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How the microbiome influences the success of cancer therapy
HAMBURG, Germany — The human microbiome comprises 39 to 44 billion microbes. That is ten times more than the number of cells in our body. Hendrik Poeck, MD, managing senior physician of internal medicine at the University Hospital Regensburg, illustrated this point at the annual meeting of the German Society for Hematology and Medical Oncology. If the gut microbiome falls out of balance, then “intestinal dysbiosis potentially poses a risk for the pathogenesis of local and systemic diseases,” explained Dr. Poeck.
Cancers and their therapies can also be influenced in this way. said Dr. Poeck.
Microbial diversity could be beneficial for cancer therapy, too. The composition of the microbiome varies significantly from host to host and can mutate. These properties make it a target for precision microbiotics, which involves using the gut microbiome as a biomarker to predict various physical reactions and to develop individualized diets.
Microbiome and Pathogenesis
The body’s microbiome fulfills a barrier function, especially where the body is exposed to an external environment: at the epidermis and the internal mucous membranes, in the gastrointestinal tract, and in the lungs, chest, and urogenital system.
Association studies on humans and experimental manipulations on mouse models of cancer showed that certain microorganisms can have either protective or harmful effects on cancer development, on the progression of a malignant disease, and on the response to therapy.
A Master Regulator?
Disruptions of the microbial system in the gut, as occur during antibiotic therapy, can have significant effects on a patient’s response to immunotherapy. Taking antibiotics shortly before or after starting therapy with immune checkpoint inhibitors (ICIs) significantly affected both overall survival (OS) and progression-free survival (PFS), as reported in a recent review and meta-analysis, for example.
Proton pump inhibitors also affect the gut microbiome and reduce the response to immunotherapy; this effect was demonstrated by an analysis of data from more than 2700 cancer patients that was recently presented at the annual meeting of the European Society for Medical Oncology (ESMO).
The extent to which the gut microbiome influences the efficacy of an ICI or predicts said efficacy was examined in a retrospective analysis published in Science in 2018, which Dr. Poeck presented. Resistance to ICI correlated with the relative frequency of the bacteria Akkermansia muciniphila in the gut of patients with cancer. In mouse models, the researchers restored the efficacy of the PD-1 blockade through a stool transplant.
Predicting Immunotherapy Response
If A muciniphila is present, can the composition of the microbiome act as a predictor for an effective ICI therapy?
Laurence Zitvogel, MD, PhD, and her working group at the National Institute of Health and Medical Research in Villejuif, France, performed a prospective study in 338 patients with non–small cell lung cancer and examined the prognostic significance of the fecal bacteria A muciniphila (Akk). The “Akkerman status” (low Akk vs high Akk) in a patient’s stool correlated with an increased objective response rate and a longer OS, independently of PD-L1 expression, antibiotics, and performance status. The OS for low Akk was 13.4 months, vs 18.8 months for high Akk in first-line treatment.
These results are promising, said Dr. Poeck. But there is no one-size-fits-all solution. No conclusions can be drawn from one bacterium on the efficacy of therapies in humans, since “the entirety of the bacteria is decisive,” said Dr. Poeck. In addition to the gut microbiome, the composition of gut metabolites influences the response to immunotherapies, as shown in a study with ICI.
Therapeutic Interventions
One possible therapeutic intervention to restore the gut microbiome is fecal microbiota transplantation (FMT). In a phase 1 study presented by Dr. Poeck, FMT was effective in the treatment of 20 patients with melanoma with ICI in an advanced and treatment-naive stage. Seven days after the patients received FMT, the first cycle with anti-PD-1 immunotherapy was initiated, with a total administration of three to four cycles. After 12 weeks, most patients were in complete or partial remission, as evidenced on imaging.
However, FMT also carries some risks. Two cases of sepsis with multiresistant Escherichia coli occurred, as well as other serious infections. Since then, there has been an FDA condition for extended screening of the donor stool, said Dr. Poeck. Nevertheless, this intervention is promising. A search of the keywords “FMT in cancer/transplant setting” reveals 46 currently clinical studies on clinicaltrials.gov.
Nutritional Interventions
Dr. Poeck advises caution about over-the-counter products. These products usually contain only a few species, such as Lactobacillus and Bifidobacterium. “Over-the-counter probiotics can even delay the reconstitution of the microbiome after antibiotics,” said Dr. Poeck, according to a study. In some studies, the response rates were significantly lower after probiotic intake or led to controversial results, according to Dr. Poeck.
In contrast, Dr. Poeck said prebiotics (that is, a fiber-rich diet with indigestible carbohydrates) were promising. During digestion, prebiotics are split into short-chain fatty acids by bacterial enzymes and promote the growth of certain microbiota.
In this way, just 20 g of extremely fiber-rich food had a significant effect on PFS in 128 patients with melanoma undergoing anti-PD-1 immunotherapy. With 20 g of fiber-rich food per day, the PFS was stable over 60 months. The most significant benefit was observed in patients with a sufficient fiber intake who were not taking probiotics.
What to Recommend?
In summary, Dr. Poeck said that it is important to “budget” well, particularly with antibiotic administration, and to strive for calculated therapy with as narrow a spectrum as possible. For patients who experience complications such as cytokine release syndrome as a reaction to cell therapy, delaying the use of antibiotics is important. However, it is often difficult to differentiate this syndrome from neutropenic fever. The aim should be to avoid high-risk antibiotics, if clinically justifiable. Patients should avoid taking antibiotics for 30 days before starting immunotherapy.
Regarding nutritional interventions, Dr. Poeck referred to the recent Onkopedia recommendation for nutrition after cancer and the 10 nutritional rules of the German Nutrition Society. According to Dr. Poeck, the important aspects of these recommendations are a fiber-rich diet (> 20 g/d) from various plant products and avoiding artificial sweeteners and flavorings, as well as ultraprocessed (convenience) foods. In addition, meat should be consumed only in moderation, and as little processed meat as possible should be consumed. In addition, regular (aerobic and anaerobic) physical activity is important.
“Looking ahead into the future,” said Dr. Poeck, “we need a uniform and functional understanding and we need a randomized prediction for diagnosis.”
This article was translated from the Medscape German edition.
A version of this article appeared on Medscape.com.
HAMBURG, Germany — The human microbiome comprises 39 to 44 billion microbes. That is ten times more than the number of cells in our body. Hendrik Poeck, MD, managing senior physician of internal medicine at the University Hospital Regensburg, illustrated this point at the annual meeting of the German Society for Hematology and Medical Oncology. If the gut microbiome falls out of balance, then “intestinal dysbiosis potentially poses a risk for the pathogenesis of local and systemic diseases,” explained Dr. Poeck.
Cancers and their therapies can also be influenced in this way. said Dr. Poeck.
Microbial diversity could be beneficial for cancer therapy, too. The composition of the microbiome varies significantly from host to host and can mutate. These properties make it a target for precision microbiotics, which involves using the gut microbiome as a biomarker to predict various physical reactions and to develop individualized diets.
Microbiome and Pathogenesis
The body’s microbiome fulfills a barrier function, especially where the body is exposed to an external environment: at the epidermis and the internal mucous membranes, in the gastrointestinal tract, and in the lungs, chest, and urogenital system.
Association studies on humans and experimental manipulations on mouse models of cancer showed that certain microorganisms can have either protective or harmful effects on cancer development, on the progression of a malignant disease, and on the response to therapy.
A Master Regulator?
Disruptions of the microbial system in the gut, as occur during antibiotic therapy, can have significant effects on a patient’s response to immunotherapy. Taking antibiotics shortly before or after starting therapy with immune checkpoint inhibitors (ICIs) significantly affected both overall survival (OS) and progression-free survival (PFS), as reported in a recent review and meta-analysis, for example.
Proton pump inhibitors also affect the gut microbiome and reduce the response to immunotherapy; this effect was demonstrated by an analysis of data from more than 2700 cancer patients that was recently presented at the annual meeting of the European Society for Medical Oncology (ESMO).
The extent to which the gut microbiome influences the efficacy of an ICI or predicts said efficacy was examined in a retrospective analysis published in Science in 2018, which Dr. Poeck presented. Resistance to ICI correlated with the relative frequency of the bacteria Akkermansia muciniphila in the gut of patients with cancer. In mouse models, the researchers restored the efficacy of the PD-1 blockade through a stool transplant.
Predicting Immunotherapy Response
If A muciniphila is present, can the composition of the microbiome act as a predictor for an effective ICI therapy?
Laurence Zitvogel, MD, PhD, and her working group at the National Institute of Health and Medical Research in Villejuif, France, performed a prospective study in 338 patients with non–small cell lung cancer and examined the prognostic significance of the fecal bacteria A muciniphila (Akk). The “Akkerman status” (low Akk vs high Akk) in a patient’s stool correlated with an increased objective response rate and a longer OS, independently of PD-L1 expression, antibiotics, and performance status. The OS for low Akk was 13.4 months, vs 18.8 months for high Akk in first-line treatment.
These results are promising, said Dr. Poeck. But there is no one-size-fits-all solution. No conclusions can be drawn from one bacterium on the efficacy of therapies in humans, since “the entirety of the bacteria is decisive,” said Dr. Poeck. In addition to the gut microbiome, the composition of gut metabolites influences the response to immunotherapies, as shown in a study with ICI.
Therapeutic Interventions
One possible therapeutic intervention to restore the gut microbiome is fecal microbiota transplantation (FMT). In a phase 1 study presented by Dr. Poeck, FMT was effective in the treatment of 20 patients with melanoma with ICI in an advanced and treatment-naive stage. Seven days after the patients received FMT, the first cycle with anti-PD-1 immunotherapy was initiated, with a total administration of three to four cycles. After 12 weeks, most patients were in complete or partial remission, as evidenced on imaging.
However, FMT also carries some risks. Two cases of sepsis with multiresistant Escherichia coli occurred, as well as other serious infections. Since then, there has been an FDA condition for extended screening of the donor stool, said Dr. Poeck. Nevertheless, this intervention is promising. A search of the keywords “FMT in cancer/transplant setting” reveals 46 currently clinical studies on clinicaltrials.gov.
Nutritional Interventions
Dr. Poeck advises caution about over-the-counter products. These products usually contain only a few species, such as Lactobacillus and Bifidobacterium. “Over-the-counter probiotics can even delay the reconstitution of the microbiome after antibiotics,” said Dr. Poeck, according to a study. In some studies, the response rates were significantly lower after probiotic intake or led to controversial results, according to Dr. Poeck.
In contrast, Dr. Poeck said prebiotics (that is, a fiber-rich diet with indigestible carbohydrates) were promising. During digestion, prebiotics are split into short-chain fatty acids by bacterial enzymes and promote the growth of certain microbiota.
In this way, just 20 g of extremely fiber-rich food had a significant effect on PFS in 128 patients with melanoma undergoing anti-PD-1 immunotherapy. With 20 g of fiber-rich food per day, the PFS was stable over 60 months. The most significant benefit was observed in patients with a sufficient fiber intake who were not taking probiotics.
What to Recommend?
In summary, Dr. Poeck said that it is important to “budget” well, particularly with antibiotic administration, and to strive for calculated therapy with as narrow a spectrum as possible. For patients who experience complications such as cytokine release syndrome as a reaction to cell therapy, delaying the use of antibiotics is important. However, it is often difficult to differentiate this syndrome from neutropenic fever. The aim should be to avoid high-risk antibiotics, if clinically justifiable. Patients should avoid taking antibiotics for 30 days before starting immunotherapy.
Regarding nutritional interventions, Dr. Poeck referred to the recent Onkopedia recommendation for nutrition after cancer and the 10 nutritional rules of the German Nutrition Society. According to Dr. Poeck, the important aspects of these recommendations are a fiber-rich diet (> 20 g/d) from various plant products and avoiding artificial sweeteners and flavorings, as well as ultraprocessed (convenience) foods. In addition, meat should be consumed only in moderation, and as little processed meat as possible should be consumed. In addition, regular (aerobic and anaerobic) physical activity is important.
“Looking ahead into the future,” said Dr. Poeck, “we need a uniform and functional understanding and we need a randomized prediction for diagnosis.”
This article was translated from the Medscape German edition.
A version of this article appeared on Medscape.com.
HAMBURG, Germany — The human microbiome comprises 39 to 44 billion microbes. That is ten times more than the number of cells in our body. Hendrik Poeck, MD, managing senior physician of internal medicine at the University Hospital Regensburg, illustrated this point at the annual meeting of the German Society for Hematology and Medical Oncology. If the gut microbiome falls out of balance, then “intestinal dysbiosis potentially poses a risk for the pathogenesis of local and systemic diseases,” explained Dr. Poeck.
Cancers and their therapies can also be influenced in this way. said Dr. Poeck.
Microbial diversity could be beneficial for cancer therapy, too. The composition of the microbiome varies significantly from host to host and can mutate. These properties make it a target for precision microbiotics, which involves using the gut microbiome as a biomarker to predict various physical reactions and to develop individualized diets.
Microbiome and Pathogenesis
The body’s microbiome fulfills a barrier function, especially where the body is exposed to an external environment: at the epidermis and the internal mucous membranes, in the gastrointestinal tract, and in the lungs, chest, and urogenital system.
Association studies on humans and experimental manipulations on mouse models of cancer showed that certain microorganisms can have either protective or harmful effects on cancer development, on the progression of a malignant disease, and on the response to therapy.
A Master Regulator?
Disruptions of the microbial system in the gut, as occur during antibiotic therapy, can have significant effects on a patient’s response to immunotherapy. Taking antibiotics shortly before or after starting therapy with immune checkpoint inhibitors (ICIs) significantly affected both overall survival (OS) and progression-free survival (PFS), as reported in a recent review and meta-analysis, for example.
Proton pump inhibitors also affect the gut microbiome and reduce the response to immunotherapy; this effect was demonstrated by an analysis of data from more than 2700 cancer patients that was recently presented at the annual meeting of the European Society for Medical Oncology (ESMO).
The extent to which the gut microbiome influences the efficacy of an ICI or predicts said efficacy was examined in a retrospective analysis published in Science in 2018, which Dr. Poeck presented. Resistance to ICI correlated with the relative frequency of the bacteria Akkermansia muciniphila in the gut of patients with cancer. In mouse models, the researchers restored the efficacy of the PD-1 blockade through a stool transplant.
Predicting Immunotherapy Response
If A muciniphila is present, can the composition of the microbiome act as a predictor for an effective ICI therapy?
Laurence Zitvogel, MD, PhD, and her working group at the National Institute of Health and Medical Research in Villejuif, France, performed a prospective study in 338 patients with non–small cell lung cancer and examined the prognostic significance of the fecal bacteria A muciniphila (Akk). The “Akkerman status” (low Akk vs high Akk) in a patient’s stool correlated with an increased objective response rate and a longer OS, independently of PD-L1 expression, antibiotics, and performance status. The OS for low Akk was 13.4 months, vs 18.8 months for high Akk in first-line treatment.
These results are promising, said Dr. Poeck. But there is no one-size-fits-all solution. No conclusions can be drawn from one bacterium on the efficacy of therapies in humans, since “the entirety of the bacteria is decisive,” said Dr. Poeck. In addition to the gut microbiome, the composition of gut metabolites influences the response to immunotherapies, as shown in a study with ICI.
Therapeutic Interventions
One possible therapeutic intervention to restore the gut microbiome is fecal microbiota transplantation (FMT). In a phase 1 study presented by Dr. Poeck, FMT was effective in the treatment of 20 patients with melanoma with ICI in an advanced and treatment-naive stage. Seven days after the patients received FMT, the first cycle with anti-PD-1 immunotherapy was initiated, with a total administration of three to four cycles. After 12 weeks, most patients were in complete or partial remission, as evidenced on imaging.
However, FMT also carries some risks. Two cases of sepsis with multiresistant Escherichia coli occurred, as well as other serious infections. Since then, there has been an FDA condition for extended screening of the donor stool, said Dr. Poeck. Nevertheless, this intervention is promising. A search of the keywords “FMT in cancer/transplant setting” reveals 46 currently clinical studies on clinicaltrials.gov.
Nutritional Interventions
Dr. Poeck advises caution about over-the-counter products. These products usually contain only a few species, such as Lactobacillus and Bifidobacterium. “Over-the-counter probiotics can even delay the reconstitution of the microbiome after antibiotics,” said Dr. Poeck, according to a study. In some studies, the response rates were significantly lower after probiotic intake or led to controversial results, according to Dr. Poeck.
In contrast, Dr. Poeck said prebiotics (that is, a fiber-rich diet with indigestible carbohydrates) were promising. During digestion, prebiotics are split into short-chain fatty acids by bacterial enzymes and promote the growth of certain microbiota.
In this way, just 20 g of extremely fiber-rich food had a significant effect on PFS in 128 patients with melanoma undergoing anti-PD-1 immunotherapy. With 20 g of fiber-rich food per day, the PFS was stable over 60 months. The most significant benefit was observed in patients with a sufficient fiber intake who were not taking probiotics.
What to Recommend?
In summary, Dr. Poeck said that it is important to “budget” well, particularly with antibiotic administration, and to strive for calculated therapy with as narrow a spectrum as possible. For patients who experience complications such as cytokine release syndrome as a reaction to cell therapy, delaying the use of antibiotics is important. However, it is often difficult to differentiate this syndrome from neutropenic fever. The aim should be to avoid high-risk antibiotics, if clinically justifiable. Patients should avoid taking antibiotics for 30 days before starting immunotherapy.
Regarding nutritional interventions, Dr. Poeck referred to the recent Onkopedia recommendation for nutrition after cancer and the 10 nutritional rules of the German Nutrition Society. According to Dr. Poeck, the important aspects of these recommendations are a fiber-rich diet (> 20 g/d) from various plant products and avoiding artificial sweeteners and flavorings, as well as ultraprocessed (convenience) foods. In addition, meat should be consumed only in moderation, and as little processed meat as possible should be consumed. In addition, regular (aerobic and anaerobic) physical activity is important.
“Looking ahead into the future,” said Dr. Poeck, “we need a uniform and functional understanding and we need a randomized prediction for diagnosis.”
This article was translated from the Medscape German edition.
A version of this article appeared on Medscape.com.
Eight wealth tips just for doctors
The average physician makes $352,000, and some earn well into the $500,000s. So, doctors don’t have to worry about money, right?
You know the answer to that.
One thing all physicians have in common about money, says James M. Dahle, MD, FACEP, founder of The White Coat Investor, is that they don’t receive any training in business, personal finance, or investing throughout their schooling or careers unless they seek it out. This leaves many unprepared to make the best investing and money-saving decisions, while others get too frustrated about their lack of knowledge to even dip their toe into the investing pool.
Exhibit A: Four out of 10 physicians have a net worth below $1 million, according to the Medscape Physician Wealth & Debt Report 2023. Elizabeth Chiang, MD, PhD, an oculoplastic surgeon and a physician money coach at Grow Your Wealthy Mindset, notes that many of those doctors are over age 65, “which means they essentially can’t retire.”
And that’s just one pain point.
Physicians have money concerns specific to their profession and background. Luckily, some fellow doctors also serve as financial and wealth advisors just for other doctors.
Blind Spot #1
The early lean years skew doctors’ money outlook. “We have an extended training period, which commonly consists of taking on a large amount of debt, followed by 3 to 8 years of being paid a modest salary, and then finally a large boost in income,” explains Dr. Chiang. This can lay a shaky foundation for the earning years to come, and as a result, a lot of doctors just don’t think about money in healthy ways. Once their incomes increase, physicians may be surprised, for example, that making a multiple six-figure salary means paying six figures in taxes.
The Fix
Treat financial health like physical health. That means money cannot be a taboo subject. “The misguided mindset is that we didn’t become physicians to make money, we did it to help people,” explains Jordan Frey, MD, creator of the blog, The Prudent Plastic Surgeon.
Dr. Frey acknowledges that the desire to help is certainly true. But the result is a false idea that “to think about our personal finances makes us a worse doctor.”
Blind Spot #2
Because doctors know a lot about one thing (medicine), they might assume they know a lot about everything (such as investing). “Totally different fields with a different language and different way to think about it,” Dahle explains. This overconfidence could lead to some negligent or risky financial decisions.
The Fix
Educate yourself. There are several books on personal finance and investing written by physicians for physicians. Dr. Chiang recommends The Physician Philosopher’s Guide to Personal Finance, by James Turner, MD; Financial Freedom Rx, by Chirag Shah, MD, and Jayanth Sridhar, MD; and The Physician’s Guide to Finance, by Nicholas Christian and Amanda Christian, MD. There are also podcasts, blogs, and courses to help educate doctors on finance, such as the Fire Your Financial Advisor course by The White Coat Investor.
Blind Spot #3
Undersaving. Retirement saving is one thing, but 24% of doctors say they don’t even put money away in a taxable savings account, according to the Wealth & Debt Report.
Cobin Soelberg, MD, JD, a board-certified anesthesiologist and founder and principal advisor with Greeley Wealth Management, is the treasurer of his anesthesiology group. “I get to see every month how much people are saving, and even on an anesthesiologist salary, where everyone’s making about $400,000 a year, a lot of people are not saving anything, which is crazy.”
Undersaving can be both a time issue and a mindset one.
Time: Doctors often start investing in their retirement accounts later than the average professional, says Dr. Chiang. “A lot of physicians will max out their 401k or 403b,” she explains. “But if you’re putting in $20,000 a year and only starting when you’re in your early 30s, that’s not enough to get you to retirement.”
Mindset: Doctors also see people of all ages who are sick, dying, and injured. “They all know someone who worked hard and saved and then dropped dead at 55,” explains Dr. Dahle. This, he says, can lead to a bit of a “you only live once” attitude that prioritizes spending over saving.
The Fix
Shoot for 20%. If you can’t save 20% of your gross now, strive to get to that point. Think of it as telling a patient they have to change their behavior or trouble will come - not if, but when. “Develop a written investing plan and then stick with it through thick and thin,” says Dr. Dahle. “Once you have a reasonable plan, all you have to do is fund it adequately by saving 20% of your gross income, and a doctor will easily retire as a multimillionaire.”
Blind Spot #4
Bad investment strategies. Thirty-six percent of doctors experience their largest financial losses from lousy investments, according to the Wealth & Debt Report. Meanwhile, 17% of PCPs and 12% of specialists say they haven’t made any investments at all. That’s a terrible mix of doing the wrong thing and doing a worse thing.
The Fix
Don’t overthink investing, but don’t underthink it either. “As high-income earners, doctors just don’t need to take this high level of risk to reach their financial goals,” Dr. Frey says. A good investment plan doesn’t require you to time the stock market or predict individual stock winners. Consider what Vanguard founder Jack Bogle once said about investing: “Be bored by the process but elated by the outcome.”
Dr. Frey suggests going super-simple: index funds. Ignore investing strategies with actively managed mutual funds or individual stocks, as well as risky alternative investments such as cryptocurrency and angel investments. Everyone assumes doctors have money to burn, and they will push sketchy investment ideas at them. Avoid.
Blind Spot #5
Not taking debt seriously enough. The average medical student debt is $250,000 and can exceed $500,000, says Dr. Soelberg. Many doctors spend the first 10 to 20 years of their careers paying this off. Today’s graduates are paying more than 7% on their loans.
And it’s not just student debt: 39% of physicians carry five or more credit cards, and 34% have mortgages larger than $300,000 (with half of those are more than than $500K), per the Wealth & Debt Report.
The Fix
Treat debt like cancer. It’s a lethal enemy you can’t get rid of right away, but a steady, aggressive, long-term attack will have the best results. Dr. Soelberg suggests allocating the most you can afford per month, whether that’s $1000 or $5000, toward debt. Raise the amount as your income grows. Do the same with your 401k or retirement plan. Whatever is left, you can spend. Five to 10 years later, you will realize, “Wow. I’m debt free.”
Blind Spot #6
Not putting in the work to improve your situation. Seventy-one percent of doctors admit they haven’t done anything to reduce major expenses, according to the Wealth & Debt Report. Are you leaving major money on the table?
The Fix
Audit yourself in major areas like housing and taxes. While the average professional may need to put 10% to 20% down on a home, physicians can qualify for physician mortgage loans and can often put down 3% or less, says Dr. Chiang. If you can afford the higher mortgage payment, excess savings earmarked for a larger down payment can be put toward debt or invested.
Another trick, if you’re able, is to seek an area that is less in demand at a higher salary. “Physicians in places like New York City or San Francisco tend to make less than physicians in the Midwest or the South,” Dr. Chiang explains. A colleague of hers moved to rural Pennsylvania, where he made a high salary and had a low cost of living for 3½ years, paid off his student debt, and then relocated to an area where he wanted to live long term.
As for taxes, become familiar with tax law. Research things like, “What is considered a business expense for doctors?” says Brett Mollard, MD, a diagnostic radiologist who provides financial advice to younger physicians. “What will your estimated total tax burden be at the end of the year? Will you need to make extra payments to prevent owing a large sum of money from underpaying or to avoid tax penalties?”
Blind Spot #7
Living like a rock star on a doctor’s income. Getting caught up in trying to live the same lifestyle as your colleagues is a classic bear trap. “Sitting in the doctor’s lounge, it’s so crazy,” Dr. Soelberg says. He describes conversations like, “‘Where did you go on your trip?’ ‘What new toys are you buying?’” There’s pressure to live up to an image of what a doctor’s life is supposed to look like before you’ve sorted the basic things like paying off debt.
The Fix
Live like a resident even if you haven’t been one for years, at least until you’re in a better financial position. “You’re already used to living a life of lower means, and you’re an expert when it comes to delaying gratification,” says Dr. Mollard. “Do it a little longer.” Live frugally and spend only on things that bring you joy. “A lot of physicians are trying to be really rich in all areas of their life instead of the ones that actually matter to them,” Dr. Soelberg says. Identify what’s important to you and only splurge on that.
Blind Spot #8
Never asking for help. The right financial planner can provide expert help. Emphasis on right. “Doctors can be very trusting of other professionals, even when they should not be,” says Dr. Dahle. He notes that in financial services, many people masquerade as knowledgeable advisors who are really just salespeople. While legitimate financial advisors strive to make their clients money, they are also ultimately out to line their pockets and love to work with physician salaries. Thus, doctors can end up working with financial planners that don’t specifically understand their situations or end up taking too much from their clients.
