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Do you attend a patient’s funeral?
I’ve never been to a patient’s funeral, though I know plenty of other doctors who have.
I suppose this is a highly personal decision. Some feel they should go out of respect to the patient, or if they had a particularly strong or longstanding relationship with them.
Part of it is feeling like an outsider. To me, funerals are a chance for loved ones and close friends to say their goodbyes. I generally try to keep a professional distance. It makes the job easier.
Another is simply a reluctance to take time off from the office. Even though someone I cared for is gone, that person is not the only one that I see. I have to continue caring for the patients who still need me.
There’s also an aspect of fear. Family members who don’t know you well may see your presence as a sign of guilt that you did something wrong. Or, in the irrational nature of grief and anger, become belligerent, accusing you of incompetence. These sorts of confrontations can never end well for either side.
All of us are facing death sooner or later. As physicians, our job is to prolong and improve quality of life as best we can, knowing that inevitably we’ll lose. When that happens, the most we can ever ask is that we did our best. And that we continue to care for those who still depend on us.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
[polldaddy:9711658]
I’ve never been to a patient’s funeral, though I know plenty of other doctors who have.
I suppose this is a highly personal decision. Some feel they should go out of respect to the patient, or if they had a particularly strong or longstanding relationship with them.
Part of it is feeling like an outsider. To me, funerals are a chance for loved ones and close friends to say their goodbyes. I generally try to keep a professional distance. It makes the job easier.
Another is simply a reluctance to take time off from the office. Even though someone I cared for is gone, that person is not the only one that I see. I have to continue caring for the patients who still need me.
There’s also an aspect of fear. Family members who don’t know you well may see your presence as a sign of guilt that you did something wrong. Or, in the irrational nature of grief and anger, become belligerent, accusing you of incompetence. These sorts of confrontations can never end well for either side.
All of us are facing death sooner or later. As physicians, our job is to prolong and improve quality of life as best we can, knowing that inevitably we’ll lose. When that happens, the most we can ever ask is that we did our best. And that we continue to care for those who still depend on us.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
[polldaddy:9711658]
I’ve never been to a patient’s funeral, though I know plenty of other doctors who have.
I suppose this is a highly personal decision. Some feel they should go out of respect to the patient, or if they had a particularly strong or longstanding relationship with them.
Part of it is feeling like an outsider. To me, funerals are a chance for loved ones and close friends to say their goodbyes. I generally try to keep a professional distance. It makes the job easier.
Another is simply a reluctance to take time off from the office. Even though someone I cared for is gone, that person is not the only one that I see. I have to continue caring for the patients who still need me.
There’s also an aspect of fear. Family members who don’t know you well may see your presence as a sign of guilt that you did something wrong. Or, in the irrational nature of grief and anger, become belligerent, accusing you of incompetence. These sorts of confrontations can never end well for either side.
All of us are facing death sooner or later. As physicians, our job is to prolong and improve quality of life as best we can, knowing that inevitably we’ll lose. When that happens, the most we can ever ask is that we did our best. And that we continue to care for those who still depend on us.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
[polldaddy:9711658]
Novel protein biomarker could accelerate ALS research
A protein found in the cerebrospinal fluid and peripheral blood cells of patients with a common type of amyotrophic lateral sclerosis may serve as a “pharmacodynamic marker,” providing a mechanism to assess RNA-based therapies that are now in clinical trials.
The protein, poly(GP), is expressed in patients who have a mutation in the gene chromosome 9 open reading frame 72 (C9ORF72), which causes one type of amyotrophic lateral sclerosis (ALS). This means that detecting poly(GP) also, eventually, may help to identify “presymptomatic individuals who are expected to benefit from early therapeutic interventions,” wrote the authors of a newly published paper (Sci Transl Med. 2017;9[383]:eaai7866).
Tania Gendron, PhD, of the department of neuroscience at the Mayo Clinic, Jacksonville, Fla., and her colleagues noted that poly(GP) was found in the cerebrospinal fluid (CSF) of both symptomatic and asymptomatic patients who carried the C9ORF72 mutation. The mutation can cause ALS, and is also associated with frontotemporal dementia (FTD) in a pattern with incomplete overlap with ALS.
However, “A limitation in moving such treatments from bench to bedside is a lack of pharmacodynamics markers for use in clinical trials,” Dr. Gendron and her collaborators wrote. The discovery that poly(GP) tracks well with C9ORF72 means that it has the potential to serve as the kind of biomarker that’s been missing in drug development for this family of neurodegenerative diseases, they said.
“To prepare for upcoming clinical trials for c9ALS, the present study used patient CSF and several preclinical models to investigate the hypothesis that poly(GP) proteins could serve as an urgently needed pharmacodynamics marker for developing and testing therapies for treating c9ALS,” Dr. Gendron and her colleagues wrote.
They looked at CSF samples from 83 patients with c9ALS and 27 patients who were asymptomatic C9ORF72 repeat expansion carriers, as well as 24 carriers who had a neurologic disease besides ALS or FTD (total n = 134). They also examined CSF samples from 120 study participants who lacked the mutation, 48 of whom were healthy controls; the remainder had ALS (n = 57) or another neurological disease.
The investigators, who were blinded to individuals’ disease status in each study arm, found that CSF poly(GP) levels were significantly higher in patients who had the C9ORF72 mutation (P less than .0001 in unadjusted and adjusted analyses). Poly(GP) was present in both asymptomatic and symptomatic carriers of the mutation, and not significantly different between these groups when data were adjusted for multiple comparisons, age, and gender.
When Dr. Gendron and her colleagues looked at poly(GP) levels over time for patients whose longitudinal data were available, they found that levels for an individual study participant were “relatively constant,” without any significant change over the median 12.9 months that these levels were tracked (P = .84).
However, “poly(GP) is not a prognostic marker,” wrote Dr. Gendron and her colleagues. They found no consistent association between levels of the protein and disease severity of progression, age at onset, or the development of FTD. Women were more likely to have lower levels, but the significance of that finding is not known, they said. There was a trend, which lost significance after statistical adjustment, for patients with cognitive impairment to have higher poly(GP) levels (adjusted P = .12).
Treatments under investigation for ALS and FTD include the use of an antisense oligonucleotide (ASO) to bind to the repeated RNA sequences and negate their ill effects. The investigators wrote that in vitro investigations using patient-derived cell models showed that poly(GP) levels dropped when cells were exposed to an ASO for 10 days. “The data indicate that poly(GP) production mirrors expression of repeat-containing C9ORF72 transcripts in lymphoblastoid cell lines,” they wrote.
The authors reported multiple governmental and private foundation sources of support for the research. Dr. Gendron and several of her coauthors are investigators in clinical trials for an ASO to target C9ORF72. Several authors reported paid and unpaid relationships and stock positions with pharmaceutical companies, including ones developing treatments for ALS and FTD.
[email protected]
On Twitter @karioakes
A protein found in the cerebrospinal fluid and peripheral blood cells of patients with a common type of amyotrophic lateral sclerosis may serve as a “pharmacodynamic marker,” providing a mechanism to assess RNA-based therapies that are now in clinical trials.
The protein, poly(GP), is expressed in patients who have a mutation in the gene chromosome 9 open reading frame 72 (C9ORF72), which causes one type of amyotrophic lateral sclerosis (ALS). This means that detecting poly(GP) also, eventually, may help to identify “presymptomatic individuals who are expected to benefit from early therapeutic interventions,” wrote the authors of a newly published paper (Sci Transl Med. 2017;9[383]:eaai7866).
Tania Gendron, PhD, of the department of neuroscience at the Mayo Clinic, Jacksonville, Fla., and her colleagues noted that poly(GP) was found in the cerebrospinal fluid (CSF) of both symptomatic and asymptomatic patients who carried the C9ORF72 mutation. The mutation can cause ALS, and is also associated with frontotemporal dementia (FTD) in a pattern with incomplete overlap with ALS.
However, “A limitation in moving such treatments from bench to bedside is a lack of pharmacodynamics markers for use in clinical trials,” Dr. Gendron and her collaborators wrote. The discovery that poly(GP) tracks well with C9ORF72 means that it has the potential to serve as the kind of biomarker that’s been missing in drug development for this family of neurodegenerative diseases, they said.
“To prepare for upcoming clinical trials for c9ALS, the present study used patient CSF and several preclinical models to investigate the hypothesis that poly(GP) proteins could serve as an urgently needed pharmacodynamics marker for developing and testing therapies for treating c9ALS,” Dr. Gendron and her colleagues wrote.
They looked at CSF samples from 83 patients with c9ALS and 27 patients who were asymptomatic C9ORF72 repeat expansion carriers, as well as 24 carriers who had a neurologic disease besides ALS or FTD (total n = 134). They also examined CSF samples from 120 study participants who lacked the mutation, 48 of whom were healthy controls; the remainder had ALS (n = 57) or another neurological disease.
The investigators, who were blinded to individuals’ disease status in each study arm, found that CSF poly(GP) levels were significantly higher in patients who had the C9ORF72 mutation (P less than .0001 in unadjusted and adjusted analyses). Poly(GP) was present in both asymptomatic and symptomatic carriers of the mutation, and not significantly different between these groups when data were adjusted for multiple comparisons, age, and gender.
