Following a series of Vascular Specialist pieces highlighting the crisis of surgeon burnout and the unique challenges that face vascular surgeons, the SVS Wellness Task Force was formed in 2017. Recognizing that burnout may compromise recruitment and retention into our specialty, a particular threat at a time when our specialty faces projected increasing physician workforce needs, and that data suggests physician burnout compromises both patient quality of care and overall satisfaction, the task force was charged with proactively addressing vascular surgeon burnout. Our task force, comprising 21 engaged SVS members from across the country, has been working with strong support from leadership and administration to identify potential SVS targets for meaningful change.

The year 2018 was one of information gathering as we attempted clarify the severity of the problem and perceived member needs. We are grateful to our membership that have helped with this effort – for their time, for their insight, and for sharing their stories (some of which have been deeply personal). Two large-scale surveys were circulated to active SVS membership, both created with the assistance of the Mayo Clinic’s Division of Health Policy and Research.

The first survey was designed with a framework of validated wellness tools and well-described risk factors for burnout, then further “personalized” to incorporate unique challenges to the vascular surgeon. About 32% of our membership responded to this survey and alarmingly, when considering nonretired active SVS members, approximately one-third self-described depressive symptoms, 35% met criteria for burnout, and 8% self-reported suicidal thoughts in the last 12 months.

The second survey has only recently closed, focusing on the ergonomic challenges that we face across the spectrum of complex open and endovascular cases. Recognizing existing data that chronic pain and physical disability are associated with burnout, this data will be linked back to the original survey responses for association. Certainly there is more to come.

Concurrent with our survey initiatives, many of you participated in a Wellness Focus Group during VAM 2018. These focus groups intentionally considered the diversity of our membership across age, gender, practice setting, and region, revealing several important themes that threaten our wellness. It was no surprise that the EMR was identified as a clear threat to vascular surgery well-being and that this is not unique to our specialty. Importantly, our membership collectively feels “undervalued” at an institutional level. Specifically given the scope of comprehensive vascular care that we provide patients, a large part of our work includes both unpredictable acute vascular surgical care (such as intraoperative consultations for vascular trauma) and remedial salvage operations to manage vascular complications inflicted during care received from other physicians. This effort leaves us with little control over our time, often without perceived reciprocal clinical support, institutional support, or compensation.

Given this data, the Wellness Task Force is now strategizing efforts for change and supporting ongoing SVS initiatives. Our Task Force is currently:

• Collaborating with key EMR stakeholders with the goal of creating tools that can be shared across the specialty and addressing best practices for system-level support.
• Drafting a “public reply” to the Office of the National Coordinator for Health Information Technology’s “Strategy on Reducing Burden Relating to the Use of Health IT and EHRs” initiative.
• Collaborating with national experts to establish peer support tools and SVS networking opportunities that may help members cope with adverse outcomes and strategize the delivery of complex care.
• Identifying institutional best practices for surgeon wellness for broad dissemination.
• Supporting existing SVS initiatives that include the PAC/APM task force, branding initiatives through the PPO as we work to “own our space” and leverage our specialty and the community practice committee as the Society works proactively to optimize workload, fairness, and reward on a larger scale for membership.

We encourage everyone to stay tuned for periodic Vascular Specialist “Wellness Features” and to attend the Wellness Session at the 2019 VAM for interim progress that will feature the following discussions.

• (Re)Finding a meaningful career in vascular surgery.
• Ergonomic challenges to the vascular surgeon and strategies to mitigate the resulting threat of disability.
• EMR best practices to optimize efficiency.
• The role of peer support in vascular surgery, including the mitigation of second victim syndrome.

Surgeon burnout is a real threat to our workforce and the well-being of our colleagues and friends. Risk factors are multifactorial and will require broad, system-level change. The SVS remains fully committed to enhancing vascular surgeon wellness and this Task Force is grateful for your ongoing engagement and support.

Dr. Coleman is an associate professor of vascular surgery at the University of Michigan, Ann Arbor.

Following a series of Vascular Specialist pieces highlighting the crisis of surgeon burnout and the unique challenges that face vascular surgeons, the SVS Wellness Task Force was formed in 2017. Recognizing that burnout may compromise recruitment and retention into our specialty, a particular threat at a time when our specialty faces projected increasing physician workforce needs, and that data suggests physician burnout compromises both patient quality of care and overall satisfaction, the task force was charged with proactively addressing vascular surgeon burnout. Our task force, comprising 21 engaged SVS members from across the country, has been working with strong support from leadership and administration to identify potential SVS targets for meaningful change.

The year 2018 was one of information gathering as we attempted clarify the severity of the problem and perceived member needs. We are grateful to our membership that have helped with this effort – for their time, for their insight, and for sharing their stories (some of which have been deeply personal). Two large-scale surveys were circulated to active SVS membership, both created with the assistance of the Mayo Clinic’s Division of Health Policy and Research.

The first survey was designed with a framework of validated wellness tools and well-described risk factors for burnout, then further “personalized” to incorporate unique challenges to the vascular surgeon. About 32% of our membership responded to this survey and alarmingly, when considering nonretired active SVS members, approximately one-third self-described depressive symptoms, 35% met criteria for burnout, and 8% self-reported suicidal thoughts in the last 12 months.

The second survey has only recently closed, focusing on the ergonomic challenges that we face across the spectrum of complex open and endovascular cases. Recognizing existing data that chronic pain and physical disability are associated with burnout, this data will be linked back to the original survey responses for association. Certainly there is more to come.

Concurrent with our survey initiatives, many of you participated in a Wellness Focus Group during VAM 2018. These focus groups intentionally considered the diversity of our membership across age, gender, practice setting, and region, revealing several important themes that threaten our wellness. It was no surprise that the EMR was identified as a clear threat to vascular surgery well-being and that this is not unique to our specialty. Importantly, our membership collectively feels “undervalued” at an institutional level. Specifically given the scope of comprehensive vascular care that we provide patients, a large part of our work includes both unpredictable acute vascular surgical care (such as intraoperative consultations for vascular trauma) and remedial salvage operations to manage vascular complications inflicted during care received from other physicians. This effort leaves us with little control over our time, often without perceived reciprocal clinical support, institutional support, or compensation.