The Fix
Find a planner who specializes in, or at least understands, physicians. Ask them how they make money, says Dr. Chiang. If someone hesitates to tell you about their fee structure or if it sounds like a lot, shop around and ask colleagues for recommendations.
“Ultimately, the path to wealth is to create and grow the margin between what you make and what you spend,” says Dr. Frey. Throw some investing into the mix and physicians can set themselves up on a path for a stress-free financial life.
A version of this article appeared on Medscape.com.
The average physician makes $352,000, and some earn well into the $500,000s. So, doctors don’t have to worry about money, right?
You know the answer to that.
One thing all physicians have in common about money, says James M. Dahle, MD, FACEP, founder of The White Coat Investor, is that they don’t receive any training in business, personal finance, or investing throughout their schooling or careers unless they seek it out. This leaves many unprepared to make the best investing and money-saving decisions, while others get too frustrated about their lack of knowledge to even dip their toe into the investing pool.
Exhibit A: Four out of 10 physicians have a net worth below $1 million, according to the Medscape Physician Wealth & Debt Report 2023. Elizabeth Chiang, MD, PhD, an oculoplastic surgeon and a physician money coach at Grow Your Wealthy Mindset, notes that many of those doctors are over age 65, “which means they essentially can’t retire.”
And that’s just one pain point.
Physicians have money concerns specific to their profession and background. Luckily, some fellow doctors also serve as financial and wealth advisors just for other doctors.
Blind Spot #1
The early lean years skew doctors’ money outlook. “We have an extended training period, which commonly consists of taking on a large amount of debt, followed by 3 to 8 years of being paid a modest salary, and then finally a large boost in income,” explains Dr. Chiang. This can lay a shaky foundation for the earning years to come, and as a result, a lot of doctors just don’t think about money in healthy ways. Once their incomes increase, physicians may be surprised, for example, that making a multiple six-figure salary means paying six figures in taxes.
The Fix
Treat financial health like physical health. That means money cannot be a taboo subject. “The misguided mindset is that we didn’t become physicians to make money, we did it to help people,” explains Jordan Frey, MD, creator of the blog, The Prudent Plastic Surgeon.
Dr. Frey acknowledges that the desire to help is certainly true. But the result is a false idea that “to think about our personal finances makes us a worse doctor.”
Blind Spot #2
Because doctors know a lot about one thing (medicine), they might assume they know a lot about everything (such as investing). “Totally different fields with a different language and different way to think about it,” Dahle explains. This overconfidence could lead to some negligent or risky financial decisions.
The Fix
Educate yourself. There are several books on personal finance and investing written by physicians for physicians. Dr. Chiang recommends The Physician Philosopher’s Guide to Personal Finance, by James Turner, MD; Financial Freedom Rx, by Chirag Shah, MD, and Jayanth Sridhar, MD; and The Physician’s Guide to Finance, by Nicholas Christian and Amanda Christian, MD. There are also podcasts, blogs, and courses to help educate doctors on finance, such as the Fire Your Financial Advisor course by The White Coat Investor.
Blind Spot #3
Undersaving. Retirement saving is one thing, but 24% of doctors say they don’t even put money away in a taxable savings account, according to the Wealth & Debt Report.
Cobin Soelberg, MD, JD, a board-certified anesthesiologist and founder and principal advisor with Greeley Wealth Management, is the treasurer of his anesthesiology group. “I get to see every month how much people are saving, and even on an anesthesiologist salary, where everyone’s making about $400,000 a year, a lot of people are not saving anything, which is crazy.”
Undersaving can be both a time issue and a mindset one.
Time: Doctors often start investing in their retirement accounts later than the average professional, says Dr. Chiang. “A lot of physicians will max out their 401k or 403b,” she explains. “But if you’re putting in $20,000 a year and only starting when you’re in your early 30s, that’s not enough to get you to retirement.”
Mindset: Doctors also see people of all ages who are sick, dying, and injured. “They all know someone who worked hard and saved and then dropped dead at 55,” explains Dr. Dahle. This, he says, can lead to a bit of a “you only live once” attitude that prioritizes spending over saving.
The Fix
Shoot for 20%. If you can’t save 20% of your gross now, strive to get to that point. Think of it as telling a patient they have to change their behavior or trouble will come - not if, but when. “Develop a written investing plan and then stick with it through thick and thin,” says Dr. Dahle. “Once you have a reasonable plan, all you have to do is fund it adequately by saving 20% of your gross income, and a doctor will easily retire as a multimillionaire.”
Blind Spot #4
Bad investment strategies. Thirty-six percent of doctors experience their largest financial losses from lousy investments, according to the Wealth & Debt Report. Meanwhile, 17% of PCPs and 12% of specialists say they haven’t made any investments at all. That’s a terrible mix of doing the wrong thing and doing a worse thing.
The Fix
Don’t overthink investing, but don’t underthink it either. “As high-income earners, doctors just don’t need to take this high level of risk to reach their financial goals,” Dr. Frey says. A good investment plan doesn’t require you to time the stock market or predict individual stock winners. Consider what Vanguard founder Jack Bogle once said about investing: “Be bored by the process but elated by the outcome.”
Dr. Frey suggests going super-simple: index funds. Ignore investing strategies with actively managed mutual funds or individual stocks, as well as risky alternative investments such as cryptocurrency and angel investments. Everyone assumes doctors have money to burn, and they will push sketchy investment ideas at them. Avoid.
Blind Spot #5
Not taking debt seriously enough. The average medical student debt is $250,000 and can exceed $500,000, says Dr. Soelberg. Many doctors spend the first 10 to 20 years of their careers paying this off. Today’s graduates are paying more than 7% on their loans.
And it’s not just student debt: 39% of physicians carry five or more credit cards, and 34% have mortgages larger than $300,000 (with half of those are more than than $500K), per the Wealth & Debt Report.
The Fix
Treat debt like cancer. It’s a lethal enemy you can’t get rid of right away, but a steady, aggressive, long-term attack will have the best results. Dr. Soelberg suggests allocating the most you can afford per month, whether that’s $1000 or $5000, toward debt. Raise the amount as your income grows. Do the same with your 401k or retirement plan. Whatever is left, you can spend. Five to 10 years later, you will realize, “Wow. I’m debt free.”
Blind Spot #6
Not putting in the work to improve your situation. Seventy-one percent of doctors admit they haven’t done anything to reduce major expenses, according to the Wealth & Debt Report. Are you leaving major money on the table?
The Fix
Audit yourself in major areas like housing and taxes. While the average professional may need to put 10% to 20% down on a home, physicians can qualify for physician mortgage loans and can often put down 3% or less, says Dr. Chiang. If you can afford the higher mortgage payment, excess savings earmarked for a larger down payment can be put toward debt or invested.
Another trick, if you’re able, is to seek an area that is less in demand at a higher salary. “Physicians in places like New York City or San Francisco tend to make less than physicians in the Midwest or the South,” Dr. Chiang explains. A colleague of hers moved to rural Pennsylvania, where he made a high salary and had a low cost of living for 3½ years, paid off his student debt, and then relocated to an area where he wanted to live long term.
As for taxes, become familiar with tax law. Research things like, “What is considered a business expense for doctors?” says Brett Mollard, MD, a diagnostic radiologist who provides financial advice to younger physicians. “What will your estimated total tax burden be at the end of the year? Will you need to make extra payments to prevent owing a large sum of money from underpaying or to avoid tax penalties?”
Blind Spot #7
Living like a rock star on a doctor’s income. Getting caught up in trying to live the same lifestyle as your colleagues is a classic bear trap. “Sitting in the doctor’s lounge, it’s so crazy,” Dr. Soelberg says. He describes conversations like, “‘Where did you go on your trip?’ ‘What new toys are you buying?’” There’s pressure to live up to an image of what a doctor’s life is supposed to look like before you’ve sorted the basic things like paying off debt.
The Fix
Live like a resident even if you haven’t been one for years, at least until you’re in a better financial position. “You’re already used to living a life of lower means, and you’re an expert when it comes to delaying gratification,” says Dr. Mollard. “Do it a little longer.” Live frugally and spend only on things that bring you joy. “A lot of physicians are trying to be really rich in all areas of their life instead of the ones that actually matter to them,” Dr. Soelberg says. Identify what’s important to you and only splurge on that.
Blind Spot #8
Never asking for help. The right financial planner can provide expert help. Emphasis on right. “Doctors can be very trusting of other professionals, even when they should not be,” says Dr. Dahle. He notes that in financial services, many people masquerade as knowledgeable advisors who are really just salespeople. While legitimate financial advisors strive to make their clients money, they are also ultimately out to line their pockets and love to work with physician salaries. Thus, doctors can end up working with financial planners that don’t specifically understand their situations or end up taking too much from their clients.
The Fix
Find a planner who specializes in, or at least understands, physicians. Ask them how they make money, says Dr. Chiang. If someone hesitates to tell you about their fee structure or if it sounds like a lot, shop around and ask colleagues for recommendations.
“Ultimately, the path to wealth is to create and grow the margin between what you make and what you spend,” says Dr. Frey. Throw some investing into the mix and physicians can set themselves up on a path for a stress-free financial life.
A version of this article appeared on Medscape.com.
The average physician makes $352,000, and some earn well into the $500,000s. So, doctors don’t have to worry about money, right?
You know the answer to that.
One thing all physicians have in common about money, says James M. Dahle, MD, FACEP, founder of The White Coat Investor, is that they don’t receive any training in business, personal finance, or investing throughout their schooling or careers unless they seek it out. This leaves many unprepared to make the best investing and money-saving decisions, while others get too frustrated about their lack of knowledge to even dip their toe into the investing pool.
Exhibit A: Four out of 10 physicians have a net worth below $1 million, according to the Medscape Physician Wealth & Debt Report 2023. Elizabeth Chiang, MD, PhD, an oculoplastic surgeon and a physician money coach at Grow Your Wealthy Mindset, notes that many of those doctors are over age 65, “which means they essentially can’t retire.”
And that’s just one pain point.
Physicians have money concerns specific to their profession and background. Luckily, some fellow doctors also serve as financial and wealth advisors just for other doctors.
Blind Spot #1
The early lean years skew doctors’ money outlook. “We have an extended training period, which commonly consists of taking on a large amount of debt, followed by 3 to 8 years of being paid a modest salary, and then finally a large boost in income,” explains Dr. Chiang. This can lay a shaky foundation for the earning years to come, and as a result, a lot of doctors just don’t think about money in healthy ways. Once their incomes increase, physicians may be surprised, for example, that making a multiple six-figure salary means paying six figures in taxes.
The Fix
Treat financial health like physical health. That means money cannot be a taboo subject. “The misguided mindset is that we didn’t become physicians to make money, we did it to help people,” explains Jordan Frey, MD, creator of the blog, The Prudent Plastic Surgeon.
Dr. Frey acknowledges that the desire to help is certainly true. But the result is a false idea that “to think about our personal finances makes us a worse doctor.”
Blind Spot #2
Because doctors know a lot about one thing (medicine), they might assume they know a lot about everything (such as investing). “Totally different fields with a different language and different way to think about it,” Dahle explains. This overconfidence could lead to some negligent or risky financial decisions.
The Fix
Educate yourself. There are several books on personal finance and investing written by physicians for physicians. Dr. Chiang recommends The Physician Philosopher’s Guide to Personal Finance, by James Turner, MD; Financial Freedom Rx, by Chirag Shah, MD, and Jayanth Sridhar, MD; and The Physician’s Guide to Finance, by Nicholas Christian and Amanda Christian, MD. There are also podcasts, blogs, and courses to help educate doctors on finance, such as the Fire Your Financial Advisor course by The White Coat Investor.
Blind Spot #3
Undersaving. Retirement saving is one thing, but 24% of doctors say they don’t even put money away in a taxable savings account, according to the Wealth & Debt Report.
Cobin Soelberg, MD, JD, a board-certified anesthesiologist and founder and principal advisor with Greeley Wealth Management, is the treasurer of his anesthesiology group. “I get to see every month how much people are saving, and even on an anesthesiologist salary, where everyone’s making about $400,000 a year, a lot of people are not saving anything, which is crazy.”
Undersaving can be both a time issue and a mindset one.
Time: Doctors often start investing in their retirement accounts later than the average professional, says Dr. Chiang. “A lot of physicians will max out their 401k or 403b,” she explains. “But if you’re putting in $20,000 a year and only starting when you’re in your early 30s, that’s not enough to get you to retirement.”
Mindset: Doctors also see people of all ages who are sick, dying, and injured. “They all know someone who worked hard and saved and then dropped dead at 55,” explains Dr. Dahle. This, he says, can lead to a bit of a “you only live once” attitude that prioritizes spending over saving.
The Fix
Shoot for 20%. If you can’t save 20% of your gross now, strive to get to that point. Think of it as telling a patient they have to change their behavior or trouble will come - not if, but when. “Develop a written investing plan and then stick with it through thick and thin,” says Dr. Dahle. “Once you have a reasonable plan, all you have to do is fund it adequately by saving 20% of your gross income, and a doctor will easily retire as a multimillionaire.”
Blind Spot #4
Bad investment strategies. Thirty-six percent of doctors experience their largest financial losses from lousy investments, according to the Wealth & Debt Report. Meanwhile, 17% of PCPs and 12% of specialists say they haven’t made any investments at all. That’s a terrible mix of doing the wrong thing and doing a worse thing.
The Fix
Don’t overthink investing, but don’t underthink it either. “As high-income earners, doctors just don’t need to take this high level of risk to reach their financial goals,” Dr. Frey says. A good investment plan doesn’t require you to time the stock market or predict individual stock winners. Consider what Vanguard founder Jack Bogle once said about investing: “Be bored by the process but elated by the outcome.”
Dr. Frey suggests going super-simple: index funds. Ignore investing strategies with actively managed mutual funds or individual stocks, as well as risky alternative investments such as cryptocurrency and angel investments. Everyone assumes doctors have money to burn, and they will push sketchy investment ideas at them. Avoid.
Blind Spot #5
Not taking debt seriously enough. The average medical student debt is $250,000 and can exceed $500,000, says Dr. Soelberg. Many doctors spend the first 10 to 20 years of their careers paying this off. Today’s graduates are paying more than 7% on their loans.
And it’s not just student debt: 39% of physicians carry five or more credit cards, and 34% have mortgages larger than $300,000 (with half of those are more than than $500K), per the Wealth & Debt Report.
The Fix
Treat debt like cancer. It’s a lethal enemy you can’t get rid of right away, but a steady, aggressive, long-term attack will have the best results. Dr. Soelberg suggests allocating the most you can afford per month, whether that’s $1000 or $5000, toward debt. Raise the amount as your income grows. Do the same with your 401k or retirement plan. Whatever is left, you can spend. Five to 10 years later, you will realize, “Wow. I’m debt free.”
Blind Spot #6
Not putting in the work to improve your situation. Seventy-one percent of doctors admit they haven’t done anything to reduce major expenses, according to the Wealth & Debt Report. Are you leaving major money on the table?
The Fix
Audit yourself in major areas like housing and taxes. While the average professional may need to put 10% to 20% down on a home, physicians can qualify for physician mortgage loans and can often put down 3% or less, says Dr. Chiang. If you can afford the higher mortgage payment, excess savings earmarked for a larger down payment can be put toward debt or invested.
Another trick, if you’re able, is to seek an area that is less in demand at a higher salary. “Physicians in places like New York City or San Francisco tend to make less than physicians in the Midwest or the South,” Dr. Chiang explains. A colleague of hers moved to rural Pennsylvania, where he made a high salary and had a low cost of living for 3½ years, paid off his student debt, and then relocated to an area where he wanted to live long term.
As for taxes, become familiar with tax law. Research things like, “What is considered a business expense for doctors?” says Brett Mollard, MD, a diagnostic radiologist who provides financial advice to younger physicians. “What will your estimated total tax burden be at the end of the year? Will you need to make extra payments to prevent owing a large sum of money from underpaying or to avoid tax penalties?”
Blind Spot #7
Living like a rock star on a doctor’s income. Getting caught up in trying to live the same lifestyle as your colleagues is a classic bear trap. “Sitting in the doctor’s lounge, it’s so crazy,” Dr. Soelberg says. He describes conversations like, “‘Where did you go on your trip?’ ‘What new toys are you buying?’” There’s pressure to live up to an image of what a doctor’s life is supposed to look like before you’ve sorted the basic things like paying off debt.
The Fix
Live like a resident even if you haven’t been one for years, at least until you’re in a better financial position. “You’re already used to living a life of lower means, and you’re an expert when it comes to delaying gratification,” says Dr. Mollard. “Do it a little longer.” Live frugally and spend only on things that bring you joy. “A lot of physicians are trying to be really rich in all areas of their life instead of the ones that actually matter to them,” Dr. Soelberg says. Identify what’s important to you and only splurge on that.
Blind Spot #8
Never asking for help. The right financial planner can provide expert help. Emphasis on right. “Doctors can be very trusting of other professionals, even when they should not be,” says Dr. Dahle. He notes that in financial services, many people masquerade as knowledgeable advisors who are really just salespeople. While legitimate financial advisors strive to make their clients money, they are also ultimately out to line their pockets and love to work with physician salaries. Thus, doctors can end up working with financial planners that don’t specifically understand their situations or end up taking too much from their clients.
The Fix
Find a planner who specializes in, or at least understands, physicians. Ask them how they make money, says Dr. Chiang. If someone hesitates to tell you about their fee structure or if it sounds like a lot, shop around and ask colleagues for recommendations.
“Ultimately, the path to wealth is to create and grow the margin between what you make and what you spend,” says Dr. Frey. Throw some investing into the mix and physicians can set themselves up on a path for a stress-free financial life.
A version of this article appeared on Medscape.com.
The 5 things dentists wished physicians weren’t missing
From overlooked gum disease to suspicious lesions, oral health can provide a critical window into broader medical concerns.
A recent statement by the U.S. Preventive Services Task Force found that dental screenings by primary care doctors may not work well enough to catch patients most at risk of oral health issues.
But dentists say a quick look during regular office visits could help catch health problems.
“Health care providers other than dentists don’t look in the mouth a lot, and if they do, they’re looking past the teeth and mouth into the throat,” said Romesh Nalliah, DDS, MHCM, an associate dean for patient services at the University of Michigan School of Dentistry in Ann Arbor.
“It can be a big ask of primary care physicians, because we already ask a lot of them. But some of these things are very simple – just a quick scan of the mouth – and could be done by other medical office staff.”
Here are five key conditions with oral signs that dentists wish primary care doctors would catch during checkups, which could unlock early detection and treatment:
Diabetes: Within the realm of oral health, type 2 diabetes can leave distinct imprints that dental professionals are trained to watch for. For example, gum disease – marked by inflamed, bleeding gums – can be a sign of the illness. People with diabetes may have a dry mouth, stemming from reduced production of saliva, leading to discomfort, a hard time swallowing, and a higher risk of dental infections. An estimated 34% to 51% of people with diabetes have dry mouth.
Another sign that can show up in the mouth is a fungal infection, such as oral thrush, which can mean the immune system isn’t working well and is often linked to uncontrolled diabetes.
“We know gum disease appears more frequently and more severely in patients with diabetes, and that treating the gum disease can help improve diabetes-related outcomes,” said Marie Jackson, DMD, FAGD, a dentist in Montclair, NJ. “Good oral health habits are just generally beneficial from an overall health perspective.”
Inflammatory bowel disease (IBD): Illnesses like Crohn’s disease and ulcerative colitis have long been recognized for their effect on the gut. However, a lesser-known aspect of these disorders is their potential to show up in the mouth, presenting a unique set of challenges for both patients and health care providers. Some people with IBD have aphthous stomatitis – more commonly known as canker sores. These oral symptoms not only add to discomfort for those with IBD, but also can show that a disease is present.
“Crohn’s disease in particular can cause mouth ulcers that look like sores,” Dr. Jackson said. “Anytime someone comes in for a checkup, we look for red patches, which can be an indicator.”
These ulcers often are shallow and round, and typically are on the soft tissues lining the mouth, such as the inner cheeks, lips, and tongue. IBD and oral ulcers come with inflammation. The body’s immune response can result in an overproduction of pro-inflammatory cytokines, triggering a cascade of events that help cause these painful ulcers.
Heart disease: The mouth may be an unexpected place to find signs of diseases of the heart and blood vessels. Heart issues often come with oral symptoms, notably a higher chance of gum disease. The connection lies in the inflammatory nature of both conditions; chronic heart disease may add to an inflammatory response that, in turn, worsens gum inflammation and leads to more severe issues with the teeth and gums. Symptoms such as bleeding gums, persistent bad breath, and gum swelling can serve as early warning signs.
Also, people with gum disease are at a higher risk of issues with their heart and blood vessels. Bacteria in the mouth can enter other areas of the body, including the heart.
“Gum disease provides an open portal to get into the bloodstream,” Dr. Jackson said.
Osteoporosis: Osteoporosis often goes unnoticed until the condition leads to injury. But research shows it can affect the teeth in noticeable ways, including tooth loss and gum disease.
For patients with implants, dentures, and bridges, weak bones may lead to looser-fitting replacements.
Unfortunately, certain medications for osteoporosis, bisphosphonate drugs, also can cause dental issues – something all doctors should be aware of when prescribing any medications, Dr. Nalliah said.
“When a medical office puts someone on a new medication, they should send them to a dentist,” Dr. Nalliah said. “Many of them can cause dry mouth, which can cause decay.”
Oral cancer: Symptoms of oral cancer that may be visible during a doctor visit include a sore on the lip or in the mouth, white or reddish patches on the inside of the mouth, loose teeth, or a lump inside the mouth.
“Anytime I have a patient with a white patch they have not had before, if they have not bitten their tongue, we have them come in again in 2 or 3 weeks, and if it’s still there, we have it biopsied,” Dr. Jackson said. “Oral cancer definitely is on the rise with HPV,” she said.
Oropharynx cancers linked to HPV infection increased yearly by 1.3% in women and by 2.8% in men from 2015 to 2019.
According to the CDC, compared with other cancers, oral and pharyngeal cancer has one of the poorest 5-year survival rates: only 52% of people diagnosed with oral cancer survive 5 years. Only 35% of oral cancer is detected at the earliest stage.
“Most patients are diagnosed at an advanced stage of the disease,” Dr. Nalliah said. “Many of those vulnerable people don’t have dental insurance.”
Effects of Oral Hygiene on Overall Health
While some health issues may show up in the mouth, the problems go both ways: Poor oral hygiene can lead to negative health outcomes. Some studies show there may even be a connection between poor oral health and worse brain health.
“What I wish physicians would talk to our patients about is the importance of regular dental visits,” said Ruchi Sahota, DDS, a general family dentist in Fremont, CA, and a consumer adviser for the American Dental Association. “Teeth don’t necessarily hurt until something big is going on. Going to the dentist regularly, brushing at least twice a day, flossing at least once a day, all of these things can contribute to greater overall health.”
A version of this article appeared on WebMD.com.
From overlooked gum disease to suspicious lesions, oral health can provide a critical window into broader medical concerns.
A recent statement by the U.S. Preventive Services Task Force found that dental screenings by primary care doctors may not work well enough to catch patients most at risk of oral health issues.
But dentists say a quick look during regular office visits could help catch health problems.
“Health care providers other than dentists don’t look in the mouth a lot, and if they do, they’re looking past the teeth and mouth into the throat,” said Romesh Nalliah, DDS, MHCM, an associate dean for patient services at the University of Michigan School of Dentistry in Ann Arbor.
“It can be a big ask of primary care physicians, because we already ask a lot of them. But some of these things are very simple – just a quick scan of the mouth – and could be done by other medical office staff.”
Here are five key conditions with oral signs that dentists wish primary care doctors would catch during checkups, which could unlock early detection and treatment:
Diabetes: Within the realm of oral health, type 2 diabetes can leave distinct imprints that dental professionals are trained to watch for. For example, gum disease – marked by inflamed, bleeding gums – can be a sign of the illness. People with diabetes may have a dry mouth, stemming from reduced production of saliva, leading to discomfort, a hard time swallowing, and a higher risk of dental infections. An estimated 34% to 51% of people with diabetes have dry mouth.
Another sign that can show up in the mouth is a fungal infection, such as oral thrush, which can mean the immune system isn’t working well and is often linked to uncontrolled diabetes.
“We know gum disease appears more frequently and more severely in patients with diabetes, and that treating the gum disease can help improve diabetes-related outcomes,” said Marie Jackson, DMD, FAGD, a dentist in Montclair, NJ. “Good oral health habits are just generally beneficial from an overall health perspective.”
Inflammatory bowel disease (IBD): Illnesses like Crohn’s disease and ulcerative colitis have long been recognized for their effect on the gut. However, a lesser-known aspect of these disorders is their potential to show up in the mouth, presenting a unique set of challenges for both patients and health care providers. Some people with IBD have aphthous stomatitis – more commonly known as canker sores. These oral symptoms not only add to discomfort for those with IBD, but also can show that a disease is present.
“Crohn’s disease in particular can cause mouth ulcers that look like sores,” Dr. Jackson said. “Anytime someone comes in for a checkup, we look for red patches, which can be an indicator.”
These ulcers often are shallow and round, and typically are on the soft tissues lining the mouth, such as the inner cheeks, lips, and tongue. IBD and oral ulcers come with inflammation. The body’s immune response can result in an overproduction of pro-inflammatory cytokines, triggering a cascade of events that help cause these painful ulcers.
Heart disease: The mouth may be an unexpected place to find signs of diseases of the heart and blood vessels. Heart issues often come with oral symptoms, notably a higher chance of gum disease. The connection lies in the inflammatory nature of both conditions; chronic heart disease may add to an inflammatory response that, in turn, worsens gum inflammation and leads to more severe issues with the teeth and gums. Symptoms such as bleeding gums, persistent bad breath, and gum swelling can serve as early warning signs.
Also, people with gum disease are at a higher risk of issues with their heart and blood vessels. Bacteria in the mouth can enter other areas of the body, including the heart.
“Gum disease provides an open portal to get into the bloodstream,” Dr. Jackson said.
Osteoporosis: Osteoporosis often goes unnoticed until the condition leads to injury. But research shows it can affect the teeth in noticeable ways, including tooth loss and gum disease.
For patients with implants, dentures, and bridges, weak bones may lead to looser-fitting replacements.