When Dr. Gendron and her colleagues looked at poly(GP) levels over time for patients whose longitudinal data were available, they found that levels for an individual study participant were “relatively constant,” without any significant change over the median 12.9 months that these levels were tracked (P = .84).
However, “poly(GP) is not a prognostic marker,” wrote Dr. Gendron and her colleagues. They found no consistent association between levels of the protein and disease severity of progression, age at onset, or the development of FTD. Women were more likely to have lower levels, but the significance of that finding is not known, they said. There was a trend, which lost significance after statistical adjustment, for patients with cognitive impairment to have higher poly(GP) levels (adjusted P = .12).
Treatments under investigation for ALS and FTD include the use of an antisense oligonucleotide (ASO) to bind to the repeated RNA sequences and negate their ill effects. The investigators wrote that in vitro investigations using patient-derived cell models showed that poly(GP) levels dropped when cells were exposed to an ASO for 10 days. “The data indicate that poly(GP) production mirrors expression of repeat-containing C9ORF72 transcripts in lymphoblastoid cell lines,” they wrote.
The authors reported multiple governmental and private foundation sources of support for the research. Dr. Gendron and several of her coauthors are investigators in clinical trials for an ASO to target C9ORF72. Several authors reported paid and unpaid relationships and stock positions with pharmaceutical companies, including ones developing treatments for ALS and FTD.
[email protected]
On Twitter @karioakes
A protein found in the cerebrospinal fluid and peripheral blood cells of patients with a common type of amyotrophic lateral sclerosis may serve as a “pharmacodynamic marker,” providing a mechanism to assess RNA-based therapies that are now in clinical trials.
The protein, poly(GP), is expressed in patients who have a mutation in the gene chromosome 9 open reading frame 72 (C9ORF72), which causes one type of amyotrophic lateral sclerosis (ALS). This means that detecting poly(GP) also, eventually, may help to identify “presymptomatic individuals who are expected to benefit from early therapeutic interventions,” wrote the authors of a newly published paper (Sci Transl Med. 2017;9[383]:eaai7866).
Tania Gendron, PhD, of the department of neuroscience at the Mayo Clinic, Jacksonville, Fla., and her colleagues noted that poly(GP) was found in the cerebrospinal fluid (CSF) of both symptomatic and asymptomatic patients who carried the C9ORF72 mutation. The mutation can cause ALS, and is also associated with frontotemporal dementia (FTD) in a pattern with incomplete overlap with ALS.
However, “A limitation in moving such treatments from bench to bedside is a lack of pharmacodynamics markers for use in clinical trials,” Dr. Gendron and her collaborators wrote. The discovery that poly(GP) tracks well with C9ORF72 means that it has the potential to serve as the kind of biomarker that’s been missing in drug development for this family of neurodegenerative diseases, they said.
“To prepare for upcoming clinical trials for c9ALS, the present study used patient CSF and several preclinical models to investigate the hypothesis that poly(GP) proteins could serve as an urgently needed pharmacodynamics marker for developing and testing therapies for treating c9ALS,” Dr. Gendron and her colleagues wrote.
They looked at CSF samples from 83 patients with c9ALS and 27 patients who were asymptomatic C9ORF72 repeat expansion carriers, as well as 24 carriers who had a neurologic disease besides ALS or FTD (total n = 134). They also examined CSF samples from 120 study participants who lacked the mutation, 48 of whom were healthy controls; the remainder had ALS (n = 57) or another neurological disease.
The investigators, who were blinded to individuals’ disease status in each study arm, found that CSF poly(GP) levels were significantly higher in patients who had the C9ORF72 mutation (P less than .0001 in unadjusted and adjusted analyses). Poly(GP) was present in both asymptomatic and symptomatic carriers of the mutation, and not significantly different between these groups when data were adjusted for multiple comparisons, age, and gender.
When Dr. Gendron and her colleagues looked at poly(GP) levels over time for patients whose longitudinal data were available, they found that levels for an individual study participant were “relatively constant,” without any significant change over the median 12.9 months that these levels were tracked (P = .84).
However, “poly(GP) is not a prognostic marker,” wrote Dr. Gendron and her colleagues. They found no consistent association between levels of the protein and disease severity of progression, age at onset, or the development of FTD. Women were more likely to have lower levels, but the significance of that finding is not known, they said. There was a trend, which lost significance after statistical adjustment, for patients with cognitive impairment to have higher poly(GP) levels (adjusted P = .12).
Treatments under investigation for ALS and FTD include the use of an antisense oligonucleotide (ASO) to bind to the repeated RNA sequences and negate their ill effects. The investigators wrote that in vitro investigations using patient-derived cell models showed that poly(GP) levels dropped when cells were exposed to an ASO for 10 days. “The data indicate that poly(GP) production mirrors expression of repeat-containing C9ORF72 transcripts in lymphoblastoid cell lines,” they wrote.
The authors reported multiple governmental and private foundation sources of support for the research. Dr. Gendron and several of her coauthors are investigators in clinical trials for an ASO to target C9ORF72. Several authors reported paid and unpaid relationships and stock positions with pharmaceutical companies, including ones developing treatments for ALS and FTD.
[email protected]
On Twitter @karioakes
Key clinical point:
Major finding: Patients with a mutation predisposing them to ALS had significantly higher levels of the protein poly(GP) (P less than .0001 in unadjusted and adjusted analyses).
Data source: Prospective blinded study of CSF samples from 83 patients with c9ALS, 27 patients who were asymptomatic C9ORF72 repeat expansion carriers, 24 carriers who had a neurologic disease besides ALS or FTD, and 120 study participants who lacked the C9ORF72 mutation.
Disclosures: The authors reported multiple governmental and private foundation sources of support for their research. Dr. Gendron and several of her coauthors are investigators in clinical trials for an ASO to target C9ORF72. Several authors reported paid and unpaid relationships and stock positions with pharmaceutical companies, including ones developing treatments for ALS and FTD.
Safe to avoid sentinel node biopsy in some breast cancer patients
SEATTLE – Sentinel lymph node biopsy is widely used in patients with early-stage breast cancer for staging the axilla, but it can be safely omitted in some patients, according to new research presented at the annual Society of Surgical Oncology Cancer Symposium.
In women aged 70 years and older with hormone receptor (HR)–positive invasive breast cancer, the risk of nodal involvement is 14%-15%, which adds support to the premise that sentinel lymph node surgery could be avoided in many of the women deemed to be low risk.
The Choosing Wisely campaign was initiated to reduce excess cost and expenditures in health care. The Society of Surgical Oncology recently released five Choosing Wisely guidelines that included specific tests or procedures commonly ordered but not always necessary in surgical oncology, explained study author Jessemae Welsh, MD, of the Mayo Clinic, Rochester, Minn. One of the recommendations was to avoid routine sentinel node biopsy in clinically node-negative women over age 70 years with hormone receptor–positive invasive breast cancer.
“Their rationale is that hormone therapy is the standard of care in these women and sentinel node surgery has shown no impact on local regional recurrence or breast cancer mortality,” said Dr. Welsh. “Therefore it would be safe to treat this population without any axillary node staging.”
She noted that the average 70-year-old woman may live another 14-16 years. “So the question is, how should we be applying the Choosing Wisely guidelines?”
Dr. Welsh and her colleagues evaluated the factors that might be impacting nodal positivity in this population, and in particular, they looked at T stage and tumor grade.
They used two large databases to identify all women over the age of 70 years with HR+ cN0 invasive disease in the institutional breast surgery database (IBSD, 2008-2016) from the Mayo Clinic and the National Cancer Database (NCDB, 2004-2013).
The rates of patients who were node positive (pN+) were based on those who had undergone axillary surgery.
The researchers then stratified patients by clinical T stage and tumor grade to compare risk of pN+ across strata.
Of 705 selected patients in the IBSD, 191 or 14.3% were pN+ and a similar rate was observed in the NCDB; 15.2% (19,607/129,216). Tumor grade and clinical T stage were associated with pN+.
“The overall rates were about 14% for both databases, and when we stratified this by T stage, we could see increasing node positivity with increasing T stage,” said Dr. Welsh.
In similar fashion, the researchers observed comparable increases when they stratified it by grade. “Increasing grades were associated with increasing rates, especially for grade 2 and higher,” said Dr. Welsh.
When the two factors were combined, the researchers were able to define low-risk criteria as clinical T1a-b, grade 1-2 or clinical T1c, grade 1. The low-risk group accounted for 54.3% (IBSD) and 43.2% (NCDB) of patients, and pN+ rates within this group were 7.6% (IBSD) and 7.4% (NCDB).
Patients outside of this subcohort had pN+ rates of 22.4% (IBSD) and 23.0% (NCDB), which extrapolated to a relative risk of 2.95 (95% CI: 1.97-4.42) and 3.11 (95% CI: 2.99-3.23), respectively (each P less than .001).
“Women in the high-risk group had three times the risk of node positivity as the low-risk group,” she said. “Based on our data, we can say that for grade 1 T1a-c we can omit sentinel node surgery, and also for grade 2 T1 a-b.”