Given this data, the Wellness Task Force is now strategizing efforts for change and supporting ongoing SVS initiatives. Our Task Force is currently:

• Collaborating with key EMR stakeholders with the goal of creating tools that can be shared across the specialty and addressing best practices for system-level support.
• Drafting a “public reply” to the Office of the National Coordinator for Health Information Technology’s “Strategy on Reducing Burden Relating to the Use of Health IT and EHRs” initiative.
• Collaborating with national experts to establish peer support tools and SVS networking opportunities that may help members cope with adverse outcomes and strategize the delivery of complex care.
• Identifying institutional best practices for surgeon wellness for broad dissemination.
• Supporting existing SVS initiatives that include the PAC/APM task force, branding initiatives through the PPO as we work to “own our space” and leverage our specialty and the community practice committee as the Society works proactively to optimize workload, fairness, and reward on a larger scale for membership.

We encourage everyone to stay tuned for periodic Vascular Specialist “Wellness Features” and to attend the Wellness Session at the 2019 VAM for interim progress that will feature the following discussions.

• (Re)Finding a meaningful career in vascular surgery.
• Ergonomic challenges to the vascular surgeon and strategies to mitigate the resulting threat of disability.
• EMR best practices to optimize efficiency.
• The role of peer support in vascular surgery, including the mitigation of second victim syndrome.

Surgeon burnout is a real threat to our workforce and the well-being of our colleagues and friends. Risk factors are multifactorial and will require broad, system-level change. The SVS remains fully committed to enhancing vascular surgeon wellness and this Task Force is grateful for your ongoing engagement and support.

Dr. Coleman is an associate professor of vascular surgery at the University of Michigan, Ann Arbor.

Following a series of Vascular Specialist pieces highlighting the crisis of surgeon burnout and the unique challenges that face vascular surgeons, the SVS Wellness Task Force was formed in 2017. Recognizing that burnout may compromise recruitment and retention into our specialty, a particular threat at a time when our specialty faces projected increasing physician workforce needs, and that data suggests physician burnout compromises both patient quality of care and overall satisfaction, the task force was charged with proactively addressing vascular surgeon burnout. Our task force, comprising 21 engaged SVS members from across the country, has been working with strong support from leadership and administration to identify potential SVS targets for meaningful change.

The year 2018 was one of information gathering as we attempted clarify the severity of the problem and perceived member needs. We are grateful to our membership that have helped with this effort – for their time, for their insight, and for sharing their stories (some of which have been deeply personal). Two large-scale surveys were circulated to active SVS membership, both created with the assistance of the Mayo Clinic’s Division of Health Policy and Research.

The first survey was designed with a framework of validated wellness tools and well-described risk factors for burnout, then further “personalized” to incorporate unique challenges to the vascular surgeon. About 32% of our membership responded to this survey and alarmingly, when considering nonretired active SVS members, approximately one-third self-described depressive symptoms, 35% met criteria for burnout, and 8% self-reported suicidal thoughts in the last 12 months.

The second survey has only recently closed, focusing on the ergonomic challenges that we face across the spectrum of complex open and endovascular cases. Recognizing existing data that chronic pain and physical disability are associated with burnout, this data will be linked back to the original survey responses for association. Certainly there is more to come.

Concurrent with our survey initiatives, many of you participated in a Wellness Focus Group during VAM 2018. These focus groups intentionally considered the diversity of our membership across age, gender, practice setting, and region, revealing several important themes that threaten our wellness. It was no surprise that the EMR was identified as a clear threat to vascular surgery well-being and that this is not unique to our specialty. Importantly, our membership collectively feels “undervalued” at an institutional level. Specifically given the scope of comprehensive vascular care that we provide patients, a large part of our work includes both unpredictable acute vascular surgical care (such as intraoperative consultations for vascular trauma) and remedial salvage operations to manage vascular complications inflicted during care received from other physicians. This effort leaves us with little control over our time, often without perceived reciprocal clinical support, institutional support, or compensation.

Given this data, the Wellness Task Force is now strategizing efforts for change and supporting ongoing SVS initiatives. Our Task Force is currently:

• Collaborating with key EMR stakeholders with the goal of creating tools that can be shared across the specialty and addressing best practices for system-level support.
• Drafting a “public reply” to the Office of the National Coordinator for Health Information Technology’s “Strategy on Reducing Burden Relating to the Use of Health IT and EHRs” initiative.
• Collaborating with national experts to establish peer support tools and SVS networking opportunities that may help members cope with adverse outcomes and strategize the delivery of complex care.
• Identifying institutional best practices for surgeon wellness for broad dissemination.
• Supporting existing SVS initiatives that include the PAC/APM task force, branding initiatives through the PPO as we work to “own our space” and leverage our specialty and the community practice committee as the Society works proactively to optimize workload, fairness, and reward on a larger scale for membership.

We encourage everyone to stay tuned for periodic Vascular Specialist “Wellness Features” and to attend the Wellness Session at the 2019 VAM for interim progress that will feature the following discussions.

• (Re)Finding a meaningful career in vascular surgery.
• Ergonomic challenges to the vascular surgeon and strategies to mitigate the resulting threat of disability.
• EMR best practices to optimize efficiency.
• The role of peer support in vascular surgery, including the mitigation of second victim syndrome.

Surgeon burnout is a real threat to our workforce and the well-being of our colleagues and friends. Risk factors are multifactorial and will require broad, system-level change. The SVS remains fully committed to enhancing vascular surgeon wellness and this Task Force is grateful for your ongoing engagement and support.

Dr. Coleman is an associate professor of vascular surgery at the University of Michigan, Ann Arbor.

SAN ANTONIO – Response to neoadjuvant chemotherapy has little if any influence on the choice of surgery among young women with early-stage breast cancer, suggests a multicenter, prospective cohort study reported at the San Antonio Breast Cancer Symposium.

Randomized, controlled trials have found high levels of mastectomy among patients who are eligible for breast-conserving surgery, according to first author Hee Jeong Kim, MD, PhD, a visiting scholar at the Dana-Farber Cancer Institute, Boston, and an associate professor in the division of breast in the department of surgery at the University of Ulsan, Seoul, South Korea.

“Young women are more likely to present with large tumors and particularly benefit from a neoadjuvant systemic approach,” she noted. “Recent data suggest that response rates, including pathological complete response, are higher in women younger than 40 than in older women, but little is known about how response to neoadjuvant chemotherapy influences surgical decisions in young women.”

The investigators studied 315 women aged 40 years or younger at diagnosis of unilateral stage I-III breast cancer who received neoadjuvant chemotherapy. Results showed that the chemotherapy doubled the proportion who were eligible for breast-conserving surgery, but 41% of all women eligible after neoadjuvant chemotherapy opted to undergo mastectomy, and the value was essentially the same (42%) among the subset who achieved a complete clinical response. The leading reason given in the medical record for this choice was personal preference in the absence of any known high-risk predisposition.

