertisements, shouldn’t discourage us from allowing kids who want to knock heads and bump shoulders to enjoy the sport at a young age. As long as the program is organized with the emphasis on fun nor structured as a fast track to elite play it will be healthier for the kids than sitting on the couch at home watching the carnage on TV.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Over the last couple of decades, I have become increasingly more uncomfortable watching American-style football on television. Lax refereeing coupled with over-juiced players who can generate g-forces previously attainable only on a NASA rocket sled has resulted in a spate of injuries I find unacceptable. The revolving door of transfers from college to college has made the term scholar-athlete a relic that can be applied to only a handful of players at the smallest uncompetitive schools.

Many of you who are regular readers of Letters from Maine have probably tired of my boasting that when I played football in high school we wore leather helmets. I enjoyed playing football and continued playing in college for a couple of years until it became obvious that “bench” was going to be my usual position. But, I would not want my grandson to play college football. Certainly, not at the elite college level. Were he to do so, he would be putting himself at risk for significant injury by participating in what I no longer view as an appealing activity. Let me add that I am not including chronic traumatic encephalopathy among my concerns, because I think its association with football injuries is far from settled. My concern is more about spinal cord injuries, which, although infrequent, are almost always devastating.

I should also make it perfectly clear that my lack of enthusiasm for college and professional football does not place me among the increasingly vocal throng calling for the elimination of youth football. For the 5- to 12-year-olds, putting on pads and a helmet and scrambling around on a grassy field bumping shoulders and heads with their peers is a wonderful way to burn off energy and satisfies a need for roughhousing that comes naturally to most young boys (and many girls). The chance of anyone of those kids playing youth football reaching the elite college or professional level is extremely unlikely. Other activities and the realization that football is not in their future weeds the field during adolescence.

Although there have been some studies suggesting that starting football at an early age is associated with increased injury risk, a recent and well-controlled study published in the journal Sports Medicine has found no such association in professional football players. This finding makes some sense when you consider that most of the children in this age group are not mustering g-forces anywhere close to those a college or professional athlete can generate.

Another recent study published in the Journal of Pediatrics offers more evidence to consider before one passes judgment on youth football. When reviewing the records of nearly 1500 patients in a specialty-care concussion setting at the Children’s Hospital of Philadelphia, investigators found that recreation-related concussions and non–sport- or recreation-related concussions were more prevalent than sports-related concussions. The authors propose that “less supervision at the time of injury and less access to established concussion healthcare following injury” may explain their observations.

Of course as a card-carrying AARP old fogey, I long for the good old days when youth sports were organized by the kids in backyards and playgrounds. There we learned to pick teams and deal with the disappointment of not being a first-round pick and the embarrassment of being a last rounder. We settled out-of-bounds calls and arguments about ball possession without adults’ assistance — or video replays for that matter. But those days are gone and likely never to return, with parental anxiety running at record highs. We must accept youth sports organized for kids by adults is the way it’s going to be for the foreseeable future.

The football that we see on TV, with all its hoopla, ugliness, and mind-numbing advertisements, shouldn’t discourage us from allowing kids who want to knock heads and bump shoulders to enjoy the sport at a young age. As long as the program is organized with the emphasis on fun nor structured as a fast track to elite play it will be healthier for the kids than sitting on the couch at home watching the carnage on TV.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Over the last couple of decades, I have become increasingly more uncomfortable watching American-style football on television. Lax refereeing coupled with over-juiced players who can generate g-forces previously attainable only on a NASA rocket sled has resulted in a spate of injuries I find unacceptable. The revolving door of transfers from college to college has made the term scholar-athlete a relic that can be applied to only a handful of players at the smallest uncompetitive schools.

Many of you who are regular readers of Letters from Maine have probably tired of my boasting that when I played football in high school we wore leather helmets. I enjoyed playing football and continued playing in college for a couple of years until it became obvious that “bench” was going to be my usual position. But, I would not want my grandson to play college football. Certainly, not at the elite college level. Were he to do so, he would be putting himself at risk for significant injury by participating in what I no longer view as an appealing activity. Let me add that I am not including chronic traumatic encephalopathy among my concerns, because I think its association with football injuries is far from settled. My concern is more about spinal cord injuries, which, although infrequent, are almost always devastating.

I should also make it perfectly clear that my lack of enthusiasm for college and professional football does not place me among the increasingly vocal throng calling for the elimination of youth football. For the 5- to 12-year-olds, putting on pads and a helmet and scrambling around on a grassy field bumping shoulders and heads with their peers is a wonderful way to burn off energy and satisfies a need for roughhousing that comes naturally to most young boys (and many girls). The chance of anyone of those kids playing youth football reaching the elite college or professional level is extremely unlikely. Other activities and the realization that football is not in their future weeds the field during adolescence.

Although there have been some studies suggesting that starting football at an early age is associated with increased injury risk, a recent and well-controlled study published in the journal Sports Medicine has found no such association in professional football players. This finding makes some sense when you consider that most of the children in this age group are not mustering g-forces anywhere close to those a college or professional athlete can generate.

Another recent study published in the Journal of Pediatrics offers more evidence to consider before one passes judgment on youth football. When reviewing the records of nearly 1500 patients in a specialty-care concussion setting at the Children’s Hospital of Philadelphia, investigators found that recreation-related concussions and non–sport- or recreation-related concussions were more prevalent than sports-related concussions. The authors propose that “less supervision at the time of injury and less access to established concussion healthcare following injury” may explain their observations.

Of course as a card-carrying AARP old fogey, I long for the good old days when youth sports were organized by the kids in backyards and playgrounds. There we learned to pick teams and deal with the disappointment of not being a first-round pick and the embarrassment of being a last rounder. We settled out-of-bounds calls and arguments about ball possession without adults’ assistance — or video replays for that matter. But those days are gone and likely never to return, with parental anxiety running at record highs. We must accept youth sports organized for kids by adults is the way it’s going to be for the foreseeable future.

The football that we see on TV, with all its hoopla, ugliness, and mind-numbing advertisements, shouldn’t discourage us from allowing kids who want to knock heads and bump shoulders to enjoy the sport at a young age. As long as the program is organized with the emphasis on fun nor structured as a fast track to elite play it will be healthier for the kids than sitting on the couch at home watching the carnage on TV.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].