But for grade 3, T2 or higher, or any grade 2 Tc tumors, clinicians should continue to consider sentinel node surgery, taking into account individual patient factors.
The investigator had no disclosures.
Are there patients older than 70 years of age who have a low risk of nodal metastasis and/or even if they had nodal metastasis, could be adequately treated with anti-hormones?
If the answer is “yes,” then sentinel node sampling can be avoided in these patients. This study identified a group with a low risk for nodal metastasis. Even though it may be difficult to estimate tumor size preoperatively for lobular cancers, this is less of a problem for ductal cancers. Another approach is to use molecular profiling to determine which patients may “skip” sentinel node biopsy. Molecular profiling can identify patients who will have an excellent outcome with adjuvant anti-hormones even in the presence of nodal metastases.
Maureen Chung, MD, FACS, is medical director of the breast care program at Southcoast Health, North Dartmouth, Mass.
Are there patients older than 70 years of age who have a low risk of nodal metastasis and/or even if they had nodal metastasis, could be adequately treated with anti-hormones?
If the answer is “yes,” then sentinel node sampling can be avoided in these patients. This study identified a group with a low risk for nodal metastasis. Even though it may be difficult to estimate tumor size preoperatively for lobular cancers, this is less of a problem for ductal cancers. Another approach is to use molecular profiling to determine which patients may “skip” sentinel node biopsy. Molecular profiling can identify patients who will have an excellent outcome with adjuvant anti-hormones even in the presence of nodal metastases.
Maureen Chung, MD, FACS, is medical director of the breast care program at Southcoast Health, North Dartmouth, Mass.
Are there patients older than 70 years of age who have a low risk of nodal metastasis and/or even if they had nodal metastasis, could be adequately treated with anti-hormones?
If the answer is “yes,” then sentinel node sampling can be avoided in these patients. This study identified a group with a low risk for nodal metastasis. Even though it may be difficult to estimate tumor size preoperatively for lobular cancers, this is less of a problem for ductal cancers. Another approach is to use molecular profiling to determine which patients may “skip” sentinel node biopsy. Molecular profiling can identify patients who will have an excellent outcome with adjuvant anti-hormones even in the presence of nodal metastases.
Maureen Chung, MD, FACS, is medical director of the breast care program at Southcoast Health, North Dartmouth, Mass.
SEATTLE – Sentinel lymph node biopsy is widely used in patients with early-stage breast cancer for staging the axilla, but it can be safely omitted in some patients, according to new research presented at the annual Society of Surgical Oncology Cancer Symposium.
In women aged 70 years and older with hormone receptor (HR)–positive invasive breast cancer, the risk of nodal involvement is 14%-15%, which adds support to the premise that sentinel lymph node surgery could be avoided in many of the women deemed to be low risk.
The Choosing Wisely campaign was initiated to reduce excess cost and expenditures in health care. The Society of Surgical Oncology recently released five Choosing Wisely guidelines that included specific tests or procedures commonly ordered but not always necessary in surgical oncology, explained study author Jessemae Welsh, MD, of the Mayo Clinic, Rochester, Minn. One of the recommendations was to avoid routine sentinel node biopsy in clinically node-negative women over age 70 years with hormone receptor–positive invasive breast cancer.
“Their rationale is that hormone therapy is the standard of care in these women and sentinel node surgery has shown no impact on local regional recurrence or breast cancer mortality,” said Dr. Welsh. “Therefore it would be safe to treat this population without any axillary node staging.”
She noted that the average 70-year-old woman may live another 14-16 years. “So the question is, how should we be applying the Choosing Wisely guidelines?”
Dr. Welsh and her colleagues evaluated the factors that might be impacting nodal positivity in this population, and in particular, they looked at T stage and tumor grade.
They used two large databases to identify all women over the age of 70 years with HR+ cN0 invasive disease in the institutional breast surgery database (IBSD, 2008-2016) from the Mayo Clinic and the National Cancer Database (NCDB, 2004-2013).
The rates of patients who were node positive (pN+) were based on those who had undergone axillary surgery.
The researchers then stratified patients by clinical T stage and tumor grade to compare risk of pN+ across strata.
Of 705 selected patients in the IBSD, 191 or 14.3% were pN+ and a similar rate was observed in the NCDB; 15.2% (19,607/129,216). Tumor grade and clinical T stage were associated with pN+.
“The overall rates were about 14% for both databases, and when we stratified this by T stage, we could see increasing node positivity with increasing T stage,” said Dr. Welsh.
In similar fashion, the researchers observed comparable increases when they stratified it by grade. “Increasing grades were associated with increasing rates, especially for grade 2 and higher,” said Dr. Welsh.
When the two factors were combined, the researchers were able to define low-risk criteria as clinical T1a-b, grade 1-2 or clinical T1c, grade 1. The low-risk group accounted for 54.3% (IBSD) and 43.2% (NCDB) of patients, and pN+ rates within this group were 7.6% (IBSD) and 7.4% (NCDB).
Patients outside of this subcohort had pN+ rates of 22.4% (IBSD) and 23.0% (NCDB), which extrapolated to a relative risk of 2.95 (95% CI: 1.97-4.42) and 3.11 (95% CI: 2.99-3.23), respectively (each P less than .001).
“Women in the high-risk group had three times the risk of node positivity as the low-risk group,” she said. “Based on our data, we can say that for grade 1 T1a-c we can omit sentinel node surgery, and also for grade 2 T1 a-b.”
But for grade 3, T2 or higher, or any grade 2 Tc tumors, clinicians should continue to consider sentinel node surgery, taking into account individual patient factors.
The investigator had no disclosures.
SEATTLE – Sentinel lymph node biopsy is widely used in patients with early-stage breast cancer for staging the axilla, but it can be safely omitted in some patients, according to new research presented at the annual Society of Surgical Oncology Cancer Symposium.
In women aged 70 years and older with hormone receptor (HR)–positive invasive breast cancer, the risk of nodal involvement is 14%-15%, which adds support to the premise that sentinel lymph node surgery could be avoided in many of the women deemed to be low risk.
The Choosing Wisely campaign was initiated to reduce excess cost and expenditures in health care. The Society of Surgical Oncology recently released five Choosing Wisely guidelines that included specific tests or procedures commonly ordered but not always necessary in surgical oncology, explained study author Jessemae Welsh, MD, of the Mayo Clinic, Rochester, Minn. One of the recommendations was to avoid routine sentinel node biopsy in clinically node-negative women over age 70 years with hormone receptor–positive invasive breast cancer.
“Their rationale is that hormone therapy is the standard of care in these women and sentinel node surgery has shown no impact on local regional recurrence or breast cancer mortality,” said Dr. Welsh. “Therefore it would be safe to treat this population without any axillary node staging.”
She noted that the average 70-year-old woman may live another 14-16 years. “So the question is, how should we be applying the Choosing Wisely guidelines?”
Dr. Welsh and her colleagues evaluated the factors that might be impacting nodal positivity in this population, and in particular, they looked at T stage and tumor grade.
They used two large databases to identify all women over the age of 70 years with HR+ cN0 invasive disease in the institutional breast surgery database (IBSD, 2008-2016) from the Mayo Clinic and the National Cancer Database (NCDB, 2004-2013).
The rates of patients who were node positive (pN+) were based on those who had undergone axillary surgery.
The researchers then stratified patients by clinical T stage and tumor grade to compare risk of pN+ across strata.
Of 705 selected patients in the IBSD, 191 or 14.3% were pN+ and a similar rate was observed in the NCDB; 15.2% (19,607/129,216). Tumor grade and clinical T stage were associated with pN+.
“The overall rates were about 14% for both databases, and when we stratified this by T stage, we could see increasing node positivity with increasing T stage,” said Dr. Welsh.
In similar fashion, the researchers observed comparable increases when they stratified it by grade. “Increasing grades were associated with increasing rates, especially for grade 2 and higher,” said Dr. Welsh.
When the two factors were combined, the researchers were able to define low-risk criteria as clinical T1a-b, grade 1-2 or clinical T1c, grade 1. The low-risk group accounted for 54.3% (IBSD) and 43.2% (NCDB) of patients, and pN+ rates within this group were 7.6% (IBSD) and 7.4% (NCDB).
Patients outside of this subcohort had pN+ rates of 22.4% (IBSD) and 23.0% (NCDB), which extrapolated to a relative risk of 2.95 (95% CI: 1.97-4.42) and 3.11 (95% CI: 2.99-3.23), respectively (each P less than .001).
“Women in the high-risk group had three times the risk of node positivity as the low-risk group,” she said. “Based on our data, we can say that for grade 1 T1a-c we can omit sentinel node surgery, and also for grade 2 T1 a-b.”
But for grade 3, T2 or higher, or any grade 2 Tc tumors, clinicians should continue to consider sentinel node surgery, taking into account individual patient factors.
The investigator had no disclosures.
Key clinical point: Sentinel node biopsy can be safely avoided in certain populations of breast cancer patients.
Major finding: In women 70 years and older with hormone receptor (HR)–positive invasive breast cancer who are at low risk, sentinel node surgery can safely be avoided.