“Surgical decisions among young women with breast cancer appear to be driven by factors beyond the extent of disease and response to neoadjuvant chemotherapy,” she commented. “We should focus our efforts to optimize surgical decisions in these patients.”

The study complements another study undertaken in the same cohort, also reported at the symposium, that assessed longer-term quality of life according to which surgery women chose; this quality-of-life study found poorer measures after mastectomy.



Drivers and explanatory factors

Session moderator Fatima Cardoso, MD, director of the Breast Unit at the Champalimaud Clinical Center in Lisbon, asked, “Do you think this is really the patient preference, or is this more the surgeon’s preference that is passed on to the patient? Because there is now data showing that breast conservation with radiation is better, even in terms of survival, than mastectomy.”

“Patient preference includes a variety of things. Maybe it is a real patient preference [driven by] fear of recurrence or their peace of mind, but another important factor is maybe the doctor, especially the surgeon. That’s why we should be aware of surgical overtreatment, especially in these young early breast cancer patients,” Dr. Kim replied. “But the good news from this study is that neoadjuvant chemotherapy can give options to the patients, they can choose mastectomy. I think that it’s totally different when the patient has no option other than mastectomy versus the patient can choose mastectomy.”

Two main groups of patients in the United States are being given neoadjuvant chemotherapy, noted session attendee Steven E. Vogl, MD, an oncologist at Montefiore Medical Center, New York. One group has large tumors, and the goal is to shrink the tumor; the other group is planning to have unilateral or bilateral mastectomy with some type of reconstruction by a plastic surgeon.

“The medical oncologist, having decided the [latter] patient needs chemotherapy, chooses to give the chemotherapy preoperatively, so it’s not delayed by 3-5 months for the wounds to heal,” he elaborated. “How many of your patients were in the second category?”

The study did not tease out that population, Dr. Kim replied.

Study details

The women studied were participants in the Young Women’s Breast Cancer Study (YWS). Some 67% had a clinical complete response (no palpable tumor in the breast) to their neoadjuvant chemotherapy, and 32% had a pathological complete response (no tumor in the breast, with or without ductal carcinoma in situ [DCIS], and no tumor deposit exceeding 0.2 mm in the lymph nodes).

Before neoadjuvant chemotherapy, 26% of the women overall were eligible for breast-conserving surgery, but after neoadjuvant chemotherapy, 42% were eligible, Dr. Kim reported.

However, in the entire cohort, breast-conserving surgery was the initial surgery in just 25% of women and the final (definitive) surgery in just 23%.

Among patients eligible for breast conservation after neoadjuvant chemotherapy, 41% chose mastectomy instead as their initial surgery. Response to the chemotherapy seemingly did not influence this choice given that 42% of the subset with a clinical complete response still chose mastectomy. Furthermore, among those eligible for breast conservation who underwent mastectomy, 35% had a pathologic complete response to the chemotherapy.

Of all patients eligible for breast-conserving surgery who opted for mastectomy (and usually a bilateral procedure), the most common reason for choosing this more extensive surgery was personal preference, documented in 53% of cases, followed by presence of a BRCA or p53 mutation or a strong family history, documented in 40%. Reasons were similar among the breast conservation–eligible women who had a clinical complete response and/or ultimately a pathological complete response but chose mastectomy.

The study did not analyze disease factors that may have influenced choice of surgery, such as multicentricity or presence of DCIS, acknowledged Dr. Kim, who disclosed that she had no relevant conflicts of interest.

In an exploratory analysis, use of neoadjuvant chemotherapy increased over time among YWS participants, from 23% among those with diagnosis in 2006-2007 to 44% among those with diagnosis in 2014-2015. There were concurrent improvements in the proportions who achieved a clinical complete response (from 64% to 77%) and a pathological complete response (from 23% to 34%). Yet the proportion undergoing breast-conserving surgery as their initial surgery fell slightly, from 21% to 19%, during the same period.

SOURCE: Kim HJ et al. SABCS 2018, Abstract GS6-01,
 

SAN ANTONIO – Response to neoadjuvant chemotherapy has little if any influence on the choice of surgery among young women with early-stage breast cancer, suggests a multicenter, prospective cohort study reported at the San Antonio Breast Cancer Symposium.

Randomized, controlled trials have found high levels of mastectomy among patients who are eligible for breast-conserving surgery, according to first author Hee Jeong Kim, MD, PhD, a visiting scholar at the Dana-Farber Cancer Institute, Boston, and an associate professor in the division of breast in the department of surgery at the University of Ulsan, Seoul, South Korea.

“Young women are more likely to present with large tumors and particularly benefit from a neoadjuvant systemic approach,” she noted. “Recent data suggest that response rates, including pathological complete response, are higher in women younger than 40 than in older women, but little is known about how response to neoadjuvant chemotherapy influences surgical decisions in young women.”

The investigators studied 315 women aged 40 years or younger at diagnosis of unilateral stage I-III breast cancer who received neoadjuvant chemotherapy. Results showed that the chemotherapy doubled the proportion who were eligible for breast-conserving surgery, but 41% of all women eligible after neoadjuvant chemotherapy opted to undergo mastectomy, and the value was essentially the same (42%) among the subset who achieved a complete clinical response. The leading reason given in the medical record for this choice was personal preference in the absence of any known high-risk predisposition.

“Surgical decisions among young women with breast cancer appear to be driven by factors beyond the extent of disease and response to neoadjuvant chemotherapy,” she commented. “We should focus our efforts to optimize surgical decisions in these patients.”

The study complements another study undertaken in the same cohort, also reported at the symposium, that assessed longer-term quality of life according to which surgery women chose; this quality-of-life study found poorer measures after mastectomy.



Drivers and explanatory factors

Session moderator Fatima Cardoso, MD, director of the Breast Unit at the Champalimaud Clinical Center in Lisbon, asked, “Do you think this is really the patient preference, or is this more the surgeon’s preference that is passed on to the patient? Because there is now data showing that breast conservation with radiation is better, even in terms of survival, than mastectomy.”

“Patient preference includes a variety of things. Maybe it is a real patient preference [driven by] fear of recurrence or their peace of mind, but another important factor is maybe the doctor, especially the surgeon. That’s why we should be aware of surgical overtreatment, especially in these young early breast cancer patients,” Dr. Kim replied. “But the good news from this study is that neoadjuvant chemotherapy can give options to the patients, they can choose mastectomy. I think that it’s totally different when the patient has no option other than mastectomy versus the patient can choose mastectomy.”

Two main groups of patients in the United States are being given neoadjuvant chemotherapy, noted session attendee Steven E. Vogl, MD, an oncologist at Montefiore Medical Center, New York. One group has large tumors, and the goal is to shrink the tumor; the other group is planning to have unilateral or bilateral mastectomy with some type of reconstruction by a plastic surgeon.