Unfortunately, certain medications for osteoporosis, bisphosphonate drugs, also can cause dental issues – something all doctors should be aware of when prescribing any medications, Dr. Nalliah said.
“When a medical office puts someone on a new medication, they should send them to a dentist,” Dr. Nalliah said. “Many of them can cause dry mouth, which can cause decay.”
Oral cancer: Symptoms of oral cancer that may be visible during a doctor visit include a sore on the lip or in the mouth, white or reddish patches on the inside of the mouth, loose teeth, or a lump inside the mouth.
“Anytime I have a patient with a white patch they have not had before, if they have not bitten their tongue, we have them come in again in 2 or 3 weeks, and if it’s still there, we have it biopsied,” Dr. Jackson said. “Oral cancer definitely is on the rise with HPV,” she said.
Oropharynx cancers linked to HPV infection increased yearly by 1.3% in women and by 2.8% in men from 2015 to 2019.
According to the CDC, compared with other cancers, oral and pharyngeal cancer has one of the poorest 5-year survival rates: only 52% of people diagnosed with oral cancer survive 5 years. Only 35% of oral cancer is detected at the earliest stage.
“Most patients are diagnosed at an advanced stage of the disease,” Dr. Nalliah said. “Many of those vulnerable people don’t have dental insurance.”
Effects of Oral Hygiene on Overall Health
While some health issues may show up in the mouth, the problems go both ways: Poor oral hygiene can lead to negative health outcomes. Some studies show there may even be a connection between poor oral health and worse brain health.
“What I wish physicians would talk to our patients about is the importance of regular dental visits,” said Ruchi Sahota, DDS, a general family dentist in Fremont, CA, and a consumer adviser for the American Dental Association. “Teeth don’t necessarily hurt until something big is going on. Going to the dentist regularly, brushing at least twice a day, flossing at least once a day, all of these things can contribute to greater overall health.”
A version of this article appeared on WebMD.com.
From overlooked gum disease to suspicious lesions, oral health can provide a critical window into broader medical concerns.
A recent statement by the U.S. Preventive Services Task Force found that dental screenings by primary care doctors may not work well enough to catch patients most at risk of oral health issues.
But dentists say a quick look during regular office visits could help catch health problems.
“Health care providers other than dentists don’t look in the mouth a lot, and if they do, they’re looking past the teeth and mouth into the throat,” said Romesh Nalliah, DDS, MHCM, an associate dean for patient services at the University of Michigan School of Dentistry in Ann Arbor.
“It can be a big ask of primary care physicians, because we already ask a lot of them. But some of these things are very simple – just a quick scan of the mouth – and could be done by other medical office staff.”
Here are five key conditions with oral signs that dentists wish primary care doctors would catch during checkups, which could unlock early detection and treatment:
Diabetes: Within the realm of oral health, type 2 diabetes can leave distinct imprints that dental professionals are trained to watch for. For example, gum disease – marked by inflamed, bleeding gums – can be a sign of the illness. People with diabetes may have a dry mouth, stemming from reduced production of saliva, leading to discomfort, a hard time swallowing, and a higher risk of dental infections. An estimated 34% to 51% of people with diabetes have dry mouth.
Another sign that can show up in the mouth is a fungal infection, such as oral thrush, which can mean the immune system isn’t working well and is often linked to uncontrolled diabetes.
“We know gum disease appears more frequently and more severely in patients with diabetes, and that treating the gum disease can help improve diabetes-related outcomes,” said Marie Jackson, DMD, FAGD, a dentist in Montclair, NJ. “Good oral health habits are just generally beneficial from an overall health perspective.”
Inflammatory bowel disease (IBD): Illnesses like Crohn’s disease and ulcerative colitis have long been recognized for their effect on the gut. However, a lesser-known aspect of these disorders is their potential to show up in the mouth, presenting a unique set of challenges for both patients and health care providers. Some people with IBD have aphthous stomatitis – more commonly known as canker sores. These oral symptoms not only add to discomfort for those with IBD, but also can show that a disease is present.
“Crohn’s disease in particular can cause mouth ulcers that look like sores,” Dr. Jackson said. “Anytime someone comes in for a checkup, we look for red patches, which can be an indicator.”
These ulcers often are shallow and round, and typically are on the soft tissues lining the mouth, such as the inner cheeks, lips, and tongue. IBD and oral ulcers come with inflammation. The body’s immune response can result in an overproduction of pro-inflammatory cytokines, triggering a cascade of events that help cause these painful ulcers.
Heart disease: The mouth may be an unexpected place to find signs of diseases of the heart and blood vessels. Heart issues often come with oral symptoms, notably a higher chance of gum disease. The connection lies in the inflammatory nature of both conditions; chronic heart disease may add to an inflammatory response that, in turn, worsens gum inflammation and leads to more severe issues with the teeth and gums. Symptoms such as bleeding gums, persistent bad breath, and gum swelling can serve as early warning signs.
Also, people with gum disease are at a higher risk of issues with their heart and blood vessels. Bacteria in the mouth can enter other areas of the body, including the heart.
“Gum disease provides an open portal to get into the bloodstream,” Dr. Jackson said.
Osteoporosis: Osteoporosis often goes unnoticed until the condition leads to injury. But research shows it can affect the teeth in noticeable ways, including tooth loss and gum disease.
For patients with implants, dentures, and bridges, weak bones may lead to looser-fitting replacements.
Unfortunately, certain medications for osteoporosis, bisphosphonate drugs, also can cause dental issues – something all doctors should be aware of when prescribing any medications, Dr. Nalliah said.
“When a medical office puts someone on a new medication, they should send them to a dentist,” Dr. Nalliah said. “Many of them can cause dry mouth, which can cause decay.”
Oral cancer: Symptoms of oral cancer that may be visible during a doctor visit include a sore on the lip or in the mouth, white or reddish patches on the inside of the mouth, loose teeth, or a lump inside the mouth.
“Anytime I have a patient with a white patch they have not had before, if they have not bitten their tongue, we have them come in again in 2 or 3 weeks, and if it’s still there, we have it biopsied,” Dr. Jackson said. “Oral cancer definitely is on the rise with HPV,” she said.
Oropharynx cancers linked to HPV infection increased yearly by 1.3% in women and by 2.8% in men from 2015 to 2019.
According to the CDC, compared with other cancers, oral and pharyngeal cancer has one of the poorest 5-year survival rates: only 52% of people diagnosed with oral cancer survive 5 years. Only 35% of oral cancer is detected at the earliest stage.
“Most patients are diagnosed at an advanced stage of the disease,” Dr. Nalliah said. “Many of those vulnerable people don’t have dental insurance.”
Effects of Oral Hygiene on Overall Health
While some health issues may show up in the mouth, the problems go both ways: Poor oral hygiene can lead to negative health outcomes. Some studies show there may even be a connection between poor oral health and worse brain health.
“What I wish physicians would talk to our patients about is the importance of regular dental visits,” said Ruchi Sahota, DDS, a general family dentist in Fremont, CA, and a consumer adviser for the American Dental Association. “Teeth don’t necessarily hurt until something big is going on. Going to the dentist regularly, brushing at least twice a day, flossing at least once a day, all of these things can contribute to greater overall health.”
A version of this article appeared on WebMD.com.
Underdiagnosed: Iron deficiency anemia during pregnancy
Jerome J. Federspiel, MD, often cares for patients who are about to deliver a baby but who have untreated iron deficiency anemia (IDA). Often, these patients require a blood transfusion after giving birth.
“I am sad to hear commonly from patients we treat that they have had iron-deficient anemia symptoms for many years. Correcting these conditions makes birth safer and, oftentimes, makes people feel much better – sometimes better than they have in years,” Dr. Federspiel, maternal-fetal medicine physician and assistant professor of obstetrics and gynecology and population health sciences at Duke University, Durham, N.C., said.
Even patients he is able to diagnose earlier “will have difficulties catching up during pregnancy.”
The condition is the most common type of anemia among people who are pregnant. IDA increases a patient’s risk of delivering preterm and developing postpartum depression and puts their infants at a risk for perinatal mortality. Without proper treatment of IDA throughout pregnancy, the condition can also lead to low birth weights in infants or failing to meet weight goals later on.
But of all women with a new diagnosis of IDA from 2021 to 2022, 10% were pregnant, according to an analysis by Komodo Health, a health care analytics company.
While estimates of the prevalence of IDA vary, research from 2021 found 6.5% of nearly 1,500 patients who were pregnant during the first trimester had the condition, a figure the researchers said might underrepresent the problem.
“In severe cases [fetal outcomes can include] abnormal fetal oxygenation, nonreassuring fetal heart rate patterns, reduced amniotic fluid volume, fetal cerebral vasodilation, and fetal death,” Alianne S. Tilley, NP, family nurse practitioner at Women’s Care of Lake Cumberland, Somerset, Ky., said.
Research has shown that adequate levels of iron are an integral component in the development of the fetal brain. Some studies have reported that IDA during pregnancy increases an infant’s risk for poor neurodevelopmental outcomes.
Lack of screening protocol
Discrepancies in guidance for testing patients who are pregnant for IDA may add to late diagnosis and low treatment, according to Katelin Zahn, MD, assistant professor of general obstetrics, gynecology, and midwifery at University of North Carolina at Chapel Hill.
“There’s no consistency, which leads to a lot of variation in individual practice, which creates variation in outcomes, too,” Dr. Zahn said. “You can only do so much as one independent physician, and you need to be able to create change in a system that functions and provides standard of care even when you aren’t there.”
The American College of Obstetricians and Gynecologists recommends screening all patients who are pregnant with a complete blood count in the first trimester and again between 24 and 27 weeks of gestation.
Patients who meet criteria for IDA based on hematocrit levels less than 33% in the first and third trimesters, and less than 32% in the second trimester, should be evaluated to determine the cause. Those with IDA should be treated with supplemental iron, in addition to prenatal vitamins, ACOG says.
But the U.S. Preventive Services Task Force in 2015 found insufficient evidence to recommend for or against screening patients without symptoms or signs of the condition. The organization is in the process of updating the recommendation.
Prevention as best practice
The most effective way to address IDA in patients who are pregnant is prevention, according to Dr. Federspiel.
“Having a systematic approach to screening and treatment is really important, and this starts before pregnancy,” Dr. Federspiel said. “On average, a typical pregnancy requires an additional 1 g of iron.”
Dr. Federspiel recommends clinicians discuss the causes and the effects of IDA with patients who are planning to or could become pregnant. Clinicians might recommend iron- and folate-rich foods and vitamins B12 and C and ask patients if they face any barriers to access.
“Prenatal vitamins with iron are the gold standard in preventing IDA in the pregnant population,” Ms. Tilley said. “Education on the significant risk factors associated with IDA in early pregnancy is key.”
A version of this article first appeared on Medscape.com.
Jerome J. Federspiel, MD, often cares for patients who are about to deliver a baby but who have untreated iron deficiency anemia (IDA). Often, these patients require a blood transfusion after giving birth.
“I am sad to hear commonly from patients we treat that they have had iron-deficient anemia symptoms for many years. Correcting these conditions makes birth safer and, oftentimes, makes people feel much better – sometimes better than they have in years,” Dr. Federspiel, maternal-fetal medicine physician and assistant professor of obstetrics and gynecology and population health sciences at Duke University, Durham, N.C., said.
Even patients he is able to diagnose earlier “will have difficulties catching up during pregnancy.”
The condition is the most common type of anemia among people who are pregnant. IDA increases a patient’s risk of delivering preterm and developing postpartum depression and puts their infants at a risk for perinatal mortality. Without proper treatment of IDA throughout pregnancy, the condition can also lead to low birth weights in infants or failing to meet weight goals later on.
But of all women with a new diagnosis of IDA from 2021 to 2022, 10% were pregnant, according to an analysis by Komodo Health, a health care analytics company.
While estimates of the prevalence of IDA vary, research from 2021 found 6.5% of nearly 1,500 patients who were pregnant during the first trimester had the condition, a figure the researchers said might underrepresent the problem.
“In severe cases [fetal outcomes can include] abnormal fetal oxygenation, nonreassuring fetal heart rate patterns, reduced amniotic fluid volume, fetal cerebral vasodilation, and fetal death,” Alianne S. Tilley, NP, family nurse practitioner at Women’s Care of Lake Cumberland, Somerset, Ky., said.
Research has shown that adequate levels of iron are an integral component in the development of the fetal brain. Some studies have reported that IDA during pregnancy increases an infant’s risk for poor neurodevelopmental outcomes.
Lack of screening protocol
Discrepancies in guidance for testing patients who are pregnant for IDA may add to late diagnosis and low treatment, according to Katelin Zahn, MD, assistant professor of general obstetrics, gynecology, and midwifery at University of North Carolina at Chapel Hill.
“There’s no consistency, which leads to a lot of variation in individual practice, which creates variation in outcomes, too,” Dr. Zahn said. “You can only do so much as one independent physician, and you need to be able to create change in a system that functions and provides standard of care even when you aren’t there.”
The American College of Obstetricians and Gynecologists recommends screening all patients who are pregnant with a complete blood count in the first trimester and again between 24 and 27 weeks of gestation.
Patients who meet criteria for IDA based on hematocrit levels less than 33% in the first and third trimesters, and less than 32% in the second trimester, should be evaluated to determine the cause. Those with IDA should be treated with supplemental iron, in addition to prenatal vitamins, ACOG says.
But the U.S. Preventive Services Task Force in 2015 found insufficient evidence to recommend for or against screening patients without symptoms or signs of the condition. The organization is in the process of updating the recommendation.
Prevention as best practice
The most effective way to address IDA in patients who are pregnant is prevention, according to Dr. Federspiel.
“Having a systematic approach to screening and treatment is really important, and this starts before pregnancy,” Dr. Federspiel said. “On average, a typical pregnancy requires an additional 1 g of iron.”
Dr. Federspiel recommends clinicians discuss the causes and the effects of IDA with patients who are planning to or could become pregnant. Clinicians might recommend iron- and folate-rich foods and vitamins B12 and C and ask patients if they face any barriers to access.
“Prenatal vitamins with iron are the gold standard in preventing IDA in the pregnant population,” Ms. Tilley said. “Education on the significant risk factors associated with IDA in early pregnancy is key.”
A version of this article first appeared on Medscape.com.
Jerome J. Federspiel, MD, often cares for patients who are about to deliver a baby but who have untreated iron deficiency anemia (IDA). Often, these patients require a blood transfusion after giving birth.
“I am sad to hear commonly from patients we treat that they have had iron-deficient anemia symptoms for many years. Correcting these conditions makes birth safer and, oftentimes, makes people feel much better – sometimes better than they have in years,” Dr. Federspiel, maternal-fetal medicine physician and assistant professor of obstetrics and gynecology and population health sciences at Duke University, Durham, N.C., said.
Even patients he is able to diagnose earlier “will have difficulties catching up during pregnancy.”
The condition is the most common type of anemia among people who are pregnant. IDA increases a patient’s risk of delivering preterm and developing postpartum depression and puts their infants at a risk for perinatal mortality. Without proper treatment of IDA throughout pregnancy, the condition can also lead to low birth weights in infants or failing to meet weight goals later on.
But of all women with a new diagnosis of IDA from 2021 to 2022, 10% were pregnant, according to an analysis by Komodo Health, a health care analytics company.
While estimates of the prevalence of IDA vary, research from 2021 found 6.5% of nearly 1,500 patients who were pregnant during the first trimester had the condition, a figure the researchers said might underrepresent the problem.
“In severe cases [fetal outcomes can include] abnormal fetal oxygenation, nonreassuring fetal heart rate patterns, reduced amniotic fluid volume, fetal cerebral vasodilation, and fetal death,” Alianne S. Tilley, NP, family nurse practitioner at Women’s Care of Lake Cumberland, Somerset, Ky., said.
Research has shown that adequate levels of iron are an integral component in the development of the fetal brain. Some studies have reported that IDA during pregnancy increases an infant’s risk for poor neurodevelopmental outcomes.
Lack of screening protocol
Discrepancies in guidance for testing patients who are pregnant for IDA may add to late diagnosis and low treatment, according to Katelin Zahn, MD, assistant professor of general obstetrics, gynecology, and midwifery at University of North Carolina at Chapel Hill.
“There’s no consistency, which leads to a lot of variation in individual practice, which creates variation in outcomes, too,” Dr. Zahn said. “You can only do so much as one independent physician, and you need to be able to create change in a system that functions and provides standard of care even when you aren’t there.”
The American College of Obstetricians and Gynecologists recommends screening all patients who are pregnant with a complete blood count in the first trimester and again between 24 and 27 weeks of gestation.
Patients who meet criteria for IDA based on hematocrit levels less than 33% in the first and third trimesters, and less than 32% in the second trimester, should be evaluated to determine the cause. Those with IDA should be treated with supplemental iron, in addition to prenatal vitamins, ACOG says.
But the U.S. Preventive Services Task Force in 2015 found insufficient evidence to recommend for or against screening patients without symptoms or signs of the condition. The organization is in the process of updating the recommendation.
Prevention as best practice
The most effective way to address IDA in patients who are pregnant is prevention, according to Dr. Federspiel.
“Having a systematic approach to screening and treatment is really important, and this starts before pregnancy,” Dr. Federspiel said. “On average, a typical pregnancy requires an additional 1 g of iron.”
Dr. Federspiel recommends clinicians discuss the causes and the effects of IDA with patients who are planning to or could become pregnant. Clinicians might recommend iron- and folate-rich foods and vitamins B12 and C and ask patients if they face any barriers to access.
“Prenatal vitamins with iron are the gold standard in preventing IDA in the pregnant population,” Ms. Tilley said. “Education on the significant risk factors associated with IDA in early pregnancy is key.”
A version of this article first appeared on Medscape.com.
Rx for resilience: Five prescriptions for physician burnout
Physician burnout persists even as the height of the COVID-19 crisis fades farther into the rear-view mirror. The causes for the sadness, stress, and frustration among doctors vary, but the effects are universal and often debilitating: exhaustion, emotional detachment, lethargy, feeling useless, and lacking purpose.
When surveyed, physicians pointed to many systemic solutions for burnout in Medscape’s Physician Burnout & Depression Report 2023, such as a need for greater compensation, more manageable workloads and schedules, and more support staff. But for many doctors, these fixes may be years if not decades away. Equally important are strategies for relieving burnout symptoms now, especially as we head into a busy holiday season.
Because not every stress-relief practice works for everyone, it’s crucial to try various methods until you find something that makes a difference for you, said Christine Gibson, MD, a family physician and trauma therapist in Calgary, Alta., and author of The Modern Trauma Toolkit.
“Every person should have a toolkit of the things that bring them out of the psychological and physical distress that dysregulates their nervous system,” said Dr. Gibson.
Once you learn the personal ways to alleviate your specific brand of burnout, you can start working on systemic changes that might help the culture of medicine overall.
Symptoms speak louder than words
It seems obvious, but if you aren’t aware that what you’re feeling is burnout, you probably aren’t going to find effective steps to relieve it. Jessi Gold, MD, assistant professor and director of wellness, engagement, and outreach in the department of psychiatry, Washington University in St. Louis, is a psychiatrist who treats health care professionals, including frontline workers during the height of the pandemic. But even as a burnout expert, she admits that she misses the signs in herself.
“I was fighting constant fatigue, falling asleep the minute I got home from work every day, but I thought a B12 shot would solve all my problems. I didn’t realize I was having symptoms of burnout until my own therapist told me,” said Dr. Gold. “As doctors, we spend so much time focusing on other people that we don’t necessarily notice very much in ourselves – usually once it starts to impact our job.”
Practices like meditation and mindfulness can help you delve into your feelings and emotions and notice how you’re doing. But you may also need to ask spouses, partners, and friends and family – or better yet, a mental health professional – if they notice that you seem burnt out.
Practice ‘in the moment’ relief
Sometimes, walking away at the moment of stress helps like when stepping away from a heated argument. “Step out of a frustrating staff meeting to go to the bathroom and splash your face,” said Eran Magan, PhD, a psychologist at the University of Pennsylvania, Philadelphia, and founder and CEO of the suicide prevention system EarlyAlert.me. “Tell a patient you need to check something in the next room, so you have time to take a breath.”
Dr. Magan recommended finding techniques that help lower acute stress while it’s actually happening. First, find a way to escape or excuse yourself from the event, and when possible, stop situations that are actively upsetting or triggering in their tracks.
Next, recharge by doing something that helps you feel better, like looking at a cute video of your child or grandchild or closing your eyes and taking a deep breath. You can also try to “catch” good feelings from someone else, said Dr. Magan. Ask someone about a trip, vacation, holiday, or pleasant event. “Ask a colleague about something that makes [them] happy,” he said. “Happiness can be infectious too.”
Burnout is also in the body
“Body psychotherapy” or somatic therapy is a treatment that focuses on how emotions appear within your body. Dr. Gibson said it’s a valuable tool for addressing trauma and a mainstay in many a medical career; it’s useful to help physicians learn to “befriend” their nervous system.
Somatic therapy exercises involve things like body scanning, scanning for physical sensations; conscious breathing, connecting to each inhale and exhale; grounding your weight by releasing tension through your feet, doing a total body stretch; or releasing shoulder and neck tension by consciously relaxing each of these muscle groups.
“We spend our whole day in sympathetic tone; our amygdala’s are firing, telling us that we’re in danger,” said Dr. Gibson. “We actually have to practice getting into and spending time in our parasympathetic nervous system to restore the balance in our autonomic nervous system.”
Somatic therapy includes a wide array of exercises that help reconnect you to your body through calming or activation. The movements release tension, ground you, and restore balance.
Bite-sized tools for well-being
Because of the prevalence of physician burnout, there’s been a groundswell of researchers and organizations who have turned their focus toward improving the well-being in the health care workforce.
One such effort comes from the Duke Center for the Advancement of Well-being Science, which “camouflages” well-being tools as continuing education credits to make them accessible for busy, stressed, and overworked physicians.
“They’re called bite-sized tools for well-being, and they have actual evidence behind them,” said Dr. Gold. For example, she said, one tools is a text program called Three Good Things that encourages physicians to send a text listing three positive things that happened during the day. The exercise lasts 15 days, and texters have access to others’ answers as well. After 3 months, participants’ baseline depression, gratitude, and life satisfaction had all “significantly improved.”
“It feels almost ridiculous that that could work, but it does,” said Dr. Gold. “I’ve had patients push back and say: ‘Well, isn’t that toxic positivity?’ But really what it is is dialectics. It’s not saying there’s only positive; it’s just making you realize there is more than just the negative.”
These and other short interventions focus on concepts such as joy, humor, awe, engagement, and self-kindness to build resilience and help physicians recover from burnout symptoms.
Cognitive restructuring could work
Cognitive restructuring is a therapeutic process of learning new ways of interpreting and responding to people and situations. It helps you change the “filter” through which you interact with your environment. Dr. Gibson said it’s a tool to use with care after other modes of therapy that help you understand your patterns and how they developed because of how you view and understand the world.
“The message of [cognitive-behavioral therapy] or cognitive restructuring is there’s something wrong with the way you’re thinking, and we need to change it or fix it, but in a traumatic system [like health care], you’re thinking has been an adaptive process related to the harm in the environment you’re in,” said Dr. Gibson.
“So, if you [jump straight to cognitive restructuring before other types of therapy], then we just gaslight ourselves into believing that there’s something wrong with us, that we haven’t adapted sufficiently to an environment that’s actually harmful.”
Strive for a few systemic changes
Systemic changes can be small ones within your own sphere. For example, Dr. Magan said, work toward making little tweaks to the flow of your day that will increase calm and reduce frustration.
“Make a ‘bug list,’ little, regular demands that drain your energy, and discuss them with your colleagues and supervisors to see if they can be improved,” he said. Examples include everyday frustrations like having unsolicited visitors popping into your office, scheduling complex patients too late in the day, or having a computer freeze whenever you access patient charts.
Though not always financially feasible, affecting real change and finding relief from all these insidious bugs can improve your mental health and burnout symptoms.
“Physicians tend to work extremely hard in order to keep holding together a system that is often not inherently sustainable, like the fascia of a body under tremendous strain,” said Dr. Magan. “Sometimes the brave thing to do is to refuse to continue being the lynchpin and let things break, so the system will have to start improving itself, rather than demanding more and more of the people in it.”
A version of this article first appeared on Medscape.com.
Physician burnout persists even as the height of the COVID-19 crisis fades farther into the rear-view mirror. The causes for the sadness, stress, and frustration among doctors vary, but the effects are universal and often debilitating: exhaustion, emotional detachment, lethargy, feeling useless, and lacking purpose.
When surveyed, physicians pointed to many systemic solutions for burnout in Medscape’s Physician Burnout & Depression Report 2023, such as a need for greater compensation, more manageable workloads and schedules, and more support staff. But for many doctors, these fixes may be years if not decades away. Equally important are strategies for relieving burnout symptoms now, especially as we head into a busy holiday season.
Because not every stress-relief practice works for everyone, it’s crucial to try various methods until you find something that makes a difference for you, said Christine Gibson, MD, a family physician and trauma therapist in Calgary, Alta., and author of The Modern Trauma Toolkit.
“Every person should have a toolkit of the things that bring them out of the psychological and physical distress that dysregulates their nervous system,” said Dr. Gibson.
Once you learn the personal ways to alleviate your specific brand of burnout, you can start working on systemic changes that might help the culture of medicine overall.
Symptoms speak louder than words
It seems obvious, but if you aren’t aware that what you’re feeling is burnout, you probably aren’t going to find effective steps to relieve it. Jessi Gold, MD, assistant professor and director of wellness, engagement, and outreach in the department of psychiatry, Washington University in St. Louis, is a psychiatrist who treats health care professionals, including frontline workers during the height of the pandemic. But even as a burnout expert, she admits that she misses the signs in herself.
“I was fighting constant fatigue, falling asleep the minute I got home from work every day, but I thought a B12 shot would solve all my problems. I didn’t realize I was having symptoms of burnout until my own therapist told me,” said Dr. Gold. “As doctors, we spend so much time focusing on other people that we don’t necessarily notice very much in ourselves – usually once it starts to impact our job.”
Practices like meditation and mindfulness can help you delve into your feelings and emotions and notice how you’re doing. But you may also need to ask spouses, partners, and friends and family – or better yet, a mental health professional – if they notice that you seem burnt out.