Data source: Two large databases of more than 150,000 women, from the Mayo Clinic and the National Cancer Database.
Disclosures: There was no funding source disclosed. The author had no disclosures.
VIDEO: Sex, intimacy part of history in gynecologic oncology care
NATIONAL HARBOR, MD. – Cancer care can feel like a sequence of crises, large and small; a comprehensive cancer care approach can keep the patient at the center of this flurry of events. But understanding a patient’s sexual history and assessing how a gynecologic malignancy has affected that patient’s sexual health can, too often, get lost in the shuffle, said Don Dizon, MD, of Massachusetts General Hospital, Boston.
“I think there are multiple reasons for that, but it has to be the job of the clinician – not necessarily the oncologist-physician – but somebody has to be able to say, ‘What is your sexual history? Can I ask about your sexual history?’ ” he said in a video interview at the annual meeting of the Society of Gynecologic Oncology.
Dr. Dizon, director of the Oncology Sexual Health Clinic at Massachusetts General Hospital*, emphasized the importance of providing sensitive sexual health care while staying true to one’s own framework of care. “I teach clinicians not to run away from their schema,” he said. “Having said that, the job of a clinician is to normalize the history, and to normalize that sex, intimacy, relationships are a part of someone’s history.”
Dr. Dizon sits on the board of the Patty Brisben Foundation and the Young Survival Coalition.
[email protected]
On Twitter @karioakes
*A previous version of this article misstated Dr. Dizon's affiliation.
NATIONAL HARBOR, MD. – Cancer care can feel like a sequence of crises, large and small; a comprehensive cancer care approach can keep the patient at the center of this flurry of events. But understanding a patient’s sexual history and assessing how a gynecologic malignancy has affected that patient’s sexual health can, too often, get lost in the shuffle, said Don Dizon, MD, of Massachusetts General Hospital, Boston.
“I think there are multiple reasons for that, but it has to be the job of the clinician – not necessarily the oncologist-physician – but somebody has to be able to say, ‘What is your sexual history? Can I ask about your sexual history?’ ” he said in a video interview at the annual meeting of the Society of Gynecologic Oncology.
Dr. Dizon, director of the Oncology Sexual Health Clinic at Massachusetts General Hospital*, emphasized the importance of providing sensitive sexual health care while staying true to one’s own framework of care. “I teach clinicians not to run away from their schema,” he said. “Having said that, the job of a clinician is to normalize the history, and to normalize that sex, intimacy, relationships are a part of someone’s history.”
Dr. Dizon sits on the board of the Patty Brisben Foundation and the Young Survival Coalition.
[email protected]
On Twitter @karioakes
*A previous version of this article misstated Dr. Dizon's affiliation.
NATIONAL HARBOR, MD. – Cancer care can feel like a sequence of crises, large and small; a comprehensive cancer care approach can keep the patient at the center of this flurry of events. But understanding a patient’s sexual history and assessing how a gynecologic malignancy has affected that patient’s sexual health can, too often, get lost in the shuffle, said Don Dizon, MD, of Massachusetts General Hospital, Boston.
“I think there are multiple reasons for that, but it has to be the job of the clinician – not necessarily the oncologist-physician – but somebody has to be able to say, ‘What is your sexual history? Can I ask about your sexual history?’ ” he said in a video interview at the annual meeting of the Society of Gynecologic Oncology.
Dr. Dizon, director of the Oncology Sexual Health Clinic at Massachusetts General Hospital*, emphasized the importance of providing sensitive sexual health care while staying true to one’s own framework of care. “I teach clinicians not to run away from their schema,” he said. “Having said that, the job of a clinician is to normalize the history, and to normalize that sex, intimacy, relationships are a part of someone’s history.”
Dr. Dizon sits on the board of the Patty Brisben Foundation and the Young Survival Coalition.
[email protected]
On Twitter @karioakes
*A previous version of this article misstated Dr. Dizon's affiliation.
AT THE ANNUAL MEETING ON WOMEN'S CANCER
Many patients’ severe asthma remains uncontrolled
ATLANTA – More than half of patients severe asthma have disease that remains uncontrolled at their index date of treatment, and 39% remained uncontrolled at 12 months of follow-up, results from a large single specialty practice study showed.
“Severe asthma accounts for only 5%-10% of all asthma [in] patients but at least half of the health care costs, and it’s a significant burden to those who suffer from it,” study author Brian D. Stone, MD, said in an interview at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.
The mean age of patients was 44.4 years, 67% were female, 78% were white, 77% had concomitant rhinitis, 21% had sinusitis, and 44% had allergic sensitivities. The mean baseline prebronchodilation FEV1 and FEV1% predicted were 2.45 L and 79.7%, respectively. The mean baseline ACT score was 17, with 61% of patients having ACT scores of 19 or lower, indicating poor symptom control.
Using National Asthma Education and Prevention Program criteria, the researchers found that 52% of patients had uncontrolled asthma at the index date and 39% remained uncontrolled at 12 months of follow-up. In an effort to better manage their severe asthma, more than one-third of patients on Step 4 therapy and 60% of patients on Step 5 therapy changed their asthma controller medications during follow-up.
“As an asthma specialist, I hoped that more [of these patients] would have come under control. These are the most difficult patients to treat,” said Dr. Stone, who practices at Allergy Partners of San Diego. “It’s a population that deserves special attention, and interventions are probably going to be on multiple levels, depending on what type of severe persistent asthma they have. More therapies are needed.”
He acknowledged certain limitations of the study, including the fact that patients were treated by specialists in allergy, asthma, and immunology and, therefore, may not represent the general population with asthma.
The study was supported by AstraZeneca. Dr. Stone reported having no relevant financial disclosures.
ATLANTA – More than half of patients severe asthma have disease that remains uncontrolled at their index date of treatment, and 39% remained uncontrolled at 12 months of follow-up, results from a large single specialty practice study showed.
“Severe asthma accounts for only 5%-10% of all asthma [in] patients but at least half of the health care costs, and it’s a significant burden to those who suffer from it,” study author Brian D. Stone, MD, said in an interview at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.
The mean age of patients was 44.4 years, 67% were female, 78% were white, 77% had concomitant rhinitis, 21% had sinusitis, and 44% had allergic sensitivities. The mean baseline prebronchodilation FEV1 and FEV1% predicted were 2.45 L and 79.7%, respectively. The mean baseline ACT score was 17, with 61% of patients having ACT scores of 19 or lower, indicating poor symptom control.
Using National Asthma Education and Prevention Program criteria, the researchers found that 52% of patients had uncontrolled asthma at the index date and 39% remained uncontrolled at 12 months of follow-up. In an effort to better manage their severe asthma, more than one-third of patients on Step 4 therapy and 60% of patients on Step 5 therapy changed their asthma controller medications during follow-up.
“As an asthma specialist, I hoped that more [of these patients] would have come under control. These are the most difficult patients to treat,” said Dr. Stone, who practices at Allergy Partners of San Diego. “It’s a population that deserves special attention, and interventions are probably going to be on multiple levels, depending on what type of severe persistent asthma they have. More therapies are needed.”
He acknowledged certain limitations of the study, including the fact that patients were treated by specialists in allergy, asthma, and immunology and, therefore, may not represent the general population with asthma.
The study was supported by AstraZeneca. Dr. Stone reported having no relevant financial disclosures.
ATLANTA – More than half of patients severe asthma have disease that remains uncontrolled at their index date of treatment, and 39% remained uncontrolled at 12 months of follow-up, results from a large single specialty practice study showed.
“Severe asthma accounts for only 5%-10% of all asthma [in] patients but at least half of the health care costs, and it’s a significant burden to those who suffer from it,” study author Brian D. Stone, MD, said in an interview at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.
The mean age of patients was 44.4 years, 67% were female, 78% were white, 77% had concomitant rhinitis, 21% had sinusitis, and 44% had allergic sensitivities. The mean baseline prebronchodilation FEV1 and FEV1% predicted were 2.45 L and 79.7%, respectively. The mean baseline ACT score was 17, with 61% of patients having ACT scores of 19 or lower, indicating poor symptom control.
Using National Asthma Education and Prevention Program criteria, the researchers found that 52% of patients had uncontrolled asthma at the index date and 39% remained uncontrolled at 12 months of follow-up. In an effort to better manage their severe asthma, more than one-third of patients on Step 4 therapy and 60% of patients on Step 5 therapy changed their asthma controller medications during follow-up.
“As an asthma specialist, I hoped that more [of these patients] would have come under control. These are the most difficult patients to treat,” said Dr. Stone, who practices at Allergy Partners of San Diego. “It’s a population that deserves special attention, and interventions are probably going to be on multiple levels, depending on what type of severe persistent asthma they have. More therapies are needed.”
He acknowledged certain limitations of the study, including the fact that patients were treated by specialists in allergy, asthma, and immunology and, therefore, may not represent the general population with asthma.
The study was supported by AstraZeneca. Dr. Stone reported having no relevant financial disclosures.
AT THE 2017 AAAAI ANNUAL MEETING
Key clinical point:
Major finding: More than half of patients with severe asthma (52%) had uncontrolled disease at the index date of treatment, and 39% remained uncontrolled at 12 months of follow-up.