“The medical oncologist, having decided the [latter] patient needs chemotherapy, chooses to give the chemotherapy preoperatively, so it’s not delayed by 3-5 months for the wounds to heal,” he elaborated. “How many of your patients were in the second category?”

The study did not tease out that population, Dr. Kim replied.

Study details

The women studied were participants in the Young Women’s Breast Cancer Study (YWS). Some 67% had a clinical complete response (no palpable tumor in the breast) to their neoadjuvant chemotherapy, and 32% had a pathological complete response (no tumor in the breast, with or without ductal carcinoma in situ [DCIS], and no tumor deposit exceeding 0.2 mm in the lymph nodes).

Before neoadjuvant chemotherapy, 26% of the women overall were eligible for breast-conserving surgery, but after neoadjuvant chemotherapy, 42% were eligible, Dr. Kim reported.

However, in the entire cohort, breast-conserving surgery was the initial surgery in just 25% of women and the final (definitive) surgery in just 23%.

Among patients eligible for breast conservation after neoadjuvant chemotherapy, 41% chose mastectomy instead as their initial surgery. Response to the chemotherapy seemingly did not influence this choice given that 42% of the subset with a clinical complete response still chose mastectomy. Furthermore, among those eligible for breast conservation who underwent mastectomy, 35% had a pathologic complete response to the chemotherapy.

Of all patients eligible for breast-conserving surgery who opted for mastectomy (and usually a bilateral procedure), the most common reason for choosing this more extensive surgery was personal preference, documented in 53% of cases, followed by presence of a BRCA or p53 mutation or a strong family history, documented in 40%. Reasons were similar among the breast conservation–eligible women who had a clinical complete response and/or ultimately a pathological complete response but chose mastectomy.

The study did not analyze disease factors that may have influenced choice of surgery, such as multicentricity or presence of DCIS, acknowledged Dr. Kim, who disclosed that she had no relevant conflicts of interest.

In an exploratory analysis, use of neoadjuvant chemotherapy increased over time among YWS participants, from 23% among those with diagnosis in 2006-2007 to 44% among those with diagnosis in 2014-2015. There were concurrent improvements in the proportions who achieved a clinical complete response (from 64% to 77%) and a pathological complete response (from 23% to 34%). Yet the proportion undergoing breast-conserving surgery as their initial surgery fell slightly, from 21% to 19%, during the same period.

SOURCE: Kim HJ et al. SABCS 2018, Abstract GS6-01,
 

SAN ANTONIO – Response to neoadjuvant chemotherapy has little if any influence on the choice of surgery among young women with early-stage breast cancer, suggests a multicenter, prospective cohort study reported at the San Antonio Breast Cancer Symposium.

Randomized, controlled trials have found high levels of mastectomy among patients who are eligible for breast-conserving surgery, according to first author Hee Jeong Kim, MD, PhD, a visiting scholar at the Dana-Farber Cancer Institute, Boston, and an associate professor in the division of breast in the department of surgery at the University of Ulsan, Seoul, South Korea.

“Young women are more likely to present with large tumors and particularly benefit from a neoadjuvant systemic approach,” she noted. “Recent data suggest that response rates, including pathological complete response, are higher in women younger than 40 than in older women, but little is known about how response to neoadjuvant chemotherapy influences surgical decisions in young women.”

The investigators studied 315 women aged 40 years or younger at diagnosis of unilateral stage I-III breast cancer who received neoadjuvant chemotherapy. Results showed that the chemotherapy doubled the proportion who were eligible for breast-conserving surgery, but 41% of all women eligible after neoadjuvant chemotherapy opted to undergo mastectomy, and the value was essentially the same (42%) among the subset who achieved a complete clinical response. The leading reason given in the medical record for this choice was personal preference in the absence of any known high-risk predisposition.

“Surgical decisions among young women with breast cancer appear to be driven by factors beyond the extent of disease and response to neoadjuvant chemotherapy,” she commented. “We should focus our efforts to optimize surgical decisions in these patients.”

The study complements another study undertaken in the same cohort, also reported at the symposium, that assessed longer-term quality of life according to which surgery women chose; this quality-of-life study found poorer measures after mastectomy.



Drivers and explanatory factors

Session moderator Fatima Cardoso, MD, director of the Breast Unit at the Champalimaud Clinical Center in Lisbon, asked, “Do you think this is really the patient preference, or is this more the surgeon’s preference that is passed on to the patient? Because there is now data showing that breast conservation with radiation is better, even in terms of survival, than mastectomy.”

“Patient preference includes a variety of things. Maybe it is a real patient preference [driven by] fear of recurrence or their peace of mind, but another important factor is maybe the doctor, especially the surgeon. That’s why we should be aware of surgical overtreatment, especially in these young early breast cancer patients,” Dr. Kim replied. “But the good news from this study is that neoadjuvant chemotherapy can give options to the patients, they can choose mastectomy. I think that it’s totally different when the patient has no option other than mastectomy versus the patient can choose mastectomy.”

Two main groups of patients in the United States are being given neoadjuvant chemotherapy, noted session attendee Steven E. Vogl, MD, an oncologist at Montefiore Medical Center, New York. One group has large tumors, and the goal is to shrink the tumor; the other group is planning to have unilateral or bilateral mastectomy with some type of reconstruction by a plastic surgeon.

“The medical oncologist, having decided the [latter] patient needs chemotherapy, chooses to give the chemotherapy preoperatively, so it’s not delayed by 3-5 months for the wounds to heal,” he elaborated. “How many of your patients were in the second category?”

The study did not tease out that population, Dr. Kim replied.

Study details

The women studied were participants in the Young Women’s Breast Cancer Study (YWS). Some 67% had a clinical complete response (no palpable tumor in the breast) to their neoadjuvant chemotherapy, and 32% had a pathological complete response (no tumor in the breast, with or without ductal carcinoma in situ [DCIS], and no tumor deposit exceeding 0.2 mm in the lymph nodes).

Before neoadjuvant chemotherapy, 26% of the women overall were eligible for breast-conserving surgery, but after neoadjuvant chemotherapy, 42% were eligible, Dr. Kim reported.

However, in the entire cohort, breast-conserving surgery was the initial surgery in just 25% of women and the final (definitive) surgery in just 23%.

Among patients eligible for breast conservation after neoadjuvant chemotherapy, 41% chose mastectomy instead as their initial surgery. Response to the chemotherapy seemingly did not influence this choice given that 42% of the subset with a clinical complete response still chose mastectomy. Furthermore, among those eligible for breast conservation who underwent mastectomy, 35% had a pathologic complete response to the chemotherapy.