Practice ‘in the moment’ relief
Sometimes, walking away at the moment of stress helps like when stepping away from a heated argument. “Step out of a frustrating staff meeting to go to the bathroom and splash your face,” said Eran Magan, PhD, a psychologist at the University of Pennsylvania, Philadelphia, and founder and CEO of the suicide prevention system EarlyAlert.me. “Tell a patient you need to check something in the next room, so you have time to take a breath.”
Dr. Magan recommended finding techniques that help lower acute stress while it’s actually happening. First, find a way to escape or excuse yourself from the event, and when possible, stop situations that are actively upsetting or triggering in their tracks.
Next, recharge by doing something that helps you feel better, like looking at a cute video of your child or grandchild or closing your eyes and taking a deep breath. You can also try to “catch” good feelings from someone else, said Dr. Magan. Ask someone about a trip, vacation, holiday, or pleasant event. “Ask a colleague about something that makes [them] happy,” he said. “Happiness can be infectious too.”
Burnout is also in the body
“Body psychotherapy” or somatic therapy is a treatment that focuses on how emotions appear within your body. Dr. Gibson said it’s a valuable tool for addressing trauma and a mainstay in many a medical career; it’s useful to help physicians learn to “befriend” their nervous system.
Somatic therapy exercises involve things like body scanning, scanning for physical sensations; conscious breathing, connecting to each inhale and exhale; grounding your weight by releasing tension through your feet, doing a total body stretch; or releasing shoulder and neck tension by consciously relaxing each of these muscle groups.
“We spend our whole day in sympathetic tone; our amygdala’s are firing, telling us that we’re in danger,” said Dr. Gibson. “We actually have to practice getting into and spending time in our parasympathetic nervous system to restore the balance in our autonomic nervous system.”
Somatic therapy includes a wide array of exercises that help reconnect you to your body through calming or activation. The movements release tension, ground you, and restore balance.
Bite-sized tools for well-being
Because of the prevalence of physician burnout, there’s been a groundswell of researchers and organizations who have turned their focus toward improving the well-being in the health care workforce.
One such effort comes from the Duke Center for the Advancement of Well-being Science, which “camouflages” well-being tools as continuing education credits to make them accessible for busy, stressed, and overworked physicians.
“They’re called bite-sized tools for well-being, and they have actual evidence behind them,” said Dr. Gold. For example, she said, one tools is a text program called Three Good Things that encourages physicians to send a text listing three positive things that happened during the day. The exercise lasts 15 days, and texters have access to others’ answers as well. After 3 months, participants’ baseline depression, gratitude, and life satisfaction had all “significantly improved.”
“It feels almost ridiculous that that could work, but it does,” said Dr. Gold. “I’ve had patients push back and say: ‘Well, isn’t that toxic positivity?’ But really what it is is dialectics. It’s not saying there’s only positive; it’s just making you realize there is more than just the negative.”
These and other short interventions focus on concepts such as joy, humor, awe, engagement, and self-kindness to build resilience and help physicians recover from burnout symptoms.
Cognitive restructuring could work
Cognitive restructuring is a therapeutic process of learning new ways of interpreting and responding to people and situations. It helps you change the “filter” through which you interact with your environment. Dr. Gibson said it’s a tool to use with care after other modes of therapy that help you understand your patterns and how they developed because of how you view and understand the world.
“The message of [cognitive-behavioral therapy] or cognitive restructuring is there’s something wrong with the way you’re thinking, and we need to change it or fix it, but in a traumatic system [like health care], you’re thinking has been an adaptive process related to the harm in the environment you’re in,” said Dr. Gibson.
“So, if you [jump straight to cognitive restructuring before other types of therapy], then we just gaslight ourselves into believing that there’s something wrong with us, that we haven’t adapted sufficiently to an environment that’s actually harmful.”
Strive for a few systemic changes
Systemic changes can be small ones within your own sphere. For example, Dr. Magan said, work toward making little tweaks to the flow of your day that will increase calm and reduce frustration.
“Make a ‘bug list,’ little, regular demands that drain your energy, and discuss them with your colleagues and supervisors to see if they can be improved,” he said. Examples include everyday frustrations like having unsolicited visitors popping into your office, scheduling complex patients too late in the day, or having a computer freeze whenever you access patient charts.
Though not always financially feasible, affecting real change and finding relief from all these insidious bugs can improve your mental health and burnout symptoms.
“Physicians tend to work extremely hard in order to keep holding together a system that is often not inherently sustainable, like the fascia of a body under tremendous strain,” said Dr. Magan. “Sometimes the brave thing to do is to refuse to continue being the lynchpin and let things break, so the system will have to start improving itself, rather than demanding more and more of the people in it.”
A version of this article first appeared on Medscape.com.
Physician burnout persists even as the height of the COVID-19 crisis fades farther into the rear-view mirror. The causes for the sadness, stress, and frustration among doctors vary, but the effects are universal and often debilitating: exhaustion, emotional detachment, lethargy, feeling useless, and lacking purpose.
When surveyed, physicians pointed to many systemic solutions for burnout in Medscape’s Physician Burnout & Depression Report 2023, such as a need for greater compensation, more manageable workloads and schedules, and more support staff. But for many doctors, these fixes may be years if not decades away. Equally important are strategies for relieving burnout symptoms now, especially as we head into a busy holiday season.
Because not every stress-relief practice works for everyone, it’s crucial to try various methods until you find something that makes a difference for you, said Christine Gibson, MD, a family physician and trauma therapist in Calgary, Alta., and author of The Modern Trauma Toolkit.
“Every person should have a toolkit of the things that bring them out of the psychological and physical distress that dysregulates their nervous system,” said Dr. Gibson.
Once you learn the personal ways to alleviate your specific brand of burnout, you can start working on systemic changes that might help the culture of medicine overall.
Symptoms speak louder than words
It seems obvious, but if you aren’t aware that what you’re feeling is burnout, you probably aren’t going to find effective steps to relieve it. Jessi Gold, MD, assistant professor and director of wellness, engagement, and outreach in the department of psychiatry, Washington University in St. Louis, is a psychiatrist who treats health care professionals, including frontline workers during the height of the pandemic. But even as a burnout expert, she admits that she misses the signs in herself.
“I was fighting constant fatigue, falling asleep the minute I got home from work every day, but I thought a B12 shot would solve all my problems. I didn’t realize I was having symptoms of burnout until my own therapist told me,” said Dr. Gold. “As doctors, we spend so much time focusing on other people that we don’t necessarily notice very much in ourselves – usually once it starts to impact our job.”
Practices like meditation and mindfulness can help you delve into your feelings and emotions and notice how you’re doing. But you may also need to ask spouses, partners, and friends and family – or better yet, a mental health professional – if they notice that you seem burnt out.
Practice ‘in the moment’ relief
Sometimes, walking away at the moment of stress helps like when stepping away from a heated argument. “Step out of a frustrating staff meeting to go to the bathroom and splash your face,” said Eran Magan, PhD, a psychologist at the University of Pennsylvania, Philadelphia, and founder and CEO of the suicide prevention system EarlyAlert.me. “Tell a patient you need to check something in the next room, so you have time to take a breath.”
Dr. Magan recommended finding techniques that help lower acute stress while it’s actually happening. First, find a way to escape or excuse yourself from the event, and when possible, stop situations that are actively upsetting or triggering in their tracks.
Next, recharge by doing something that helps you feel better, like looking at a cute video of your child or grandchild or closing your eyes and taking a deep breath. You can also try to “catch” good feelings from someone else, said Dr. Magan. Ask someone about a trip, vacation, holiday, or pleasant event. “Ask a colleague about something that makes [them] happy,” he said. “Happiness can be infectious too.”
Burnout is also in the body
“Body psychotherapy” or somatic therapy is a treatment that focuses on how emotions appear within your body. Dr. Gibson said it’s a valuable tool for addressing trauma and a mainstay in many a medical career; it’s useful to help physicians learn to “befriend” their nervous system.
Somatic therapy exercises involve things like body scanning, scanning for physical sensations; conscious breathing, connecting to each inhale and exhale; grounding your weight by releasing tension through your feet, doing a total body stretch; or releasing shoulder and neck tension by consciously relaxing each of these muscle groups.
“We spend our whole day in sympathetic tone; our amygdala’s are firing, telling us that we’re in danger,” said Dr. Gibson. “We actually have to practice getting into and spending time in our parasympathetic nervous system to restore the balance in our autonomic nervous system.”
Somatic therapy includes a wide array of exercises that help reconnect you to your body through calming or activation. The movements release tension, ground you, and restore balance.
Bite-sized tools for well-being
Because of the prevalence of physician burnout, there’s been a groundswell of researchers and organizations who have turned their focus toward improving the well-being in the health care workforce.
One such effort comes from the Duke Center for the Advancement of Well-being Science, which “camouflages” well-being tools as continuing education credits to make them accessible for busy, stressed, and overworked physicians.
“They’re called bite-sized tools for well-being, and they have actual evidence behind them,” said Dr. Gold. For example, she said, one tools is a text program called Three Good Things that encourages physicians to send a text listing three positive things that happened during the day. The exercise lasts 15 days, and texters have access to others’ answers as well. After 3 months, participants’ baseline depression, gratitude, and life satisfaction had all “significantly improved.”
“It feels almost ridiculous that that could work, but it does,” said Dr. Gold. “I’ve had patients push back and say: ‘Well, isn’t that toxic positivity?’ But really what it is is dialectics. It’s not saying there’s only positive; it’s just making you realize there is more than just the negative.”
These and other short interventions focus on concepts such as joy, humor, awe, engagement, and self-kindness to build resilience and help physicians recover from burnout symptoms.
Cognitive restructuring could work
Cognitive restructuring is a therapeutic process of learning new ways of interpreting and responding to people and situations. It helps you change the “filter” through which you interact with your environment. Dr. Gibson said it’s a tool to use with care after other modes of therapy that help you understand your patterns and how they developed because of how you view and understand the world.
“The message of [cognitive-behavioral therapy] or cognitive restructuring is there’s something wrong with the way you’re thinking, and we need to change it or fix it, but in a traumatic system [like health care], you’re thinking has been an adaptive process related to the harm in the environment you’re in,” said Dr. Gibson.
“So, if you [jump straight to cognitive restructuring before other types of therapy], then we just gaslight ourselves into believing that there’s something wrong with us, that we haven’t adapted sufficiently to an environment that’s actually harmful.”
Strive for a few systemic changes
Systemic changes can be small ones within your own sphere. For example, Dr. Magan said, work toward making little tweaks to the flow of your day that will increase calm and reduce frustration.
“Make a ‘bug list,’ little, regular demands that drain your energy, and discuss them with your colleagues and supervisors to see if they can be improved,” he said. Examples include everyday frustrations like having unsolicited visitors popping into your office, scheduling complex patients too late in the day, or having a computer freeze whenever you access patient charts.
Though not always financially feasible, affecting real change and finding relief from all these insidious bugs can improve your mental health and burnout symptoms.
“Physicians tend to work extremely hard in order to keep holding together a system that is often not inherently sustainable, like the fascia of a body under tremendous strain,” said Dr. Magan. “Sometimes the brave thing to do is to refuse to continue being the lynchpin and let things break, so the system will have to start improving itself, rather than demanding more and more of the people in it.”
A version of this article first appeared on Medscape.com.
Time to stop routine maintenance therapy in myeloma?
For more than 10 years, ongoing treatment with lenalidomide following autologous hematopoietic stem cell transplantation (ASCT) has been the unchallenged gold standard.
The new findings were from the MASTER study, published in The Lancet Haematology, along with an invited commentary by Dr. Derman. In MASTER, patients who showed no evidence of disease after transplantation and two phases of consolidation therapy had the opportunity to avoid lenalidomide maintenance.
In the lenalidomide-free group, just 9% of patients without high-risk chromosome abnormalities or just one HRCA progressed within 2 years. About 47% of patients with two or more HRCAs progressed within 2 years.
The MASTER authors concluded that modern regimens of induction plus ASCT/consolidation might be good enough for many patients. Avoiding maintenance therapy “lead to most patients with newly diagnosed multiple myeloma reaching an MRD [minimal residual disease]-free, treatment-free state with a low risk of disease progression.” They also cautioned that the approach was “not optimal” for high-risk patients.
“We have been indoctrinated into continuous therapy,” said lead author Luciano Costa, MD, professor of medicine at the University of Alabama at Birmingham. “This was a reasonable approach at the time when [induction and consolidation] therapy was not as effective.”
Lenalidomide for post-ASCT maintenance became a guideline standard following a pivotal study published in the New England Journal of Medicine in 2012. The study showed that lenalidomide maintenance after transplantation almost doubled the time to progression (P < .001) and improved survival (P = .03).
Shaji Kumar, MD, is chair of the National Comprehensive Cancer Network Multiple Myeloma Guidelines and professor of medicine at the Mayo Clinic in Rochester, Minn.
Dr. Kumar said that the MASTER results alone are not sufficient to change current guidelines because the study was a single-arm, uncontrolled, phase 2 trial. However, there are “multiple reasons why we would like to stop treatment at some point in time,” Dr. Kumar said.
“Quality of life, the financial cost, and the toxicity are three main reasons why we would like to discontinue the maintenance or give maintenance only for the amount of time that a patient needs it,” Dr. Kumar added. “So then the question comes up, how do we identify the people who need long term treatment versus the people who don’t?”
“Response” in MM is conventionally classified by criteria laid down by the International Myeloma Working Group. However, the MASTER trial made use of a different measure: MRD negativity, in which myeloma cells can no longer be detected in bone-marrow aspirate at a level of 1 in 100,000 (10–5) or, in some studies, 1 in 1 million (10–6).
MRD is a rare bird in oncology: A surrogate endpoint that provides answers faster than progression-free survival or overall survival but is a reliable guide to both. In 2020 a team headed by Nikhil Munshi, MD, professor of medicine at Harvard Medical School, Boston, published a large meta-analysis showing that a negative MRD in a patient with MM was significantly prognostic for both progression-free survival (hazard ratio, 0.33; P < .001) and overall survival (HR, 0.45; P < .001).
In an interview from 2022, Dr. Munshi explained that patients with MRD negativity are not necessarily “cured”: “Simply, physiologically, it means that if a patient has one [myeloma] cell in a million, that cell is going to take a much longer time to grow up to be myeloma.”
In MASTER, which was based at five U.S. academic medical centers, 81% of participants (96/118) achieved MRD negativity at the 10–5 cutoff. Eighty-four people (71%) had two consecutive MRD-negative results and did not go on to lenalidomide maintenance. Instead, they were monitored with lab tests every 8 weeks for the first 24 weeks and every 16 weeks thereafter and assessed for any changes in MRD after 6 months and 18 months.
The median age in MASTER was 61 years, 43% were women, and 20% were non-Hispanic Black. About 20% of participants had two or more HRCAs, 37% had one HRCA, and 43% had no HRCAs. All participants had four 28-day cycles of induction with Dara-KRd (daratumumab, carfilzomib, lenalidomide, and dexamethasone). This was followed by ASCT and up to two phases of consolidation with Dara-KRd.
MASTER is not the only study to show that MRD-guided discontinuation of lenalidomide seems feasible in some patients. In November 2023, Spanish researchers published a study in Blood testing a combination of lenalidomide, dexamethasone, and ixazomib. The trial allowed MRD-negative patients to stop therapy after 2 years. Progression was 17.2% over the following 4 years in the group that dropped maintenance, which included high-risk patients. The authors concluded that their results “support the safety of maintenance therapy discontinuation in patients with negative MRD at 2 years.”
These two trials are conspicuous by their rarity.
Said Dr. Derman: “We haven’t done a great job until recently of designing trials that look into discontinuation.”
Both Dr. Derman and Dr. Costa raised the elephant in the room: industry funding.
“Maintenance therapy is big business,” said Dr. Derman. He added that he had experienced problems in the past obtaining industry funding for research that involved stopping therapy.
Dr. Costa, coauthor of the MASTER trial, agreed in part: “Most pharmaceutical companies do not embark on trials like this because they’re primarily doing registration trials.” MASTER garnered some industry funding, however, and Dr. Costa found that encouraging.
How much money is at stake? In other words, what are the financial savings if patients with zero to one HRCAs who are MRD negative start to take treatment holidays from lenalidomide maintenance?
In the United States in 2019 approximately 6,410 patients received ASCT. The MASTER publication stated that “around 85%” of newly diagnosed MM patients have zero to one HRCAs and that 73% of these patients were able to stop therapy in the trial. This suggests that, each year, approximately 4,000 new patients might be eligible to avoid lenalidomide after ASCT.
The price tag of lenalidomide is approximately $20,000 per month in the United States, according to Dr. Derman. A cohort of 4,000 patients avoiding lenalidomide each year represents lost revenue of $80 million per month or almost $1 billion per year. And this does not take into account patients already on lenalidomide from previous years – or sales outside the United States. The MM multiple research pipeline reflects a lack of enthusiasm for paring down maintenance.
There are currently 229 interventional clinical studies in MM taking place nationwide. Of these, just three trials are testing what happens when patients stop therapy in the post-ASCT setting and none of the three is sponsored by industry (NCT04108624, NCT05091372, and NCT04071457). (All data from clinicaltrials.gov; search covered phase 2, 3, or 4 studies still accruing data; descriptions hand-checked; search terms: maintenance/consolidation/post-ASCT.)
Dr. Derman said that it is “incumbent on investigators” to carry out the studies to identify who is eligible to stop therapy because industry is “probably always going to err on the side of treating more.”
Sergio Giralt, MD, head of the adult bone marrow transplant service at Memorial Sloan Kettering Cancer Center, New York, was an author of the key 2012 study that enshrined lenalidomide maintenance in the guidelines. Dr. Giralt expressed concerns about the single-arm design of MASTER and said he would like to see a randomized study where some patients continued treatment and others stopped.
Dr. Giralt cautioned: “If you’re MRD negative, the chances of having to deal with your disease in the next 5 years is one in five.” Physicians could certainly “have a conversation” with patients who are MRD negative about stopping therapy, but this would need to be weighed against the need for bone-marrow biopsies every 3-6 months to check progress. (In MASTER, MRD was checked at 6 and 18 months.)
Dr. Kumar believes that “we need to pursue the concept of decreasing the duration of treatment.” However, newer immunotherapies may be the answer: “Who knows? That may be the future, that we will do more of this hit-and-run approach rather than trying to keep them persistently on something.”
Dr. Derman said: “I personally think that the data is already there ... [MASTER] shows that perhaps this notion of indefinite maintenance therapy is one that really has to go by the wayside ... patients should have the option to consider with their physician [the chance to] potentially discontinue treatment.”
For 15 years, relentless lenalidomide maintenance has “quite rightly been the strongest pillar of therapy”, said Dr. Costa. “But for patients, this is not something that they easily embrace – it’s not ideal that you are going to have to take therapy for the rest of your life.”
Dr. Costa concluded: “I don’t think we had a single patient who was reluctant to stop therapy.”
Dr. Munshi reported relationships with Adaptive, Abbvie, Amgen, Bristol-Myers Squibb, Celgene, Janssen, Karyopharm, Legend, Millennium, Novartis, Pfizer, and he is the scientific founder of Oncopep and DCT. Dr. Derman disclosed ties with Janssen, Cota, and BMS. Dr. Costa reported ties with Amgen, Cota, Janssen, BMS, AbbVie, Ionis, Genentech, Sanofi, Karyopharm, AstraZeneca, Adaptive Biotechnologies, Takeda, and Pfizer. Dr. Kumar declared relationships with AbbVie, Amgen, BMS, GlaxoSmithKline, Karyopharm, Regeneron, Roche, Sanofi, Takeda, and BeiGene. Dr. Giralt reported ties with Amgen, CSL Behring, Caladrius, Celgene, Ceramedix, ExpertConnect, GlaxoSmithKline, Janssen, Karyopharm, Kite Pharmaceuticals, Magnolia Innovation, Novartis, Omeros, Pfizer, Physicians’ Education Resource, Sanofi, TRM Oncology, and Xcenda.
For more than 10 years, ongoing treatment with lenalidomide following autologous hematopoietic stem cell transplantation (ASCT) has been the unchallenged gold standard.
The new findings were from the MASTER study, published in The Lancet Haematology, along with an invited commentary by Dr. Derman. In MASTER, patients who showed no evidence of disease after transplantation and two phases of consolidation therapy had the opportunity to avoid lenalidomide maintenance.
In the lenalidomide-free group, just 9% of patients without high-risk chromosome abnormalities or just one HRCA progressed within 2 years. About 47% of patients with two or more HRCAs progressed within 2 years.
The MASTER authors concluded that modern regimens of induction plus ASCT/consolidation might be good enough for many patients. Avoiding maintenance therapy “lead to most patients with newly diagnosed multiple myeloma reaching an MRD [minimal residual disease]-free, treatment-free state with a low risk of disease progression.” They also cautioned that the approach was “not optimal” for high-risk patients.
“We have been indoctrinated into continuous therapy,” said lead author Luciano Costa, MD, professor of medicine at the University of Alabama at Birmingham. “This was a reasonable approach at the time when [induction and consolidation] therapy was not as effective.”
Lenalidomide for post-ASCT maintenance became a guideline standard following a pivotal study published in the New England Journal of Medicine in 2012. The study showed that lenalidomide maintenance after transplantation almost doubled the time to progression (P < .001) and improved survival (P = .03).
Shaji Kumar, MD, is chair of the National Comprehensive Cancer Network Multiple Myeloma Guidelines and professor of medicine at the Mayo Clinic in Rochester, Minn.
Dr. Kumar said that the MASTER results alone are not sufficient to change current guidelines because the study was a single-arm, uncontrolled, phase 2 trial. However, there are “multiple reasons why we would like to stop treatment at some point in time,” Dr. Kumar said.
“Quality of life, the financial cost, and the toxicity are three main reasons why we would like to discontinue the maintenance or give maintenance only for the amount of time that a patient needs it,” Dr. Kumar added. “So then the question comes up, how do we identify the people who need long term treatment versus the people who don’t?”
“Response” in MM is conventionally classified by criteria laid down by the International Myeloma Working Group. However, the MASTER trial made use of a different measure: MRD negativity, in which myeloma cells can no longer be detected in bone-marrow aspirate at a level of 1 in 100,000 (10–5) or, in some studies, 1 in 1 million (10–6).
MRD is a rare bird in oncology: A surrogate endpoint that provides answers faster than progression-free survival or overall survival but is a reliable guide to both. In 2020 a team headed by Nikhil Munshi, MD, professor of medicine at Harvard Medical School, Boston, published a large meta-analysis showing that a negative MRD in a patient with MM was significantly prognostic for both progression-free survival (hazard ratio, 0.33; P < .001) and overall survival (HR, 0.45; P < .001).
In an interview from 2022, Dr. Munshi explained that patients with MRD negativity are not necessarily “cured”: “Simply, physiologically, it means that if a patient has one [myeloma] cell in a million, that cell is going to take a much longer time to grow up to be myeloma.”
In MASTER, which was based at five U.S. academic medical centers, 81% of participants (96/118) achieved MRD negativity at the 10–5 cutoff. Eighty-four people (71%) had two consecutive MRD-negative results and did not go on to lenalidomide maintenance. Instead, they were monitored with lab tests every 8 weeks for the first 24 weeks and every 16 weeks thereafter and assessed for any changes in MRD after 6 months and 18 months.
The median age in MASTER was 61 years, 43% were women, and 20% were non-Hispanic Black. About 20% of participants had two or more HRCAs, 37% had one HRCA, and 43% had no HRCAs. All participants had four 28-day cycles of induction with Dara-KRd (daratumumab, carfilzomib, lenalidomide, and dexamethasone). This was followed by ASCT and up to two phases of consolidation with Dara-KRd.
MASTER is not the only study to show that MRD-guided discontinuation of lenalidomide seems feasible in some patients. In November 2023, Spanish researchers published a study in Blood testing a combination of lenalidomide, dexamethasone, and ixazomib. The trial allowed MRD-negative patients to stop therapy after 2 years. Progression was 17.2% over the following 4 years in the group that dropped maintenance, which included high-risk patients. The authors concluded that their results “support the safety of maintenance therapy discontinuation in patients with negative MRD at 2 years.”
These two trials are conspicuous by their rarity.
Said Dr. Derman: “We haven’t done a great job until recently of designing trials that look into discontinuation.”
Both Dr. Derman and Dr. Costa raised the elephant in the room: industry funding.
“Maintenance therapy is big business,” said Dr. Derman. He added that he had experienced problems in the past obtaining industry funding for research that involved stopping therapy.
Dr. Costa, coauthor of the MASTER trial, agreed in part: “Most pharmaceutical companies do not embark on trials like this because they’re primarily doing registration trials.” MASTER garnered some industry funding, however, and Dr. Costa found that encouraging.
How much money is at stake? In other words, what are the financial savings if patients with zero to one HRCAs who are MRD negative start to take treatment holidays from lenalidomide maintenance?
In the United States in 2019 approximately 6,410 patients received ASCT. The MASTER publication stated that “around 85%” of newly diagnosed MM patients have zero to one HRCAs and that 73% of these patients were able to stop therapy in the trial. This suggests that, each year, approximately 4,000 new patients might be eligible to avoid lenalidomide after ASCT.
The price tag of lenalidomide is approximately $20,000 per month in the United States, according to Dr. Derman. A cohort of 4,000 patients avoiding lenalidomide each year represents lost revenue of $80 million per month or almost $1 billion per year. And this does not take into account patients already on lenalidomide from previous years – or sales outside the United States. The MM multiple research pipeline reflects a lack of enthusiasm for paring down maintenance.
There are currently 229 interventional clinical studies in MM taking place nationwide. Of these, just three trials are testing what happens when patients stop therapy in the post-ASCT setting and none of the three is sponsored by industry (NCT04108624, NCT05091372, and NCT04071457). (All data from clinicaltrials.gov; search covered phase 2, 3, or 4 studies still accruing data; descriptions hand-checked; search terms: maintenance/consolidation/post-ASCT.)
Dr. Derman said that it is “incumbent on investigators” to carry out the studies to identify who is eligible to stop therapy because industry is “probably always going to err on the side of treating more.”
Sergio Giralt, MD, head of the adult bone marrow transplant service at Memorial Sloan Kettering Cancer Center, New York, was an author of the key 2012 study that enshrined lenalidomide maintenance in the guidelines. Dr. Giralt expressed concerns about the single-arm design of MASTER and said he would like to see a randomized study where some patients continued treatment and others stopped.