Data source: A retrospective review of 12,922 patients aged 12 years and older with severe asthma who were treated between Jan. 1, 2010, and April 30, 2016.
Disclosures: The study was supported by AstraZeneca. Dr. Stone reported no relevant financial disclosures.
Robot-assisted surgery: Twice the price
HOUSTON – Robot-assisted operations for inguinal hernia repair (IHR) and cholecystectomy have grown steadily in recent years, but these procedures can be done equally well by traditional operations at a fraction of the cost, according to a study from Geisinger Medical Center in Pennsylvania.
Ellen Vogels, DO, of Geisinger, reported results of a study of 1,248 cholecystectomies and 723 initial IHRs from 2007 to 2016. The cholecystectomies were done via robot-assisted surgery or laparoscopy in the hospital or via laparoscopy in an ambulatory surgery center (ASC). The IHRs were done robotically, open, or laparoscopically in the hospital, or open or laparoscopically in an ASC.
Dr. Vogels quoted statistics from the ECRI Institute that showed robotic surgery procedures have increased 178% between 2009 and 2014, and the two procedures the group studied are the most frequently performed robotic procedures.
Within the Geisinger system, the study found a 3:1 cost disparity for IHR: $6,292 total cost for hospital-based robotic surgery vs. $3,421 for ASC-based laparoscopy IHR and $1,853 for ASC-based open repair. For cholecystectomy, the disparity isn’t as wide – it’s 2:1 – but is still significant: Total costs for hospital-based robotic surgery are $6,057 vs. $3,443 for ASC-based cholecystectomy and $3,270 for hospital-based laparoscopic cholecystectomy (the study did not include any open cholecystectomies).
Total costs not only include costs for the procedure but also all related pre- and postoperative care. The cost analysis did not account for the cost of the robot, including maintenance contracts, or costs for laparoscopic instruments. Variable costs also ranged from about $3,000 for robotic IHR to $942 for ASC open repair – which means the lowest per-procedure cost for the latter was around $900.
“Translating this into the fact that cholecystectomies and inguinal hernia repairs are the most often performed general surgery procedures, ambulatory surgery centers can save over $60 billion over the next 10 years in just overhead costs as well as increased efficiency,” Dr. Vogels said.
The study also found access issues depending on where patients had their operations. “As far as service and access in our institution alone, we found that patients going to the main hospital spent as much as two times longer getting these procedures done as compared to the ambulatory surgery centers,” Dr. Vogels said.
Robotic procedures also required longer operative times, the study found – an average of 109 minutes for IHR vs. about an hour for ASC procedures and hospital-based open surgery (but averaging 78 minutes for in-hospital laparoscopy); and 73 minutes for robotic cholecystectomy, 60 minutes for hospital laparoscopy, and 45 minutes for ASC laparoscopy.
Robotic session moderator Dmitry Oleynikov, MD, FACS, of the University of Nebraska Medical Center, Omaha, asked Dr. Vogels if putting a robotic platform in an ambulatory surgery setting would make it more cost effective.
That’s not practical from a cost or efficiency perspective, she said.
“When you look at the cost of the ASCs, specifically in the hernia group, the lowest-cost hernia repair is about $800; with the robot it’s going to be significantly higher than that, up to three times higher than that,” Dr. Vogels replied. “Then you’re also changing all those simple ambulatory surgery procedures to more involved robotic procedures, so it’s hard to justify doing that in the ASC.”
Dr. Vogels and her coauthors had no relevant financial disclosures.
HOUSTON – Robot-assisted operations for inguinal hernia repair (IHR) and cholecystectomy have grown steadily in recent years, but these procedures can be done equally well by traditional operations at a fraction of the cost, according to a study from Geisinger Medical Center in Pennsylvania.
Ellen Vogels, DO, of Geisinger, reported results of a study of 1,248 cholecystectomies and 723 initial IHRs from 2007 to 2016. The cholecystectomies were done via robot-assisted surgery or laparoscopy in the hospital or via laparoscopy in an ambulatory surgery center (ASC). The IHRs were done robotically, open, or laparoscopically in the hospital, or open or laparoscopically in an ASC.
Dr. Vogels quoted statistics from the ECRI Institute that showed robotic surgery procedures have increased 178% between 2009 and 2014, and the two procedures the group studied are the most frequently performed robotic procedures.
Within the Geisinger system, the study found a 3:1 cost disparity for IHR: $6,292 total cost for hospital-based robotic surgery vs. $3,421 for ASC-based laparoscopy IHR and $1,853 for ASC-based open repair. For cholecystectomy, the disparity isn’t as wide – it’s 2:1 – but is still significant: Total costs for hospital-based robotic surgery are $6,057 vs. $3,443 for ASC-based cholecystectomy and $3,270 for hospital-based laparoscopic cholecystectomy (the study did not include any open cholecystectomies).
Total costs not only include costs for the procedure but also all related pre- and postoperative care. The cost analysis did not account for the cost of the robot, including maintenance contracts, or costs for laparoscopic instruments. Variable costs also ranged from about $3,000 for robotic IHR to $942 for ASC open repair – which means the lowest per-procedure cost for the latter was around $900.
“Translating this into the fact that cholecystectomies and inguinal hernia repairs are the most often performed general surgery procedures, ambulatory surgery centers can save over $60 billion over the next 10 years in just overhead costs as well as increased efficiency,” Dr. Vogels said.
The study also found access issues depending on where patients had their operations. “As far as service and access in our institution alone, we found that patients going to the main hospital spent as much as two times longer getting these procedures done as compared to the ambulatory surgery centers,” Dr. Vogels said.
Robotic procedures also required longer operative times, the study found – an average of 109 minutes for IHR vs. about an hour for ASC procedures and hospital-based open surgery (but averaging 78 minutes for in-hospital laparoscopy); and 73 minutes for robotic cholecystectomy, 60 minutes for hospital laparoscopy, and 45 minutes for ASC laparoscopy.
Robotic session moderator Dmitry Oleynikov, MD, FACS, of the University of Nebraska Medical Center, Omaha, asked Dr. Vogels if putting a robotic platform in an ambulatory surgery setting would make it more cost effective.
That’s not practical from a cost or efficiency perspective, she said.
“When you look at the cost of the ASCs, specifically in the hernia group, the lowest-cost hernia repair is about $800; with the robot it’s going to be significantly higher than that, up to three times higher than that,” Dr. Vogels replied. “Then you’re also changing all those simple ambulatory surgery procedures to more involved robotic procedures, so it’s hard to justify doing that in the ASC.”
Dr. Vogels and her coauthors had no relevant financial disclosures.
HOUSTON – Robot-assisted operations for inguinal hernia repair (IHR) and cholecystectomy have grown steadily in recent years, but these procedures can be done equally well by traditional operations at a fraction of the cost, according to a study from Geisinger Medical Center in Pennsylvania.
Ellen Vogels, DO, of Geisinger, reported results of a study of 1,248 cholecystectomies and 723 initial IHRs from 2007 to 2016. The cholecystectomies were done via robot-assisted surgery or laparoscopy in the hospital or via laparoscopy in an ambulatory surgery center (ASC). The IHRs were done robotically, open, or laparoscopically in the hospital, or open or laparoscopically in an ASC.
Dr. Vogels quoted statistics from the ECRI Institute that showed robotic surgery procedures have increased 178% between 2009 and 2014, and the two procedures the group studied are the most frequently performed robotic procedures.
Within the Geisinger system, the study found a 3:1 cost disparity for IHR: $6,292 total cost for hospital-based robotic surgery vs. $3,421 for ASC-based laparoscopy IHR and $1,853 for ASC-based open repair. For cholecystectomy, the disparity isn’t as wide – it’s 2:1 – but is still significant: Total costs for hospital-based robotic surgery are $6,057 vs. $3,443 for ASC-based cholecystectomy and $3,270 for hospital-based laparoscopic cholecystectomy (the study did not include any open cholecystectomies).
Total costs not only include costs for the procedure but also all related pre- and postoperative care. The cost analysis did not account for the cost of the robot, including maintenance contracts, or costs for laparoscopic instruments. Variable costs also ranged from about $3,000 for robotic IHR to $942 for ASC open repair – which means the lowest per-procedure cost for the latter was around $900.
“Translating this into the fact that cholecystectomies and inguinal hernia repairs are the most often performed general surgery procedures, ambulatory surgery centers can save over $60 billion over the next 10 years in just overhead costs as well as increased efficiency,” Dr. Vogels said.
The study also found access issues depending on where patients had their operations. “As far as service and access in our institution alone, we found that patients going to the main hospital spent as much as two times longer getting these procedures done as compared to the ambulatory surgery centers,” Dr. Vogels said.
Robotic procedures also required longer operative times, the study found – an average of 109 minutes for IHR vs. about an hour for ASC procedures and hospital-based open surgery (but averaging 78 minutes for in-hospital laparoscopy); and 73 minutes for robotic cholecystectomy, 60 minutes for hospital laparoscopy, and 45 minutes for ASC laparoscopy.
Robotic session moderator Dmitry Oleynikov, MD, FACS, of the University of Nebraska Medical Center, Omaha, asked Dr. Vogels if putting a robotic platform in an ambulatory surgery setting would make it more cost effective.