Of all patients eligible for breast-conserving surgery who opted for mastectomy (and usually a bilateral procedure), the most common reason for choosing this more extensive surgery was personal preference, documented in 53% of cases, followed by presence of a BRCA or p53 mutation or a strong family history, documented in 40%. Reasons were similar among the breast conservation–eligible women who had a clinical complete response and/or ultimately a pathological complete response but chose mastectomy.

The study did not analyze disease factors that may have influenced choice of surgery, such as multicentricity or presence of DCIS, acknowledged Dr. Kim, who disclosed that she had no relevant conflicts of interest.

In an exploratory analysis, use of neoadjuvant chemotherapy increased over time among YWS participants, from 23% among those with diagnosis in 2006-2007 to 44% among those with diagnosis in 2014-2015. There were concurrent improvements in the proportions who achieved a clinical complete response (from 64% to 77%) and a pathological complete response (from 23% to 34%). Yet the proportion undergoing breast-conserving surgery as their initial surgery fell slightly, from 21% to 19%, during the same period.

SOURCE: Kim HJ et al. SABCS 2018, Abstract GS6-01,
 

The Merriam-Webster dictionary defines value as “the regard that something is held to deserve; the importance, worth, or usefulness of something” and “relative worth, utility, or importance.” We usually assess our professional worth by how we are treated at work. In social valuing framework, we are given social status based on how others regard us for who we are, what we do, and what we are worth. This is described as “felt worth,” which encapsulates our feelings about how we are regarded by others, in contrast to self-esteem, which is more of an internally held belief.

Our power came from our relationship with our patients and our ability to communicate and influence our patients, peers and administrators. As owners of our practices and small businesses, our currency with hospitals and lawmakers was our ability to bring revenue to hospitals and patient concerns directly to legislators. Practicing in more than one hospital made us more valuable and hospitals battled with each other to provide us and our patients the latest tools and conveniences. In return, we gave our valuable time freely without compensation to hospitals as committee members, task force members, and sounding boards for the betterment of the community. If I were a conspiracy theorist, which I am not, and wanted to devalue physicians I would seek to weaken the physician-patient bond. The way to implement this would be for a single hospital employer to put us on a treadmill chasing work relative value units, give us hard-to-accomplish goals, and keep moving the goalpost. Like I said, I do not believe in conspiracies.

The tsunami of byzantine regulations, Stark laws, and complicated reimbursement formulas has sapped our energy to counter the devaluation. Some are glad to see physicians, particularly surgeons, get their comeuppance because we are perceived as having large egos. This may be true in some instances. Yet, it turns out that the top three job titles with the largest egos are: private household cooks, chief executives, and farm and ranch managers.¹

References

1. www.chicagotribune.com/business/ct-payscale-ego-survey-0830-biz-20160829-story.html

2. www.medpagetoday.com/primarycare/generalprimarycare/60446

3. https://nurse.org/articles/gallup-ethical-standards-poll-nurses-rank-highest/

4.https://news.gallup.com/poll/120890/healthcare-americans-trust-physicians-politicians.aspx

Bhagwan Satiani, MD, MBA, is professor of clinical surgery in the division of vascular diseases and surgery at Ohio State University, Columbus. He blogs at www.savvy-medicine.com . Reach him on Twitter @savvycutter.

The Merriam-Webster dictionary defines value as “the regard that something is held to deserve; the importance, worth, or usefulness of something” and “relative worth, utility, or importance.” We usually assess our professional worth by how we are treated at work. In social valuing framework, we are given social status based on how others regard us for who we are, what we do, and what we are worth. This is described as “felt worth,” which encapsulates our feelings about how we are regarded by others, in contrast to self-esteem, which is more of an internally held belief.

Our power came from our relationship with our patients and our ability to communicate and influence our patients, peers and administrators. As owners of our practices and small businesses, our currency with hospitals and lawmakers was our ability to bring revenue to hospitals and patient concerns directly to legislators. Practicing in more than one hospital made us more valuable and hospitals battled with each other to provide us and our patients the latest tools and conveniences. In return, we gave our valuable time freely without compensation to hospitals as committee members, task force members, and sounding boards for the betterment of the community. If I were a conspiracy theorist, which I am not, and wanted to devalue physicians I would seek to weaken the physician-patient bond. The way to implement this would be for a single hospital employer to put us on a treadmill chasing work relative value units, give us hard-to-accomplish goals, and keep moving the goalpost. Like I said, I do not believe in conspiracies.

The tsunami of byzantine regulations, Stark laws, and complicated reimbursement formulas has sapped our energy to counter the devaluation. Some are glad to see physicians, particularly surgeons, get their comeuppance because we are perceived as having large egos. This may be true in some instances. Yet, it turns out that the top three job titles with the largest egos are: private household cooks, chief executives, and farm and ranch managers.¹

References

1. www.chicagotribune.com/business/ct-payscale-ego-survey-0830-biz-20160829-story.html

2. www.medpagetoday.com/primarycare/generalprimarycare/60446

3. https://nurse.org/articles/gallup-ethical-standards-poll-nurses-rank-highest/

4.https://news.gallup.com/poll/120890/healthcare-americans-trust-physicians-politicians.aspx

Bhagwan Satiani, MD, MBA, is professor of clinical surgery in the division of vascular diseases and surgery at Ohio State University, Columbus. He blogs at www.savvy-medicine.com . Reach him on Twitter @savvycutter.

The Merriam-Webster dictionary defines value as “the regard that something is held to deserve; the importance, worth, or usefulness of something” and “relative worth, utility, or importance.” We usually assess our professional worth by how we are treated at work. In social valuing framework, we are given social status based on how others regard us for who we are, what we do, and what we are worth. This is described as “felt worth,” which encapsulates our feelings about how we are regarded by others, in contrast to self-esteem, which is more of an internally held belief.

Our power came from our relationship with our patients and our ability to communicate and influence our patients, peers and administrators. As owners of our practices and small businesses, our currency with hospitals and lawmakers was our ability to bring revenue to hospitals and patient concerns directly to legislators. Practicing in more than one hospital made us more valuable and hospitals battled with each other to provide us and our patients the latest tools and conveniences. In return, we gave our valuable time freely without compensation to hospitals as committee members, task force members, and sounding boards for the betterment of the community. If I were a conspiracy theorist, which I am not, and wanted to devalue physicians I would seek to weaken the physician-patient bond. The way to implement this would be for a single hospital employer to put us on a treadmill chasing work relative value units, give us hard-to-accomplish goals, and keep moving the goalpost. Like I said, I do not believe in conspiracies.