Dr. Giralt cautioned: “If you’re MRD negative, the chances of having to deal with your disease in the next 5 years is one in five.” Physicians could certainly “have a conversation” with patients who are MRD negative about stopping therapy, but this would need to be weighed against the need for bone-marrow biopsies every 3-6 months to check progress. (In MASTER, MRD was checked at 6 and 18 months.)
Dr. Kumar believes that “we need to pursue the concept of decreasing the duration of treatment.” However, newer immunotherapies may be the answer: “Who knows? That may be the future, that we will do more of this hit-and-run approach rather than trying to keep them persistently on something.”
Dr. Derman said: “I personally think that the data is already there ... [MASTER] shows that perhaps this notion of indefinite maintenance therapy is one that really has to go by the wayside ... patients should have the option to consider with their physician [the chance to] potentially discontinue treatment.”
For 15 years, relentless lenalidomide maintenance has “quite rightly been the strongest pillar of therapy”, said Dr. Costa. “But for patients, this is not something that they easily embrace – it’s not ideal that you are going to have to take therapy for the rest of your life.”
Dr. Costa concluded: “I don’t think we had a single patient who was reluctant to stop therapy.”
Dr. Munshi reported relationships with Adaptive, Abbvie, Amgen, Bristol-Myers Squibb, Celgene, Janssen, Karyopharm, Legend, Millennium, Novartis, Pfizer, and he is the scientific founder of Oncopep and DCT. Dr. Derman disclosed ties with Janssen, Cota, and BMS. Dr. Costa reported ties with Amgen, Cota, Janssen, BMS, AbbVie, Ionis, Genentech, Sanofi, Karyopharm, AstraZeneca, Adaptive Biotechnologies, Takeda, and Pfizer. Dr. Kumar declared relationships with AbbVie, Amgen, BMS, GlaxoSmithKline, Karyopharm, Regeneron, Roche, Sanofi, Takeda, and BeiGene. Dr. Giralt reported ties with Amgen, CSL Behring, Caladrius, Celgene, Ceramedix, ExpertConnect, GlaxoSmithKline, Janssen, Karyopharm, Kite Pharmaceuticals, Magnolia Innovation, Novartis, Omeros, Pfizer, Physicians’ Education Resource, Sanofi, TRM Oncology, and Xcenda.
For more than 10 years, ongoing treatment with lenalidomide following autologous hematopoietic stem cell transplantation (ASCT) has been the unchallenged gold standard.
The new findings were from the MASTER study, published in The Lancet Haematology, along with an invited commentary by Dr. Derman. In MASTER, patients who showed no evidence of disease after transplantation and two phases of consolidation therapy had the opportunity to avoid lenalidomide maintenance.
In the lenalidomide-free group, just 9% of patients without high-risk chromosome abnormalities or just one HRCA progressed within 2 years. About 47% of patients with two or more HRCAs progressed within 2 years.
The MASTER authors concluded that modern regimens of induction plus ASCT/consolidation might be good enough for many patients. Avoiding maintenance therapy “lead to most patients with newly diagnosed multiple myeloma reaching an MRD [minimal residual disease]-free, treatment-free state with a low risk of disease progression.” They also cautioned that the approach was “not optimal” for high-risk patients.
“We have been indoctrinated into continuous therapy,” said lead author Luciano Costa, MD, professor of medicine at the University of Alabama at Birmingham. “This was a reasonable approach at the time when [induction and consolidation] therapy was not as effective.”
Lenalidomide for post-ASCT maintenance became a guideline standard following a pivotal study published in the New England Journal of Medicine in 2012. The study showed that lenalidomide maintenance after transplantation almost doubled the time to progression (P < .001) and improved survival (P = .03).
Shaji Kumar, MD, is chair of the National Comprehensive Cancer Network Multiple Myeloma Guidelines and professor of medicine at the Mayo Clinic in Rochester, Minn.
Dr. Kumar said that the MASTER results alone are not sufficient to change current guidelines because the study was a single-arm, uncontrolled, phase 2 trial. However, there are “multiple reasons why we would like to stop treatment at some point in time,” Dr. Kumar said.
“Quality of life, the financial cost, and the toxicity are three main reasons why we would like to discontinue the maintenance or give maintenance only for the amount of time that a patient needs it,” Dr. Kumar added. “So then the question comes up, how do we identify the people who need long term treatment versus the people who don’t?”
“Response” in MM is conventionally classified by criteria laid down by the International Myeloma Working Group. However, the MASTER trial made use of a different measure: MRD negativity, in which myeloma cells can no longer be detected in bone-marrow aspirate at a level of 1 in 100,000 (10–5) or, in some studies, 1 in 1 million (10–6).
MRD is a rare bird in oncology: A surrogate endpoint that provides answers faster than progression-free survival or overall survival but is a reliable guide to both. In 2020 a team headed by Nikhil Munshi, MD, professor of medicine at Harvard Medical School, Boston, published a large meta-analysis showing that a negative MRD in a patient with MM was significantly prognostic for both progression-free survival (hazard ratio, 0.33; P < .001) and overall survival (HR, 0.45; P < .001).
In an interview from 2022, Dr. Munshi explained that patients with MRD negativity are not necessarily “cured”: “Simply, physiologically, it means that if a patient has one [myeloma] cell in a million, that cell is going to take a much longer time to grow up to be myeloma.”
In MASTER, which was based at five U.S. academic medical centers, 81% of participants (96/118) achieved MRD negativity at the 10–5 cutoff. Eighty-four people (71%) had two consecutive MRD-negative results and did not go on to lenalidomide maintenance. Instead, they were monitored with lab tests every 8 weeks for the first 24 weeks and every 16 weeks thereafter and assessed for any changes in MRD after 6 months and 18 months.
The median age in MASTER was 61 years, 43% were women, and 20% were non-Hispanic Black. About 20% of participants had two or more HRCAs, 37% had one HRCA, and 43% had no HRCAs. All participants had four 28-day cycles of induction with Dara-KRd (daratumumab, carfilzomib, lenalidomide, and dexamethasone). This was followed by ASCT and up to two phases of consolidation with Dara-KRd.
MASTER is not the only study to show that MRD-guided discontinuation of lenalidomide seems feasible in some patients. In November 2023, Spanish researchers published a study in Blood testing a combination of lenalidomide, dexamethasone, and ixazomib. The trial allowed MRD-negative patients to stop therapy after 2 years. Progression was 17.2% over the following 4 years in the group that dropped maintenance, which included high-risk patients. The authors concluded that their results “support the safety of maintenance therapy discontinuation in patients with negative MRD at 2 years.”
These two trials are conspicuous by their rarity.
Said Dr. Derman: “We haven’t done a great job until recently of designing trials that look into discontinuation.”
Both Dr. Derman and Dr. Costa raised the elephant in the room: industry funding.
“Maintenance therapy is big business,” said Dr. Derman. He added that he had experienced problems in the past obtaining industry funding for research that involved stopping therapy.
Dr. Costa, coauthor of the MASTER trial, agreed in part: “Most pharmaceutical companies do not embark on trials like this because they’re primarily doing registration trials.” MASTER garnered some industry funding, however, and Dr. Costa found that encouraging.
How much money is at stake? In other words, what are the financial savings if patients with zero to one HRCAs who are MRD negative start to take treatment holidays from lenalidomide maintenance?
In the United States in 2019 approximately 6,410 patients received ASCT. The MASTER publication stated that “around 85%” of newly diagnosed MM patients have zero to one HRCAs and that 73% of these patients were able to stop therapy in the trial. This suggests that, each year, approximately 4,000 new patients might be eligible to avoid lenalidomide after ASCT.
The price tag of lenalidomide is approximately $20,000 per month in the United States, according to Dr. Derman. A cohort of 4,000 patients avoiding lenalidomide each year represents lost revenue of $80 million per month or almost $1 billion per year. And this does not take into account patients already on lenalidomide from previous years – or sales outside the United States. The MM multiple research pipeline reflects a lack of enthusiasm for paring down maintenance.
There are currently 229 interventional clinical studies in MM taking place nationwide. Of these, just three trials are testing what happens when patients stop therapy in the post-ASCT setting and none of the three is sponsored by industry (NCT04108624, NCT05091372, and NCT04071457). (All data from clinicaltrials.gov; search covered phase 2, 3, or 4 studies still accruing data; descriptions hand-checked; search terms: maintenance/consolidation/post-ASCT.)
Dr. Derman said that it is “incumbent on investigators” to carry out the studies to identify who is eligible to stop therapy because industry is “probably always going to err on the side of treating more.”
Sergio Giralt, MD, head of the adult bone marrow transplant service at Memorial Sloan Kettering Cancer Center, New York, was an author of the key 2012 study that enshrined lenalidomide maintenance in the guidelines. Dr. Giralt expressed concerns about the single-arm design of MASTER and said he would like to see a randomized study where some patients continued treatment and others stopped.
Dr. Giralt cautioned: “If you’re MRD negative, the chances of having to deal with your disease in the next 5 years is one in five.” Physicians could certainly “have a conversation” with patients who are MRD negative about stopping therapy, but this would need to be weighed against the need for bone-marrow biopsies every 3-6 months to check progress. (In MASTER, MRD was checked at 6 and 18 months.)
Dr. Kumar believes that “we need to pursue the concept of decreasing the duration of treatment.” However, newer immunotherapies may be the answer: “Who knows? That may be the future, that we will do more of this hit-and-run approach rather than trying to keep them persistently on something.”
Dr. Derman said: “I personally think that the data is already there ... [MASTER] shows that perhaps this notion of indefinite maintenance therapy is one that really has to go by the wayside ... patients should have the option to consider with their physician [the chance to] potentially discontinue treatment.”
For 15 years, relentless lenalidomide maintenance has “quite rightly been the strongest pillar of therapy”, said Dr. Costa. “But for patients, this is not something that they easily embrace – it’s not ideal that you are going to have to take therapy for the rest of your life.”
Dr. Costa concluded: “I don’t think we had a single patient who was reluctant to stop therapy.”
Dr. Munshi reported relationships with Adaptive, Abbvie, Amgen, Bristol-Myers Squibb, Celgene, Janssen, Karyopharm, Legend, Millennium, Novartis, Pfizer, and he is the scientific founder of Oncopep and DCT. Dr. Derman disclosed ties with Janssen, Cota, and BMS. Dr. Costa reported ties with Amgen, Cota, Janssen, BMS, AbbVie, Ionis, Genentech, Sanofi, Karyopharm, AstraZeneca, Adaptive Biotechnologies, Takeda, and Pfizer. Dr. Kumar declared relationships with AbbVie, Amgen, BMS, GlaxoSmithKline, Karyopharm, Regeneron, Roche, Sanofi, Takeda, and BeiGene. Dr. Giralt reported ties with Amgen, CSL Behring, Caladrius, Celgene, Ceramedix, ExpertConnect, GlaxoSmithKline, Janssen, Karyopharm, Kite Pharmaceuticals, Magnolia Innovation, Novartis, Omeros, Pfizer, Physicians’ Education Resource, Sanofi, TRM Oncology, and Xcenda.
Despite effective therapies, fibroid care still lacking
In 2022, two colleagues from Johns Hopkins University, Baltimore, Bhuchitra Singh, MD, MPH, MS, MBA, and James Segars Jr., MD, reviewed the available literature to evaluate the effectiveness of newer minimally invasive therapies in reducing bleeding and improving the quality of life and control of symptoms linked to uterine fibroids.
Their goal, according to Dr. Segars, a professor of obstetrics and gynecology and director of the division of women’s health research at Johns Hopkins, was to help guide clinicians and patients in making decisions about the use of the newer therapies, including radiofrequency ablation and ultrasound-guided removal of lesions.
But he and Dr. Singh, the director of clinical research at the Howard W. and Georgeanna Seegar Jones Laboratory of Reproductive Sciences and Women’s Health Research, were surprised by their findings. “The outcomes were relatively the same,” Dr. Segars said. “All of the modalities lead to significant reduction in bleeding and other fibroid-related symptoms.”
The data on long-term complications and risk for recurrence are sparse for some of the newer approaches, and not enough high-quality long-term studies have been conducted for the Food and Drug Administration to approve them as fertility-sparing treatments.
But perhaps, the biggest challenge now is to ensure that women can take advantage of these newer therapies, with large gaps in both the diagnosis of fibroids and geographic access to minimally invasive treatments.
A widespread condition widely underdiagnosed
Uterine fibroids occur in most women (the incidence rises with age) and can be found in up to 70% of women by the time they reach menopause. Risk factors include family history, increasing interval since last birth, hypertension, and obesity. Increasing parity and use of oral contraceptives are protective.
But as many as 50% of cases go undiagnosed, and one reason for this is the failure of clinicians to dig deeply enough into women’s menstrual histories to diagnose fibroids.
“The most common cause of anemia is heavy menstrual bleeding,” said Shannon Laughlin-Tommaso, MD, MPH, a professor of obstetrics and gynecology at Mayo Clinic in Rochester, Minn. She frequently sees patients who have already undergone colonoscopy to work-up the source of their anemia before anyone suspects that fibroids are the culprit.
“When women tell us about their periods, what they’ve been told is normal [bleeding] – or what they’ve always had and considered normal – is actually kind of on the heavier spectrum,” she said.
Ideally, treatment for uterine fibroids would fix abnormally prolonged or heavy menstrual bleeding, relieve pain, and ameliorate symptoms associated with an enlarged uterus, such as pelvic pressure, urinary frequency, and constipation. And the fibroids would never recur.
By those measures, hysterectomy fits the bill: Success rates in relieving symptoms are high, and the risk for recurrence is zero. But the procedure carries significant drawbacks: short-term complications of surgery, including infection, bleeding, and injury to the bowels and bladder along with potential long-term risks for cardiovascular disease, cancer, ovarian failure and premature menopause, depression, and decline in cognitive function. Those factors loom even larger for women who still hope to have children.
For that reason, the American College of Obstetricians and Gynecologists recommends myomectomy, or surgical removal of individual fibroids, for women who desire uterine preservation or future pregnancy. And the literature here is solid, according to Dr. Singh, who found that 95% of myomectomy patients achieved control of their bleeding symptoms, whether it was via laparoscopy, hysteroscopy, or laparotomy. Up to 40% of women may develop new fibroids, or leiomyomas, within 3 years, although only 12.2% required a second surgery up to after 5 years.
But myomectomy is invasive, requiring general anesthesia, incisions in the uterus, and stitches to close the organ.
Newer techniques have emerged that can effectively treat symptoms of fibroids without requiring surgery. Uterine artery embolization (UAE), which involves passing a catheter into the femoral artery, or laparoscopic uterine artery occlusion can be used to cut off the blood supply of the fibroid. Other techniques, including focused ultrasound surgery and radiofrequency ablation (RFA), use various forms of energy to heat and ablate fibroids. The latter two can be performed in outpatient settings and often without general anesthesia.
Approved for use in 1994, UAE has the most data available, with reduction in the volume of fibroids and uterine tissue lasting up to 5 years, and rates of reintervention of 19%-38% between 2 and 5 years after the procedure. Dr. Singh’s review found that 79%-98.5% of recipients of the procedure reported declines in bleeding that persisted for several years, which is comparable to myomectomy. Quality of life and pain scores also showed good improvement, with follow-up in the different studies ranging from 12 months to over 5 years, the analysis showed.
UAE does have its drawbacks. In rare cases, embolization can deprive the entire uterus and ovaries of blood, which can cause ovarian dysfunction and potentially result in premature menopause, although this outcome is most common in women who are older than 45 years. The procedure can often also be painful enough that overnight hospitalization is required.
Focused ultrasound surgeries, which include magnetic resonance–guided focused ultrasound surgery (MRgFUS) and high-intensity focused ultrasound (HIFU), were approved by the FDA in 2004. Focused ultrasound waves pass through the abdominal wall and produce significant heating, causing a burn that destroys the targeted tissue without damaging surrounding tissue. As with UAE, improvements in fibroid-associated bleeding and measures of quality of life were similar to those after myomectomy up to 3 years later.
But Dr. Singh noted that both focused ultrasound and RFA can damage the skin or internal organs. “[As] always with the thermal interventions, there is the probability of skin as well as internal organs that might get the thermal energy if it’s not focused correctly on to the fibroid itself,” he said. In addition, MRgFUS is not an option for women who are not good candidates to undergo an MRI, such as those with claustrophobia or pacemakers.
Also, with focus ultrasound and RFA, “we do worry about that fibroid getting blood flow back,” which can lead to recurrence of heavy menstrual bleeding, Dr. Laughlin-Tommaso noted.
Although data on RFA are limited to 12 months of follow-up, most women reported meaningful reductions in bleeding symptoms. Longer follow-up has been reported for bleeding symptoms after MRgFUS, with similar results up to 3 years later.
For Leslie Hansen-Lindner, MD, chief of obstetrics and gynecology at Atrium Health in Charlotte, N.C., choosing the right procedure starts with a patient-centered conversation weighing the pros and cons of the options and the woman’s goals.
“Is their goal to reduce the size and impact of their fibroid, bleed less, and have a better quality of life on their period?” Dr. Hansen-Lindner said. “Or is their goal to have the entire fibroid removed?”
If the former, an RFA is appealing to many women. If the latter, laparoscopic or mini-laparotomy myomectomy might be a better choice. Although fewer than 10% of patients require surgical reintervention at 3 years of follow-up for RFA, myomectomy has more consistent long-term evidence showing that fewer women require re-intervention and preserve their fertility, she added.
Age also plays a role in the decision: The closer a woman is to menopause, the less likely she is to experience a recurrence, so a less-invasive procedure is preferable. But for younger women hoping to become pregnant, the lower risk for recurrence and good prognosis for future fertility might sway the choice toward myomectomy.
The first laparoscopic RFA procedures were approved for uterine fibroids in 2012. Dr. Hansen-Lindner is a proponent of transcervical fibroid ablation (TFA), a newer RFA procedure that the FDA approved in 2018. Performed through the cervix, TFA requires no incisions and can generally be done without general anesthesia. Eligible candidates would be any woman with symptomatic fibroids, such as heavy menstrual bleeding, pain, or bulk symptoms. The contraindications are few.
“It’s going to come down to size and location of fibroids, and whether or not they would be accessible by the TFA,” Dr. Hansen-Lindner said. “I have to make sure that there isn’t a fibroid blocking their cervix and that the fibroids are accessible with this device.”
TFA also is not suitable for removing most submucosal lesions, which typically must be removed by hysteroscopic myomectomy. Dr. Hansen-Lindner said that she often uses TFA in conjunction with hysteroscopic myomectomy for this scenario. Although data on pregnancy after RFA (including TFA), MRgFUS, and HIFU are lacking, Gynesonics, the manufacturer of the Sonata System (the device that delivers radiofrequency energy to shrink the fibroid) has documented 79 pregnancies among the 2,200 women who have undergone TFA in the United States since 2018.
Disparities hampering care
Uterine fibroids are a particular problem for Black women, whose symptoms are more likely to be ignored by clinicians, according to Jodie Katon, PhD, a core investigator at the Veterans Affairs Greater Los Angeles Center for the Study of Healthcare Innovation, Implementation and Policy. Dr. Katon cited studies in which Black women interviewed about their experiences reported a consistent theme: Clinicians dismissed their symptoms, told them these were nothing to worry about, and advised them to lose weight. Those interactions not only delayed diagnosis among Black women but also led many of them to mistrust clinicians and avoid the health care system altogether.
The failure of clinicians to take their complaints seriously is just one of the disparities affecting Black women. In reviewing the literature, Dr. Laughlin-Tommaso, who also serves as the associate dean for Education Diversity, Equity, and Inclusion at the Mayo Clinic, found that African American women experience two to three times the risk for fibroids, compared with White women, as well as earlier onset and more severe disease, as measured by number and size of the lesions.
According to Dr. Katon, the etiology of fibroids is still poorly understood. “What we do know is that Black women are disproportionately exposed to a variety of factors that we have shown through observational studies are associated with increased risk of development of uterine fibroids.”
The list includes factors like stress; interpersonal racism; early age at menarche; various indicators of poor diets, such as vitamin D deficiency; the use of certain beauty products, specifically hair straighteners; as well as exposure to air pollution and other environmental toxins.
Laughlin-Tommaso also pointed to historical disparities in management, citing a doubled risk for hysterectomy for Black women in a study published in 2007 despite survey data suggesting that Black women report being more interested in uterine-preserving therapies rather than a hysterectomy.
Breaking down barriers of access to new treatments
Dr. Laughlin-Tommaso looked at more recent trends in the management of fibroids using data from the multicenter COMPARE-UF study, which enrolled women between 2015 and 2020 undergoing fibroid treatment into a longitudinal registry to track their outcomes. She found that Black women underwent hysterectomies at a lower rate than did White women and were instead more likely to undergo myomectomy or UAE.
Some of the change may reflect lack of approved minimally invasive procedures before 2000. “But now that we have expanded options, I think most women are opting not to have a hysterectomy,” Dr. Laughlin-Tommaso said.
Dr. Katon has research funding from the VA to look more closely at racial disparities in the treatment of fibroids. In a study published in April 2023, she reported some surprising trends.
During the period from 2010 to 2018, she found that Black veterans diagnosed with fibroids were less likely than White veterans were to receive treatment, regardless of their age or the severity of their symptoms. This finding held even among women with anemia, which should have been a clear indication for treatment.
But, as in the COMPARE-UF study, the subset of Black veterans who received an interventional treatment were less likely than their White peers were to undergo hysterectomy in favor of a fertility-sparing treatment as their initial procedure. Dr. Katon called it a “welcome but unexpected finding.”
But another significant barrier remains: The two newest types of procedures, RFA and guided focused ultrasound, are not commonly performed outside of tertiary care facilities. However, studies have found that all these procedures are cost effective (studies for myomectomy, UAE, MRgFUS, and TFA). The implementation of a category 1 billing code for laparoscopic RFA in 2017 has led more insurance companies to cover the service, and a category 1 code will be available for TFA effective January 2024.
Although RFA does require investment in specialized equipment, which limits facilities from offering the procedure, any gynecologist who routinely performs hysteroscopy can easily learn to do TFA. And the VA, which is committed to eliminating disparities in women’s health, established a 2-year advanced fellowship in minimally invasive gynecologic surgery in 2022 to help expand their capacity to offer these procedures.
The VA has been rapidly expanding their gynecology services, and Katon said that she is confident that ultrasound-guided procedures and RFA will become more available within the system. “I would say we’re keeping pace. And in some ways, you know, as a national system we may be positioned to actually outpace the rest of the U.S.”
Dr. Segars reported prior research funding for clinical trials from BioSpecifics Technologies, Bayer, Allergan, AbbVie, and ObsEva and currently receives funding from Myovant Sciences. Dr. Hansen-Lindner reported personal fees from Gynesonics. Dr. Singh, Dr. Laughlin-Tommaso, and Dr. Katon reported no financial conflicts of interest.
A version of this article first appeared on Medscape.com.
In 2022, two colleagues from Johns Hopkins University, Baltimore, Bhuchitra Singh, MD, MPH, MS, MBA, and James Segars Jr., MD, reviewed the available literature to evaluate the effectiveness of newer minimally invasive therapies in reducing bleeding and improving the quality of life and control of symptoms linked to uterine fibroids.
Their goal, according to Dr. Segars, a professor of obstetrics and gynecology and director of the division of women’s health research at Johns Hopkins, was to help guide clinicians and patients in making decisions about the use of the newer therapies, including radiofrequency ablation and ultrasound-guided removal of lesions.
But he and Dr. Singh, the director of clinical research at the Howard W. and Georgeanna Seegar Jones Laboratory of Reproductive Sciences and Women’s Health Research, were surprised by their findings. “The outcomes were relatively the same,” Dr. Segars said. “All of the modalities lead to significant reduction in bleeding and other fibroid-related symptoms.”
The data on long-term complications and risk for recurrence are sparse for some of the newer approaches, and not enough high-quality long-term studies have been conducted for the Food and Drug Administration to approve them as fertility-sparing treatments.
But perhaps, the biggest challenge now is to ensure that women can take advantage of these newer therapies, with large gaps in both the diagnosis of fibroids and geographic access to minimally invasive treatments.
A widespread condition widely underdiagnosed
Uterine fibroids occur in most women (the incidence rises with age) and can be found in up to 70% of women by the time they reach menopause. Risk factors include family history, increasing interval since last birth, hypertension, and obesity. Increasing parity and use of oral contraceptives are protective.
But as many as 50% of cases go undiagnosed, and one reason for this is the failure of clinicians to dig deeply enough into women’s menstrual histories to diagnose fibroids.
“The most common cause of anemia is heavy menstrual bleeding,” said Shannon Laughlin-Tommaso, MD, MPH, a professor of obstetrics and gynecology at Mayo Clinic in Rochester, Minn. She frequently sees patients who have already undergone colonoscopy to work-up the source of their anemia before anyone suspects that fibroids are the culprit.
“When women tell us about their periods, what they’ve been told is normal [bleeding] – or what they’ve always had and considered normal – is actually kind of on the heavier spectrum,” she said.
Ideally, treatment for uterine fibroids would fix abnormally prolonged or heavy menstrual bleeding, relieve pain, and ameliorate symptoms associated with an enlarged uterus, such as pelvic pressure, urinary frequency, and constipation. And the fibroids would never recur.
By those measures, hysterectomy fits the bill: Success rates in relieving symptoms are high, and the risk for recurrence is zero. But the procedure carries significant drawbacks: short-term complications of surgery, including infection, bleeding, and injury to the bowels and bladder along with potential long-term risks for cardiovascular disease, cancer, ovarian failure and premature menopause, depression, and decline in cognitive function. Those factors loom even larger for women who still hope to have children.
For that reason, the American College of Obstetricians and Gynecologists recommends myomectomy, or surgical removal of individual fibroids, for women who desire uterine preservation or future pregnancy. And the literature here is solid, according to Dr. Singh, who found that 95% of myomectomy patients achieved control of their bleeding symptoms, whether it was via laparoscopy, hysteroscopy, or laparotomy. Up to 40% of women may develop new fibroids, or leiomyomas, within 3 years, although only 12.2% required a second surgery up to after 5 years.