That’s not practical from a cost or efficiency perspective, she said.
“When you look at the cost of the ASCs, specifically in the hernia group, the lowest-cost hernia repair is about $800; with the robot it’s going to be significantly higher than that, up to three times higher than that,” Dr. Vogels replied. “Then you’re also changing all those simple ambulatory surgery procedures to more involved robotic procedures, so it’s hard to justify doing that in the ASC.”
Dr. Vogels and her coauthors had no relevant financial disclosures.
AT SAGES 2017
Key clinical point: Outcomes for robot-assisted inguinal hernia repair and cholecystectomy are similar to those for outpatient open and laparoscopic procedures.
Major finding: Robotic IHR costs up to three times more than open outpatient surgery, and robotic cholecystectomy costs twice as much as outpatient surgery.
Data source: Study of 1,971 in-hospital robotic, laparoscopic, and open procedures, and outpatient laparoscopic and open operations done from 2007 to 2016 at Geisinger Medical Center.
Disclosures: Dr. Vogels and coauthors reported having no financial disclosures.
Video: Try ‘PLISSIT’ to address postcancer sexual health
NATIONAL HARBOR, MD. – Comprehensive care of patients with gynecologic malignancies should include a sensitive and thorough assessment of sexual health.
In a video interview at the annual meeting of the Society of Gynecologic Oncology, Don Dizon, MD, of Massachusetts General Hospital, Boston, gives a series of practical tips to help physicians take a thorough sexual health history and provide information and guidance for patients and their partners.
Dr. Dizon, professor of gynecologic oncology and director of the oncology sexual health clinic at Brigham and Women’s Hospital, also in Boston, said that he likes to begin with the PLISSIT model, where patients are given permission (P) to talk about sexual problems. Then, the clinician gives the patient limited (LI) scientific or clinical information about the situation, followed by specific suggestions (SS) that might help. Finally, patients may be referred to mental health providers or sex counselors for intensive therapy (IT) if needed.
“It’s also important not to confuse terminology,” said Dr. Dizon. “Intimacy is experienced very differently between men and women. Women experience intimacy through arousal, desire, and, when desire is satisfied, that’s intimacy. Intercourse is not a part of that equation.” For men, he said, intimacy is more often experienced through intercourse. “So the disconnect is greater after cancer is diagnosed,” making it especially important to acknowledge problems sensitively, and to helps patients and partners find a way forward.
“The word I like to use is ‘play,’ ” said Dr. Dizon. When a renegotiation of an intimate relationship is framed in terms of play, the pressure is off, and “men can wrap their hands around that idea,” he said.
Dr. Dizon sits on the board of the Patty Brisben Foundation and the Young Survival Coalition.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @karioakes
NATIONAL HARBOR, MD. – Comprehensive care of patients with gynecologic malignancies should include a sensitive and thorough assessment of sexual health.
In a video interview at the annual meeting of the Society of Gynecologic Oncology, Don Dizon, MD, of Massachusetts General Hospital, Boston, gives a series of practical tips to help physicians take a thorough sexual health history and provide information and guidance for patients and their partners.
Dr. Dizon, professor of gynecologic oncology and director of the oncology sexual health clinic at Brigham and Women’s Hospital, also in Boston, said that he likes to begin with the PLISSIT model, where patients are given permission (P) to talk about sexual problems. Then, the clinician gives the patient limited (LI) scientific or clinical information about the situation, followed by specific suggestions (SS) that might help. Finally, patients may be referred to mental health providers or sex counselors for intensive therapy (IT) if needed.
“It’s also important not to confuse terminology,” said Dr. Dizon. “Intimacy is experienced very differently between men and women. Women experience intimacy through arousal, desire, and, when desire is satisfied, that’s intimacy. Intercourse is not a part of that equation.” For men, he said, intimacy is more often experienced through intercourse. “So the disconnect is greater after cancer is diagnosed,” making it especially important to acknowledge problems sensitively, and to helps patients and partners find a way forward.
“The word I like to use is ‘play,’ ” said Dr. Dizon. When a renegotiation of an intimate relationship is framed in terms of play, the pressure is off, and “men can wrap their hands around that idea,” he said.
Dr. Dizon sits on the board of the Patty Brisben Foundation and the Young Survival Coalition.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @karioakes
NATIONAL HARBOR, MD. – Comprehensive care of patients with gynecologic malignancies should include a sensitive and thorough assessment of sexual health.
In a video interview at the annual meeting of the Society of Gynecologic Oncology, Don Dizon, MD, of Massachusetts General Hospital, Boston, gives a series of practical tips to help physicians take a thorough sexual health history and provide information and guidance for patients and their partners.
Dr. Dizon, professor of gynecologic oncology and director of the oncology sexual health clinic at Brigham and Women’s Hospital, also in Boston, said that he likes to begin with the PLISSIT model, where patients are given permission (P) to talk about sexual problems. Then, the clinician gives the patient limited (LI) scientific or clinical information about the situation, followed by specific suggestions (SS) that might help. Finally, patients may be referred to mental health providers or sex counselors for intensive therapy (IT) if needed.
“It’s also important not to confuse terminology,” said Dr. Dizon. “Intimacy is experienced very differently between men and women. Women experience intimacy through arousal, desire, and, when desire is satisfied, that’s intimacy. Intercourse is not a part of that equation.” For men, he said, intimacy is more often experienced through intercourse. “So the disconnect is greater after cancer is diagnosed,” making it especially important to acknowledge problems sensitively, and to helps patients and partners find a way forward.
“The word I like to use is ‘play,’ ” said Dr. Dizon. When a renegotiation of an intimate relationship is framed in terms of play, the pressure is off, and “men can wrap their hands around that idea,” he said.
Dr. Dizon sits on the board of the Patty Brisben Foundation and the Young Survival Coalition.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @karioakes
AT THE ANNUAL MEETING ON WOMEN’S CANCER
Following the Trajectory of PTSD
Does the course of posttraumatic stress disorder (PTSD) differ depending on whether the person is in the military or has left? Researchers from Naval Health Research Center and the VA wondered whether separation from the military could create a “significant disruption of routine, order, and structure,” which might exacerbate PTSD symptoms, and would the symptoms subside as the veteran adjusted to civilian life?
Using data from the Millennium Cohort Study, researchers examined trajectories of PTSD among 22,080 military personnel across 4 time points, about 3 years apart, from 2001 to 2013. They compared trajectories between people who separated before the second time point or remained in the military across the entire study period. The researchers assessed PTSD screening and symptoms using the PTSD Checklist-Civilian, for which higher scores represent more severe symptoms.
The researchers say 4 distinct classes described symptom trajectories: resilient, delayed onset, improving, and elevated-recovering. Overall, the trajectories were similar for veterans and active-duty personnel. Veterans had a higher likelihood of screening positive for PTSD at baseline before separation and were more likely to newly screen positive for PTSD at waves 2, 3, and 4. Of participants who screened positive for PTSD, veterans had more severe symptoms compared with active-duty personnel at baseline but not at any subsequent assessments.
However, differences between the “elevated-recovering” classes grew over time, showing that veterans did not recover as soon or as “dramatically,” the researchers say. This might be due to symptoms being exacerbated by the change in routine.
The good news is that most veterans and active-duty personnel fell into the resilient class (82% and 87%, respectively). The researchers cite other studies that have found resilience is the most common response to PTSD.
The researchers noted several risk factors for slower recovery, such as lower physical well-being and a history of multiple life stressors. The “delayed onset” group may be a good target for interventions, they suggest. This group reported high use of VA care, but still 26% reported no VA care, indicating that they could benefit from continued efforts to identify and treat them.
Does the course of posttraumatic stress disorder (PTSD) differ depending on whether the person is in the military or has left? Researchers from Naval Health Research Center and the VA wondered whether separation from the military could create a “significant disruption of routine, order, and structure,” which might exacerbate PTSD symptoms, and would the symptoms subside as the veteran adjusted to civilian life?
Using data from the Millennium Cohort Study, researchers examined trajectories of PTSD among 22,080 military personnel across 4 time points, about 3 years apart, from 2001 to 2013. They compared trajectories between people who separated before the second time point or remained in the military across the entire study period. The researchers assessed PTSD screening and symptoms using the PTSD Checklist-Civilian, for which higher scores represent more severe symptoms.
The researchers say 4 distinct classes described symptom trajectories: resilient, delayed onset, improving, and elevated-recovering. Overall, the trajectories were similar for veterans and active-duty personnel. Veterans had a higher likelihood of screening positive for PTSD at baseline before separation and were more likely to newly screen positive for PTSD at waves 2, 3, and 4. Of participants who screened positive for PTSD, veterans had more severe symptoms compared with active-duty personnel at baseline but not at any subsequent assessments.
However, differences between the “elevated-recovering” classes grew over time, showing that veterans did not recover as soon or as “dramatically,” the researchers say. This might be due to symptoms being exacerbated by the change in routine.
The good news is that most veterans and active-duty personnel fell into the resilient class (82% and 87%, respectively). The researchers cite other studies that have found resilience is the most common response to PTSD.