The tsunami of byzantine regulations, Stark laws, and complicated reimbursement formulas has sapped our energy to counter the devaluation. Some are glad to see physicians, particularly surgeons, get their comeuppance because we are perceived as having large egos. This may be true in some instances. Yet, it turns out that the top three job titles with the largest egos are: private household cooks, chief executives, and farm and ranch managers.¹

References

1. www.chicagotribune.com/business/ct-payscale-ego-survey-0830-biz-20160829-story.html

2. www.medpagetoday.com/primarycare/generalprimarycare/60446

3. https://nurse.org/articles/gallup-ethical-standards-poll-nurses-rank-highest/

4.https://news.gallup.com/poll/120890/healthcare-americans-trust-physicians-politicians.aspx

Bhagwan Satiani, MD, MBA, is professor of clinical surgery in the division of vascular diseases and surgery at Ohio State University, Columbus. He blogs at www.savvy-medicine.com . Reach him on Twitter @savvycutter.

In order to provide healthcare professionals with updated guidance in the use of novel preventive and acute treatments for migraine in adults, a recent position statement released by the American Headache Society updates prior recommendations and outlines the indications for initiating, continuing, combining, and switching preventive and acute treatments. Input was sought from health insurance providers, employers, pharmacy benefit service companies, device manufacturers, pharmaceutical and biotechnology companies, patients, and patient advocates. In addition, expert clinicians and researchers in the field of headache medicine from across North America and the European Union provided input and feedback.

The principles of pharmacologic preventive treatment of migraine with oral treatments have been as follows:

• Use evidence‐based treatments when possible and appropriate.
• Start with a low dose and titrate slowly; newer injectable treatments may work faster and may not need titration.
• Reach a therapeutic dose if possible.
• Allow for an adequate treatment trial duration.
• Establish expectations of therapeutic response and adverse events and maximize adherence.

The principles of acute treatment include:

• Use evidence‐based treatments when possible and appropriate.
• Treat early after the onset of a migraine attack.
• Choose a non-oral route of administration for selected patients.
• Account for tolerability and safety issues.
• Consider self‐administered rescue treatments.
• Avoid overuse of acute medications.

American Headache Society. The American Headache Society position statement on integrating new migraine treatments into clinical practice. [Published online ahead of print December 10, 2018]. Headache. doi:10.1111/head.13456.

In order to provide healthcare professionals with updated guidance in the use of novel preventive and acute treatments for migraine in adults, a recent position statement released by the American Headache Society updates prior recommendations and outlines the indications for initiating, continuing, combining, and switching preventive and acute treatments. Input was sought from health insurance providers, employers, pharmacy benefit service companies, device manufacturers, pharmaceutical and biotechnology companies, patients, and patient advocates. In addition, expert clinicians and researchers in the field of headache medicine from across North America and the European Union provided input and feedback.

The principles of pharmacologic preventive treatment of migraine with oral treatments have been as follows:

• Use evidence‐based treatments when possible and appropriate.
• Start with a low dose and titrate slowly; newer injectable treatments may work faster and may not need titration.
• Reach a therapeutic dose if possible.
• Allow for an adequate treatment trial duration.
• Establish expectations of therapeutic response and adverse events and maximize adherence.

The principles of acute treatment include:

• Use evidence‐based treatments when possible and appropriate.
• Treat early after the onset of a migraine attack.
• Choose a non-oral route of administration for selected patients.
• Account for tolerability and safety issues.
• Consider self‐administered rescue treatments.
• Avoid overuse of acute medications.

American Headache Society. The American Headache Society position statement on integrating new migraine treatments into clinical practice. [Published online ahead of print December 10, 2018]. Headache. doi:10.1111/head.13456.

In order to provide healthcare professionals with updated guidance in the use of novel preventive and acute treatments for migraine in adults, a recent position statement released by the American Headache Society updates prior recommendations and outlines the indications for initiating, continuing, combining, and switching preventive and acute treatments. Input was sought from health insurance providers, employers, pharmacy benefit service companies, device manufacturers, pharmaceutical and biotechnology companies, patients, and patient advocates. In addition, expert clinicians and researchers in the field of headache medicine from across North America and the European Union provided input and feedback.

The principles of pharmacologic preventive treatment of migraine with oral treatments have been as follows:

• Use evidence‐based treatments when possible and appropriate.
• Start with a low dose and titrate slowly; newer injectable treatments may work faster and may not need titration.
• Reach a therapeutic dose if possible.
• Allow for an adequate treatment trial duration.
• Establish expectations of therapeutic response and adverse events and maximize adherence.

The principles of acute treatment include:

• Use evidence‐based treatments when possible and appropriate.
• Treat early after the onset of a migraine attack.
• Choose a non-oral route of administration for selected patients.
• Account for tolerability and safety issues.
• Consider self‐administered rescue treatments.
• Avoid overuse of acute medications.

American Headache Society. The American Headache Society position statement on integrating new migraine treatments into clinical practice. [Published online ahead of print December 10, 2018]. Headache. doi:10.1111/head.13456.

Migraine with aura was associated with increased risk of incident atrial fibrillation (AF), according to a recent study, which may potentially lead to ischemic strokes. In the Atherosclerosis Risk in Communities (ARIC) study, participants were interviewed for migraine history from 1993 through 1995 and were followed for incident AF through 2013. AF was adjudicated using electrocardiograms (ECGs), discharge codes, and death certificates. Multivariable Cox proportional hazards models were used to study the relation between migraine and its subtypes with incident AF, compared with controls without headaches. Researchers found:

• Of 11,939 participants assessed for headache and without prior AF or stroke, 426 reported migraine with visual aura, 1090 migraine without visual aura, 1018 non-migraine headache, and 9405 no headache.
• Over a 20-year follow-up period, incident AF was noted in 232 (15%) of 1516 with migraine and 1623 (17%) of 9405 without headache.
• After adjustment for multiple confounders, migraine with visual aura was associated with increased risk of AF compared to no headache as well as when compared to migraine without visual aura.

Sen S, Androulakis XM, Duda V, et al. Migraine with visual aura is a risk factor for incident atrial fibrillation. A cohort study. [Published online ahead of print December 11, 2018]. Neurology. doi:10.1212/WNL.0000000000006650.