But myomectomy is invasive, requiring general anesthesia, incisions in the uterus, and stitches to close the organ.
Newer techniques have emerged that can effectively treat symptoms of fibroids without requiring surgery. Uterine artery embolization (UAE), which involves passing a catheter into the femoral artery, or laparoscopic uterine artery occlusion can be used to cut off the blood supply of the fibroid. Other techniques, including focused ultrasound surgery and radiofrequency ablation (RFA), use various forms of energy to heat and ablate fibroids. The latter two can be performed in outpatient settings and often without general anesthesia.
Approved for use in 1994, UAE has the most data available, with reduction in the volume of fibroids and uterine tissue lasting up to 5 years, and rates of reintervention of 19%-38% between 2 and 5 years after the procedure. Dr. Singh’s review found that 79%-98.5% of recipients of the procedure reported declines in bleeding that persisted for several years, which is comparable to myomectomy. Quality of life and pain scores also showed good improvement, with follow-up in the different studies ranging from 12 months to over 5 years, the analysis showed.
UAE does have its drawbacks. In rare cases, embolization can deprive the entire uterus and ovaries of blood, which can cause ovarian dysfunction and potentially result in premature menopause, although this outcome is most common in women who are older than 45 years. The procedure can often also be painful enough that overnight hospitalization is required.
Focused ultrasound surgeries, which include magnetic resonance–guided focused ultrasound surgery (MRgFUS) and high-intensity focused ultrasound (HIFU), were approved by the FDA in 2004. Focused ultrasound waves pass through the abdominal wall and produce significant heating, causing a burn that destroys the targeted tissue without damaging surrounding tissue. As with UAE, improvements in fibroid-associated bleeding and measures of quality of life were similar to those after myomectomy up to 3 years later.
But Dr. Singh noted that both focused ultrasound and RFA can damage the skin or internal organs. “[As] always with the thermal interventions, there is the probability of skin as well as internal organs that might get the thermal energy if it’s not focused correctly on to the fibroid itself,” he said. In addition, MRgFUS is not an option for women who are not good candidates to undergo an MRI, such as those with claustrophobia or pacemakers.
Also, with focus ultrasound and RFA, “we do worry about that fibroid getting blood flow back,” which can lead to recurrence of heavy menstrual bleeding, Dr. Laughlin-Tommaso noted.
Although data on RFA are limited to 12 months of follow-up, most women reported meaningful reductions in bleeding symptoms. Longer follow-up has been reported for bleeding symptoms after MRgFUS, with similar results up to 3 years later.
For Leslie Hansen-Lindner, MD, chief of obstetrics and gynecology at Atrium Health in Charlotte, N.C., choosing the right procedure starts with a patient-centered conversation weighing the pros and cons of the options and the woman’s goals.
“Is their goal to reduce the size and impact of their fibroid, bleed less, and have a better quality of life on their period?” Dr. Hansen-Lindner said. “Or is their goal to have the entire fibroid removed?”
If the former, an RFA is appealing to many women. If the latter, laparoscopic or mini-laparotomy myomectomy might be a better choice. Although fewer than 10% of patients require surgical reintervention at 3 years of follow-up for RFA, myomectomy has more consistent long-term evidence showing that fewer women require re-intervention and preserve their fertility, she added.
Age also plays a role in the decision: The closer a woman is to menopause, the less likely she is to experience a recurrence, so a less-invasive procedure is preferable. But for younger women hoping to become pregnant, the lower risk for recurrence and good prognosis for future fertility might sway the choice toward myomectomy.
The first laparoscopic RFA procedures were approved for uterine fibroids in 2012. Dr. Hansen-Lindner is a proponent of transcervical fibroid ablation (TFA), a newer RFA procedure that the FDA approved in 2018. Performed through the cervix, TFA requires no incisions and can generally be done without general anesthesia. Eligible candidates would be any woman with symptomatic fibroids, such as heavy menstrual bleeding, pain, or bulk symptoms. The contraindications are few.
“It’s going to come down to size and location of fibroids, and whether or not they would be accessible by the TFA,” Dr. Hansen-Lindner said. “I have to make sure that there isn’t a fibroid blocking their cervix and that the fibroids are accessible with this device.”
TFA also is not suitable for removing most submucosal lesions, which typically must be removed by hysteroscopic myomectomy. Dr. Hansen-Lindner said that she often uses TFA in conjunction with hysteroscopic myomectomy for this scenario. Although data on pregnancy after RFA (including TFA), MRgFUS, and HIFU are lacking, Gynesonics, the manufacturer of the Sonata System (the device that delivers radiofrequency energy to shrink the fibroid) has documented 79 pregnancies among the 2,200 women who have undergone TFA in the United States since 2018.
Disparities hampering care
Uterine fibroids are a particular problem for Black women, whose symptoms are more likely to be ignored by clinicians, according to Jodie Katon, PhD, a core investigator at the Veterans Affairs Greater Los Angeles Center for the Study of Healthcare Innovation, Implementation and Policy. Dr. Katon cited studies in which Black women interviewed about their experiences reported a consistent theme: Clinicians dismissed their symptoms, told them these were nothing to worry about, and advised them to lose weight. Those interactions not only delayed diagnosis among Black women but also led many of them to mistrust clinicians and avoid the health care system altogether.
The failure of clinicians to take their complaints seriously is just one of the disparities affecting Black women. In reviewing the literature, Dr. Laughlin-Tommaso, who also serves as the associate dean for Education Diversity, Equity, and Inclusion at the Mayo Clinic, found that African American women experience two to three times the risk for fibroids, compared with White women, as well as earlier onset and more severe disease, as measured by number and size of the lesions.
According to Dr. Katon, the etiology of fibroids is still poorly understood. “What we do know is that Black women are disproportionately exposed to a variety of factors that we have shown through observational studies are associated with increased risk of development of uterine fibroids.”
The list includes factors like stress; interpersonal racism; early age at menarche; various indicators of poor diets, such as vitamin D deficiency; the use of certain beauty products, specifically hair straighteners; as well as exposure to air pollution and other environmental toxins.
Laughlin-Tommaso also pointed to historical disparities in management, citing a doubled risk for hysterectomy for Black women in a study published in 2007 despite survey data suggesting that Black women report being more interested in uterine-preserving therapies rather than a hysterectomy.
Breaking down barriers of access to new treatments
Dr. Laughlin-Tommaso looked at more recent trends in the management of fibroids using data from the multicenter COMPARE-UF study, which enrolled women between 2015 and 2020 undergoing fibroid treatment into a longitudinal registry to track their outcomes. She found that Black women underwent hysterectomies at a lower rate than did White women and were instead more likely to undergo myomectomy or UAE.
Some of the change may reflect lack of approved minimally invasive procedures before 2000. “But now that we have expanded options, I think most women are opting not to have a hysterectomy,” Dr. Laughlin-Tommaso said.
Dr. Katon has research funding from the VA to look more closely at racial disparities in the treatment of fibroids. In a study published in April 2023, she reported some surprising trends.
During the period from 2010 to 2018, she found that Black veterans diagnosed with fibroids were less likely than White veterans were to receive treatment, regardless of their age or the severity of their symptoms. This finding held even among women with anemia, which should have been a clear indication for treatment.
But, as in the COMPARE-UF study, the subset of Black veterans who received an interventional treatment were less likely than their White peers were to undergo hysterectomy in favor of a fertility-sparing treatment as their initial procedure. Dr. Katon called it a “welcome but unexpected finding.”
But another significant barrier remains: The two newest types of procedures, RFA and guided focused ultrasound, are not commonly performed outside of tertiary care facilities. However, studies have found that all these procedures are cost effective (studies for myomectomy, UAE, MRgFUS, and TFA). The implementation of a category 1 billing code for laparoscopic RFA in 2017 has led more insurance companies to cover the service, and a category 1 code will be available for TFA effective January 2024.
Although RFA does require investment in specialized equipment, which limits facilities from offering the procedure, any gynecologist who routinely performs hysteroscopy can easily learn to do TFA. And the VA, which is committed to eliminating disparities in women’s health, established a 2-year advanced fellowship in minimally invasive gynecologic surgery in 2022 to help expand their capacity to offer these procedures.
The VA has been rapidly expanding their gynecology services, and Katon said that she is confident that ultrasound-guided procedures and RFA will become more available within the system. “I would say we’re keeping pace. And in some ways, you know, as a national system we may be positioned to actually outpace the rest of the U.S.”
Dr. Segars reported prior research funding for clinical trials from BioSpecifics Technologies, Bayer, Allergan, AbbVie, and ObsEva and currently receives funding from Myovant Sciences. Dr. Hansen-Lindner reported personal fees from Gynesonics. Dr. Singh, Dr. Laughlin-Tommaso, and Dr. Katon reported no financial conflicts of interest.
A version of this article first appeared on Medscape.com.
In 2022, two colleagues from Johns Hopkins University, Baltimore, Bhuchitra Singh, MD, MPH, MS, MBA, and James Segars Jr., MD, reviewed the available literature to evaluate the effectiveness of newer minimally invasive therapies in reducing bleeding and improving the quality of life and control of symptoms linked to uterine fibroids.
Their goal, according to Dr. Segars, a professor of obstetrics and gynecology and director of the division of women’s health research at Johns Hopkins, was to help guide clinicians and patients in making decisions about the use of the newer therapies, including radiofrequency ablation and ultrasound-guided removal of lesions.
But he and Dr. Singh, the director of clinical research at the Howard W. and Georgeanna Seegar Jones Laboratory of Reproductive Sciences and Women’s Health Research, were surprised by their findings. “The outcomes were relatively the same,” Dr. Segars said. “All of the modalities lead to significant reduction in bleeding and other fibroid-related symptoms.”
The data on long-term complications and risk for recurrence are sparse for some of the newer approaches, and not enough high-quality long-term studies have been conducted for the Food and Drug Administration to approve them as fertility-sparing treatments.
But perhaps, the biggest challenge now is to ensure that women can take advantage of these newer therapies, with large gaps in both the diagnosis of fibroids and geographic access to minimally invasive treatments.
A widespread condition widely underdiagnosed
Uterine fibroids occur in most women (the incidence rises with age) and can be found in up to 70% of women by the time they reach menopause. Risk factors include family history, increasing interval since last birth, hypertension, and obesity. Increasing parity and use of oral contraceptives are protective.
But as many as 50% of cases go undiagnosed, and one reason for this is the failure of clinicians to dig deeply enough into women’s menstrual histories to diagnose fibroids.
“The most common cause of anemia is heavy menstrual bleeding,” said Shannon Laughlin-Tommaso, MD, MPH, a professor of obstetrics and gynecology at Mayo Clinic in Rochester, Minn. She frequently sees patients who have already undergone colonoscopy to work-up the source of their anemia before anyone suspects that fibroids are the culprit.
“When women tell us about their periods, what they’ve been told is normal [bleeding] – or what they’ve always had and considered normal – is actually kind of on the heavier spectrum,” she said.
Ideally, treatment for uterine fibroids would fix abnormally prolonged or heavy menstrual bleeding, relieve pain, and ameliorate symptoms associated with an enlarged uterus, such as pelvic pressure, urinary frequency, and constipation. And the fibroids would never recur.
By those measures, hysterectomy fits the bill: Success rates in relieving symptoms are high, and the risk for recurrence is zero. But the procedure carries significant drawbacks: short-term complications of surgery, including infection, bleeding, and injury to the bowels and bladder along with potential long-term risks for cardiovascular disease, cancer, ovarian failure and premature menopause, depression, and decline in cognitive function. Those factors loom even larger for women who still hope to have children.
For that reason, the American College of Obstetricians and Gynecologists recommends myomectomy, or surgical removal of individual fibroids, for women who desire uterine preservation or future pregnancy. And the literature here is solid, according to Dr. Singh, who found that 95% of myomectomy patients achieved control of their bleeding symptoms, whether it was via laparoscopy, hysteroscopy, or laparotomy. Up to 40% of women may develop new fibroids, or leiomyomas, within 3 years, although only 12.2% required a second surgery up to after 5 years.
But myomectomy is invasive, requiring general anesthesia, incisions in the uterus, and stitches to close the organ.
Newer techniques have emerged that can effectively treat symptoms of fibroids without requiring surgery. Uterine artery embolization (UAE), which involves passing a catheter into the femoral artery, or laparoscopic uterine artery occlusion can be used to cut off the blood supply of the fibroid. Other techniques, including focused ultrasound surgery and radiofrequency ablation (RFA), use various forms of energy to heat and ablate fibroids. The latter two can be performed in outpatient settings and often without general anesthesia.
Approved for use in 1994, UAE has the most data available, with reduction in the volume of fibroids and uterine tissue lasting up to 5 years, and rates of reintervention of 19%-38% between 2 and 5 years after the procedure. Dr. Singh’s review found that 79%-98.5% of recipients of the procedure reported declines in bleeding that persisted for several years, which is comparable to myomectomy. Quality of life and pain scores also showed good improvement, with follow-up in the different studies ranging from 12 months to over 5 years, the analysis showed.
UAE does have its drawbacks. In rare cases, embolization can deprive the entire uterus and ovaries of blood, which can cause ovarian dysfunction and potentially result in premature menopause, although this outcome is most common in women who are older than 45 years. The procedure can often also be painful enough that overnight hospitalization is required.
Focused ultrasound surgeries, which include magnetic resonance–guided focused ultrasound surgery (MRgFUS) and high-intensity focused ultrasound (HIFU), were approved by the FDA in 2004. Focused ultrasound waves pass through the abdominal wall and produce significant heating, causing a burn that destroys the targeted tissue without damaging surrounding tissue. As with UAE, improvements in fibroid-associated bleeding and measures of quality of life were similar to those after myomectomy up to 3 years later.
But Dr. Singh noted that both focused ultrasound and RFA can damage the skin or internal organs. “[As] always with the thermal interventions, there is the probability of skin as well as internal organs that might get the thermal energy if it’s not focused correctly on to the fibroid itself,” he said. In addition, MRgFUS is not an option for women who are not good candidates to undergo an MRI, such as those with claustrophobia or pacemakers.
Also, with focus ultrasound and RFA, “we do worry about that fibroid getting blood flow back,” which can lead to recurrence of heavy menstrual bleeding, Dr. Laughlin-Tommaso noted.
Although data on RFA are limited to 12 months of follow-up, most women reported meaningful reductions in bleeding symptoms. Longer follow-up has been reported for bleeding symptoms after MRgFUS, with similar results up to 3 years later.
For Leslie Hansen-Lindner, MD, chief of obstetrics and gynecology at Atrium Health in Charlotte, N.C., choosing the right procedure starts with a patient-centered conversation weighing the pros and cons of the options and the woman’s goals.
“Is their goal to reduce the size and impact of their fibroid, bleed less, and have a better quality of life on their period?” Dr. Hansen-Lindner said. “Or is their goal to have the entire fibroid removed?”
If the former, an RFA is appealing to many women. If the latter, laparoscopic or mini-laparotomy myomectomy might be a better choice. Although fewer than 10% of patients require surgical reintervention at 3 years of follow-up for RFA, myomectomy has more consistent long-term evidence showing that fewer women require re-intervention and preserve their fertility, she added.
Age also plays a role in the decision: The closer a woman is to menopause, the less likely she is to experience a recurrence, so a less-invasive procedure is preferable. But for younger women hoping to become pregnant, the lower risk for recurrence and good prognosis for future fertility might sway the choice toward myomectomy.
The first laparoscopic RFA procedures were approved for uterine fibroids in 2012. Dr. Hansen-Lindner is a proponent of transcervical fibroid ablation (TFA), a newer RFA procedure that the FDA approved in 2018. Performed through the cervix, TFA requires no incisions and can generally be done without general anesthesia. Eligible candidates would be any woman with symptomatic fibroids, such as heavy menstrual bleeding, pain, or bulk symptoms. The contraindications are few.
“It’s going to come down to size and location of fibroids, and whether or not they would be accessible by the TFA,” Dr. Hansen-Lindner said. “I have to make sure that there isn’t a fibroid blocking their cervix and that the fibroids are accessible with this device.”
TFA also is not suitable for removing most submucosal lesions, which typically must be removed by hysteroscopic myomectomy. Dr. Hansen-Lindner said that she often uses TFA in conjunction with hysteroscopic myomectomy for this scenario. Although data on pregnancy after RFA (including TFA), MRgFUS, and HIFU are lacking, Gynesonics, the manufacturer of the Sonata System (the device that delivers radiofrequency energy to shrink the fibroid) has documented 79 pregnancies among the 2,200 women who have undergone TFA in the United States since 2018.
Disparities hampering care
Uterine fibroids are a particular problem for Black women, whose symptoms are more likely to be ignored by clinicians, according to Jodie Katon, PhD, a core investigator at the Veterans Affairs Greater Los Angeles Center for the Study of Healthcare Innovation, Implementation and Policy. Dr. Katon cited studies in which Black women interviewed about their experiences reported a consistent theme: Clinicians dismissed their symptoms, told them these were nothing to worry about, and advised them to lose weight. Those interactions not only delayed diagnosis among Black women but also led many of them to mistrust clinicians and avoid the health care system altogether.
The failure of clinicians to take their complaints seriously is just one of the disparities affecting Black women. In reviewing the literature, Dr. Laughlin-Tommaso, who also serves as the associate dean for Education Diversity, Equity, and Inclusion at the Mayo Clinic, found that African American women experience two to three times the risk for fibroids, compared with White women, as well as earlier onset and more severe disease, as measured by number and size of the lesions.
According to Dr. Katon, the etiology of fibroids is still poorly understood. “What we do know is that Black women are disproportionately exposed to a variety of factors that we have shown through observational studies are associated with increased risk of development of uterine fibroids.”
The list includes factors like stress; interpersonal racism; early age at menarche; various indicators of poor diets, such as vitamin D deficiency; the use of certain beauty products, specifically hair straighteners; as well as exposure to air pollution and other environmental toxins.
Laughlin-Tommaso also pointed to historical disparities in management, citing a doubled risk for hysterectomy for Black women in a study published in 2007 despite survey data suggesting that Black women report being more interested in uterine-preserving therapies rather than a hysterectomy.
Breaking down barriers of access to new treatments
Dr. Laughlin-Tommaso looked at more recent trends in the management of fibroids using data from the multicenter COMPARE-UF study, which enrolled women between 2015 and 2020 undergoing fibroid treatment into a longitudinal registry to track their outcomes. She found that Black women underwent hysterectomies at a lower rate than did White women and were instead more likely to undergo myomectomy or UAE.
Some of the change may reflect lack of approved minimally invasive procedures before 2000. “But now that we have expanded options, I think most women are opting not to have a hysterectomy,” Dr. Laughlin-Tommaso said.
Dr. Katon has research funding from the VA to look more closely at racial disparities in the treatment of fibroids. In a study published in April 2023, she reported some surprising trends.
During the period from 2010 to 2018, she found that Black veterans diagnosed with fibroids were less likely than White veterans were to receive treatment, regardless of their age or the severity of their symptoms. This finding held even among women with anemia, which should have been a clear indication for treatment.
But, as in the COMPARE-UF study, the subset of Black veterans who received an interventional treatment were less likely than their White peers were to undergo hysterectomy in favor of a fertility-sparing treatment as their initial procedure. Dr. Katon called it a “welcome but unexpected finding.”
But another significant barrier remains: The two newest types of procedures, RFA and guided focused ultrasound, are not commonly performed outside of tertiary care facilities. However, studies have found that all these procedures are cost effective (studies for myomectomy, UAE, MRgFUS, and TFA). The implementation of a category 1 billing code for laparoscopic RFA in 2017 has led more insurance companies to cover the service, and a category 1 code will be available for TFA effective January 2024.
Although RFA does require investment in specialized equipment, which limits facilities from offering the procedure, any gynecologist who routinely performs hysteroscopy can easily learn to do TFA. And the VA, which is committed to eliminating disparities in women’s health, established a 2-year advanced fellowship in minimally invasive gynecologic surgery in 2022 to help expand their capacity to offer these procedures.
The VA has been rapidly expanding their gynecology services, and Katon said that she is confident that ultrasound-guided procedures and RFA will become more available within the system. “I would say we’re keeping pace. And in some ways, you know, as a national system we may be positioned to actually outpace the rest of the U.S.”
Dr. Segars reported prior research funding for clinical trials from BioSpecifics Technologies, Bayer, Allergan, AbbVie, and ObsEva and currently receives funding from Myovant Sciences. Dr. Hansen-Lindner reported personal fees from Gynesonics. Dr. Singh, Dr. Laughlin-Tommaso, and Dr. Katon reported no financial conflicts of interest.
A version of this article first appeared on Medscape.com.
Bariatric surgery still best option for some with obesity
Bariatric surgery continues to play a major role in obesity management despite the emergence of potent new weight-loss medications, according to two experts who spoke at an Endocrine Society science writers briefing.
“Bariatric surgery is safe, effective, and unfortunately underutilized for treating obesity and its complications,” said Jaime Almandoz, MD, medical director of the Weight Wellness Program at the University of Texas Southwestern Medical Center, Dallas.
Added Dr. Almandoz, who is triple board-certified in internal medicine, endocrinology, and obesity medicine, “Sometimes this gets presented in a linear fashion. ‘We’ll try lifestyle first, and if that doesn’t work, we’ll try medications, and if that doesn’t work, we’ll try surgery.’ But sometimes we might need to go straight to surgery instead of going through medications first, because it may be the most effective and evidence-based treatment for the person in the office in front of you.”
Moreover, he pointed out that currently, Medicare and many private insurers don’t cover antiobesity medications but do cover bariatric surgery.
Indeed, Srividya Kidambi, MD, professor and chief of endocrinology and molecular medicine at the Medical College of Wisconsin/Froedtert Hospital, Milwaukee, said there are certain types of patients for whom she might consider bariatric surgery first. One would be a person with a body mass index (BMI) greater than 40 kg/m2 or with a BMI greater than 35 kg/m2 and severe comorbidities.
Another, she said, would be young, relatively healthy people with obesity who have no comorbid conditions. “We know that if we stop the medication, the weight comes back. So, if I see a 20- to 25-year-old, am I really to commit them to lifelong therapy, or is bariatric surgery a better option in these cases? These drugs have not been around that long ... so I tend to recommend bariatric surgery in some patients.”
During the recent briefing, Dr. Almandoz summarized the evidence base for the benefits of bariatric surgery beyond weight loss, which include remission of type 2 diabetes and fatty liver disease, reduction of the risks of cardiovascular disease and cancer, and increased life expectancy.
“Everyone seems to be talking about GLP-1s for facilitating weight loss and treating obesity. ... What I want to do is provide a counterpoint to accessible therapies that are covered by more insurance plans and that may, in fact, have a better evidence base for treating obesity and its related complications,” he said in his introduction.
Bariatric surgery has been used for decades, and many centers of excellence perform it, with greatly reduced complication rates seen today than in the past. “It’s comparable to having a gallbladder surgery in terms of perioperative risk,” he noted.
Medicare and private insurers generally cover bariatric surgery for people with BMI greater than 40 kg/m2 or 35-39 kg/m2 and at least one weight-related comorbidity, including type 2 diabetes, obstructive sleep apnea, hypertension, atherosclerotic disease, hyperlipidemia, and fatty liver disease.
Data suggest that weight reduction of about 3% can lead to meaningful reductions in blood glucose and triglyceride levels, but weight loss of 15% or greater is associated with reductions in cardiovascular events and type 2 diabetes remission. Lifestyle modification typically produces about 5% weight loss, compared with 20%-35% with bariatric surgery with sleeve gastrectomy or gastric bypass.
Older weight loss medications produced weight loss of 5%-10%; only the newer medications, semaglutide 2.4 mg and tirzepatide, come close to that. Weight loss with semaglutide is about 15%, while tirzepatide can produce weight loss of up to 22%. But, there are still issues with affordability, access, and lack of coverage, Dr. Almandoz noted.
One recent randomized trial of more than 400 individuals showed that bariatric surgery was more effective than lifestyle and medical therapies for treating metabolic-associated steatohepatitis without worsening of fibrosis.
Another showed that the surgery was associated with fewer major adverse liver outcomes among people who already had MASH. That same study showed a 70% reduction in cardiovascular events with bariatric surgery.
For patients with type 2 diabetes, numerous trials have demonstrated long-term remission and reduced A1c at 5 years and 10 years post surgery, along with reductions in microvascular and macrovascular complications.
Other data suggest that a shorter history of type 2 diabetes is among the factors predicting remission with bariatric surgery. “Oftentimes, both patients and providers will wait until the diabetes is quite advanced before they even have the conversation about weight loss or even bariatric surgery. This suggests that if we intervene earlier in the course of disease, when it is less severe and less advanced, we have a higher rate of causing remission in the diabetes,” Dr. Almandoz said.
The American Diabetes Association’s Standards of Care incorporate bariatric surgery as either “recommended” or “may be considered” to treat type 2 diabetes, depending on BMI level, for those who don’t achieve durable weight loss with nonsurgical methods, he noted.
A retrospective cohort study showed significant reductions in cardiovascular outcomes with bariatric surgery among people with baseline cardiovascular disease. “This is not just about bariatric surgery to cause weight loss. This is about the multitude of effects that happen when we treat obesity as a disease with highly effective therapies such as surgery,” he said.
Even cancer risk and cancer-related mortality were significantly reduced with bariatric surgery, another study found.
And in the long-term Swedish Obese Subjects Study, among people with obesity, bariatric surgery was associated with a 3-year increase in life expectancy, compared with not undergoing surgery.
However, Dr. Almandoz also pointed out that some patients may benefit from both weight-loss medication and bariatric surgery. “Once someone has undergone pharmacotherapy, there may still be a role for bariatric procedures in helping to optimize body weight and control body weight long term. And likewise for those who have undergone bariatric surgery, there’s also a role for pharmacotherapy in terms of treating insufficient weight loss or weight recurrence after bariatric surgery. ... So I think there’s clearly a role for integration of therapies.”
Dr. Almandoz serves as consultant/advisory board member for Novo Nordisk, Boehringer Ingelheim, and Eli Lilly. Dr. Kidambi is director of TOPS Center for Metabolic Research and is medical editor of TOPS Magazine, for which her institution receives an honorarium.
A version of this article first appeared on Medscape.com.