The researchers noted several risk factors for slower recovery, such as lower physical well-being and a history of multiple life stressors. The “delayed onset” group may be a good target for interventions, they suggest. This group reported high use of VA care, but still 26% reported no VA care, indicating that they could benefit from continued efforts to identify and treat them.
Does the course of posttraumatic stress disorder (PTSD) differ depending on whether the person is in the military or has left? Researchers from Naval Health Research Center and the VA wondered whether separation from the military could create a “significant disruption of routine, order, and structure,” which might exacerbate PTSD symptoms, and would the symptoms subside as the veteran adjusted to civilian life?
Using data from the Millennium Cohort Study, researchers examined trajectories of PTSD among 22,080 military personnel across 4 time points, about 3 years apart, from 2001 to 2013. They compared trajectories between people who separated before the second time point or remained in the military across the entire study period. The researchers assessed PTSD screening and symptoms using the PTSD Checklist-Civilian, for which higher scores represent more severe symptoms.
The researchers say 4 distinct classes described symptom trajectories: resilient, delayed onset, improving, and elevated-recovering. Overall, the trajectories were similar for veterans and active-duty personnel. Veterans had a higher likelihood of screening positive for PTSD at baseline before separation and were more likely to newly screen positive for PTSD at waves 2, 3, and 4. Of participants who screened positive for PTSD, veterans had more severe symptoms compared with active-duty personnel at baseline but not at any subsequent assessments.
However, differences between the “elevated-recovering” classes grew over time, showing that veterans did not recover as soon or as “dramatically,” the researchers say. This might be due to symptoms being exacerbated by the change in routine.
The good news is that most veterans and active-duty personnel fell into the resilient class (82% and 87%, respectively). The researchers cite other studies that have found resilience is the most common response to PTSD.
The researchers noted several risk factors for slower recovery, such as lower physical well-being and a history of multiple life stressors. The “delayed onset” group may be a good target for interventions, they suggest. This group reported high use of VA care, but still 26% reported no VA care, indicating that they could benefit from continued efforts to identify and treat them.
Rare Cancer Gets Timely Right Treatment
Be careful not to assume multiple cancerous lesions are advanced stage metastatic cancer, caution clinicians from H Plus Yangji Hospital in Seoul, and Inje University Haeundae Paik Hospital in Busan, both in the Republic of Korea. They came close to making that mistake.
Related: A Mysterious Massive Hemorrhage
The researchers reported on a patient who was on the verge of getting only palliative care for advanced laryngeal cancer with multiple lung metastases, when in fact he was a candidate for curative-aim chemotherapy. Thanks to a “meticulous approach,” the researchers switched their plan in time.
The patient was referred to their hospital because of symptoms such as “foreign body sensation” and voice change. A smoker for 45 years, he stopped 5 years before. A physical examination revealed that lymph nodes in the neck, axillary, and inguinal areas were not enlarged. Blood count and laboratory data were all normal, but a computed tomography (CT) scan and MRI revealed that the patient had an unusual constellation of simultaneous triple primary cancers: laryngeal supraglottic cancer, small cell lung cancer (SCLC), and squamous cell lung cancer.
Head and neck cancer with synchronous or metachronous lung cancers during follow-up isn’t rare, the clinicians say. But their patient’s case is uncommon because the coexistence of SCLC and squamous cell lung cancer has rarely been reported.
Related: Finding Synchronous Cancers
Supraglottic laryngeal cancer is usually diagnosed in the advanced stages with cervical lymph node metastasis because of its nonspecific presenting symptoms and its anatomic characteristics, including a rich lymphatic network, the researchers say. That was why at the initial presentation they presumed the patient had advanced metastatic cancer. If there had not been “high suspicion” or effort to confirm the 2 distinct lung masses by invasive diagnostic procedures, the patient would have received the expected palliative treatment and not the curative-aim treatment.
After the patient received concurrent chemoradiation therapy with weekly cisplatin, the supraglottic laryngeal cancer was “markedly decreased” without newly developed cervical lymph node metastasis. A follow-up chest CT showed partial response for the SCLC in the left upper lobe; the squamous cell lung cancer in the right lower lobe remained stable. The patient was given additional chemotherapy with etoposide and cisplatin. He has survived without recurrence.
Related: Timeliness of Lung Cancer Diagnosis and Treatment
Source:
Kim EK, Kim JY, Kim BM, Lim SN. BMJ Case Rep. 2017;2017.
doi: 10.1136/bcr-2016-216305.
Be careful not to assume multiple cancerous lesions are advanced stage metastatic cancer, caution clinicians from H Plus Yangji Hospital in Seoul, and Inje University Haeundae Paik Hospital in Busan, both in the Republic of Korea. They came close to making that mistake.
Related: A Mysterious Massive Hemorrhage
The researchers reported on a patient who was on the verge of getting only palliative care for advanced laryngeal cancer with multiple lung metastases, when in fact he was a candidate for curative-aim chemotherapy. Thanks to a “meticulous approach,” the researchers switched their plan in time.
The patient was referred to their hospital because of symptoms such as “foreign body sensation” and voice change. A smoker for 45 years, he stopped 5 years before. A physical examination revealed that lymph nodes in the neck, axillary, and inguinal areas were not enlarged. Blood count and laboratory data were all normal, but a computed tomography (CT) scan and MRI revealed that the patient had an unusual constellation of simultaneous triple primary cancers: laryngeal supraglottic cancer, small cell lung cancer (SCLC), and squamous cell lung cancer.
Head and neck cancer with synchronous or metachronous lung cancers during follow-up isn’t rare, the clinicians say. But their patient’s case is uncommon because the coexistence of SCLC and squamous cell lung cancer has rarely been reported.
Related: Finding Synchronous Cancers
Supraglottic laryngeal cancer is usually diagnosed in the advanced stages with cervical lymph node metastasis because of its nonspecific presenting symptoms and its anatomic characteristics, including a rich lymphatic network, the researchers say. That was why at the initial presentation they presumed the patient had advanced metastatic cancer. If there had not been “high suspicion” or effort to confirm the 2 distinct lung masses by invasive diagnostic procedures, the patient would have received the expected palliative treatment and not the curative-aim treatment.
After the patient received concurrent chemoradiation therapy with weekly cisplatin, the supraglottic laryngeal cancer was “markedly decreased” without newly developed cervical lymph node metastasis. A follow-up chest CT showed partial response for the SCLC in the left upper lobe; the squamous cell lung cancer in the right lower lobe remained stable. The patient was given additional chemotherapy with etoposide and cisplatin. He has survived without recurrence.
Related: Timeliness of Lung Cancer Diagnosis and Treatment
Source:
Kim EK, Kim JY, Kim BM, Lim SN. BMJ Case Rep. 2017;2017.
doi: 10.1136/bcr-2016-216305.
Be careful not to assume multiple cancerous lesions are advanced stage metastatic cancer, caution clinicians from H Plus Yangji Hospital in Seoul, and Inje University Haeundae Paik Hospital in Busan, both in the Republic of Korea. They came close to making that mistake.
Related: A Mysterious Massive Hemorrhage
The researchers reported on a patient who was on the verge of getting only palliative care for advanced laryngeal cancer with multiple lung metastases, when in fact he was a candidate for curative-aim chemotherapy. Thanks to a “meticulous approach,” the researchers switched their plan in time.
The patient was referred to their hospital because of symptoms such as “foreign body sensation” and voice change. A smoker for 45 years, he stopped 5 years before. A physical examination revealed that lymph nodes in the neck, axillary, and inguinal areas were not enlarged. Blood count and laboratory data were all normal, but a computed tomography (CT) scan and MRI revealed that the patient had an unusual constellation of simultaneous triple primary cancers: laryngeal supraglottic cancer, small cell lung cancer (SCLC), and squamous cell lung cancer.
Head and neck cancer with synchronous or metachronous lung cancers during follow-up isn’t rare, the clinicians say. But their patient’s case is uncommon because the coexistence of SCLC and squamous cell lung cancer has rarely been reported.
Related: Finding Synchronous Cancers
Supraglottic laryngeal cancer is usually diagnosed in the advanced stages with cervical lymph node metastasis because of its nonspecific presenting symptoms and its anatomic characteristics, including a rich lymphatic network, the researchers say. That was why at the initial presentation they presumed the patient had advanced metastatic cancer. If there had not been “high suspicion” or effort to confirm the 2 distinct lung masses by invasive diagnostic procedures, the patient would have received the expected palliative treatment and not the curative-aim treatment.
After the patient received concurrent chemoradiation therapy with weekly cisplatin, the supraglottic laryngeal cancer was “markedly decreased” without newly developed cervical lymph node metastasis. A follow-up chest CT showed partial response for the SCLC in the left upper lobe; the squamous cell lung cancer in the right lower lobe remained stable. The patient was given additional chemotherapy with etoposide and cisplatin. He has survived without recurrence.
Related: Timeliness of Lung Cancer Diagnosis and Treatment
Source:
Kim EK, Kim JY, Kim BM, Lim SN. BMJ Case Rep. 2017;2017.
doi: 10.1136/bcr-2016-216305.