Migraine with aura was associated with increased risk of incident atrial fibrillation (AF), according to a recent study, which may potentially lead to ischemic strokes. In the Atherosclerosis Risk in Communities (ARIC) study, participants were interviewed for migraine history from 1993 through 1995 and were followed for incident AF through 2013. AF was adjudicated using electrocardiograms (ECGs), discharge codes, and death certificates. Multivariable Cox proportional hazards models were used to study the relation between migraine and its subtypes with incident AF, compared with controls without headaches. Researchers found:

• Of 11,939 participants assessed for headache and without prior AF or stroke, 426 reported migraine with visual aura, 1090 migraine without visual aura, 1018 non-migraine headache, and 9405 no headache.
• Over a 20-year follow-up period, incident AF was noted in 232 (15%) of 1516 with migraine and 1623 (17%) of 9405 without headache.
• After adjustment for multiple confounders, migraine with visual aura was associated with increased risk of AF compared to no headache as well as when compared to migraine without visual aura.

Sen S, Androulakis XM, Duda V, et al. Migraine with visual aura is a risk factor for incident atrial fibrillation. A cohort study. [Published online ahead of print December 11, 2018]. Neurology. doi:10.1212/WNL.0000000000006650.

Migraine with aura was associated with increased risk of incident atrial fibrillation (AF), according to a recent study, which may potentially lead to ischemic strokes. In the Atherosclerosis Risk in Communities (ARIC) study, participants were interviewed for migraine history from 1993 through 1995 and were followed for incident AF through 2013. AF was adjudicated using electrocardiograms (ECGs), discharge codes, and death certificates. Multivariable Cox proportional hazards models were used to study the relation between migraine and its subtypes with incident AF, compared with controls without headaches. Researchers found:

• Of 11,939 participants assessed for headache and without prior AF or stroke, 426 reported migraine with visual aura, 1090 migraine without visual aura, 1018 non-migraine headache, and 9405 no headache.
• Over a 20-year follow-up period, incident AF was noted in 232 (15%) of 1516 with migraine and 1623 (17%) of 9405 without headache.
• After adjustment for multiple confounders, migraine with visual aura was associated with increased risk of AF compared to no headache as well as when compared to migraine without visual aura.

Sen S, Androulakis XM, Duda V, et al. Migraine with visual aura is a risk factor for incident atrial fibrillation. A cohort study. [Published online ahead of print December 11, 2018]. Neurology. doi:10.1212/WNL.0000000000006650.

Women with active migraine have a lower risk of developing type 2 diabetes (T2D), according to a recent study, and a decrease in active migraine prevalence prior to diabetes diagnosis. Researchers used data from a prospective population-based study initiated in 1990 on a cohort of women born between 1925 and 1950. From eligible women in the study, researchers included those who completed a 2002 follow-up questionnaire with information available on migraine. They then excluded prevalent cases of T2D, leaving a final sample of women who were followed up between 2004 and 2014. All potential occurrences of T2D were identified through a drug reimbursement database. They found:

• From the 98,995 women in the study, 76,403 women completed the 2002 follow-up survey.
• Of these, 2156 were excluded because they had T2D, leaving 74,247 women.
• During 10 years of follow-up, 2372 incident T2D cases occurred.
• A lower risk of T2D was observed for women with active migraine compared with women with no migraine history (univariate hazard ratio, 0.80, multivariable-adjusted hazard ratio, 0.7).

Fagherazzi G, El Fatouhi D, Fournier A, et al. Associations between migraine and type 2 diabetes in women: Findings from the E3N Cohort Study. [Published online ahead of print December 17, 2018]. JAMA Neurology. doi:10.1001/jamaneurol.2018.3960.

Women with active migraine have a lower risk of developing type 2 diabetes (T2D), according to a recent study, and a decrease in active migraine prevalence prior to diabetes diagnosis. Researchers used data from a prospective population-based study initiated in 1990 on a cohort of women born between 1925 and 1950. From eligible women in the study, researchers included those who completed a 2002 follow-up questionnaire with information available on migraine. They then excluded prevalent cases of T2D, leaving a final sample of women who were followed up between 2004 and 2014. All potential occurrences of T2D were identified through a drug reimbursement database. They found:

• From the 98,995 women in the study, 76,403 women completed the 2002 follow-up survey.
• Of these, 2156 were excluded because they had T2D, leaving 74,247 women.
• During 10 years of follow-up, 2372 incident T2D cases occurred.
• A lower risk of T2D was observed for women with active migraine compared with women with no migraine history (univariate hazard ratio, 0.80, multivariable-adjusted hazard ratio, 0.7).

Fagherazzi G, El Fatouhi D, Fournier A, et al. Associations between migraine and type 2 diabetes in women: Findings from the E3N Cohort Study. [Published online ahead of print December 17, 2018]. JAMA Neurology. doi:10.1001/jamaneurol.2018.3960.

Women with active migraine have a lower risk of developing type 2 diabetes (T2D), according to a recent study, and a decrease in active migraine prevalence prior to diabetes diagnosis. Researchers used data from a prospective population-based study initiated in 1990 on a cohort of women born between 1925 and 1950. From eligible women in the study, researchers included those who completed a 2002 follow-up questionnaire with information available on migraine. They then excluded prevalent cases of T2D, leaving a final sample of women who were followed up between 2004 and 2014. All potential occurrences of T2D were identified through a drug reimbursement database. They found:

• From the 98,995 women in the study, 76,403 women completed the 2002 follow-up survey.
• Of these, 2156 were excluded because they had T2D, leaving 74,247 women.
• During 10 years of follow-up, 2372 incident T2D cases occurred.
• A lower risk of T2D was observed for women with active migraine compared with women with no migraine history (univariate hazard ratio, 0.80, multivariable-adjusted hazard ratio, 0.7).

Fagherazzi G, El Fatouhi D, Fournier A, et al. Associations between migraine and type 2 diabetes in women: Findings from the E3N Cohort Study. [Published online ahead of print December 17, 2018]. JAMA Neurology. doi:10.1001/jamaneurol.2018.3960.

A back pain screening questionnaire developed for ankylosing spondylitis performs well for identifying the subset of axial psoriatic arthritis patients who have active symptoms, according to researchers.

The inflammatory back pain criteria didn’t perform as well when patients with established disease but no symptoms were included, though using a lower cutoff point for the questionnaire improved its sensitivity, the researchers reported in the Annals of the Rheumatic Diseases.

Previous investigations showed that the inflammatory back pain criteria, as defined by the Assessment of Spondyloarthritis International Society (ASAS), had low sensitivity and high specificity for axial involvement in psoriatic arthritis.

Those earlier studies may have registered suboptimal performance of the inflammatory back pain criteria by not distinguishing between patients with axial disease in remission and those with active symptoms, according to Muhammad Haroon, PhD, of the division of rheumatology at University Hospital Kerry in Tralee, Ireland, and his coinvestigators.