Bariatric surgery continues to play a major role in obesity management despite the emergence of potent new weight-loss medications, according to two experts who spoke at an Endocrine Society science writers briefing.
“Bariatric surgery is safe, effective, and unfortunately underutilized for treating obesity and its complications,” said Jaime Almandoz, MD, medical director of the Weight Wellness Program at the University of Texas Southwestern Medical Center, Dallas.
Added Dr. Almandoz, who is triple board-certified in internal medicine, endocrinology, and obesity medicine, “Sometimes this gets presented in a linear fashion. ‘We’ll try lifestyle first, and if that doesn’t work, we’ll try medications, and if that doesn’t work, we’ll try surgery.’ But sometimes we might need to go straight to surgery instead of going through medications first, because it may be the most effective and evidence-based treatment for the person in the office in front of you.”
Moreover, he pointed out that currently, Medicare and many private insurers don’t cover antiobesity medications but do cover bariatric surgery.
Indeed, Srividya Kidambi, MD, professor and chief of endocrinology and molecular medicine at the Medical College of Wisconsin/Froedtert Hospital, Milwaukee, said there are certain types of patients for whom she might consider bariatric surgery first. One would be a person with a body mass index (BMI) greater than 40 kg/m2 or with a BMI greater than 35 kg/m2 and severe comorbidities.
Another, she said, would be young, relatively healthy people with obesity who have no comorbid conditions. “We know that if we stop the medication, the weight comes back. So, if I see a 20- to 25-year-old, am I really to commit them to lifelong therapy, or is bariatric surgery a better option in these cases? These drugs have not been around that long ... so I tend to recommend bariatric surgery in some patients.”
During the recent briefing, Dr. Almandoz summarized the evidence base for the benefits of bariatric surgery beyond weight loss, which include remission of type 2 diabetes and fatty liver disease, reduction of the risks of cardiovascular disease and cancer, and increased life expectancy.
“Everyone seems to be talking about GLP-1s for facilitating weight loss and treating obesity. ... What I want to do is provide a counterpoint to accessible therapies that are covered by more insurance plans and that may, in fact, have a better evidence base for treating obesity and its related complications,” he said in his introduction.
Bariatric surgery has been used for decades, and many centers of excellence perform it, with greatly reduced complication rates seen today than in the past. “It’s comparable to having a gallbladder surgery in terms of perioperative risk,” he noted.
Medicare and private insurers generally cover bariatric surgery for people with BMI greater than 40 kg/m2 or 35-39 kg/m2 and at least one weight-related comorbidity, including type 2 diabetes, obstructive sleep apnea, hypertension, atherosclerotic disease, hyperlipidemia, and fatty liver disease.
Data suggest that weight reduction of about 3% can lead to meaningful reductions in blood glucose and triglyceride levels, but weight loss of 15% or greater is associated with reductions in cardiovascular events and type 2 diabetes remission. Lifestyle modification typically produces about 5% weight loss, compared with 20%-35% with bariatric surgery with sleeve gastrectomy or gastric bypass.
Older weight loss medications produced weight loss of 5%-10%; only the newer medications, semaglutide 2.4 mg and tirzepatide, come close to that. Weight loss with semaglutide is about 15%, while tirzepatide can produce weight loss of up to 22%. But, there are still issues with affordability, access, and lack of coverage, Dr. Almandoz noted.
One recent randomized trial of more than 400 individuals showed that bariatric surgery was more effective than lifestyle and medical therapies for treating metabolic-associated steatohepatitis without worsening of fibrosis.
Another showed that the surgery was associated with fewer major adverse liver outcomes among people who already had MASH. That same study showed a 70% reduction in cardiovascular events with bariatric surgery.
For patients with type 2 diabetes, numerous trials have demonstrated long-term remission and reduced A1c at 5 years and 10 years post surgery, along with reductions in microvascular and macrovascular complications.
Other data suggest that a shorter history of type 2 diabetes is among the factors predicting remission with bariatric surgery. “Oftentimes, both patients and providers will wait until the diabetes is quite advanced before they even have the conversation about weight loss or even bariatric surgery. This suggests that if we intervene earlier in the course of disease, when it is less severe and less advanced, we have a higher rate of causing remission in the diabetes,” Dr. Almandoz said.
The American Diabetes Association’s Standards of Care incorporate bariatric surgery as either “recommended” or “may be considered” to treat type 2 diabetes, depending on BMI level, for those who don’t achieve durable weight loss with nonsurgical methods, he noted.
A retrospective cohort study showed significant reductions in cardiovascular outcomes with bariatric surgery among people with baseline cardiovascular disease. “This is not just about bariatric surgery to cause weight loss. This is about the multitude of effects that happen when we treat obesity as a disease with highly effective therapies such as surgery,” he said.
Even cancer risk and cancer-related mortality were significantly reduced with bariatric surgery, another study found.
And in the long-term Swedish Obese Subjects Study, among people with obesity, bariatric surgery was associated with a 3-year increase in life expectancy, compared with not undergoing surgery.
However, Dr. Almandoz also pointed out that some patients may benefit from both weight-loss medication and bariatric surgery. “Once someone has undergone pharmacotherapy, there may still be a role for bariatric procedures in helping to optimize body weight and control body weight long term. And likewise for those who have undergone bariatric surgery, there’s also a role for pharmacotherapy in terms of treating insufficient weight loss or weight recurrence after bariatric surgery. ... So I think there’s clearly a role for integration of therapies.”
Dr. Almandoz serves as consultant/advisory board member for Novo Nordisk, Boehringer Ingelheim, and Eli Lilly. Dr. Kidambi is director of TOPS Center for Metabolic Research and is medical editor of TOPS Magazine, for which her institution receives an honorarium.
A version of this article first appeared on Medscape.com.
Bariatric surgery continues to play a major role in obesity management despite the emergence of potent new weight-loss medications, according to two experts who spoke at an Endocrine Society science writers briefing.
“Bariatric surgery is safe, effective, and unfortunately underutilized for treating obesity and its complications,” said Jaime Almandoz, MD, medical director of the Weight Wellness Program at the University of Texas Southwestern Medical Center, Dallas.
Added Dr. Almandoz, who is triple board-certified in internal medicine, endocrinology, and obesity medicine, “Sometimes this gets presented in a linear fashion. ‘We’ll try lifestyle first, and if that doesn’t work, we’ll try medications, and if that doesn’t work, we’ll try surgery.’ But sometimes we might need to go straight to surgery instead of going through medications first, because it may be the most effective and evidence-based treatment for the person in the office in front of you.”
Moreover, he pointed out that currently, Medicare and many private insurers don’t cover antiobesity medications but do cover bariatric surgery.
Indeed, Srividya Kidambi, MD, professor and chief of endocrinology and molecular medicine at the Medical College of Wisconsin/Froedtert Hospital, Milwaukee, said there are certain types of patients for whom she might consider bariatric surgery first. One would be a person with a body mass index (BMI) greater than 40 kg/m2 or with a BMI greater than 35 kg/m2 and severe comorbidities.
Another, she said, would be young, relatively healthy people with obesity who have no comorbid conditions. “We know that if we stop the medication, the weight comes back. So, if I see a 20- to 25-year-old, am I really to commit them to lifelong therapy, or is bariatric surgery a better option in these cases? These drugs have not been around that long ... so I tend to recommend bariatric surgery in some patients.”
During the recent briefing, Dr. Almandoz summarized the evidence base for the benefits of bariatric surgery beyond weight loss, which include remission of type 2 diabetes and fatty liver disease, reduction of the risks of cardiovascular disease and cancer, and increased life expectancy.
“Everyone seems to be talking about GLP-1s for facilitating weight loss and treating obesity. ... What I want to do is provide a counterpoint to accessible therapies that are covered by more insurance plans and that may, in fact, have a better evidence base for treating obesity and its related complications,” he said in his introduction.
Bariatric surgery has been used for decades, and many centers of excellence perform it, with greatly reduced complication rates seen today than in the past. “It’s comparable to having a gallbladder surgery in terms of perioperative risk,” he noted.
Medicare and private insurers generally cover bariatric surgery for people with BMI greater than 40 kg/m2 or 35-39 kg/m2 and at least one weight-related comorbidity, including type 2 diabetes, obstructive sleep apnea, hypertension, atherosclerotic disease, hyperlipidemia, and fatty liver disease.
Data suggest that weight reduction of about 3% can lead to meaningful reductions in blood glucose and triglyceride levels, but weight loss of 15% or greater is associated with reductions in cardiovascular events and type 2 diabetes remission. Lifestyle modification typically produces about 5% weight loss, compared with 20%-35% with bariatric surgery with sleeve gastrectomy or gastric bypass.
Older weight loss medications produced weight loss of 5%-10%; only the newer medications, semaglutide 2.4 mg and tirzepatide, come close to that. Weight loss with semaglutide is about 15%, while tirzepatide can produce weight loss of up to 22%. But, there are still issues with affordability, access, and lack of coverage, Dr. Almandoz noted.
One recent randomized trial of more than 400 individuals showed that bariatric surgery was more effective than lifestyle and medical therapies for treating metabolic-associated steatohepatitis without worsening of fibrosis.
Another showed that the surgery was associated with fewer major adverse liver outcomes among people who already had MASH. That same study showed a 70% reduction in cardiovascular events with bariatric surgery.
For patients with type 2 diabetes, numerous trials have demonstrated long-term remission and reduced A1c at 5 years and 10 years post surgery, along with reductions in microvascular and macrovascular complications.
Other data suggest that a shorter history of type 2 diabetes is among the factors predicting remission with bariatric surgery. “Oftentimes, both patients and providers will wait until the diabetes is quite advanced before they even have the conversation about weight loss or even bariatric surgery. This suggests that if we intervene earlier in the course of disease, when it is less severe and less advanced, we have a higher rate of causing remission in the diabetes,” Dr. Almandoz said.
The American Diabetes Association’s Standards of Care incorporate bariatric surgery as either “recommended” or “may be considered” to treat type 2 diabetes, depending on BMI level, for those who don’t achieve durable weight loss with nonsurgical methods, he noted.
A retrospective cohort study showed significant reductions in cardiovascular outcomes with bariatric surgery among people with baseline cardiovascular disease. “This is not just about bariatric surgery to cause weight loss. This is about the multitude of effects that happen when we treat obesity as a disease with highly effective therapies such as surgery,” he said.
Even cancer risk and cancer-related mortality were significantly reduced with bariatric surgery, another study found.
And in the long-term Swedish Obese Subjects Study, among people with obesity, bariatric surgery was associated with a 3-year increase in life expectancy, compared with not undergoing surgery.
However, Dr. Almandoz also pointed out that some patients may benefit from both weight-loss medication and bariatric surgery. “Once someone has undergone pharmacotherapy, there may still be a role for bariatric procedures in helping to optimize body weight and control body weight long term. And likewise for those who have undergone bariatric surgery, there’s also a role for pharmacotherapy in terms of treating insufficient weight loss or weight recurrence after bariatric surgery. ... So I think there’s clearly a role for integration of therapies.”
Dr. Almandoz serves as consultant/advisory board member for Novo Nordisk, Boehringer Ingelheim, and Eli Lilly. Dr. Kidambi is director of TOPS Center for Metabolic Research and is medical editor of TOPS Magazine, for which her institution receives an honorarium.
A version of this article first appeared on Medscape.com.
Why don’t doctors feel like heroes anymore?
In April 2020, as many Americans prepared to spend the Easter holiday in lockdown, pop star Mariah Carey released a video honoring the “sacrifices and courage” of frontline workers battling COVID-19 – her 1993 hit, “Hero.”
“The sorrow that you know will melt away,” Ms. Carey sang. “When you feel like hope is gone,” the song continued, strength and answers can be found within, and “a hero lies in you.”
For health care professionals, the reality of 2020 wasn’t quite so uplifting. PPE shortages and spillover ICUs had many feeling helpless, exhausted, and overwhelmed. Few if any medical professionals felt their sorrows “melt away.”
We can’t expect depth and nuance from pop songs, but we can find in them the imagery that runs through our culture. The “hero narrative” – the idea that doctors, nurses, and others in health care have superhuman endurance and selflessness – has long been an undercurrent in the medical field.
And yet, without a workforce willing to perform without adequate sleep, food, or time off, the health care system couldn’t function, says Brian Park, MD, MPH, a family medicine physician at Oregon Health & Science University, Portland. At many academic health centers, for example, residents are “the bedrock of the workforce,” he explains. If they didn’t work 80-100 hours per week, those systems wouldn’t exist.
So, how do we look at the health care system in a way that is both grateful and critical, Dr. Park wonders. “How do we honor extreme acts of heroism and also acknowledge that the system sometimes gets by on the acts of heroes to patch up some of the brokenness and fragmentation within it?”
Heroes are determined
Ala Stanford, MD, a pediatric surgeon in Philadelphia, has frequently been called a “health care hero.” Given the title by CNN in 2021, she has received numerous other awards and accolades, featured in Fortune Magazine’s “World’s 50 Greatest Leaders” in 2021 and USA Today’s “Women of the Year” in 2022.
In 2020, Dr. Stanford was sheltering in place and watching “way too much” cable news. “They would play solemn music and show photos of all the people who had died,” she recalls. “I thought, ‘All these people are Black or brown. What is going on?’”
The standard explanation was that people of color were more vulnerable because they were more likely to be essential workers or have chronic health conditions. But Dr. Stanford believed this was only part of the story. The reason she saw that local Black communities had higher positivity rates was because people couldn’t get a COVID test.
Dr. Stanford got call after call from Philadelphians who had been turned away from testing centers. When she questioned colleagues, “they gave me every reason under the sun,” Dr. Stanford says. “It was because someone took public transportation, and they were only testing people in cars, or because they weren’t over 65, or because they didn’t have other comorbid health conditions, or because they weren’t a health care worker, or because they hadn’t traveled to China ...” The list went on.
Dr. Stanford appealed to local, state, and federal health authorities. Finally, she took matters into her own hands. She found tests, packed a van with masks, gowns, and gloves, and drove across the city going door to door. Eventually, she organized testing in the parking lots of Black churches, sometimes seeing more than 400 people per day.
The services were funded entirely through her own bank account and donations until she was eventually awarded a CDC grant through the Coronavirus Aid, Relief, and Economic Security (CARES) Act of 2020 and began to receive contracts from the city.
Since then, Dr. Stanford’s mission has evolved. She and her team provided COVID vaccinations to thousands, and in 2021, opened the Dr. Ala Stanford Center for Health Equity. The center offers primary care for all ages in underserved communities.
Still, Dr. Stanford doesn’t think of herself as a hero, and she stresses that many other people contributed to her success. “I think the world was on fire, and we were all firefighters,” Dr. Stanford says. “Someone said to me, ‘Ala, you ran to the fire and everyone else was running away from it, and you didn’t have to.’ … I feel like I was able to galvanize people to realize the power that they actually had. Maybe independently, they couldn’t do a whole lot, but collectively, we were a force.”
Heroes are selfless
Nicole Jackson, RN, an emergency room manager and nurse at Advocate Trinity Hospital in Chicago, was recently honored as a Health Care Hero by the American Red Cross of Greater Chicago.
On June 23, 2022, Jackson’s emergency department was understaffed and struggling with an influx of patients when three gunshot victims arrived. Two needed to be transferred to a trauma center, and one – with multiple gunshot wounds – required a critical care nurse in the ambulance. But the ETA for that transport was 90 minutes, which meant the patient might not survive. Although Ms. Jackson was already working beyond her shift, she rode in the ambulance with the patient herself and probably saved his life.
While this incident stood out to a colleague who nominated her for the Red Cross award, Ms. Jackson finds herself working extra hours fairly often. “Since COVID, that’s pretty much been like any other hospital,” she says. “We’ve had staffing challenges that we work through every day. So, the nurses come, they show up, and they do the best that they can with what we have to keep our patients safe.”
A 2022 survey by McKinsey estimated that by 2025, there could be a gap of 200,000 to 450,000 nurses in the United States. A two-year impact assessment from the American Nurses Foundation found that among more than 12,500 nurses, 40% were considering leaving their positions before the pandemic. By 2022, that number had jumped to 52% with the top reasons being insufficient staffing and negative effects on health and well-being.
Can the “hero narrative” help that situation? Ms. Jackson says she doesn’t see herself as a hero, but the supportive environment and gestures of recognition by staff do make her feel appreciated. These include daily messages offering “kudos” and nominations for the DAISY Award, which she herself received in 2022.
“I have people who I have encouraged to become nurses,” Ms. Jackson says, “and when they saw [the award], they were really excited about becoming a nurse.”
Heroes are strong
Jasmine Marcelin, MD, an infectious disease physician with Nebraska Medicine in Omaha, understands the need for heroes as symbols and sources of inspiration. Dr. Marcelin is a fan of the superhero movie genre. There is value, she says, in feeling hope and excitement while watching Superman or Wonder Woman save the day. Who doesn’t want to believe (if only briefly) that the good guys will always win?
In reality, Dr. Marcelin says, “none of us are invincible.” And it’s dangerous to forget that “the people behind the symbols are also human.”
In 2021, Dr. Marcelin gave a TEDx talk entitled, “The Myth of the Health Care Hero.” In it she discussed the extreme physical and mental toll of the pandemic on health care workers and urged her audience to think less about extravagant praise and more about their personal responsibilities. “We don’t want or need to be called heroes,” Dr. Marcelin said. “Right now, our love language is action. We need your help, and we cannot save the world on our own.”
Dr. Marcelin also sees links between superhuman expectations and the high levels of burnout in the medical field.
“It’s a systemic issue,” she explains, “where it requires a revamping and revitalization of the entire psyche of health care to recognize that the people working within this profession are human. And the things that we think and feel and need are the same as anybody else.”
Heroes are self-sacrificing
Well-being, burnout, and disengagement in health care has become a focus for Oregon Health & Science’s Dr. Park, who is also director of RELATE Lab, an organization that aims to make health care more human-centered and equitable through leadership training, research, and community organizing.
For him, hearing neighbors banging pots and pans during the early pandemic was complicated. “The first phase for me was, ‘Thank you. I feel seen. I feel appreciated,’ ” he says. “Yes, I’m wearing a mask. I’m going in. I’m changing in the garage when I come home, so my kid and my partner don’t get sick.”
But after a while, the cheers started to feel like pressure. “Have I done anything heroic today?” Dr. Park asked himself. “Have I been as heroic as my friend who is in the hospital in the ICU? I don’t deserve this, so don’t bang those pots and pans for me.”
When your identity becomes about being a hero, Dr. Park says, when that becomes the standard by which you measure yourself, the result is often a sense of shame.
“I think a lot of people feel ashamed that they feel burnout,” he says, “because they’re supposed to be heroes, putting on their capes and masks. They’re waking up and saying, ‘I’m exhausted, and I can’t play that part today. But I know that’s the social expectation of me.’ “
Heroes are noble
There may not be a clear solution, but for many health care professionals, symbolic gestures alone are inadequate and, in certain cases, insulting.
On Doctor’s Day 2023, Alok Patel, MD, a pediatric hospitalist, tweeted a photo of an appreciation “gift” for staff from an unnamed hospital. The small items had metaphorical meanings – a rubber band “as a reminder to stay flexible,” a quarter “as a reminder to ‘call’ for help,” etc.
“Welcome to how you give thanks to ‘health care heroes,’ ” Dr. Patel tweeted.
For Dr. Patel, the issue is not lavish gifts but a need for an attitude shift. He recalls colleagues who felt ashamed asking for mental health services or time off, “because they were bombarded by the hero narrative, by the manufactured pressure that they needed to put their jobs above their own health – because that’s what ‘heroes’ do. I’m willing to bet most physicians would rather receive a sincere email with a transparent plan to better support health care workers than any Doctor’s Day gift,” he says.
In Dr. Marcelin’s TEDx talk, she quotes Spider-Man’s classic adage, “With great power, comes great responsibility.” She argues that this motto doesn’t just apply to those who can fly or deflect bullets; that’s not what heroism is. In fact, most people have their own definition of the word.
For Dr. Stanford, a hero is “someone who is selfless, putting the needs of others before their own.” Dr. Park believes there are no individual heroes. “It’s the work of the collective that’s truly heroic.”
By those standards, clearly anyone can step up, offer help, act with courage and kindness, and be heroic. “We humans, as ordinary as we are, can be extraordinary by using our power to do what’s right,” Dr. Marcelin says, “because there’s no such thing as health care heroes, just good people doing the right thing.”
A version of this article first appeared on Medscape.com.
In April 2020, as many Americans prepared to spend the Easter holiday in lockdown, pop star Mariah Carey released a video honoring the “sacrifices and courage” of frontline workers battling COVID-19 – her 1993 hit, “Hero.”
“The sorrow that you know will melt away,” Ms. Carey sang. “When you feel like hope is gone,” the song continued, strength and answers can be found within, and “a hero lies in you.”
For health care professionals, the reality of 2020 wasn’t quite so uplifting. PPE shortages and spillover ICUs had many feeling helpless, exhausted, and overwhelmed. Few if any medical professionals felt their sorrows “melt away.”
We can’t expect depth and nuance from pop songs, but we can find in them the imagery that runs through our culture. The “hero narrative” – the idea that doctors, nurses, and others in health care have superhuman endurance and selflessness – has long been an undercurrent in the medical field.
And yet, without a workforce willing to perform without adequate sleep, food, or time off, the health care system couldn’t function, says Brian Park, MD, MPH, a family medicine physician at Oregon Health & Science University, Portland. At many academic health centers, for example, residents are “the bedrock of the workforce,” he explains. If they didn’t work 80-100 hours per week, those systems wouldn’t exist.
So, how do we look at the health care system in a way that is both grateful and critical, Dr. Park wonders. “How do we honor extreme acts of heroism and also acknowledge that the system sometimes gets by on the acts of heroes to patch up some of the brokenness and fragmentation within it?”
Heroes are determined
Ala Stanford, MD, a pediatric surgeon in Philadelphia, has frequently been called a “health care hero.” Given the title by CNN in 2021, she has received numerous other awards and accolades, featured in Fortune Magazine’s “World’s 50 Greatest Leaders” in 2021 and USA Today’s “Women of the Year” in 2022.
In 2020, Dr. Stanford was sheltering in place and watching “way too much” cable news. “They would play solemn music and show photos of all the people who had died,” she recalls. “I thought, ‘All these people are Black or brown. What is going on?’”
The standard explanation was that people of color were more vulnerable because they were more likely to be essential workers or have chronic health conditions. But Dr. Stanford believed this was only part of the story. The reason she saw that local Black communities had higher positivity rates was because people couldn’t get a COVID test.
Dr. Stanford got call after call from Philadelphians who had been turned away from testing centers. When she questioned colleagues, “they gave me every reason under the sun,” Dr. Stanford says. “It was because someone took public transportation, and they were only testing people in cars, or because they weren’t over 65, or because they didn’t have other comorbid health conditions, or because they weren’t a health care worker, or because they hadn’t traveled to China ...” The list went on.
Dr. Stanford appealed to local, state, and federal health authorities. Finally, she took matters into her own hands. She found tests, packed a van with masks, gowns, and gloves, and drove across the city going door to door. Eventually, she organized testing in the parking lots of Black churches, sometimes seeing more than 400 people per day.
The services were funded entirely through her own bank account and donations until she was eventually awarded a CDC grant through the Coronavirus Aid, Relief, and Economic Security (CARES) Act of 2020 and began to receive contracts from the city.
Since then, Dr. Stanford’s mission has evolved. She and her team provided COVID vaccinations to thousands, and in 2021, opened the Dr. Ala Stanford Center for Health Equity. The center offers primary care for all ages in underserved communities.
Still, Dr. Stanford doesn’t think of herself as a hero, and she stresses that many other people contributed to her success. “I think the world was on fire, and we were all firefighters,” Dr. Stanford says. “Someone said to me, ‘Ala, you ran to the fire and everyone else was running away from it, and you didn’t have to.’ … I feel like I was able to galvanize people to realize the power that they actually had. Maybe independently, they couldn’t do a whole lot, but collectively, we were a force.”
Heroes are selfless
Nicole Jackson, RN, an emergency room manager and nurse at Advocate Trinity Hospital in Chicago, was recently honored as a Health Care Hero by the American Red Cross of Greater Chicago.
On June 23, 2022, Jackson’s emergency department was understaffed and struggling with an influx of patients when three gunshot victims arrived. Two needed to be transferred to a trauma center, and one – with multiple gunshot wounds – required a critical care nurse in the ambulance. But the ETA for that transport was 90 minutes, which meant the patient might not survive. Although Ms. Jackson was already working beyond her shift, she rode in the ambulance with the patient herself and probably saved his life.
While this incident stood out to a colleague who nominated her for the Red Cross award, Ms. Jackson finds herself working extra hours fairly often. “Since COVID, that’s pretty much been like any other hospital,” she says. “We’ve had staffing challenges that we work through every day. So, the nurses come, they show up, and they do the best that they can with what we have to keep our patients safe.”
A 2022 survey by McKinsey estimated that by 2025, there could be a gap of 200,000 to 450,000 nurses in the United States. A two-year impact assessment from the American Nurses Foundation found that among more than 12,500 nurses, 40% were considering leaving their positions before the pandemic. By 2022, that number had jumped to 52% with the top reasons being insufficient staffing and negative effects on health and well-being.
Can the “hero narrative” help that situation? Ms. Jackson says she doesn’t see herself as a hero, but the supportive environment and gestures of recognition by staff do make her feel appreciated. These include daily messages offering “kudos” and nominations for the DAISY Award, which she herself received in 2022.
“I have people who I have encouraged to become nurses,” Ms. Jackson says, “and when they saw [the award], they were really excited about becoming a nurse.”
Heroes are strong
Jasmine Marcelin, MD, an infectious disease physician with Nebraska Medicine in Omaha, understands the need for heroes as symbols and sources of inspiration. Dr. Marcelin is a fan of the superhero movie genre. There is value, she says, in feeling hope and excitement while watching Superman or Wonder Woman save the day. Who doesn’t want to believe (if only briefly) that the good guys will always win?
In reality, Dr. Marcelin says, “none of us are invincible.” And it’s dangerous to forget that “the people behind the symbols are also human.”
In 2021, Dr. Marcelin gave a TEDx talk entitled, “The Myth of the Health Care Hero.” In it she discussed the extreme physical and mental toll of the pandemic on health care workers and urged her audience to think less about extravagant praise and more about their personal responsibilities. “We don’t want or need to be called heroes,” Dr. Marcelin said. “Right now, our love language is action. We need your help, and we cannot save the world on our own.”