Warfarin, aspirin linked to higher risk of ICH in AFib
An analysis of data from the ARISTOTLE trial suggests patients with atrial fibrillation (AFib) have a higher risk of intracranial hemorrhage (ICH) when they receive warfarin as opposed to apixaban.
The analysis also indicates that concomitant aspirin use increases the risk of ICH among AFib patients taking either warfarin or apixaban as stroke prophylaxis.
“We know that aspirin has only a modest effect in preventing stroke in atrial fibrillation patients, yet it was one of the top predictors of intracranial hemorrhage,” said study author Renato D. Lopes, MD, PhD, of Duke Clinical Research Institute in Durham, North Carolina.
“Our finding demonstrates that aspirin is not as safe as one might think.”
Dr Lopes and his colleagues reported this finding in Blood.
Previous results from the ARISTOTLE trial, published in 2011, suggested that apixaban was superior to warfarin in terms of preventing stroke and systemic embolism, reducing bleeding, and reducing mortality in AFib patients.
However, a report published in 2013 suggested the results of this trial may have been affected by patients at 1 or more clinical trial sites receiving the wrong medication or dose, adverse events going unreported, and records being changed.
Bristol-Myers Squibb and Pfizer (funders of ARISTOTLE) said these issues likely had a negligible effect on the trial results. And the US Food and Drug Administration agreed when it approved apixaban for use in AFib patients in 2013.
Current analysis
For the current analysis, researchers used ARISTOTLE data to investigate the frequency and characteristics of ICH. They analyzed data from 18,140 AFib patients treated with warfarin or apixaban at sites in North America, Latin America, Europe, and Asia.
In all, 174 patients developed ICH. Most of these bleeds were spontaneous (71.2%) rather than traumatic (28.8%).
Apixaban vs warfarin
Patients randomized to receive apixaban had a lower incidence of ICH than those randomized to warfarin—0.33% per year and 0.80% per year, respectively.
The risk of ICH was significantly lower in the apixaban arm than the warfarin arm (hazard ratio [HR]=0.42, 95% CI 0.30–0.58; P<0.0001). The same was true for spontaneous ICH (HR=0.52, 95% CI 190 0.35–0.75; P=0.0006) and traumatic ICH (HR=0.26, 95% CI 0.13–0.53; P=0.0002).
In the warfarin arm, the median time from the most recent international normalized ratio (INR) test to ICH was 13 days (range, 6-21).
Most patients (78.5%) in the warfarin arm who developed ICH had a pre-ICH INR below 3.0. The median INR was 2.6 (range, 2.1-3.0).
Other risk factors
The researchers found that several factors other than study treatment were associated with an increased risk of ICH.
Patients treated at trial sites in Asia (HR=3.19) or Latin America (HR=1.57) had an increased risk of ICH compared to patients treated in Europe.
Each 5-year increase in patient age was associated with an increased risk of ICH (HR=1.25.)
Patients with a prior stroke or transient ischemic attack (HR=1.83) had an increased risk of ICH, as did patients receiving aspirin at baseline (HR=1.37).
The researchers said the increased risk of ICH associated with aspirin use was particularly pronounced in older patients. 
An analysis of data from the ARISTOTLE trial suggests patients with atrial fibrillation (AFib) have a higher risk of intracranial hemorrhage (ICH) when they receive warfarin as opposed to apixaban.
The analysis also indicates that concomitant aspirin use increases the risk of ICH among AFib patients taking either warfarin or apixaban as stroke prophylaxis.
“We know that aspirin has only a modest effect in preventing stroke in atrial fibrillation patients, yet it was one of the top predictors of intracranial hemorrhage,” said study author Renato D. Lopes, MD, PhD, of Duke Clinical Research Institute in Durham, North Carolina.
“Our finding demonstrates that aspirin is not as safe as one might think.”
Dr Lopes and his colleagues reported this finding in Blood.
Previous results from the ARISTOTLE trial, published in 2011, suggested that apixaban was superior to warfarin in terms of preventing stroke and systemic embolism, reducing bleeding, and reducing mortality in AFib patients.
However, a report published in 2013 suggested the results of this trial may have been affected by patients at 1 or more clinical trial sites receiving the wrong medication or dose, adverse events going unreported, and records being changed.
Bristol-Myers Squibb and Pfizer (funders of ARISTOTLE) said these issues likely had a negligible effect on the trial results. And the US Food and Drug Administration agreed when it approved apixaban for use in AFib patients in 2013.
Current analysis
For the current analysis, researchers used ARISTOTLE data to investigate the frequency and characteristics of ICH. They analyzed data from 18,140 AFib patients treated with warfarin or apixaban at sites in North America, Latin America, Europe, and Asia.
In all, 174 patients developed ICH. Most of these bleeds were spontaneous (71.2%) rather than traumatic (28.8%).
Apixaban vs warfarin
Patients randomized to receive apixaban had a lower incidence of ICH than those randomized to warfarin—0.33% per year and 0.80% per year, respectively.
The risk of ICH was significantly lower in the apixaban arm than the warfarin arm (hazard ratio [HR]=0.42, 95% CI 0.30–0.58; P<0.0001). The same was true for spontaneous ICH (HR=0.52, 95% CI 190 0.35–0.75; P=0.0006) and traumatic ICH (HR=0.26, 95% CI 0.13–0.53; P=0.0002).
In the warfarin arm, the median time from the most recent international normalized ratio (INR) test to ICH was 13 days (range, 6-21).
Most patients (78.5%) in the warfarin arm who developed ICH had a pre-ICH INR below 3.0. The median INR was 2.6 (range, 2.1-3.0).
Other risk factors
The researchers found that several factors other than study treatment were associated with an increased risk of ICH.
Patients treated at trial sites in Asia (HR=3.19) or Latin America (HR=1.57) had an increased risk of ICH compared to patients treated in Europe.
Each 5-year increase in patient age was associated with an increased risk of ICH (HR=1.25.)
Patients with a prior stroke or transient ischemic attack (HR=1.83) had an increased risk of ICH, as did patients receiving aspirin at baseline (HR=1.37).
The researchers said the increased risk of ICH associated with aspirin use was particularly pronounced in older patients.
An analysis of data from the ARISTOTLE trial suggests patients with atrial fibrillation (AFib) have a higher risk of intracranial hemorrhage (ICH) when they receive warfarin as opposed to apixaban.
The analysis also indicates that concomitant aspirin use increases the risk of ICH among AFib patients taking either warfarin or apixaban as stroke prophylaxis.
“We know that aspirin has only a modest effect in preventing stroke in atrial fibrillation patients, yet it was one of the top predictors of intracranial hemorrhage,” said study author Renato D. Lopes, MD, PhD, of Duke Clinical Research Institute in Durham, North Carolina.
“Our finding demonstrates that aspirin is not as safe as one might think.”
Dr Lopes and his colleagues reported this finding in Blood.
Previous results from the ARISTOTLE trial, published in 2011, suggested that apixaban was superior to warfarin in terms of preventing stroke and systemic embolism, reducing bleeding, and reducing mortality in AFib patients.
However, a report published in 2013 suggested the results of this trial may have been affected by patients at 1 or more clinical trial sites receiving the wrong medication or dose, adverse events going unreported, and records being changed.
Bristol-Myers Squibb and Pfizer (funders of ARISTOTLE) said these issues likely had a negligible effect on the trial results. And the US Food and Drug Administration agreed when it approved apixaban for use in AFib patients in 2013.
Current analysis
For the current analysis, researchers used ARISTOTLE data to investigate the frequency and characteristics of ICH. They analyzed data from 18,140 AFib patients treated with warfarin or apixaban at sites in North America, Latin America, Europe, and Asia.
In all, 174 patients developed ICH. Most of these bleeds were spontaneous (71.2%) rather than traumatic (28.8%).
Apixaban vs warfarin
Patients randomized to receive apixaban had a lower incidence of ICH than those randomized to warfarin—0.33% per year and 0.80% per year, respectively.
The risk of ICH was significantly lower in the apixaban arm than the warfarin arm (hazard ratio [HR]=0.42, 95% CI 0.30–0.58; P<0.0001). The same was true for spontaneous ICH (HR=0.52, 95% CI 190 0.35–0.75; P=0.0006) and traumatic ICH (HR=0.26, 95% CI 0.13–0.53; P=0.0002).
In the warfarin arm, the median time from the most recent international normalized ratio (INR) test to ICH was 13 days (range, 6-21).
Most patients (78.5%) in the warfarin arm who developed ICH had a pre-ICH INR below 3.0. The median INR was 2.6 (range, 2.1-3.0).
Other risk factors
The researchers found that several factors other than study treatment were associated with an increased risk of ICH.
Patients treated at trial sites in Asia (HR=3.19) or Latin America (HR=1.57) had an increased risk of ICH compared to patients treated in Europe.
Each 5-year increase in patient age was associated with an increased risk of ICH (HR=1.25.)
Patients with a prior stroke or transient ischemic attack (HR=1.83) had an increased risk of ICH, as did patients receiving aspirin at baseline (HR=1.37).
The researchers said the increased risk of ICH associated with aspirin use was particularly pronounced in older patients.