The present study, which they said represents a much larger cohort than earlier investigations, included 406 patients with psoriatic arthritis, about one-quarter of whom had rheumatologist-diagnosed axial psoriatic arthritis. The mean age of the axial psoriatic arthritis patients was 51 years and 53% were male.

The researchers found that the inflammatory back pain criteria had poor sensitivity but good specificity at 59% and 84%, respectively, in patients with established axial psoriatic arthritis, defined as axial disease regardless of whether it was active or in remission.

By contrast, the criteria had good sensitivity and good specificity at 82% and 88%, respectively, in patients who had active axial psoriatic arthritis, according to the investigators.

The standard cutoff points used by the ASAS inflammatory back pain criteria may be too high for screening for early disease or for evaluating patients already receiving systemic therapies for psoriatic disease, the investigators said.

Looking at a lower cutoff point of three of five ASAS criteria, sensitivity was “quite high” for detecting established axial psoriatic arthritis, they said, increasing from 59% to 84%, while specificity remained relatively high, decreasing from 84% to 80%.

“We suggest that the standard cutoffs for this questionnaire be used for patients with active axial psoriatic arthritis, and the lower cutoffs should be used among patients with established axial psoriatic arthritis, where patients can potentially be in remission or partial remission,” they wrote in their report.

These findings could have important implications for the use of this screening tool in patients with psoriatic arthritis; however, more research is needed to validate the observations, the researchers cautioned.

Dr. Haroon reported competing interests related to AbbVie, Pfizer, and Celgene.

SOURCE: Haroon M et al. Ann Rheum Dis. 2018 Dec 14. doi: 10.1136/annrheumdis-2018-214583.

A back pain screening questionnaire developed for ankylosing spondylitis performs well for identifying the subset of axial psoriatic arthritis patients who have active symptoms, according to researchers.

The inflammatory back pain criteria didn’t perform as well when patients with established disease but no symptoms were included, though using a lower cutoff point for the questionnaire improved its sensitivity, the researchers reported in the Annals of the Rheumatic Diseases.

Previous investigations showed that the inflammatory back pain criteria, as defined by the Assessment of Spondyloarthritis International Society (ASAS), had low sensitivity and high specificity for axial involvement in psoriatic arthritis.

Those earlier studies may have registered suboptimal performance of the inflammatory back pain criteria by not distinguishing between patients with axial disease in remission and those with active symptoms, according to Muhammad Haroon, PhD, of the division of rheumatology at University Hospital Kerry in Tralee, Ireland, and his coinvestigators.

The present study, which they said represents a much larger cohort than earlier investigations, included 406 patients with psoriatic arthritis, about one-quarter of whom had rheumatologist-diagnosed axial psoriatic arthritis. The mean age of the axial psoriatic arthritis patients was 51 years and 53% were male.

The researchers found that the inflammatory back pain criteria had poor sensitivity but good specificity at 59% and 84%, respectively, in patients with established axial psoriatic arthritis, defined as axial disease regardless of whether it was active or in remission.

By contrast, the criteria had good sensitivity and good specificity at 82% and 88%, respectively, in patients who had active axial psoriatic arthritis, according to the investigators.

The standard cutoff points used by the ASAS inflammatory back pain criteria may be too high for screening for early disease or for evaluating patients already receiving systemic therapies for psoriatic disease, the investigators said.

Looking at a lower cutoff point of three of five ASAS criteria, sensitivity was “quite high” for detecting established axial psoriatic arthritis, they said, increasing from 59% to 84%, while specificity remained relatively high, decreasing from 84% to 80%.

“We suggest that the standard cutoffs for this questionnaire be used for patients with active axial psoriatic arthritis, and the lower cutoffs should be used among patients with established axial psoriatic arthritis, where patients can potentially be in remission or partial remission,” they wrote in their report.

These findings could have important implications for the use of this screening tool in patients with psoriatic arthritis; however, more research is needed to validate the observations, the researchers cautioned.

Dr. Haroon reported competing interests related to AbbVie, Pfizer, and Celgene.

SOURCE: Haroon M et al. Ann Rheum Dis. 2018 Dec 14. doi: 10.1136/annrheumdis-2018-214583.

A back pain screening questionnaire developed for ankylosing spondylitis performs well for identifying the subset of axial psoriatic arthritis patients who have active symptoms, according to researchers.

The inflammatory back pain criteria didn’t perform as well when patients with established disease but no symptoms were included, though using a lower cutoff point for the questionnaire improved its sensitivity, the researchers reported in the Annals of the Rheumatic Diseases.

Previous investigations showed that the inflammatory back pain criteria, as defined by the Assessment of Spondyloarthritis International Society (ASAS), had low sensitivity and high specificity for axial involvement in psoriatic arthritis.

Those earlier studies may have registered suboptimal performance of the inflammatory back pain criteria by not distinguishing between patients with axial disease in remission and those with active symptoms, according to Muhammad Haroon, PhD, of the division of rheumatology at University Hospital Kerry in Tralee, Ireland, and his coinvestigators.

The present study, which they said represents a much larger cohort than earlier investigations, included 406 patients with psoriatic arthritis, about one-quarter of whom had rheumatologist-diagnosed axial psoriatic arthritis. The mean age of the axial psoriatic arthritis patients was 51 years and 53% were male.

The researchers found that the inflammatory back pain criteria had poor sensitivity but good specificity at 59% and 84%, respectively, in patients with established axial psoriatic arthritis, defined as axial disease regardless of whether it was active or in remission.

By contrast, the criteria had good sensitivity and good specificity at 82% and 88%, respectively, in patients who had active axial psoriatic arthritis, according to the investigators.

The standard cutoff points used by the ASAS inflammatory back pain criteria may be too high for screening for early disease or for evaluating patients already receiving systemic therapies for psoriatic disease, the investigators said.

Looking at a lower cutoff point of three of five ASAS criteria, sensitivity was “quite high” for detecting established axial psoriatic arthritis, they said, increasing from 59% to 84%, while specificity remained relatively high, decreasing from 84% to 80%.

“We suggest that the standard cutoffs for this questionnaire be used for patients with active axial psoriatic arthritis, and the lower cutoffs should be used among patients with established axial psoriatic arthritis, where patients can potentially be in remission or partial remission,” they wrote in their report.

These findings could have important implications for the use of this screening tool in patients with psoriatic arthritis; however, more research is needed to validate the observations, the researchers cautioned.

Dr. Haroon reported competing interests related to AbbVie, Pfizer, and Celgene.

SOURCE: Haroon M et al. Ann Rheum Dis. 2018 Dec 14. doi: 10.1136/annrheumdis-2018-214583.