Dr. Marcelin also sees links between superhuman expectations and the high levels of burnout in the medical field.
“It’s a systemic issue,” she explains, “where it requires a revamping and revitalization of the entire psyche of health care to recognize that the people working within this profession are human. And the things that we think and feel and need are the same as anybody else.”
Heroes are self-sacrificing
Well-being, burnout, and disengagement in health care has become a focus for Oregon Health & Science’s Dr. Park, who is also director of RELATE Lab, an organization that aims to make health care more human-centered and equitable through leadership training, research, and community organizing.
For him, hearing neighbors banging pots and pans during the early pandemic was complicated. “The first phase for me was, ‘Thank you. I feel seen. I feel appreciated,’ ” he says. “Yes, I’m wearing a mask. I’m going in. I’m changing in the garage when I come home, so my kid and my partner don’t get sick.”
But after a while, the cheers started to feel like pressure. “Have I done anything heroic today?” Dr. Park asked himself. “Have I been as heroic as my friend who is in the hospital in the ICU? I don’t deserve this, so don’t bang those pots and pans for me.”
When your identity becomes about being a hero, Dr. Park says, when that becomes the standard by which you measure yourself, the result is often a sense of shame.
“I think a lot of people feel ashamed that they feel burnout,” he says, “because they’re supposed to be heroes, putting on their capes and masks. They’re waking up and saying, ‘I’m exhausted, and I can’t play that part today. But I know that’s the social expectation of me.’ “
Heroes are noble
There may not be a clear solution, but for many health care professionals, symbolic gestures alone are inadequate and, in certain cases, insulting.
On Doctor’s Day 2023, Alok Patel, MD, a pediatric hospitalist, tweeted a photo of an appreciation “gift” for staff from an unnamed hospital. The small items had metaphorical meanings – a rubber band “as a reminder to stay flexible,” a quarter “as a reminder to ‘call’ for help,” etc.
“Welcome to how you give thanks to ‘health care heroes,’ ” Dr. Patel tweeted.
For Dr. Patel, the issue is not lavish gifts but a need for an attitude shift. He recalls colleagues who felt ashamed asking for mental health services or time off, “because they were bombarded by the hero narrative, by the manufactured pressure that they needed to put their jobs above their own health – because that’s what ‘heroes’ do. I’m willing to bet most physicians would rather receive a sincere email with a transparent plan to better support health care workers than any Doctor’s Day gift,” he says.
In Dr. Marcelin’s TEDx talk, she quotes Spider-Man’s classic adage, “With great power, comes great responsibility.” She argues that this motto doesn’t just apply to those who can fly or deflect bullets; that’s not what heroism is. In fact, most people have their own definition of the word.
For Dr. Stanford, a hero is “someone who is selfless, putting the needs of others before their own.” Dr. Park believes there are no individual heroes. “It’s the work of the collective that’s truly heroic.”
By those standards, clearly anyone can step up, offer help, act with courage and kindness, and be heroic. “We humans, as ordinary as we are, can be extraordinary by using our power to do what’s right,” Dr. Marcelin says, “because there’s no such thing as health care heroes, just good people doing the right thing.”
A version of this article first appeared on Medscape.com.
In April 2020, as many Americans prepared to spend the Easter holiday in lockdown, pop star Mariah Carey released a video honoring the “sacrifices and courage” of frontline workers battling COVID-19 – her 1993 hit, “Hero.”
“The sorrow that you know will melt away,” Ms. Carey sang. “When you feel like hope is gone,” the song continued, strength and answers can be found within, and “a hero lies in you.”
For health care professionals, the reality of 2020 wasn’t quite so uplifting. PPE shortages and spillover ICUs had many feeling helpless, exhausted, and overwhelmed. Few if any medical professionals felt their sorrows “melt away.”
We can’t expect depth and nuance from pop songs, but we can find in them the imagery that runs through our culture. The “hero narrative” – the idea that doctors, nurses, and others in health care have superhuman endurance and selflessness – has long been an undercurrent in the medical field.
And yet, without a workforce willing to perform without adequate sleep, food, or time off, the health care system couldn’t function, says Brian Park, MD, MPH, a family medicine physician at Oregon Health & Science University, Portland. At many academic health centers, for example, residents are “the bedrock of the workforce,” he explains. If they didn’t work 80-100 hours per week, those systems wouldn’t exist.
So, how do we look at the health care system in a way that is both grateful and critical, Dr. Park wonders. “How do we honor extreme acts of heroism and also acknowledge that the system sometimes gets by on the acts of heroes to patch up some of the brokenness and fragmentation within it?”
Heroes are determined
Ala Stanford, MD, a pediatric surgeon in Philadelphia, has frequently been called a “health care hero.” Given the title by CNN in 2021, she has received numerous other awards and accolades, featured in Fortune Magazine’s “World’s 50 Greatest Leaders” in 2021 and USA Today’s “Women of the Year” in 2022.
In 2020, Dr. Stanford was sheltering in place and watching “way too much” cable news. “They would play solemn music and show photos of all the people who had died,” she recalls. “I thought, ‘All these people are Black or brown. What is going on?’”
The standard explanation was that people of color were more vulnerable because they were more likely to be essential workers or have chronic health conditions. But Dr. Stanford believed this was only part of the story. The reason she saw that local Black communities had higher positivity rates was because people couldn’t get a COVID test.
Dr. Stanford got call after call from Philadelphians who had been turned away from testing centers. When she questioned colleagues, “they gave me every reason under the sun,” Dr. Stanford says. “It was because someone took public transportation, and they were only testing people in cars, or because they weren’t over 65, or because they didn’t have other comorbid health conditions, or because they weren’t a health care worker, or because they hadn’t traveled to China ...” The list went on.
Dr. Stanford appealed to local, state, and federal health authorities. Finally, she took matters into her own hands. She found tests, packed a van with masks, gowns, and gloves, and drove across the city going door to door. Eventually, she organized testing in the parking lots of Black churches, sometimes seeing more than 400 people per day.
The services were funded entirely through her own bank account and donations until she was eventually awarded a CDC grant through the Coronavirus Aid, Relief, and Economic Security (CARES) Act of 2020 and began to receive contracts from the city.
Since then, Dr. Stanford’s mission has evolved. She and her team provided COVID vaccinations to thousands, and in 2021, opened the Dr. Ala Stanford Center for Health Equity. The center offers primary care for all ages in underserved communities.
Still, Dr. Stanford doesn’t think of herself as a hero, and she stresses that many other people contributed to her success. “I think the world was on fire, and we were all firefighters,” Dr. Stanford says. “Someone said to me, ‘Ala, you ran to the fire and everyone else was running away from it, and you didn’t have to.’ … I feel like I was able to galvanize people to realize the power that they actually had. Maybe independently, they couldn’t do a whole lot, but collectively, we were a force.”
Heroes are selfless
Nicole Jackson, RN, an emergency room manager and nurse at Advocate Trinity Hospital in Chicago, was recently honored as a Health Care Hero by the American Red Cross of Greater Chicago.
On June 23, 2022, Jackson’s emergency department was understaffed and struggling with an influx of patients when three gunshot victims arrived. Two needed to be transferred to a trauma center, and one – with multiple gunshot wounds – required a critical care nurse in the ambulance. But the ETA for that transport was 90 minutes, which meant the patient might not survive. Although Ms. Jackson was already working beyond her shift, she rode in the ambulance with the patient herself and probably saved his life.
While this incident stood out to a colleague who nominated her for the Red Cross award, Ms. Jackson finds herself working extra hours fairly often. “Since COVID, that’s pretty much been like any other hospital,” she says. “We’ve had staffing challenges that we work through every day. So, the nurses come, they show up, and they do the best that they can with what we have to keep our patients safe.”
A 2022 survey by McKinsey estimated that by 2025, there could be a gap of 200,000 to 450,000 nurses in the United States. A two-year impact assessment from the American Nurses Foundation found that among more than 12,500 nurses, 40% were considering leaving their positions before the pandemic. By 2022, that number had jumped to 52% with the top reasons being insufficient staffing and negative effects on health and well-being.
Can the “hero narrative” help that situation? Ms. Jackson says she doesn’t see herself as a hero, but the supportive environment and gestures of recognition by staff do make her feel appreciated. These include daily messages offering “kudos” and nominations for the DAISY Award, which she herself received in 2022.
“I have people who I have encouraged to become nurses,” Ms. Jackson says, “and when they saw [the award], they were really excited about becoming a nurse.”
Heroes are strong
Jasmine Marcelin, MD, an infectious disease physician with Nebraska Medicine in Omaha, understands the need for heroes as symbols and sources of inspiration. Dr. Marcelin is a fan of the superhero movie genre. There is value, she says, in feeling hope and excitement while watching Superman or Wonder Woman save the day. Who doesn’t want to believe (if only briefly) that the good guys will always win?
In reality, Dr. Marcelin says, “none of us are invincible.” And it’s dangerous to forget that “the people behind the symbols are also human.”
In 2021, Dr. Marcelin gave a TEDx talk entitled, “The Myth of the Health Care Hero.” In it she discussed the extreme physical and mental toll of the pandemic on health care workers and urged her audience to think less about extravagant praise and more about their personal responsibilities. “We don’t want or need to be called heroes,” Dr. Marcelin said. “Right now, our love language is action. We need your help, and we cannot save the world on our own.”
Dr. Marcelin also sees links between superhuman expectations and the high levels of burnout in the medical field.
“It’s a systemic issue,” she explains, “where it requires a revamping and revitalization of the entire psyche of health care to recognize that the people working within this profession are human. And the things that we think and feel and need are the same as anybody else.”
Heroes are self-sacrificing
Well-being, burnout, and disengagement in health care has become a focus for Oregon Health & Science’s Dr. Park, who is also director of RELATE Lab, an organization that aims to make health care more human-centered and equitable through leadership training, research, and community organizing.
For him, hearing neighbors banging pots and pans during the early pandemic was complicated. “The first phase for me was, ‘Thank you. I feel seen. I feel appreciated,’ ” he says. “Yes, I’m wearing a mask. I’m going in. I’m changing in the garage when I come home, so my kid and my partner don’t get sick.”
But after a while, the cheers started to feel like pressure. “Have I done anything heroic today?” Dr. Park asked himself. “Have I been as heroic as my friend who is in the hospital in the ICU? I don’t deserve this, so don’t bang those pots and pans for me.”
When your identity becomes about being a hero, Dr. Park says, when that becomes the standard by which you measure yourself, the result is often a sense of shame.
“I think a lot of people feel ashamed that they feel burnout,” he says, “because they’re supposed to be heroes, putting on their capes and masks. They’re waking up and saying, ‘I’m exhausted, and I can’t play that part today. But I know that’s the social expectation of me.’ “
Heroes are noble
There may not be a clear solution, but for many health care professionals, symbolic gestures alone are inadequate and, in certain cases, insulting.
On Doctor’s Day 2023, Alok Patel, MD, a pediatric hospitalist, tweeted a photo of an appreciation “gift” for staff from an unnamed hospital. The small items had metaphorical meanings – a rubber band “as a reminder to stay flexible,” a quarter “as a reminder to ‘call’ for help,” etc.
“Welcome to how you give thanks to ‘health care heroes,’ ” Dr. Patel tweeted.
For Dr. Patel, the issue is not lavish gifts but a need for an attitude shift. He recalls colleagues who felt ashamed asking for mental health services or time off, “because they were bombarded by the hero narrative, by the manufactured pressure that they needed to put their jobs above their own health – because that’s what ‘heroes’ do. I’m willing to bet most physicians would rather receive a sincere email with a transparent plan to better support health care workers than any Doctor’s Day gift,” he says.
In Dr. Marcelin’s TEDx talk, she quotes Spider-Man’s classic adage, “With great power, comes great responsibility.” She argues that this motto doesn’t just apply to those who can fly or deflect bullets; that’s not what heroism is. In fact, most people have their own definition of the word.
For Dr. Stanford, a hero is “someone who is selfless, putting the needs of others before their own.” Dr. Park believes there are no individual heroes. “It’s the work of the collective that’s truly heroic.”
By those standards, clearly anyone can step up, offer help, act with courage and kindness, and be heroic. “We humans, as ordinary as we are, can be extraordinary by using our power to do what’s right,” Dr. Marcelin says, “because there’s no such thing as health care heroes, just good people doing the right thing.”
A version of this article first appeared on Medscape.com.
Revisiting the role of hydrocortisone, fludrocortisone in septic shock
Earlier this year, I stumbled across a podcast in a content update email from the Journal of the American Medical Association. The moderator was interviewing the first author of a study comparing hydrocortisone and fludrocortisone (hydro/fludro) to hydrocortisone alone for treatment of septic shock. In the introduction,
I thought this issue had been settled with publication of the COIITSS trial in 2010. This study randomly assigned 509 patients with septic shock to hydro/fludro versus hydrocortisone alone. There was a nonsignificant reduction in mortality with hydro/fludro and everyone I knew stopped adding fludrocortisone for septic shock. It wasn’t included in guidelines (and still isn›t). I figured the only docs still using it were also prescribing ivermectin and vitamin C – another treatment touted to work in an apocryphal podcast.
It wasn’t just COIITSS that killed fludrocortisone for me. Back in 2002, I was a loyal adherent. That year, a randomized controlled trial (RCT) published by “the lord of corticosteroids for critical illness” doctor, Djillali Annane, found benefit to hydro/fludro in septic shock . Everyone in that study had a cosyntropin stim test and only certain subgroups had better outcomes. As a medical resident paying obeisance to all things evidence-based medicine, I rigidly adopted their protocol for all septic patients. I also kept their insulin between 80 and 110 mg/dL, prescribed drotrecogin alfa, and made sure they were floating in crystalloid. But those are topics for another time.
Subsequent trials and meta-analyses cast doubt on the need for the stim test, and a consensus around hydrocortisone at moderate doses for patients with septic shock emerged. Because one part of the Annane protocol was already deemed unnecessary (the cosyntropin stim test), it was easy to dismiss fludrocortisone after COIITTS was published. Yes, I read Annane’s 2018 APROCCHSS trial, and I’m aware that it found that hydro/fludro reduced 90-day mortality. Like others, I rationalized this finding by framing it as a function of baseline mortality. The two Annane RCTs that found that hydro/fludro reduced mortality in enrolled patients who were considerably more likely to die than those enrolled in RCTs of hydrocortisone alone were negative. It was the target population mortality rate and not the addition of fludrocortisone that made the difference, right?
Rethinking hydro/fludro
The author interviewed for the recent JAMA podcast forced me to rethink my blithe dismissal of fludrocortisone. He contended that the COIITTS trial was underpowered and the two Annane RCTs that used fludrocortisone supply the evidence that shows corticosteroids reduce septic shock mortality. As discussed earlier, he found clinical equipoise among his colleagues. Last, he invoked pleiotropic mineralocorticoid effects, such as activation of innate immunity and clearance of alveolar fluid, to support the need to reexamine hydro/fludro.
In his study, he used Big Data to compare hospital records from 2016 to 2020. He analyzed a total of 88,275 patients with septic shock. Most were prescribed hydrocortisone alone (85,995 [97.4%] vs. only 2.6% hydro/fludro). After a number of statistical adjustments and sensitivity analyses, the authors concluded that the addition of fludrocortisone to hydrocortisone for patients with septic shock provides a 3.7% absolute risk reduction in mortality (or discharge to hospice) when compared with hydrocortisone alone. That’s a number needed to treat of 28 to prevent one death (or discharge to hospice).
Key takeaways
The study isn’t perfect. In their methods section they use terms like “ensemble machine learner (super learner)” and “immortal time bias.” The first is a fancy way of saying they did a form of propensity scoring, which in turn is a fancy way of saying they tried to control for confounding. The second is a way to adjust for time delays between drug administration. Both are attempts to compensate for the observational design, as is their argument for biologic plausibility. Here they’re on particularly thin ice when trying to prove causal inference. Biologic plausibility is never hard to find; after all, what compound doesn’t have pleiotropic effects? Furthermore, the analysis lacks any data to support their biologic plausibility hypothesis that fludrocortisone’s effect on mortality is mediated via activation of innate immunity and/or clearance of alveolar fluid.
The editorial accompanying this Big Data study endorsed adding fludrocortisone. We have very little that reduces ICU mortality so the low number needed to treat is enticing, especially in light of the low risk from adverse events, so I’m going to start using it. Do I think I’ll save one life for every 28 patients with septic shock to whom I give hydro/fludro instead of hydrocortisone alone? I sure don’t. No way an oral mineralocorticoid at that dose has that type of impact on top of hydrocortisone alone. I still believe that the Annane studies are positive because of the mortality rate in the population enrolled and not because fludrocortisone was added. It all comes full circle, though – 20 years after I abandoned hydro/fludro, I’m going back to it.
Aaron B. Holley, MD, is a professor of medicine at Uniformed Services University in Bethesda, Md., and a pulmonary/critical care and sleep medicine physician at MedStar Washington Hospital Center in Washington, D.C.
A version of this article first appeared on Medscape.com.
Earlier this year, I stumbled across a podcast in a content update email from the Journal of the American Medical Association. The moderator was interviewing the first author of a study comparing hydrocortisone and fludrocortisone (hydro/fludro) to hydrocortisone alone for treatment of septic shock. In the introduction,
I thought this issue had been settled with publication of the COIITSS trial in 2010. This study randomly assigned 509 patients with septic shock to hydro/fludro versus hydrocortisone alone. There was a nonsignificant reduction in mortality with hydro/fludro and everyone I knew stopped adding fludrocortisone for septic shock. It wasn’t included in guidelines (and still isn›t). I figured the only docs still using it were also prescribing ivermectin and vitamin C – another treatment touted to work in an apocryphal podcast.
It wasn’t just COIITSS that killed fludrocortisone for me. Back in 2002, I was a loyal adherent. That year, a randomized controlled trial (RCT) published by “the lord of corticosteroids for critical illness” doctor, Djillali Annane, found benefit to hydro/fludro in septic shock . Everyone in that study had a cosyntropin stim test and only certain subgroups had better outcomes. As a medical resident paying obeisance to all things evidence-based medicine, I rigidly adopted their protocol for all septic patients. I also kept their insulin between 80 and 110 mg/dL, prescribed drotrecogin alfa, and made sure they were floating in crystalloid. But those are topics for another time.
Subsequent trials and meta-analyses cast doubt on the need for the stim test, and a consensus around hydrocortisone at moderate doses for patients with septic shock emerged. Because one part of the Annane protocol was already deemed unnecessary (the cosyntropin stim test), it was easy to dismiss fludrocortisone after COIITTS was published. Yes, I read Annane’s 2018 APROCCHSS trial, and I’m aware that it found that hydro/fludro reduced 90-day mortality. Like others, I rationalized this finding by framing it as a function of baseline mortality. The two Annane RCTs that found that hydro/fludro reduced mortality in enrolled patients who were considerably more likely to die than those enrolled in RCTs of hydrocortisone alone were negative. It was the target population mortality rate and not the addition of fludrocortisone that made the difference, right?
Rethinking hydro/fludro
The author interviewed for the recent JAMA podcast forced me to rethink my blithe dismissal of fludrocortisone. He contended that the COIITTS trial was underpowered and the two Annane RCTs that used fludrocortisone supply the evidence that shows corticosteroids reduce septic shock mortality. As discussed earlier, he found clinical equipoise among his colleagues. Last, he invoked pleiotropic mineralocorticoid effects, such as activation of innate immunity and clearance of alveolar fluid, to support the need to reexamine hydro/fludro.
In his study, he used Big Data to compare hospital records from 2016 to 2020. He analyzed a total of 88,275 patients with septic shock. Most were prescribed hydrocortisone alone (85,995 [97.4%] vs. only 2.6% hydro/fludro). After a number of statistical adjustments and sensitivity analyses, the authors concluded that the addition of fludrocortisone to hydrocortisone for patients with septic shock provides a 3.7% absolute risk reduction in mortality (or discharge to hospice) when compared with hydrocortisone alone. That’s a number needed to treat of 28 to prevent one death (or discharge to hospice).
Key takeaways
The study isn’t perfect. In their methods section they use terms like “ensemble machine learner (super learner)” and “immortal time bias.” The first is a fancy way of saying they did a form of propensity scoring, which in turn is a fancy way of saying they tried to control for confounding. The second is a way to adjust for time delays between drug administration. Both are attempts to compensate for the observational design, as is their argument for biologic plausibility. Here they’re on particularly thin ice when trying to prove causal inference. Biologic plausibility is never hard to find; after all, what compound doesn’t have pleiotropic effects? Furthermore, the analysis lacks any data to support their biologic plausibility hypothesis that fludrocortisone’s effect on mortality is mediated via activation of innate immunity and/or clearance of alveolar fluid.
The editorial accompanying this Big Data study endorsed adding fludrocortisone. We have very little that reduces ICU mortality so the low number needed to treat is enticing, especially in light of the low risk from adverse events, so I’m going to start using it. Do I think I’ll save one life for every 28 patients with septic shock to whom I give hydro/fludro instead of hydrocortisone alone? I sure don’t. No way an oral mineralocorticoid at that dose has that type of impact on top of hydrocortisone alone. I still believe that the Annane studies are positive because of the mortality rate in the population enrolled and not because fludrocortisone was added. It all comes full circle, though – 20 years after I abandoned hydro/fludro, I’m going back to it.
Aaron B. Holley, MD, is a professor of medicine at Uniformed Services University in Bethesda, Md., and a pulmonary/critical care and sleep medicine physician at MedStar Washington Hospital Center in Washington, D.C.
A version of this article first appeared on Medscape.com.
Earlier this year, I stumbled across a podcast in a content update email from the Journal of the American Medical Association. The moderator was interviewing the first author of a study comparing hydrocortisone and fludrocortisone (hydro/fludro) to hydrocortisone alone for treatment of septic shock. In the introduction,
I thought this issue had been settled with publication of the COIITSS trial in 2010. This study randomly assigned 509 patients with septic shock to hydro/fludro versus hydrocortisone alone. There was a nonsignificant reduction in mortality with hydro/fludro and everyone I knew stopped adding fludrocortisone for septic shock. It wasn’t included in guidelines (and still isn›t). I figured the only docs still using it were also prescribing ivermectin and vitamin C – another treatment touted to work in an apocryphal podcast.
It wasn’t just COIITSS that killed fludrocortisone for me. Back in 2002, I was a loyal adherent. That year, a randomized controlled trial (RCT) published by “the lord of corticosteroids for critical illness” doctor, Djillali Annane, found benefit to hydro/fludro in septic shock . Everyone in that study had a cosyntropin stim test and only certain subgroups had better outcomes. As a medical resident paying obeisance to all things evidence-based medicine, I rigidly adopted their protocol for all septic patients. I also kept their insulin between 80 and 110 mg/dL, prescribed drotrecogin alfa, and made sure they were floating in crystalloid. But those are topics for another time.
Subsequent trials and meta-analyses cast doubt on the need for the stim test, and a consensus around hydrocortisone at moderate doses for patients with septic shock emerged. Because one part of the Annane protocol was already deemed unnecessary (the cosyntropin stim test), it was easy to dismiss fludrocortisone after COIITTS was published. Yes, I read Annane’s 2018 APROCCHSS trial, and I’m aware that it found that hydro/fludro reduced 90-day mortality. Like others, I rationalized this finding by framing it as a function of baseline mortality. The two Annane RCTs that found that hydro/fludro reduced mortality in enrolled patients who were considerably more likely to die than those enrolled in RCTs of hydrocortisone alone were negative. It was the target population mortality rate and not the addition of fludrocortisone that made the difference, right?
Rethinking hydro/fludro
The author interviewed for the recent JAMA podcast forced me to rethink my blithe dismissal of fludrocortisone. He contended that the COIITTS trial was underpowered and the two Annane RCTs that used fludrocortisone supply the evidence that shows corticosteroids reduce septic shock mortality. As discussed earlier, he found clinical equipoise among his colleagues. Last, he invoked pleiotropic mineralocorticoid effects, such as activation of innate immunity and clearance of alveolar fluid, to support the need to reexamine hydro/fludro.
In his study, he used Big Data to compare hospital records from 2016 to 2020. He analyzed a total of 88,275 patients with septic shock. Most were prescribed hydrocortisone alone (85,995 [97.4%] vs. only 2.6% hydro/fludro). After a number of statistical adjustments and sensitivity analyses, the authors concluded that the addition of fludrocortisone to hydrocortisone for patients with septic shock provides a 3.7% absolute risk reduction in mortality (or discharge to hospice) when compared with hydrocortisone alone. That’s a number needed to treat of 28 to prevent one death (or discharge to hospice).
Key takeaways
The study isn’t perfect. In their methods section they use terms like “ensemble machine learner (super learner)” and “immortal time bias.” The first is a fancy way of saying they did a form of propensity scoring, which in turn is a fancy way of saying they tried to control for confounding. The second is a way to adjust for time delays between drug administration. Both are attempts to compensate for the observational design, as is their argument for biologic plausibility. Here they’re on particularly thin ice when trying to prove causal inference. Biologic plausibility is never hard to find; after all, what compound doesn’t have pleiotropic effects? Furthermore, the analysis lacks any data to support their biologic plausibility hypothesis that fludrocortisone’s effect on mortality is mediated via activation of innate immunity and/or clearance of alveolar fluid.
The editorial accompanying this Big Data study endorsed adding fludrocortisone. We have very little that reduces ICU mortality so the low number needed to treat is enticing, especially in light of the low risk from adverse events, so I’m going to start using it. Do I think I’ll save one life for every 28 patients with septic shock to whom I give hydro/fludro instead of hydrocortisone alone? I sure don’t. No way an oral mineralocorticoid at that dose has that type of impact on top of hydrocortisone alone. I still believe that the Annane studies are positive because of the mortality rate in the population enrolled and not because fludrocortisone was added. It all comes full circle, though – 20 years after I abandoned hydro/fludro, I’m going back to it.
Aaron B. Holley, MD, is a professor of medicine at Uniformed Services University in Bethesda, Md., and a pulmonary/critical care and sleep medicine physician at MedStar Washington Hospital Center in Washington, D.C.
A version of this article first appeared on Medscape.com.